Constituting good health citizenship through British Columbia's COVID-19 public updates.

The COVID-19 pandemic has augmented discourses of individual citizen responsibility for collective health. This article explores how British Columbia, Canada's widely praised COVID-19 communication participates in the development of neo-communitarian "active citizenship" governmentalities focused on the civic duty of voluntarily taking responsibility for the health of one's community. We do so by investigating how public health updates from BC's acclaimed Provincial Health Officer Dr. Bonnie Henry articulate this civic imperative through the rhetorical constitution of the "good covid citizen." Our rhetorical analysis shows how this pro-social communication interpellates citizens within a discourse of behavioral, epistemic, and ethical responsibilisation. The communal ethos constituted through this public health communication significantly increases the burden of personal responsibility for health beyond norms of self-care. Making the protection of community health primarily the responsibility of individual citizens also presumes a privileged identity of empowered, active agency and implicitly excludes citizens who lack the means to successfully fulfill the expectations of good covid citizenship.

Representations of clinical practice guidelines and health equity in healthcare literature: An integrative review.

AIM: This paper reports an integrative review of international health literature that discusses health equity in relation to clinical practice guidelines (CPGs). BACKGROUND: Healthcare professionals (HCPs), policy makers, and decision makers rely on sound empirical evidence to make fiscally responsible and appropriate decisions about the allocation of health resources and health service delivery. CPGs provide statements and recommendations that aim to standardize care with an implicit goal of achieving equity of care among diverse populations. Developers of CPGs must be careful not to exacerbate inequity when making recommendations. As such, it is important to determine how equity is discussed within the context of CPGs. DESIGN: This integrative review was conducted according to integrative review methods as outlined by Whittemore and Knafl (2005), and Toronto and Remington (2020). These authors outlined a systematic process for the identification of relevant literature across health disciplines to examine the state of knowledge pertaining to a phenomenon such as health equity. SEARCH METHODS: The computerized databases PubMed, CINAHL, Cochrane, Embase, Medline, and Web of Science were searched using a combination of keywords. Search parameters included international peer-reviewed published, full-text, English language articles, editorials, and reports over the last decade (January 2011 to February 2022). A reference search of included articles was conducted to identify any additional articles. Dissertations and theses were not included. SEARCH OUTCOME: A total of 139 peer-reviewed English language articles were identified. RESULTS: The findings of this review revealed five main ways in which health equity is in context of CPGs including if they target or exacerbate inequity among disadvantaged populations, equity and CPG development, implementation, and evaluation, and checklists and tools to assist developers and users of CPG to consider equity. Although critical appraisal tools exist to assist users of CPGs assess and to evaluate how well CPGs address issues of equity, the definition of equity and how CPG development panels should incorporate and articulate it remains unclear and haphazard. As such, recommendations intended to be implemented by HCPs to optimize health equity remains diverse and unclear. CONCLUSION: The way equity is discussed within the reviewed health literature has implications for their uptake by and utility for HCPs. The ability of HCPs to implement CPGs may be hindered without an appreciation and integration of equity considerations across the various phases of CPG conceptualization, development, implementation, and evaluation, and their relevance and appropriateness to diverse geographic and socioeconomic contexts with variable access to health human resources and services. This situation could be improved if equity were more clearly articulated within all aspects of the CPG process. CLINICAL RELEVANCE: Understanding how equity is discussed in the literature relative to CPGs has implications for their uptake by and utility for HCPs in their goal of providing equitable health care. Successful implementation of CPGs with consideration equity could be improved if equity were more clearly articulated within all aspects of the CPG process including conceptualization, development, implementation, and evaluation.

Public health promotion of "local food": Constituting the self-governing citizen-consumer.

This article explores how the recent and growing promotion of local foods by public health units in Ontario, Canada, rhetorically interpellates the "good" health citizen as someone who not only takes responsibility for personal health but, through the consumption and support of "local food," also accepts and fulfills her responsibilities to care for the local economy, the community's well-being, and the natural environment. Drawing on Charland's concept of constitutive rhetoric, we analyze a selection of public health unit documents about local food to develop a textured account of the complex, multifaceted forms of health citizenship they constitute. Our analysis reveals that, despite their appeals to environmental sustainability and community well-being, these materials primarily characterize the ideal health citizen as an informed consumer who supports the interests of the neoliberal state through individualized lifestyle behaviors, consuming goods produced and distributed through private enterprise. By exhorting individuals to "buy local," public health discourse therefore frames responsible health citizenship principally in consumerist terms that constrain the range of available options for citizens to engage in meaningful action vis-à-vis their food systems.

Rhetorics of health citizenship: exploring vernacular critiques of government's role in supporting healthy living.

This article explores how older adults negotiate and partially counter normative expectations of "health citizenship" that stress individual responsibility for maintaining health and preventing health problems. Based on interviews with 55 participants in Canada and the U.K. about what healthy living means to them in their everyday lives, we examine how the dominant discourse of personal responsibility in participants' responses is counterpointed by a more muted, yet significant, alternative critical perspective on the relative roles and responsibilities of government and citizens in making healthy living possible. Drawing on Hauser's (1999) concept of vernacular rhetoric along with recent theories of environmental citizenship, we analyze how participants exercise their civic-political judgment by using a logic of dissociation to argue that what government says about the importance of healthy living is incompatible with what government does to support citizens' abilities to eat healthily and live actively. By deploying this technique of argumentation to address structural-political-economic dimensions of healthy living, participants enact, in modest ways, an alternative, critical-collective mode of health citizenship that complicates and, at least partially, disrupts neoliberal constructions of the individually responsible, "good" health citizen.

Standards and stories: the interactional work of informed choice in Ontario midwifery care.

This paper uses a discourse-rhetorical approach to analyze how Ontario midwives and their clients interactionally accomplish the healthcare communicative process of "informed choice." Working with four excerpts from recorded visits between Ontario midwives and women, the analysis focuses on the discursive rendering during informed choice conversations of two contrasting kinds of evidence - professional standards and story-telling - related to potential interventions during labour. We draw on the concepts of discursive hybridity (Sarangi and Roberts 1999) and recontextualization (Linell 1998; Sarangi 1998) to trace the complex and creative ways in which the conversational participants reconstruct the meanings of these evidentiary sources to address their particular care contexts. This analysis shows how, though very different in their forms, both modes of evidence function as hybrid and flexible discursive resources that perform both instrumental and social-relational healthcare work.

The moralization of healthy living: Burke's rhetoric of rebirth and older adults' accounts of healthy eating.

This article develops a rhetorical analysis of how older adults in Canada and the UK engage with civic-moral imperatives of healthy living. The analysis draws on Burke's concepts of 'symbolic hierarchies' and the 'rhetoric of rebirth' to explore how participants discursively negotiate the moralizing framework of self-regulation and self-improvement central to healthy eating discourse, in particular. Working from the premise that healthy eating is a 'principle of perfection' that citizens are encouraged to strive to achieve, the article traces the vocabularies and logical distinctions of 'guilt', 'purification' and 'redemption' in participants' accounts of what healthy eating means to them. This analysis reveals some of the complex, situated and often strategic ways in which they rearticulate and reconfigure the normative imperatives of healthy eating in ways suited to their lived experience and their priorities for health and well-being in older age.

Informing health? Negotiating the logics of choice and care in everyday practices of 'healthy living'.

This paper reports on a qualitative study examining everyday practices of healthy living (HL). Forty-four semi-structured interviews were undertaken with Canadian and UK citizens, aged 45 - 70, in April-May 2010. The research sits within the now substantial literature concerned with how health information is mediated, both by people and technologies, and employed in the context of 'good' health citizenship. Throughout this work, notions of 'choice' and 'empowerment' have been interrogated, theoretically and empirically, to reveal both the knowledge/power relationships integral to 'informing' processes and the shifting relationship between information and care in contemporary health encounters. In this paper, we analyse how people make sense of what it means to live healthily and how they know if they are doing so by focussing on three ways in which study participants become informed about healthy living: through their engagement with universal HL messages, through their own information searches, and through their attempts to measure their 'healthiness'. Following Mol's (2008) critique of the "logic of choice" in contemporary healthcare, we understand healthy living as a "situation of choice" where complex problems are framed as simple matters of choice and where information and technologies are understood as neutral aids to decision-making in support of 'correct' choices. Our analysis builds on and extends Mol's work by exploring how participants negotiate between this "logic of choice" and her alternative "logic of care" in their accounts of everyday HL informing practices and how the two logics "interfere" with one another. These accounts show resistance to the logic of choice through 'calls for care' but they also show clearly how the disciplining logic of choice works to (re)present such calls for care as failed attempts at healthy living, undermining the very practices the logic of choice seeks to encourage.

Negotiating public and professional interests: a rhetorical analysis of the debate concerning the regulation of midwifery in Ontario, Canada.

This article investigates the uneasy process of integrating midwifery's alternative, women-centered model of childbirth care within the medically-dominated healthcare system in Canada. It analyses the impure processes of rhetorical identification and differentiation that characterized the debate about how to regulate midwifery in Ontario by examining a selection of submissions from diverse health care groups with vested interest in the debate's outcome. In divergent ways, these groups strategically appeal to the value of the "public interest" in order to advance professional concerns. The study considers the implications of this rhetorical process for re-defining midwifery's distinctive professional identity in relation to other health professions, to the state, and to the women for whom midwives care. Likewise, it suggests the relevance of rhetorical analysis for understanding the discursive formation and re-formation of health models, values, and professions in Western culture.