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Power and empowerment in health promotion: Discuss the implications of power and empowerment in community based health promotion.

Chronic disease is now a major concern for the western world. No longer are infectious and acute diseases the leading causes of death in the UK, but chronic diseases such as cancers and obesity related disorders have now taken over as the biggest health threats to the general population. Many chronic disorders are a result, to some degree, of behavioural factors like lifestyle choices or diet. Lung cancer from smoking and Type II Diabetes through poor diet (obesity) and sedentary lifestyle are prime examples of the link between modern life and a shift towards chronic disease. As a result of this partially behavioural foundation to illness, there is the opportunity to change open to many people, and ultimately the ability to improve health and health outcomes such as life expectancy or quality of life.

Health can thus be seen to be potentially determined by our actions. One way of letting people know what they should be doing to stay healthy or to improve their health is through health promotion. As set out in the Ottawa Charter for Health Promotion (WHO, 1986), health promotion can be defined as 'the process of enabling people to increase control over, and to improve their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment.'

The strategies used in health promotion programmes have been reported as diverse, through engaging in; awareness, information provision, influencing social policy, fighting for change and intervention type programmes. (Speller et al 1997) Traditionally health promotion has focused around education, prevention and protection interventions (Tannahill, 1985) and has been designed, implemented and evaluated from a top-down approaches and programmes. This is where behaviour change is generally the focus of outcome, and the issues that are being investigated are set by some form of authority, like a local health authority or even at a national level through the Government. Top down is thus where a small number of select people make the choices for people lower down the chain - effectively a minority with power over the majority.

Health promoters who operate in this capacity can thus be seen to hold and exert power over the population or different communities through their setting of the health promotion programmes, and through acting as gatekeepers of the information they choose to share. People in such decision-making positions may also have control over issues such as resource allocation and funding or who is given decision-making responsibilities (Laverack & Laonte, 2000) and all of these factors work to take away power from the grass-roots / individual level. 'Real power is possessed by those who define the problem.' (McKnight, 1999) Decision makers such as health promoters or authorities that dictate what people need, and what they can and cannot have in relation to health information, promotion and intervention also exert power over the population through creating individual dependency on health professionals for maintaining and responsibility for their health and wellbeing.

The Ottawa Charter highlighted the need for health promotion to move beyond what is an essentially person-passive approach of receiving health promotion information and interventions, to one where individuals are enabled to become much more active participants with greater control over their health and well-being, and through instigating greater action on a community and group level. A concept known as 'empowerment' with roots in social psychology constructs such as self-efficacy and health locus of control, refers to 'processes of social interaction of individuals and groups, which aim at enabling people to enhance their individual and collective skills and the scope and range of controlling their lives.' (Erben, Franzkowiak & Wenzel, 2000) Empowerment can thus occur at both individual and group levels, such as within communities.

The basis of empowerment is essentially associated with the so-called bottom-up approach to health promotion (where the decision making process begins at the individual or group level, and these ideas are taken up the chain for approval and implementation) which has given focus to 'issues of concern to particular groups or individuals, and regards some improvement in their overall power or capacity as the important health outcome.' (Laverack & Labonte, 2000)

Empowerment is seen as a particularly important strategy in enabling more marginalized groups of society, those who may be 'powerless' in many other aspects of their lives as well as in regards to control over their health (Bergsma, 2004). The Ottawa Charter (WHO,1986) outlined the 8 fundamental pre-requisites it believed were necessary for attaining improvement in health and well-being; peace, shelter, education, food, income, a stable natural environment, sustainable resources, and lastly social justice and equity.

People from marginalized groups or those who are from a lower socio-economic-status (SES) background may have the basics of these elements, but not in the quantities or to the levels of those from higher SES groups. Difficulties in these areas that are common amongst marginalized and low SES groups each in themselves have implications for health (Bergsma, 2004). Low income families are more likely to have an unhealthier and less nutritious diet. This is thought to stem from financial considerations of buying some foods, but may also be a consequence of poorer education. Low SES neighborhoods are also generally found to be more stressful places to live. Higher crime rates, poorer community facilities and educational institutions have the potential of confounding the problem further.

Types of work amongst different SES groups can affect health - some of the blue-collar jobs types associated with low SES groups are catergorised as some of the most stressful work environments; those with low control and low decision authority such as factory work are thought more stressful than typical white-collar jobs like managerial work. Stress is well established as linked to poorer health through work like PNI (psychoneuroimmunology) where psychological stress can be translated by the body into physiological responses and cause short-term and long-term health problems (Karasek, Baker, Marxer, Ahlborn & Thorell, 1981) as well as psychological distress.

As factors such as low income (money worries) crime rates (living in dangerous neighborhoods) and work all and feelings of powerlessness and have the potential to cause high levels of stress, those that are experiencing a good number of these factors are likely to have poorer health (Bergsma, 2004) than those who do not have such worries or uncontrollable stressors. These factors can thus be seen to be to a large extent, difficult to control, and as such people can feel powerless to make any changes in regards to such difficulties, either through feeling that they would be unable to make any change especially making change as a lone individual (Erben, Franzkowiak & Wenzel, 2000) or where through education or poor health people are not aware of what changes could help them, or being in a position to take any action.

It is for reasons such as these that research have found that change in knowledge did not necessarily translate into behaviour change through action, or ultimately improved health of those within health promotion education programmes.

Health promotion at an individual level may thus not be effective for all individuals who come to the education or intervention with different experiences or backgrounds. Educational level may dictate the level to which people can understand health promotion campaigns or the medical reasons why they may need to alter their behaviour. Health education promotion may also be unable to interest everyone due to the different motivations for change that people may have - someone who is struggling to pay the mortgage bills to keep their house may have less motivation to ensure they are eating healthily to make sure they do not develop diabetes.

These individual differences in regards to health may exert a potentially large detrimental effect on the efficacy of health promotion programmes when decision making in regards to targeted behaviour, resource allocation etc, have been made without consultation with those the intervention is designed for, as is the case in typically top-down programming approaches.

Some authors have however argued that top-down and bottom-up programmes for health promotion need not necessarily operate on a mutually exclusive basis. (Laverack & Labonte, 2000) These authors argue that the way in which bottom-up approaches can be incorporated into top-down programmes is through more 'subtle' targeting of behaviours for change. The example provided by Laverack & Labonte (2000) is through concern 'more with the group member's experiences of empowerment in terms of the quality of their social relationships and self-identities than with changes in specified health behaviours.'

Programmes with this focus may create an environment conducive to, and a support network for people to begin to critically evaluate their health behaviour. A study involving a sample of lower income women and their concerns about themselves (body image, parental ability, managing household budgets etc) found that within the supportive environment of the group, the women began to perceive they had more control over their situation and through this an increased feeling of self-esteem through which they began to evaluate health concerns such as smoking. (Labonte, 1996; Kort 1990) In this capacity health promoters and authorities can retain control of resources and project design, although the direction of the project will be guided by a need raised by the community. Greater priority is thus gained from understanding what a group or community needs through its participation in early stages, and not assuming what may be effective (Laverack & Labonte, 2000). Through this kind of design strategy the powerless are becoming empowered to participate in the orientation and type of health promotion they receive.

Empowerment within health promotion can thus be seen to involve enabling people to take more control over their health, through teaching them the skills they need to do this; developing self-efficacy (confidence in one's ability to perform / complete a task) decision making and problem solving skills, and life skills like communication, in general. Empowerment reestablishes the individual with autonomy over their health. (Hubley, 2002) Implications of empowering people on an individual level with their health, means that people have the chance to assess what is important to them, and to be in a position of making an informed choice about what they could do to improve or resolve their health problem, and to have the skills and knowledge of knowing where to start in the correction process if they come to the decision that they do want to change.

Giving someone the capacity to make an informed choice over their health does not however guarantee that they will always make the same choices as health promoters or authorities may wish them to, simply that the power has been given back to them on deciding how to proceed. Empowered individuals may subsequently decide to give up drinking but continue smoking for example. There will be consequences of individual decisions at higher levels resulting from empowerment; those that continue to engage in unhealthy behaviours that have also received empowering health promotion interventions have used health promotion resources as well as potentially needing healthcare resources such as hospital stays, surgery or palliative care later on in their life as a result of behaviours they engage in.

People may also experience guilt and psychological distress after making decisions that result in a poor health outcome, or may feel under stress from the responsibility of making choices that can affect their health. Those that through empowerment have taken positive action in regards to their health may reduce their future needs for resources from the health service, and may spread knowledge such as health dieting and exercise engagement with their family and friends. There are therefore both positive and negative implications for enabling people to take the driving seat in decision-making for their health. Western contemporary society does however favor the notion of personal control rather than state control, and this therefore is complimentary to the notion of health empowerment within the health promotion perspective.

Personal empowerment can be complemented through community empowerment. This model from a bottom-up approach, takes into account the many social inequalities that exist within society, and the effect that such inequalities have on the health outcomes for minority / marginalized or low SES groups, and the extent to which they can bring about change in themselves and their situations socially. Community empowerment looks at re-establishing people's power in relation to these factors at a social and community level that is theoretically proposed as benefiting health.

A community can be defined as a geographical construct, but can also relate to 'a group of people who share a sense of social identity, common norms, values, goals and institutions.' (Bergsma, 2004) The community empowerment construct seeks to help people develop these skills within small groups or communities, in order to allow them to be in a position to participate in the decision making process within their wider community, over issues that will affect their health and their lives and 'control over personal, social, economic and political forces in order to take action to improve their lives.' (Israel et al, 1994)

One way through which communities can do this is through participatory action research, which is when professionals work in collaboration with communities to define issues, designing the research questions gathering and evaluating the data, and designing resolutions to the problems investigated and finally in acting out the change required. (Gebbie, Rosenstock & Hernandez, 2002) Action within a community setting towards health is one of the five principles that were outlined in the Ottawa Charter, as the WHO believed that people needed to hold some degree of control over their living and working conditions in order to develop 'lifestyles conducive to health, (WHO, 1986) as community empowerment health promotion allows individuals to gain mastery and impact the social, environmental ad economic conditions that determine their health (Bergsma, 2004).

Implications of working from a community empowerment model within a bottom-up health promotion strategy, can be seen to be more informed decision makers within health authorities and those in charge of resource allocation, through being better informed about community level need through the use of 'local knowledge.' Through this strategy a number of positive implications are potentially viable in comparison to tradition top-down programmes. Decisions based on local knowledge of need are likely to result in better health change and outcome as resources are more appropriately targeted with a better understanding of the people the services are aimed at. Closer collaboration between health authorities and communities is likely to create stronger collaborative relationships, which can create an environment of trust and openness.

This has positive implications two ways, firstly through a more open relationship individuals within a community may more honestly assess their health behaviours and need through which authorities will be able to target resources even more efficiently. Within the community itself, collaborative work will continue to empower individuals allowing community participation to evolve to higher capabilities over time. On the more negative side, community empowerment initiatives that do not reflect the community perspective are likely to be construed as a waste of time by those who have participated, and this may cause distrust within the community towards health authorities and future health promotion initiatives, through the community disengaging with the health authority, health services, or future research, or resisting health promotion programmes.

In summary, traditional top-down health promotion programmes can be seen to have operated in a way in which a minority had power over those which it aimed to help, through the control it exerted in regards to targeting health behaviours for change, resource allocation, information gate keeping, and dependency of health professionals to make decisions over individual health. This is compounded further for groups who are already marginalized within society, who have little control over other aspects of their living and working conditions, which have the potential to influence their health status - power is associated with health to the extent to which those with the least power, have the poorest health.

Bottom-up approaches to health promotion have begun to readdress the balance of power, through the use of empowerment strategies on both an individual and community level, in order to get people back involved (and capable) of making decisions about their health. It is found that empowerment on both these levels has a number of implications (positive and negative) for the individual and society in general, although it is felt that empowerment is more conducive to our notion of what society should be, and the power that individuals should have of making informed decisions over their own health.

REFERENCES

Bergsma, L (2004) 'Empowerment education' American Behavioural Scientist Vol.48, 2
Erben, R. Franzkowiak, P & Wenzel, E (2000) 'People empowerment vs. social capital. From health promotion to social marketing' Health Promotion Journal of Australia ol.9, 3
Gebbie, Rosenstock & Hernandez (2002) cited in Bergsma, L (2004) 'Empowerment education' American Behavioural Scientist Vol.48, 2
Hagquist, C & Starrin, B (1997) 'Health education in schools - from information to empowerment models' Health Promotion International Vol.12, 3
Hubley, J (2002) 'Health empowerment, health literacy and health promotion - putting it all together' Review paper, Leeds
Israel et al (1994) cited in Judd, J. Frankish, J & Moulton, G (2001) 'Setting standards in the evaluation of community-based health promotion programmes - a unifying approach' Health Promotion International Vol.16, 4
Judd, J. Frankish, J & Moulton, G (2001) 'Setting standards in the evaluation of community-based health promotion programmes - a unifying approach' Health Promotion International Vol.16, 4
Karasek, Baker, Marxer, Ahlborn & Thorell (1981) cited in Bergsma, L (2004) 'Empowerment education' American Behavioural Scientist Vol.48, 2
Kort (1990) Laverack, G & Labonte, R (2000) 'A planning framework for community empowerment goals within health promotion' Health Policy and Planning Vol.15, 3
Labonte (1996) cited in Laverack, G & Labonte, R (2000) 'A planning framework for community empowerment goals within health promotion' Health Policy and Planning Vol.15, 3
Laverack, G & Labonte, R (2000) 'A planning framework for community empowerment goals within health promotion' Health Policy and Planning Vol.15, 3
Laverack, G & Wallerstein, N (2001) 'Measuring community empowerment: a fresh look at organizational domains' Health Promotion International Vol.16, 2
McKnight (1999) cited in Bergsma, L (2004) 'Empowerment education' American Behavioural Scientist Vol.48, 2
Speller et al (1997) cited in Laverack, G & Labonte, R (2000) 'A planning framework for community empowerment goals within health promotion' Health Policy and Planning Vol.15, 3
Tannahill (1985) cited in Laverack, G & Labonte, R (2000) 'A planning framework for community empowerment goals within health promotion' Health Policy and Planning Vol.15, 3
WHO (1986) 'Ottawa Charter for Health Promotion' First International Conference on Health Promotion
WHO (1997) 'New players for a new era - Leading health promotion into the 21st century' Jakarta Declaration

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