Using Vignettes to Tap Into Moral Reasoning in Public Health Policy: Practical Advice and Design Principles From a Study on Food Advertising to Children

Abstract

In this article, we describe a process for designing and applying vignettes in public health policy research and practice. We developed this methodology for a study on moral reasoning underpinning policy debate on food advertising to children.

Using vignettes prompted policy actors who were relatively entrenched in particular ways of speaking professionally about a controversial and ethically challenging issue to converse in a more authentic and reflective way.

Vignettes hold benefits and complexities. They can focus attention on moral conflicts, draw out different types of evidence to support moral reasoning, and enable simultaneous consideration of real and ideal worlds. We suggest a process and recommendations on design features for crafting vignettes for public health policy.

Vignettes have been identified as a useful device to elicit discussion on beliefs, values, and norms.^1–3 They are short stories based on fictional or fictionalized (hypothetical) scenarios, in which respondents are asked to draw upon their own experience to predict how characters will—or should—behave.^4–7 Vignettes have a long history in social inquiry, including psychology, social work, and health education. Vignettes are useful for several qualitative data collection functions: to set a tone for an encounter by serving as ice-breaker or concluding device (for example, at the opening or closing of an interview or focus group, where shifts between concrete and abstract concepts need to be made),⁸ to capture complexity in the operationalization of concepts through their representation of real-world situations,⁹ to place potential actions in specific situational contexts,⁸ to facilitate expression of personal or subjective experiences and beliefs,^1,2,10 and to analyze judgments in response to moral dilemmas.⁸

We outline a process for designing and applying vignettes in public health policy research and practice that we developed for a study on the moral reasoning underpinning policy debate on food advertising to children. Vignettes prompted policy actors, who were relatively entrenched in particular ways of speaking professionally about the issue, to converse in a more authentic and reflective way. First, we describe the issue of food and beverage advertising to children, focusing on how it presents specific challenges for qualitative policy research. Second, we include an in-depth illustrative look at our study methodology. Third, we have included a brief selection of results from the study, focusing on themes that highlight the function of the vignettes. Fourth, we conclude with lessons learned on the practical application of vignettes, from conception to implementation, and how they can serve as a useful tool for public health policy deliberation.

FOOD AND BEVERAGE ADVERTISING TO CHILDREN

This work on vignettes was derived from our study, Food Advertising to Children: Ethics for Policy (FACE), whose aim was to develop a national consultation process to better understand the ethical underpinnings of policy debate on this issue in Canada. Although one jurisdiction in Canada, the province of Quebec, has had a consumer protection statute in place restricting commercial advertising directed toward children for more than 3 decades, the predominant form of policy is industry-led voluntary self-regulation (i.e., pledges or standards for advertising directed toward children and youths).

Globally, the broad issue of food and beverage advertising to children has received much policy attention, but has also been a source of ongoing debate. Mounting evidence has demonstrated that the advertising of food and beverages to children has adverse effects on food knowledge, dietary behaviors, consumption practices, and health status, including obesity.^11–14 The debate about specific policy interventions to reduce the impact of food and beverage advertising to children remains intense. Health agencies and jurisdictions have suggested a spectrum of policy changes from comprehensive bans (statutes prohibiting large swathes of commercial advertising such as junk food ad bans) to stepwise restrictions that limit advertising to children in particular settings or in specific forms of media, amid a default of industry self-regulation.^15,16

From an ethical and moral standpoint, the issue provokes questions about the role of commercial advertising in society, what constitutes an appropriate or “normal” childhood, and the intersection between the state and the relationship between parent and child; such questions all deal with contested social values. A relatively narrow framing of moral justifications for policy, based on individual liberties, has also made consensus difficult. For example, some actors emphasize the need for legislation to limit or prohibit food advertising, citing ethical concerns about preventing harm to children, a vulnerable population group with important future potential.¹⁷ Some industry actors argue that consumers, including children, have the right to access all types of product information freely, which includes advertising.¹⁸ Still others note that advertising subverts parents’ ability to parent effectively, thus requiring state intervention to uphold parental freedoms.¹⁹ Taking classic explorations of liberty into account (e.g., Berlin²⁰), all 3 justifications could be argued as promoting a concept of public health intervention related to upholding liberty, although liberty is defined differently in each situation. In the first justification, advertising itself can limit a child’s positive liberty (a right to fulfill one’s promise or, at least, what one is capable of doing); in the second, advertising regulation limits a child’s negative liberty (opportunity to act without infringement); and in the third, it is advertising that limits parents’ negative liberty (opportunity to act without infringement).

The result is that food and beverage advertising to children raises 3 types of practical problems for effective deliberation in public health policy research and practice. The first problem is how to operationalize contested concepts within the issue for empirical research, given that the issue is complex, with multifactorial causality, and for which there is not only disagreement on the moral end-goals of policy, but also on the definitions of goals themselves (e.g., liberty, a “normal” childhood, “good” parenting, or “healthy” food). The second problem is, amid an intense public debate, to ensure what is referred to in participatory action research as authenticity, or authentic involvement of policy informants, in terms of understandings that are “sincerely held and stated.”^21(p576) The Institute of Medicine, describing work of Diane Finegood, documents how “authentic trust” is essential in intersectoral policy action in public health, such as for obesity prevention.^{22(pp38–42)} A third problem is how to navigate the intersection between public (professional) and private identities and morality; all policy actors have an existing private understanding of child and parental roles in this debate. This relates, in part, to a distinction that we might make in terms of ethics, the generalized frameworks of values, virtues, and principles that can guide decision-making in the public sphere,^23,24 and morality, the reasoning and judgments that people apply in specific situations in light of their foundational beliefs and experiences.²⁴

Vignettes hold promise for tackling each of these problems. Vignettes portray a set of characters, offering a less threatening way to explore sensitive or controversial subjects, that nonetheless speaks to real-world experience. They also allow individuals to define situations presented in their own terms during a social interaction. It has been noted that the distancing of an ethically sensitive topic through a vignette promotes more transparent and honest responses from participants through a type of anonymity²⁵—in a conversation, the focus is on the character’s actions, and not their own. Those responding to vignettes can express ideas without feeling personally exposed.²⁶ Given that vignettes can elicit responses uniformly whether participants have detailed knowledge of the topics under consideration,⁵ we also posited that vignettes could actually structure a public health policy dialogue such that participants would interpret that they did not need to apply only their detailed (i.e., “expert”) knowledge of the issue at hand.

RESEARCH DESIGN

Our study asked 2 key questions: What ethical principles drive policy debates about food and beverage advertising targeted to children in Canada? How can diverse forms of moral reasoning about this issue be reconciled through deliberative policy practices?

Our 2-year study was modeled on a 2-step design, informed by the general structure of a policy Delphi^27,28: phase 1, to elicit core individual input through semistructured telephone interviews with key informants, and phase 2, a deliberative dialogue with a small subgroup of the original participants. The discussion of vignette method in this article drew principally from 1-on-1 semi-structured telephone interviews with key informants (n = 35) that we conducted in May through June 2012. We recruited participants from 5 researcher-defined groups of actors based on their current professional activities, through purposive sampling from known policy networks on the issue and snowball sampling from our advisory committee members. The principal inclusion criterion was that individuals had to be well-established actors involved in this issue. We completed 35 interviews with public health decision-makers (n = 10), the private sector (including food industry and media; n = 5), health practitioners (n = 7), civil society representatives (n = 11) and academics (n = 2). Our observations are also informed by a conference workshop (June 2013) that we hosted with public health researchers, practitioners, and decision-makers, and the aforementioned deliberative dialogue (July 2013).

DESIGN OF THE VIGNETTES

In this section, we describe “methods of the method”: an overview of the process of creating the vignettes in our study and implementing them in data collection, as an illustration of how vignette method can work in a real-world study. We recognized early in our research that although many sources exist on vignette-based research, few offered an approachable how-to or process-oriented look to help those unfamiliar with vignettes to think about the systematic steps behind their creation and use.

First, based on a review of academic literature and drawing from key sources on variable testing using vignettes (factorial design),^29,30 we mined background documents from our existing database of sources for the project, recently updated for grant applications and policy work, to synthesize the current normative arguments in the policy debate. We followed the typical steps in a knowledge synthesis: we defined eligibility for inclusion of sources as a team, then a team member assembled the document set and extracted information from the documents into an Excel (Microsoft, Redmond, WA) spreadsheet with illustrative quotations. Three members of the team then conducted a thematic analysis of the extracted data.

We included 30 documents, encompassing peer-reviewed academic literature on public health ethics as applied to this issue or childhood obesity, policy documents specific to the food and beverage advertising issue (such as the Canadian Code of Advertising Standards), and mass media articles. The principal inclusion criterion was whether documents included a clear policy prescription and rationale (i.e., complete arguments for or against regulation of advertising directed toward children). We extracted specific arguments from each of the documents until saturation (frequent repetition of existing arguments), for a total of 110 arguments, then thematically classified them into 44 unique arguments. Unique arguments included, for example: used to argue for regulation—“unhealthy advertising promotes an obesogenic environment” and “government has a multifaceted responsibility as a steward of public health”; used to argue against regulation—“food companies are responsible for producing healthier foods,” “advertising to children must be truthful,” and “restrictions on advertising will be bad for the economy.”

We then dismantled each of the arguments into underlying variables that needed to be operationalized to answer our core research questions. For example, “government has a multifaceted responsibility as a steward of public health” can be dismantled into government as an actor, a stewardship value weighed against other goals and responsibilities of the state, and the public as a beneficiary of policy. Variables included policy values (liberty, security, equity, efficiency), the presence of tensions and tradeoffs between values, the role of evidence, and the perceived responsibility of different policy actors. We also identified concrete themes and colloquial terms within the issue domain (e.g., breakfast cereals, advergames, schools, sponsorship, social media) to come up with a list of narrative building blocks to flesh out the stories in the vignettes.

This process reflected our attempt to meet a few imperatives in qualitative public health policy research: the importance of establishing the state of the existing evidence based on academic as well as gray literature sources, the idea that qualitative analysis in public health is based on a unique combination of deductive and inductive reasoning, and that the quality we refer to as authenticity throughout this paper relies on being versed in up-to-date policy language.

Second, we drafted 4 sample vignettes that incorporated the prominent variables and the narrative building blocks. Table A (available as a supplement to the online version of this article at http://www.ajph.org) maps out the variables and building blocks that went into each of the vignettes. Because the vignettes were originally meant to be used in a telephone interview context, each vignette was designed to be best interacted with through oral communication. This means that we paid attention to details such as how each vignette would sound when read aloud by an interviewer over the telephone; and we considered the length and complexity of the vignettes, so that all of the narrative elements could be easily understood and recalled without reference to a written text on the part of research participants. We also designed these vignettes for busy policy actors, intending them to be relevant to a public health practice workshop setting, where a facilitator could read the vignette aloud without visual aids, and health professional participants could be expected to engage in a discussion with little advance preparation. (We anticipate that other tailoring of the vignettes, as well as their delivery, would be needed if public audiences were expected.) Two of the vignettes incorporated developmental elements; this vignette technique presents a single narrative through an unfolding series of developments, so that interview participants can gradually refine their interpretation of vignette characters as new variables are introduced.^6,10,31

Third, we constructed 4 probing questions to accompany the draft vignettes: (1) What should [central character X] do? (2) Why do you think [central character X] is struggling with the issue? (3) In your opinion, how much food and beverage advertising should [child character Y] be exposed to? (4) In an ideal world, how do you think we can get there as a society? The style of the probes aimed to encourage use of colloquial language and discourage jargon, and to focus on action (and the moral reasoning around action), rather than on the reasoning itself. The first probe explored actor roles, attributes, and responsibilities; the second encouraged identification of key moral dilemmas; the third asked about perceived ideal outcomes of policy; and the fourth was a prompt for specific actions that could be taken by individuals, groups, or society as a whole, and to make an explicit link between ideal and real worlds.

In the preamble to the interview, we included specific instructions for participants to “put themselves into the shoes of the characters.” They were encouraged to “answer questions from a whole life perspective,” defined as drawing upon their personal life, family life, or professional life to the extent that they felt comfortable, being reassured that they were not being asked to speak on behalf of an organization. This allowed us to analyze a parental dimension (and personal perspectives on parenting and the state) as a crosscutting factor, rather than excluding this from the operationalization of how moral questions would be answered within professional activities, the usual way of engaging policy elites.

Finally, to ensure authenticity (discussed further below) as well as to establish construct validity (the extent to which our vignettes operationalized key variables, such as liberty or efficiency, in the way we defined them from the theory), we sought pilot feedback to refine our draft vignettes in 2 rounds. We began with a review process by our advisory committee, composed of 4 individuals with professional expertise in marketing, public health ethics, work in federal government, and civil society advocacy, respectively. Next, we edited the vignettes based on feedback from pilot interviews with individuals from each of 4 targeted actor groups (n = 5), as well as with qualitative researchers and health practitioners with no direct professional experience working in this issue area, but related expertise (e.g., individuals working on tobacco control policy; n = 4).

The final set of vignettes were based on 4 central characters: (1) Mandy and her 6-year-old daughter, Olivia; (2) Peter and his 9-year-old son, Robert; (3) Mohammed, a principal at an inner-city elementary school; and (4) Mary, a public health nurse working with Patrick, a participant in her youth program.

The box at the top of the next page presents 2 of our vignettes: Mohammed, the school principal, and Mary, the public health nurse, a developmental vignette. Mohammed was also the specific vignette that we also tested in the deliberative dialogue and conference settings in addition to our informant interviews.

Sample Vignettes: Mohammed and Mary

Mohammed, a School Principal

Mohammed is a principal at an inner-city elementary school. The school is facing tough budget constraints and the School Board has asked all principals to think of creative ways to save money without compromising the quality of the education. Mohammed is considering an offer from a fast food company to build a school playground free of charge. The only stipulation is that they would require a permanent sign with their logo to be placed at one end of the playground. Mohammed is conflicted. On the one hand he feels that the playground would be beneficial to the students and will certainly save money. On the other hand, he is concerned that the required branding may negatively influence the attitudes and values of the students.

Mary, a Public Health Nurse

[Development #1] As a public health nurse, part of Mary’s job is to run a youth program for 13- and 14-year-old adolescents, which aims to promote healthy lifestyles. She is concerned because one of her favorite participants in the program, Patrick, is overweight. Although she is able to provide him with information on diet and nutrition, she worries that Patrick’s exposure to food advertisements has shaped his food preferences toward heavily advertised, nonnutritious foods. On the one hand, Mary thinks it is important for Patrick to learn how to make healthy choices for himself. On the other hand she feels that he needs a healthy diet now to avoid the risk of long term health consequences.

[Development #2] Like many kids his age Patrick has a Facebook account, and a cell phone. One day at the youth program, Mary noticed that most of Patrick’s Facebook status updates and texts to his friends were linked to an online social marketing campaign by a soft drink company. While she realizes that these new technologies are now a big part of life for young people, she is concerned that the advertising seems to be much more pervasive than she had originally thought.

THE DYNAMIC FUNCTION OF THE VIGNETTES

We observed that the vignettes fulfilled their role in focusing interview participants’ attention on ethical issues and moral conflicts within the public health policy debate, prompting participants to move fluidly between discussion of real and ideal worlds. For example, a few participants used the second person voice to highlight what appeared to be a blend of their own self-reflections on the parental role, ideal attributes for parents, and uncomfortable realities of the scenario presented, in the same breath.

One dollar you know to promote healthy living is invested actually compared to five thousand dollars to promote junk food so it’s really powerful . . . the [marketing] message and the campaigns, and so you have to be well equipped . . . as a parent you can’t pay any [money] . . . those kids don’t come with any instructions.

You want to do the very best [Laugh] for your child and have them you know fit in with all of the other kids in the daycare, or in the school, that are also watching television, and know about Sponge Bob, or know about Dora the Explorer, or whatever the hit is on TV. You don’t want them to be singled out.

We also observed that the narrative nature of the vignettes encouraged participants to blend different types of evidence to defend their moral reasoning, including referring to peer-reviewed research blended with references to professional or personal anecdotes and metaphors.

I’m a very evidence-based person. I’m like: what did the stats say? That’s what I base my decisions [on], on statistics, but as a parent would it change my behaviour, would I not let him watch the hockey game? No, I’d be more concerned about his being exposed to that crazy guy who wears the suits [referring to Don Cherry, a famous Canadian hockey color commentator]

We found that interviewees were particularly empathetic and sympathetic to certain types of vignette characters. “Oh, poor Mohammed,” or some variation thereof, was a phrase that we heard often. Yet we observed that familiar characters such as Mandy, a parent of a young child, and Mary, the public health nurse, produced responses that we did not predict. We found that these characters’ relatability—a relationship constructed between participant and vignette character—influenced vignette responses. For example, participants who were practicing health professionals were more critical of Mary as public health nurse than they were of Mohammed the school administrator, in terms of what constituted appropriate professional roles and responsibilities. This is an observation that could be tested systematically in future empirical work on vignettes with different professional groups.

I think it’s lovely that Mary gives a crap but at the same time unfortunately obesity and weight is extremely private and I’m not certain that it’s her role to really get in anybody’s face about what they are or aren’t eating.

Well, I think [Laugh] Mary needs to give her head a shake. She is worried that Patrick’s eating is the result of food advertising. While what’s she smoking? Come on actually let me tell you also that I think Mary is a big part of the problem. . . .

Overall, we found that the vignettes were very useful for establishing new types of discussion in this public health policy issue. They allowed individuals to engage in the policy issue in ways that were rooted in but also going beyond their usual speaking points. We found that the vignettes enabled a rapid building of rapport at the outset of an interview, even over the telephone. Several interviewees remarked that they were having “fun,” something that we did not expect given the intensity and even rancor that we had observed at public health conferences and meetings on this issue in our policy community.

RECOMMENDATIONS ON VIGNETTE DESIGN

Based on our experience, we recommend 5 key design features for using vignettes in public health policy work of this kind (see the box on the bottom of this page).

Key Design Features for Public Health Policy Vignettes

Authentic—rooted in real-world public health policy and practice experiences

Judicious detail—enough information to convey a sense of story and character but allows filling in of gaps

Factorial—identifies key concepts/variables to be examined; not purely open-ended

Developmental—the story (and dilemmas) become richer and more complex in successive steps

Reflexive—enables reflection on process of deliberation upon the vignette; probes can be used to determine fixity of responses

First, the vignettes need to be authentic.^21,22 As a tool in building trust with seasoned policy actors who are “media ready” and not necessarily inclined to sincerely express their underlying moral reasoning, our vignettes needed to be rooted in lived experiences of public health policy and practice. Miles has written about how vignettes are tools that permit a “snapshot, or perhaps a mini-movie, of a professional practitioner at work” in contrast to structured case studies.^32(p38) This could be seen as speaking to professional identity, where our legitimacy as applied researchers depended on our ability to represent professional knowledge and experiences in a realistic way. Yet authenticity also speaks to enabling reflexivity among policy actors, when their attention is called to embedded (often tacit) conflicts in meaning.^33–36 Interdisciplinary capacity on the research team, including health professional practice perspectives, and conscientious planning of pilot interviews were assets to be drawn upon to develop authentic vignettes.

Second, vignettes work best when they employ judicious detail. Here, we would situate vignettes in contrast to longer case studies as a deliberative tool. Vignettes offer enough information to convey a sense of story and character but permit participants to fill in gaps. In our study, we also saw that vignettes prompt “filling out,” or taking the bare bones of the story to expand the scenario and quandaries that should be considered at any moment. By contrast, we would suggest that case studies are usually intended to be more complete, supplying all of the relevant evidence required to process the questions at hand.^{37(pp186-187)}

Third, we think vignettes used for public health policy work should be factorial (i.e., deductively testing key variables or factors operationalized from the research questions). Even though vignettes allow for conceptual expansion and creative filling in and out, as we have described above, they are not purely open-ended. To increase their appeal to the pragmatic context in which public health policy and practice occurs, vignettes can be thought of as classic recipes, which present few detailed instructions, but situate key ingredients in reliable ratios as the basis for substantial elaboration and refinement. This allowed us to combine a deductive manipulation and layering in of key variables of interest along with an inductive approach that permitted cocreative contributions on the part of the interviewees, themselves expert in the issue area.

Fourth, we found it useful to incorporate the developmental vignette technique, where story elements are gradually revealed in stages rather than all at once. Because the policy actors we spoke to were well versed in the issue, having debated it in many forums, we were worried that they would be inclined to speed through without spending enough time immersed in the moral dilemmas we presented. Several times during our interviews, participants would begin predicting the next development in the vignette or predicting the inclusion of narrative building blocks that had not yet been discussed. For example, upon introducing Mohammed, our school principal, one participant remarked, “Oh this is the Coke machine in the school! I could feel it coming.” The developmental vignette technique was a way to slow down and hence focus the conversation when needed.

Fifth, and returning to the notion of authenticity, we believe that vignettes should be reflexive, where those writing or facilitating vignettes with participants are explicit about their intention to have respondents actively reflect on their envisioned ideals. This has the function of granting permission to policy actors to deviate from their usual script or to consider how the real and ideal considerations intersect and interact. In other words, vignettes have a particular quality that renders the fiction visible.⁷

LIMITATIONS OF VIGNETTES AND POTENTIAL SOLUTIONS

We identified a number of challenges and limitations, as well as potential methods for resolving them. The counterpoint to authenticity is plausibility, and our vignettes needed both piloting and successive rounds of refinement to create believable situations. If vignette scenarios and characters are depicted as too extreme, even if authentic for the interviewees’ experiences, they may detract from the core of the discussion. Conversely, if the scenarios are oversimplified, the complex nature of reality is lost.³⁰ The most frequently cited theoretical limitation of employing vignettes pertains to the gap between the constructed vignette and social reality—what people believe they would do in a given situation versus how they would behave in the real-world context.³⁸ We found that careful adjustments and testing for authenticity in crafting vignettes can produce what were able to observe: that interviewees moved comfortably between ideal and real-world discussion, drawing upon experiences that are important to them.³⁹ This is a rich space that is important to capture in qualitative policy work.

Social desirability bias in terms of moral reasoning, when research participants initially describe a socially acceptable way in which they would respond to a dilemma, which may be different than how they truly believe they would respond or behave, has also been identified as a problem with vignettes.³⁸ We felt, however, that this could be countered by effective probing on the part of the interviewer or facilitator. We also think that this apparent problem is why vignettes are especially interesting to use in policy elite interviews: elites are more secure in terms of power and social standing, which can allow for provocation and probing beyond the socially normative.^40,41

The principal challenge with vignette method is time. Good vignettes take time to construct and implement well. The richness of the qualitative data produced also requires a great deal of time for sensitive analysis and reflection on the part of researchers and facilitators. The richness of our own data exceeded our expectations, illustrating unforeseen patterns of relationships between variables for which we needed to rethink altogether the deliberative dialogue phase of our study. We addressed this “analytical overdose”² by referring frequently to how we originally defined the research questions and variables, which was another reason we found the factorial approach to be so effective.

In summary, information presented in the form of a vignette can never reproduce real life, but rather, represents it and encourages those who engage with vignettes to actively interpret it. Vignettes thus allow rich exploration of complex or conflict-embedded topics in public health policy in novel ways.