Why does community empowerment matter-can it change our lives?
I have started this blog to enage people with the issues/theory/practice experiences of using community empowertment approaches-any questions pse ask away.
What works best in helping to empower others-what is the evidence (empirical, anecdotal, professional observation etc)?
Why do individuals become engaged collectively to try to empower themselves collectively-what are the motivational factors (social networks, personal trauma-the 'trigger effect')?
What are the most effective strategies that collectively people have used to influence government, polcy makers, local agencies etc?
Having worked in community development in Samoa for over 20 years, I have always found income generation as the best catalyst from my professional observation in operating an ecotour business in Samoa for over 10 years. We prepared 2 Operations Manuals: (i) How to operate a Pacific Ecotour and (ii) How to operate a Samoan/Pacific Community-Based Resort (i.e. a few inexpensive traditional beachside houses / fales / bures). The response was fantastic as long as the experience was fantastic (i.e. best sandy beach, best traditional food, local villagers, good English and safe). This was a very simple formula and today, this is a multi-million dollar sub-sector of tourism in Samoa (i.e. as many as 50% of all bed-nights in Samoa are spent in beach fale resorts).
Steve, you are correct-resource mobilization is a key domain for community empowerment and i know of similar experiences of communities entering into partnership with private sector (hotels) in the Pacific in order to raise funds.
The issue is how these funds are distributed within the community-are they equitably used or held by elite interests-participation and local leadership are therefore 2 other key domains for success
We are now trying a second approach to help empower communities: reduce cost of living and increase employment through provision of cheap local bioenergy power solutions (i.e. coconut biogiesel, biodigestion to compress methane gas emissions off large dual purpose 'septic tanks' or biodigesters, and biomass gasification (combustion of waste plant materials). Then there's biocharcoal options/technologies which can also combust household waste-to-energy. Once fully operational, cost of electricity can be reduced, allowing communities to dry their agricultural produce. END RESULT? Improved energy security and improved food security, along with new jobs. Community Based Organizations (CBOs) in Samoa are today taking a collective approach to find new markets for their dried nonu, copra, cocoa, kava, etc., but what is still missing is the cheap power to value-add their goods. And to briefly answer the 3rd question, 2 innovative ideas have been adopted in Samoa and they are (i) to take a more private sector approach once (ii) your foreign direct investments have been secured, but to reach this level, you have to have a well prepared bankable business plan. Once successful, you are then in a much better position to influence policymakers (i.e. your alternate energy supplies are cleaner, cheaper and moreincome generating for communities than say power generated from imported diesel).
From a community empowerment perspective the issue is how to connect these dfferent initiatives to create a network/coailition that is strong enoguh to cuallenge gvt policy-there are may examples of how this has happened elsewhere in other sectors - do u know any in the sustainable livelihood sector?
PROBLEM IS: If energy and agricultural policymakers are not technically informed of the alternate bioenergy technologies, then they cannot write climate-smart agricultural policy and formulate much better strategies that will lead to a low carbon development strategy for Samoa.
In conclusion, be innovative, attract the funding needed, demonstrate your development paradigm and then convincing others is made easier. However, research and development into alternate energy sources within the Pacific may have mistakingly focussed on solar, wind, coconut oil, geo-thermal, etc, and not realized that agricultural waste-to-bioenergy technologies being suggested here are, what we think, the novel catalyst to a new community-based development paradigm for the Pacific Islands, in fact all Small Island Developing States (SIDS) globally. Glenn's interest in following this project in Samoa may help quantify our answers above to these very pertinent questions tabled.
PS - without bioenergy technologies being made available to communities in Samoa, community development would continue to face extreme obstacles, but I look forward to hearing your comments to additional approaches that can be equally considered.
PPS And climate change impacts on Pacific Islanders are already increasing our vulnerability as Pacific cultures (i.e. Oceania already has the highest rate of loss of languages in the world, and climate change impacts will only hasten this loss as atmospheric CO2 levels continue to .......see www.CO2now.org).
Pacific island communities need to, for more reasons than one, displace/replace their diesel fuel imports that are causing additional greenhouse effects globally. We Pacific islanders need to lead by example as the global 'fossil-fuel based' economy is simply non-sustainable, globally irresponsible, and poverty creating (i.e. our proven austerity measures have been in place within the Pacific for over 40,000 years...we are in fact, the professors of sustainable economic growth that nurtures our future generations of Pacific Islanders. But we are running out of time as those living in Kiribati look to buying land in Fiji as 'climate refugees).
Steve, can u say why policy makers in Samoa are not able to make 'climate smart policy'?
The island context is especially relevant given its vulnerability and isolation. This is not my field but another example that comes to mind are the use of small water turbines in Northern Vietnam run from steams and providing enough to power household needs.
I am interested in any comments on the use of the term empowerment in the health care realm. I am finding it is a new buzz word used with patient-centred care, control in decision making, self-care and so on but lacks the true flavor of community and individual engagement. Cynthia
Cynthia, you are correct- much of the discussion on patient emp does lack the flavour of individual and collective empowerment. It is a form of emp in that it attempts to enable others to gain more control but in the sense of eleviating the burden on health services-such as self care, treatement, monitoring bllod pressure, chaning dressings etc- although there is evidence to suggest that this does lead to better and quicker health outcomes.
Nurses work to enable patients to take more control in decision making over their health, promoting patient independence, information exchange and being aware of their needs. In practice, this translates into acts of care such as making sure patients had their call bell within reach, respecting their choices, providing information about future care options and working quietly at night to allow patients to sleep (Faulkner, 2001). But an empowerment approach gives more credibility to what the individual has to offer in patient centred care and goes beyond self-care to what the individual can offer to improve the system. An individualistic approach focuses on supporting people to make informed choices, relationship building, self-management and partnerships. The broader empowerment of patients enables them to have an influence on the health system through networking and the engagement with patient advocacy and pressure groups. The purpose is collective action, as well as, individual self care.
To follow on from my earlier comments about patient empowerment i am providing 2 examples. The first is on 'Patient Advocacy Groups' that allow people to represent others and to speak out for their rights as patients (and as human beings).
One hospital in the UK asked patients to pass on comments to staff or to make formal complaints, but there was no way of bringing together patient comments to effect improvement. The Patient Involvement Action Group (PIAG) was established by the hospital to allow patients to voice their comments and concerns, anonymously if they wished, and have feedback about actions taken. Patients and their carers’ were given PIAG comment forms which could be returned to a member of staff or placed in a collection box. Once a month all of the comments, both positive and negative, were reviewed by the PIAG and action was decided upon at an appropriate level, or a report given about action already taken. The results of each action were posted on display boards in the wards to inform the patients and their carers and examples of the actions taken as a direct result of patient complaints through the PIAG include: • Side rooms for infection control have had curtains fitted to act as a screening door to prevent staff from walking straight into the room when a patient is carrying out personal functions; • Frosted glass in some rooms, which the patients felt had made them feel like prison cells, were replaced with clear glass and blinds; • Wards which suffered from solar glare have received vertical blinds to improve conditions. • Shelves have been put up in bathrooms for cosmetics, sponge bags etc to help patients to manage their own care. Each ward was asked to nominate representatives of whom one would be available to attend each a monthly PIAG meeting. The number of formal complaints decreased to less than 20% of the previous level as patients gained confidence that their comments would be acted upon and that the ward environment had improved (http://www.tin.nhs.uk/patient-involvement accessed 10/11/2011).
The second post will cover Patient networks for empowerment.
Networks for patients can be supported by an outside agent such as a health service employer, or may be independent and are formed by its members for the benefit of its members, both patients and health practitioners.
Patient Concern (UK), for example, relies on the dedication of volunteers, on donations, expertise and experience free of charge. Patient Concern operates a network in collaboration with other active campaigning groups run by patients on issues that matter to them, including: • Protection for whistleblowers: To ensure that professionals are not afraid to complain when they see neglect, indifference and poor care. This requires a direct confidential whistleblower line and legislation to ensure that they do not suffer for raising legitimate concerns, for example, that their careers are not damaged. • Assisted suicide: Advocating for a change in the law to allow physician assisted suicide for the terminally ill. • Save our beds: Campaigning against the reduction of hospital beds. • Complaints procedure: Strengthening a complaints system for patients to have the right to an independent investigation of serious issues. • Access to medical records: Patients uncensored access to their health records (http://www.patientconcern.org.uk/ accessed 15/12/2011).
The Patients Association is a joint campaign with the Nursing Standard (a professional magazine) that aims to tackle poor care and the causes of poor care. It is based around the most frequent complaints received by the Patients Association: poor communication; toileting; pain relief; nutrition and hydration. The campaign aims to highlight the complex causes of poor care and identify how these causes can be addressed. The Patients Association (UK) established the Network for Patients in 2009 with a group of over 30 charities to collaborate about common patient issues for better information and support. The Network for Patients is able to make a bigger impact than if each individual charity campaigned on their own. The Association addresses the shared concerns of its members including the General Practice “duty to refer”, for patients to be able to trust that their doctors are making sure they are getting access to the best treatment. Access to information is the best way to make sure this is happening and patient support groups are ideally placed to provide this service. Doctors cannot be expected to be experts in all fields and so it is important for them to be able to direct patients to other organizations which have the expertise. Doctors can then actively support patients in finding patient support groups and networks that could help them with managing their condition (http://www.patients-association.com accessed 15/12/2011).
A good example of how giving people more control over their lives (and health) can be illustrated in the context of patient empowerment.
Giving the client more control over decisions can have real benefits as demonstrated in one study (Bassett and Prapavessis, 2007) on physical therapy for ankle sprains. The study showed that the home-based groups had similar outcome scores for post-treatment ankle function, adherence and motivation to a standard physical therapy intervention. However, the home-based group had significantly better attendance at clinic appointments and a better physical therapy completion rate. Patients were helped to set goals and to develop personal action plans to complete the therapy as well as education and skills training on the treatment such as strapping techniques. The patients had more control and were better informed about their recovery and this sharing of the power (knowledge, skills) by the Practitioner was a form of power-with which led to a viable home-based option for the clients. Self-care can be a complicated issue that is not appropriate for all situations or people but under the right conditions, as this study showed, can offer the Practitioner the opportunity to work in a more empowering way.
Bassett, S. F., and Prapavessis, H (2007) Home-based physical therapy intervention with adherence-enhancing strategies versus clinic based management for patients with ankle sprains. Physical Therapy. Vol 87 (9): 1132-1143.
Speaking of patient empowerment, I want to talk about family empowerment. My mom has received in-home care for a few months since last December. I have been really discouraged since I cannot find respite services for family like me. My mom’s care coordinator told that my mom is unlikely to accept in any facilities due to her unstable mental conditions. Nursing homes take clients who give little burden on their workers but reject someone like my mom. The Japanese welfare system used to rely on family and in fact still does and expects women to sacrifice their jobs to take care of their families. I feel dis-empowered not finding any solutions for me and my mom. Are there any suggestions or thoughts?
Makie, I am not familiar with the Japanese Welfare System- however your situation is the basis for empowerment-other people surely suffer the same inequalities/difficulties regarding care. If so, empowerment starts when these people come together to form an action group/network to address the issue and to begin to develop a strategy to change government policy. How would this work in Japan?
Thanks Glenn! In Japanese society where people believe that they should prioritize the benefit of a whole society over their individual autonomy, family’s issues tend to be the last thing to think about. People often think that they should manage family matters without asking for help particularly from the government. People are entitled to use long-term care services but claiming the right seem to be considered to be selfish. People may not even be aware that they have the right. Even if I found people who have the same perspective, taking actions is still challenging as people are afraid of being ostracized from their community.
Makie, so this is an interesting cultural perspective on collectivism-similar political contexts might be communism but i am unaware of another cultural comparison. There must be examples of Japanese community empowerment-ie. actions leading to social and polticial change - and i will do some research into this-however i know that your own research came to some interesting conslusions about this-can u share them with us?
Discusses the rise of civil society action in Japan. Thx for this reference Makie. However, his conclusion is that 'This meant working within the community and building ties with local governments, bureaucrats and corporations'. Activist actions such as protests are down played and confrontation avoided. Change is more of a collaborative/manipulative process between civil society and those in authority.
HOW LONG CAN THIS LAST BEFORE PEOPLE ARE TOTALLY DISENCHANTED BY A SYSTEM THAT DOES NOT MEET THEIR NEEDS GIVEN RECENT PUBLICITY ABOUT INCOMPETENCE AND CORRUPTION IN THE JAPANESE SYSTEM?
One of health activists, according to your definitions, that came to my mind is Dr. Hiroshi Maruyama (1909-1996). He challenged the authorities who tried to ignore or undermine long-term consequences of arsenic-contaminated baby formula produced by a large milk producer, which occurred in the1960s. He was a professor at Osaka University. It can be said that he used epidemiology as a tool for his activism as his research had tremendous effects to achieve social justice for the victims. (It was not ‘conventional’ for scholars to present their research to accuse the government at his time. And therefore, he can be considered as health activist. Am I correct?). He presented epidemiological evidences that demonstrated the fact that victims suffered from after-effects of exposure to the formula, which includes blain paralysis. It was the period of high economic growth after WWII and the government tried to protect companies not citizens to achieve the national goal. So, in this period, it was, I guess, not easy for victims to win the battle. One of their successes to gain compensations is, I think, that Dr. Maruyama was in the privileged position to use his power to protest against the government and the company. If citizens, which mean the victims, did not have his power, the battle might not even have existed. It is not like a conventional bottom-up approach. But, I have not found how I can describe this type of activism.
social epidemiology provides a measure of the well-being of populations, documenting and establishing trends based on its ‘expert’ and ‘legitimate’ power. Social epidemiology is the systematic study of health, well-being, social conditions or problems and diseases and their determinants, using epidemiology and social science methods to develop interventions, programmes and policies that can lead to a reduction in any adverse impact on populations. The definition social epidemiology emphasizes that it is the study, by qualified researchers, of social problems in combination with epidemiology linked to the heath status of populations. This sets standards of ‘normality’ that can be compared in relation to other population groups. In this way, health practice can build upon political concerns and create issues that they show can be overcome by using their ‘expert’ knowledge and power.
This is in contrast to mlay epidemiology which I argue is a much more empowering process for people!
Lay epidemiology is an interesting concept. It took me for a while to figure it out. I agree with you suggesting that lay epidemiology helps people to gain power. In the case that I wrote above, I believe that lay knowledge also had some significant roles. But, it seems to me that it was not considered as relevant. It should be come to light in order to help people become empowered.
Lay epidemiology is a term that has been widely used to describe the processes by which people in their everyday life understand and interpret risks, including risks to their health and well-being. To reach conclusions about the risks they access information from a variety of sources including the mass media, the internet, friends and family. Lay epidemiology can be an empowering experience for ordinary people and can help them to challenge the accepted ‘wisdom’ of health professionals.
Lay epidemiology is the basis for many empowerment approaches. Communities are influenced by the information that they receive, sometimes from many conflicting sources, and that they feel can place them at risk. For example, in the UK public concerns were raised about the Measles, Mumps and Rubella vaccine. The public health authorities saw this as an effective option with few side effects. However, following media reports of conflicting scientific evidence the public became increasingly concerned that the vaccine could lead to bowel cancer and autism. These concerns were confounded by the past distrust between the authorities and the public over the handling of the ‘mad cow’s disease’ and conflicting evidence on the benefits of screening, for example, the benefits of mammography.
A REASON WHY PEOPLE WANT TO CHALLENGE THE WISDOM OF RESEARCHERS AND USE THEIR OWN LAY INTERPRETATION! The Tuskegee study was conducted by the US public health service between 1932 and 1972 and involved 500 black sharecroppers and men with untreated syphilis to document the course of the disease. The men were not told that they had syphilis, and did not receive any counseling or treatment for the disease even though since 1943 penicillin had been an effective drug. The study was brought to a halt under pressure from concerned researchers but after an expert panel meeting it was allowed to continue to allow autopsies to be carried out. Eventually, those concerned went to the press and a media scandal ensued which brought the study to an end. The legacy has been that black and minority people have a mistrust of the medical profession which can act as a serious barrier to ongoing clinical research projects (Cwikel, 2006).
MORE ACTIVISTS OF IMPORTANCE: Sir Edwin Chadwick (1800 –1890) was an English social reformer, noted for his work on the Poor Laws and the improvement of sanitary conditions and public health. In 1832 Chadwick was employed to inquire into the operation of and reform of the Poor. In 1834 individual parishes were formed into Poor Law Unions each with a union workhouse, although Chadwick fought for a more centralised system of administration controlled from a central board. While still officially working with the Poor Law, Chadwick also took up the question of poor sanitation. Chadwick was a commissioner of the Metropolitan Commission of Sewers in London from 1848 to 1849 and a commissioner of the General Board of Health from its establishment in 1848 to its abolition in 1854. In January 1884 he was appointed as the first president of the Association of Public Sanitary Inspectors (now the Chartered Institute of Environmental Health) (http://www.cieh.org/ accessed 15/1/2012).
Harvey Milk (1930-1978) is described as one of the most influential gay rights activists of the 20th century. Milk started the Castro Valley Association, an organization that helped the gay community become politically organized and gain allies within labour unions and local political leaders. After running for a seat on the San Francisco Board for four times, he won the election in 1977, becoming the first openly gay person to hold office in the United States. But this victory would not last and Milk was murdered after he had served only 11 months on the board. Milk's legacy continued and one hundred thousand people marched on the first anniversary of his death to the nation's capital in support of gay rights.
These two concepts are often confused/overlap and misused to represent oneanother. The 2 are very different in practice.
However, my main issue with participation is as follows:
It is generally agreed that participation alone:
• does not lead to action or empowerment. • does not lead to improved health outcomes. • does not lead to improved health care. • does not lead to improved access to health care.
SO WHY DO WE CONTINUE TO FUND AND IMPLEMENT PARTICIPATION AS A PROJECT INPUT?
IS THERE AN ALTERNATIVE TO NOT INCLUSING PARTICIPATION as a part of programme design. For many practitioners this would be unthinkable and so even though there is little evidence that participation leads to improved health, access to health care services or improved health care it is still implemented.
THE ALTERNATIVE IS of course a more top-down and paternalistic style of programming which we also know has its limitations and may have only benefited the 'healthy wealhty' sectors of society therefore contributing to health inequalities.
IF NEITHER TOP-DOWN NOT BOTTOM-UP WORK SOLELY-WHAT IS THE SOLUTION?
I think that it can be to synthesize both ways. For example, making public health policies based on evidences derived from qualitative data, which includes people’s voices.
CHILDREN AND EMPOWERMENT-A DIFFICULT AREA? the very young, the very old or people with an addiction, may not have the ability to organise and mobilise themselves towards collective empowerment. A key issue, for example, when working with children is at what age they begin to understand the social world in a concrete and abstract way such that they can fully engage with the concept of empowerment and the underlying, often political, causes of their powerlessness. An approach to childhood based on rights, or the participation agenda, sees children as social actors who act on the world around them. Practitioners can then engage with children about their worlds and involve them in decision making. Although there is not a definitive ‘youngest’ age at which children can be engaged to empower themselves collectively, my own inquiries into this issue have led to a guide of 14 years, give or take a year, depending on the individual. Empowerment interventions have been successfully used with adolescents but the successful engagement of children under the age of 14 years in empowerment approaches is not clear. Does anyone know better?
WHAT IS PH FRIGHTENED ABOUT? Social injustice is killing people on a grand scale caused by inequities in power, money and resources The perpetrators of the social injustice are known to us and it is timely for empowerment and health activism to be used as a means to take action against them. The perpetrators are the faceless multinational and national corporations, companies and capitalists to whom profits are the main priority. They are the bureaucrats, policy makers and governments that insist on an agenda of individualism and economic conservatism, to whom future cost-savings in health care services are the main priority. The role of health activism is to challenge the perpetrators of social injustice by using, if necessary, action that goes beyond the conventional. In this book I discuss the different tactics that can be used by health activists and have given case study examples of how these have worked to influence the political drivers and perpetrators of social injustice.
ACTIVISM IS NOT NEW IN PH In fact, the combination of science and activism used by social reformers taking political action to change government policy is not a new idea and takes us back to the development of key public health legislation such as the 1833 Factories Act (Baggott, 2000) in the nineteenth century.
THE TIME FOR HEALTH ACTIVISM IS NOW! Activists that have worked with health practitioners to further their cause, engaging with leaders who are open to debate and to creating opportunities for dialog, have managed to gain some success. Professional bodies have used their ‘expert power’ to legitimize the concerns of others, for example, the support of the medical profession to the political lobby for the stricter legal regulation of boxing based on health grounds and for the pressure group ‘Action on Smoking and Health’ to ban smoking in public places. Activists have also worked with health researchers to access evidence documenting problems and enumerating the benefits of policy proposals to support their cause. The public is open to rational discussion and activists are right to engage with practitioners and researchers to offer advice that is based on sound scientific evidence.
What are Community Based Concepts? Community based concepts largely increase the assets and attributes that a community is able to draw upon in order to improve the lives and health of their members. Essentially, they share the same characteristics and are forms of social organization and mobilization seeking to address the inequalities in life. Over the past thirty years there has been a growth in the use of community-based concepts but with little attempt to clarify how they interact with one another or the differences that exist between them. This is because they have evolved in an ad hoc manner, sometimes to meet immediate needs and sometimes through a more thoughtful process of interpretation, usually by practitioners and academics. At a practical level there is a real need to show how these concepts can be used to enable practitioners to better interact with communities and to plan and implement health promotion programmes.
i WILL DO THIS FOR A NUMBER OF CONCEPTS INCLUDING COMMUNITY PARTICIPATION, ACTION ,DEVELOPMENT AND EMPOWERMENT
Community participation can be described as a process by which people become involved in issues in which they share a common concern or need. People can increase their assets and attributes during this process but this is not carried out in a systematic way or even stated as an intended outcome.
But does it work.
Susan Rifkin (an eminent commentator on cp) says that it:
does not lead to action or empowerment. does not lead to improved health outcomes. does not lead to improved health care. does not lead to improved access to health care.
The key difference between community empowerment and the other community-based concepts is the sense of struggle and liberation that is bound in the process of gaining power. Power cannot be given and must be gained or seized by those who want it against those in authority. Community empowerment is therefore a process by which communities gain more control over the decisions and resources that influence their lives, including the determinants of health. Community empowerment builds from the individual to the group to a wider collective and embodies the intention to bring about social and political change. This is achieved in favour of the ‘community’ through the redistribution of power, for example, in an improved access to resources or decision making.
The overlap between community-empowerment and the many other communitgy based concepts lies in how and why people interact. The similarity lies in the process that people follow from the individual, to groups, to ‘communities of interest’ and to civil society. The difference often lies in the intended purpose or outcome. The purpose may simply be the participation of people. This interaction may later become more concerned with building the competencies and capacities of people. Alternatively, the interaction may become more directed toward specific goals and actions. But only when these goals are directed at social and political change do communities begin to empower themselves. If properly applied community-based concepts can help health promotion practitioners to better understand the way in which communities operate. They can also help practitioners to appreciate the role that they have in facilitating community participation, action and empowerment in their everyday work.
The (PHM) launched a campaign in 2006 to strengthen the right to health with a focus on defending the right to health care. The campaign looks at what measures are needed to tackle human rights violations in the context of a broader analysis of power and social inequalities. It seeks social transformations indispensable to resolving such inequalities as they affect health. As such, the campaign focuses on changing national and global health sector reform policies that affect access to health care by the poor, the disadvantaged and the marginalized. One of the key purposes of the PHM has been to give a voice to those currently excluded from global forums, and to diversify the views represented within them as a means of improving the governance of global health
I often get asked questions regarding community empowerment and so will devote the next few blogs to answering some of the more common Q&A.
What is the connection between individual and collective/community empowerment?
These two overlapping concepts are linked (and can be most esily explained by the empowerment continuum) as people are 'triggered' into taking action often because of an injustice in their lives. This motivates them to become involved in self-help or local action groups and thus to move toward collective empowerment. It takes the individual-who may already be experiencing more self esteem and control to a broader level in which they have to address the underlying causes of their powerlessness and thus engage in political strategies and tactics.
by definition power cannot be given - empowerment is the means to seizing or gaining power-it is a process of capacity building that can be facilitated by outside agencies such as public health poractitioners. There are sevberal levels of power (power from within, power with and power-over) and the book link below provides an easy introduction to these as the literature on power and empowerment is very dense and comlicated.
For many years the World Health Organization (WHO) has provided the global direction and leadership that has helped to shape the way we view health promotion today. This has been marked by key international conferences, documents and charters. The WHO has had a significant role in orchestrating these milestones through its international convening powers. The relevance of the WHO, its future within global health governance and criticisms from its own Director General, Margaret Chan, of being overextended and unable to respond with speed and agility to today’s global health challenges, have recently put the organisation into a crisis. At the time of writing this commentary, the future of health promotion, like other functions at WHO, is uncertain. The question of who will provide the future direction of health promotion therefore needs to be addressed now.
see how this might be achieved at
Global Health Promotion 1757-9759; Vol 19(2): 63– 65; 441231
I have just returned from Japan where I was giving a series of talks on empowerment. I met a number of interesting and committed people to bottom-up ways of working. Hello to those of you reading this blog for the 1st time and below is an entry on an issue in Japan on which u may want to comment.
Collectivism and health promotion in Japan is a neglected area. Collectivism may well exclude people whose lifestyle or behaviours are not considered normative and this provides a traditional role of health promotion to ‘enable’ others to engage in action to take more control of their lives in regard to statutory rights or to facilitate greater social support through, for example, self-help groups with day labourers. How, for example, does exclusion from a ‘guaranteed minimum standard of living’ relate to poorer health outcomes? There are a number of examples from Japan of collective action to address broad issues of social injustice and health inequalities-these would support an argument for the role of ‘empowerment’ and health promotion-such as mass demonstrations regarding government incompetence over the nuclear disaster an issue that affected everyone.
Collectivism provides a focus on the ‘struggle’, ‘fight’ or ‘battle’ against a disease or illness. The emphasis is on self-blame (there is an under-current of guilt that runs through the Japanese culture), personal responsibility and individual conformity. Individuals may be committed to change but this does not address the broader structural level. People who are passionate, even angry about, for example, nuclear contamination of food sources, can be mobilised to protest about an issue that affects us all. But if the issue is not perceived as a threat to us all collectively this makes action difficult-and is considered as non-conformist, not normal and not patriotic.
Politicians are sensitive and react to public opinion and to the pressure applied from those that are able to play to the strengths of their position within a particular social, political and economic context. Between 2006 and 2010, for example, the New York City Food Movement (NYCfm) made progress in changing food policy, the creation of new programmes, engagement of new voices influenced media coverage of food issues. The NYCfm used a variety of tactics including open network meetings, websites, advocacy and information sharing and played a key role in the approvals of the local initiatives to provide affordable food in inner city areas.
Top-down programmes and individualism is a dangerous combination and unlikely to have any discernable impact on population health, in fact the evidence suggests that they will lead to greater health inequality. We have to develop more effective strategies for preventing disease and promoting health by working more closely with people to address their needs. This means changing the way we plan, deliver and evaluate public health, the way we train the next generation of practitioners, organise and finance programmes, conduct research and view our role as ‘public health professionals'.
The framing of health as individualized creates another obstacle for public health. The personalization of health provides a focus on the ‘struggle’ against a disease or illness. Health is individualized by people who regard it as personal in nature and responsible for the things, both good and bad, that happen to them. Although individuals may be committed to change this is only at the personal level and does not address the broader structural level. People who are passionate about, for example, climate change, can be collectively mobilised to protest because it is an issue that affects us all. But obesity and heart disease affect us individually, and the response is to deal with these issues at a personal level. The issue is not perceived as a threat to us all and this makes collective public health action, an effective strategy, difficult.
Obesity and heart disease can be perceived as a threat to us all if those make healthcare expenditure skyrocketed and therefore, reduces the cost of social security.
This is true. People can also get involved collectively about other health related issues such as a safer environment-free from violence-so that they can use open areas-road safety-cycling lanes etc But not about health directly-even demonstrations about pay cuts and job losses are obviously linked to health.
Top-down programmes that target individuals to change their ‘unhealthy’ behaviours, for example, by encouraging exercise, eating a balanced diet, not smoking and the moderate use of alcohol are unervingly common. This is consistent with a political commitment to address the broader determinants of health only to ‘drift’ inevitably to much narrower lifestyle interventions. A political trend that has been termed the ‘lifestyle drift’ and illustrated by Australia’s ‘Swap it, don’t swap’ campaign. The main character is ‘Eric’, a blue balloon type figure, who urges others to swap unhealthy aspects of their lifestyle, such as physical inactivity, for healthier lifestyle habits. However, the changes necessary for ‘Eric’ to lead a healthier life actually requires a change in the structures in which he lives, such as a safe neighbourhood. WHY KEEP WASTING THE HEALTH $ IN THIS WAY?
The Commission on Social Determinants of Health had an opportunity when it published its final report on what needs to be done to reduce health inequalities within and between countries. The commission was made up of nineteen experienced members, mostly academics, with the power to make independent recommendations including actions to deal with the named perpetuators of social injustice. Instead, the commission threw away a beautiful opportunity by choosing not to make a strong political statement and was subsequently critized for dutifully presenting the evidence. In time, their decision to remain apolitical may return to haunt the members of the commission because this may prove to have set back the struggle to address health inequality in the long term!
It seems a bit petty having a go at the commission for the SDH. It is after all a document of our time and carried the names of some very important people-self important some would say. But why has the WHO, the organisation to commission the commission, cut it adrift=almost disowned it? Yes, WHO is under a huge reorganisation - at least at HQ - but it is not known for letting go of any credit that it can get hold of. Why are the commissioners themselves finding it so hard to get governments interested in the SDH? Is the SDH just a fad-whilst the real issues of inequality, equity and social justice will really stand the test of time........................
I am in Estonian at the IUHPE european conference - compared to Canada and Australia there is so much more happening here in regard to community based approaches-esp in the nordic and some Baltic countries. Look at the website for the Institute of Health and Development in Estonia regarding health profiles and communty health promotion programmes for example.
The Commission on Social Determinants of Health had an opportunity to name the perpetuators of social injustice when it published its final report on what needs to be done to reduce health inequalities within and between countries. The commission was made up of nineteen experienced members, mostly academics, with the power to make independent recommendations including actions to deal with the named perpetuators of social injustice. Instead, the commission threw away a beautiful opportunity by choosing not to make a strong political statement and was subsequently critized for dutifully presenting the evidence. In time, their decision to remain apolitical will return to haunt the members of the commission because this may prove to have set back the struggle to address health inequality.
Some of the key questions in my mind are:
ReplyDeleteWhat works best in helping to empower others-what is the evidence (empirical, anecdotal, professional observation etc)?
Why do individuals become engaged collectively to try to empower themselves collectively-what are the motivational factors (social networks, personal trauma-the 'trigger effect')?
What are the most effective strategies that collectively people have used to influence government, polcy makers, local agencies etc?
Any othyers???
Having worked in community development in Samoa for over 20 years, I have always found income generation as the best catalyst from my professional observation in operating an ecotour business in Samoa for over 10 years. We prepared 2 Operations Manuals: (i) How to operate a Pacific Ecotour and (ii) How to operate a Samoan/Pacific Community-Based Resort (i.e. a few inexpensive traditional beachside houses / fales / bures). The response was fantastic as long as the experience was fantastic (i.e. best sandy beach, best traditional food, local villagers, good English and safe). This was a very simple formula and today, this is a multi-million dollar sub-sector of tourism in Samoa (i.e. as many as 50% of all bed-nights in Samoa are spent in beach fale resorts).
ReplyDeleteTupaemanaia Steve
Steve, you are correct-resource mobilization is a key domain for community empowerment and i know of similar experiences of communities entering into partnership with private sector (hotels) in the Pacific in order to raise funds.
DeleteThe issue is how these funds are distributed within the community-are they equitably used or held by elite interests-participation and local leadership are therefore 2 other key domains for success
We are now trying a second approach to help empower communities: reduce cost of living and increase employment through provision of cheap local bioenergy power solutions (i.e. coconut biogiesel, biodigestion to compress methane gas emissions off large dual purpose 'septic tanks' or biodigesters, and biomass gasification (combustion of waste plant materials). Then there's biocharcoal options/technologies which can also combust household waste-to-energy.
ReplyDeleteOnce fully operational, cost of electricity can be reduced, allowing communities to dry their agricultural produce.
END RESULT? Improved energy security and improved food security, along with new jobs.
Community Based Organizations (CBOs) in Samoa are today taking a collective approach to find new markets for their dried nonu, copra, cocoa, kava, etc., but what is still missing is the cheap power to value-add their goods.
And to briefly answer the 3rd question, 2 innovative ideas have been adopted in Samoa and they are (i) to take a more private sector approach once (ii) your foreign direct investments have been secured, but to reach this level, you have to have a well prepared bankable business plan.
Once successful, you are then in a much better position to influence policymakers (i.e. your alternate energy supplies are cleaner, cheaper and moreincome generating for communities than say power generated from imported diesel).
However problems arise.
Tupaemanaia Steve
SZteve, have u published these experiences?
DeleteFrom a community empowerment perspective the issue is how to connect these dfferent initiatives to create a network/coailition that is strong enoguh to cuallenge gvt policy-there are may examples of how this has happened elsewhere in other sectors - do u know any in the sustainable livelihood sector?
PROBLEM IS: If energy and agricultural policymakers are not technically informed of the alternate bioenergy technologies, then they cannot write climate-smart agricultural policy and formulate much better strategies that will lead to a low carbon development strategy for Samoa.
ReplyDeleteIn conclusion, be innovative, attract the funding needed, demonstrate your development paradigm and then convincing others is made easier.
However, research and development into alternate energy sources within the Pacific may have mistakingly focussed on solar, wind, coconut oil, geo-thermal, etc, and not realized that agricultural waste-to-bioenergy technologies being suggested here are, what we think, the novel catalyst to a new community-based development paradigm for the Pacific Islands, in fact all Small Island Developing States (SIDS) globally.
Glenn's interest in following this project in Samoa may help quantify our answers above to these very pertinent questions tabled.
PS - without bioenergy technologies being made available to communities in Samoa, community development would continue to face extreme obstacles, but I look forward to hearing your comments to additional approaches that can be equally considered.
PPS And climate change impacts on Pacific Islanders are already increasing our vulnerability as Pacific cultures (i.e. Oceania already has the highest rate of loss of languages in the world, and climate change impacts will only hasten this loss as atmospheric CO2 levels continue to .......see www.CO2now.org).
Pacific island communities need to, for more reasons than one, displace/replace their diesel fuel imports that are causing additional greenhouse effects globally.
We Pacific islanders need to lead by example as the global 'fossil-fuel based' economy is simply non-sustainable, globally irresponsible, and poverty creating (i.e. our proven austerity measures have been in place within the Pacific for over 40,000 years...we are in fact, the professors of sustainable economic growth that nurtures our future generations of Pacific Islanders. But we are running out of time as those living in Kiribati look to buying land in Fiji as 'climate refugees).
Tupaemanaia Steve
Steve, can u say why policy makers in Samoa are not able to make 'climate smart policy'?
DeleteThe island context is especially relevant given its vulnerability and isolation. This is not my field but another example that comes to mind are the use of small water turbines in Northern Vietnam run from steams and providing enough to power household needs.
I am interested in any comments on the use of the term empowerment in the health care realm. I am finding it is a new buzz word used with patient-centred care, control in decision making, self-care and so on but lacks the true flavor of community and individual engagement.
ReplyDeleteCynthia
Cynthia, you are correct- much of the discussion on patient emp does lack the flavour of individual and collective empowerment. It is a form of emp in that it attempts to enable others to gain more control but in the sense of eleviating the burden on health services-such as self care, treatement, monitoring bllod pressure, chaning dressings etc- although there is evidence to suggest that this does lead to better and quicker health outcomes.
DeleteNurses work to enable patients to take more control in decision making over their health, promoting patient independence, information exchange and being aware of their needs. In practice, this translates into acts of care such as making sure patients had their call bell within reach, respecting their choices, providing information about future care options and working quietly at night to allow patients to sleep (Faulkner, 2001). But an empowerment approach gives more credibility to what the individual has to offer in patient centred care and goes beyond self-care to what the individual can offer to improve the system. An individualistic approach focuses on supporting people to make informed choices, relationship building, self-management and partnerships. The broader empowerment of patients enables them to have an influence on the health system through networking and the engagement with patient advocacy and pressure groups. The purpose is collective action, as well as, individual self care.
Patient Empowerment
ReplyDeleteTo follow on from my earlier comments about patient empowerment i am providing 2 examples. The first is on 'Patient Advocacy Groups' that allow people to represent others and to speak out for their rights as patients (and as human beings).
One hospital in the UK asked patients to pass on comments to staff or to make formal complaints, but there was no way of bringing together patient comments to effect improvement. The Patient Involvement Action Group (PIAG) was established by the hospital to allow patients to voice their comments and concerns, anonymously if they wished, and have feedback about actions taken. Patients and their carers’ were given PIAG comment forms which could be returned to a member of staff or placed in a collection box. Once a month all of the comments, both positive and negative, were reviewed by the PIAG and action was decided upon at an appropriate level, or a report given about action already taken. The results of each action were posted on display boards in the wards to inform the patients and their carers and examples of the actions taken as a direct result of patient complaints through the PIAG include:
• Side rooms for infection control have had curtains fitted to act as a screening door to prevent staff from walking straight into the room when a patient is carrying out personal functions;
• Frosted glass in some rooms, which the patients felt had made them feel like prison cells, were replaced with clear glass and blinds;
• Wards which suffered from solar glare have received vertical blinds to improve conditions.
• Shelves have been put up in bathrooms for cosmetics, sponge bags etc to help patients to manage their own care.
Each ward was asked to nominate representatives of whom one would be available to attend each a monthly PIAG meeting. The number of formal complaints decreased to less than 20% of the previous level as patients gained confidence that their comments would be acted upon and that the ward environment had improved (http://www.tin.nhs.uk/patient-involvement accessed 10/11/2011).
The second post will cover Patient networks for empowerment.
Networks for patients can be supported by an outside agent such as a health service employer, or may be independent and are formed by its members for the benefit of its members, both patients and health practitioners.
ReplyDeletePatient Concern (UK), for example, relies on the dedication of volunteers, on donations, expertise and experience free of charge. Patient Concern operates a network in collaboration with other active campaigning groups run by patients on issues that matter to them, including:
• Protection for whistleblowers: To ensure that professionals are not afraid to complain when they see neglect, indifference and poor care. This requires a direct confidential whistleblower line and legislation to ensure that they do not suffer for raising legitimate concerns, for example, that their careers are not damaged.
• Assisted suicide: Advocating for a change in the law to allow physician assisted suicide for the terminally ill.
• Save our beds: Campaigning against the reduction of hospital beds.
• Complaints procedure: Strengthening a complaints system for patients to have the right to an independent investigation of serious issues.
• Access to medical records: Patients uncensored access to their health records (http://www.patientconcern.org.uk/ accessed 15/12/2011).
The Patients Association is a joint campaign with the Nursing Standard (a professional magazine) that aims to tackle poor care and the causes of poor care.
It is based around the most frequent complaints received by the Patients Association: poor communication; toileting; pain relief; nutrition and hydration. The campaign aims to highlight the complex causes of poor care and identify how these causes can be addressed. The Patients Association (UK) established the Network for Patients in 2009 with a group of over 30 charities to collaborate about common patient issues for better information and support. The Network for Patients is able to make a bigger impact than if each individual charity campaigned on their own. The Association addresses the shared concerns of its members including the General Practice “duty to refer”, for patients to be able to trust that their doctors are making sure they are getting access to the best treatment. Access to information is the best way to make sure this is happening and patient support groups are ideally placed to provide this service. Doctors cannot be expected to be experts in all fields and so it is important for them to be able to direct patients to other organizations which have the expertise. Doctors can then actively support patients in finding patient support groups and networks that could help them with managing their condition (http://www.patients-association.com accessed 15/12/2011).
PATIENT EMPOWERMENT
ReplyDeleteA good example of how giving people more control over their lives (and health) can be illustrated in the context of patient empowerment.
Giving the client more control over decisions can have real benefits as demonstrated in one study (Bassett and Prapavessis, 2007) on physical therapy for ankle sprains. The study showed that the home-based groups had similar outcome scores for post-treatment ankle function, adherence and motivation to a standard physical therapy intervention. However, the home-based group had significantly better attendance at clinic appointments and a better physical therapy completion rate. Patients were helped to set goals and to develop personal action plans to complete the therapy as well as education and skills training on the treatment such as strapping techniques. The patients had more control and were better informed about their recovery and this sharing of the power (knowledge, skills) by the Practitioner was a form of power-with which led to a viable home-based option for the clients. Self-care can be a complicated issue that is not appropriate for all situations or people but under the right conditions, as this study showed, can offer the Practitioner the opportunity to work in a more empowering way.
Bassett, S. F., and Prapavessis, H (2007) Home-based physical therapy intervention with adherence-enhancing strategies versus clinic based management for patients with ankle sprains. Physical Therapy. Vol 87 (9): 1132-1143.
Speaking of patient empowerment, I want to talk about family empowerment. My mom has received in-home care for a few months since last December. I have been really discouraged since I cannot find respite services for family like me. My mom’s care coordinator told that my mom is unlikely to accept in any facilities due to her unstable mental conditions. Nursing homes take clients who give little burden on their workers but reject someone like my mom. The Japanese welfare system used to rely on family and in fact still does and expects women to sacrifice their jobs to take care of their families. I feel dis-empowered not finding any solutions for me and my mom. Are there any suggestions or thoughts?
ReplyDeleteMakie, I am not familiar with the Japanese Welfare System- however your situation is the basis for empowerment-other people surely suffer the same inequalities/difficulties regarding care. If so, empowerment starts when these people come together to form an action group/network to address the issue and to begin to develop a strategy to change government policy. How would this work in Japan?
ReplyDeleteThanks Glenn! In Japanese society where people believe that they should prioritize the benefit of a whole society over their individual autonomy, family’s issues tend to be the last thing to think about. People often think that they should manage family matters without asking for help particularly from the government. People are entitled to use long-term care services but claiming the right seem to be considered to be selfish. People may not even be aware that they have the right. Even if I found people who have the same perspective, taking actions is still challenging as people are afraid of being ostracized from their community.
DeleteMakie, so this is an interesting cultural perspective on collectivism-similar political contexts might be communism but i am unaware of another cultural comparison. There must be examples of Japanese community empowerment-ie. actions leading to social and polticial change - and i will do some research into this-however i know that your own research came to some interesting conslusions about this-can u share them with us?
DeleteFlowering of civic activism
DeleteBy JEFF KINGSTON
Discusses the rise of civil society action in Japan. Thx for this reference Makie. However, his conclusion is that 'This meant working within the community and building ties with local governments, bureaucrats and corporations'. Activist actions such as protests are down played and confrontation avoided. Change is more of a collaborative/manipulative process between civil society and those in authority.
HOW LONG CAN THIS LAST BEFORE PEOPLE ARE TOTALLY DISENCHANTED BY A SYSTEM THAT DOES NOT MEET THEIR NEEDS GIVEN RECENT PUBLICITY ABOUT INCOMPETENCE AND CORRUPTION IN THE JAPANESE SYSTEM?
One of health activists, according to your definitions, that came to my mind is Dr. Hiroshi Maruyama (1909-1996). He challenged the authorities who tried to ignore or undermine long-term consequences of arsenic-contaminated baby formula produced by a large milk producer, which occurred in the1960s. He was a professor at Osaka University. It can be said that he used epidemiology as a tool for his activism as his research had tremendous effects to achieve social justice for the victims. (It was not ‘conventional’ for scholars to present their research to accuse the government at his time. And therefore, he can be considered as health activist. Am I correct?). He presented epidemiological evidences that demonstrated the fact that victims suffered from after-effects of exposure to the formula, which includes blain paralysis. It was the period of high economic growth after WWII and the government tried to protect companies not citizens to achieve the national goal. So, in this period, it was, I guess, not easy for victims to win the battle. One of their successes to gain compensations is, I think, that Dr. Maruyama was in the privileged position to use his power to protest against the government and the company. If citizens, which mean the victims, did not have his power, the battle might not even have existed. It is not like a conventional bottom-up approach. But, I have not found how I can describe this type of activism.
DeleteThis is social epidemiology.
Deletesocial epidemiology provides a measure of the well-being of populations, documenting and establishing trends based on its ‘expert’ and ‘legitimate’ power. Social epidemiology is the systematic study of health, well-being, social conditions or problems and diseases and their determinants, using epidemiology and social science methods to develop interventions, programmes and policies that can lead to a reduction in any adverse impact on populations. The definition social epidemiology emphasizes that it is the study, by qualified researchers, of social problems in combination with epidemiology linked to the heath status of populations. This sets standards of ‘normality’ that can be compared in relation to other population groups. In this way, health practice can build upon political concerns and create issues that they show can be overcome by using their ‘expert’ knowledge and power.
This is in contrast to mlay epidemiology which I argue is a much more empowering process for people!
Lay epidemiology is an interesting concept. It took me for a while to figure it out. I agree with you suggesting that lay epidemiology helps people to gain power. In the case that I wrote above, I believe that lay knowledge also had some significant roles. But, it seems to me that it was not considered as relevant. It should be come to light in order to help people become empowered.
DeleteLay epidemiology is a term that has been widely used to describe the processes by which people in their everyday life understand and interpret risks, including risks to their health and well-being. To reach conclusions about the risks they access information from a variety of sources including the mass media, the internet, friends and family. Lay epidemiology can be an empowering experience for ordinary people and can help them to challenge the accepted ‘wisdom’ of health professionals.
DeleteLay epidemiology is the basis for many empowerment approaches. Communities are influenced by the information that they receive, sometimes from many conflicting sources, and that they feel can place them at risk. For example, in the UK public concerns were raised about the Measles, Mumps and Rubella vaccine. The public health authorities saw this as an effective option with few side effects. However, following media reports of conflicting scientific evidence the public became increasingly concerned that the vaccine could lead to bowel cancer and autism. These concerns were confounded by the past distrust between the authorities and the public over the handling of the ‘mad cow’s disease’ and conflicting evidence on the benefits of screening, for example, the benefits of mammography.
DeleteA REASON WHY PEOPLE WANT TO CHALLENGE THE WISDOM OF RESEARCHERS AND USE THEIR OWN LAY INTERPRETATION!
DeleteThe Tuskegee study was conducted by the US public health service between 1932 and 1972 and involved 500 black sharecroppers and men with untreated syphilis to document the course of the disease. The men were not told that they had syphilis, and did not receive any counseling or treatment for the disease even though since 1943 penicillin had been an effective drug. The study was brought to a halt under pressure from concerned researchers but after an expert panel meeting it was allowed to continue to allow autopsies to be carried out. Eventually, those concerned went to the press and a media scandal ensued which brought the study to an end. The legacy has been that black and minority people have a mistrust of the medical profession which can act as a serious barrier to ongoing clinical research projects (Cwikel, 2006).
MORE ACTIVISTS OF IMPORTANCE:
ReplyDeleteSir Edwin Chadwick (1800 –1890) was an English social reformer, noted for his work on the Poor Laws and the improvement of sanitary conditions and public health. In 1832 Chadwick was employed to inquire into the operation of and reform of the Poor. In 1834 individual parishes were formed into Poor Law Unions each with a union workhouse, although Chadwick fought for a more centralised system of administration controlled from a central board. While still officially working with the Poor Law, Chadwick also took up the question of poor sanitation. Chadwick was a commissioner of the Metropolitan Commission of Sewers in London from 1848 to 1849 and a commissioner of the General Board of Health from its establishment in 1848 to its abolition in 1854. In January 1884 he was appointed as the first president of the Association of Public Sanitary Inspectors (now the Chartered Institute of Environmental Health) (http://www.cieh.org/ accessed 15/1/2012).
Harvey Milk (1930-1978) is described as one of the most influential gay rights activists of the 20th century. Milk started the Castro Valley Association, an organization that helped the gay community become politically organized and gain allies within labour unions and local political leaders. After running for a seat on the San Francisco Board for four times, he won the election in 1977, becoming the first openly gay person to hold office in the United States. But this victory would not last and Milk was murdered after he had served only 11 months on the board. Milk's legacy continued and one hundred thousand people marched on the first anniversary of his death to the nation's capital in support of gay rights.
ReplyDeleteMY EMAIL ADDRESS FOR PAPER-INFORMATION-QUERIES
ReplyDeletegrlavera@hotmail.com
ReplyDeletePARTICIPATION vs EMPOWERMENT
ReplyDeleteThese two concepts are often confused/overlap and misused to represent oneanother. The 2 are very different in practice.
However, my main issue with participation is as follows:
It is generally agreed that participation alone:
• does not lead to action or empowerment.
• does not lead to improved health outcomes.
• does not lead to improved health care.
• does not lead to improved access to health care.
SO WHY DO WE CONTINUE TO FUND AND IMPLEMENT PARTICIPATION AS A PROJECT INPUT?
IS THERE AN ALTERNATIVE TO NOT INCLUSING PARTICIPATION as a part of programme design. For many practitioners this would be unthinkable and so even though there is little evidence that participation leads to improved health, access to health care services or improved health care it is still implemented.
ReplyDeleteTHE ALTERNATIVE IS of course a more top-down and paternalistic style of programming which we also know has its limitations and may have only benefited the 'healthy wealhty' sectors of society therefore contributing to health inequalities.
IF NEITHER TOP-DOWN NOT BOTTOM-UP WORK SOLELY-WHAT IS THE SOLUTION?
I think that it can be to synthesize both ways. For example, making public health policies based on evidences derived from qualitative data, which includes people’s voices.
DeleteCHILDREN AND EMPOWERMENT-A DIFFICULT AREA?
ReplyDeletethe very young, the very old or people with an addiction, may not have the ability to organise and mobilise themselves towards collective empowerment. A key issue, for example, when working with children is at what age they begin to understand the social world in a concrete and abstract way such that they can fully engage with the concept of empowerment and the underlying, often political, causes of their powerlessness. An approach to childhood based on rights, or the participation agenda, sees children as social actors who act on the world around them. Practitioners can then engage with children about their worlds and involve them in decision making. Although there is not a definitive ‘youngest’ age at which children can be engaged to empower themselves collectively, my own inquiries into this issue have led to a guide of 14 years, give or take a year, depending on the individual. Empowerment interventions have been successfully used with adolescents but the successful engagement of children under the age of 14 years in empowerment approaches is not clear. Does anyone know better?
A wonderful symposium in Germany on community empowerment that I will be attending this year-please - check the weblink.
ReplyDeletehttp://www.epi-regensburg.de/wp/empowerment-symposium
I have been a little quiet of late due to work travel to varios places biut will resume mu blog posts shortly
ReplyDeleteWHAT IS PH FRIGHTENED ABOUT?
ReplyDeleteSocial injustice is killing people on a grand scale caused by inequities in power, money and resources The perpetrators of the social injustice are known to us and it is timely for empowerment and health activism to be used as a means to take action against them. The perpetrators are the faceless multinational and national corporations, companies and capitalists to whom profits are the main priority. They are the bureaucrats, policy makers and governments that insist on an agenda of individualism and economic conservatism, to whom future cost-savings in health care services are the main priority. The role of health activism is to challenge the perpetrators of social injustice by using, if necessary, action that goes beyond the conventional. In this book I discuss the different tactics that can be used by health activists and have given case study examples of how these have worked to influence the political drivers and perpetrators of social injustice.
ACTIVISM IS NOT NEW IN PH
ReplyDeleteIn fact, the combination of science and activism used by social reformers taking political action to change government policy is not a new idea and takes us back to the development of key public health legislation such as the 1833 Factories Act (Baggott, 2000) in the nineteenth century.
THE TIME FOR HEALTH ACTIVISM IS NOW!
ReplyDeleteActivists that have worked with health practitioners to further their cause, engaging with leaders who are open to debate and to creating opportunities for dialog, have managed to gain some success. Professional bodies have used their ‘expert power’ to legitimize the concerns of others, for example, the support of the medical profession to the political lobby for the stricter legal regulation of boxing based on health grounds and for the pressure group ‘Action on Smoking and Health’ to ban smoking in public places. Activists have also worked with health researchers to access evidence documenting problems and enumerating the benefits of policy proposals to support their cause. The public is open to rational discussion and activists are right to engage with practitioners and researchers to offer advice that is based on sound scientific evidence.
What are Community Based Concepts?
ReplyDeleteCommunity based concepts largely increase the assets and attributes that a community is able to draw upon in order to improve the lives and health of their members. Essentially, they share the same characteristics and are forms of social organization and mobilization seeking to address the inequalities in life. Over the past thirty years there has been a growth in the use of community-based concepts but with little attempt to clarify how they interact with one another or the differences that exist between them. This is because they have evolved in an ad hoc manner, sometimes to meet immediate needs and sometimes through a more thoughtful process of interpretation, usually by practitioners and academics. At a practical level there is a real need to show how these concepts can be used to enable practitioners to better interact with communities and to plan and implement health promotion programmes.
i WILL DO THIS FOR A NUMBER OF CONCEPTS INCLUDING COMMUNITY PARTICIPATION, ACTION ,DEVELOPMENT AND EMPOWERMENT
Community participation can be described as a process by which people become involved in issues in which they share a common concern or need. People can increase their assets and attributes during this process but this is not carried out in a systematic way or even stated as an intended outcome.
ReplyDeleteBut does it work.
Susan Rifkin (an eminent commentator on cp) says that it:
does not lead to action or empowerment.
does not lead to improved health outcomes.
does not lead to improved health care.
does not lead to improved access to health care.
So why bother?
The key difference between community empowerment and the other community-based concepts is the sense of struggle and liberation that is bound in the process of gaining power. Power cannot be given and must be gained or seized by those who want it against those in authority. Community empowerment is therefore a process by which communities gain more control over the decisions and resources that influence their lives, including the determinants of health. Community empowerment builds from the individual to the group to a wider collective and embodies the intention to bring about social and political change. This is achieved in favour of the ‘community’ through the redistribution of power, for example, in an improved access to resources or decision making.
ReplyDeleteThe overlap between community-empowerment and the many other communitgy based concepts lies in how and why people interact. The similarity lies in the process that people follow from the individual, to groups, to ‘communities of interest’ and to civil society. The difference often lies in the intended purpose or outcome. The purpose may simply be the participation of people. This interaction may later become more concerned with building the competencies and capacities of people. Alternatively, the interaction may become more directed toward specific goals and actions. But only when these goals are directed at social and political change do communities begin to empower themselves. If properly applied community-based concepts can help health promotion practitioners to better understand the way in which communities operate. They can also help practitioners to appreciate the role that they have in facilitating community participation, action and empowerment in their everyday work.
ReplyDeleteThe (PHM) launched a campaign in 2006 to strengthen the right to health with a focus on defending the right to health care. The campaign looks at what measures are needed to tackle human rights violations in the context of a broader analysis of power and social inequalities. It seeks social transformations indispensable to resolving such inequalities as they affect health. As such, the campaign focuses on changing national and global health sector reform policies that affect access to health care by the poor, the disadvantaged and the marginalized. One of the key purposes of the PHM has been to give a voice to those currently excluded from global forums, and to diversify the views represented within them as a means of improving the governance of global health
ReplyDeleteGo to: http://www.phmovement.org/
I often get asked questions regarding community empowerment and so will devote the next few blogs to answering some of the more common Q&A.
ReplyDeleteWhat is the connection between individual and collective/community empowerment?
These two overlapping concepts are linked (and can be most esily explained by the empowerment continuum) as people are 'triggered' into taking action often because of an injustice in their lives. This motivates them to become involved in self-help or local action groups and thus to move toward collective empowerment. It takes the individual-who may already be experiencing more self esteem and control to a broader level in which they have to address the underlying causes of their powerlessness and thus engage in political strategies and tactics.
CAN POWER BE GIVEN?
ReplyDeleteby definition power cannot be given - empowerment is the means to seizing or gaining power-it is a process of capacity building that can be facilitated by outside agencies such as public health poractitioners. There are sevberal levels of power (power from within, power with and power-over) and the book link below provides an easy introduction to these as the literature on power and empowerment is very dense and comlicated.
http://www.sagepub.co.uk/booksProdDesc.nav?prodId=Book225583
For many years the World Health Organization
ReplyDelete(WHO) has provided the global direction and
leadership that has helped to shape the way we view
health promotion today. This has been marked by
key international conferences, documents and
charters. The WHO has had a significant role in orchestrating these milestones through its international convening powers. The
relevance of the WHO, its future within global health
governance and criticisms from its own Director
General, Margaret Chan, of being overextended and
unable to respond with speed and agility to today’s
global health challenges, have recently put the
organisation into a crisis. At the time of writing
this commentary, the future of health promotion, like
other functions at WHO, is uncertain. The question
of who will provide the future direction of health
promotion therefore needs to be addressed now.
see how this might be achieved at
Global Health Promotion 1757-9759; Vol 19(2): 63–
65; 441231
I have just returned from Japan where I was giving a series of talks on empowerment. I met a number of interesting and committed people to bottom-up ways of working. Hello to those of you reading this blog for the 1st time and below is an entry on an issue in Japan on which u may want to comment.
ReplyDeleteCollectivism and health promotion in Japan is a neglected area. Collectivism may well exclude people whose lifestyle or behaviours are not considered normative and this provides a traditional role of health promotion to ‘enable’ others to engage in action to take more control of their lives in regard to statutory rights or to facilitate greater social support through, for example, self-help groups with day labourers. How, for example, does exclusion from a ‘guaranteed minimum standard of living’ relate to poorer health outcomes? There are a number of examples from Japan of collective action to address broad issues of social injustice and health inequalities-these would support an argument for the role of ‘empowerment’ and health promotion-such as mass demonstrations regarding government incompetence over the nuclear disaster an issue that affected everyone.
ReplyDeleteCollectivism provides a focus on the ‘struggle’, ‘fight’ or ‘battle’ against a disease or illness. The emphasis is on self-blame (there is an under-current of guilt that runs through the Japanese culture), personal responsibility and individual conformity. Individuals may be committed to change but this does not address the broader structural level. People who are passionate, even angry about, for example, nuclear contamination of food sources, can be mobilised to protest about an issue that affects us all. But if the issue is not perceived as a threat to us all collectively this makes action difficult-and is considered as non-conformist, not normal and not patriotic.
Politicians are sensitive and react to public opinion and to the pressure applied from those that are able to play to the strengths of their position within a particular social, political and economic context. Between 2006 and 2010, for example, the New York City Food Movement (NYCfm) made progress in changing food policy, the creation of new programmes, engagement of new voices influenced media coverage of food issues. The NYCfm used a variety of tactics including open network meetings, websites, advocacy and information sharing and played a key role in the approvals of the local initiatives to provide affordable food in inner city areas.
ReplyDeleteTop-down programmes and individualism is a dangerous combination and unlikely to have any discernable impact on population health, in fact the evidence suggests that they will lead to greater health inequality. We have to develop more effective strategies for preventing disease and promoting health by working more closely with people to address their needs. This means changing the way we plan, deliver and evaluate public health, the way we train the next generation of practitioners, organise and finance programmes, conduct research and view our role as ‘public health professionals'.
ReplyDeleteThe framing of health as individualized creates another obstacle for public health. The personalization of health provides a focus on the ‘struggle’ against a disease or illness. Health is individualized by people who regard it as personal in nature and responsible for the things, both good and bad, that happen to them. Although individuals may be committed to change this is only at the personal level and does not address the broader structural level. People who are passionate about, for example, climate change, can be collectively mobilised to protest because it is an issue that affects us all. But obesity and heart disease affect us individually, and the response is to deal with these issues at a personal level. The issue is not perceived as a threat to us all and this makes collective public health action, an effective strategy, difficult.
ReplyDeleteObesity and heart disease can be perceived as a threat to us all if those make healthcare expenditure skyrocketed and therefore, reduces the cost of social security.
DeleteThis is true. People can also get involved collectively about other health related issues such as a safer environment-free from violence-so that they can use open areas-road safety-cycling lanes etc But not about health directly-even demonstrations about pay cuts and job losses are obviously linked to health.
DeleteTop-down programmes that target individuals to change their ‘unhealthy’ behaviours, for example, by encouraging exercise, eating a balanced diet, not smoking and the moderate use of alcohol are unervingly common. This is consistent with a political commitment to address the broader determinants of health only to ‘drift’ inevitably to much narrower lifestyle interventions. A political trend that has been termed the ‘lifestyle drift’ and illustrated by Australia’s ‘Swap it, don’t swap’ campaign. The main character is ‘Eric’, a blue balloon type figure, who urges others to swap unhealthy aspects of their lifestyle, such as physical inactivity, for healthier lifestyle habits. However, the changes necessary for ‘Eric’ to lead a healthier life actually requires a change in the structures in which he lives, such as a safe neighbourhood. WHY KEEP WASTING THE HEALTH $ IN THIS WAY?
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ReplyDeleteThe Commission on Social Determinants of Health had an opportunity when it published its final report on what needs to be done to reduce health inequalities within and between countries. The commission was made up of nineteen experienced members, mostly academics, with the power to make independent recommendations including actions to deal with the named perpetuators of social injustice. Instead, the commission threw away a beautiful opportunity by choosing not to make a strong political statement and was subsequently critized for dutifully presenting the evidence. In time, their decision to remain apolitical may return to haunt the members of the commission because this may prove to have set back the struggle to address health inequality in the long term!
It seems a bit petty having a go at the commission for the SDH. It is after all a document of our time and carried the names of some very important people-self important some would say. But why has the WHO, the organisation to commission the commission, cut it adrift=almost disowned it? Yes, WHO is under a huge reorganisation - at least at HQ - but it is not known for letting go of any credit that it can get hold of. Why are the commissioners themselves finding it so hard to get governments interested in the SDH? Is the SDH just a fad-whilst the real issues of inequality, equity and social justice will really stand the test of time........................
ReplyDeleteI am in Estonian at the IUHPE european conference - compared to Canada and Australia there is so much more happening here in regard to community based approaches-esp in the nordic and some Baltic countries. Look at the website for the Institute of Health and Development in Estonia regarding health profiles and communty health promotion programmes for example.
ReplyDeleteThe Commission on Social Determinants of Health had an opportunity to name the perpetuators of social injustice when it published its final report on what needs to be done to reduce health inequalities within and between countries. The commission was made up of nineteen experienced members, mostly academics, with the power to make independent recommendations including actions to deal with the named perpetuators of social injustice. Instead, the commission threw away a beautiful opportunity by choosing not to make a strong political statement and was subsequently critized for dutifully presenting the evidence. In time, their decision to remain apolitical will return to haunt the members of the commission because this may prove to have set back the struggle to address health inequality.
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