Ambiguous Facilitation: An Ethnographic Study of the Contextual Aspects of Participation in Group Activities in a Norwegian Healthy Life Centre

Round 1

Reviewer 1 Report

This is a clearly written manuscript that has the potential to make an innovative contribution to the literature on health promotion practice. In particular, the observational research in Norway offers a window into the tensions in implementing health-promoting services within Healthy Life Centres. I especially appreciated the descriptions of the physical context and commend the authors on accomplishing extensive ethnographic observations and clearly describing the structure of the programs. I have a number of comments which I hope the authors will consider to further strengthen the manuscript.

1.     The paper illustrates a particular facet of health promotion practice in Norway. In some respects, the services described also resemble therapeutic interventions insofar as they include ‘individual counselling’ and tailoring to individual needs. The authors have not really addressed the ways that these services depart from community-based health promotion principles. It isn’t clear from the manuscript whether this is characteristic of broader health promotion practice in Norway. However, an international readership may expect the authors to demonstrate an awareness of the way these programs do and don’t fit with the principles of health promotion. The authors may find it helpful to draw on the following references for insight into health promotion practitioners’ perspectives from another context:

Carter, S. M. (2014). Health promotion: an ethical analysis. Health Promotion Journal of Australia, 25(1), 19-24.

Carter, S. M., Klinner, C., Kerridge, I., Rychetnik, L., Li, V., & Fry, D. (2012). The ethical commitments of health promotion practitioners: an empirical study from New South Wales, Australia. Public Health Ethics, 5(2), 128-139.

2.     The concept of ‘ambiguous facilitation’ is central to the argument developed in the manuscript. However, the implications of this concept for broader health promotion practice are not clearly articulated. The themes of the special issue are equity, empowerment and inclusiveness and it could be helpful to better connect the central themes and arguments developed around participation to these pillars of health promotion. It may be worth considering the implications of the ‘ambiguous facilitation’ concept in terms of the responsibility it places on HPs for making these programs ‘work’. In some ways, I suspect that there is something inherently problematic in the model of the programs themselves in that they are possibly not fit for purpose (if the purpose is to achieve equity and inclusiveness).

3.     Ethnographic methodology – great care has been taken to explain what the ethnographer did and how they wrote reflective fieldnotes. Yet little detail is given on the background of the ethnographer or the other authors and the reader is not able to learn how these reflections or personal experiences of the ethnographer intersected with the analysis. In ethnography, observations are usually supplemented with conversations with some of the participants to enable the participant observer to clarify their understanding and better grasp the perspectives of the participants. Even though the authors describe the unit of analysis as the interactions between service users and HP, as part of the methods it would be good for the authors to describe how the participant observer interacted with participants and what they learned from these interactions. Were they regarded differently by HPs or service users? Did they develop relationships with any of the HPs during the many hours of observing their programs? Most importantly, how did these interactions shape the analysis and the learnings?

4.     Data Analysis, p5 – I found this section to be overly detailed and largely unnecessary. The overemphasis on the coding process of the analysis stands in stark contrast to the absence of detail on the ethnographic analysis that happened as part of the participant observation (addressed in point 3 above). Moreover, I did not find this detailed description of coding to assist with understanding how the analysis actually took place. I found Table 2 to be difficult to decipher as a reader and would prefer the space be devoted to more detail regarding the participant observer interactions. If the authors wish to provide an overview of the analysis, it may be more useful to synthesise the quotes and themes as a summary of the findings.  

5.     p6, line 217 – possible typo, “aim” should be “aims”

6.     p7, line 221-223 – I found this sentence confusing and wasn’t sure what the authors were saying.

7.     Given that the objective of HLCs is to recruit people from socioeconomically disadvantaged groups, it would be helpful to have a sense of whether there were clear socioeconomic disparities between HPs and service-users. Were the HPs unable to identify with the service users and their challenges because they came from different social strata?

8.     p13, lines 529-532 – the authors imply that these health promotion programs ought to be able to cater to individuals with complex needs and suggest that future research should investigate possible “cream skimming” in HLCs. I wondered whether this study and others might more usefully examine the strategies that HPs engage in to try and deal with the complex needs of individuals. A wonderful example of this is provided on p8, lines 273-276 where an HP discusses how she tries to choose exercises to illustrate rather than explain. What other ways to HPs try to accommodate their programs to the complex needs? It seems that there would be more productive learning from this avenue of analysis rather than focusing only on the “cream skimming” aspects.

9.     p14-15 – I felt that there was something a bit contradictory about the authors’ arguments about time schedules. On the one hand, they point out the negative impact of tight time schedules on dialogue and collective reflection processes and other aspects of the programs. On the other hand, they also assert that the findings from this study highlight that unpredictable/flexible timeframes act as a barrier to participation. The paradoxical nature of these findings has not been addressed by the authors. It is important that these contradictory points are drawn out further in terms of their implications to avoid misinterpretation. There may be risks involved in reducing flexibility and these are not fully addressed when labelling this as a barrier.

10.  It may be helpful to define salutogenesis early on in the paper.

Author Response

Thank you for the kind and constructive feedback on our manuscript. We have gone through them and will upload a file with point by point response to each comment. We hope this will strengthen the manuscript. 

Author Response File: Author Response.pdf

Reviewer 2 Report

This a very good article. Well constructed and clear. Congratulations to the authors.

1. What is the main question addressed by the research?

The article has great interest since it analyses HLC from an anthropological (ethnographic) perspective. The analysis of HLCs is an extremely interesting research topic. The study adequately shows the paradoxes or ambiguities of this type of center. In fact, it analyses the phenomenon of paternalism and also what the authors call “ambiguous facilitation”.

2. Do you consider the topic original or relevant in the field? Does it
address a specific gap in the field?

The paper is innovative and fits, appropriately, to qualitative research on the ethnographic character. The authors enter a hybrid environment between the health and social domains. The study of HLCs is of great interest because of the social possibilities it offers. I am not only referring to Norway, but also to the possibility of taking this type of center as a model to be implemented in other regions. In this sense, this research is of great interest as it tries to show all the complexity that we find in them.

3. What does it add to the subject area compared with other published
material?

The paper is adequately adjusted to a study of an ethnographic and sociological nature. The authors show their perspective on departure and the results obtained are clarified very well. I think it is a great contribution to social studies and to understanding the paradoxes and social difficulties that we encounter. The analysis of the HLCs is really exhaustive and allows us to understand the participatory processes.

4. What specific improvements should the authors consider regarding the
methodology? What further controls should be considered?

The methodology is well structured and carried out. Some authors might consider that it is necessary to add more subjective information from the researchers. Others, including myself, consider that not. That's why I think the work is impeccable.

5. Are the conclusions consistent with the evidence and arguments
presented and do they address the main question posed?

The conclusions are enough. I admit that I would have liked them to be more extensive, but this is an opinion and, therefore, it is scientifically questionable.

6. Are the references appropriate?

Very good bibliographic work.

Author Response

Thank you for your kind and encouraging feedback on our work, and interesting perspectives on the topic under study. As you do not ask for any specific changes, we have discussed your feedback together with the comments and questions from reviewer 1 and revised the manuscript from that part of departure. We really appreciate your review and upload a file where we go through you comments point by point. 

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The authors have thoughtfully addressed the review comments and the additions have clarified both the central concept of the paper and the significance of the results. Well done.

There are two minor typos in the new additions:

1. p2 Line 59: focus should be focuses

2. p15 Line 689: counteract should be counteracted