Public Health: Power, Empowerment and Professional Practice

Public Health Power, Empowerment and Professional Practice

Glenn Laverack

Public Health

Also by Glenn Laverack HEALTH PROMOTION PRACTICE: Power and Empowerment

Public Health Power, Empowerment and Professional Practice Glenn Laverack

© Glenn Laverack 2005 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First published in 2005 by PALGRAVE MACMILLAN Houndmills, Basingstoke, Hampshire RG21 6XS and 175 Fifth Avenue, New York, N.Y. 10010 Companies and representatives throughout the world. PALGRAVE MACMILLAN is the global academic imprint of the Palgrave Macmillan division of St. Martin’s Press, LLC and of Palgrave Macmillan Ltd. Macmillan® is a registered trademark in the United States, United Kingdom and other countries. Palgrave is a registered trademark in the European Union and other countries. ISBN-13: 978–1–4039–4560–0 paperback ISBN-10: 1–4039–4560–8 paperback This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. A catalogue record for this book is available from the British Library. A catalog record for this book is available from the Library of Congress. 10 9 8 7 6 5 4 3 2 1 14 13 12 11 10 09 08 07 06 05 Printed in China.

Contents List of tables, figures and boxes

viii

Acknowledgements

x

Preface

xi

An overview of the book

xiii

1 Power and public health practice An empowering approach to public health practice Helping individuals to gain power Helping groups and communities to gain power Public health programming ‘Parallel-tracking’ empowerment in public health programming

1 1 4 5 7 10

2 Public health in context Public health Practitioners and their clients Power and public health practice in bureaucratic settings Professional versus lay interpretations of health Empowerment and public health discourse Public health and social movement theory

14 14 15 17 21 23

3 Power and empowerment What is power? Power-from-within Power-over Hegemonic power Power-with Zero-sum and non-zero-sum forms of power What is powerlessness? What is the means to attaining power? Cultural and contextual interpretations of power and empowerment

27 27 28 29 30 30 31 33 35 36

4 Helping individuals to gain power Practitioners as more effective communicators One-to-one communication Learning to listen Combining communication channels Increasing the critical self-awareness of clients Mapping positions of power Ranking complex issues

40 40 41 43 45 47 47 48

v

vi · Contents Strategies for decision making Developing a strategic plan for decision making Fostering an empowering professional–client relationship The power of language

49 50 52 53

5 Helping groups and communities to gain power What is a ‘community’? Community empowerment as a 5-point continuum The ‘domains’ of community empowerment A framework for helping groups and communities to gain power Empowering individuals for action Empowering groups Empowering groups for the development of community organisations Empowering community organisations to develop partnerships Empowering communities to take social and political action

57 57 58 60 63 64 66

6 Helping marginalised groups to gain power Introduction A case study of helping marginalised groups to gain power The public health context An approach to promote health and empowerment Strengthening community empowerment Building healthy public policy and creating a supportive environment Dealing with conflict

75 75 77 78 78 79

7 The measurement and visual representation of empowerment Developing a working definition of power and empowerment Collecting and analysing qualitative information Collecting and analysing qualitative information in a cross-cultural context The measurement of empowerment Visual representations of community empowerment The interpretation and visual representation of community empowerment 8 Power, empowerment and professional practice Introduction Addressing the constraints in public health practice Building a better understanding of the meaning of power and empowerment Addressing the bureaucratic constraints Using an empowering approach to public health programming

69 72 73

82 85

89 89 89 94 97 102 103 110 110 112 113 113 115

Contents · vii Using measurement to empower others Understanding the means to empower individual clients, groups and communities The practical application of the ideas in the book

116 117 118

References

120

Index

126

List of tables, figures and boxes 䊏 Tables 4.1 4.2 4.3 5.1 5.2 5.3

Communication skills checklist The decision-making matrix Empowering and non-empowering professional language The overlap of empowering concepts The empowerment domains Role of the Practitioner to strengthen the process of empowerment 7.1 The ranking for each generic empowerment descriptor

44 52 56 61 62 63 99

䊏 Figures 1.1 4.1 5.1 6.1 7.1 7.2 7.3 7.4 7.5 7.6

Parallel-tracking public health programming Combining communication channels Combining the empowerment continuum and empowerment ‘domains’ Applying the parallel-track approach Developing a working definition for community empowerment Facilitator role types Spider web for Naloto Spider web for Nasikawa Spider web for Orto Spider web for Kyzil Oi community

9 46 59 84 91 96 104 105 107 108

䊏 Boxes 1.1 1.2 2.1 2.2 3.1 3.2

Helping Individuals to Gain Power in Canada Helping Groups to Gain Power in Canada The Origins of the WHO Definition of ‘Health’ Social Movement Theory and Partnerships in Brazil Experiencing Powerlessness Surplus Powerlessness and Women Living in Inner-city Housing in Canada 4.1 Developing Individual Skills in Canada 4.2 The GATHER Approach to One-to-one Communication 4.3 Learning to Listen

viii

5 6 19 25 33 34 42 42 43

List of tables, figures and boxes · ix 4.4 4.5 4.6 4.7 4.8 5.1 5.2 5.3 5.4 5.5 6.1 6.2 6.3 7.1

Guidelines for Using Teaching Aids Mapping Positions of Power Individual Expressions of Health Public Health Practitioners as ‘Enablers’ for Empowerment Language and the Professional–Client Relationship The Key Characteristics of ‘Community’ The Characteristics of Participation in Empowering Others Participation and Personal Action in Australia Problem Identification through Community Stories Resource Mobilisation and Empowerment in South Asia Defining Minority Groups Positions of Power and Conflict Defining the Issues of Conflict Developing a Working Definition for Empowerment in Fiji

45 48 49 53 55 58 65 65 68 71 76 86 87 90

Acknowledgements I would like to acknowledge the many people with whom I have had the privilege of working and exchanging ideas during the course of writing this book. In particular I would like to thank Dr Yvonne Birks, Dr Rachel Dixey, Andrew Chetley, Bill Hardy and Jane Arnaud. To Andrew Jones, a friend who knew the secret to surviving unequal worlds. And to my family, Elizabeth, Ben, Holly and Rebecca for their love and support.

x

Preface This book has been written as a practical guide for public health professionals who want to help their clients to gain power. Public health always entails some power differential and in this book this is described in regard to the relationship between Practitioners and their clients. I have used the term ‘Practitioners’ to describe the range of public health professionals, who in their everyday work, have an opportunity to help to empower individuals, groups and communities. I have used the term ‘clients’ to describe the range of people who act as the recipients of the information, resources and services that are delivered by the Practitioners to promote their health. To exercise choice is the simplest form of power. To the extent that our personal choices can constrain those of others, power becomes an exercise of control. People with the ability to control decisions at the political and economic levels, for example, condition and constrain the ability of people to exercise choice at the individual and group levels. People have power-over others and are constrained and influenced by those that have power-over themselves and this can result in inequalities in people’s lives, including their health. To better understand how power can be exercised in a positive manner, by sharing it with others in a professional context, this book discusses the ways in which Practitioners can help individual clients, groups and communities to gain more control over the influences on their lives and health. Empowerment, the means to attaining power, is a process of capacity building with the goal of bringing about social and political change in favour of the individuals, groups and communities seeking more control. Macro-level changes have been achieved through community action, for example, nuclear disarmament and the ‘Solidarity movement’ and in this book I discuss the relationship between public health, social movement theory and empowerment. However to only view empowerment as a means of mass emancipation is to miss the majority of empowering activities that occur on a day-to-day basis. And it is through these activities that Practitioners can become involved with concerned individuals, residents and community-based groups to help them to gain power to address such micro-level public health issues as anti-social behaviour and poor housing. Even so, the struggle of socially excluded groups is sometimes not included in mainstream public health programming. It is a paradox of empowerment approaches that the most marginalised populations are often unable to articulate their needs, are not represented or are unaware of opportunities and, as a result, do not have the opportunity to voice their concerns. In this book I discuss the implications of an empowering public health practice and how Practitioners can better help marginalised groups to gain power. It is the Practitioners who have an understanding of the means to attaining power that will be better placed to help those clients who wish to achieve empowerment.

xi

xii · Preface The book builds on my earlier work and in particular on the publication entitled Health Promotion Practice: Power & Empowerment. The book has also been written to meet the demand from many Practitioners who want to work with their clients in a more empowering way. The book draws on international experiences of empowerment and uses a broad range of practical exercises and case study examples to illustrate how Practitioners can work with other people to help them to gain power. Most of all, the book draws on my own personal experience, supported by research and the wider literature, and with discussions over many years, and in many different contexts, with other Practitioners. GLENN LAVERACK Auckland, New Zealand

An overview of the book This book has three main purposes: 1

To provide the reader with an understanding of the concepts of power and empowerment. 2 To introduce the reader to practical approaches for helping individuals, groups and communities to gain power. 3 To provide the reader with a means to measure and visually represent empowerment.

䊏 Chapter 1 Power and public health practice Chapter 1 introduces the reader to the idea of how Public Health Practitioners can act in their everyday work to transform power relationships at the individual, group and community levels. This includes a discussion of the tensions that exist in public health programming and the introduction of a methodology for ‘parallel-tracking’ empowerment such that ‘top-down’ and ‘bottom-up’ approaches do not have to be mutually exclusive.

䊏 Chapter 2 Public health in context Chapter 2 provides an introduction as to how our professional interpretation of public health is also a function of our understanding of the concept of health. The different roles of the Public Health Practitioner and the sometimes problematic relationship that they have with their clients are discussed. Chapter 2 also introduces the reader to the influence of bureaucratic settings, in which most Public Health Practitioners work, on professional practice. Finally, the evolution of the discourse of empowerment in public health and the influence that social movement theory has had on professional practice are discussed.

䊏 Chapter 3 Power and empowerment Chapter 3 defines and discusses, in a practical sense, the key concept of power and the means to attaining power and empowerment. Chapter 3 moves the reader into the territory of how power and empowerment are central to public health practice. The purpose is to make these complex concepts, and the way in which they interact, more understandable to Public Health Practitioners.

xiii

xiv · An overview of the book

䊏 Chapter 4 Helping individuals to gain power Chapter 4 addresses how Public Health Practitioners can better work with individuals to help them to gain power, and in particular, by becoming better communicators, by increasing the critical self-awareness of their clients and by fostering an empowering working relationship. Chapter 4 also discusses the power of professional language and how this can influence the professional–client relationship.

䊏 Chapter 5 Helping groups and communities to gain power

Chapter 5 addresses those aspects of empowerment that enhance the ability of groups and communities to better organise and mobilise themselves towards gaining power. Chapter 5 introduces a new methodology that combines the continuum and the nine ‘domains’ of empowerment and that will help Practitioners to empower groups and communities.

䊏 Chapter 6 Helping marginalised groups to gain power Chapter 6 takes the discussion further to examine how Practitioners can help marginalised groups to gain power. In particular, Chapter 6 provides a case study example of how indigenous communities can be helped to gain power and to improve their health. The approach uses a framework that combines the principles of the Ottawa Charter for Health Promotion and the nine ‘empowerment domains’.

䊏 Chapter 7 The measurement and visual representation of empowerment

Chapter 7 discusses the importance of, and provides the means to develop a working definition of empowerment in different cultural contexts. The measurement of the empowerment of individuals, groups and communities and the visual representation of this information is then discussed.

䊏 Chapter 8 Power, empowerment and professional practice The final chapter brings together the central themes of power and empowerment and discusses the main conclusions as a number of questions in regard to public health practice. Chapter 8 also discusses the major constraints that must be addressed in order to help clients to gain power and for the public health profession to embrace a more empowering practice.

Chapter 1

Power and public health practice Public health is an approach that aims to promote health, prevent disease, treat illnesses, prolong valued life, care for the infirm and to provide health services. Traditionally, such goals of public health have been used to curb the spread of infectious diseases and to protect the well-being of the general population whilst others see a much greater role in regulation and reducing inequalities in health (Baggott, 2000). Such a broad range of goals also means that the term ‘public health’ is used to cover a number of specialist areas including water supply and sanitation, environmental health, nursing and health promotion. Not surprisingly, public health remains a contested and contradictory term given the wide range of competing perspectives, priorities and services that it claims to deliver. The different interests within public health help to shape what it looks like and the directions it takes as a professional practice by competing for limited resources, the control over decisions and the development of national policies. Public health also involves ‘communities’ and incorporates methods that connect collective action to the broader aims of political influence. Power and empowerment are therefore key concepts to a public health practice that seeks to redress inequalities in health and to change the determinants of health through collective and community-based action. In practice, public health still belongs primarily to people employed in the health sector, in the sense that it provides these workers with some conceptual models, professional legitimacy and resources. These people may be titled ‘public health promoters’ or ‘health communicators’ while many more who look to the idea of public health occupy jobs such as health visitors, doctors and environmental health officers. In this book, I refer to all these people as the ‘Practitioners’. Their ‘clients’ cover the range of people with whom they work including the homeless, youth, middle-aged men and other professionals. These definitions are also discussed in Chapter 2. The term ‘stakeholders’ is used to mean both Practitioners and their clients who have some interest in promoting their own, or the health of others.

䊏 An empowering approach to public health practice In public health today there exists a contradiction between professional discourse and practice: many Practitioners continue to exert power-over their clients

1

2 · Public health through ‘top-down’ programming and controlling working practices whilst at the same time using an emancipatory ideology and discourse. The term ‘discourse’ is used here to describe an interrelated system of statements around commonly understood meanings and values resulting from social factors and the interplay of power relations, rather than an individual’s own ideas or beliefs. The term discourse also implies the political and strategic role of words to form sentences and meanings and is therefore better placed to use rather than the terms language or rhetoric. Whilst not wishing to devalue the skills, knowledge, trust and expertise that many Practitioners hold or to erode their professional autonomy and status, I argue that this contradiction continues because often 1

2 3

Practitioners have a superficial understanding of the meaning of power and how the relationships between different stakeholders are understood and appropriately acted upon by the profession; Practitioners lack clarity about the influences on the process of community empowerment; The shift in public health discourse towards empowerment has not been accompanied by a corresponding clarification of how to make this concept operational.

Plainly put, many Practitioners do not have a clear understanding of how the empowerment of individuals, groups and communities can be practically accommodated within public health practice. However, the situation is more complicated than this and to simply blame the Practitioners would be to underestimate the important role that they can have in empowering their clients. One of the main tensions that Practitioners face in an empowering approach to public health practice is whether their clients actually want to be empowered. Public health practice is traditionally professionally led, for example, it is the Practitioners or their agency that chooses the clients to be empowered and the methods to be used to empower them. The initiation of the empowerment process and the enthusiasm for its direction and progress is often led by the Practitioner. This is contradictory to an empowering approach in which the issue to be addressed and the means of reaching an empowered solution are the responsibility of the client(s) and not an outside agent such as the Practitioner. Some clients may not want to be empowered. People, especially if they have lived in oppressive or powerless circumstances, may feel that they do not have the right or do not possess the motivation to empower themselves. Kieffer (1984, p. 16) provides an example of the individual experience of powerlessness by Sharon, a Native American living in Harlem: ‘It would never have occurred to me to have expressed an opinion on anything … It was inconceivable that my opinion had any value … that’s lower than powerlessness … You don’t even know the word “power” exists.’ Some clients may not want the responsibility of making important decisions and to avoid the regret of making a misjudgement may wish to ‘delegate’ this type of authority to a health professional in whom they have trust

Power and public health practice · 3 and who they perceive as having the ‘expert power’, for example, the immunisation of their child. Some individuals and groups, for example, the mentally ill and the young, may not have the ability to organise and mobilise themselves towards empowerment. Do people have a right not to be empowered? What must be remembered is that power cannot be given to people but must be gained or seized by themselves. The right or choice essentially rests with the individual and the role of the Practitioners is to encourage their clients to take greater responsibility and control over their lives. For those people who cannot or who refuse to take responsibility then public health practice may have to intervene and resort to other means, for example, policy and legislation, to ensure the well-being of the general population. In this book I argue that Practitioners can and often do play an important role in facilitating change in their clients, either on a one-to-one basis or through working with groups and communities. Practitioners can take a lead in the process of empowerment that places an emphasis on their clients gaining opportunities for self-help and greater control of their lives. Practitioners, who are in a position of relative power, work to help their clients, who are in a relatively powerless position, to gain more control. For example, by allocating control over resources, by providing skills development, education and advisory services, using their professional influence to legitimise community concerns and by pushing (advocating, lobbying) for statutory change. To achieve this Practitioners must work with other professionals and agencies, both public and private and in many other sectors, such as education, housing and social services, if they are to develop effective strategies. Public health is also a product of a global market and strategies must increasingly cross national as well as organisational boundaries. Practitioners must be flexible in their approach to working with clients whose abilities and competencies may have to be developed, for example, during a public health programme. The Practitioner may initially not involve consultation with clients and the programme staff may undertake the responsibility of planning. The main reason for this is usually to ensure that interventions are in place in time for reporting deadlines. Participation is compromised and clients are involved by simply attending meetings. Susan Rifkin (1990, p. 19) describes a public health programme in Hong Kong which wanted to improve health and health care among the urban refugee community. The aim was to have the community maintain its own health care and the local hospital decided that this could be best achieved by improving service delivery. The hospital set up three community clinics and a health insurance scheme in the refugee area but without consulting the community about its own needs and health concerns. The result was that the community initially saw the programme as being the responsibility of the hospital bureaucracy without a role for themselves. However these same people can later become involved in a much more meaningful way by taking a greater role in the decisions related to the management of the programme. The role of the Practitioner shifts to being an ‘enabler’, and gaining the trust of and establishing common ground with the clients is crucial to this process. The Practitioner can use ‘tools’ such as the spider web configuration (discussed

4 · Public health in Chapter 7) to help promote transparency so that everyone in the programme can establish what was done, by whom and at what cost ( Jones and Laverack, 2003). Whilst Practitioners cannot be expected to have an influence on transforming power relationships across all sectors and at all levels of their everyday work there are two areas of importance in which they do have a role: 1

2

Practitioners are involved in influencing policies and practices that affect health, from national ‘down’ to the community level, for example, through their ‘expert’ power in meetings, technical advisory groups and committees. In order to influence policy and practice, Practitioners need to have a better understanding of the meaning of power and how their relationships with different clients are understood and appropriately acted upon by the profession. This is explained in Chapter 3. In most democratic countries, the process of collective action is used to influence social and political changes through public, economic and regulatory policies. These changes are achieved through the legitimate action of individuals who use their power (decision making) for example, to vote. Practitioners, involved in their day-to-day work with individuals and groups, can help their clients to use their power-over decisions to have a greater influence over factors that influence their lives, including their health. This involves their participation in organisations and ‘communities’ that share their interests. To be more empowering in their work Practitioners need to have a clear understanding about the influence that they can have on the process of community empowerment when working with individuals and groups and this is discussed in Chapters 4, 5 and 6.

In practice, an empowering approach to public health involves helping individuals, and the groups and communities in which people participate, to gain power. It also means helping individuals to increase their control over the decisions which influence their lives and their participation in groups and organisations that share their concerns. Participation in interest groups and organisations is the first step for many individuals towards collective action. The Practitioner then has the opportunity to help the individuals to increase their skills and competencies through working with these groups and organisations.

䊏 Helping individuals to gain power Gaining a greater sense of self-confidence is an important step towards individuals becoming more involved with others who share their concerns in interest groups and organisations. This is important because, by participating, individuals can become more critically aware of the issues concerning how they can gain more power. The Practitioner can help individuals by giving advice, connecting them with others in, for example, self-help groups and by sharing his/her power with clients in a way that involves the provision of both services and resources. An example of a how a Practitioner helped individuals to gain more power is

Power and public health practice · 5 Box 1.1 Helping Individuals to Gain Power in Canada Ronald Labonte (1998), discusses female residents of a rooming house in Toronto, Canada. The women complained of men demanding sexual favours in exchange for letting individual women gaining access to the bathroom. The women requested assistance from the community nurse (the Practitioner) to use her authority and professional status to lend credibility to their complaints. The nurse agreed. She also advised the women to form a group and secured a commitment that, after her initial assistance, they would have to collectively pursue the issue with the appropriate authorities themselves, and she would mentor them on how to do so. In this way, the nurse strengthened the power-from-within of the individual women, first by using her power-over (status, authority) and then by supporting them to act collectively as their own advocates. But in laying down her power-over condition (‘I’ll do this, but only if you’ll learn how to do it yourselves’) she exercised her power with the intent of increasing the power-from-within of the others (the women) in the relationship. This is the hallmark of the transformative use of power, the intent with which it is exercised.

provided by Ronald Labonte (1998), a veteran community development practitioner, in Box 1.1. In Chapter 4, I describe three approaches and a number of practical exercises that can be effectively used in public health practice to help individual clients to gain power: 1

Becoming a more effective communicator. This approach includes using communication strategies in both one-to-one and group settings to increase knowledge and to develop skills. On an individual basis this involves the Practitioner developing better verbal and non-verbal communication skills such as listening, helping people to talk, giving advice and obtaining feedback; 2 Increasing the critical self-awareness of their clients. This approach includes helping individuals to be able to reflect on the underlying causes, such as the economic, political and social, of their poor state of health and powerlessness. It is a process of learning through discussion and self-reflection; and 3 Fostering an empowering professional–client relationship. This approach describes a process of relationships in which power-over is used by the Practitioner to increase the client’s own power-from-within. The concept of power-from-within is explained in Chapter 3.

䊏 Helping groups and communities to gain power In this book, the term ‘community’ comprises heterogeneous individuals involving themselves in groups that share common needs and interests. Community

6 · Public health empowerment, the means by which groups of individuals can attain power, is a dynamic process that allows the members of a ‘community’ to better organise and mobilise themselves for social and political action. This process can be enhanced by the Practitioner in helping ‘communities’ to develop stronger organisational structures, broader networks and to have more active participation within and between other interest groups. An example of how a Practitioner helped groups to gain power is provided by Ronald Labonte (1998) in Box 1.2. Two notable approaches have been designed to address how communities can empower themselves. The first approach, developed over a decade ago, uses a 5-point continuum to conceptualise the process as it develops: (1) Personal action; (2) The development of small mutual groups; (3) Community organisations; (4) Partnerships; and (5) Social and political action ( Jackson et al., 1989). Each of the five points on the continuum is necessary for community empowerment, and yet each is insufficient in itself. The continuum offers a useful interpretation of how Practitioners can build more empowered and capable communities, in a programme context. For example, at the first point (personal action) the

Box 1.2 Helping Groups to Gain Power in Canada Ronald Labonte (1998) discusses a fatal fire in a rooming house that led to renewed efforts by community service agencies to mobilise roomers around housing issues and tenants rights. Early community organising efforts, intent on creating tenants’ unions and possible rent strikes, had failed. Roomers felt that their own concerns were not being respected in the rush towards social action and felt anger towards their landlords. At the same time, Public Health Nurses were welcomed for the one-to-one personal care they offered. For many of the male roomers, the idea of groups was intimidating and a reminder of forced groups in psychiatric institutions and prisons. However, some roomers decided that a community kitchen would be a good idea. Staples and food were provided by a local service agency and church. As time passed, trust developed between the Public Health Nurses and the male roomers. This increase in trust allowed the Public Health Nurses to provide individual counselling and to offer short educational programs on health-related topics. This led to a dramatic personal growth in some of the men, who developed good social, organisational and leadership skills. In one nurse’s own words, ‘We cannot expect people to do this “social action” process just because we can see a need for social change. They may see the need themselves, or simply wish for life to be better. But to expect them to work through a complex organizing process for major social change is grossly unfair and inappropriate. We can support the individual and group building work. We can help people build some small base amongst themselves, and support them in going as far along an empowerment process as they are willing and able to go.’

Power and public health practice · 7 Practitioner helps individuals to increase their self-esteem and to become more critically aware eventually linking with groups that share their concerns. As small mutual groups and community organisations are built around the programme issue (or other topic of concern to the participants), key capacities that can be enhanced by the Practitioners are skills in problem assessment, greater participation in programme activities and the development of local leadership. As participants progress into forming partnerships, their abilities to mobilise internal and external resources for their work, ensuring the democratic accountability of their own community organisations and creating effective links with other groups, become more central. The second approach, developed more recently, uses nine ‘domains’ to strengthen the process of community empowerment within a programme context (Laverack, 2001): ● ● ● ● ● ● ● ● ●

Participation; Problem assessment capacities; Local leadership; Organisational structures; Resource mobilisation; Links to other organisations and people; Ability to ‘ask why’; Control over programme management; and An equitable relationship with outside agents.

A domain is a significant area of influence on the process of community empowerment and together they represent those aspects that allow individuals and groups to better organise and mobilise themselves towards social and political action. Chapter 5 discusses a new framework that combines these two approaches to help to strengthen the process of empowerment.

䊏 Public health programming In practice, public health is most commonly implemented as activities set within the context of an intervention, a project or a programme. In this book, I have used the term ‘programme’ to refer to all these situations. The programme cycle is conventionally managed and monitored by the Practitioner and commonly includes: a period of identification; design; appraisal; approval; implementation; management and evaluation. Ideally, the initial ideas that emerge from discussions with the clients are developed into a form that makes sense to all stakeholders and are reflected in the design of the programme. These and other considerations are often documented in a Memorandum of Understanding or as a logical framework that outlines the objectives, inputs and outputs for the programme. The logical framework system was developed in the late 1960s and its adaptation has spread to many agencies for the purposes of programme design, monitoring and evaluation (Cracknell, 1996). The basic design of the logical framework system is a simple 4 ⫻ 3 matrix. Down the left-hand side are listed the wider and immediate

8 · Public health objects of the programme, and the outputs and inputs needed to achieve them. Across the top are three columns headed indicators of progress, how these indicators are to be quantified or assessed and the risks and assumptions involved. The basic concepts underlying the logical framework system are the clear statement of objectives, identifying in advance suitable indicators of progress and the prior assessment of risks and assumptions towards the success of the programme. The strengths of using the logical framework system are that its design has validity, having already been widely employed as a ‘tool’ for programme management and evaluation. The logical framework also provides a simple and systematic approach to strategic planning. The design of the methodology will, therefore, have a better chance of being understood and utilised by all the programme stakeholders. The major weakness of utilising a logical framework system is that it is ethnocentric. The approach is a Westernised model and yet it is often superimposed upon non-Westernised cultural contexts. The logical framework system has also been criticised for the inflexible nature of its design that does not allow changes to evolve with the programme, and the necessity to ensure that findings at the policy level are fed back into the system. The way in which public health ‘problems’ are to be addressed and are defined in a programme is one of the most important issues in programming and can take two main forms: ‘top-down’ and ‘bottom-up’. ‘Top-down’ describes programmes where problem identification comes from the top structures in the system down to the community, while ‘bottom-up’ is the reverse, where the community identifies its own problems and communicates these to the top structures. I intentionally use these two terms in this book because they help to illustrate the power relationship that exists in public health programming: The outside agent (the Practitioner) who uses the power-over to push down a predefined agenda onto the community. Top-down and bottom-up approaches are ideal types of best practice that demonstrate the important differences in relation to programme design. These differences can be distinguished by whether ● ●

●

●

●

The programme has a fixed timeframe or is flexible and long-term; It is the outside agent or the community who identifies the objectives to be addressed; It is the outside agent or the community who has control over the implementation and management of the programme; The type of terminology used to describe the programme is top-down or bottom-up; and The evaluation is concerned with targets and outcomes and is carried out by the outside agent or is concerned with capacity building and processes that actively involve the community. (Laverack and Labonte, 2000)

The two types of programming are often viewed as having different agendas that create a bottom-up versus top-down ‘tension’. However, public health programmes do not have to be viewed as a top-down versus bottom-up situation because practice often moves between the two approaches. Public health programmes are not usually designed with the aim of building community empowerment. At best, community empowerment is seen as a lower

Power and public health practice · 9 level objective and the main aim of the programme may typically be centred on improving health or preventing disease. The challenge to the Practitioner is how to accommodate community empowerment (bottom-up) approaches within topdown programming. To achieve this the process of community empowerment can be better viewed as a ‘parallel track’ running alongside the main ‘programme or public health track’. The tensions between the two, rather than being conventionally viewed as a top-down versus bottom-up situation, occur at each stage of the programme cycle, making their resolution much easier. This helps to move our thinking on from a simple bottom-up/top-down dichotomy and to formalise bottom-up community empowerment objectives and processes within more conventional top-down public health programmes (see Figure 1.1).

Programme Design Phase: Identification; Appraisal; Approval

Public health track

Empowerment track

2. Programme objectives Empowerment objectives How are the programme objectives and empowerment objectives accommodated to gether within the programme?

Objectives

Strategic approach

3. Strategic approach How does the strategic approach of the programme link and strengthen the strategic approach for empowerment?

Strategy

Manage

5. Evaluation of the programme outcomes How is the programme evaluation appropriate for community empowerment?

Individual empowerment – small groups – organisations – networks – social and political action

Empowerment domains

4. Strategic implementation and management How does the implementation of the programme achieve positive and planned changes in the operational domains?

Level of control and choice over health and life decisions

Planned and positive changes in the operational domains: Participation, organisational structures, links with others, resource mobilisation, leadership, outside agents, programme management, asking why, problem assessment

Evaluation of empowerment outcomes Evaluate

Participatory evaluation techniques used for community empowerment

Figure 1.1 Parallel-tracking public health programming (Laverack and Labonte, 2000, p. 257)

10 · Public health

䊏 ‘Parallel-tracking’ empowerment in public health programming

䊐 The design phase The first opportunity where the ‘top-down’ and ‘bottom-up’ tension can begin to be resolved is in the design phase of the programme which can be made more empowering by using strategic and participatory planning approaches. Such approaches allow the involvement of the participants and help to resolve conflicts that may arise later during implementation and management. It is at the design phase that the power relationship is established between the outside agents, the Practitioners or their agency, and the other stakeholders of the programme, in particular, the intended beneficiaries. Top-down programming is a manifestation of power-over, in which the Practitioner exercises control of financial and other material resources over the beneficiaries of the programme. It is a form of dominance and authority in which control is exerted through the design, implementation and evaluation of the programme. One assumption of top-down approaches is that power can be given to the community simply through education, resource allocation or ‘expert’ assistance from outside. Whilst these are important elements in an empowering public health practice, they can also create a dependency on the Practitioner. The important issue is: Who has the power-over (access to resources, technical expertise and political influence) on the implementation and management of the programme? ‘Parallel-tracking’ empowerment in public health programming assumes a more precise role for the Practitioner to help the clients to gain power. The Practitioner must first allow his/her clients to define the issues to be addressed and then through their own actions to resolve these issues. To achieve this within a programme context the issues to be addressed are identified in the design phase. The Practitioners assist their clients to gain better access to resources, technical expertise and political influence. The programming issue at stake is how the public health track and the empowerment track become linked during the progressive stages of the programme cycle. Through ‘parallel-tracking’ financial, material, human and knowledge resources can be made available to the community, at their request, through the design of the programme. The concept of the programme itself changes and becomes essentially a vehicle through which community empowerment is gradually built as a process. The time necessary to move from a relatively powerless to a more empowered position involves building competencies that can typically take five years at the individual level and, for a community, up to seven years or longer (Raeburn, 1993). Therefore, a long time frame is necessary in programmes using empowerment approaches. Too short a programme time frame runs the real risk of initiating community-level changes, only to end before such changes have reached some degree of sustainability within the community. Community empowerment

Power and public health practice · 11 approaches can be slow and difficult and may inevitably lead to external resistance between the powerless and those in authority and to internal conflict between different members. The design of programmes with an empowerment ‘track’ should therefore include strategies of dealing with conflict (discussed in Chapter 6). The design must also take into consideration the low level of skills and technical knowledge that the community may have at the beginning of the programme. The empowerment process should therefore start with realistic community issues which are achievable and that can produce visible successes in the short term to sustain interest and promote the progression onto more complex initiatives (Laverack, 2004).

䊐 Setting programme objectives Objective setting within conventional top-down programming is usually centred around disease prevention, a reduction in morbidity and mortality and lifestyle management such as a change in specific health-related behaviours. The issue is how to give empowerment objectives equal priority with disease prevention objectives. Whilst the specific nature of the programme objectives will vary according to its purpose, they should also be reflected in the empowerment ‘track’. The Practitioner must first ascertain from the participants what are their needs and concerns. This information is then used to set the empowerment objectives. The Practitioner must also help the participants to be able to analyse the activities and decisions that will be necessary to achieve the objectives. This includes the identification of achievable and measurable targets. Empowerment objectives need to be flexible as they are likely to change as the experiences of the programme participants also change over time. For example, broad health-related concerns that might be expressed initially by groups such as high unemployment in a given locality, may change as the group engages in activities towards this long-term goal. This can be facilitated by the Practitioner through strategies such as dialogue and problem analysis to assist the group to narrow its focus towards more immediate and resolvable issues, for example, increasing child care facilities for working mothers.

䊐 Developing the strategic approach It is important that the strategic approach that is used by the programme should also strengthen community empowerment. Chapter 5 specifically discusses strategies for how community empowerment, as a dynamic process, can be strengthened along a 5(-)point continuum and through each of nine ‘domains’. Positive changes or improvements in each of the domains represent a more empowered, or capable, community, one that is better able, for example, to exercise control over the determinants of its health. The role of the Practitioner is to contribute towards this process, partly by attending to the dynamics that underpin the different

12 · Public health points along the continuum, and partly by ensuring that the strategies they use directly strengthen community empowerment.

䊐 Programme management and implementation The programme management process is traditionally concerned with planning, organising, leading and controlling the utilisation of resources, both human and material, to achieve its objectives (O’Connor and Parker, 1995). The person who controls, or has power-over, this process determines the direction and the chance of success in achieving the objectives. In more general terms, management is concerned with effectiveness, the extent to which objectives are achieved, and efficiency, the way in which the objectives are achieved as compared to other means (Ewles and Simnett, 2003). Management is not only concerned with achieving tasks but also involves the people, personalities and politics of a programme. The role of the Practitioner is to be sympathetic to stakeholder ownership and involvement, and to help make the management process an empowering experience for the participants. This can be achieved by encouraging participants to take on greater responsibility for programme management, for example, activities like reporting, budgeting and the procurement of resources. In order to have the confidence to undertake these responsibilities the participants may require generic skills training in writing, interpersonal communication, research and public presentation. However, critical management skills are also very important and include developing self-awareness, managing stress and conflict, creative problem solving, delegation and decision making and conducting effective group meetings. Jan Smithies and Georgina Webster (1998, p. 94) provide a case study example of community involvement in managing the Hutson Street Health Project in Bradford, England. The Project covered a deprived inner-city area and was established to work on community health through a number of interconnecting ways, such as establishing networks and group activities. An evaluation of the Project found that community involvement was promoted through ‘word of mouth’ rather than through official channels. Community confidence was built up through small group activities such as cooking and exercise classes, a credit union and playgroup for children. The Project was steered by the expressed needs and involvement of the community, facilitated by the sympathetic role of the Practitioner, and this allowed the community to develop its own action plans and activities for implementation as well as being involved in the day-to-day running of the project. The evaluation of the Project also showed that it had a strong positive affect on the confidence of the community members who felt that this in turn had a positive influence on their health. In order to build the capacity and confidence of their clients it is necessary that they are initially involved in short-term tasks that are realistic and achievable. To do this, the Practitioner can ask the participants to set ambitious short-term performance goals, for example, the establishment of self-directed teams to achieve specific tasks and activities. This is important because short-term successes can help

Power and public health practice · 13 to motivate people towards the achievement of long-term objectives. The progress should be periodically reviewed with the participants to reflect on the success and failures. For example, how quickly are tasks achieved when set against their own time frame? What further support do they need or what changes to work practices can they adopt? The practices that do work should be built into the management and implementation of the programme (O’Connor and Parker, 1995).

䊐 Evaluation of the programme The final stage of ‘parallel-tracking’ is the evaluation of both the programme and the empowerment outcomes. Community empowerment can be a long and slow process and as an outcome it may not occur until many years after the programme time frame has been completed. Thus, evaluation of community empowerment within a programme context can more appropriately assess changes in the process rather than in any particular outcome. In effect, the achievement of each point of the process becomes an outcome. Success is better judged in terms of how the participants, through a self-assessment, experienced an improvement at each point on the continuum, using for example, the nine ‘domains’, discussed in Chapter 5. The measurement and visual interpretation of empowerment is discussed in Chapter 7. In Chapter 2 I discuss how our professional interpretation of public health is also a function of our understanding of the concept of health. Chapter 2 also discusses the influence of bureaucratic settings in public health and the importance of social movement theory in the development of professional discourse.

Chapter 2

Public health in context 䊏 Public health Practitioners and their clients As a profession, public health is largely controlled by government departments, agencies or government-funded Non-Governmental Organizations (NGOs). These people are employed as ‘professionals’ to engage in programmes designed to improve or maintain the health of individuals, groups and communities. Professional groups within public health are expected to display a specialisation of knowledge, technical competence, social responsibility and service to their clients. Their level of professionalism is attained through education, specialised training, the testing of competence by formal examinations, the membership of a professional organisation and the inclusion of a professional code of practice (Turner, 1995). Public health always entails some power relationship between different stakeholders, primarily between Practitioners and their clients. Practitioners are employed to deliver information, resources and services and are often seen as an outside agent to the people who are their clients. The Practitioner can be an individual, such as a Public Health Nurse or an organisation, for example, a health department, health trust or NGO. Their clients cover the range of people who act as the recipients of the information, resources and services being delivered to promote health, for example, pregnant women, school children, the unemployed and concerned groups of individuals such as residents or organisations who have been formed to address a specific health issue. One role of the Practitioner has traditionally been as an enforcer of public health legislation, for example, the Environmental Health Officer or ‘Sanitary Policeman’. The role has been supported by much of the work of environmental health departments that are concerned with inspection, licensing, complaint investigations and legal proceedings. An enforcement of the wide range of public health, public protection and food safety legislation by Practitioners has been seen to be necessary to maintain a healthy and safe environment in the home, at work and during recreation. The role of the public health enforcer has helped to establish the image of some Practitioners as that of professionals with power-over their clients through the use of legislative controls. Another role of the Practitioner has been concerned with education, training and specialist services such as diagnosis, for example, as that of a nurse providing a talk to community groups and of a doctor providing advice and treatment to their patients. This role has helped to broaden the image of the Practitioner as a health professional with ‘expert’ power (see Chapter 3) and access to superior technical resources, skills and knowledge.

14

Public health in context · 15 There is a further role of the Practitioners, one that has developed more recently and that is complementary to their roles as enforcers, educators and specialists. It is an important role that has been largely overlooked because many Practitioners have only a superficial understanding of how their day-to-day practice can be empowering for their clients. At the heart of this role is the ability of the Practitioners to transform their own power-over (access to information, resources and expertise) to a power-with relationship in which their clients are helped to gain more power-from-within. The outcome is that individuals, groups and communities are helped to gain greater control over decision making and the access to available resources in regard to public health issues.

䊏 Power and public health practice in bureaucratic settings The public health profession provides a network of Practitioners that dispense ‘expert’ advice and services largely through bureaucratic settings. A bureaucratic setting consists of a number of distinctive positions of control or power with specialist duties that are usually formally defined. The officials who hold these positions of power are recruited according to specific rules and their employment is usually based on a system of salaries. Power is hierarchically top-down and the official is expected to act in accordance with, and without challenging, the instructions descending from their superiors. Examples of public health bureaucratic settings include government departments and hospitals. Positioning oneself within the hierarchy of a bureaucratic setting provides a professional legitimacy and status. This is achieved not necessarily because that person has particular expertise but because the institutionalisation of the position creates the idea that she/he is an expert. For example, students respond according to the ‘expertise’ of their teacher, a situation that is reinforced by his/her authority to determine the quality of their work and to pass or fail an individual. Within bureaucratic settings certain Practitioners can be attributed more occupational autonomy and control over the process by which their particular service is delivered than others. For example, the medical profession has been successful in maintaining its position of dominance within the bureaucratic hierarchy by controlling access to health care delivery. This professional dominance has been paralleled with an increase in the legitimacy of medical knowledge, urbanisation, the expansion of health insurance and the growth of bureaucratic settings such as hospitals as centres for ‘professional excellence’ (Turner, 1995). The means of governing people, governmentality, is itself dependant on such ‘expert’ systems of knowledge and truths as a means by which to regulate and manage individuals. Public health experts can play an important mediating role between those in authority and those ‘out there’ in civil society by helping to shape their daily conduct through the ‘power of truth’, rationality and self-regulation. I define ‘civil society’ as people, in their capacity as citizens, associating with each other in social organisations such as clubs, religious groups, community betterment societies and public interest groups. This is linked to the discourse and

16 · Public health ‘expert’ language used by Practitioners (discussed in Chapter 4). Public health as a bureaucratic activity also provides a measure of the well-being of populations, documenting and establishing trends based on its ‘expert’ and ‘legitimate’ power. This sets standards of ‘normality’ that can be compared in relation to other population groups. In this way, public health practice can build upon political concerns and create issues that they show can be overcome by using their ‘expert’ knowledge and power. Public health as a bureaucratic activity can therefore be used in a coercive and manipulative way to influence the way people think and act (Lupton, 1995). If it is true that public health is a bureaucratic activity, carried out by or within governmental organisations or government funded agencies, it is also true that many of these organisations remain chained to traditional ways of thinking and acting, ways which inhibit the effective inclusion of empowering approaches. Various studies of both government and NGO agencies have found that the concept of empowerment used in policy and in practice are often quite different (Grace, 1991; Turbyne, 1996). Despite the intent to ‘empower’ communities, the organisations and their staff tended to retain control over programming rather than to relinquish power to others. The agencies operated within a contradiction between discourse and practice; many Practitioners continued to exert power-over (control) the community through top-down programming whilst at the same time using an emancipatory discourse. Judith Turbyne (1996), a researcher who looked at the transformation of concepts in policy-making processes, found that, although NGOs, which were conservative and traditional in their programming (top-down), used a strongly empowering discourse. However, this was transformed before it reached the programme interface with the community. Turbyne uses the interesting analogy of a glass prism to represent the policy-making process which refracts and alters the concept, dependent on the history, resultant ideology and internal structure of the organisation. Although this refraction of the concept of empowerment was found to be more problematic in large bureaucratic settings almost all organisations used a Weberian notion of bureaucracy as a ‘tool’ of the authorities to implement their political decisions by translating them into policy and by delivering them through programmes. To build a more empowering practice, public health must redress the constraints placed on the profession by its bureaucratic nature. This can become compounded in such a broad profession when Practitioners collaborate with other professional groups who do not necessarily share an ideology of empowerment. As I discuss in Chapter 3, before Practitioners can empower others they must first be themselves empowered and understand the sources of their own power. This includes a bureaucratic setting in which they feel valued and which provides them with the resources, skills and knowledge to empower others. But governments and the bureaucracies that they create, at least in democratic countries, are not monolithic entities. Not only are there often contradictions between the policies and actions of different government agencies but different Practitioners with differing ideas often exist and work together. Practitioners working

Public health in context · 17 in large bureaucratic settings can find their professional autonomy being undermined by the hierarchical structure of rules and lines of control. Professional groups can also become fragmented into subgroups or else their power base is encroached upon by para-professional groups. These circumstances present opportunities of an empowering practice to develop within even the largest, most rigid bureaucracies. To take advantage of these opportunities the public health profession must better understand how to address imbalances in the power relationships in the structures and procedures of their agencies at all levels. The agencies that fund and implement public health activities, for example, central government, metropolitan councils and the private sector, must relinquish some of their ‘power-over’ (‘expert-dominance’ and access to resources) to allow the elements of an empowering public health practice, discussed in this book, to become possible. Bottom-up approaches are dependent on funding and their continued support relies much on there being a political will to implement them. This may be difficult when the goal of the individuals, groups and communities (civil society) who are involved in community empowerment, is to bring about a change in the social and political order that challenges the very agencies (the state) that provide the funding for their continuation. Hence the problematic relationship that can exist between the state and civil society and between formal agencies and the community. Public health is primarily concerned with people and communities ‘out there’ in civil society. But empowerment must also occur within the profession and in the organisations that employ Practitioners from the top tiers of policy and planning ‘down’ to the people working at the interface with the community. It is precisely this type of a fundamental issue that must be addressed if Practitioners are to engage an empowering approach in their daily practice. To achieve this, professionals and their organisations should have a better understanding of the meaning of power and the means to attaining power, empowerment, that enable individuals, groups and communities to transform their identified needs and concerns into social and political action. The danger of this is that it presents an illusion of greater individual and collective choice and can act to hide an agenda of more typical top-down approaches that coerce and manipulate others into doing what we as professionals want them to do, even against their will (power-over). Public health becomes a method of social and financial control, the very opposite of an empowering practice. The question then becomes: Do Practitioners want to help to empower people or to change people?

䊏 Professional versus lay interpretations of health The multiplicity of meanings assigned to public health is also a function of the multiplicity of meanings assigned to our understandings of health. In particular, it is useful to consider the distinction between official understandings – those used by public health professionals, and lay understandings – the more popular perceptions

18 · Public health held by those who are usually the recipients of health interventions, the public. Practitioners have largely used official interpretations because these are easier to define and measure, rather than lay interpretations of health, which are subjective, being based on the experiences of the individual. In particular, the medical or bio-medical interpretation of health has established itself as the most dominant official interpretation. It is the medical profession, which has been the champion of this model of health, based on the absence of disease and illness, and upon which other health professions have modelled themselves including the field of public health. The bio-medical model evolved as a result of scientific discoveries and technological advances in the eighteenth and nineteenth centuries and this led to a greater understanding of the structure and functioning of the human body. As knowledge and understanding about the functioning of the human body increased, health took on an increasingly mechanistic meaning. The body was viewed as a machine that needed to be fixed. A professional split between the body and mind developed, the body and its physical illness was the responsibility of physicians while psychologists and psychiatrists looked after the psyche and its illnesses. However, the focus remained on the external causes of ill health and was reinforced by the constant threat of disease and death from epidemics such as polio and scarlet fever. Peter Aggleton (1991), a commentator on public health and health promotion issues, divides the official interpretations of health into two main types: those, which define health negatively, and those, which adopt a more positive stance. There are two main ways of viewing health negatively. The first equates with the absence of disease or bodily abnormality, the second with the absence of illness or the feelings of anxiety, pain or distress that may or may not accompany the disease. Aggleton points to the importance of recognising that some people may be diseased without knowing it. People are unaware of their illnesses until they start to suffer pain and discomfort, when the person is said to be ill. Negative definitions of health emphasise the absence of disease or illness and are the basis for the medical model. A number of problems have been raised concerning the negative definition of health. In particular, the notion of abnormality or pathology implies that certain universal ‘norms’ exist against which an individual can be assessed when making a judgement as to whether or not they are healthy. This assumes that such standards actually exist in human anatomy and physiology. Positive interpretations of health have also been widely used by health professionals. The first modern positive definition of health came in 1948 when the World Health Organisation (WHO) stated that health was ‘a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity’ ( Jackson et al., 1989). Physical well-being is concerned with concepts such as the proper functioning of the body, biological normality, physical fitness and capacity to perform tasks. Social well-being includes interpersonal relationships as well as wider social issues such as marital satisfaction, employability and community involvement. The role of relations, the family and status at work are important to a person’s social well-being. Mental well-being involves concepts

Public health in context · 19

Box 2.1 The Origins of the WHO Definition of ‘Health’ The WHO definition was written soon after the Second World War by an official who had spent his time working in the Resistance. He had come to this definition from his experience and explained that he had never felt healthier than during that terrible period: for he daily worked for goals about which he cared passionately, he was certain that should he be killed in his dangerous work, his family would be cared for by the network of Resistance workers. It was under these circumstances that he felt most healthy, most alive. The definition of health was developed by a person who was passionately involved with others to change social and political structures. In other words, they were involved in taking control over those things which affect their lives and by doing so empowered themselves and improved their own health and well-being as well as that of others with whom they associated ( Jackson et al., 1989).

such as self-efficacy, subjective well-being and social inclusion and is the ability of people to adapt to their environment and the society in which they function. The WHO definition has become one of the most influential and commonly used in public health and for that reason its origins, which are set in the context of empowerment, are worthwhile exploring in Box 2.1. The WHO definition of health, as an ideal state of physical, social and mental well-being has been criticised for not taking other dimensions of health into account, namely the emotional and spiritual aspects of health (Ewles and Simnett, 2003). The definition has also been criticised for viewing health as a state or product rather than as a dynamic relationship, a capacity, a potential or a process and does not clarify how to define or measure its components. The way in which people interpret the meaning of their own health is a personal and sometimes unique experience. Health is a subjective concept and its interpretation is relative to the environment and culture in which people find themselves. Health can mean different things to different people. Many people define health in functional terms by their ability to carry out certain roles and responsibilities rather than the absence of disease. People may be willing to bear the discomfort and pain of an illness because it does not outweigh the inconvenience, loss of control or financial cost of having the condition treated. This subjective view of health raises the issue of radical relativism which maintains that the only ‘true’ reality is the unique experience of the individual. Whilst it is important to understand individual feelings and experiences about health there may be others that are common to particular groups. Inter-subjectivity is a concept used to overcome the limitations of radical relativism. It claims that any given person’s understanding of the world is unique but because it is constructed from a field of more or less common social meanings and experiences, communication between people is possible. In other words, the meanings we create of our

20 · Public health own experiences, for example of health, overlap sufficiently so that we can communicate and share these with others (Labonte, 1993). The importance of personal interpretations of health is becoming increasing well recognised, for example, the link between individual control and health has been demonstrated in several studies (Brunner, 1996; Everson et al., 1997). Everson et al. (1997) undertook a study of Finnish middle-aged white males and concluded that stress induced from job demands and feelings of a lack of control was the strongest predictor of arterial heart disease. A review of heart health inequalities in Canada found that people who experience low income, less control in their lives and at work and who had a poor education are more likely to experience morbidity and mortality. In other words, the higher one’s position in the workplace or society, one’s power (control), wealth and status, the better one’s health and sense of self-esteem (Labonte, 1993). Self-esteem is actually a social phenomenon and not an individual creation. A person’s self-regard and sense of coherence is not grounded in ‘the self ’, but in relation to friends, family, colleagues, the communities and settings in which they live and work. In turn, these relationships, communities and settings are influenced by the political, cultural, social and economic context that privilege some and oppress others. This illustrates one of the dilemmas when implementing public health interventions that include self-esteem interventions targeted at individuals, the socially excluded or marginalised groups. The intervention focuses on the individual and the sense of self without critically assessing the deeper causes of political and social inequalities. Social support is therefore also generally accepted as having a beneficial effect on health, both at home or in the community; for example, by sharing problems people are better able to cope with stressful events. Social support is connected to other similar overlapping concepts such as social capital, social inclusiveness, social exclusiveness and social cohesion. These concepts fundamentally address a sense of connection to a ‘community’ and the involvement and trust between its members manifested through customs, rituals and traditional groupings such as weddings. Official definitions of health can differ significantly from lay definitions but both are ideal types and in practice coexist and inform one another. Practitioners have embraced a discourse that uses an official definition that goes beyond health care and lifestyle to feelings of well-being. Health is considered to be a means to an end that can be expressed in functional terms as a resource which permits people to lead an individually, socially and economically productive life. However, in practice, public health programming has increasingly been concerned with accountability to funders, effectiveness and value for money (Boutilier, 1993). Budgetary constraints, competition for funding and priorities for health have also had a strong influence on the way in which health has been interpreted. The public health profession has taken the pragmatic view that whatever interpretation of health is used it must be measurable and accountable, otherwise programmes employing its ideology and strategies will be in jeopardy of being unable to justify their economic and quantifiable effectiveness. This being the case, the measurement

Public health in context · 21 of health has focussed on the bio-medical approach that is concerned with demonstrating a relationship between a health status measure and a behaviour such as smoking or a condition such as morbidity and mortality. The boundaries for public health practice and discourse have consequently been defined by the interpretations of illness and disease rather than by the way in which most people generally view their own health.

䊏 Empowerment and public health discourse Empowerment is defined here as a process by which people are able to gain or seize power (control) over decisions and resources that influence their lives. The term ‘discourse’ is described in Chapter 1 and applies to an individual’s ideas, and rhetoric and implies the political and strategic role of words to form sentences and meanings. The concept of empowerment developed in public health discourse as an important ideology in the mid-nineteenth century. The political liberalism of the Victorian period led to the creation of many pressure groups, such as the Health Towns Association, with a concern for equity and social justice. These pressure groups, with the assistance of key public health reformers such as Edwin Chadwick were active in mobilising the middle classes who in turn had an influence on the press and on the government. This is called the ‘sanitation phase’ and was a period that through both influential reformers and collective action resulted in the government passing key public health legislation such as the 1833 Factories Act and the 1848 Public Health Act (Baggott, 2000). However, these actions were also influenced by the desire of the government to reduce their own responsibilities and to improve the efficiency of the nation’s workforce. Public health reform was as much due to the discourse of economic production as it was to the discourse of empowerment and to good governance. During the second phase, occupying the first half of the twentieth century, the growing status of the medical profession added to the political influence of the public health lobby. Consequently, the emphasis was on a public health discourse dominated by a bio-medical model and a focus on the absence of disease and illness. It was not until the 1960s and 1970s that empowerment became part of the discourse stemming from a growing body of ‘new knowledge’ that sought to challenge conventional thinking. Within public health, the discourse also broadened from the bio-medical model to include a behavioural and lifestyle component. The main reasons for this change in thinking were an increase in the role of chronic degenerative diseases such as heart disease as the leading causes of morbidity and mortality. These chronic diseases involve the interplay of different factors or determinants over time such as smoking, lack of exercise and a poor diet and have become synonymous with a ‘healthy lifestyle’. However public health, now more closely associated with health promotion and health education, placed an emphasis on the responsibility of the individual and on a ‘victim-blaming’ philosophy rather than on collective action and social equity.

22 · Public health Internationally, the need for social justice in the challenge to improve health was increasingly recognised and became the subject of professional discourse, for example, the 30th World Health Assembly, held in Geneva in May 1977, which set the target of health for all by the year 2000. The following year, an international conference on primary health care in Alma Ata in the former USSR endorsed this and strongly affirmed the WHO’s positive definition of health (World Health Organisation, 1986), noting that it was a fundamental human right. The Alma Ata declaration of 1978 recognised that the gross inequalities in the health status between and within countries was unacceptable and identified primary health care as the key to attaining health for all by the year 2000. The declaration recognised that people must be actively involved in the process of development and states: ‘The people have the right and duty to participate individually and collectively in the planning and implementation of their health care’ (World Health Organisation, 1978, p. 1). The declaration goes beyond participation to imply that empowerment is a necessary component to primary health care and public health. The Alma Ata Declaration does not use the term empowerment but many of its points imply involvement by individuals and the community. This is in part a reflection of the discourse in the early 1970s when the concept of empowerment had not become fully legitimised. The concept of community participation was viewed as a means to target people as beneficiaries of development by involving them in the process. The discourse argued that participation would allow local knowledge and needs to be incorporated into a programme and would give the people more control in decision making. In practice, this depends on the power relationships between Practitioners and their clients. If Practitioners use their power-over and take a paternalistic stance, this can lead to community control or coercion in programme planning and implementation. Since the early 1980s there has been a shift within public health discourse towards empowerment and community participation embodied in the socioenvironmental approach (Robertson and Minkler, 1994). This shift was guided by key strategic documents, such as the Ottawa Charter for Health Promotion (WHO, 1986), but was also due to other contributory factors of a social nature. One of these factors was an increased awareness of growing inequalities in health status between different social groups and the narrowness of the focus on individual behaviour that ignored the psychosocial and physical environments, community and culture. For example, it was recognised that the individualistic nature of public health education campaigns did not recognise the social and environmental contexts in which personal behaviours are embedded and which were, in themselves, important health determinants. Another significant factor was the maturing of many pressure groups and social movements such as the environment movements including Friends of the Earth and the gay rights and public health movements, who challenged the notion of the medical and behavioural approaches to health and raised concerns for social justice and environmental sustainability (Freeman, 1983). Social movements can provide a bridge between the ideology that they espouse and the established discourses and practices of bureaucracies and it is this, in relation to public health, which I next explore.

Public health in context · 23

䊏 Public health and social movement theory Although there is no real agreement as to the nature of social movements one major division has been between the views of structural conflict and those that interpret movements as a normal part of change in society. The diversity of the interpretations of social movements to some extent mirrors the diversity of theoretical and ideological allegiances. In recent years social movements have popularly been viewed by scholars in Westernised countries along three schema; Resource Mobilisation Theory (RMT), popular with American researchers taking an economic rationalism view, Action Identity Theory (AIT) and New Social Movement Theory (NSMT) popular with European researchers and based on Marxist and Durkheimian traditions. It is the emancipatory discourse of the NSMT that is shared by what has been termed the ‘new public health movement’ (Baum, 1990). However, this term, as I now explain, can be misleading because it hides the bureaucratic and sometimes controlling nature of public health towards civil society. A distinction can be made between what are considered to be ‘old’ social movements and ‘new’ social movements (Melucci, 1985). New social movements are not solely concerned with structural revolution or reform but more with cultural and expressive objectives based on the formation of an identity. Identity is created not simply through the existence of a social movement but also through action within the movement. The identity is shared by all its members and it is the process of internal action and negotiation that connects and bonds them through social relationships. The main purpose of the ‘new’ movements is the transformation of values and change in, for example, the nature of health care and social services, rather than a radical restructuring. In the context of ‘new’ public health movements the process and outcome of such action is to promote the health and well-being of its members. For example, the collective action among mental health service users in Nottingham in England who formed the Nottingham Advocacy Group. This group grew out of the meetings held by patients on hospital wards and with the support of similar groups slowly developed into a national advisory network. Whilst involved in the personal development of its members the main aim of the group was to have an influence on shaping mental health policy and services (Barnes, 2002). Within the literature the main theories about social movements are: ●

The collective behaviour approach, closely related to the mass movement and society interpretations deeply rooted in Talcott Parsons’ structural–functional theory. Mass social movements are viewed as a semi-rational response of the populace to abnormal or extraordinary circumstances of socio-structural strain. This strain leads to anxiety and a generalised belief of the populace in a responsibility to restore harmony leading to social mobilisation of the people and by the people. This approach has been criticised as being too extreme but in spite of this has been endorsed by many empirically orientated American scholars.

24 · Public health ●

●

●

●

The class expression accounts are a distinct extension of the collective behaviour approach and a response to the communist revolutions of the 1930s to the 1950s in Spain, Portugal and Central Europe. These are ‘extremist’ movements linked with conditions of threat and displacement and are in contrast to those linked with institutionalised democratic politics. However, these movements are viewed as a normal part of socio-historical development linked to class interests. The resource mobilisation account was mainly developed by American researchers. Movements are viewed as an extension of rational democratic politics and take shape as public campaigns, lobbying and interest group politics. The new values perspective is viewed as an extension of the collective behavioural, resource mobilisation and class expressive interpretations. However the main emphasis of the new values interpretation is not a link between class or politics, but on generation of specific experiences and ‘alternative value paradigms’, for example, the shift from materialist to post-materialist values and thinking in the 1960s, traced to the economic and social security that prevailed after the Second World War. The action identity accounts and the new social movements interpretations inspired by Marxist tradition. The action identity approach rejects the tenets of structural-functionalism and proposes an analysis based on power relations in social and political struggles. Likewise, the new social movements interpretation views conflict in the socio-political sphere in regard to control and authority relations.

Social movements therefore have a structure, a pattern of inter-relations between individuals and groups. This pattern evolves through its processes of mobilisation, participation and organisation. Formal social movements may possess bureaucratic procedures but they do not operate from within bureaucracies. Social movements exist within civil society as community-based groups, developed by the people, against systematic structures and ideologies held by those in authority (Pakulski, 1991), for example, social clubs, pressure groups and community organisations. To illustrate this, Box 2.2 provides an example of social movement theory and community partnerships in Brazil. Ron Eyerman, a sociologist, and Andrew Jamison, an academic interested in social and political policy (1991), add to the discussion on social movements by examining their intellectual activities. Eyerman and Jamison argue that these activities can change societal values and norms, for example, public values towards health issues such as smoking and air pollution. In particular, there are two main concepts in the approaches that they discuss that are relevant to the evolution of empowerment in public health discourse: cognitive praxis; and movement intellectuals. Cognitive praxis is the ‘knowledge interests’ that are held by a movement and the ‘dynamic and mediating role that movements play in the shaping of knowledge’ (Eyerman and Jamison, 1991, p. 47). This is the origin of new knowledge generated by a movement and to do this intellectuals within the movement draw

Public health in context · 25 Box 2.2 Social Movement Theory and Partnerships in Brazil Frances O’Gorman (1995), a Brazilian/Canadian community development expert, provides a case study of community empowerment through partnerships and social movements in Brazil. Self-help groups addressing issues such as police violence, poverty and political corruption recognised that their strengths lay in unity and used the slogan ‘united, the people will never be overcome’. Isolated projects and groups began to link up and form partnerships which developed into a network of popular movements. Using their collective strength, the movements were able to exert greater public pressure on the government to coerce it into addressing issues of social justice and equity. The movements increased their links with NGOs in neighbouring Latin American countries that had the shared interests of human rights and social justice. Through these links, the organisations were able to exchange resources and strengthen their membership through people who shared their ideology of emancipation.

upon and reinterpret established intellectual concepts. Cognitive praxis plays another important role, the development of new societal images and identities. Examples of how society transforms its self-identity through the knowledge generated by social movements include setting new problems for society to solve and advancing new values for ethical identification by individuals. Eyerman and Jamison identify that the role of movement actors is normally viewed as those that lead and those that are led, and that the role of ‘movement intellectuals’ to strategically plan and create new knowledge is an important one which is often overlooked. As the movement matures and new organisations emerge there may be a transformation in the relationship between the intellectual and the movement. Movement intellectuals occupy the ‘space’ created for them temporarily before they seek legitimacy elsewhere, for example, in academia, media and government agencies. They establish their new identities and thus act as a vehicle through which movement knowledge can be dispersed socially. In this way, intellectuals create movements and movements create intellectuals in processes within society to challenge conventional knowledge and wisdom. Eyerman and Jamison (1991) theorise that movements are the engines of social change and contribute in this way to contemporary discourse. As the movements create new knowledge and intellectuals both become absorbed and institutionalised by society they create a bridge between new knowledge challenges and the established knowledge constructions and practice. In this way the legitimisation of the discourse on public health issues has been influenced through the absorption of movement ‘intellectuals’ either into, or their direct influence upon government, academic and private sector agencies. In particular, the main themes of the discourse of NSMT, emancipation and social

26 · Public health justice, have relevance to an empowering public health practice. NSMT has an emancipatory role and places an emphasis on challenges to counter oppressive forms of power-over (discussed in Chapter 3) and the dominant discourse that has been taken for granted, created whilst gaining political legitimacy (Eyerman and Jamison, 1991). Examples of these movements include Green Peace and the Campaign for Nuclear Disarmament (CND) that challenged the knowledge that global resources were infinite. However, public health itself is not a social movement because whilst it shares the emancipatory discourse of NSMT, in practice it is carried out within the controlling sphere of bureaucratic settings. Public health remains disease based, embracing a bio-medical interpretation of health and employing top-down approaches to programming. Its purpose is to reduce the burden of disease and programme goals remain driven by the reduction of morbidity and mortality. This bureaucratic logic prevents Practitioners and their clients from employing strategies to address the social determinants of health central to which is the empowerment of individuals and groups. In Chapter 3, I move the reader into the territory of how power, as a concept, is central to public health practice; what does power look like; what is the means to attaining power and how can Practitioners act to transform personal and social power relationships at the individual, group and community levels.

Chapter 3

Power and empowerment Power and empowerment are central to public health and yet many Practitioners still have a superficial understanding of the different meanings and in particular, how these two concepts can be applied to their everyday work. For public health to use an empowering approach, its members need to understand how power suffuses the relationships between Practitioners and their clients, and how they can transform unhealthy into healthy power relationships.

䊏 What is power? The most common interpretation of power used in the literature is in the form of one person having power-over and mastery of others or ‘the capacity of some persons to produce intended and foreseen effects on others’ (Wrong, 1988, p. 2). The anthropologist, Richard Adams (1977) further discusses the idea that power can be a social phenomenon, one that can be vested in both individuals and social groups. As social organisations and communities develop, they are better able to identify and control the basis of their power. The concept of power can be viewed as both a limited, finite entity (zero-sum) and as an expanding, infinite entity (nonzero-sum). These are important distinctions for public health practice that I will discuss later in this chapter. Bertram Raven and Tchia Litman-Adizes (1986) considered the resources that Practitioners may bring to bear on their client in order to change their beliefs, attitudes and behaviours. These are identified as six bases of social power-over (the relationship between people in which a powerful person has power-over on others): coercion; reward; legitimacy; expertise; reference and information. ●

●

●

In coercive power, the Practitioner may bring about negative consequences or punishment for the clients if they do not comply, for example, through prosecution. In reward power, the Practitioner may bring about positive consequences for the client upon compliance, for example by awarding a certificate of good practice. Both the coercive and reward bases of social power depend upon the Practitioner’s ability and readiness to mediate the consequences for the client by the way in which the power-over is used. Legitimate power stems from the client accepting a social role relationship with the Practitioner, a structural relationship that grants him/her the right to prescribe behaviour for the client, while the client accepts an obligation to comply with the requests of the Practitioner.

27

28 · Public health ●

●

●

Expert power stems from the client attributing superior knowledge and ability to the Practitioner, for example, the term ‘Doctor knows best’ illustrates the expert power relationship between patient and doctor. Referent power stems from an identification of the client with the Practitioner, a feeling of communality, similarity and mutual interest. The client then gets some satisfaction from believing and complying in a manner consistent with the beliefs, attitudes and behaviours of the Practitioner. Informational power is based on the explicit information communicated to the client from the Practitioner, a persuasive communication that will convince the client that the recommended behaviour is indeed in the client’s best interests. Informational power is the form commonly used in health education through the provision of knowledge.

It is important to note that the term ‘knowledge is power’ can be misleading and is not necessarily correct. New knowledge without the means to carry out the prescribed actions can simply lead to people having a greater sense of powerlessness. For example, informing individuals to eat healthy foods when they have no access to or cannot afford to buy these products, can contribute to their sense of a lack of control. To exercise choice is the simplest form of power. This may involve the trivial health choices of everyday life such as which brand of toothpaste to buy or the more critical choices such as whether or not to stop smoking. Practitioners should recognise that the rhetoric of choice can become an excuse for health professionals to avoid difficult issues and to transfer blame. The trivial choices should not overwhelm and cloud the more critical issues where the powerless have no choice, for example, promoting an active lifestyle when poor people cannot afford or do not have the time to do more exercise. To the extent our personal choices constrain those of others, power becomes an exercise of control. People with the ability to control decisions at the macro (political and economic) level, for example, condition and constrain the ability of people to exercise control or choice at the micro (individual and group) levels. People both have control (power)-over others and are acted upon (constrained, influenced) by those that have control-over themselves. To better understand how power can be exercised in both a positive manner (the sharing of control with others) and a negative manner (the use of control to exert influence over others), it is helpful for Practitioners to consider three different variations: ‘power-from-within’; ‘power-over’; and ‘power-with.’

䊏 Power-from-within Power-from-within can be described as an experience of ‘self ’, a personal power or some inner sense of self-knowledge, self-discipline and self-esteem (Labonte, 1996). Power-from-within is also known as individual, personal or psychological empowerment, the means of gaining (a sense of ) control over one’s life (Rissel, 1994). The goal of psychological empowerment is to increase feelings of value

Power and empowerment · 29 and a sense of personal mastery. Thomas Wartenberg (1990), a writer on the different forms of power, argues that even in the most male-dominated, controlling society, women have power, the power-from-within. Likewise, Western feminist theory claims that although women are not socially dominant, they do have special skills and inner strengths that have enabled them to act in invaluable ways. Once one has accepted this, Wartenberg’s (1990, p. 188) argument that ‘the seemingly contradictory claim that women both have and lack power in a male dominated society’ can be seen to contain an important insight because it makes power-over a decentred notion. Individuals can become more powerful from within and do not necessarily have to accumulate power as money, status or authority. However the individualisation of this concept can lead to public health approaches that aim to increase the notion of ‘self ’, for example in assertiveness of classes, ignoring how another form of power, power-over, can constrain experiences of control in the ‘real world’ (Laverack, 2004).

䊏 Power-over Power-over describes social relationships in which one party is made to do what another party wishes them to, despite their resistance and even if it may not be in their best interests. For example, Starhawk (1990, p. 9) describes power-over in its rawest form as ‘the power of the prison guard, of the gun, power that is ultimately backed by force’. However the exercise of power-over does not always have to be negative, for example, legislation to control the spread of diseases through quarantine or to impose fines for unhygienic behaviour such as for food handlers not washing their hands, are what we consider as ‘healthy’ power-over. In public health practice the issue is: Whose choices (control over decisions or power) are constrained and do these lead to the powerlessness of others? Power-over can take different forms depending on how it is used to exert control or to affect the actions of others: dominance, or the direct power to control people’s choices, usually by force or its threat; hegemony, or the ability of a dominant group to control the actions and behaviours of others by intense persuasion and exploitation, or the indirect power to control people’s choices through economic relations, in which those who control capital (primarily money) also have control over those who do not (Wrong, 1988). Speer and Hughley (1995) discuss three instruments of material power-over in relation to its oppressive use in Appalachian communities in North America. The first instrument of power is manifested through superior bargaining resources that can be used to reward and punish. Therefore, those with the greatest resources have the greatest power. A second instrument of power is the ability to construct barriers to participation or eliminate barriers to participation through setting agendas and defining issues. Thus by controlling access to decision-making processes, the topics and timing of discussion those with power can effectively limit participation and perspectives in public debate. The third instrument of power is a force that influences or shapes shared consciousness through the control of information.

30 · Public health Power-over is resource dependant and is viewed as being ‘capacity’ reliant on some type of a material product. However, it essentially ignores that power must also be a property of social relations including the relationship one has with oneself (power-from-within) (Clegg, 1989).

䊏 Hegemonic power Hegemonic power is that form of power-over that is invisible and internalised such that it is structured into our everyday lives and taken for granted (Foucault, 1979). To Foucault, a prominent theorist and commentator on power, the only form of resistance to hegemonic power was a concealment of one’s life from those in authority and the judgements that it can create. Practical examples of this are a single mother living in government-funded housing hiding her sick child from a health visitor (Bloor and McIntosh, 1990) or lowering the toilet seat to avoid suspicion that she was seeing a man. Persons living in conditions of hegemonic power-over, of oppression and exploitation, internalise these conditions as being their personal responsibility. This internalisation increases their own self-blame and decreases their self-esteem. One of the subtle ways in which Practitioners participate in hegemonic power is when they continually impose their ‘expert’ ideas of what are important health problems (top-down and power-over) without listening to what their clients think are the important health concerns. Piven and Cloward (1977) suggest that in conditions of oppressive forms of power-over and poverty where people have few institutional and material resources, the marginalised and poor cannot rely upon support from the established system. Marginalised groups must then use the only significant resource they have, the capacity to cause trouble. The tactics used are protests, riots, demonstrations and strikes. The disruption, public support and the reaction of those in authority become the basis for political influence. This is a limited option and only possible under extreme and specific circumstances but, historically, it has given rise to examples of dramatic change, for example, the collective action of lower-class tenants in the United States of America in regard to poor housing in the middle years of the twentieth century. The crux of Piven and Cloward’s argument is to maximise these occasions and to push for full concessions in return for a cease to disruption. It is a costly and risky strategy but it is also the most effective means of utilising the limited resources available to people living under non-supportive, repressive social and political conditions.

䊏 Power-with Power-with describes a different set of social relationships, in which power-over is used carefully and deliberately to increase other people’s power-from-within, rather than to dominate or exploit them. Power-over transforms to power-with only when it has effectively reached its end, when the submissive person in the relationship has accrued enough power-from-within to exercise his or her own

Power and empowerment · 31 choices and decisions. The person with the power-over chooses not to command or exert control, but to suggest and to begin a discussion that will increase the other’s sense of power-from-within. The Practitioners offer advice to their clients in the identification and resolution of problems to help develop their power-fromwithin, their abilities and inner strengths. The transformative use of power-over also demands a great deal of self-vigilance and self-discipline by all persons in the relationship, but in particular by the initially more dominant person, the Practitioner. If not, the relationship can remain as power-over, for example, using the different instruments of social power discussed above by Raven and LitmanAdizes (1986): referent power or mentoring that does not try to come to completion can become charismatic authority or ‘guruization’; and legitimate or expert power that does not acknowledge that others in the relationship may have their own expertise can lead to a patronising inducement of dependency. An example of the delicate balance of the transformative use of power-over can be illustrated in the doctor–patient relationship. This professional relationship is fundamentally unequal where all competence and expertise is considered to belong to one party, the person with the power-over or the doctor. The patient voluntarily surrenders to the unspoken claim of medical (expert) power, for example, the phrase ‘Doctor knows best’ epitomises this situation. The doctor has control over the knowledge even though that knowledge concerns the patient’s own body. The attributes of health are viewed as an individual ‘case’ and the diagnosis is made on the basis of the medical model (the presence or absence of disease or illness) that serves to protect the legitimate and expert bases of power held by the doctor. However, in the health system, the power-over relationship does not stop at diagnosis because the doctor often also controls the admission and discharge, choice of treatment, referral and care of the patient. Doctors also form a powerful pressure group both as a collective work force and through key associations such as the British Medical Association and the Royal Colleges. The medical profession, although not a monopoly because of the growth of other occupational health groups, has been granted considerable control to maintain self-regulation and clinical autonomy in their work. Much of the power-over held by the profession is also supported by the public who expect confidentiality in the special relationship that they hold with their doctor. Doctors have also been careful to create an alignment between professional and public interests, for example, in regard to the under-resourcing of the National Health Service, long waiting times for treatment and the unacceptable demands placed on hospital staff. All this provides the medical profession with a greater scope for power-over and therefore a greater need for self-vigilance and self-discipline in its transformative use to power-with.

䊏 Zero-sum and non-zero-sum forms of power Zero-sum power exists when one can only possess x amount of power to the extent that someone else has the absence of an equivalent amount. It is therefore a ‘win/lose’ situation. My power-over you, plus your absence of that power, equals

32 · Public health zero (thus the term, ‘zero-sum’). I win and you lose. For you to gain power, you must seize it from me. If you can, you win and I lose. Power is used as leverage to raise the position of one person or group, while simultaneously lowering it for another person or group. However, at any one time there will be only so much leverage (wealth, control, resources, etc.) possessed within a society. This distribution and the decision-making authority that goes with it is zero-sum. At the same time, there are dominant forms of status or privilege, such as class, gender, education and ethnic background that tend to structure power-over relations in most social situations. The role of the Practitioner in this zero-sum construction of power is to assist individuals, groups and communities to gain power, meaning here more control over resources or decision making that influence their health and lives, from other individuals, groups and communities. There is another important concept of power, one that is regarded not as fixed and finite, but as infinite and expanding. These ‘non-zero-sum’ forms of power are ‘win/win’, since they are based on the idea that if any one person or group gains, everyone else also gains. Trust, caring and other aspects of our social relationships with one another are examples of non-zero-sum power. To be more empowering in their work, Practitioners should gravitate towards the non-zero-sum formulation. Power is no longer seen as a finite commodity, such as wealth, or as the comparative status and authority that this might confer. Rather, non-zero-sum power takes the form of relationship behaviours based on respect, generosity, service to others, a free flow of information and the commitment to the ethics of caring and justice. The role of the Practitioner in this construction of power is to use these attributes to engender them in others and to transfer power by encouraging individuals to access information by themselves, in part by providing better access to resources and information (Laverack, 2004). In practice, public health simultaneously involves zero-sum and non-zero-sum formulations of power. Power cannot be given but communities can be enabled by Practitioners to gain or seize power from others. Practitioners must first identify their own power bases and then through the professional–client relationship enable others to share these to develop their ability to gain control over the influences on their lives and health. Practitioners need to know both how to use their own power to help themselves into a position of more control and how to help others to gain power. Practitioners generally do have more power or a stronger power base than their clients, for example, their education level and professional training, higher incomes, expert status and social class, access to information and resources, influence over decision makers, familiarity with systems of bureaucracy and control over budget allocations. A Practitioner can have many clients; individuals, groups and communities, who are not homogeneous but consist of competing interests and therefore in the course of their work it is unavoidable to empower some whilst not others. This raises the ethical dilemma: Which groups, at the expense of others, should get priority of the limited resources and assistance from the Practitioner? What criteria should be used to select one group or community in preference to another group or community? Poverty indices and scores have been used, for example, the Jarman score and

Power and empowerment · 33 the Index of Local Conditions, to identify particular areas of social deprivation. However, these measures are based on census variables and can only be updated every ten years. Focussing limited resources on only a few deprived populations may be neither the most effective or equitable approach to public health, which has a responsibility to maintain the health and well-being of everyone.

䊏 What is powerlessness? Powerlessness, or the absence of power, whether imagined or real, is an individual concept with the expectancy that the behaviour of a person cannot determine the outcomes they seek. It combines an attitude of self-blame, a sense of generalised distrust, a feeling of alienation from resources for social influence, an experience of disenfranchisement and economic vulnerability, and a sense of hopelessness in gaining social and political influence (Kieffer, 1984). The process by which people may perceive themselves as being powerless is described in Box 3.1. Michael Lerner (1986), a political scientist and psychotherapist, argues that a similar phenomenon occurs with persons living in risk conditions. He named this process ‘surplus powerlessness’, a surplus created by, but distinct from, external or objective conditions of powerlessness. An example of surplus powerlessness is provided in Box 3.2. Individuals internalise their objective or external powerlessness and create a potent psychological

Box 3.1 Experiencing Powerlessness The process by which people may perceive themselves as being powerless can begin when individuals and groups living in risk conditions or who experience inequalities in health (poor housing, unemployment, insanitary conditions) feel distress with the unfairness of their situation (their low status on some hierarchy of power or authority, indicated in part by wealth). These people then internalise this feeling of unfairness as aspects of their own ‘badness’ or ‘failure’. This internalisation adds to their distress, if not also to their loss of meaning and purpose, with measurable effects on their bodies such as hypertension (Labonte, 1998). The powerless often experience little leverage on the events and conditions that impinge on their existence, either directly or through access to resources, information and facilities. This situation is made worse, when the dominant social discourse on success is competitiveness, individualism and meritocracy, where people are presumed to succeed or fail purely on the basis of their own initiative or ability (Lerner, 1986). This internalisation of ‘badness’ leads to what is described as both false consciousness, ‘failing to utilize the power that one has and failing to acquire powers that one can acquire’ (Morriss, 1987, p. 94), and learned helplessness (Seligman, 1975).

34 · Public health Box 3.2 Surplus Powerlessness and Women Living in Inner-city Housing in Canada On a large inner-city housing estate in Canada, a community organising project had formed around food, gardens, housing and welfare. Many of the women involved in this estate complained of having low self-esteem. A principle reason for this was the fact that, by being on welfare, they had ceased being self-empowered individuals and had become a form of public property. They had internalised the idea that people on social assistance were only eligible for income that was less than the lowest wage available in the job market. They had become lesser persons. Not only did the women have low self-esteem; they knew they had it, and they pinpointed one of the reasons for it: media stereotypes about welfare recipients. These stereotypes came in two forms: On Saturdays came the story of the super welfare heroine who transforms welfare into a business and, by buying day-old bread and second-hand but functional clothing, manages to virtually ‘turn a profit’. On Wednesdays were the ‘macaroni and cheese stories’ about how horrible it was to barely subsist on welfare. Just as society-at-large externalises these stereotypes, many of the women had internalised them. The result was ‘surplus powerlessness’, a further disempowerment. With the first stereotype, they could not measure up to the welfare heroine and so experienced themselves as personal failures. With the second stereotype, their reality was consistently portrayed as bleak and uncompromising (Labonte, 1998; in Laverack, 2004).

barrier to empowering action. They do not even engage in activities that meet their real needs. They begin to accept aspects of their world that are self-destructive to their own health and well-being, thinking that these are unalterable features of what they take to be ‘reality’. An example of the effect of powerlessness can be seen amongst communities which are subject to sudden catastrophes such as the Aberfan coal waste disaster. ‘People who feel their humanity violated and unrecognised by others internalise that diminished sense of themselves in ways that impair their capacity for recovery or even hope.’ Part of this internalising process is isolation, removing oneself from active group participation because of low self-esteem and high self-blame (Couto, 1989, p. 238). The challenge is to strengthen individuals’ power-from-within, partly by helping them to identify their own sources of power-over. People’s power or powerlessness, for example, is always relative to that of others in their community. One has authority or social status by virtue of others not having it. There is a degree of flexibility here, however, since someone may have authority or status in one situation, relative to others, but not in another. For example, an immigrant man may hold the position of a leader or hereditary chief within his own community,

Power and empowerment · 35 but within his work place in his adopted country, he may have only a low-paying menial job with little responsibility or status. Rather than begin their work from the perspective that people who are, in general terms, relatively economically and politically powerless, Practitioners need to look for, and work from, areas in peoples’ lives in which they are relatively powerful.

䊏 What is the means to attaining power? Empowerment, the means to attaining power, in the broadest sense is best described as ‘the process by which disadvantaged people work together to increase control over events that determine their lives’ (Werner, 1988, p. 1). Most definitions give the term a similarly positive value and embody the notion that empowerment must come from within an individual or group. The essence of empowerment is that it cannot be bestowed and must be gained by those who seek it. Those that have power or have access to it, such as Practitioners, and those who want it, such as their clients, must work together to create the conditions necessary to make empowerment possible. In professional practice, this is a mutual role played out by the Practitioner who can facilitate change and the clients who identify and execute the change. However, as already discussed above, one must be able to identify one’s own power base in order to share it with others. The inability of some Practitioners to identify and activate their power base may account for the act of gaining power being neglected in favour of the act of attempting to empower others simply through the delivery of resources. To provide clarity to the concept of empowerment it is useful to consider three different levels: individual, organisational and community. Christopher Rissel (1994, p. 41) includes a heightened or increased level of psychological (individual) empowerment as a part of community empowerment. He argues that community empowerment includes ‘a political action component in which members have actively participated, and the achievement of some redistribution of resources or decision making favourable to the community or group in question’. Barbara Israel and her colleagues (1994) similarly identify psychological and political action as two levels of community empowerment, but include a third, and intermediary level between them, that of organisational empowerment. An empowered organisation is one that is democratically managed, its members share information and control over decisions and are involved in the design, implementation and control of efforts towards goals defined by group consensus. Haynes and Singh (1993) provide a further model for ‘family empowerment’ as a social unit within communities which are able to organise themselves into ‘advocacy groups’ to assist them to gain power. This is a common theme in nonWesternised societies where importance is placed on the well-being of social units such as the family rather than on the individual. The family is the core unit of society and the purpose of empowerment is to give people more control so that they can address their own concerns. Family empowerment can be viewed as a sub-level of analysis of organisational empowerment.

36 · Public health Community empowerment is a synergistic interaction between individual empowerment, organisational empowerment and broader social and political actions. Community empowerment is both an individual and a group phenomena. It is a dynamic process that never ends, involving continual shifts in individual empowerment (power-from-within) and changes in power-over relations between different social groups and decision makers in the broader society. Community empowerment is also an outcome and in this form it can vary, for example, as a redistribution of resources (Rappaport, 1984), a decrease in powerlessness or a success in achieving predefined goals (Kieffer, 1984; Rappaport, 1985). But it is most consistently viewed as a process along a continuum representing progressively more organised and broadly based forms of social and collective action. This is the continuum of community empowerment and is discussed in detail in Chapter 5.

䊏 Cultural and contextual interpretations of power and empowerment

Many of the definitions of power and empowerment have been developed by psychologists in industrialised countries in the areas of neighbourhood empowerment and community mental health (Rappaport, 1987; Swift and Levin, 1987), for example: Empowerment may be generally described as the connection between a sense of personal competence, a desire for and a willingness to take action in the public domain. (Zimmerman and Rappaport, 1988, p. 725) The ability to act collectively to solve problems and influence important issues. (Kari and Michels, 1991, p. 719) Empowerment may hold a very different connotation for people living in different cultural contexts, for example, what might be perceived as empowering by women in an industrialised country may be very different for women in a developing country. This includes the degree of, or expectation of, power-over the events in life such as choosing who to marry, where and with whom to live, what to be employed as, what to wear or even if enough control is permissible, to leave the house alone. John Raeburn (1993), a veteran commentator on health and community organisation, provides an interpretation of power, one that has a spiritual meaning to the Maori people of New Zealand. This meaning is embodied in the term ‘mana’ combined with dignity, humility and the status gained from one’s presence. Raeburn argues that being involved in empowering community processes can lead to the attainment of this cultural sense of power. Sharry Erzinger (1994), a health consultant in Latin America, explains the meaning of empowerment in Ecuador where poverty, religion, superstition and political dominance all function to maintain ‘power-over’ authority and control in most people’s lives. Erzinger points out that

Power and empowerment · 37 in the Spanish language empowerment is not an individual or solitary phenomenon but is connected to the family or community. In Westernised countries, public health programmes are very often targeted at the individual, for example, to change behaviour or to increase knowledge. These ‘models’ can then become inappropriately superimposed onto socio-cultural contexts that focus on the family unit rather than the individual such as in non-Westernised countries. Contextual influences in both industrial and developing countries such as poverty (economic), social norms (socio-cultural), bureaucratic structures (political), historical and colonial circumstances can also lead to different perceptions of power and empowerment. An example of the economic context is provided by Viviene Taylor (1995), a commentator on social welfare and development, in her account of social reconstruction and the transition to democracy in South Africa. Taylor argues that the inability of those in power (the government) to establish an economic context that absorbed surplus unemployed labour significantly contributed to the crisis in that country. The unemployed had no income and many turned to conflict, violence and crime to support themselves and their families and as a result, this led to feelings of powerlessness amongst the population. Maruja Barrig (1990), a community worker in South America, provides an example of how the economic context can also have a positive influence on people’s empowerment. Women in Peru, forced by an economic crisis, which led to depressed incomes and unemployment, were placed in a deprived situation and had to empower themselves. Women’s community-based organisations helped to establish communal kitchens, to channel relief and to set up self-help groups for the people worst hit by the economic crisis, especially those in the shanty towns. The economic context created desperate conditions, which in turn acted as a ‘trigger’ for the women to embark on a process of empowerment to bring about action to help themselves and others. In many parts of Asia, traditional authority relations continue to dominate village life. The socio-cultural tendency is for communities to follow strong leadership rather than make collective decisions. Such concentrated leadership offers limited scope for participation in decision making and community empowerment. The basis for power-over decision making is centred on local leaders, who although they do have the authority to mobilise community members to undertake development activities, choose not to do so in order to maintain their control in the community (Asthana, 1994). Gill Gordon (1995), a community development worker, discusses the effects of both the social and economic context on the Krobo people in Ghana, West Africa. To alleviate economic hardship young women have traditionally worked for a few years in the neighbouring country of Ivory Coast in order to purchase essentials and to make enough capital to set themselves up in business. These visits are organised by the older women of the community and it is socially accepted that sexual relationships would contribute to the economic success of these young women. In the mid-1980s young women started to come home with a fatal disease later diagnosed as AIDS. Without better economic alternatives young women continued to follow in the footsteps of their sisters and friends and to continue the cycle of infection. The economic context

38 · Public health had led to the need to develop sexual relationships as a means of income but this was maintained because of the social acceptability of this practice. This has had dire consequences for the families of the Krobo people who provide the support and care necessary once the young women develop AIDS. In a zero-sum political context, power-over access to resources is finite and creates a win/lose situation: my power-over you, plus your absence of that power means that I win and you lose. In these circumstances, it is in the interest of the community groups to either work with the political context taking a strategic approach for empowerment or to work against it to agitate for reform. In a supportive political context, those in governance support the self-determination of some groups and communities over others but may place the needs of the majority into a national agenda. If a supportive political context does not exist, the onus is on the community to gain power through whatever leverage it can use to raise their position over others. This usually involves empowering themselves through legitimate localised action, for example, by writing a petition and raising the issue with government representatives, leading eventually to broader social and political change. However in certain political contexts (undemocratic, totalitarian), the legitimate means to empowerment do not exist and groups and communities may have to take more radical action to bring about social and political change, for example, mass protests, riots and strikes. The historical context of community action may determine future involvement, set precedents or predetermined assumptions about power and empowerment. A history of resistance between the church in Latin America and the land-owning aristocracy provides the backdrop for a major empowering force through critical reflection. Church activists, inspired by their own theology, rejected the elitist and corrupt practices of the landowners and pioneered resistance movements against those in power. In Latin America, the church continues to promote community action among the poor through co-operative solutions, self-help and participatory approaches (Asthana, 1994). Knowledge of the historical context of the community can help identify potential barriers to community empowerment such as experiences of conflict or feelings of helplessness. Goodman et al. (1998) argue that communities with access to information about their history, verbal or written, have a better chance of affecting change, than those that do not have access. However a historical context of colonialism has been shown to generate an atmosphere in which empowerment is difficult to achieve. Serrano-Garcia (1984) uses Puerto Rico as a case study and argues that an ideology of conservatism and pro-American values has been forced into the culture. The weakening of this ideology was one of the main goals of the Esfuerazo project in order to gain cultural identity, independence and collective empowerment. However, Serrano-Garcia argues that this has only created an illusion of empowerment because newly gained control over a person’s life still exists within an oppressive colonial context, which continues to determine the physical and physiological well-being of the population. Historically the extent of colonialism has been widespread in the world and the definition provided in Blair and Bernard (1998, p. 205) as ‘the practice or idea of

Power and empowerment · 39 one nation seeking to extend or keep control over other peoples or lands’ can be applied to the present situation in many countries. For example, the control of the Western world over resources which many developing countries depend upon for their source of foreign income and the stability of their economy (Friedmann, 1992). This power relationship can maintain feelings of dependency and powerlessness which as Serrano-Garcia (1984) argues, can generate individual and social decay. Neocolonialism has also had an influence on the empowerment of many countries. First, in creating a new indigenous elite within ex-colonies who perpetuate relationships of dependency with former colonial powers as well as maintain control of economic conditions. Second, in industrialised nations which, faced with the impossibility of creating and maintaining new colonies under direct administrative control, nevertheless attempt to perpetuate hegemony and to create new relations of international dependency. Next, in Chapter 4, I explain how Practitioners can work with individual clients to help them to gain power through strategies that improve communication, increase critical awareness and promote an empowering professional practice.

Chapter 4

Helping individuals to gain power Helping individuals to gain power involves building their power-from-within and helping them to participate in ‘interest’ groups and community organisations. It is collective, rather than individual, action that eventually brings about social and political change. People achieve this through the development of social networks, the mobilising of resources and improving competencies towards achieving these goals. To help empower individuals it is important to recognise the key difference between participation and empowerment, which lies in the agenda and purpose of the process. Empowerment has an explicit purpose to bring about social and political changes, participation does not, and this is embodied in the emancipatory sense of direct personal and collective action. Empowerment involves both the development of specific skills and an increased sense of political awareness at an individual level and decision making at a collective level. Individuals must have the self-confidence to participate and interact in a group setting in such a way as to make their opinions and concerns count. As discussed in Chapter 3, self-confidence and self-esteem are characteristics of power-from-within. To build power-from-within, the Practitioners use strategies to increase feelings of value and a sense of control in their clients. Whilst the ability of the Practitioner to be an effective communicator can be closely linked to the way in which people feel about themselves, individuals become more powerful through their own sense of worth rather than from a simple transfer of resources or information. There are many strategies that can help individuals to gain power and whilst it would be unrealistic for Practitioners to attempt to use them all, here I select three key approaches that can be used as part of their everyday work: 1 2 3

Practitioners as more effective communicators; Increasing the critical self-awareness of clients; and Fostering an empowering professional–client relationship.

䊏 Practitioners as more effective communicators Practitioners often use health education, health communication and Information, Education and Communication (IEC) strategies in their everyday work to impart information to their clients. Practitioners also use communication to advocate on

40

Helping individuals to gain power · 41 behalf of their clients or to mediate between conflicting interest groups. Health education is aimed at informing people to influence their individual decision making centred around lifestyle choices, whereas health promotion aims at complementary social and political actions that facilitate broader changes in peoples’ lives to enhance health (Green and Kreuter, 1991). For example, health education around tobacco issues might include school-based awareness programmes or smoking cessation courses. Health promotion around tobacco issues extends to legislation restricting access to tobacco products, bans on advertising and laws or policies restricting where smoking might be allowed. Health communication is the exchange of information in regard to health issues to raise awareness, develop a dialogue and to educate people. The main purpose of health communication is to influence health-related behaviours. Likewise, IEC is a general term for communication activities to promote a variety of issues including health. What all these approaches have in common is that they are based on the need to make those concerned become more effective communicators. In practice, health promotion encompasses health education and health communication approaches and can be viewed as an umbrella term for a range of educational and health promoting activities (Ewles and Simnett, 2003). The communication can be individually focussed on a one (the Practitioner)to-one (the client) basis, for example, a doctor talking to a patient in his/her surgery. The communication can also be focussed to reach a larger audience on health-related issues, for example, a group discussion that is used to develop a dialogue between the participants using their own knowledge and experiences. Communication can help individuals to gain power by providing: ●

●

●

an increase in health knowledge and skills, for example, for the preparation of an oral rehydration solution; information that is necessary for them to make a specific ‘informed choice or decision’ to have greater control in regard to health, for example, the benefits of breast feeding or immunisation; an increase in the understanding of the underlying causes of their lack of power, for example, unemployment and a low income.

䊏 One-to-one communication One-to-one communication is important because this allows a dialogue to develop between the client and the Practitioner. The dialogue is often based on a sharing of knowledge and experiences in a two-way communication that is necessary to help individuals to better retain information, to clarify personal issues and to develop skills. An example of this type of approach is provided in Box 4.1. Verbal communication is probably the most common channel of relaying information between the Practitioner and the client and can be either one-way (Practitioner to client) or two-way (sharing information between Practitioner and client). Non-verbal communication is also commonly used for providing information, for example, body language, posture and facial expressions.

42 · Public health Box 4.1 Developing Individual Skills in Canada In La Casa Dona Juana, a social space for Latin American women in Toronto, participants are helped by Practitioners to identify the different skills that individual members bring to the group and to its activities. Women who are skilled in writing prepare the grant applications, and teach other women, on a one-to-one basis, in the process. Women who are skilled in cooking take a leadership role in the collective kitchen, and pass skills on to other women during the process. Women who are skilled in budgeting plan the menus, again transferring their knowledge to other collective members on a one-to-one basis. In the ‘outside’ world, budgeting and grantwriting skills may be highly valued, and those who have them may be given more social status and power-over others. In La Casa Dona Juana budgeting and grants-writing are merely one set of social skills no more or less important than those involved in cooking, menu-planning or sewing. The purpose is to help others to build their own power-from-within by developing appropriate knowledge, skills and competencies within the group (Labonte, 1996).

Box 4.2 The GATHER Approach to One-to-one Communication G Greet the clients make them feel comfortable, show respect, trust and empathy. A Ask them about their problem: Help them to talk about their problems and needs, listen to them and encourage their feedback. T Tell them any relevant information: Provide technical information about their health issue, use simple language and focus on the important points. H Help them to make decisions: By exploring the options to their particular circumstances and by developing a realistic action plan. E Explain any misunderstandings: Ask questions and clarify any issues raised. R Return to follow up on them: Revisit, make a reappointment or refer the clients to another practitioner to ensure that the issues were understood and acted upon. Obtain and give feedback. (Adapted from Hubley, 1993, p. 97) Situations where one-to-one communication takes place include: ● ● ● ●

a health worker talking to a patient at a clinic; providing physiotherapy advice to an individual; counselling someone on a sensitive issue such as the result of a medical test; helping someone to cope with a difficult situation such as a bereavement.

Helping individuals to gain power · 43 The relationship of Practitioners with their clients can be influenced by the level of control (power) that they have through their choice of communication style. It is important to emphasise that the choice of the communication style is usually at the discretion of the Practitioner, who decides, based on the circumstances and the type of client, what is most ethically acceptable. For example, using a controlling approach such as a direct instruction to make the client take a prescribed medication might be seen as an unethical imposition of the Practitioner’s values. Whenever possible the Practitioner should consider a communication style that is non-controlling such as the GATHER approach outlined in Box 4.2 or follow a simple procedure of listening, giving advice and obtaining and providing feedback.

䊏 Learning to listen Listening is an active process and the Practitioner needs to focus on what the individual is saying and if necessary to help the speaker to express his/her feelings or to give an opinion on an issue. Box 4.3 provides a simple exercise that can help Practitioners to learn to listen to their clients. The skill of helping people to talk can be facilitated in one-to-one communication by inviting a person to speak, paying attention to what the person is saying, encouraging someone to continue speaking by using an occasional supportive sound, such as ‘mmm’ or ‘go on’, by exhibiting some empathy with the client such as ‘You seem unhappy’ and by providing a brief summary of what has been said and then asking the client to make a comment. When giving advice the Practitioner is exerting his/her expert and legitimate power to persuade the client into actually accepting a subservient role relationship. The relationship grants the Practitioner the right to prescribe advice (behaviour or

Box 4.3 Learning to Listen Work in groups of 3–6 people. Appoint someone as a timekeeper. 1

2 3 4

5

Person A speaks for 2 minutes, without interruption, on a subject of choice to do with work or a personal interest. Everyone else in the group listens without taking notes. Person B repeats as much as can be remembered accurately, without anyone else interrupting, using the same words and phrases as person A. A and the rest of the group, identify and agree to what was actually said. The group then discusses what helped them to listen, what helped them to remember, what hindered them from listening and how could they become better listeners? The exercise can be repeated until all members of the group have had a turn to speak and to listen. (Ewles and Simnett, 2003, p. 189)

44 · Public health knowledge) while the client accepts an obligation to comply with the advice. This can relate to a range of different types of information and behaviour change for a healthier lifestyle, for example, a reduction in body mass (nutritional advice). The Practitioner may have to use power-over in a form of dominance to control people’s choices. This is sometimes a necessary communication style when, for example, giving precise instruction such as the self-treatment of a wound by the patient. Obtaining and giving feedback enables the Practitioner to clarify what the client wants, that they have understood previous communication or retained skills. This may mean obtaining feedback based on specific information using closed questions that require short factual (yes/no) answers or based on an open form of questioning to provide fuller answers. Giving feedback is important for the achievement of effective communication and in particular positive feedback that reinforces the strengths of the client’s knowledge or skills level. The client is encouraged to share his/her concerns, feelings and opinions but the discussion is directed by the Practitioner. To facilitate this process the Practitioner can use ‘people centred’ approaches such as role play and story-telling or the use of participatory materials such as three pile sorting cards, discussion posters and flipcharts to help people to learn. An assessment of the procedure of communication involving listening, giving advice and obtaining and providing feedback can be an important part of the learning process for the Practitioner. A communication skills checklist is Table 4.1 Communication skills checklist (adapted from Lloyd and Bor, 2004, p. 190) Did the Practitioners Introduce themselves Use the client’s name Greet the client Explain their role and purpose Ensure that the client was comfortable Establish and maintain eye contact Listen to what the client was saying Use open-ended questions Inform the client that information would be recorded Maintain interest in what the client was saying during note taking Identify and respond to verbal and non-verbal cues Give appropriate and accurate advice Provide a summary of what was said and agreed Obtain feedback from the client Give a pleasant thank you and farewell

Yes

No

Comments

Helping individuals to gain power · 45 provided in Table 4.1 and can be used by trainers in role-play or practice sessions. The Practitioner is observed by the trainer, or by another Practitioner, who completes each section of the checklist and then provides immediate feedback. The identified strengths of inter-personal communication and the areas that need further work are then discussed to improve the ability of the Practitioner.

䊏 Combining communication channels Communication strategies can be made to be more effective for increasing knowledge by using a combination of channels as a part of the same intervention. The most commonly used channels are the mass media, print materials, one-to-one communication, popular media and school-based activities. The mass media includes radio, television, audio-cassettes and telecommunications such as the internet. These approaches are used to reach a large audience rapidly and at a relatively low cost. Print materials include posters, leaflets, booklets and flip charts and these can be used as a part of one-to-one communication to assist the transfer of information and skills when working with both literate and non-literate populations. The picture material is used to generate a two-way discussion between the Practitioner and the clients and is especially useful in an informal teaching environment such as with a group of mothers at a health clinic. Box 4.4 provides guidelines to Practitioners for using teaching aids, such as picture cards,

Box 4.4 Guidelines for Using Teaching Aids When using teaching aids such as picture cards the Practitioner should follow these simple guidelines: ● ●

●

●

●

●

●

Hold the visual aid up in a position that can be seen by all the clients; Start by asking the clients an open-ended question based on the visual aid, for example, ‘What do you see in this picture? Tell me what you see?’ Encourage participation by getting the client(s) involved in a two-way discussion, for example, by directing your question at a particular person; Relate what is said to their own lives by drawing on the experiences of the clients; Identify problems or concerns through the experiences identified by the clients. Some visual aids have been designed to specifically address problem identification, for example, ‘Story with a gap’ and ‘Unserialised posters’; Through the discussion and visual images identify solutions to the problems or concerns; Identify a strategic plan that provides actions to carry out the solutions to the problems identified by the clients (discussed later in this chapter). (Adapted from Linney, 1995)

46 · Public health A mass medium Television and radio

Popular media, puppets, songs, stories

One-to-one communication Counselling and direct discussion

Printed materials Leaflets and flashcards

Figure 4.1 Combining communication channels (adapted from Laverack and Dao, 2003, p. 367)

with their clients. Popular media include drama, songs and puppets and these are often used because of their entertainment value and ability to address sensitive topics with humour, such as the use of condoms. School-based activities include participatory exercises for life skills, competitions and contests and counselling (one-to-one communication) covering a range of issues. Communication strategies used in public health programmes have traditionally been implemented as interventions relying on only one or two channels, for example, a mass media campaign on road safety. This is because the frequency and design of communication activities has been largely determined by the availability of resources. Figure 4.1 offers a methodology that illustrates how different communication channels can be combined as a part of the same intervention. The communication intervention is represented as a triangle. Each point of the triangle represents a different communication channel that is implemented on a regular basis as part of the intervention, for example, weekly radio broadcasts, the distribution of leaflets and counselling sessions between the Practitioner and a client. The centre of the triangle represents an ‘opportunistic channel’, such as community theatre, one that is used when the opportunity arises, usually when people congregate in a public place, for example, at out-reach clinics, in shopping malls or at open-air markets. The combination of channels can be changed, to develop different communication interventions, and are designed to be used together to strengthen the approach. For example, formal didactic methods can be made

Helping individuals to gain power · 47 more participatory and more empowering when used with teaching aids such as picture cards and flipcharts. The triangle method in Figure 4.1 helps to make communication more effective by improving the flexibility, quality and delivery of interventions through better planning and implementation using a simple and structured approach. To achieve this, the triangle method is implemented in a way that is focussed, reinforcing, attractive, entertaining, simple and sustainable as shown below: ●

●

●

●

Focussed. The target audience(s) must be clearly identified. The message content must be specific to each target audience and to the purpose of the strategy. Reinforcing. The message content must be reinforced by being consistently delivered to the target audiences through different channels of communication. Attractive. The materials must be attractive in design: colourful, well presented clear and entertaining to appeal to the target audiences. Simple and sustainable. The approach should be low cost so that production and distribution can be reasonably sustained, for example, by using low cost leaflets or booklets for clients to take home and read.

䊏 Increasing the critical self-awareness of clients Helping individuals to gain power ultimately involves their ability to make and carry out healthier lifestyle choices. This often begins by increasing their critical self-awareness. I define critical self awareness here as ‘the ability of the individual to reflect on the assumptions underlying his/her state of health and on actions to achieve alternative behaviours or styles of living’. Critical self-awareness is a process of learning through discussion, reflection and action. There are many strategies that are available for Practitioners to use to help individuals to increase their critical self-awareness (see Srinivasan, 1993 and Welbourn, 1995). Here I describe three practical exercises that Practitioners can use in their everyday work: mapping positions of power; ranking complex issues; and strategies for decision making.

䊏 Mapping positions of power Susan Rifkin and Pat Pridmore (2001), two academic commentators on participatory approaches, provide a summary of several different techniques for mapping including geographical maps, social maps, institutional maps and seasonal calendars. The main purpose of all these techniques is to allow the individual to understand better, through a visual means, how they can build their power base (material and social) from an existing position of strength. Mapping positions of power (Box 4.5) is an exercise to help individuals to map or to identify their own positions of control in a simple visual way that is easy to interpret. The drawing can be a picture, a chart or another form of visual representation such as a

48 · Public health Box 4.5 Mapping Positions of Power 1

Individuals are asked to produce a small drawing showing themselves in a position of power-over another person in both a social and work setting. 2 After a few minutes they are then asked to produce a small drawing showing themselves in a position of powerlessness – that is when another person has power-over them in the same settings. 3 The individuals are asked to comment on how they feel in each situation. Which of the two positions felt most familiar? How can they change each situation to make them feel more comfortable? Does this involve more power-over, more power-from-within or more power-with the other person? (Welbourn, 1995, p. 138)

montage and can be created by using pencils, paints, chalks or pictures cut from magazine. The picture provides information about how the person is situated in relation to others in terms of geographical location, hierarchical status, time and work or personal relationship. The role of the Practitioners is to act as guides to individuals to encourage them to think critically about what are their own strengths (skills, knowledge), their access to external resources such as finance, health and education facilities and their ability to make decisions. Once the material and personal power-bases have been drawn or ‘mapped’ it is the role of the Practitioner to help the individual to develop a strategy for decision making and action (discussed later in this chapter). What is important is that the strategy only requires a small change in behaviour by the client in order to achieve more control (power), otherwise the decision can be made without the action being carried out by the client.

䊏 Ranking complex issues Ranking is a simple exercise by which individuals can ‘unpack’ complex issues or concepts, such as health, into its different elements so that they can be placed into a specific order and then further analysed. An example of this is provided by Ronald Labonte (1993) who asked several individuals to (rank) ‘Think of the last time you experienced yourself as healthy’, and then to write down a few phrases (categorise) that described the feeling, and the context. Box 4.6 provides a number of these individual expressions of feeling healthy. Noticeably absent from this list is any reference to disease or wellness, and the minimal attention given to physical evaluations such as fitness levels. Instead, the individuals often identified feelings of power as being closely associated with experiences of health, for example,

Helping individuals to gain power · 49 Box 4.6 Individual Expressions of Health being loved, loving being in control fitting in, doing relaxed, stress-free giving/receiving, sharing outdoors, nature friends, belonging, meaning in life able to do things I enjoy happiness, wholeness (Labonte, 1993)

power-from-within, feelings of ‘loving’, ‘being loved’, ‘giving’ and ‘belonging’ and power-over, ‘able to do the things I enjoy’ and ‘being in control’. Feelings of power, defined by one’s status and level of control, are therefore very important to our experience of being healthy. One cannot have low status without someone else having high status. One cannot be poor without someone else being wealthy (zero-sum power). The higher one’s social status (one’s power and wealth) the higher one’s health status. The more steeply hierarchical this distribution of power and wealth, the greater the difference in health status between those at the top and those at the bottom (Wilkinson, 1996). Ranking is also a way of asking the individual to prioritise or categorise issues that are important to them. The order in which the issues are ranked is made by the individual. The prioritised list can then be scored, giving the highest score to the issue at the top of the list and the lowest score to the issue at the bottom of the list. The Practitioner discusses the reasons why one issue is scored higher than another in the list. When working with clients who are non-literate, pictures or drawings can be used instead of words to develop a ranked list. This simple technique provides information that can then be used to develop strategies to resolve each issue in the list. Susan Rifkin and Pat Pridmore (2001) discuss several ranking techniques to help Practitioners to identify the priority concerns of their individual clients: preference ranking; pair-wise ranking; matrix scoring; and well-being or wealth ranking. Each can be used in a participatory manner to suit different client needs or used together to provide cross-checking information.

䊏 Strategies for decision making Choice, or the ability to exercise control over decisions, is the simplest form of power. Strategies for better decision making about different health options, can therefore be a very empowering tool for Practitioners to use when working with

50 · Public health individuals. Decision making is a highly complex procedure and a practical approach to promote the basic principles of this process is outlined below.

䊏 Developing a strategic plan for decision making This approach was developed by the author (Laverack, 2003) to promote decisionmaking skills with individuals and groups and has been field tested in a number of different cultural contexts.

䊐 Step 1. Ranking key options Individuals first make a list or ranking of the key options covering their particular health concern. The Practitioner can help by providing specific and accurate technical information to answer any questions about the issue. The ranking must come from the individuals without them being led or coerced by the Practitioner. If the number of ranked options is large, the Practitioner can assist the individuals to produce a prioritised list. For example, a ranked list for health options might include: 1 2 3 4

To stop smoking in the next six months; To do more exercise; To have a reduced calorie intake; To eat more fruit and vegetables.

However, the ranking of the different options or choices is in itself insufficient to empower individuals who must also have the ability to transform this information into decisions and actions. This is achieved through strategic planning for positive changes in each of the prioritised options using: A discussion on how to improve the present situation; the development of a strategy to improve upon the present situation and the identification of any necessary resources.

䊐 Step 2. A discussion on how to improve the present situation The individual is asked to decide how the situation can be improved for each prioritised option or health choice. The purpose is to first identify the most feasible actions that will improve the present situation and to provide a lead into a more detailed strategy that follows in Step 3. If the individual decides that the present situation does not require any improvement, no strategy will be developed. Taking the first ranked health option in Step 1 the actions to improve the present situation might be to: ● ● ●

Remove all cigarettes from the home and workplace; To attend motivation classes to help to stop smoking; To use a substitute for smoking such as chewing gum or nicotine patches.

Helping individuals to gain power · 51

䊐 Step 3. Developing a strategy to improve the present situation The individual is next asked to consider how, in practice, the most feasible actions can be carried out and, in particular, to identify specific activities, to sequence activities in order to make an improvement and to set a realistic time frame including any significant personal benchmarks or targets. Continuing from the example in Step 2 the strategy to improve the present situation to stop smoking might include the following sequence of activities: ● ●

●

●

Collect all cigarettes in house and dispose. Do not purchase any more cigarettes; Identify local classes. Make time to attend one class per week. Identify a friend to attend initial classes for support; Discuss best alternative products with a doctor or pharmacist. Make an appointment to speak with a doctor in the next 7 days; Buy product from pharmacy. Take on a prescribed basis for the next 3 months.

䊐 Step 4. Assessing resources The individual identifies the resources that are necessary to implement the actions, for example, technical information, equipment, finance, training, and so on. The Practitioner can help the individual to map the resources, both internal and external, and to provide technical advice. To achieve the strategy to stop smoking the resources necessary might include: ● ● ●

●

The availability of local self-motivation class; Money to pay for classes and time to attend the classes; Access to a pharmacy or Practitioner to discuss the best options for a smoking substitute and; Money to purchase substitute products.

䊐 The matrix The strategy for decision making can be visually represented by using a simplified matrix (see Table 4.2). The ranking is placed in the left-hand side column followed by sequential columns for (1) a discussion on how to improve the present situation, (2) a strategy to improve the present situation and (3) the resources necessary. The matrix provides a summary of the decisions and actions to be taken by the individual. This can provide the basis for an ‘informal contract’ between the Practitioner and the client to undertake certain tasks or actions and to provide resources or assistance within an agreed time frame.

52 · Public health Table 4.2 The decision-making matrix Ranking or priority

How to improve

Strategy to improve

Resources necessary

Stop smoking in the next 6 months

Remove all cigarettes

Collect all cigarettes in house and dispose

None

Do not purchase any more cigarettes Attend motivation classes

Identify local classes Make time to attend Identify friend to attend initial classes for support

Local classes or selfmotivation class via internet or postage Finance to pay for classes Time to attend classes

Purchase substitute gum

Discuss best product with doctor or pharmacist Buy gum from chemist

Pharmacy GP Finance to purchase gum

Take on prescribed basis

䊏 Fostering an empowering professional–client relationship Fostering an empowering professional–client relationship describes a process in which power-over is used carefully and deliberately by the Practitioner to increase the power-from-within of their client. This is the transformative use of powerwith as described in Chapter 3. The qualities of an empowering relationship include a non-coercive dialogue between the Practitioner and the client in the identification of needs or problems and practical actions, such as developing a decision-making matrix, to address and resolve the problems. The key role of the Practitioner is that of an ‘enabler’ and in Box 4.7 I provide some of the main characteristics of this type of an empowering practice. However, these characteristics do not apply to all public health work, for example, Practitioners involved in enforcement, licensing and legal proceedings will have fewer opportunities to empower others than those professionals working in an advisory role with individuals, groups and communities. This is because enforcement uses a power-over approach to maintain authority in contrast to an advisory and educational role that uses a power-with approach that can be used to build the power-from-within of other people. An empowering professional–client relationship when working with individuals, groups and communities also involves many of the characteristics and skills discussed in this book. For example, the ability to be a good communicator, a good listener, helping people to become more critically aware, dealing with conflict, linking individuals to groups that share their interests and building the capacity of these groups to develop into functional organisations and partnerships.

Helping individuals to gain power · 53 Box 4.7 Public Health Practitioners as ‘Enablers’ for Empowerment ● ●

● ● ● ● ● ● ●

Clearly defining and communicating their roles to their clients. Promoting the profile of their clients to funders and other support services. Promoting the profile of their clients to political leaders. Fostering the support of community leaders. Fostering the support of other community-based organisations. Brokering new partnerships with other organisations. Brokering new partnerships with the private sector. Facilitating change through activities such as skills training. Facilitating the involvement of socially excluded or marginalised groups. (Adapted from Laverack, 2004, p. 98)

An empowering professional–client relationship in public health also involves the Practitioner using an empowering discourse (ideology and language) that is conscious in linking the individual with his/her political context. The language that we choose to use as professionals can have a significant influence upon the clients with whom we work and it is this that I next explore in the context of public health practice.

䊏 The power of language It is worth noting that our language exerts considerable force in our world constructions and this will apply to our professional as well as our social worlds (Seidman and Wagner, 1992). In particular, the way in which ‘to empower’, the central action in an empowering public health practice, has been interpreted is critical. Labonte (1994, p. 255) discusses the transitive and intransitive meanings of the verb ‘to empower’. The transitive (direct) meaning is to ‘bestow power on others, an enabling act, sharing some of the power we hold over others’. Empowerment is cast as a relationship between the stakeholders of a programme, those with power-over and those without power. Empowerment becomes a dynamic in which this relationship continually shifts towards a more empowering situation where power is equitably shared between the stakeholders. However, the advantage is held by the one with the power-over and language becomes an important structuring factor in the professional–client relationship. The intransitive (indirect) meaning suggests the act of gaining or assuming power. This is the litmus test of empowerment because as already discussed, power in its purist form cannot be given but must be taken by individuals and groups who seek it. This is a process that can be facilitated by the Practitioner by helping to create the conditions

54 · Public health necessary to make it possible for power to be gained. In a professional–client relationship, this is a mutual role played out by the Practitioner who facilitates change, and the client who identifies and executes the change. The language used in public health largely uses the meaning of power in the transitive interpretation: bestowing it upon others. However in practice, public health simultaneously involves both interpretations of power. Power cannot be given but clients can be enabled by Practitioners using the intransitive meaning to gain or seize power from others. It is the relationship between the Practitioners and their clients that is the empowering mechanism to achieve control over the influences on their lives. ‘Empowerment’ has become a fashionable term. It is possible to be an ‘empowered’ consumer by buying a particular product, to be an ‘empowered’ customer by using a particular service or to be an ‘empowered’ viewer by watching a particular television show. What this language tells us is that the individual could gain more control (over decisions, resources, information) by partaking in a particular relationship. The ‘empowering’ relationship is cast between the different people, those with the power-over particular information or services and those without or with relatively less knowledge. In public health practice, the advantage is often held by the one with the powerover (the Practitioner) and the language that they choose to use can either strengthen or weaken the professional–client relationship. Box 4.8 shows how the use of language can have both an empowering and a non-empowering effect on the professional–client relationship. The first account of Beatrice uses a powerover approach in which the Practitioner presents a series of negative and nonempowering statements about the client. For example, Beatrice is described as being ‘unemployed’, ‘undernourished’ and having ‘a low birth weight’ child. The account implies a person who is unhealthy and powerless and when confronted by such a description, through her contact with different Practitioners and institutions, Beatrice may begin to internalise it as being true about herself. This process is called learned helplessness or surplus powerlessness, discussed in Chapter 3, and is a manifestation of powerover the client by the Practitioners or by the agency with which they work. In the second account of Beatrice she is portrayed by using positive language centred around her own capacities or power-base, for example, ‘trying to give up smoking’, ‘fluent in French and Spanish’ and ‘trained laboratory technician’. The account also provides opportunities for the Practitioner to have a role in helping the client to gain power, for example, providing Beatrice with baby-sitting facilities or referring her case to the housing department. This provides the basis for an empowering professional–client relationship, discussed earlier in this chapter, and is a manifestation of power-with the client. Technical terms are a part of the everyday language of Practitioners, for example, medical diagnostic vocabulary, and have evolved as knowledge and skills develop within a profession’s ‘subculture’ (other subcultures include ethnic groups, social class, sexuality). However the use of specialist language is often confusing to lay people or to professionals not part of the ‘subculture’. This can contribute to

Helping individuals to gain power · 55 Box 4.8 Language and the Professional–Client Relationship Which account of Beatrice is more empowering? Beatrice is: a low income, single mother; unemployed; is undernourished and anaemic; is living in a one room basement apartment; looking after two children, her first child was of low birth weight; not able to speak English well; a smoker and drinks alcohol. ● ● ● ● ● ● ●

Beatrice is: looking for work that will fit her skills as a trained laboratory technician; is trying to find ways to supplement her diet but is unable to afford extra money for food shopping; living in a small tidy apartment but is looking for better accommodation; looking after her two healthy and happy children; learning English at night-class but finds it difficult to get a baby sitter; fluent in Spanish and French; trying to give up smoking. ● ●

● ● ● ● ●

(Adapted from Labonte, 1998, p. 46)

their sense of powerlessness by emphasising a lack of access to knowledge and the ‘expert’ power of the other person using the language. The use of terms such as ‘high risk’ and ‘target group’ imply passivity and locate the problem within the group rather than as a relationship to the broader social and environmental health determinants. Whilst it may sometimes be necessary to use specific technical terms the professional–client relationship is more empowering when it uses language and terminology that is understood by the receivers so that they are not confused, alienated or mystified by the communicator. To build the power-from-within of their clients the Practitioner must relinquish the control over the use of technical language and engage in a more empowering language. In Table 4.3 I provide examples of the differences between an empowering and a non-empowering language. What an empowering professional language means in practice is that the Practitioners should be aware that no discourse is value-free. It is important to understand the influence of their professional language and to be sensitive to the position and perceptions of their individual clients. Such awareness is termed a ‘reflexive practice’ in which the Practitioners are critical about the way they use their knowledge and power (expert, legitimate) to have professional influence over other professionals and their clients. Scrambler (1987) provides an example of a

56 · Public health Table 4.3 Empowering and non-empowering professional language Empowering language

Non-empowering language

Uses simple technical terms

Uses complex technical terms

Focuses on the problem and solution seeking of the client

Focuses on the problems faced by the Practitioner

Uses local language, for example, shit sample rather than ‘stool sample’

Uses technical terms

Uses positive words to build the powerfrom-within of the client, for example, ‘Good, well done, try again’

Uses negative words that undermine the client, for example, ‘Not good enough, poor work’

Encourages participation, involvement and control by the client

Words that assume control will be used by the Practitioner

Promotes the idea of a partnership between the client and the Practitioner

Promotes the idea that the Practitioner has power-over the client in the relationship

Uses words that are non-patronising and non-paternalistic

Uses patronising and paternalistic language that treats the client like a child

Encourages feedback from the client to share his/her ideas and experiences

Language does not seek feedback from the client

Language is open, respectful, noncoercive and two way. Practitioner maintains eye contact and open body language

Language is coercive and didactic (one way). Body language is defensive, for example, Practitioner does not face client

consultation between a health professional and the client, a pregnant woman. The Practitioner began the discussion using ‘lay’ terms to describe the complications associated with her condition but quickly switched to a technical–rational language when her advice was challenged by the client. The client was then coerced into complying with the Practitioner because she suddenly felt uncertain and lacking in knowledge. The client had been disempowered by the Practitioner who was unaware of the switch to a technical, power-over use of language. Next, Chapter 5 discusses how the Practitioners, in their everyday work, can help groups and communities to gain power and introduces a new framework that enhances the ability of people to better organise and mobilise themselves towards empowerment.

Chapter 5

Helping groups and communities to gain power Helping groups and communities to gain power involves a process of capacity building and collective action. To understand how this process can be successfully applied to provide a more empowering approach to public health practice it is first necessary to consider what a ‘community’ is.

䊏 What is a ‘community’? It is important for Practitioners to think beyond the customary view of a community as a place where people live such as a village or neighbourhood because such areas can be just an aggregate of non-connected people. The main issue when working with communities is whether they are a social, geographic or demographic concept. Jim Ward, a Practitioner with experience of working with ‘street communities’ in Brisbane, Sydney and Toronto, describes these as ‘groups of people perceiving common needs and problems, that acquire a sense of identity focussed around these problems and that a common set of objectives grow out of these identified issues’ (Ward, 1987, p. 18). What can be concluded is that geographic communities consist of heterogeneous individuals with changing and dynamic social relations who may organise into groups to take action towards achieving shared goals. The concept of ‘community’ includes several key characteristics and these have been listed in Box 5.1. The diversity of individuals and groups within a geographic community can create problems with regard to the selection of representation by its members (Zakus and Lysack, 1998). Practitioners need to carefully consider who are ‘legitimate’ representatives of a community. Those individuals who have the energy, time and motivation to become involved in activities may, in fact, not be supported by other community members and may be considered as acting out of self-interest. In these circumstances, a dominant minority may dictate the community needs unless adequate precautions are taken to involve everyone. Within the geographic or spatial dimensions of ‘community’, multiple communities exist and individuals may belong to several different ‘interest’ groups or communities at the same time. Interest groups exist as a legitimate means by which individuals can find a ‘voice’ and are able to participate in a more formal way to achieve their goals, for example, through committees, social clubs and religious associations. Interest groups provide the opportunity for people to collectively

57

58 · Public health Box 5.1 The Key Characteristics of ‘Community’ 1 2

A spatial dimension, that is, a place or locale. Non-spatial dimensions (interests, issues, identities) that involve people who otherwise make up heterogeneous and disparate groups. 3 Social interactions that are dynamic and bind people into relationships with one another. 4 Identification of shared needs and concerns that can be achieved through a process of collective action. (Laverack, 2004, p. 46)

address mutual concerns, for example, the members of a smoking cessation club or broader concerns such as the siting of a new airport. These groups provide individuals with a vehicle through which they can take a step closer towards achieving their goals. This involves the collective action of individuals who share the same concerns and form a ‘community of interest’ which in turn seeks to gain power. The process of gaining power is ‘community empowerment’.

䊏 Community empowerment as a 5-point continuum Community empowerment has been most consistently viewed in the literature as a 5-point continuum comprised of the following elements (see also Figure 5.1): 1 2 3 4 5

personal action; the development of small mutual groups; community organisations; partnerships; and social and political action ( Jackson et al., 1989; Labonte, 1990).

Labonte (1990) claims that the continuum was first developed in Australia in workshops with health and social service workers in 1988. Labonte subsequently published his version of the continuum for community empowerment followed by Jackson et al. (1989) who published their version for community development in 1989 using a similar 5-point continuum. Rissel (1994) later adapted these two interpretations of the continuum to explain how psychological empowerment relates to the process of community empowerment. These three authors use slightly different terminologies that essentially hold the same meaning and represent the same conceptual design: the potential of people to progress from individual to collective action along a continuum. The continuum model has remained unchallenged in the literature and explains how collective action can potentially be maximised as people progress

Helping groups and communities to gain power · 59 The continuum model 1

2

Personal action

Small mutual groups

3

4

5

Community organisations

Partnerships

Social and political action

The empowerment domains Participation Problem assessment skills Leadership skills Organisational structures Resource mobilisation

Links to others Asking why

Figure 5.1 Combining the empowerment continuum and empowerment ‘domains’

from individual to community empowerment. The continuum model offers a simple, linear interpretation of what is actually a dynamic and complex concept. The continuum also articulates the various levels of empowerment from personal, to organisational through collective (community) action. Each point on the continuum can be viewed as a progression towards the goals of community empowerment: social and political action. If this is not achieved the community reaches stasis or even a moves back to the preceding point on the continuum. The development of community organisations in the continuum are crucial to allow small groups to make the transition to a broader network of alliances. It is through these partnerships that organisations are able to gain greater support and resources to achieve a favourable outcome for their particular concerns. The key challenge to public health is how Practitioners and the agencies they represent structure their work with the explicit intent to assist individuals and groups in the progression along the community empowerment continuum. There are limitations to the concept of a continuum of community empowerment. The groups and organisations that arise in the process of community empowerment have their own dynamics. They may flourish for a time, then fade away for reasons as much to do with changes in the people and community as with a lack of broader political or financial support. Public health practice is a part of

60 · Public health this dynamic, an important part that, as I explain in this book, can help people to become more empowered.

䊏 The ‘domains’ of community empowerment Several authors have attempted to identify the areas of influence on community empowerment (Goodman et al., 1998; Laverack, 2001; Rifkin et al., 1988). In Table 5.1, I summarise the work of other authors to identify areas of influence on overlapping concepts with community empowerment. This work has assisted in the identification of both social and organisational aspects and has been a useful step towards making this complex concept more operational. The practical purpose is to provide a guide to Practitioners in their planning, application and evaluation of empowerment approaches in public health programmes. The recent work by Laverack (2001, 2004) identifies a set of nine ‘domains’ of community empowerment: 1 2 3 4 5 6 7 8 9

Community participation; Problem assessment capacities; Local leadership; Organisational structures; Resource mobilisation; Links to other organisations and people; Ability to ‘ask why’ (critical awareness); Community control over programme management; and An equitable relationship with outside agents.

A summary of each domain is given in Table 5.2. Research was carried out to identify the empowerment ‘domains’ using: ● ● ●

a review of the relevant literature; a concept-mapping involving a textual analysis of case studies; and inter-observer agreement on selection of empowerment domains.

A review of relevant literature, with particular reference to the fields of health, social sciences and education, provided an in-depth understanding of programmes which sought to achieve the same empowerment goals: to bring about social and political change. The ‘domains’ were categorised from a textual analysis of the literature and the validity of this data was cross-checked by two other researchers using a confusion matrix approach as discussed by Robson (1993, p. 222). Although these nine domains have been used individually by Practitioners, both explicitly and implicitly in empowerment approaches, for many years, their purposeful integration in a public health programme context is more recent. The role of the Practitioner in empowering others has been traditionally concerned with facilitating the movement of people along the 5-point continuum as discussed above.

Table 5.1 The overlap of empowering concepts (adapted from Laverack, 2001) Community participation Rifkin et al. (1988) Factors

Community competence Eng et al. (1994) Dimensions

Community participation Shrimpton (1995) Indicators

Community empowerment Laverack (2001) Domains

Community capacity Goodman et al. (1998) Dimensions

Participation

Participation

Leadership

Leadership

Leadership

Organisation

Organisational structures

Sense of community, an understanding of community history and values Resources

Participation Machinery for participant interaction and decision making Leadership Organisation

Social support

Resource mobilisation

Resource mobilisation

Resource mobilisation

Needs assessment

Needs assessment/ action choice

Problem assessment

Self-awareness, clarity of definitions

Asking why

Critical reflection

Management of relations with wider society

Links with others

Social and interorganisational networks

Outside agents Management programmes

Management (programme)

Programme management

Training

Skills

Articulation

Orientation of actions

Community power

Commitment

Monitoring and evaluation

61

Conflict containment

62 · Public health Table 5.2 The empowerment domains (Laverack and Labonte, 2000) Domain

Description

Participation

Only by participating in small groups or larger organisations can individual community members act on issues of general concern to the broader community

Leadership

Participation and leadership are closely connected. Leadership requires a strong participant base just as participation requires the direction and structure of strong leadership

Organisational structures

Organisational structures in a community represent the ways in which people come together in order to socialise and to address their concerns and problems

Problem assessment

Empowerment presumes that the identification of problems, solutions to the problems and actions to resolve the problems are carried out by the community

Resource mobilisation

The ability of the community to mobilise resources both from within and the ability to negotiate resources from beyond itself is an important factor in its ability to achieve success in its efforts

‘Asking why’

The ability of the community to critically assess the causes of its own inequalities

Links with others

Links with people and organisations, including partnerships, coalitions and voluntary alliances between the community and others, can assist the community in addressing its issues

Role of the outside agents

The outside agent increasingly transforms power relationships such that the community assumes increasing programme authority

Programme management

Programme management that empowers the community includes the control by the primary stakeholders over decisions on planning, implementation, evaluation, finances, reporting and conflict resolution

A ‘domains approach’ gives a slightly different, and more precise, way of developing strategies whilst at the same time progressing along the continuum. The key question Practitioners need to ask themselves is: How has the programme, from its planning through its implementation, through its evaluation, intentionally sought to enhance community empowerment through each domain and at each stage of the continuum? (Laverack, 2004). I will now discuss a new framework to explain how Practitioners can combine the continuum model and ‘domains’ approach to build more empowered communities and relate this to the theory on power and empowerment discussed in Chapter 3.

Helping groups and communities to gain power · 63

䊏 A framework for helping groups and communities to gain power

Figure 5.1 illustrates the sequence of interaction between the empowerment domains and the continuum model. The purpose is to provide Practitioners with a better understanding of how they can strengthen the process of community empowerment and this book offers a number of practical suggestions for its application in a programme context. The role of the Practitioner when using this framework increasingly becomes that of an enabler at the request of the clients, in addition to the provision of resources, services and information. Table 5.3 summarises some of

Table 5.3 Role of the Practitioner to strengthen the process of empowerment Continuum model

Domain

Key role of the Practitioner

1. Personal action

Participation

Build a greater sense of control in peoples’ lives and bring them together in small groups around issues of mutual concern

2. Small mutual groups

Problem assessment skills Leadership skills

Assist the community to identify and prioritise its problems, solutions to the problems and actions to resolve the problems. To strengthen local leadership skills

3. Community organisations

Leadership skills Organisational structures Resource mobilisation Asking why

Strengthen organisational structures. Link organisations to resources and develop skills to identify, mobilise and access resources. Promote critical awareness (asking why)

4. Partnerships

Organisational structures Resource mobilisation Links to others

To develop a shared agenda with other organisations and build local partnerships and alliances between groups. Provide access to resources outside the community

5. Social and political action

Links to others Asking why

Provide legitimacy to the issues and concerns raised by the community by using their own expert power and political influence

64 · Public health the key enabling roles of the Practitioner in strengthening the continuum through each of the domains. The basic logic offered by the framework can be seen in everyday life by groups and communities seeking to gain power. This is often voiced as a struggle for social justice and equity, for example, the localised actions of residents to gain adequate street lighting, or the wider actions of citizens demonstrating against the poor governance of their country.

䊏 Empowering individuals for action 䊐 Continuum point 1 and empowerment domain: Participation A personal action to improve health can begin when individuals feel powerless about a situation, feel the desire to rectify, what they perceive as, an unjust situation or want to take action in response to an emotive experience in their lives. Kieffer (1984) provides an example of how this happened to one woman who became active in a small community support group for neighbourhood safety following an assault on her way home. The self-help group was working towards addressing the issues of her concern, for example, improved policing in her neighbourhood. In a programme context, the basis for personal action is most often developed during the planning phase through an identification of participants’ own needs and problems, and later developed as the aims and objectives. Individuals have a better chance of achieving their goals if they can share their concern with other people who are affected by the same or similar circumstances. By participating in groups and organisations, individuals can better define, analyse and then, through the support of others, act on their concerns. Zakus and Lysack (1998, p. 2) provide a useful definition of participation set in this context as: the process by which members of the community, either individually or collectively and with varying degrees of commitment: develop the capability to assume greater responsibility for assessing their health needs and problems; plan and then act to implement their solutions and create and maintain organisations in support of these efforts. Bracht and Tsouros (1990) and Goodman et al. (1998) address the issue of how individuals participate and agree in their conclusions that it is a combination of involvement in decision-making mechanisms, accessibility to community organisations and the development of appropriate skills such as planning and resource mobilisation. The advantage of participation is that community-based organisations are better at strengthening social networks, competing for limited resources and increasing the necessary skills and competencies of its members. Empowering individuals for action must therefore involve helping them to participate in group and community activities. Box 5.2 provides some of the main characteristics of participation in empowering others for personal action. Box 5.3 provides an example of how the participation in a group activity led to a direct personal action.

Helping groups and communities to gain power · 65 Box 5.2 The Characteristics of Participation in Empowering Others 1 2 3 4 5 6 7

A strong participant base involving all stakeholders, including marginalised groups, but sensitive to the cultural and social context. Participants define their own needs, solutions and actions. Participants involved in decision-making mechanisms at planning, implementation and evaluation stages. Participants are encouraged to extend into broader issues of the structural causes of powerlessness and to become critically self-aware. Mechanisms exist to allow free flow of information between the different participants through effective communication. Representatives are appointed by members of all groups. The Practitioner fosters an empowering professional–client relationship. (Laverack, 1999)

Box 5.3 Participation and Personal Action in Australia Some years ago a gay men’s group wanted to set up an information booth on HIV/AIDS in the market square of a small rural town in Australia. Every Sunday, vendors and community groups were entitled to set up their stalls. But the gay group was refused. Its members were told that their booth would offend families walking in the square. The group set up their booth anyway, claiming it was their democratic right. Police came. The media came. Arrests were made. And for over a year each Sunday, the ritual was replayed until the group’s right to be there was affirmed legally and politically. One of the organisers tells a story of how a media cameraman covering the story suddenly appeared one weekend without his camera. Instead, he linked arms with the demonstrators and ‘came out’ for this first time in his life before the media cameras of other national news stations. Something about the struggle for dignity had given him the courage to claim his own hidden identity with pride. The same organiser goes on to relate how the cameraman, months later and amongst a new group of friends, told him: I never practiced safe sex before that first Sunday in the market square. Until I saw others who were prepared to go to jail to defend my right to be who I was. It made me want to care and participate.’ ‘Since that Sunday, there’s never been a time I’ve had unsafe sex.’ (Labonte, 1993)

66 · Public health

䊏 Empowering groups 䊐 Continuum point 2 and empowerment domain: Problem assessment The involvement in and the development of small mutual groups by concerned individuals is the start of collective action. This locale provides an opportunity for the Practitioner to assist the individual to gain skills and is a locus for developing stronger social support and interpersonal connectedness. These are elements that are important for working with and empowering groups and for linking individuals to the groups and organisations that mobilise the resources necessary to support collective action. The role of the Practitioner at this point of the continuum is to bring people together in small groups around issues, which they feel are important. For example, the Practitioner can provide individuals with information about membership criteria, provide a list of contacts or websites for related groups, invite members of a group to give a presentation to interested clients or themselves act as a personal contact to introduce the client to a particular ‘interest’ group. Groups include: 1

‘Self-help’ or ‘interest’ groups organised around a specific problem such as ‘Weight Watchers’ or consumers wanting to find suppliers for organically grown produce. Members usually have a shared knowledge and interest in the problem, are participatory and supportive and the groups are often set-up and managed by the participants; 2 Community health groups that usually come together to campaign on a specific issue, for example, facilities for socially excluded groups such as the elderly. People are motivated to come together usually for short-term periods of time, however, these groups can also form long-lasting associations such as NIMBY’s (Not In My Back Yard) in regard to broader issues that influence geographical community such as the siting of a radio mast; and 3 Community development health projects such as neighbourhood-based projects set up to address issues of local concern such as poor housing, and with an appointed and paid government community worker (discussed further in Jones and Sidell, 1997). Andrew Jones and Glenn Laverack (2003) identify a number of characteristics of small, functional ‘interest’ groups: ● ● ● ● ● ● ●

Had a membership of elected representatives; The majority of its members met on a regular basis; Had an agreed membership structure (chairperson, secretary, core members, etc.); All members actively participated in the meetings; The group met with a Practitioner to discuss issues on a regular basis; Kept records of previous meetings; Kept financial accounts;

Helping groups and communities to gain power · 67 ● ●

Were able to identify and resolve conflicts quickly; and Were able to identify the ‘problems’ of and the resources available to the ‘interest group’.

Each interest group had achieved a number of successes, such as repairs to a school roof and better access to quality agricultural products, improvements to an irrigation system and the establishment of a handicrafts centre. These small successes had helped to build the confidence and the connectedness of the members of the groups. However, not all communities were found to have functional groups and some had the characteristics of a limited capacity. For example, the groups tended to focus on immediate needs or problems and whilst these were often important issues, it did not promote longer-term planning and sustainability. Consequently, the less functional groups viewed Practitioners not as partners in helping them to build their own capacity but rather as sources of credit (the term ‘partner’ implies a working relationship based on recognition of overlapping or mutual interests, and interpersonal and inter-organisational respect). The Practitioners were unintentionally acting as top-down and power-over sources of assistance even though their purpose was to facilitate a bottom-up and power-with approach ( Jones and Laverack, 2003). The membership of small groups is not homogeneous and conflict regarding internal issues can arise, especially during the shift from an inward (self-help) to an outward (social action) orientation. Ronald Labonte (1998) provides an example of this in a community garden project in Toronto, Canada that involved single mothers on social assistance. The group conflict was based on the importance of the garden. Some of the mothers saw the garden as a meeting place where they organised themselves to eventually become strong enough to address broader issues of social change influencing their lives. Other mothers saw the garden for the simple purpose of growing vegetables. Both activities, the self-help garden and the social mobilisation it could create, are important empowerment outcomes and illustrates how small groups can become focussed on individual problems and not necessarily on the deeper causes of poverty and powerlessness. Problem assessment skills are necessary for small groups to be able to identify the common problems of their members, solutions to the problems and actions to resolve the problems. When these skills do not exist or are weak the role of the Practitioner will be to assist the community to make an assessment of its own concerns and problems. A number of participatory methods have been developed specifically for this purpose including Participatory Rural Appraisal (Marsden et al., 1994) and also simple exercises such as three pile sorting cards and open-ended problem drama (Srinivasan, 1993) and pocket charts (Wood et al., 1998). Box 5.4 provides a practical technique, community stories, that can be used to help groups to make an assessment of its own concerns and problems. Ronald Labonte (1998) provides a practical example of how Practitioners used community stories to help their clients to address their concerns in Ontario, Canada. The government plans to implement progressive welfare reform in the province became stalled due to high costs. This sparked the creation of a massive

68 · Public health Box 5.4 Problem Identification through Community Stories Community stories are a practical exercise to help groups to identify important problems in their community, to help build mutual understanding and power-from-within. The exercise takes between 1 and 2 hours and uses a simple tool called ‘unserialised posters’ which are prepared in advance of the exercise and are pictures, for example, cuttings from magazines or handdrawn diagrams. The pictures show a variety of situations relevant to the community such as the building of a new road, a community meeting or a road traffic accident. The group members are asked to select four of the unserialised posters and to develop a story about their community using the pictures. The group is asked to give names to the people and places in the pictures and to give the story a beginning, a middle and an end. The group is then asked to present the story. Other participants are encouraged to ask questions about the story and in particular, the facilitator (the Practitioner) should ask: Are these stories about events in your community? What issues have been raised that could be considered to be problems in your community? How could these problems be solved? What other problems does your community face? The Practitioner keeps a record of the problems that have been identified during the presentation of the story. These points are then used to generate a discussion with the group on what it has learned during the exercise, what were its main problems and what problems it feels could be addressed by the community. The Practitioner can help the community to address its problems by, for example, developing a strategy to address its concerns and by linking the group to organisations or other groups that share the same concerns. (Adapted from Wood et al., 1998, p. 24)

coalition of welfare advocates, organisations, church and labour groups. A community health centre in a small neighbourhood, providing public health care and health promotion services, all managed by an elected board of residents, got heavily involved. The neighbourhood it served had a high ratio of single mothers on welfare who came to the centre for their medical services because the Practitioners spent time with them, listening to their concerns about money, counselling them on their stresses and hearing about their loneliness. But these services were not enough. The Practitioners knew that these women’s health problems were less rooted in their bodies, and even in their health behaviours, than in the structured inadequacies of the welfare system. These Practitioners created small groups on health exploration that offered a supportive learning experience, breaking through some of the isolation and learned helplessness engendered by poverty. The Practitioners used community stories as a practical

Helping groups and communities to gain power · 69 exercise to help the groups to identify the problems in the women’s lives. These stories wove a tapestry with the studies collected by other Practitioners in a powerful policy statement advocated by the board of residents. Practitioners, through their professional associations, lobbied senior government bodies, issued press releases, and joined with coalitions advocating reform. Board members met with politicians and with the media, addressed protesting rallies and linked with ‘social movement’ groups in their effort to locate the reforms within a larger social justice agenda. The failure of some Practitioners to recognise the importance of identifying and moving forward with the concerns of the community can be illustrated by the experiences of a public health programme in Sri Lanka. The funding agency held a number of meetings with the community members to discuss their health concerns. When asked what the main cause of ill health was in their community the people responded by saying that it was because of the ‘spirits’ coming from the cemetery. The agents acknowledged this but having already set their own agenda to build wells and latrines in the community they ignored these concerns and went ahead with a water and sanitation project. The community participated in the project by providing voluntary labour to dig the wells and latrines and by employing local masons to complete the stonework. The outside agent provided the funds to purchase the building materials. The result was that the community saw the wells and latrines as being part of a government project and most were never used and consequently fell into disrepair. Two years after the project started the community continued to blame their ill health on the ‘spirits’ (Laverack, 1999). The important lesson for Practitioners is that they must be prepared to listen to what the members of the group want, they may not necessarily like what they hear, but they must be committed to moving forward and building upon these issues.

䊏 Empowering groups for the development of community organisations

䊐 Continuum point 3 and empowerment domains: Organisational structures, ‘Asking why’, resource mobilisation and leadership skills

Community organisations include youth groups and community-based committees, co-operatives and associations. These are the organisational elements in which people come together in order to socialise and to address their broader concerns. Community organisations are not only larger than small mutual groups they also have an established structure, more functional leadership, the ability to better organise their members to mobilise resources and to gain the skills that are necessary to allow small groups to make the transition to partnerships and alliances. These skills include planning and strategy development, management of time, team building, networking, negotiation, fund-raising, marketing, managing publicity and proposal writing. While small groups generally focus inwards on the needs of their members, community organisations focus outwards to the environment that

70 · Public health creates those needs in the first place, or offers the means (resources, opportunities) to resolving them. Once the community has become more critically aware of the underlying causes of its powerlessness they can take the necessary steps to develop actions to redress the situation and to try to gain more power for themselves. There are many strategies that Practitioners can use to help to develop the ability of their clients to be more critically aware and many of these are based on the work of educationalist Paulo Freire (Freire, 1973). Freire originally developed his ideas on building awareness through learning or education in literacy programmes in the 1950s for slum dwellers and peasants in Brazil. The central premise is that education is not neutral but is influenced by the context of one’s life. People become the subjects of their own learning involving critical reflection and analysis of their personal circumstances. To achieve this, Freire proposed a group dialogue approach to share ideas and experiences and to promote critical thinking by posing problems to allow people to uncover the root causes of their powerlessness. This is an on-going interaction between the Practitioner and their client in a cycle of action/reflection/action and often leads to a collective social and political activity (Freire, 1973). This approach does involve a considerable commitment from the client to be able to gradually understand the causes of their powerlessness and to develop realistic actions to begin to resolve the situation. Caroline Wang and Mary Ann Burris (1994) discuss the application of Freire’s approach using a simple exercise called ‘Photo-novella’. In this exercise, the clients, women and children in rural communities, were given cameras to visually document their life conditions as they saw them. These images were then used to stimulate a dialogue to share ideas and experiences, facilitated by the Practitioner, to promote critical thinking to identify the actual causes of their powerlessness. This process of empowerment involves the education of the clients by the Practitioner who provides answers to their questions and access to supporting sources of information. The clients were encouraged to develop a strategy for action to resolve their identified problems towards greater control. Community organisations enable people to progress along the empowerment continuum by improving the ability of small groups to raise internal resources and to access external resources. Internal resources are those raised within the community and include land, food, money, people skills and local knowledge. External resources are those brought into the community by, for example, the Practitioner, and include financial assistance, technical expertise, ‘new’ knowledge and equipment. The ability of the community to mobilise resources from within and to negotiate resources from beyond itself is an indication of a high degree of skill and organisation. The role of the Practitioner is that of a link between appropriate resources and the community. Box 5.5 provides an example of how Practitioners can help groups and communities to mobilise resources. The development of community organisations and local leadership are closely connected. Leadership requires a strong participant base just as community organisations require the direction and structure of strong leadership (Goodman et al., 1998). Where leaders appear to have a limited vision of their

Helping groups and communities to gain power · 71 Box 5.5 Resource Mobilisation and Empowerment in South Asia Sue Wheat (1997), a reporter for the Guardian Weekly, describes how women in Bangladeshi communities are becoming more empowered through micro-financing with the help of the Grameen Bank (the outside agent). The success of the project’s outcome and loan repayment is attributed to the solidarity of small community organisations, social support and the financial advantage offered by the loan. Although the loans are small, the Grameen Bank covers more than one-third of villages in Bangladesh with over 22,000 borrowers amounting to more than 1.8 million dollars. However, whilst the loans are intended to give women more control over decisions regarding income generation the issue is more complicated as 63 per cent of women claimed to have only ‘partial, very limited or no control over their loan’. This indicates that patriarchal control is dominant.

aims or lack a strategy, the role of the Practitioner is to help develop their skills, for example, in management, accounting and proposal writing. The Practitioner should also consider: who represents the ‘community’, how they are selected, what is their existing level of training and skills and what is the balance between their economic and traditional influence in the community. The problem of selecting appropriate leadership is discussed by Goodman et al. (1998), who argue that a pluralistic approach in the community, one where there is an interplay between the positional leaders – those who have been elected or appointed and the reputed leaders – those who informally serve the community, has a better chance of leading to community empowerment. Otherwise, the dominance of one leader may result in them using their power-over the community, or groups within the community, to manipulate situations to their own advantage. Lucy Earle et al. (2004, p. 27), a community development researcher, and her colleagues provide an example of the manipulation of programmes by local leaders in Central Asia. The village leader in one community had used his influence to obtain assistance from an NGO to help provide irrigation pipes and an electric pump to improve the water supply of the community. But not all members of the community were satisfied with these developments, especially groups of lowincome women. The water supplied was too expensive for them and the pipes were laid to better serve the family members of the village leader. However, they could not complain because to contradict the leader could mean serious consequences for the livelihoods of poor families; for example, the village leader provided temporary employment during harvest and distributed flour to poorer residents. Not only did the leader hold an influential position in the community but his sons also held posts in the local government administration. The village leader was able to use his power-over others in the community, mostly over marginalised groups, to manipulate the distribution of resources and gain access to decision-making processes.

72 · Public health

䊏 Empowering community organisations to develop partnerships

䊐 Continuum point 4 and empowerment domain: Links to others To be effective in influencing ‘higher level’ policy decision making, community organisations need to link with others sharing similar concerns. The purpose of partnerships is to allow community organisations to grow beyond their own local concerns and to take a stronger position on broader issues through networking and resource mobilisation. The key empowerment issue is to remain focussed on the shared concern that brings the groups together, and not on the individual needs or issues of the different groups in the partnership. Ronald Labonte (1993) provides an example of the role of a Practitioner who convened a committee on housing standards with local activists who wanted safer, better heated homes and more affordable living conditions. The Practitioner desired her agency to be more relevant to the issues expressed by community groups. The committee met for a year, documenting that the activists’ concerns were legitimate. The report then went through a prolonged process of internal review by the management. Eventually, the recommendations were rewritten, watered down in a completely non-challenging, non-committal way. By this time, the community groups had withdrawn from the partnership, feeling that their demands had not been honoured. The mistake was in confusing partnership in a bureaucratic process (putting the health agency and local authority in the centre) with participation in a social change process (where the problem of ensuring policies for healthy housing are central). Instead of asking ‘How can I involve community groups in my policy work?’, the partnership question the practitioner should have been asking herself is ‘What activities are best suited to effecting political change in housing policy.’ Korsching and Borich (1997, p. 342) provide another useful account of how small rural communities in Iowa, America have started to empower themselves by forming cluster communities. A cluster community is defined as ‘voluntary alliances between two or more communities to address common problems, needs and interests’. The communities were faced with concerns common to many rural populations: a lack of resources; a decline in employment; loss of young people and the closing of businesses and institutions caused by sweeping social and economic changes in society. In response, many community groups have adopted a similar strategy of creating partnerships to pool resources, discuss issues and plan for action. Korsching and Borich (1997) argue that the emergence of cluster communities follows a familiar pattern; initiation by a concerned individual or organisation, establishment of meetings with other groups, formal organisation, development of further links and partnerships through an expansion of community concerns to address broader issues. To be successful, the clusters initially remained small scale but soon became legal entities and developed links with private and public organisations such as companies and universities. The strength of the cluster concept lies in its ability to establish productive links with others whilst

Helping groups and communities to gain power · 73 at the same time remaining flexible and small enough to allow the participation of community members to be maintained. The role of the Practitioner was first to help to bring cluster communities together and then to support the positions raised by local partnerships, helping to legitimise the issues by their ‘expert’ power in the development of supporting policy.

䊏 Empowering communities to take social and political action

䊐 Continuum point 5 Whilst individuals are able to influence the direction and implementation of a programme through their participation this alone does not constitute community empowerment. If concerned individuals remained at the small mutual group level, the conditions leading to their poverty would not be resolved. Equally, if concerned individuals only engaged in mainstream forms of ‘action’ such as voting, when their concerns are often diluted by being represented by people in authority and by decisions being made centrally, those with power-over economic and political decisions would have little reason to listen. The individual plays a small part in the process and his/her role is often indirect and passive, for example, that of writing to a local political representative, registering a complaint, lobbying or putting one’s name on a petition. Practitioners are involved in approaches in their day-to-day work in ways that can help their clients to become more critically aware and to take a more active role in social and political issues through collective action. This involves encouraging their participation in community groups and organisations and in partnership development towards direct actions such as publicity campaigns, civil protests, public demonstrations and legal action. Gaining power to influence economic, political, social and ideological change will inevitably involve the individuals, groups and communities in a struggle with those already holding power (a zero-sum situation, discussed in Chapter 3). Within a programme context the role of the Practitioner, at the request of the community, is to build capacity, provide resources and technical support to individuals, groups and organisations. Practitioners need to recognise that an empowering public health practice is a political activity. The structures of power-over, of bureaucracy and authority remain dominant and part of the role of the Practitioner is to strive to challenge these circumstances, in favour of the clients. Finally, it is important to recognise that empowerment takes on meaning in relation to issues around which the group impetus grows or fades. There is never absolute power or empowerment for individuals, groups and communities. Rather, both only ever exist in relation to particular issues around which clients act together to create, or to resist, change. It is through individual action and collective empowerment that people can gain the power that is necessary to address their concerns. The skills, competencies and capacities that they will need to develop

74 · Public health can be supported as part of the everyday work of Practitioners. The framework discussed in this chapter is a means to better conceptualise how individuals can progress from a position of personal concern to a point where they are collectively and actively involved with redressing the deeper underlying causes that influence peoples’ health and lives, such as, poverty, unemployment and powerlessness. Next, in Chapter 6, I discuss a means by which Practitioners can help marginalised groups to gain power and, in particular, discuss an example of helping to empower indigenous communities involved in a public health programme.

Chapter 6

Helping marginalised groups to gain power 䊏 Introduction Marginalisation is a process by which an individual or a group of individuals are denied access to, or positions of, power, for example, economic, religious and political, within a society (Marshall, 1998). Marginalisation is relevant to public health practice because these groups often exist on the margins of a society from where they can become excluded from the access to health and education services. In practical terms we consider marginalised groups to be those that are most in need, not able to meet their own needs, have a limited access to resources, are powerless or exist largely outside dominant social power structures. Marginalised groups include the elderly, the mentally ill, people of a low socio-economic status. Marginalisation can also be based on gender, ethnicity, (dis)ability and sexual preference. Although marginal groups are often a small population size relative to other groups in society they can actually be a numerical majority, for example, coloured people in South Africa during apartheid. Simpson and Yinger (1965) provide a broad based interpretation that does not place a numerical value on minority but its emphasis is on the social position of the group (see Box 6.1). This definition also refers to the psychological status of the minority and their status within social power structures: do they feel themselves to be members of a particular social group that is clearly distinguished by them from other such groups? The group regard themselves as objects of collective discrimination having been singled out from the majority of others in the society in which they live, or by those who hold positions of power, for unequal treatment. Helping marginalised groups is an important part of the work of Practitioners because these people are often less likely to participate in public health programmes. It is a paradox of empowerment approaches that the most marginalised populations are often unable to articulate their needs, are not represented or are unaware of opportunities and, as a result, do not have the opportunity to voice their concerns. The circumstances of their marginalisation, or the low self-esteem that it produces, can also contribute to their exclusion from, for example, main stream public health programming. In a programme context, this might manifest itself as the exclusion of particular representatives from meetings between those in power (the Practitioner) and the community leaders.

75

76 · Public health Box 6.1 Defining Minority Groups Minorities are subordinate segments of complex state societies, have special physical or cultural traits that are held in low esteem by the dominant segments of the society, are self-conscious units bound together by special traits which their members share. (Simpson and Yinger, 1965, p. 17)

Practitioners who want to work with marginalised groups must have a clear understanding of: ●

●

What are the circumstances that cause the marginalisation of their clients, for example, inequalities in access to education or health facilities, prejudicial policies, negative societal attitudes or hegemonic political power structures. These structures can exclude others in society, predicate inequality and contribute to the powerlessness of marginalised groups. They refer to a hierarchy of social and political power that can exclude those who do not conform to societal values and can occur directly, for example, a government policy that makes homosexual practices illegal, or indirectly, for example, structures that provide low socio-economic children with poorer educational facilities thus restricting later opportunities for employment. This incorporates the concept of social inclusion/exclusion and raises the question: How do Practitioners include individuals and groups into a set of social and political power structures that are responsible for excluding them in the first place? It also raises the question: To what extent do the efforts of Practitioners to include marginalised groups only situate them in a position of relative powerlessness without actually challenging the hierarchical structures that created it; How material powerlessness can lead to internalised psychological powerlessness, for example, the distress experienced with the unfairness of their lack of material power (access to resources, wealth) is internalised as aspects of their own ‘badness’ or ‘failure’ and adds to their sense of powerlessness and low selfesteem. Jim Ward (1987, p. 21), a Practitioner with experience of working with skid row populations (concentrations of unemployed males), provides an example of their internalised sense of ‘badness’: ‘we are where we are because of what we are … bums are bums because they are lazy, stupid etc.’. The members of this marginalised group did not recognise that their circumstances were the result of wider structural reasons such as a weak economic policy leading to a high level of unemployment. Their sense of uselessness was reinforced every time they came into contact with a ‘non-marginal’, including government workers such as the staff at the social services department. This raises the issue of what should get a greater priority: using resources to work directly with marginalized groups or working to change the policies that create the circumstances that exclude them.

Helping marginalised groups to gain power · 77 Indigenous communities are a marginalised group to whom Simpson and Yinger’s interpretation of a ‘feeling of belonging or not belonging’ has particular relevance. Indigenous communities can be a collection of families, language groups or clans who can be in competition with one another and who may be geographically isolated (Scrimgeour, 1997). Whilst not homogeneous, indigenous groups do largely share the same needs and interests especially in regard to public health. An example of indigenous communities living as a marginalised group within society is the Aboriginal people in Australia. Whilst traditionally living a nomadic and rural lifestyle, Aboriginal people now mostly live in urban areas where they form a minority group. Aboriginal people experience a public health status well below the Australian average, as for example, indicators of child survival rates, birth weight and the growth and nutrition of babies. Much of the poor physical health of Aboriginal people has been related to their poor psychological health resulting from cultural disintegration, dispossession of their lands, unemployment, poverty and the feeling of not belonging to the wider society in which they live (O’Connor and Parker, 1995). I next present a case study to describe an approach that can be used by Practitioners to help Aboriginal groups to gain power. To protect the privacy of the members of the community the names of individuals and the identity of the location have not been used in the case study.

䊏 A case study of helping marginalised groups to gain power

This remote community is situated approximately 400 kilometres or 1 hour by light aircraft from Darwin, Australia in scheduled Aboriginal land. A total of fifteen clan groups occupy the community and relate to one another through three ceremonial groups who form the foundation for the Council of Elders. The estimated population is 2200 of which 68 per cent are under the age of 25 years and more than 32 per cent are school aged. The members of the community have a low socio-economic status and this combined with an isolated location and the lack of opportunity for its young population has led to a high rate of unemployment. As a consequence, crime and juvenile offences, drug abuse and conflict between the clan groups are real issues that threaten to undo the social fabric of the community. The Council of Elders were well aware of these issues and considered the break down in family values to be an important factor in the social problems of the community. Although the community is not homogeneous, its members do share the same needs and interests to improve their health and to address its social issues. With the help of the Practitioner, the Council of Elders submitted a proposal to the Northern Territory health authorities to ‘re-establish traditional family values through family support and community infrastructure’. The overall aim of the proposal was to increase the self-esteem and cohesion of the community. The proposal offered a number of strategies to improve the health of the community

78 · Public health including better access to recreational facilities. The central argument of the strategy was that a swimming pool would provide the focus to improve public health, safety and the cohesion of the community.

䊏 The public health context The main physical health benefits of swimming pools in Aboriginal communities include a reduction in skin and ear infections and injuries. In hot weather children will seek out opportunities to swim and play in water. Where a swimming pool is not available children use creeks, billabongs, sewage tanks and the sea (Peart and Szoeke, 1998). These unregulated water sources are a hazard to health because of heavy bacterial contamination and the risk of injury from hidden objects, jellyfish, crocodiles and sharks. Skin infections such as scabies are a major problem in Aboriginal communities. In one study, 48 per cent of children examined in an inland community had skin sores (pyoderma) that showed an encouraging improvement after a swimming pool was built (Carapetis et al., 1995). It is estimated that between 10 and 67 per cent of school children in Aboriginal communities have perforated tympanic membranes and a further 14–67 per cent suffer from some degree of hearing loss. The presence of swimming pool facilities in remote Aboriginal communities has also been associated with a reduction in the infection of the middle ear (otitis media) (Peart and Szoeke, 1998). Silva et al. (1998) conclude that 93 per cent of all Aboriginal drownings in the Northern Territory of Australia between 1985 and 1994 were in open waterways. Aboriginal children are twice as likely to die from accidents, including injury, and drowning. No deaths were recorded from drowning in Aboriginal communities in a supervised swimming pool. Swimming pools provide a place of recreation where youth, families and adults can meet and participate in physical activities. This is important because obesity is an increasing health problem in Aboriginal communities. Supervised pools in Aboriginal communities can discourage anti-social behaviour such as petrol and glue sniffing, the use of alcohol and violence. The pool is an environment where people can feel safe and where they can enjoy the company of others away from their home. Swimming pools provide the opportunity to promote public health, hygiene and safety amongst the whole community and, in particular, amongst the principal users of the pool, the young people. Swimming pools also provide the opportunity to build social relations, community cohesion and empowerment. However if not properly maintained and supervised they may become a major vector of disease and a number of pathogenic organisms have been isolated from the water of inadequately maintained swimming pools including staphylococci and cryptosporidium.

䊏 An approach to promote health and empowerment To promote the health and empowerment of the community through the swimming pool, the principles of the Ottawa Charter for Health Promotion

Helping marginalised groups to gain power · 79 (World Health Organisation, 1986) and the nine ‘domains’ discussed in Chapter 5 can be applied. Public health and health promotion are two approaches that overlap in their purpose to redress inequalities in health through community-based action. Central to both these approaches are the concepts of power and empowerment and in particular the involvement of individuals, groups and communities. Community empowerment is embraced as a key strategy in the Ottawa Charter which identifies five action areas for achieving better health: (1) Building healthy public policy; (2) Creating supportive environments; (3) Strengthening community action; (4) Developing personal skills; (5) Reorienting health services. The Charter also refers to enabling people to increase control over, and to improve, their health, as an important role for Practitioners. Enabling means ‘taking action in partnership with individuals or groups to empower them, through the mobilisation of human and material resources, to promote and protect their health’ (World Health Organisation, 1997).

䊏 Strengthening community empowerment The area ‘strengthening community action (empowerment)’ is referred to in the Charter as follows: Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities, their ownership and control of their own endeavours and destinies. (World Health Organisation, 1986, p. 2) The Charter describes an empowered community as one in which individuals and organisations apply their skills and resources in collective efforts to address health priorities and meet their respective health needs. A distinction can be made between individual and community empowerment. Community empowerment involves individuals acting collectively to gain greater influence and control over their health. In the programme this translates to the community increasing control over, and improving the health of its members through the swimming pool. The ‘domains approach’ is specifically designed to strengthen community action through each of the nine empowerment domains as follows: Participation: Special efforts are made to ensure that representatives from all the clans in the community participate in group discussions during the preparation of the programme. People are encouraged to take an active interest in the programme through raising their awareness in regard to the public health benefits of utilising the pool and how these extend into the home. Regular meetings are held in the community centre to discuss the programme, facilitated by the Practitioners, Public Health Officers and Aboriginal Health Promotion Officers.

80 · Public health Leadership: The Council of Elders are responsible for the development of the pool but other local leaders should also be involved in the planning and administration of the programme, for example, the representatives of youth groups. These leaders can receive training and instruction in management skills to allow them to take more control of and to plan to run the pool. At the beginning of the programme the leadership is guided by the Practitioners who hold regular consultations with the local leaders. This process can be facilitated by providing specific technical support, for example, to undertake a cost–benefit analysis of the pool programme, to help guide the Council of Elders. The purpose is to increasingly devolve responsibility for the pool to the community, even if this is in a small way such as facilitating a meeting. Problem assessment: The Council of Elders (the people representing the community) are encouraged to map and prioritise the immediate (short-term) ‘problems’ in developing the pool. These might include a lack of community support, lack of money and low skill level in managing a programme of this size. These issues then become the basis for the planning of strategies for decision-making activities and for the identification of the resources necessary to support these new roles (discussed in Chapter 4). Asking why: Discussions during the problem assessment exercise can lead the participants to begin to identify the underlying causes of their powerlessness and poor health, for example, youth unemployment and social conflict between clan groups. Community development can be constrained by a bureaucratic or political system that does not always address these circumstances. It was a ‘critical awareness’ of, what the community representatives had felt to be, the injustice of their circumstances that had led to the inception of the swimming pool proposal. The Council of Elders had recognised that it was essential to increase the self-esteem and cohesion of the community in order to also begin to improve public health. Organisational structures: The Council of Elders gave responsibility to an existing community organisation, the Community Management Board, to manage the pool programme. Other organisational groups within the community can also be involved in the discussion of key issues in regard to the pool, for example, the women’s centre. To enable people to increase control of, and improve health through the management and supervision of the swimming pool it is necessary to develop an understanding of the key issues. For example, the health and safety issues in relation to the pool, the need to keep the pool area clean including the toilets, showers and pool surround and the prevention of potential accidents. The health promotion action area ‘developing personal skills’ provides opportunities for better access to information and education through the development of personal skills. Skill development increases the options available to people to exercise more control over their own health and environment. This can be facilitated in the school, the Community Management Board, the women’s group or at the swimming pool and would involve technical and management skills training,

Helping marginalised groups to gain power · 81 facilitated by the Practitioners. A pool for this size of a community can attract an estimated 200–300 people per day (Peart and Szoeke, 1998). This provides an opportunity to observe behaviour, identify children with potential problems of abuse and to talk with and listen to young people. Skill development for at least one pool supervisor should include an understanding of the social problems faced by young people. This person will act as a liaison officer with departments such as Mental Health and Family and Children’s Services. Resource mobilization: Public swimming pools invariably operate at a loss. These costs are borne or subsidised because swimming pools are seen as a recreational facility that promote the well-being of the population. A survey of 13 swimming pools in remote Aboriginal communities identified costs for supervision, security and maintenance as the most important economic considerations and often the greatest obstacles to sustainability (Peart and Szoeke, 1998). The community may have access to only limited resources but will still have to raise finances to maintain the pool, for example, the replacement of chemicals, repairs to pumps and filters, replacement of water and repairs caused by vandalism. The community can start to raise additional internal resources on a small scale through fund raising and entrance fees and raise external resources through seeking small government funding, assisted by the Practitioner. Links to others: There are other remote Aboriginal communities which have had many years of experience in managing swimming pools. The community can use strategies to develop links with other communities that already have a pool and arrange for visits to exchange experiences. The members of the Community Management Board may visit these communities to discuss the key issues. If this is not possible, the community may invest in a computer and internet link with the resources it had raised to help establish contacts to both national and international organisations involved in running pools in remote settings. The Practitioner can assist by providing a list of suitable contact addresses of organisations and communities involved with community-based swimming pools and/or provide funding to buy a computer. Outside agents: The Practitioners can play an important role in helping the community to raise resources, develop skills and capacities, gain access to policy makers and to support the programme through their own ‘expert’ and legitimate power, for example, by raising the concerns of the community with government officials. Programme management: The purpose of programme management is to increasingly give control to the Community Management Board. This includes management, decision making, administration, fund raising and liaison with government officials. The role of the Practitioner should diminish but remain to provide assistance and resource support at the request of the Community Management Board. The support of the Practitioner is especially important at the beginning of a programme when the confidence and skill level of the community members may be low and capacity building has to be developed.

82 · Public health

䊏 Building healthy public policy and creating a supportive environment

The action area ‘building healthy public policy’ is characterised by an explicit concern for health and equity in all areas of policy and by an accountability for health impact. The aim is to create a supportive environment to enable people to lead healthier lives and include settings where people live, their local community, their home, where they work and play. In turn, supportive environments for health offer people the opportunity to expand their capabilities and develop self-reliance including people’s access to resources for health and empowerment.

䊐 Building healthy public policy There is an opportunity to promote health in the community through a swimming pool facility by sanctioning a policy on health. The purpose is to provide equal access to the pool to everyone in the community as an enjoyable, hygienic, safe and health-promoting facility. This would be co-ordinated with other stakeholders including governmental departments such as environmental health, the community school, the Police and Sport and Recreation. Health and safety public policy at the pool might include ●

● ●

The design of the pool and washing/toilet facilities use materials that promote safety and hygiene. For example, floor surfaces are non-slip, soap dispensers are provided in toilets, obstacles and hazards are removed. The entrance fee should be affordable to children and adults. Anti-social behaviour of young people and youth is minimised. Any child not attending school is prohibited from gaining access to the pool that day: ‘A no school no pool policy.’

䊐 Creating a supportive environment To create a supportive social and physical environment that promotes health, it is necessary to recognise that people are an integral part of the pool environment. The pool provides an opportunity for people to socialise in a safe and enjoyable setting and this facility should promote ‘healthy’ activities for all members of the community: ●

●

●

The pool facilities should cater for all sectors of the community, for example, water play for children, swimming for youth and adults, wading and leisure areas for the elderly and screened areas for women. The pool area should cater for out of water activities, for example, shaded areas for sitting, grassed areas to play ball games and a barbecue. Proper supervision by pool staff should be carried out at all times and this must be supported with established rules and regulations regarding conduct in the pool area.

Helping marginalised groups to gain power · 83

䊐 Reorienting health services The role of the health services is to move beyond its responsibility for providing treatment and curative services. The health services need to embrace a wider mandate, one that is sensitive to the socio-cultural needs of Aboriginal people. Using the pool as the focus for promoting health in the community, the role of the health services is to support the physical and social aspects, for example: ●

●

●

The health clinic staff should be provided with additional resources to deal with potential accidents and injuries at the pool, for example, chemical spillage, broken limbs and drowning. Young people identified with social problems or anti-social behaviour such as drug abuse must be provided with the support they require from a trained supervisor. These cases may be referred to the appropriate service for follow-up. Health clinic staff in the community will require to be trained in the use of health education materials so that they can also carry out the dissemination of information regarding the health benefits of the pool.

The public health outcome of the pool programme is an improvement in the health and well-being of the community. The empowerment outcome of the pool programme is to give Aboriginal people more control over the decisions regarding the development of the swimming pool and that will in the future be more capable of addressing other shared concerns. For example, in Aboriginal communities other key concerns include housing repair, living conditions and overcrowding. An insanitary living environment makes personal hygiene more difficult to maintain and this has been shown to have an adverse affect on the nutritional status and health of Aboriginal children. Continual diarrhoeal infections in children, caused by enterogenic pathogens ingested primarily through contact with faecal material in food and water, leads to a deterioration of the small gut lining and to the subsequent malabsorption of nutrients (Kukuruzovic et al., 1999). The empowerment outcome can be specifically strengthened through each of the nine ‘domains’. This is achieved by the development of strategies to support each of these aspects of empowerment where a need has been identified by the community. In turn this strengthens the social aspects of empowerment, for example, the existence of functional leadership, supported by established organisational structures with the participation of all its members who have demonstrated the ability to mobilise resources, would indicate a more cohesive community, which has begun to develop strong social support elements (Laverack, 2001). The process of empowerment, as discussed in Chapter 5, strengthens the cohesiveness of the community and builds the competencies and skills of its members. This process can be facilitated by the Practitioner who brings individuals together in small groups or by working with existing groups, such as the women’s centre. The development of the swimming pool can provide the focus and direction for the community, with guidance from the Practitioner, to channel resources and around which its members can organise and mobilise themselves.

84 · Public health The accommodation of empowerment as an outcome within the swimming pool programme can be illustrated by using a ‘parallel track’ approach as discussed in Chapter 2. An example is provided in Figure 6.1 to show how at each stage of the programme cycle: objective setting; strategic approach; implementation and management; and evaluation, the public health track has been matched by an empowerment track. This provides the empowerment outcome, a more capable community, and with an equal priority to the public health outcome, a healthy community. Both the process and outcome of the empowerment track can be measured and visually represented through using the approach discussed in Chapter 7.

1. Programme Design Phase: Identification; Appraisal; Approval

Public health track

Empowerment track

2. Programme objectives To improve the health and well-being of the community i.e. epidemiological data

Empowerment objectives Objectives

3. Strategic approach Combining the principles of the Ottawa Charter for Health Promotion and the nine empowerment domains

Strategic approach

Strategy

4. Strategic Implementation and Management Phased release of responsibility for management of the programme to the Community Management Board

Following the empowerment continuum: Individual empowerment – small groups – organisations – networks – social and political action

Empowerment domains

Manage

5. Evaluation of the programme outcomes Participatory approaches to include community members and morbidity and mortality indicators

To empower the community to be able to manage the pool facility

Planned and positive changes in the domains: Participation, organisational structures, links with others, resource mobilisation, leadership, outside agents, programme management, asking why, problem assessment

Evaluation of empowerment outcomes Evaluate

Evaluation techniques used for each domain including visual representation (Chapter 7)

Figure 6.1 Applying the parallel-track approach (adapted from Laverack and Labonte, 2000, p. 257)

Helping marginalised groups to gain power · 85 As discussed in Chapter 3, power in its simplest form is about control over decisions and choices, both at the individual and collective levels. In an Aboriginal context, this is a complex issue. The nomadic ‘hunter–gatherer’ culture of Aboriginal people was until recently the key to survival in a harsh environment. People were conditioned to be opportunistic and to take whatever was available at that time rather than having to make a rational decision about longer-term control, for example, over resources. The unwillingness to accept responsibility for personal and collective decisions is just one factor (others include ‘humbug’ or the obligation to share resources with relatives, a different ‘world view’ and low self-esteem) why empowerment must be seen as a long-term goal in Aboriginal communities (Cresswell, 2004). Today, Aboriginal communities are often a collection of families, language groups or clans who can be in competition over limited resources and who may have been traditionally geographically isolated. The term ‘community’ was applied to the formation of the settlements or ‘Aboriginal reserves’ by bureaucratic intellectuals and those in authority because it provided a convenient label for the assimilation of a heterogeneous group of people (Scrimgeour, 1997). Inevitably, these ‘artificial’ communities led to conflict, family feuds and violence fuelled by the frustration of a lack of opportunities, low income and access to alcohol.

䊏 Dealing with conflict The beginnings of conflict are often caused by poor communication between interest groups, weak local leadership, internal struggles to gain access to limited resources and struggles between the powerless and those seen to have the power or authority. In conflict situations, those with the power-over tend to try to dominate, to use pressure tactics, to offer few concessions and this can make it difficult to reach a negotiated agreement that is satisfactory to all parties. This creates the alienation of those who are powerless and presents two main options for them to gain power: (1) to resistance by increasing their own resources, organisation and mobilisation and using this in tactics of civil disobedience and militancy; (2) to induce those with power to use it more benevolently and to be sympathetic to the helplessness and position of inequality of those with less power. In Box 6.2 I provide an exercise that can help Practitioners and clients to understand the strategies and tactics that can be used by the relatively powerless and to have participants reflect on their own reactions in a position of power imbalance. The power is represented by the allocation of resources. Whilst the difference in allocation is minor this is representative of more meaningful ones that can result in the participants making connections to other areas in their lives where they may be unaware of the disparities of access to power (Coleman, 2000). Conflict can be a negative ingredient of the empowerment process by taking attention away from important issues, by dividing community groups and by undermining individuals’ power-from-within. However if managed correctly it can also be a positive ingredient. Dealing with conflict in a positive way can resolve disputes, help to release emotions and anxieties and make the community

86 · Public health Box 6.2 Positions of Power and Conflict Participants are asked to leave the room. The trainer then organises the tables into two areas each to accommodate half of the participants. In one area, the table is provided with markers, coloured pens, paints, coloured paper, scissors, magazines and other decorative items. In the other area, the table is provided with one sheet of blank paper and two lead pencils. The participants are invited back into the room and randomly allocated to one of the two areas. The two groups are given the same objective: to develop a working definition of power and empowerment. They are informed that once the groups have finished the exercise they will be asked to display their definitions and a vote will be taken by everyone in the room to select the best and most attractive definition. The groups are then asked to begin the exercise and the trainers actively support the group with most resources whilst actively ignoring the group with the least resources. The definitions are displayed and a discussion held to discuss the best definition including the use of colour, attractiveness and technical content. The participants are also asked to discuss the dynamics of the two groups, their feelings and how they interacted during the exercise. Participants may be unaware of the disparities in resource allocation, may have tried to persuade the other group to give them extra resources or even to take resources without asking. These points are discussed in relation to the issue of power and conflict. (Adapted from Coleman, 2000, pp. 127–8)

address sensitive issues whilst at the same time improving co-operation and communication. There are a number of strategies that Practitioners can use in their everyday work to help groups and communities to deal better with conflict and these include: 1 2 3 4 5 6 7 8

Providing leadership training to include the identification and analysis of potentially controversial issues; Providing training for conflict management; Developing communication tools to better disseminate information (discussed in Chapter 4 and Boxes 4.4 and 5.4); Using listening to clarify understanding (discussed in Box 4.3); Eliminating power-over to build power-with others (discussed in Chapter 3); Providing a facilitated dialogue to resolve issues (discussed in Chapter 7); Defining or mapping the issues needed to chart needs, concerns and positions of power (discussed in Chapter 4 and Box 4.5); Naming personal issues that cloud the picture and assess the problem in its broader context by using approaches of critical thinking (discussed in Chapter 5);

Helping marginalised groups to gain power · 87 9

Provide activities that promote personal and group reflection among diverse members and provide a forum for differences to be articulated and discussed.

An example of an activity to promote personal and group reflection among diverse members is given here for a community in Fiji. The clan leaders of two separate communities identified that their differences had created considerable conflict and that this inhibited opportunities for community empowerment. To resolve this situation the Practitioner provided the clan chiefs with kava and a neutral venue to allow their differences to be peaceably discussed. In Fiji formal meetings begin with the ceremony of sevusevu. This involves introductory speeches by the guests and senior members of the group and the acceptance and drinking of kava. The sevusevu must initiate all major meetings because it is the Fijian way of asking the ancestral gods, the Vu, for their permission and blessing to proceed. Kava is made from the root of the pepper plant and has a mild psychoactive and soporific effect. The two resources provided by the Practitioner, kava and a venue, allowed the traditional protocol to be respected and the

Box 6.3 Defining the Issues of Conflict To carry out this exercise the Practitioner should have some prior idea about the key questions that will be asked and some of the solutions that can be discussed. This will help the Practitioner to focus the discussion on the practical and not on the personal points. The Practitioner should be able to firstly define the issues and the problem areas of the conflict in neutral terms that all participants can agree upon. 1

The participants are asked to construct a list of key questions about the conflict, the potential solutions to the questions. 2 The participants and the Practitioner next identify sources of the information regarding each of the key questions, for example, web sites, local leaders, government officials, that are necessary to move into a problemsolving stage. 3 The participants are asked to prepare a summary of the conflict by comparing each question with a possible solution and a source of information. This can be usefully summarised in a table in a compact format. 4 After a period of discussion between the different parties the table can be rewritten to highlight how major changes in one conflict alters over time as circumstances change. It is necessary to note that this type of a problem-solving exercise is not a negotiation or a political commitment, it is merely a commitment to further analysis and discussion. (Adapted from Mitchell and Banks, 1998, p. 31)

88 · Public health personal differences to be resolved through an open and facilitated discussion (Laverack, 1999). Box 6.3 provides an example of a simple exercise that can be used by the Practitioners to help resolve conflict by, first, listing or mapping the main questions and issues held between the different parties and then by developing strategies to address each concern. In general, the role of the Practitioner in helping to resolve conflict involves assessing the situation, being a good listener, inviting audience participation, suggesting topics, using empowering language (see Chapter 4) and referring clients to relevant resources. Practitioners cannot use all these strategies in their everyday work but can choose to adopt one or two in a situation of conflict when working with individuals, groups and communities. Next, in Chapter 7, I discuss the importance of developing a working definition for power and empowerment in a programme context. I also discuss an approach to specifically measure empowerment through each of the nine ‘domains’ and a ‘spider web’ configuration to visually represent and interpret this information. I illustrate this approach with examples set within the context of public health programmes.

Chapter 7

The measurement and visual representation of empowerment 䊏 Developing a working definition of power and empowerment

Empowerment is widely viewed in Western literature as a process of capacity building towards greater control over decisions, often in regard to the distribution of limited resources. This is a form of power-over that can lead to some people gaining at the expense of others or a zero-sum situation. But as I explain in Chapter 3, the Westernised concepts of power and empowerment can have different interpretations in social settings in non-Westernised countries. Associated terms such as participation and capacity building are also increasingly used as named outputs in relation to public health programming. However, how relevant are these terms to the lives and work of clients? The key point is to use terms that have been identified and defined by the clients themselves. These lay interpretations of power and empowerment can then be used as an alternative to the use of technical language and terminology. The purpose is to provide all stakeholders with a more mutual understanding of the programme in which they are involved and towards which they are expected to contribute. The identification of a working definition of power and empowerment in public health programming can be developed at the beginning of the programme during the design phase. Box 7.1 and Figure 7.1 provide an example of the procedure for developing a working definition of power and empowerment in a Fijian context. The procedure is achieved through the use of simple social inquiry techniques, for example, qualitative interviews and observational methods. The procedure of collecting and analysing qualitative information is normally carried out by the stakeholders with the technical assistance of the Practitioner.

䊏 Collecting and analysing qualitative information In interviewing, the aim is to discover the interviewee’s own framework of meanings and to avoid imposing the interviewer’s structures and assumptions as far as possible. The interviewer needs to remain open to the possibility that the concepts and variables that emerge may be very different from those that might have been predicted at the outset. The interviewer needs to be sensitive to the language and

89

90 · Public health Box 7.1 Developing a Working Definition for Empowerment in Fiji In Fiji, the use of simple qualitative techniques have been shown to identify the key terms in regard to power and empowerment. Unstructured interviews were first used to identify the headings for power-over or lewa, power-fromwithin and power-with or kaukauwa. Then through semi-structured interviews the term ‘lewa’ was further identified to refer to ‘chiefly lewa’, the control of the village chief and the power-over bestowed at work or in the home. The term kaukauwa is the closest concept in a Fijian context to empowerment. It refers to community strength and unity which can be developed and assisted by its members and can be used to describe the right a person has to do something. Chiefly lewa is a state, a status that is bestowed by birthright or by others in an accepted way and is interdependent on the strength or kaukauwa of the community. It is in the interests of the person with the chiefly lewa and the members of the community to maintain and increase the kaukauwa. The relationship is reciprocal and in this way, the lewa and kaukauwa play an important role in the unity and strength of the community. The kaukauwa may be a mechanism by which the members of a community manage the authority delegated to them by the person with the lewa. It may also be a mechanism used when the community decides to resist and challenge this authority. Although the two terms provide a common understanding this can depend on how they are used. For example, the term kaukauwa in the form ‘veivakakaukauwataki’ suggests action and a process rather than just a concept and would be a more useful term to use in a programme context. (Laverack, 1998)

concepts used by the interviewee and check that they have understood the meanings of the respondent. The flexibility of the interviewing technique will allow a change in the pace and direction and this can be used by the interviewer to avoid any misunderstandings during the inquiry (Britten, 1995).

䊐 Qualitative interviewing Two main interview types can be used; unstructured and semi-structured. Unstructured interviews may cover only one or two issues and whilst semi-structured interviews are also conducted on a loose structure consisting of open-ended questions that define the area to be explored, the interviewer may diverge in order to pursue an idea in more detail and depth. The less structured the interview, the less the questions are determined and standardised in advance of the interview. However, most interviews will have a list

The measurement of empowerment · 91 Starting the inquiry with unstructured interviews. Key informant, one-to-one interviews around themes of power and empowerment

Identification of main headings for further discussion: ‘Lewa’ or power-from-within and ‘Kaukauwa’ or power-with

Gaining in-depth information with semi-structured interviews. Focus group discussions with a cross section of community members and some oneto-one interviews

Chiefly power-over

Power-over at work

Power-over in the home

Unity and disunity

Kaukauwa Links to lewa as strength and Kaukauwa

The identification of ‘veivakakaukauwataki’ as most closely referring to community empowerment in a Fijian context

Figure 7.1 Developing a working definition for community empowerment (Laverack, 1999, p. 211)

of core questions that define the areas to be covered (Britten, 1995). Questions should be open ended, neutral, sensitive and clear to the interviewee, usually starting with questions that the interviewee can easily answer and then proceeding to more difficult and sensitive topics.

䊐 Starting the inquiry to collect qualitative information The initial part of the inquiry uses unstructured interviews with key informants to identify the main themes of power and empowerment in the specific cultural

92 · Public health context. Unstructured one-to-one interviews are used to discover the interviewee’s own framework of meanings. This type of interview dispenses with formal schedules and ordering of questions and relies on the social interaction between the interviewer and the informant to elicit information (Minichiello et al., 1990). The unstructured interview takes on the appearance of a normal everyday conversation. However, it is always a controlled conversation, which is geared to the interviewer’s interests. The element of control is minimal but present in order to keep the informant ‘relating to experiences and attitudes that are relevant to the problem’ (Burgess, 1982, p. 107). More than one unstructured interview can be used so that further questions could be based on what previous interviews had said and these should consist mostly of clarification and probing for more depth and detail. It is important to carry out as many unstructured interviews as are necessary to be sure that all the main headings for power and empowerment have been identified. The interviewees can be different but the interviews are to be based on the same themes of power and empowerment. They ought to begin with the interviewer asking ‘This interview is about power in your cultural context. Can you tell me about your experiences, what you think this means and how it works in your communities?’ The interviews can be held at the interviewees’ places of work, homes or in a neutral setting, at a predetermined and convenient time. The interviews must be recorded either manually or by using a tape-recorder and normally ought to last between 30 and 90 minutes.

䊐 Gaining in-depth information The findings of the unstructured interviews provide the main headings for the next part of the inquiry, semi-structured group interviews. The questions do not have a fixed order or wording, but act as a guide to the interviewer who uses them in small groups consisting of stakeholders of similar characteristics. The purpose of the interviews is to provide more depth and comprehension to the main headings and to provide anecdotal information to highlight the findings. Questions are developed in regard to the key terms to determine who has power and how the different forms of power interrelate. The sample selection for the interviews is undertaken to ensure a representative range of age and socio-economic background of the interviewees in the community. Group interviews are a quick and convenient way to simultaneously collect data from several people. This means that instead of the interviewer asking each person to respond to a question in turn, there is some interaction and people are encouraged to talk, ask questions, exchange anecdotes and to comment on each others’ experiences. Some of the potential advantages are that the technique does not discriminate against people who cannot read or write and encourages participation and discussion especially from those who might normally feel that they have nothing to say. However, the articulation of group norms may silence individual voices of dissent and it is these contradictions that the interviewer may want to gain access to as a part of the findings. The presence of other interviewees

The measurement of empowerment · 93 may also compromise the confidentiality of the session, however, groups are not always inhibiting and may actively facilitate the discussion of taboo topics. Participants may provide mutual support in expressing feelings that are common to the group (Kitzinger, 1995). The success of the group interviews depends on both the skill of the facilitator and the discussion environment. Sessions should be relaxed, in a comfortable and familiar setting, refreshments may be available and the seating should be arranged in a circle or sequence acceptable to the participants. The facilitator should be able to ‘take a back seat’ but also be able to use debate to continue the conversation beyond the stage where it might have otherwise ended. The facilitator should be able to use disagreement to encourage participants to elucidate their point of view and to clarify why they think as they do. Basically, the facilitator should be sensitive to the group and to its particular dynamics (Minichiello et al., 1990; Kitzinger, 1995). Observational methods involve systematic, detailed observation of behaviour and talk, watching and recording what people do and say. This can involve asking questions and analysing documents, but the primary focus on observation makes it distinct from a qualitative interview (Mays and Pope, 1995). ‘Observer’ as ‘participant’ is essentially a short interaction with the respondents with no enduring relationship based on lengthy observation. The important advantage of observation is that it can help to overcome the discrepancy between what people say and what they actually do. It circumvents the biases inherent in the accounts people give of their actions caused by factors such as the wish to present themselves in a good light, differences in recall, selectivity and the influences of the roles they occupy. It is impossible to record everything during this process and so it is inevitably selective and relies on the interviewer to document what he or she observes. Therefore, it is vital that the observations are systematically recorded and analysed (Mays and Pope, 1995) and as far as possible the interviewer aims to record exactly what happened.

䊐 Keeping a record of the inquiry A number of different notes can be used by the interviewer to help compile a record of events, for example, a simple notebook can be used to keep detailed records of events, conversations, activities and descriptions. The type of notes can be distinguished as either mental jottings and full notes. Mental notes are made of discussions or observations after the event, jotted notes are quick, short hand notes to remind the interviewer of events. Full field notes are the running notes made throughout the day during or after the observational period and are both descriptive and analytical. The descriptive notes portray the context in which the observations and discussions took place. The analytical notes try to make sense of what has been observed and may be made after the observation when the interviewer has more time to reflect and clarify his or her impressions (Glesne and Peshkin, 1992).

94 · Public health

䊐 Analysing the qualitative information The aim of the analysis of the qualitative information is to look for areas of common ground and differences between the respondents of the interviews rather than provide a number of separate accounts. The recommended procedure for analysis uses a cut and paste technique which is quick, simple and cost effective for small amounts of qualitative data such as provided when developing a working definition. The information, which is available in the form of field notes and transcribed interviews, goes through a process of disaggregation and reaggregation using the following steps: 1

The process of disaggregation begins when photocopies are made of the original field notes. The copies are used to identify a classification system for the major categories of discussion. The categories are identified in the text by using coloured marker pens to highlight their presence in the text. The recorded text is thoroughly reread and all the marked relevant phrases, sentences or exchanges of recorded conversation are checked. 2 Once the colour coding is complete the marked text is cut up and sorted into files that have been marked one for each category. The categories will form the headings of the discussion of the findings. 3 The process of reaggregation happens by rereading each category file to analyse the content in its new context alongside information of a similar nature. New insights and confirmations begin to emerge and the structure of the findings and discussion begin to form.

䊏 Collecting and analysing qualitative information in a cross-cultural context

Public health programmes can be targeted at different cultural, socio-economic and marginalised groups where the clients are often quite distinct from the Practitioner. Public health programmes can also be set within a country context in which the Practitioners are from a different cultural background or country. Before collecting qualitative information in a cross cultural context there are issues which need to be taken into account, for example, the unfamiliarity with a specific cultural context makes it more difficult for a Practitioner to reflect the reality of the situation. This means that important information might be lost during the interpretation across cultures (Cuthbert, 1985). The most significant difficulties faced by external Practitioners have been their inability to speak the local language, holding a different belief and value system, poor communication and different styles of interaction, social relationships, attitudes towards time, infrastructure and political sensitivities (Merryfield, 1985). It is recognised that knowledge of the local language, whilst important, is not essential, and that building a rapport with potential clients is more a function of time spent on site and of interpersonal skills than it is of cultural identity and linguistics (Ginsberg, 1988).

The measurement of empowerment · 95 Collecting qualitative information can be improved by taking the cultural context into account. It may not be possible to have a facilitated group discussion due to the language and cultural differences between the Practitioner and clients. In this case, a facilitated design can be used that takes the cultural context into account. This requires a facilitator to be appointed to work with the Practitioner, one who is familiar with the cultural context. Facilitation introduces higher levels of control, the ability to focus on specific goals within a limited time period and is not merely translation or interpretation. Apart from ‘process’ skills of accurate interpreting and ‘back translation’ to the Practitioner during the course of the meeting, the ways in which facilitators work in the group setting as well as their role, style, background and appearance is crucial in shaping interactions. Figure 7.2 provides a typology of roles that a facilitator can play during any cross-cultural group meeting. Based on the levels of facilitator direction (leading and control techniques) and rapport (trust-building and distance reducing techniques), four general types of role can be delineated: empathy; engagement; railroading and disengagement (Laverack and Brown, 2003). Empathy involves the facilitator being able to achieve insightful understandings based on taking the point of view of the other. This is most likely when rapport (an equivalence of meaning construction between parties) is high and facilitator direction is low. Engagement also requires high rapport together with greater levels of facilitator direction, for example, where the facilitator encourages a particular direction for discussion. Low rapport results in role types that should be avoided. When rapport is lost or not gained, higher direction can force discussion to areas of lesser interest to the participants and is a kind of railroading. Low rapport combined with low levels of direction can leave the facilitator as a disengaged ‘outsider’ whose observations may lack validity. In practice, movement occurs between role types as the group meeting progresses whereas the arrows in Figure 7.2 represent an ideal facilitation model with an interplay of engagement and empathy that characterise the duration of the group meeting. High rapport is maintained and direction levels lowered and raised optimally according to the flow of the group interaction. The requirement for good facilitation is crucial to many aspects of qualitative research. Cross cultural facilitators are able to speak the local language, understand local customs and more easily explain complex concepts without the need for translation and this will help to expedite the meeting. However, Laverack and Brown (2003) observed that cross cultural facilitators, for example, in Fiji, at times ●

●

●

Tended to lead the discussion and took a directive, rather than a participatory approach (railroading); Encouraged discussion but did not try to involve all the participants (loss of rapport); Dominated and directed group interaction and it was observed that they did not allow the focus of discussion to move towards its members as the workshop progressed (too directive);

96 · Public health High-level facilitator direction

Engagement

Railroading

High rapport

Low rapport

Empathy

Disengagement

Low-level facilitator direction

Figure 7.2 Facilitator role types (Laverack and Brown, 2003, p. 4) ●

Left the room and the participants were very able to continue each exercise but control of the discussion resumed with the facilitators upon their return (too directive).

Stewart and Shamdasani (1990) point out that personal bias by facilitators in focus groups, who tend to direct the discussion and reinforce certain points of view, is a phenomenon common to Westernised cultures. Apparently, this also occurs in non-Westernised cultures. Skilful facilitation is an issue common to qualitative approaches and the question; ‘how to ensure proper facilitation?’ constantly needs to be addressed. This includes the maintenance of a good standard of facilitation skills in order to aim consistently for a successful balance between direction and rapport. Possessing the necessary skills and experience does not guarantee against facilitator bias but proper training may reduce unintentional influences. While high rapport is always the goal of skilful facilitation, in a cross-cultural context this may have to be achieved through roles embodying lower levels of rapport and differing levels of engagement. The purpose of this approach is to better position the facilitators to achieve an empathetic understanding of the participants. Cross-cultural contexts can provide essentially novel or unique issues and problems. The facilitators may have to be prepared to be more and less directive and engaged when collecting qualitative information, adapting their approach to the specific requirements of the participants. This can be described as an ‘inward’ and ‘outward’ movement by the facilitators towards a terrain of empathy conveying a similar pattern to those noted in qualitative and participant observatory research (Glesne and Peshkin, 1992). A key feature, and therefore a key skill of facilitation, in these circumstances is the ability of the facilitator to

The measurement of empowerment · 97 correctly identify the moments of transition and apply an empowering language (discussed in Chapter 4). In general, there are two other categories when working in a cross-cultural context that can be improved: the use of appropriate technologies; and the engagement of suitable personnel. Appropriate technologies for collecting cross-cultural information have been identified as a more naturalistic approach; the use of qualitative methods such as case studies and interviews which use the strong narrative and oral traditions of different cultures (Cuthbert, 1985; Russon, 1995). The approach should use both qualitative and quantitative information to cross-check the findings. The technologies should also be flexible in terms of time and attitudes, be participatory and use culturally sensitive instruments for data collection (Cuthbert, 1985; Merryfield, 1985). The skills and personal qualities required of the people collecting the crosscultural information have been identified as: tolerance for ambiguity; patience; adaptiveness; capacity for tacit learning; and courtesy (Seefeldt, 1985). A number of authors have suggested that a team comprising both foreign personnel and facilitators from the host community, preferably someone working closely with the public health programme, provides the most suitable approach (Chow et al., 1996; Cuthbert, 1985; Westwood and Brous, 1993). When it is not possible to work in a team, or if a local person is not available, then adequate training about the cultural context should be provided to anyone not from the specific cultural context (Russon, 1995). It is also important for the outside agent to have a prior understanding of the fluid social dynamics and complex balance of relationships that occur between programme stakeholders in a cross cultural context. Activities that may have little or no relevance to the Practitioner, such as the seating arrangements in a meeting, may have profound implications for the clients. This understanding can be improved through cross cultural awareness training and the provision of better communication skills as is discussed in Chapter 4 (Cass et al., 2002).

䊏 The measurement of empowerment Of the different levels of empowerment it has been the psychological element which has received the most attention in terms of measurement (Rissel et al., 1996; Zimmerman and Rappaport, 1988; Zimmerman and Zahniser, 1991). Other authors have used predetermined indicators of outcome as a part of external assessments of empowerment in a programme context (Barr, 1995; IRED, 1997; Labonte, 1994). These indicators cover a range of social, political and economic factors relating to the level of control that a community has over the influences on their lives. However, none of these authors discuss the development of a practical methodology or ‘tool’ for the measurement of community empowerment. A ‘domains approach’ can be used to measure community empowerment through each of the nine domains, discussed in Chapter 5, such that a programme ● ●

improves stakeholder participation; increases problem assessment and evaluation capacities;

98 · Public health ● ● ● ● ● ● ●

develops local leadership; builds empowering organisational structures; improves resource mobilisation; strengthens links to other organisations and people; enhances stakeholder ability to ‘ask why’ (critical awareness and analysis); increases stakeholder control over programme management; and creates an equitable relationship with outside agents (Practitioners).

Details of the identification and interpretation of the nine domains are provided elsewhere in Laverack (2001) and a summary of each domain is provided in Table 5.1. A methodology for the measurement of community empowerment that uses the ‘domains approach’ has been developed (Laverack, 2003) and the experiences of field testing this approach are also discussed elsewhere in Gibbon et al. (2002). The ‘domains approach’ is carried out by the community members or their representatives (traditional leaders and leaders of community-based organisations). The participants are first provided with five qualitative statements, or descriptors, for each of the nine empowerment domains, written on a separate sheet of paper (a generic version of the five descriptors for each domain are provided in Table 7.1). The five statements represent a range of empowering situations. Each statement can also be rewritten by the participants to reflect the actual situation in their community. Taking one domain at a time, the participants are asked to select the statement that most closely describes the present situation in their community. The statements are not numbered or marked in any way and each is read out loud to encourage group discussion. The selection of a statement by the participants is then based on their own experiences and knowledge (Laverack, 2003). Next, it is important that the participants record the reasons justifying the measurement for each selected domain. This assists other people who make subsequent measurements and who need to take the previous record into account. It also provides some defensible or empirically observable criteria for the selection. This overcomes one of the weaknesses in the use of qualitative statements, that of reliability over time or across different participants making the assessment (Uphoff, 1991). The justification needs to include verifiable examples of the actual experiences of the participants taken from their community to illustrate in more detail the reasoning behind the selection of the statement. The sum of the measurement is a set of nine qualitative statements, one for each domain, which represent the strengths and weaknesses of empowerment in the community at that particular time. The five statements for each domain are pre-ranked or pre-rated from 1 (least empowering) to 5 (most empowering). The ratings are not shared with the participants during the measurement to avoid bias. For example, Laverack (1999) found that the use of pre-quantified rating scales unacceptably influenced the behaviour and actions of the participants. The use of the rating scales led to the introduction of subject bias such that the participants did not make an independent assessment but instead provided consistently high ratings to match the expectations of their members. Each selected qualitative

Table 7.1 The ranking for each generic empowerment descriptor (Laverack, 1999) Domain

1

2

3

4

5

Community participation

Not all community members and groups are participating in community activities and meetings such as women, youth and men

Community members are attending meetings but not involved in discussion and helping

Community members involved in discussions but not in decisions on planning and implementation

Community members involved in decisions on planning and implementation

Participation in decision making has been maintained

No problem assessment undertaken by the community

Community lacks skills and awareness to carry out an assessment

Problem assessment capacities

Limited to activities such as voluntary labour and financial donations Community has skills Problems and priorities identified by the community Did not involve participation of all sectors of the community

Local leadership

Some community organisations without a leader

Leaders exist for all community organisations Some organisations not functioning under their leaders

Mechanism exists to share information between members

Community identified problems, solutions and actions Assessment used to strengthen community planning

Community members involved in activities outside the community

Community continues to identify and is the owner of problems, solutions and actions

Community organisations functioning under leaders

Leaders are taking initiative with support from their organisations

Leaders taking full initiative

Some organisations do not have the support of leaders outside the community

Leaders require skills training

Leaders work with outside groups to gain resources

Organisations in full support

99

Table 7.1 Continued 1

2

3

4

5

Organisational structures

Community has no organisational structures such as committees

Organisations have been established by the community but are not active

More than one organisation which are active

Many organisations have established links with each other within the community

Organisations actively involved in and outside the community

Resources raised also used for activities outside the community

Considerable resources raised and community decide on distribution

Resource mobilisation

Resources are not being mobilised by the community

Only rich and influential people mobilise resources raised by community Community members are made to give resources

Links to others

None

Community has informal links with other organisations and people Does not have a well-defined purpose

Ability to ‘ask why’

No group discussions held to

Small group discussions are

Organisations have mechanism to allow their members to provide meaningful participation Community has increasingly supplied resources, but no collective decision about distribution Resources raised have had limited benefits

Discussion by community on distribution but not fairly distributed

Community committed to its own and to other organisations

Resources fairly distributed

Community has agreed links but not involved in community activities and development

Links inter dependant, defined and involved in community development

Links generating resources, finances and recruiting new members

Based on mutual respect

Decisions resulting in improvements for the community

Groups held to listen about community

Dialogue between community groups

Community groups have ability to self

100

Domain

ask why about community issues

being held to ask ‘why’ about community issues and to challenge received wisdom

issues. These have the ability to reflect on assumptions underlying their ideas and actions

to identify solutions, self-test and analyse Some experience of testing solutions

analyse and improve its efforts overtime. This is leading towards collective change

Are able to challenge received wisdom Programme management

By agent

By agent in discussion with community

By community supervised by agent Decision-making mechanisms mutually agreed

By community in planning, policy and evaluation with limited assistance from agent

Roles and responsibility clearly defined

Developing sense of community ownership

Community selfmanage independent of agent Management is accountable

Community has not received skills training in programme management Relationship with outside agent

Agents in control of policy, finances, resources and evaluation of the programme

Agents in control but discuss with community

Agents and community make joint decisions

No decision making by community

Role of agent mutually agreed

Agent facilitates change by training and support

Agents facilitate change at request of community who makes the decisions Agent acts on behalf of the community to build capacity

101

Agent acting on behalf of agency to produce outputs

Community makes decisions with support from agents

102 · Public health statement is rated by the facilitator, following the measurement, to give it a quantitative value that can then be used to plot the data. For example, for the domain ‘leadership’ the ranking descriptors are: 1 2

Some community organisations without a leader. Leaders exist for all community organisations. Some organisations not functioning under their leaders. 3 Community organisations functioning under leaders. Some organisations do not have the support of leaders outside the community. 4 Leaders are taking initiative with support from their organisations. Leaders require skills training. 5 Leaders taking full initiative. Organisations in full support. Leaders work with outside groups to gain resources. If the participants choose the descriptor ‘Leaders exist for all community organisations. Some organisations not functioning under their leaders’, this domain will be given a rating of 2. The measurement, analysis and interpretation of this information need to be shared with all stakeholders, from policy makers ‘down’ to the community members. The information may also have to be compared over a specific time frame and between the different components of a programme. For this purpose, visual representations of the measurement of community empowerment can be an appropriate way to interpret and share qualitative information.

䊏 Visual representations of community empowerment Several authors have used visual representations as a ‘tool’ to compare changes in the factors or domains that can influence the process of community empowerment. For example, John Roughan (1986), a community development practitioner, developed a wheel configuration and used rating scales to measure three areas: personal growth; material growth and social growth for village development in the Solomon Islands. The rating scale had ten points that radiated outwards like the spokes of a wheel for each indicator of the three growth areas. Each scale was plotted following an evaluation by the village members to provide a visual representation of growth and development. The approach used a total of 18 complex, interrelated indicators such as equity and solidarity to evaluate village development. Rifkin et al. (1988) in Nepal and later Bjaras et al. (1991) in Sweden, were the first commentators on the use of the ‘spider web’ configuration for the visual representation of community participation. Their approach identifies five factors: leadership; needs evaluation; management; organisation and resource mobilisation, and uses a similar simple rating scale. The approach was not carried out as a selfevaluation by the community and did not promote strategic planning. However, these early experiences of measurement have provided the basis for subsequent attempts with visual representation. For example, Marion Gibbon (1999), a

The measurement of empowerment · 103 community development practitioner, in her measurement of community capacity in Nepal utilised a set of eight domains, similar to those independently developed by Laverack (1999), and a set of indicators with a rank assigned from 1 (low) to 4 (high). The rankings were then plotted onto a spider web configuration similar to the approach used by Rifkin et al. (1988). Different stakeholders in the same programme used the interpretation of this visual representation to make comparisons of each domain during the life of the programme.

䊏 The interpretation and visual representation of community empowerment

The spider web configuration has been used with some success for visual representation and has also been urged by several of the community empowerment models (Bopp et al., 1999; Hawe et al., 2000; Laverack, 1999). The spider web can be an especially useful tool when using a ‘domains approach’, as discussed earlier, to measure community empowerment because the assessment of each domain can be visually communicated and shared by all stakeholders. The spider web also provides a quick picture of the strengths and weaknesses within a community (defined by the nine domains) and between communities in the same programme. What is missing from the literature is a description of how to interpret the spider web configuration and I next address this issue by taking four examples from the measurement of community empowerment in two different programmes. The first two examples are from a community development programme in Fiji (Laverack, 1999). The measurement was carried out as part of a doctoral research in two rural Fijian communities on the main island of Viti Levu. The third and fourth examples are taken from a community development programme in Kyrgyzstan ( Jones and Laverack, 2003), which aimed to promote self-help capacities at the community level. Both programmes held discussions with those community representatives and leaders who participated in the measurement of community empowerment.

䊐 Measuring empowerment in the Naloto community The spider web configuration in Figure 7.3 provides a distribution of high and low ratings of seven of the nine domains, illustrating a range of strengths and weaknesses in empowerment in the Naloto community in Fiji (Laverack, 1999). The community members had decided that as there was no donor agency working in their village at that time they would remove the domains ‘outside agent’ and ‘programme management’. The Practitioner had first developed a working definition for community empowerment (see Box 7.1) and had also reviewed the relevance of each of the nine domains within the cultural context. This was achieved through using the simple qualitative techniques discussed earlier in this chapter.

104 · Public health Participation 4.0 3.0 Critical assessment

Organisational structures

2.0 1.0 External linkages

Leadership

Problem assessment

Resource mobilisation

Figure 7.3 Spider web for Naloto

Participation, given a low rating of 1.0, was identified as being weak because of the failure of local leaders to communicate information to other members of the community. Traditional protocol in Fiji maintains that the approval of the village chief must be sought before holding a community meeting. Individuals may be reluctant to defer to the chief or to ask for a particular favour, such as organising a meeting, if they lack respect for the chief or if they are not on good terms with the chief at the time. In the Naloto community this situation had led to a reduction in the number of village meetings and in a poor level of participation in decision making by its members. Interestingly, the interpretation of the spider web in Figure 7.3 gives ‘leadership’ a high rating of 3.5. A Fijian chief is always accorded the outward signs of respect. Even though another person may gain prominence, respect and authority within the community because of his/her personal qualities or through the acquisition of wealth, he/she would have to defer to the chief on matters of tradition and culture. Local leaders are rarely challenged and community members abide by traditional views. In these circumstances, it is important that the participants engage in a ‘facilitated dialogue’, through a person such as the Practitioner, to reach a consensus on the selection of each domain that represents the actual situation in their community. Following the measurement exercise in Naloto community its members decided to establish a new protocol and to first gain the approval of the village chief to meet on a regular basis and on predetermined dates. This overcame the constraint of having to follow the previous protocol of asking the chief for his approval before

The measurement of empowerment · 105 every meeting but maintained respect for local customs in their community. In addition, a village secretary was appointed to attend the meetings and to record what was said. This was then posted in the village community centre so that everyone could read, or be read to, about what had happened at any particular meeting in the village. It was thought that this situation would improve communication and dissipate the potential conflict that had begun in the community because of the weak leadership and poor communication (see Chapter 6 ‘Dealing with conflict’). The implication for the community members was that the use of a visual representation had helped to promote the free flow of information. This has been identified as an important factor in the effectiveness of programmes in addition to inter-agency collaboration, communication, and a dialogue between community organisations and their members (Speer and Hughley, 1995). The sharing of information from one person to others, even when everyone has an equal sense of ownership, can present a challenge during programme implementation. The spider web configuration allows stakeholders at all levels to visualise, better articulate and share their ideas on the building of community empowerment.

䊐 Measuring empowerment in the Nasikawa community The configuration in Figure 7.4 provides a ‘broken’ or partially developed spider web in which several domains have received a 0 rating. Interpretation is focused on the weakest empowerment domains in the Nasikawa community in Participation 4.0 Agents

3.0

Organisational structures

2.0 1.0 Critical assessment

Leadership -

Project management

Resource mobilisation

External linkages

Problem assessment

Figure 7.4 Spider web for Nasikawa

106 · Public health Fiji: participation; the outside agents; critical awareness; programme management; and external linkages. However, following the measurement exercise the members of the Nasikawa community decided that it would rather build upon its existing strengths and choose the domain ‘organisational structures’ which had received a rating of 1.0. The participants first developed a checklist of indicators for a safe and hygienic community and then used the list to make a survey of health and safety standards. Through the use of this list, the village leaders identified remedial work to clean the environment and to repair water and sanitation facilities. The participants next chose the domain ‘resource mobilisation’ that had been given a rating of 2.0 as another strength to help them to raise local resources to carry out the remedial works. The community members discussed strategies on how to achieve this by working with local leaders through the ‘organisational structures’ in their community, for example, by mobilising local groups for women and youth and by liaising with the appropriate government representatives. Together with the resources they were able to raise and the participation (which showed an improvement as a result of this process) of its members the community improved the water supply to the village. The measurement of community empowerment had engaged the community members in a process of logical thinking and had acted as a ‘trigger’ for further action that involved individuals working together in small groups, co-operating with local leaders and raising resources. This is a process of community development as described by Jackson et al. (1989). Murray and Graham (1995) describe a similar phenomena in Scottish communities where a participatory process was observed to facilitate changes and action after identifying the needs and resources to address concerns about local transport and the security of children’s play areas. But whilst the process can stimulate community mobilisation it does not guarantee community empowerment. Community empowerment, as I have already discussed, is a longer-term process of capacity building with an explicit purpose of bringing about social and political changes.

䊐 Measuring empowerment in the Orto community Figure 7.5 provides a ‘small’ spider web configuration in which all the domain ratings have been given a low value by the participants of the community of Orto in Kyrgyzstan. The community decided to combine the domain ‘outside agents’ with the domain ‘programme management’ because they felt that the Practitioner already worked for the community-based programme. The small spider web is an indication that the overall level of empowerment is weak and that there is a need for the community to prioritise which domains they want to begin to strengthen. Prioritisation is necessary because communities do not usually have the resources at their disposal to address all the domains as a part of the same strategy, even if assisted by a Practitioner. The community decided that it would prioritise the domains ‘resource mobilisation’ and ‘participation’ because these were traditionally seen as two important

The measurement of empowerment · 107 Participation 4.0 Critical assessment

3.0

Organisational structures

2.0 1.0 SLLPC Project management

-

External linkages

Leadership

Resource mobilisation Problem assessment

Figure 7.5 Spider web for Orto

elements of a strong and functional village. The ability of the community to mobilise resources from within and to negotiate resources from beyond itself is an important step towards developing the skills and organisational structures necessary for community empowerment. Internal resources are those raised within the community and include land, food, money, people skills and local knowledge. External resources are those brought into the community by the outside agent and include financial assistance, technical expertise, ‘new’ knowledge and equipment. In the community of Orto the role of the outside agent was to act as a link between the external resources and the community and to assist its members to identify the internal resources that they already had to help them build from a position of strength. One traditional method to achieve this was by using hashars, an activity in which everyone in the community is expected to participate by contributing their labour or another form of assistance in a joint effort to improve living standards in the village. This can be to build a community centre, a school latrine, to dig trenches for water and gas pipes serving the community or raise funds through selling local produce. Orto community was also able to mobilise resources by offering matching funds offered by the programme to rehabilitate facilities such as irrigation pipes serving household plots. The community was encouraged to mobilise approximately 60 per cent of the cost of materials, as well as supplying labour to install the pipe work ( Jones and Laverack, 2003).

108 · Public health

䊐 Measuring empowerment in the Kyzil Oi community Figure 7.6 provides an example of how the spider web can be used to compare the measurement of community empowerment over a specific time frame and is taken from the village of Kyzil Oi in Kyrgyzstan ( Jones and Laverack, 2003). The two measurements, taken in the same community with the same participants, were made 6 months apart. After the first measurement, the community representatives developed a strategic plan to strengthen the eight domains (outside agents were combined with programme management), and in particular ‘resource mobilisation’, ‘participation’ and ‘organisational structures’. The community representatives decided to consolidate their meetings, to hold these on a more regular basis, to review the membership, to improve record keeping and to organise events to involve the community more in income generation activities, such as hashars and ‘exhibition days’, to make and sell local arts and crafts. In the second measurement of community empowerment there was a selfassessed improvement in six domains: programme management; critical awareness; organisational structures; leadership; resource mobilisation and problem assessment. There had been no improvement in the level of participation and the number of external linkages had reduced. The spider web was used by the community representatives along with the Practitioner to interpret this information. This discussion revealed that the village had gained confidence from its experiences of organising events to mobilise resources and this had helped to strengthen leadership, organisational structures and links with the programme management. However, these events had been carried out with the involvement of the same core Participation 1.0 Critical assessment

0.8

Organisational structures

0.6 0.4 0.2 SLLPC Project management

Leadership

-

External linkages

Resource mobilisation

Problem assessment Pilot assessment

2003

Figure 7.6 Spider web for Kyzil Oi community

The measurement of empowerment · 109 membership of people as earlier activities and participation had therefore not increased. The community had also not been able to maintain its links with other community groups due to poor facilities for communication, such as the lack of a telephone, fax and transportation. The measurement and the use of the spider web for interpretation had helped all stakeholders to better understand the reasons for the successes and failures in building community empowerment in the village. The community representatives were then able to develop a new strategic plan for the next 6-month period to focus their activities and the assistance provided by the Practitioner to continue to strengthen community empowerment as a part of the programme. Next, in Chapter 8, I bring together the central themes of the book, power and empowerment, and draw conclusions for the future development of public health policy and practice.

Chapter 8

Power, empowerment and professional practice 䊏 Introduction In this the final chapter, I bring together the central themes of the book and discuss the major constraints that public health agencies, and the Practitioners that they employ, must address in order to help their clients to gain power. The purpose is to remind the reader of their present role in empowering their clients and of their future role in developing public health policy and practice. But first, I discuss the main conclusions of the book as a number of key questions in regard to professional practice in public health.

䊐 Do Public Health Practitioners want to help to empower their clients or to change their clients?

This question addresses the fundamentals of what is an empowering public health practice. Some Practitioners want to improve the health of their clients by controlling the resources and decisions that influence their lives and to do this they use the different forms of power-over discussed in Chapter 3. They want to change the behaviours and lifestyles of people by using methods of control, coercion and manipulation. Other Practitioners think that they can empower their clients and improve their health by transferring knowledge. The assumption being that people will make rational decisions based on an informed choice. The aim of the Practitioner is to change the behaviour of their clients through another form of power-over discussed in Chapter 3, informational power. The approach uses the control of information to convince the client that the recommended behaviour is indeed in their best interest. This approach is commonly used in public health education strategies. Practitioners that use an empowering approach to public health want to improve the health of their clients by helping them to build their capacity, to take greater control over decisions, to gain greater access to resources and to build their inner strengths and sense of self-worth.

䊐 Can Practitioners empower their clients? The verb ‘to empower’ can be interpreted as the transitive (direct) meaning to ‘bestow power on others’ or the intransitive (indirect) meaning as the ‘act of gaining or assuming power’. As discussed in Chapter 3, power cannot be given but must

110

Power, empowerment and professional practice · 111 be taken or seized by the individuals and groups who seek it. The term ‘power’ refers to both the control over decisions and resources and the power-from-within or an inner source of psychological strength. Whilst Practitioners cannot give power to their clients they can help them to gain power. The Practitioner begins to achieve this by deliberately using their own power-over to increase other people’s power-from-within, their access to resources and to systems of decision making. Strategies to achieve the transformative use of power-over when working with individuals, groups and communities have been discussed in Chapters 4, 5, 6 and 7.

䊐 Do clients have a right not to be empowered? Some people, including the relatively powerless, may not want to be empowered, to gain or seize power. If they have lived in conditions in which they have continually experienced power-over themselves, for example in poverty, they may feel that they do not have the right, do not possess the motivation or the means to empower themselves. Other individuals and groups, for example, the mentally ill, may not have the ability to organise and mobilise themselves towards collective empowerment. Whilst the Practitioner must be sensitive to these circumstances, the right or choice to be empowered always rests with the client (power cannot be given but must be taken or seized by those who seek it). Even so there may be some people who cannot or who refuse to accept the responsibility to take greater control over their lives and health. In some circumstances this can result in the health of others, a third party, being put at risk, for example, someone who has an infectious disease but refuses to seek treatment knowingly puts others at risk of infection. Public health practice has developed specific means to intervene in and to control the health of others in order to protect the well-being of the general population. The development of a range of policy and legislation, such as the Public Health Acts, is an example of this type of a power-over control by professional practice.

䊐 Should some individuals, groups and communities, at the expense of others, get priority of the limited assistance provided by the Practitioner?

This question raises an ethical and political dilemma faced by the Practitioner. As discussed in Chapter 5, communities are not homogeneous but often consist of competing interests to gain more control over resources and decisions. Practitioners, in the course of their work, may find it unavoidable to help some individuals and groups but not others. Public health policy sometimes places such a requirement on Practitioners to work with specific groups such as the poor, the homeless or the ‘unhealthy’. This is a zero-sum situation, as discussed in Chapter 3, when one can only possess x amount of power to the extent that someone else has the absence of an equivalent amount. It is based on the interpretation of power as being resource dependant and reliant on some type of a material product. It essentially ignores that power may also be a property of social relations including the relationship one has with oneself (power-from-within). Zakus and Lysack (1998) provide an interesting point of view in relation to a zero-sum construction of power which

112 · Public health they argue increases competition and a lack of community cohesion. They suggest that ‘community empowerment’ is a contradiction in terms and that by empowering some at the expense of others, Practitioners are actually breaking down the ties that hold a community together. Some gain more control but the community as a whole starts to disintegrate. However as discussed in Chapter 6, competing groups within a community can be willing to put aside their differences to organise and mobilise themselves around shared concerns. This then creates a ‘community of interest’ with which the Practitioner can work to help them to gain power.

䊏 Addressing the constraints in public health practice At the beginning of this book I argue that there exists a contradiction between professional discourse and professional practice. Many Practitioners continue to exert power-over their clients through ‘top-down’ programming and controlling working practices whilst at the same time using a language that implies empowerment. I argue that the basis for this contradiction continues because of at least three reasons: 1

2 3

A superficial understanding of the meaning of power and how the relationship between Practitioners and their clients can be appropriately acted upon to empower others; The lack of clarity about the influences on the process of community empowerment; The shift in public health discourse towards empowerment has not been accompanied by a corresponding clarification of how to make this concept operational in a programme context.

In practice the situation is plainly more complicated than this and rather than to simply blame the Practitioner, which would be to undervalue the important role that they can play, I have identified the major constraints that the profession faces in trying to empower their clients: ● ● ● ●

A superficial understanding of the meaning of power and empowerment; The constraints of working in bureaucratic settings; The tension between top-down and bottom-up programming; The lack of understanding about the means of empowering individual clients, groups and communities in their everyday work.

The way in which professional practice addresses these constraints is crucial to the development of future public health policy and a professional practice that are more empowering. Each constraint has a different set of implications for professional practice and I now discuss ways in which these can be addressed.

Power, empowerment and professional practice · 113

䊏 Building a better understanding of the meaning of power and empowerment

Both ‘power’ and ‘empowerment’ have become contested terms. What this means is that the definition and conceptualisation of these terms remains unresolved especially in the way that they can be used in practice. It is, therefore, not surprising that both these terms have sometimes been misused and as a result have lost their real sense of meaning: to have control or to increasingly gain control. This is the first constraint that the public health profession must address in trying to empower both their Practitioners and their clients. Practitioners must be able to identify their own power bases to enable them to share these with others. To do this Practitioners must have a clear understanding of the concept of power and the means to gaining power, empowerment, and in particular, how both can be applied to their everyday work. Chapter 3 discusses these concepts and Chapters 4, 5 and 6 offer practical approaches that can enable Practitioners to help their clients to gain power. Building a better understanding of the meaning of power and empowerment means that Practitioners should use a discourse (language, political and strategic interpretations, ideas and professional values) that is accurate about the purpose of their work. Rather than use terms such as ‘empowering’ and ‘empowerment’ or ‘giving control to’ Practitioners should use a language that is designed to better reflect the purpose of their work. Practitioners who want to improve the health of their clients by retaining power-over the resources and decisions that influence their lives, including the use of top-down programming, should use language such as, ‘to involve the community’ or to ‘encourage participation’. The difference between a participatory approach, most commonly used in public health programming, and an empowering approach is in the agenda and purpose of the process. Empowerment approaches have an explicit purpose to bring about social and political changes, participation does not, and this is embodied in the client gaining control through personal and collective action. Practitioners are encouraged to use a public health discourse that promotes individual and collective empowerment. The empowering discourse must then be accompanied by an organisational or bureaucratic commitment to help others to gain power.

䊏 Addressing the bureaucratic constraints If the first constraint is the use of a more accurate discourse then the second is a redress of the constraint placed on public health by its bureaucratic nature and the problematic power relationship that this can create between the Practitioner and their clients. In Chapter 2, I describe public health as a bureaucratic activity, carried out by or within governmental organisations or government-funded agencies. The purpose of these public health agencies is primarily concerned with maintaining

114 · Public health the health and well-being of people. To achieve this Practitioners work with individual clients and the groups and communities that they occupy ‘out there’ in civil society. The goal of their clients, who are seeking to gain power, is to bring about a change in the social and political order and this can challenge the bureaucracies that provide the funding for their development. Hence the problematic relationship that can exist between bureaucratic organisations, the Practitioners that they employ and their clients. The constraint of bureaucratic settings is that many of these organisations remain governed by traditional ways of thinking and acting, ways that inhibit the effective inclusion of empowering approaches. For example, the dominance of top-down approaches and rigid funding cycles in public health programming, the use of coercive and manipulative methods to influence the way people think and act and the reluctance of Practitioners to relinquish control to their clients. This book has been written to encourage public health agencies to embrace strategies to help their Practitioners and their clients to gain power. What this means is that agencies will be moving away from a power-over agenda concerned with disease prevention and reductions in morbidity and mortality to enable their clients to address their own concerns. Without this type of flexibility public health runs the risk of being seen only to involve their clients without taking the responsibility of assisting people to gain power towards improving their own lives and health. An example of the need for a change in the constraints placed on public health by its bureaucratic nature and by the problematic power relationship that this can create is provided by the Multiple Risk Factors Intervention Trial (MRFIT) and the Community Intervention Trials for Smoking Cessation (COMMIT). Both MRFIT and COMMIT were designed as top-down public health programmes implemented by Practitioners employed by bureaucratic agencies. MRFIT was a 10-year programme designed to reduce mortality from heart disease in the top 10 per cent male risk group. The trial undertook a massive survey of 400,000 men in 22 cities and randomly selected 6000 for the intervention and 6000 for the control group. The trial was the most ambitious, expensive and intensive anywhere tried at the time in 1971. The trial failed and after six years the men in the intervention group did not achieve a lower mortality level from coronary heart disease than men in the control group. The COMMIT consisted of nationwide studies involving over 10,000 heavy smokers in 11 cities with a matched control group. At the end of this trial there was only a modest difference in the rate of people stopping smoking between the intervention and control groups. The trial, which cost millions of dollars and used a team of highly motivated and trained ‘experts’ to implement, similarly failed (Laverack, 2004). Leonard Syme, an eminent public health practitioner who carried out an analysis of the MRFIT and COMMIT programmes, points the finger at the Practitioners and the agencies they worked for as a major contributing factor towards failure. The motivation to change one’s behaviour, to gain control or power, must come from within the client. However, the idea of relinquishing control to their clients or even accepting the expertise that they may already possess such as lay health

Power, empowerment and professional practice · 115 knowledge, can be alien to many public health professionals. Accepting the powerbase of their clients is a necessary prerequisite for the Practitioner to be able to identify and share their own power-over. Informational power, for example, through awareness campaigns, does play a role but this must support the issues and problems that have already been identified by the client as being relevant and important to themselves (Syme, 1997). It should also be noted that bureaucratic organisations can play an important role in shaping and defining what is important in political discourse through, for example, the implicit and explicit statements made by the types of services they offer, and the policies they create and make public. Bureaucratic organisations can endorse the concerns of less powerful groups and this provides their issues with more professional and political credibility. For example, the support of the medical profession in Ireland that smoking is detrimental to health has given professional credibility to the concerns of the government and to public health groups lobbying against smoking such as Action on Smoking and Health (ASH). The ‘expert’ power of the bureaucracy is shared to legitimise the issue of their clients and can lead to further political support or funding opportunities (Toronto Department of Public Health, 1991). In Ireland, this has contributed to a nationwide ban on smoking in public places.

䊏 Using an empowering approach to public health programming

The key question in regard to the constraint of public health programming is: Can Practitioners through planning, implementation and measurement, empower their clients in a programme context? In Chapter 1, I imply that there is a ‘hidden agenda’ to public health programming: Practitioners wish to maintain control through a power-over and top-down approach. This can create a lack of trust between the public health agencies and their Practitioners and between the Practitioners and their clients. This is a situation that can be made more difficult by problems of cross cultural misunderstandings, personal animosities and jealousies (Leach, 1994). But why do some public health agencies want to maintain power over their clients in a programme context? Marie Boutilier (1993), a commentator on public health research and practice argues that an often undefined purpose of top-down programmes is in regard to accountability to the funders. Agencies are increasingly concerned with the economic and quantifiable effectiveness of programmes. This makes empowerment, by definition, an especially difficult concept to measure, an unattractive approach. By maintaining power-over programming it is more likely that the inputs and outputs will remain accountable. It is therefore more desirable to the funding agency to have control over the definition of the objectives, the selection of the stakeholders, the budget, the time frame, implementation, management and the measurement of quantifiable outcomes. As the agencies press for greater accountability and control there is an expectation for better programme management,

116 · Public health a higher level of skills and more sophisticated methods of monitoring such as the logical framework system. In such circumstances, the funding agency becomes less willing to transfer responsibility to the clients because they, at least initially, lack the necessary skills and experience to manage the programme. The agencies are themselves bound by fixed and usually annual funding cycles and the expectation to fulfil targeted expenditures. This is, in turn, bound by the need for more effective programme implementation and accountability. It is a top-down approach to public health programming which gives agencies the most control over implementation and management. Top-down programming is a manifestation of power-over, in which the Practitioner exercises control of financial and other material resources over the ‘targeted’ beneficiaries of the programme. Many public health programmes are designed to prevent disease with the aim of improving the health and well-being of specific population groups. They do not usually include objectives to build community empowerment that is often seen as an additional but unplanned outcome. Bottom-up or community empowerment approaches are generally not favoured because they are difficult to measure, are small scale and low budget, are designed to have flexible inputs and outputs and use a time frame beyond standard funding cycles. In practice, the challenge is to identify ways in which the Practitioner can accommodate community empowerment (bottom-up) approaches within topdown programming. Chapters 1 and 6 introduce the system of ‘parallel-tracking’ to accommodate community empowerment within public health programming. The tensions between the top-down and bottom-up approaches can then be addressed at each stage of the programme cycle, making their resolution much easier, rather than a simple bottom-up/top-down dichotomy. These principles of accommodating community empowerment can be applied regardless of the subject area and have been used in health promotion, sustainable livelihoods, community development and water supply and sanitation ( Jones and Laverack, 2003; Laverack, 2004).

䊏 Using measurement to empower others The measurement of community empowerment has traditionally used qualitative information to provide ‘thick’ descriptive accounts, based on the experiences of the participants, which produce a large quantity of data such as transcribed interviews. This type of data is difficult and time consuming for Practitioners to analyse and for other stakeholders to interpret. Developments in the monitoring and evaluation of programmes have supported the use of locally specific approaches such as Participatory Rural Appraisal. The trade off is between the use of timely but not so in-depth generic approaches such as standardised checklists with the more locally appropriate information procured from participatory ‘tools’ which are potentially time consuming. The practical application of the approaches discussed in this book, some of which are generic in design, are discussed later in this chapter. The aim of an empowering approach to

Power, empowerment and professional practice · 117 measurement is to strengthen the design, to provide all stakeholders with a mutual understanding of the programme and to make Practitioners more sensitive to differences in meaning such as the cultural context. Chapter 7 has discussed practical approaches to measure empowerment, for example, the spider web configuration, to produce a visual representation of the experiences of clients based on the ‘domains approach’ discussed in Chapter 5. The visualisation of a complex concept such as empowerment presents an attractive option to Practitioners. The concept can then be quantified and analysed over a specific time frame and in a way that is understandable to both literate and nonliterate stakeholders. The advantage is that the same information can be shared with the client, with other Practitioners and with the funders of public health agencies. This approach of measuring and then sharing information on empowerment has successfully been used by Practitioners in South Asia and the South Pacific (Gibbon et al., 2002) and in Central Asia ( Jones and Laverack, 2003) but is equally applicable to communities in industrialised countries.

䊏 Understanding the means to empower individual clients, groups and communities

Practitioners, in the course of their work, have the opportunity of developing working relationships with individuals, groups and communities who want to become empowered. That is, they want to have more control over the decisions that influence their lives including better access to resources. The key constraint that Practitioners face is having an understanding of how to help their clients to gain power, through the application of empowering approaches and exercises, as a part of their everyday work. Helping individuals to gain power involves both the development of personal skills and an increased sense of political awareness. The purpose is to enable individuals to make their own decisions and to take actions for themselves in regard to improving their health and their lives. The basis for this is collective action centred around issues of shared concern. The involvement in groups and communities is necessary because they allow individuals to have the opportunity and confidence to participate actively. The role of the Practitioner is that of an ‘enabler’ to link individuals to those groups and ‘communities of interest’ that do share their concerns. Chapter 4 discusses practical strategies and exercises for Practitioners to use in their everyday work to help individual clients to build their self-esteem and political awareness, for example, mapping positions of power and the ranking of complex issues. The Practitioners can also develop their own competencies towards helping individuals to gain power, for example, improving their ability to be good communicators, good listeners and by acquiring specific skills such as conflict resolution skills. The use of practical exercises to develop these competencies are also discussed in Chapter 4. The development of community organisations in the process of empowerment is a crucial step because it allows interest groups to make the transition to broader

118 · Public health partnerships that in turn allow them to gain greater support for their concerns. The key challenge to the Practitioners is how they can work with groups and organisations to help them make this transition. Chapter 5 provides a framework that is designed to help Practitioners to develop a better understanding of how they can strengthen the process of community empowerment and offers practical solutions for its use in a programme context. Addressing the constraints faced by the profession means that Practitioners must take the responsibility to improve their understanding of the concepts of power and empowerment. Practitioners must use a language that is empowering and use strategies in their everyday work that enable their clients to gain power. Addressing the constraints faced by the profession also means that public health agencies must take the responsibility to reorientate their organisational and management practices. The purpose is to provide the flexibility for the Practitioners that they employ to be able to work with those clients who want to become empowered.

䊏 The practical application of the ideas in the book The concept of ‘parallel-tracking’ discussed in Chapter 1, the strategies for helping individuals, groups and communities to gain power discussed in Chapters 4, 5 and 6 and the measurement of empowerment in Chapter 7 are all designed for Practitioners who want to help their clients to gain power. These strategies consist of practical approaches and exercises that have been used by the author or by other Practitioners in the design of public health programmes to empower their clients. One implication for practice is the generic nature of the ideas discussed in this book and the ability of the Practitioner to replicate the same results of helping their clients to gain power in different cultural contexts. To address this issue the ideas discussed in this book have been designed with the following considerations: 1

2

3

4 5

A widely accepted understanding of the process of community empowerment as a 5-point continuum, supported by many years of field work experience (Chapter 5); A widely accepted understanding of the interpretation of ‘community’, supported by the work of other authors, that heterogeneous individuals are able to achieve community empowerment based on their shared needs and interests (Chapter 5); The use of established principles of participatory and empowering approaches and practical programme ‘tools’ such as the logical framework system and strategic planning (Chapters 1, 4–7); The use of the ‘domains’ of community empowerment which have been drawn from a broad range of case study data (Chapter 5); A field tested methodology for the planning, implementation and measurement of community empowerment, using parallel-tracking and a ‘domains’ approach (Chapters 1 and 5);

Power, empowerment and professional practice · 119 6

A field-tested approach for the visual representation and interpretation of the domains of community empowerment using the spider web configuration (Chapter 7).

The strategies, approaches and exercises discussed in this book can be used by Practitioners to both help their clients to gain power and also to take control away from their clients. For example, the ‘domains approach’ discussed in Chapter 5 can be used to build and measure empowerment or it can be used by the Practitioners, and by the agencies for whom they work, as a means to audit programme implementation and to closely control their clients within a programme context. Likewise, the concept of parallel-tracking discussed in Chapter 1 can be used to design programmes to better accommodate empowerment or it can be used by Practitioners in a top-down approach to audit and control inputs and outputs. The spirit in which this book has been written is for Practitioners to consciously use the strategies, approaches and exercises discussed to purposefully help their clients to gain power and not as a means to gain power-over their clients. The extent to which this happens will depend on how far Practitioners are willing to relinquish control (power-with) to their clients and of the programmes, which they manage. It also depends on how honest Practitioners are prepared to be about their role in achieving an empowering public health practice. Given the constraints, discussed above, faced by many Practitioners in their everyday work this is one of the most difficult challenges to using an empowering approach. It means that the Practitioner must use a great deal of self-vigilance and self-discipline if the professional–client relationship is to be transformative. The person with the power-over, the Practitioner, must share this power with others, their clients, to enable them to gain power. In this book, I explain how public health agencies, and the Practitioners that they employ, can use simple strategies and exercises to become more empowering in policy development and in their everyday practices. The book does not call for a radical reorientation of public health practice. Rather the book offers the profession a gradual way forward to develop existing public health practice and programming. A way that is more empowering for both the Practitioners and the individual clients, groups and communities with which they work. The book recognises that not all clients want to be empowered and not all Practitioners want to help their clients to gain power. The challenge lies with public health to find new ways, some of which are provided in this book, to create an empowering professional practice that motivates their agencies, Practitioners and clients to work together to share power.

References Adams, R. N. (1977) ‘Power in human societies: a synthesis’, in Fogelson, R. D. and Adams, R. N. (eds) (1977) The Anthropology of Power: Ethnographic Studies from Asia, Oceania, and the New World. New York: Academic Press: 387–410. Aggleton, P. (1991) Health. London: Routledge. Asthana, S. (1994) ‘Community participation in health and development’, in Phillips, D. and Verhasselt, Y. (eds) Health and Development. London: Routledge: 182–96. Baggott, R. (2000) Public Health: Policy and Politics. London: St. Martin’s Press. Barnes, M. (2002) ‘User movements, community development and health promotion’, in Adams, L., Amos, M. and Munro, J. Promoting Health: Politics and Practice. London: Sage Publications. Barr, A. (1995) ‘Empowering communities beyond fashionable rhetoric? Some reflections on Scottish experience’. Community Development Journal, 30(2): 121–32. Barrig, M. (1990) ‘Women and development in Peru: old models, new actors’. Community Development Journal, 25(4): 377–85. Baum, F. (1990) ‘The new public health: force for change or reaction?’. Health Promotion International, 5(2): 145–50. Bjaras, G., Haglund, B. J. A. and Rifkin, S. (1991) ‘A new approach to community participation evaluation’. Health Promotion International, 6(3): 1999–2006. Blair, D. and Bernard, J. R. L. (eds) (1998) Macquarie Pocket Dictionary. Sydney: Jacaranda Wiley Ltd. Bloor, M. and McIntosh, J. (1990) ‘Surveillance and concealment’, in Cunningham-Burley, S. and McKeganey, N. P. (eds) Readings in Medical Sociology. New York: Tavistock/ Routledge. Bopp, M., Germann, K., Bopp, J., Littlejohns, L. B. and Smith, N. (1999) Evaluating Community Capacity for Change. Calgary: Four Worlds Development. Boutilier, M. (1993) The Effectiveness of Community Action in Health Promotion: A Research Perspective. Toronto: University of Toronto. ParticiACTION. 3. Bracht, N. and Tsouros, A. (1990) ‘Principles and strategies of effective community participation’. Health Promotion International, 5(3): 199–208. Britten, N. (1995) ‘Qualitative interviews in medical research’. British Medical Journal, 311: 251–3. Brunner, E. (1996) ‘The social and biological basis of cardiovascular disease in office workers’, in Blane, D., Brunner, E. and Wilkinson, R. (eds) Health and Social Organisation: Towards a Health Policy for the 21st Century. New York: Routledge. Burgess, R. G. (1982) Field Research: A Source Book and Field Manual. London: Allen & Unwin. Carapetis, J. R., Johnston, F., Nadjamerrek, J. and Kairupan, J. (1995) ‘Skin sores in Aboriginal children’. Journal of Paediatrics and Child Health, 31: 563. Letter to Editor. Cass, A., Lowell, A., Christie, M., Snelling, P. L., Flack, M., Marrnganyin, B. and Brown, I. (2002) ‘Sharing the true stories: improving communication between Aboriginal patients and health care workers’. The Medical Journal of Australia, 176(10): 466–70. Chow, J., Murry, S. and Angeli, C. (1996) International and multicultural teaming: a kaleidoscope of kolors. Annual Conference of the American Evaluation Association. Atlanta, Indiana University. Clegg, S. R. (1989) Frameworks of Power. London: Sage Publications. Coleman, P. T. (2000) ‘Power and conflict’, in Deutsch, M. and Coleman, P. T. (2000) (eds) The Handbook of Conflict Resolution. Theory and Practice. San Francisco, CA.: Jossey-Bass Publishers.

120

References · 121 Couto, R. A. (1989) ‘Catastrophe and community empowerment: the group formulations of Aberfan’s survivors’. Journal of Community Psychology, 17( July): 236–48. Cracknell, B. E. (1996) ‘Evaluating development aid’. Evaluation, 2(1): 23–33. Cresswell, H. (2004) Personal email correspondence. 14/5/2004. Cuthbert, M. (1985) ‘Evaluation encounters in third world settings: a Caribbean perspective’, in Patton, M. Q. (ed.) Culture and Evaluation. San Francisco, CA.: Jossey-Bass: 29–35. Earle, L., Fozilhujaev, B., Tashbaeva, C. and Djamankulova, K. (2004) ‘Community development in Kazakhstan, Kyrgyzstan and Uzbekistan’. Occasional paper number 40. Oxford: INTRAC. Eng, E. and Parker, E. (1994) ‘Measuring community competence in the Mississippi delta: the interface between programme evaluation and empowerment’. Health Education Quarterly, 21(2): 199–220. Erzinger, S. (1994) ‘Empowerment in Spanish: words can get in the way’. Health Education Quarterly, 21(3): 417–19. Everson, S. A., Lynch, J. W., Chesney, M. A., Kaplan, G. A., Goldberg, D. E., Shade, S. B., Cohen, R. D., Salonen, R. and Salonen, J. T. (1997) ‘Interaction of workplace demands and cardiovascular reactivity in progression of carotid atherosclerosis: population based study’. British Medical Journal, 314: 553–8. Ewles, L. and Simnett, I. (2003) (fifth edition) Promoting Health. A Practical Guide. London: Bailliere Tindall. Eyerman, R. and Jamison, A. (1991) Social Movements. A Cognitive Approach. Cambridge: Polity Press. Foucault, M. (1979) Discipline and Punishment: The Birth of the Prison. Middlesex: Peregrine Books. Freeman, J. (ed.) (1983) Social Movements of the Sixties and Seventies. New York: Longman. Freire, P. (1973) Education for Critical Consciousness. New York: Seabury Press. Friedmann, J. (1992) Empowerment: The Politics of Alternative Development. Oxford: Blackwell Publishers. Gibbon, M. (1999) Meetings with meaning: health dynamics in rural Nepal, unpublished PhD thesis. London: South Bank University. Gibbon, M., Labonte, R. and Laverack, G. (2002) ‘Evaluating community capacity’. Health and Social Care in the Community, 10(6): 485–91. Ginsberg, P. E. (1988) ‘Evaluation in cross-cultural perspective’. Evaluation and Program Planning, 11: 189–95. Glesne, C. and Peshkin, A. (1992) Becoming Qualitative Researchers. New York: Longman Publishing Group. Goodman, R. M., Speers, M. A., McLeroy, K., Fawcett, S., Kegler, M., Parker, E., Rathgeb Smith, S., Sterling, T. D. and Grace, V. M. (1991) ‘The marketing of empowerment and the construction of the health consumer: a critique of health promotion’. International Journal of Health Services, 21(2): 329–43. Goodman, R. M., Speers, M. A., McLeroy, K., Fawcett, S., Kegler, M., Parker, E., Rathgeb Smith, S., Sterling, T. D. and Wallerstein, N. (1998) ‘Identifying and defining the dimensions of community capacity to provide a basis for measurement’. Health Education & Behavior, 25(3): 258–78. Gordon, G. (1995) ‘Participation, empowerment and sexual health in Africa’, in Craig, G. and Mayo, M. (eds) Community Empowerment. A Reader in Participation and Development. London: Zed Books. 181–93. Grace, V. M. (1991) ‘The marketing of empowerment and the construction of the health consumer: a critique of health promotion’. International Journal of Health Services, 21(2): 329–43. Green, L. and Kreuter, M. (1991) Health Promotion Planning. An Educational and Environmental Approach. Toronto: Mayfield Publishing Company. Hawe, P., King, L., Noort, M., Jordens, C. and Lloyd, B. (2000) Indicators to help with capacity building in health promotion. Sydney: Australian Centre for Health Promotion/NSW Health.

122 · References Haynes, A. W. and Singh, R. N. (1993) ‘Helping families in developing countries: a model based on family empowerment and social justice’. Social Development Issues, 15(1): 27–37. Hubley, J. (1993) Communicating Health: An Action Guide to Health Education and Health Promotion. London: MacMillan. IRED (1997) People’s Empowerment. Grassroots Experiences in Africa, Asia and Latin America. Rome: IRED-NORD. Israel, B. A., Checkoway, B., Schultz, A. and Zimmerman, M. (1994) ‘Health education and community empowerment: conceptualizing and measuring perceptions of individual, organisational and community control’. Health Education Quarterly, 21(2): 149–70. Jackson, T., Mitchell, S. and Wright, M. (1989) ‘The community development continuum’. Community Health Studies, 8(1): 66–73. Jones, A. and Laverack, G. (2003) ‘Building Capable Communities within a Sustainable Livelihoods Approach: Experiences from Central Asia’. http://www.livelihoods.org/ lessons/Central Asia & Eastern Europe/SLLPC. 1.9.2003 Jones, L. and Sidell, M. (eds) (1997) The Challenge of Promoting Health. Exploration and Action. London: MacMillan. Kari, N. and Michels, P. (1991) ‘The Lazarus programme: the politics of empowerment’. The American Journal of Occupational Therapy, 45: 719–25. Kieffer, C. H. (1984) ‘Citizen empowerment: a development perspective’. Prevention in Human Services, 3: 9–36. Kitzinger, J. (1995) ‘Introducing focus groups’. British Medical Journal, 311: 299–302. Korsching, P. F. and Borich, T. O. (1997) ‘Facilitating cluster communities: lessons from the Iowa experience’. Community Development Journal, 32(4): 342–53. Kukuruzovic, R., Haase, A., Dunn, K., Bright, A. and Brewster, D. R. (1999) ‘Intestinal permeability and diarrhoeal disease in Aboriginal Australians’. Archives for Diseases of Children, 81: 304–8. Labonte, R. (1990) ‘Empowerment: notes on professional and community dimensions’. Canadian Review of Social Policy (26): 64–75. Labonte, R. (1993) Health promotion and empowerment: practice frameworks. Toronto: University of Toronto. ParticiACTION. 3. Labonte, R. (1994) ‘Health promotion and empowerment: reflections on professional practice’. Health Education Quarterly, 21(2): 253–68. Labonte, R. (1996) Community development in the public health sector: the possibilities of an empowering relationship between the state and civil society, PhD thesis. Toronto: York University. Labonte, R. (1998) A community development approach to health promotion: a background paper on practice tensions, strategic models and accountability requirements for health authority work on the broad determinants of health. Edinburgh: Health Education Board for Scotland. Laverack, G. (1998) ‘The concept of empowerment in a traditional Fijian context’. Journal of Community Health and Clinical Medicine for the Pacific, 5(1): 26–9. Laverack, G. (1999) Addressing the contradiction between discourse and practice in health promotion, unpublished PhD thesis. Melbourne: Deakin University. Laverack, G. and Labonte, R. (2000) ‘A planning framework for the accommodation of community empowerment goals within health promotion programming’. Health Policy and Planning, 15(3): 255–62. Laverack, G. (2001) ‘An identification and interpretation of the organizational aspects of community empowerment’. Community Development Journal, 36(2): 40–52. Laverack, G. and Wallerstein, N. (2001) ‘Measuring community empowerment: a fresh look at organizational domains’. Health Promotional International, 16(2): 179–85. Laverack, G. (2003) ‘Building capable communities: experiences in a rural Fijian context’. Health Promotion International, 18(2): 99–106. Laverack, G. and Brown, K. M. (2003) ‘Qualitative research in a cross-cultural context: Fijian experiences’. Qualitative Health Research, 13(3): 1–10.

References · 123 Laverack, G. and Dao, H. D. (2003) ‘Transforming information, education and communication in Vietnam’. Health Education, 103(6): 363–9. Laverack, G. (2004) Health Promotion Practice: Power and Empowerment. London: Sage Publications. Leach, F. (1994) ‘Expatriates as agents of cross-cultural transmission’. Compare, 24(3): 217–31. Lerner, M. (1986) Surplus Powerlessness. Oakland, CA.: The Institute for Labour and Mental Health. Linney, B. (1995) Pictures, People and Power. People-Centred Visual Aids for Development. London: MacMillan. Lloyd, M. and Bor, R. (2004) (second edition) Communication Skills for Medicine. London: Churchhill Livingstone. Lupton, D. (1995) The Imperative of Health: Public Health and the Regulated Body. London: Sage Publications. Marsden, D., Oakley, P. and Pratt, B. (1994) Measuring the Process: Guidelines for Evaluating Social Development. Oxford: INTRAC. Marshall, G. (1998) A Dictionary of Sociology. London: Oxford University Press. Mays, N. and Pope, C. (1995) ‘Observational methods in health care settings’. British Medical Journal, 311: 182–4. Melucci, A. (1985) ‘The symbolic challenge of contemporary movements’. Social Research, 52(4): 789–816. Merryfield, M. M. (1985) ‘The challenge of cross-cultural evaluation: some views from the field’, in Patton, M. Q. (ed.) Culture and Evaluation. San Francisco, C.A.: Jossey-Bass: 3–17. Minichiello, V., Aroni, R., Timewell, E. and Alexander, L. (1990) Indepth Interviewing. Researching People. Australia: Longman Cheshire. Mitchell, C. and Banks, M. (1998) Handbook of Conflict Resolution. The Analytical Problem-Solving Approach. London: Pinter. Morriss, P. (1987) Power. A Philosophical Analysis. New York: St. Martin’s Press. Murray, S. A. and Graham, L. J. C. (1995) ‘Practice based needs evaluation: use of four methods in a small neighbourhood’. British Medical Journal, 310: 1443–8. O’Connor, M. and Parker, E. (1995) Health Promotion: Principles and Practice in the Australian Context. St Leonards, NSW: Allen & Unwin Pty Ltd. O’Gorman, F. (1995) ‘Brazilian community development: changes and challenges’, in Craig, G. and Mayo, M. (eds) Community Empowerment. A Reader in Participation and Development. London: Zed Books: 206–17. Pakulski, J. (1991) Social Movements. The Politics of Moral Protest. Sydney: Longman Cheshire. Peart, A. and Szoeke, C. (1998) Recreational water use in remote indigenous communities. Cooperative Research Centre for Water Quality and Treatment. Australian National University (unpublished report). Piven, F. F. and Cloward, R. (1977) Poor Peoples’ Movements. Why they Succeed, How they Fail. New York: Pantheon Books. Raeburn, J. (1993) How effective is strengthening community action as a strategy for health promotion? Toronto: University of Toronto. ParticiACTION. 3. Rappaport, J. (1984) Studies in Empowerment: Steps toward Understanding and Action. New York: Haworth Press. Rappaport, J. (1985) ‘The power of empowerment language’. Social Policy, Fall: 15–21. Rappaport, J. (1987) ‘Terms of empowerment/exemplars of prevention. Toward a theory of community psychology’. American Journal of Community Psychology, 15: 121–47. Raven, B. H. and Litman-Adizes, T. (1986) ‘Interpersonal influence and social power in health promotion’, in Ward, W. B. (ed.) Advances in Health Education and Promotion. London: Elsevier Science Ltd.: 181–209. Rifkin, S. B. and Pridmore, P. (2001) Partners in Planning: Information, Participation and Empowerment. London: MacMillan Education. Rifkin, S. B. (1990) Community participation in maternal and child health/family planning programmes. Geneva: World Health Organisation.

124 · References Rifkin, S. B., Muller, F. and Bichmann, W. (1988) ‘Primary health care: on measuring participation’. Social Science Medicine, 9: 931–40. Rissel, C. (1994) ‘Empowerment: the holy grail of health promotion?’. Health Promotion International, 9(1): 39–47. Rissel, C., Perry, C. and Finnegan, J. (1996) ‘Toward the assessment of psychological empowerment in health promotion: initial tests of validity and reliability’. Journal of the Royal Society of Health, 116(4): 211–18. Robertson, A. and Minkler, M. (1994) ‘New health promotion movement: a critical examination’. Health Education Quarterly, 21(3): 295–312. Robson, C. (1993) Real World Research. Oxford: Blackwell Publishers Ltd. Roughan, J. J. (1986) Village organization for development, PhD thesis. Honolulu: Department of Political Science, University of Hawaii. Russon, C. (1995) ‘The influence of culture on evaluation’. Evaluation Journal of Australasia, 7(1): 44–9. Scrambler, G. (1987) ‘Habermas and the power of medical expertise’, in Scrambler, G. (ed.) Sociological Theory and Medical Sociology. New York: Methuen Press. Scrimgeour, D. (1997) ‘Community control of aboriginal health services in the Northern Territory’. Darwin: Menzies School of Health Research, 2/97. Seefeldt, F. M. (1985) ‘Cultural considerations for evaluation consulting in the Egyptian context’, in Patton, M. Q. (ed.) Culture and Evaluation. San Francisco, CA.: Jossey-Bass: 69–78. Seidman, S. and Wagner, D. G. (eds) (1992) Postmodernism and Social Theory. The Debate Over General Theory. Oxford: Blackwell. Seligman, M. (1975) Helplessness: On Depression, Development and Death. San Francisco, CA.: W. H. Freeman. Serrano-Garcia, I. (1984) ‘The illusion of empowerment: community development within a colonial context’, in Rappaport, J. (eds) Studies in Empowerment: Steps toward Understanding Action. New York: Haworth Press: 173–200. Shrimpton, R. (1995) ‘Community participation in food and nutrition programmes: an analysis of recent governmental experiences’, in Pinstrup-Andersen, P., Pellitier, D. and Alderman, H. (eds) Child Growth and Nutrition in Developing Countries: Priorities for Action. USA: Ithaca: Cornell University Press: 243–61. Silva, D. T., Uben, A. R., Wronski, I., Stronach, P. and Woods, M. (1998) ‘Excessive rates of childhood mortality in the Northern Territory, 1985–94’. Journal of Paediatric Child Health, 34: 63–68. Simpson, G. E. and Yinger, J. M. (1965) Racial and Cultural Minorities. New York: Harper and Row. Smithies, J. and Webster, G. (1998) Community Involvement in Health. Aldershot, England: Ashgate Publishing Ltd. Speer, P. and Hughley, J. (1995) ‘Community organising. an ecological route to empowerment and power’. American Journal of Community Psychology, 23(5): 729–48. Srinivasan, L. (1993) Tools for Community Participation. A Manual for Training Trainers in Participatory Techniques. New York: PROWWESS/UNDP. Starhawk, M. S. (1990) Truth or Dare. Encounters with Power, Authority and Mystery. New York: HarperCollins. Stewart, D. W. and Shamdasani, P. N. (1990) Focus Groups. Theory and Practice. London: Sage Publications. Swift, C. and Levin, G. (1987) ‘Empowerment: an emerging mental health technology’. Journal of Primary Prevention, 8(1 and 2): 71–94. Syme, L. (1997) ‘Individual vs community interventions in public health practice: some thoughts about a new approach’. Vichealth Letter, July (2): 2–9. Taylor, V. (1995) ‘Social reconstruction and community development in the transition to democracy in South Africa’, in Craig, G. and Mayo, M. (eds) Community Empowerment: A Reader in Participation and Development. London: Zed Books: 168–80.

References · 125 Toronto Department of Public Health (1991) Advocacy for basic health prerequisites: Policy report. City of Toronto, Department of Public Health. Turbyne, J. (1996) The enigma of empowerment: a study of the transformation of concepts in policy making processes, PhD thesis. Bath: University of Bath. Turner, B. S. and Samson, C. (1995) Medical Power and Social Knowledge. London: Sage Publications. Uphoff, N. (1991) ‘A field methodology for participatory self-education’. Community Development Journal, 26(4): 271–85. Wallerstein, N. (1992) ‘Powerlessness, empowerment and health. Implications for health promotion programs’. American Journal of Health Promotion, 6(3): 197–205. Wallerstein, N. (1998) ‘Identifying and defining the dimensions of community capacity to provide a basis for measurement’. Health Education & Behavior, 25(3): 258–78. Wang, C. and Burris, M. (1994) ‘Empowerment through photo novella. Portraits of participants’. Health Education Quarterly, 21(2): 171–86. Ward, J. (1987) ‘Community development with marginal people: the role of conflict’, Community Development Journal, 22(1): 18–21. Wartenberg, T. E. (1990) The Forms of Power. From Domination to Transformation. Philadelphia, PA.: Temple University Press. Welbourn, A. (1995) Stepping Stones. A Training Package on HIV/AIDS, Communication and Relationship Skills. London: ACTIONAID. Werner, D. (1988) ‘Empowerment and health’. Contact, Christian Medical Commission, 102: 1–9. Westwood, J. and Brous, D. (1993) ‘Cross-cultural evaluation: lessons from experience’. Evaluation Journal of Australasia, 5(1): 43–8. Wheat, S. (1997) ‘Banking on a better future’. Guardian Weekly, Manchester, February 9: 19. Wilkinson, R. (1996) Unhealthy Societies: The Afflictions of Inequality. New York: Routledge. Wood, S., Sawyer, R. and Simpson-Hebert, M. (1998) PHAST Step-by-step-Guide. Geneva: WHO. World Health Organisation (1978) ‘Declaration of Alma Ata’. Geneva: WHO. World Health Organisation (1986) ‘Ottawa Charter for Health Promotion’. Geneva: WHO. World Health Organisation (1997) Health Promotion Glossary. Geneva: WHO. Wrong, D. H. (1988) Power. Its Forms, Bases and Uses. Chicago, IL.: The University of Chicago Press. Zakus, J. D. L. and Lysack, C. L. (1998) ‘Revisiting community participation’. Health Policy and Planning, 13(1): 1–12. Zimmerman, M. A. and Rappaport, J. (1988) ‘Citizen participation, perceived control and psychological empowerment’. American Journal of Community Psychology, 16(5): 725–43. Zimmerman, M. A. and Zahniser, J. H. (1991) ‘Refinements of sphere-specific measures of perceived control: development of a socio-political control scale’. Journal of Community Psychology, 19: 189–204.

Index Aboriginal communities and empowerment 79–85 and public health 77, 78 Alma Ata declaration 22 asking ‘why’; see also critical awareness 62, 70

legitimisation of 25 professional discourse 112 domains of community empowerment 60–2 definition 7 use of 118–19

behavioural/Lifestyle approaches 21, 22 bottom-up programming 8–10, 17, 49, 67, 112, 116

empowerment community 36 descriptors 99–101 family 35 organisational 35 psychological 35 working definition of 89

civil society, 23, 24, 114 definition 15, 17 cluster communities 72, 73 cognitive praxis 24, 25 communication and the GATHER approach 42 combining channels 45 one to one 41 community characteristics of 58 interpretations of 57 community capacity definitions 61 community development 5, 25, 37, 58, 66, 71, 80, 102–3, 116 community empowerment 2, 4, 6 bottom-up programmes 8, 10, 17 continuum 6, 59 definition 35, 36, 79 domains 7, 60, 62 economic context 37, 115 language 37, 53, 113 measurement 97, 116 methodology to build 98 overlap with concepts 61 parallel-tracking 9 as a process 58 visual representations 102–8 community organising 6, 34 conflict dealing with 85–8 critical-self awareness 5, 47–52, 70, 80, 108 discourse 15–16, 20, 26, 53, 55, 113, 115 definition 2 empowerment and public health 21–2

facilitator role types 95, 96 false consciousness 33 Freire, Paulo 70 health and individual control 20 expressions of 62, 63 inequalities 33, 76, 79 lay interpretations 17, 18 official interpretations 17, 18 WHO definition of 19 health determinants 22, 55 health education 28, 40–1, 83, 110 and health promotion 21 health promotion 18, 21–2, 68 definition 41 helping groups and communities to gain power 5–7, 57–74 helping individuals to gain power 4–5, 40–56 helping marginalised groups to gain power 75–88 Information, Education and Communication (IEC) 40, 41 leadership skills 6, 59, 63, 69 learned helplessness 33, 54, 68 links with other people and organisations 7, 9, 61, 62, 72, 81, 84, 109; see also partnerships listening skills 43

126

Index · 127 mapping positions of power 47–8, 117 marginalized groups 20, 30, 53, 65, 71, 75–88, 94 definition 75 medical approach 21 minority groups, defining 76–7 New Social Movement Theory 23 and partnerships in Brazil 25 movement intellectuals 25 social justice 22 Not In My Back Yard (NIMBY’s) 66 organisational structures 6, 9, 59–60, 62–3, 69, 83–4, 104–8 Ottawa Charter for Health Promotion 22, 78, 84 outside agents as enablers 53 parallel-tracking 9, 10, 119 participation 62, 64, 65 partnerships; see also links to others 25, 59, 62, 72 personal action and participation 64, 65 photo-novella 70 political action 35, 59, 73 power definition 27 different cultural interpretations 36–9, 90 hegemonic 30 and language 53 non-zero-sum, zero-sum 31 power-from-within 5, 15, 28–9 powerlessness 33 power-over 29–30 power-with 30 problem assessment 59–63, 66–8, 80, 84

professional-client relationship 5, 32, 40, 52–3, 54–5, 65, 119 programme management 12, 62, 81 public health and bureaucratic settings 15–17 definition 14 New Social Movement Theory 25 versus discourse and practice 2, 16, 112 public health programming 7 bottom-up programming 8 evaluation 13 management 12 marginalised populations 78 parallel tracking 9, 10 size 12 timeframe 10 top-down programming 8, 10 qualitative information collecting 89–94 in cross-cultural context 94–7 radical relativism 19 self-help groups 4, 25, 37, 64 spider web configuration 3, 88, 102–9, 117, 119 stakeholders 7–10, 62, 65, 82, 89, 92, 115–17 definition 1 strategies for decision making 49–51, 80 matrix 51 surplus powerlessness 33 and women 34 top-down programming 2, 10, 11, 16, 112–13, 116 World Health Organisation 18, 22, 79 definition of health 19