Table 2.

Vignettes of Experiences With Reflexivity From Three Health Promotion Practitioners and Researchers

1 (NB)	Before doing a master’s degree in community health, I worked as a nurse in a local health organization. Even though the organization’s mandate included health promotion, it was particularly difficult for professionals to integrate health promotion into their practice, given that the daily schedule was overloaded with individual appointments. Reflecting back on this situation, I realized that we were working in an environment where the organizational culture was mostly focused on providing clinical care, and that the supply of health services were more reactive, defined by demand, without necessarily anticipating the population’s needs. I also realized that professionals had little understanding of the importance of acting on the social determinants of health. After becoming a professional in a regional public health department, I continued to reflect on the conditions that would support the integration of health promotion into the practices of my former colleagues in local health organizations. The triggering event that allowed me to think about a concrete solution for this problem was a meeting with the executive director of a community primary care center, who wondered whether there was a real possibility to support health promotion practice in his organization. I realized then that challenges for integrating health promotion into the health system were more organizational, requiring the implementation of a different structure of training that would, apart from enhancing the health professionals’ competencies, also modify organizational conditions of practice. I started reading about practice change processes, professional development, adult education/learning, and reflexivity. Through my reading, it became clear to me that to achieve this shift in practice, we would need to create a space for collective reflection allowing professionals to question their practices and their organizational environment, to better understand health promotion and how to implement health promotion practice. Prompted by this, I developed a professional development program, the Health Promotion Laboratory, targeting public health professionals from local health and social services centers. This professional development project aims to support multidisciplinary teams of local centers in planning new health promotion interventions, building on a collaborative learning, participatory and reflective approach. Throughout the Health Promotion Laboratory processes, teams are encouraged to revisit their individual and preventive care practices from a health promotion perspective and a social determinants of health angle. For instance, a team from the education sector, whose members have long focused on the individual management of school dropout, has now collectively developed (with community partners) an intervention to foster student retention at school.
2 (MHR)	As part of my PhD research I conducted ethnographic fieldwork with health promoters in the City of Copenhagen (see, e.g., Rod, 2015). Among other things, I followed the implementation of a program that sought to involve parents of teenagers in preventing (or at least postponing) the onset of alcohol use. One of the aims of the fieldwork was to tease out the moral and ethical dimensions of alcohol prevention and, at several occasions, I engaged in discussions with health promoters in order to stimulate reflexivity about these issues. During these discussions I presented a framework for reflexivity concerning the ideas and assumptions underlying professional practices. The basic idea was that specific health promotion policies and interventions are bound to answer the question “How should one live?” in particular ways that are rarely made transparent and explicit. Inspired by Lakoff and Collier (2004), I asked health promoters to consider three dimensions of this question: (i) The “how”: i.e. reflexivity concerning the specific techniques that are used to promote health and induce change in people’s lives. (ii) The “should”: i.e. teasing out implicit norms and values. And (iii) The “one”: i.e. addressing the implicit assumptions about the target group. The discussions showed that the health promoters did not always agree about basic underlying ideas and premises of their work. Thus, the value of the framework (and perhaps of reflexivity more generally) was not to enable consistent interpretations and clear conclusions, but rather to highlight inherent ambiguities in health promotion practice. E.g., the alcohol prevention program promoted the idea that parents should adopt a restrictive stance towards the alcohol use of all children below the age of 16 and should refrain from entering into negotiations on this issue. In contrast, some health promoters had adopted a more open and flexible stance towards the alcohol use of their own children, because they felt that it was more important to nurture trust and to take stock of the individual child’s maturity level. At a more general level, this example highlights a potential contradiction between the generalized advice and knowledge claims that are made in health promotion programs and the situated nature of personal relations with which such programs interfere.
3 (MW)	A team of researchers developed an approach to promote reflexive practice in health promotion and prevention in Germany called Participatory Quality Development (PQD) [PQD Handbook http://www.pq-hiv.de/en]. At the core of PQD is the critical reflection on the power dynamics in developing and implementing interventions, specifically advocating for the participation of community members and non-professional actors. We conduct various activities, such as workshops, to promote a culture of reflexivity among communities of practice. In one workshop, a social worker described a drop-in neighborhood center for mothers with young children located in a poorer district in a large German city. The center’s purpose was to strengthen the bond between new mothers and their children, and thus prevent later involvement of child protection or family services. This included addressing several well-being and health related topics. Very few mothers were using the center, so the staff began to reflect on why. They decided to work with a university to conduct a qualitative study of the mothers to understand their needs. The study revealed several issues, particularly the need to be relieved periodically of childcare responsibilities. The social worker described how she and her colleagues struggled with this issue, as their mandate from the local authority was to promote the mother-child bonding. In the workshop, we critically examined the assumptions behind the center, particularly the focus on bonding, implying that the mothers were deficient in this area. A service was proposed without first finding out what the mothers needed; they were objects of an intervention and not partners in promoting health. The problem and the solution were formulated based on expert knowledge, excluding lived experience. During the discussion, the social worker became irritated, saying that her organization was not certified to provide childcare, and that they would need more staff and possibly different facilities. She then suggested that they could potentially justify the additional service if, during childcare, the mothers would agree to participate in childrearing training. The other workshop participants—who were predominantly women, many of whom also mothers—questioned the reasoning of the social worker. They argued that the need to be relieved of childcare responsibilities is common among mothers. Whereas, middle class mothers can use well-resourced networks of other parents; mothers in poorer neighborhoods tend to be in networks whose members are overburdened with their own lives. Also, middle class mothers are not seen categorically as having deficits, unlike the mothers in the district under question. Instead of working with the mothers to problem-solve about childcare issues to give them more free time, the social worker assumed that she needed to provide another service, reinforcing the client role of the mothers. The reflexive dialogue at the workshop resulted in the participants becoming aware of how the logic of service provision can objectify “target groups,” preventing them from being seen as competent partners and real-life experts in the development of services.