Health Promotion Practice: Power and Empowerment

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Glenn Laverack

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    List of Figures, Tables and Boxes

    Figures
    • 2.1 An analytical framework for the determinants of health 26
    • 4.1 Community empowerment as a continuum 48
    • 6.1 A planning framework for the accommodation of community empowerment into top-down health promotion programmes 76
    • 8.1 A new methodology for building and evaluating community empowerment 107
    • 9.1 The ‘spider web’ configuration 124
    • 10.1 The influence of the political context on community empowerment 129
    Tables
    • 2.1 Three different health explanatory systems 24
    • 5.1 The different characteristics of top-down and bottom-up health promotion approaches 59
    • 6.1 The operational domains 83
    • 8.1 Matrix configuration to improve leadership in Bemana Tikina Health Committee 111
    • 9.1 Matrix configuration for the Naloto Tikina Health Committee 123
    • 10.1 Basic rights and the political context 130
    Boxes
    • 1.1 Three faces of health promotion 5
    • 1.2 Key international health promotion declarations 10
    • 2.1 Experiences of health 17
    • 2.2 Health promotion and social justice: equality of opportunity or equality of outcome? 23
    • 2.3 Surplus powerlessness and women living in inner-city housing 29
    • 3.1 Power-from-within in Maori people 37
    • 3.2 Power transformation through health promotion practice 41
    • 4.1 The key characteristics of ‘community’ 46
    • 4.2 Organizing East African women on the issue of female genital mutilation 49
    • 4.3 The Seniors' Mobilization Project 51
    • 4.4 Community empowerment by the residents of Werribee 56
    • 5.1 The North Karelia Project: 20 years of success 62
    • 5.2 The Dalby-Wambo Health 2000 Project 65
    • 5.3 Organizational structures in a Guatemalan village 67
    • 5.4 Empowering women living in low-income housing 70
    • 6.1 Smoking behaviour in Latin American men 80
    • 7.1 The characteristics of participation in empowering programmes 88
    • 7.2 Community organization to reduce suicide in fanning communities 90
    • 7.3 The Bournville Community Development Project 92
    • 7.4 Empowerment education in a women's health programme 94
    • 7.5 The Asian women's swimming project 96
    • 7.6 The role of the outside agent in a health project 97
    • 7.7 Outside agents as ‘enablers’ 98
    • 7.8 The empowering characteristics of programme management 99

    Foreword

    Most of us know that our health is more than good medical care when we are sick, or healthy living to stave off disease. Our daily lives teach us that our health is enwrapped in our experiences of community – a word that means ‘the quality of sharing and caring’ – and in our powers of choice, what Nobel economist Amartya Sen1 calls our ‘capacity to live a life one has reason to value’. Research increasingly affirms that social justice (‘sharing’), social capital (‘caring’) and empowerment (‘the capacity of choice’) are key determinants of our health: as individuals, as communities, as societies. Power and the means to its attainment – empowerment – are what lies at the heart of this book.

    For almost 30 years, a small practice within many countries' health sector has been acting upon this knowledge. Health promotion – a return to the public health activism of earlier centuries – describes the efforts of educators, social workers, nurses, physicians and other trained professionals (some of them even trained as ‘health promoters’) to give weight to that metric-adjusted truism of a gram of prevention being worth a kilogram of cure. For almost 30 years, its practice also has had to grapple with the seeming opposites it straddles. Is health promotion about changing unhealthy lifestyles or unhealthy living conditions? Does it target individuals or attempt collective mobilization? Should it preach self-regulation ‘do this, don't do that’ or espouse empowerment (autonomy of choice)? Perhaps most importantly, does its practice strike the right balance between valued professional expertise and invaluable community wisdom? No-one working in the field is blind to these tensions. But rarely are these the foci of an introductory text.

    Not so with this book. Glenn Laverack, drawing upon his own experiences and a masterful summary of some of the important footsteps he encourages readers to follow, makes ‘power’ and its transformation the central theme of health promotion practice. Each of its transformative junctures is illustrated with case studies from practice. But there are two things that make this book a unique contribution. First is his synthesis of empowerment's major ‘domains’. Second is his elucidation of a framework for how health promoters can make empowerment goals a ‘parallel track’ that can begin to link health promotion's befuddling ‘top down’/‘bottom up’ opposites. The question is no longer whether health promoters should spend their time urging people to exercise more (unhealthy lifestyles), or organizing people around anti-poverty campaigns (unhealthy living conditions); depending on the context, either or both can be important health promoting priorities. The question, instead, is how can health promoters, regardless of the content of their programme work, plan it to facilitate desired changes in community empowerment's domains?

    Readers may not close this book's last page with a recipe for a social marketing campaign, group educational session, community mobilization strategy or any of the other techniques that fill up health promotion's toolbox. Texts on those there are aplenty. But what they will take away is the foundational idea that health promotion is not only an ‘evidence-based’ technical practice, but an activist commitment to social change; and a few beguilingly simple yet fundamentally transformative tools to help them translate that idea into action.

    Ronald Labonte Director, Saskatchewan Population Health and Evaluation Research Unit, Universities of Saskatchewan and Regina, Canada

    1Sen, A.(1999) Development as Freedom. New York: Knopf.

    Preface

    I call this book Health Promotion Practice: Power and Empowerment. What I mean by this title is that power, the ability to create or resist change, is an important foundation for individual and community health. It provides people with the capacities to change their lives and their living conditions. People experience power in many different ways and health promotion is one potential means by which this experience might be enhanced. This book is written, with an international context in mind, for persons who are, or are considering becoming, health promoters and who have the potential to enhance the power of others.

    Empowerment, the process by which people gain more power, is at the heart of the ‘new’ health promotion that has arisen since publication of the Ottawa Charter for Health Promotion in 1986. The Charter has helped to define this ‘new’ practice and states that ‘health promotion is a process of enabling people to increase control over, and to improve, their health’ (World Health Organisation, 1986). I call this ‘enabling’ practice ‘empowerment’ and its outcome ‘community empowerment’. At the same time individuals accrue more power; in fact, this is essential to the process but it is as a community, or group, phenomenon that I am most interested in empowerment in this book.

    For over a century, many governments, religious and non-governmental organizations have attempted to improve the power of relatively poor or marginalized groups. They called this ‘community development’ and although it was rarely undertaken for health purposes, it often had an indirect effect of making people healthier.

    Community empowerment as a concept rose in the 1980s and began to supplant the term ‘community development’. Its popularity fell in the 1990s, tarnished by overuse, misuse and poor definition, although it is the term I prefer to use in this book precisely because of the emphasis it places on ‘power’. Many practitioners and researchers now use the term ‘community capacity building’ to describe the same goals and practices of community development and community empowerment. All three terms (community development, empowerment and capacity) convey that there is something very important in the nature and quality of our day-to-day relationships ‘in community’: in our neighbourhoods, our workplaces, our leisure activities and through our friendships. These relationships, and the social conditions in which they exist, define who we are as people and play an important role in determining individual and community health. A community's success in making these conditions healthier is affected by its ability to mobilize resources, organize actions and participate in decision-making that shape the social and physical world in which it exists. An empowering approach to health promotion helps to improve these abilities. Detailing how health promotion might do this is the main theme of this book.

    This book comes from personal experiences as much as from an analysis of the literature. My intent is to share some of this experience, supported by the wider literature and my discussions over the past several years with many other health promoters.

    Acknowledgements

    I would like to acknowledge the many people with whom I have had the privilege of working and exchanging ideas in relation to this book. In particular I would like to thank Dr Ronald Labonte for his insightful contributions to the early draft. I would also like to thank Professor John Catford; Dr John Hubley; Professor La wry St Ledger; Dr Nina Wallerstein; Dr Kevin Brown; Dr Susan Rifkin and Dr Pat Pridmore. And to my family, Elizabeth, Ben, Holly and Rebecca for their continued support and patience during the course of writing this book.

    An Overview of the Book

    This book has three main purposes:

    • To introduce the readers to health promotion practice as a political activity, one that attempts to get at the underlying social determinants of disease.
    • To help the readers understand the importance of power relations, and their transformation in health promotion practice.
    • To introduce the readers to a new methodology for planning, implementing and evaluating empowering health promotion programmes.
    Chapter 1 Health Promotion in Context

    In Chapter 1 define and discuss two key concepts: health promotion and community empowerment in the context of political activism. I also identify practice tensions that underpin health promotion's efforts to be ‘empowering’.

    Chapter 2 Promoting Health: It All Depends on What We Mean by ‘Health’

    Health promotion is about improving people's lives and health. But what do e mean by ‘health’ and how do our interpretations influence the way we approach different health promotion strategies? Chapter 2 discusses three main discourses of health, provides a simple framework of health determinants and explains their implication for an empowering health promotion practice.

    Chapter 3 Power Transformation and Health Promotion Practice

    Chapter 3 moves the reader into the territory of power, a concept that is central to the ‘new’ health promotion. But what does power look like and how can health promoters act to transform unhealthy into healthy personal and social power relationships? Chapter 3 addresses these questions and this allows conclusions to be reached about power and empowerment within health promotion practice in a programme context.

    Chapter 4 Community Empowerment and Health Promotion Practice

    In Chapter 4 I continue the discussion of power transformation and discuss the concept of community empowerment and how it can be successfully applied to health promotion practice to provide a more empowering approach.

    Chapter 5 Addressing the Tensions in Health Promotion Programming

    Chapter 5 extends the discussion of power and empowerment into the territory of health promotion programming. One of the basic tensions in an empowering health promotion practice is between ‘top-down’ approaches (in which experts decide what is best for communities) and ‘bottom-up’ approaches (in which communities work with experts on issues they both believe are important). I argue that these two approaches, and the power ‘tensions’ that they create, are not, or at least do not have to be, mutually exclusive.

    Chapter 6 ‘Parallel-Tracking’ Community Empowerment into Health Promotion Programming

    All health promotion work involves ‘programmes’, but not all ways of planning, implementing and evaluating programmes are empowering. Chapter 6 identifies the key differences and presents a framework for the systematic accommodation of community empowerment (‘bottom-up’ approaches) into ‘top-down’ health promotion programming.

    Chapter 7 The Domains of Community Empowerment

    Chapter 7 defines and describes the nine operational domains of community empowerment: participation; leadership; organizational structures; problem assessment; resource mobilization; asking why; links with others; the role of outside agents; and programme management. These domains represent those aspects of the process of community empowerment that allow individuals and groups to organize and mobilize themselves toward social and political change, and they can be used to promote and evaluate this concept; discussed further in Chapters 8 and 9.

    Chapter 8 Building Community Empowerment Approaches in Health Promotion

    Chapter 8 provides two case study examples of empowering health promotion approaches that use the empowerment domains discussed in Chapter 7. A new methodology for building community empowerment is discussed and a case study of its successful implementation in Fiji is examined.

    Chapter 9 Evaluating Community Empowerment Approaches

    Chapter 9 addresses how we plan our health promotion programmes so that they will succeed in the evaluation of empowerment. These are important aspects of our work, not only for our employers (who need results to keep us employed), but also for our communities (is our work helpful to them?) and ourselves (how can we improve our efforts?). I discuss what to look for, and what evaluation methods to choose that are both rigorous and that fit with contemporary health promotion practice.

    Chapter 10 Implications for an Empowering Health Promotion Practice

    In the final chapter I discuss the broader implications and limitations for an empowering professional practice and examine the influence that the external context can place on practice, in particular the political, economic and socio-cultural contexts. I draw hope from the optimism that exists in health promotion practice, and examine how the organizational context in which health promotion practitioners work can provide more scope and opportunity to embrace empowerment.

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