Empowerment in Health Promotion.

[Maurice Mittelmark]

I have two copies Torill....

[Pius.Attandoh]

It is indeed challenging for (empowered) communities outside of the policy-making cycle to significantly influence health policies unless they are able to win over key elements within the policy making group.I will give an example:about 4years ago, British America Tobacco( with their usual cunning advertising tactic) opted to give a facelift to a very huge shopping mall in the Accra (Ghana) city centre,and later flagrantly splashed on it the logo of one of their cigarette brands.All efforts by some (empowered) community activists to have the painting effaced yielded no result. The difference was when the then Director-General of the Health Service (an empowered community person with an influence on policy)joined the campaign, which in no time culminated in the building getting re painted.
The point is this:that community empowerment alone may not be sufficient to impact health policies,unless we are able to coopt persons that potentially wield the influence on policies.In other words we need the 'empowered of the empowered' to lead health promtion changes.

Is community empowerment a wothwhile strategy in HP programmes?
EG. The evidence that community based actions actually do influence health policy is weak- rather than just having a localised (NIMBY) effect.

The use of petitions, lobbying and even demonstrations have a diluted effect. Communities need to be able to access the internal process of policy making -which is difficult to do. The best that they can hope for is to raise the profile of an issue to such an extent that someone in a position of influence will act as the 'champion' for their cause. Why should HPs bother trying to mobilise communities if the level of influence that they can have is minimal - if any at all?

Any comments?

[glenn.laverack]

Pius, you are correct. Local leadership or local champions are crucial to community empowerment. In fact this is one domain of 9 that have been identified as having an influence on this process. What this means is that HPs can now more systematically plan, implement and measure community empowerment within a programme context. This approach has been used in several countries, inlcuding in Africa.

Having lived and worked in Ghana for 5 years I can understand the relevance of your example and this raises another important issue - that of context. Some contexts (socio, political, economic, colonial etc) promote CE whilst others suppress it. Both can act as a catalyst for community based action towards community empowerment (social and political change). However, the context may change between countries and within a country. So when planning for community empowerment/equity we must take this into consideration.

Examples of both these issues (domains and contexts) in regard to community empowerment are provided in:

Laverack, G. (2004) Health Promotion Practice: Power & Empowerment. London. SAGE Publications.

Glenn.

[ksrini]

Thanks for the opportunity.
I would like to respond the following questions.

• What is empowerment?
• Why is community empowerment crucial to the future success of health promotion programming?
• What other concepts overlap with and are relevant to empowerment and health promotion?

Empowerment
Empowerment is not what the policy maker's perspective on empowerment. It is very contextual. To empower communities decentralization is always advocated. In India three tier structure was created for decentralization. This is called Panchayati Raj Institutions. If we look at the local administration, all these Institutions are now represented by political parties which are either of national characteristics or of regional identity. These are not the real representation of the community. When an election of these institutions conducted, the real need of the community are masked by the Parties and their agenda is projected. Some issues are not a priority for the community.

Why is community empowerment crucial to the future success of health promotion programming?

As per Ottawa charter, Health Promotion is “the process of enabling people to increase control over their health and its determinants, and thereby improve their health.”

Community empowerment will help in the members of the community to recognize the health needs, and identifying the social determinants of health. However, it does not mean the kind of empowerment I mentioned in the earlier paragraphs. Empowering the community members means making members aware of their power on what they actually need and not making them to accept what policy makers suggest. Or involving the community in policy making. The challenge is the process of involvement in policy making. The empowerment also will help them to identify the social determinants which are affecting their help. For an example, in Reproductive Health, the literacy level of women plays a vital role. It is important to empower the women to identify and recognize the link between them. Similarly, community members will have to be empowered to raise their voice for the basic amenities such as drinking water, sanitation and so on for their wellbeing. This will help them achieve their health goals. So, the Health Promotion should focus on empowering community members for achieving health of the community.

[andre-anne]

I find the last definition interesting but I wonder... When you work with community members, making them aware of the social determinants of health and so on, do you actually empower the members or the community itself? Can we use the same strategies in both cases? Is poilicy making a way to empower a community or only the people affected by the policy? Participation is obviously important but can we limit our action with those who participate ou do we, as health promoters, have an obligation to go beyond the people who participate? How can our action also empower the people who do not participate in the community? I am wondering because what I actually see is alot of action around the official structures (concertation tables, neighborhood committees, etc.) but not alot of work done with the most marginal people who could benefit such an action...
Thanks for giving the opportunity to share my questions,
André-Anne

[Marie-Claude.Jean]

Hi,

So far, I find the conversation very interesting. I would like to add some things to our thinking. Participation is a key concept of great importance in most definitions of empowerment. However, there seems to be little information on the intensity and duration of participation needed to really have a process of empowerment. In addition, the evaluation of the contributions of an empowerment intervention generally take place on a short period of time and target very specific elements. I wonder if those aspects (complexity of the process and the measurement difficulties) dilute the positive effects of empowerment interventions and minimize the effectiveness of these interventions? Intuitively, we tend to believe in the effectiveness of empowerment, but there is little evidence in the literature to support this idea (as least at the collective level). In your opinion, why is this so?

Marie-Claude

[rorev1]

Hi
I found an article that contains a critical view about the empowerment that I want to share. Like health promotion, empowerment is the subject of two approaches, an individual and social. through the social approach is seen from the power structures in society and the individual is achieved mainly with the transfer of knowledge to individuals.
I enclose the abstract and the reference in Cadernos de Saude Publica, a popular Brazilian:
Santos Ferreira, M.; Castiel, Luis David "Which empowerment, which Health Promotion? Conceptual convergences and divergences in preventive health practices" in Cad. Saúde Pública v.25 n.1 Rio de Janeiro enero 2009

ABSTRACT

Based on the multiple meanings, "empowerment" can be identified with either conservative or critical Health Promotion approaches. From a conservative approach, the concept is viewed as an essentially individual phenomenon, centered on the provision of information and the external transfer of power in the name of the collective good. From this approach, the relationship between "psychological" and "community" empowerment is not considered. From a critical approach, the concept is viewed as a relational phenomenon that manifests itself in the dialectic conflict of interests between individuals, groups, and social classes. From this approach, "psychological" and "community" empowerment are seen as micro and macro levels of analysis, and social transformations are the result of simultaneous changes at these levels. The use of the notion of empowerment without critical reflection or political analysis of power relations in society disseminates vague, romantic, and homogeneous views of "community". Therefore, to assume the relational nature of empowerment means to accept its interdependence with the notion of participation, without which there can be no social transformation. Thus, one should be vigilant about multiple meanings that empowerment can given in Health Promotion discourse.

Roman Restrepo-villa

[hamid]

I would like to comment on some interesting thoughts from André-Anne and Marie-Claude

do you actually empower the members or the community itself? Can we use the same strategies in both cases? André-Anne

I will say it depends on your objectives. However, the community is not a homogeneous entity in term of needs, socio- economic characteristics, gender, age and ethnic background. If you want to implement an efficient strategy you need to breakdown the community in subgroups. For instance, you will not have the same strategy if you want to empower white males living in wealthy area or black females living in deprived area.

I am wondering because what I actually see is a lot of action around the official structures (concertation tables, neighborhood committees, etc.) but not a lot of work done with the most marginal people who could benefit such an action... André-Anne

Empowering marginalised individual or groups is a difficult task. We are speaking about asylum seekers, immigrants, children, women in some country, disable … For example, children’s health is influenced and shaped to a large extend, by parents and society (Policy, school, peers and other organisations) and also by other social determinants. Can we really speak of empowerment for an individual who is not considered yet, by part of the society, as autonomous? In theory, empowering children is in a way giving them some autonomy towards their health, choices. In practice, how ready are we, as parents, educator or health professional to let the children make their own choices? And how do the current structures allow them to influence policies (local, regional or national) towards their health? What are their “powers”?

I wonder if those aspects (complexity of the process and the measurement difficulties) dilute the positive effects of empowerment interventions and minimize the effectiveness of these interventions? Marie-Claude

Measuring empowerment will bring us back to what is empowerment. Are we really speaking of empowerment when “normal” citizen are only allowed/able to influence minor decisions? What about the important decisions that will affect in a dramatic way their health? Do you measure empowerment according to the number of “normal” citizen involved in committees or the level of influence they can have on decision. I am asking this question because often consulting the community is seen as a way of empowering them. It is only a step, as the next steps should be community led projects.

Hamid

[LindaDavey]

How fascinating. I feel rather like an alien entering a parallel universe. I hope the inhabitants are friendly towards outsiders. I have stumbled upon this forum, having just spent an entire semester in a different on-line forum discussing and trying to understand the concept of empowerment. The forum I was involved with comprised a group of students studying health promotion as part of the Masters of Nursing course at UTS in Sydney, Australia.

This is all rather fascinating to me, I have been in Nursing for 6 years and previously in business and spent most of my youth in Advertising and marketing. So I came to the topic of health promotion with many pre-conceptions of what health promotion was, derived mainly from the perspective of this background. The word "promotion" had certain connotations from many years in advertising; while the word "health" was strictly influenced from my recent life experience as a nurse in an acute hospital setting.

Empowerment just didn't enter the scope of my understanding until the last few months. I have read "Health Promotion Practice Power & Empowerment" thank you Mr Laverack for the perspective - and most of the other papers listed in reference to this forum.

I found most interesting opinion derived within the forum in which I previously participated was the number of postings that found that government legislation to promote health was acceptable to the majority of the population. I would have thought there would have been more concern with paternalism and "big brother" politics.

I think you'll find this quotation from one member of the other forum interesting "One cannot hide the fact that health promoters have become powerful in terms of handing down health opportunities to people and is a significant force in minimizing the injustice of politics".

Linda

[sobara]

Hi Hamid
I'm an independent researcher in Public Health and also often translate for various HP agencies, incl. IUHPE. At present, I'm supposed to provide English and French equivalents for German literature and links on various aspects of HP practice. For 'empowerment', I have simply taken your suggested reading list. Are you ok with that? Any suggestions for French?
And thanks for keeping the forum, it's great.
Barbara