Health Promotion Practice

Power and Empowerment

Glenn Laverack

• Publisher: SAGE Publications Ltd
• Year: 2004
• ISBN:
  9781446231012
• Edition: 1
• Topic: Médecine
• Subtopic: Santé publique, administration et soins

?This book, written from an international perspective and thus eminently readable by a wider audience, draws on the author?s considerable experience and is amply supplied with a good range of illustrations from real-life practice…The logical structure and accessible style makes this a useful addition to the personal library of anyone who has an interest in "bottom-up" empowerment-based approaches to health promotion? - RCN Research Headlines

?The author draws on a wealth of personal experiences in the field, giving the book both readability and credibility. Good examples from different international contexts, illustrated in relevant case studies, let the reader relate theory to practice and bring the concepts to life. The author takes the central thrust of health promotion for the past few decades and unravels it for the reader in a clear, comprehensive way? - Health Matters

In health promotion, the concept of power can be defined as the ability to create or resist change, and this is an important foundation for individual and community health. By enabling people to empower themselves, health promoters can provide the capacity for the individual or community to change their lives and their living conditions, and therefore their health. Health Promotion Practice explores the issue of how such an approach to health promotion practice can improve a community?s success towards achieving healthier conditions through its own actions.

Placing empowerment at the heart of health promotion practice, and offering advice for health promoters who accept the challenge to work in such a way, Health Promotion Practice defines key concepts of health, health promotion and community empowerment. It also:

Introduces readers to a ?social? model of health promotion practice, one that attempts to get at the underlying social determinants of disease;

Helps readers understand the importance of power relations and their transformation in this practice;

Introduces readers to a new `community capacity-building? approach to plan,

implement and evaluate health promotion programmes.

Health Promotion Practice is an invaluable resource to students and practitioners of health promotion who want to help empower the communities that they work with.

1	Health Promotion in Context

John McKnight (1987), an influential American community health thinker, once observed that ‘Universities learn by studies, institutions learn by reports and communities learn by stories’. While the distinction between these three approaches to knowledge is more blurred than we might think, the experiences from people’s lives remain one of the most potent ways we have devised to share wisdom. Listening to the testimony of community members’ experiences is also a basic starting point in the approach to health promotion used in this book. A story, then, seems an apt way to introduce some of the ‘empowering’ practice characteristics of health promotion, and the personal commitments it demands.

Health professional as political activist

In 1847, the Prussian province of Silesia was ravaged by a typhoid epidemic. Because the crisis threatened the population of coal miners in the area, and thus the economy, the Prussian government hired a young pathologist, Rudolf Virchow, to investigate the problem. His employers imagined that Virchow would return with the recommendation then in vogue: a little more fresh air, a little more fresh drinking water. But Virchow had much more to say about the situation.

He had spent three weeks in early 1848, not studying disembodied statistics or bureaucratic reports, but living with the miners and their families. One of the first points he made in his report to the Prussian government was that typhoid was only one of several diseases afflicting the coal miners, prime amongst the others being dysentery, measles and tuberculosis. Virchow referred to these diseases as ‘artificial’ to emphasize that, while they had their origin with a particular and ‘naturally’ occurring bacterium, their epidemic rates in Silesia were determined by poor housing, working conditions, diet and lack of sanitation amongst the coal miners. For Virchow, the answer to the question as to how to prevent typhoid outbreaks in Silesia was to incite the population to a united effort. Education, freedom and welfare would be attained only from the people’s realization of their real needs.

To facilitate people realizing their own needs, Virchow proposed a joint committee involving both lay people and professionals. This group would monitor the spread of typhoid and other diseases while organizing agricultural food cooperatives to ensure that the people had sufficient food to eat. Virchow’s solutions to the typhoid epidemic over the longer term, based on his talks with the miners and their families, were even more radical, and included improved occupational health and safety, better wages, decreased working hours and strong local and regional self-government. Virchow argued for progressive tax reform, removing the burden from the working poor and placing it on the nouveau riche, who expropriated great wealth from the mines while regarding the Silesians themselves not as human beings but as machines. He also advocated democratic forms of industrial development, and even suggested hiring temporarily unemployed miners to build roadways, making it easier to transport fresh produce during the winter.

These recommendations were not exactly what the Prussian government had expected. They had not hired Virchow to call into question the economics of the coal industry and industrial capitalism. He had none of the legitimating rhetoric of the Ottawa Charter for Health Promotion and its argument that health sectors needed to attend more to such ‘basic health prerequisites’ as ‘peace, shelter, education, food, income, a stable ecosystem, social justice and equity’ (World Health Organisation, 1986). Virchow was thanked for his report and promptly fired.

Scarcely one week later, on his return to Berlin, Virchow joined with other street demonstrators erecting barricades and demonstrating passionately for political changes that they hoped would bring democracy, which Virchow believed was essential for health. He established a radical, yet prestigious, magazine entitled Medical Reform, in which writers commented on the importance of full employment, adequate income, housing and nutrition in creating health. A decade later, still believing that political action was necessary for health, Virchow became a member of the Berlin Municipal Council and eventually of the Prussian Parliament itself. Throughout his 20 years as an elected official, Virchow campaigned tirelessly to get disease treated as a social as well as a medical issue. He planned and implemented a system of sewage disposal in Berlin and drafted legislation for proper food handling and inspection. He established better systems of building ventilation and heating, and introduced the first health service and health education programmes in the schools. He also lobbied to improve the working conditions of health professionals, particularly those of nurses.

To Virchow, there was no distinction between being a health professional and a political activist because all disease had two causes, one pathological and the other political. While he is largely remembered in medical schools for his enormous contributions to pathology, Virchow died believing that his most important work was the time he spent with the Silesian miners, understanding how social conditions can either create health or produce illness. That this story is from the past also allows us to see that our current interest in the social dimensions of health is not something new, rather something rediscovered (Taylor and Rieger, 1985).

Lessons from the past

Many diseases that consume us today, at least in more affluent countries, are different from the infectious ills of Virchow’s time. But Virchow’s story tells us that, whether infectious or chronic, diseases are physiological events that arise within, and derive their meaning, or significance, from particular social and political contexts.

Virchow’s story also foreshadows the important role played by educated, empowered and organized groups of citizens in creating healthy social change. Infectious diseases declined dramatically in industrialized countries at the end of the last century, a transition in large part resulting from social and political changes:

• Improved sanitation. Many life-threatening infectious diseases such as cholera are spread through the contamination of drinking water by infected human sewage. Once sewage disposal was separate from sources of drinking water, water-borne diseases began to be reduced.
• Improved working and living conditions. Nineteenth-century factories were dirty and dangerous places to work. The clogged and smoggy air in the metal, textile and pottery towns damaged people’s lungs and made them more susceptible to tuberculosis, one of the big killers of the past century. As occupational standards were drafted and enforced, workers’ health improved. Labour standards and collective bargaining gradually raised workers’ wages, shortened working weeks and eliminated child labour, while public education and more effective town planning improved social living conditions.
• Improved nutrition. As workers’ wages improved, they could afford more nutritious foods, which strengthened their physical health and their abilities to resist infection.
• Family planning. The constant childbearing that was commonplace a hundred years ago literally wore out the bodies of many women. Not surprisingly, children who were born later into large families were weaker and more diseased than first-born children, reflecting the deteriorating conditions of their mother’s bodies. With birth control and family planning came longer lived, healthier mothers, smaller families and less crowded living conditions.

These changes did not come easily. Employers often opposed sanitary reforms and quarantines on imported goods because they reduced profits. Working class organization for improved wages and better working conditions was often brutally repressed by élite groups whose interests were challenged. It can therefore be argued that many of the health gains of the nineteenth century arose from the entwined efforts of:

• organized workers’ groups that struck for higher wages, safer conditions and the eight-hour day;
• organized women’s groups that struggled for suffrage and the right to birth control;
• public health professionals, who lobbied for progressive social reforms and implemented sanitary and quarantine measures; and
• progressive political reformers, who wrote these claims for health and social justice in legislation.

Similar alliances are needed today for creating what is now called ‘healthy public policies’, or legislative reforms in environment, economy and social welfare that take into account their short and long term health implications. Even where the concerns are lifestyles, such as tobacco or alcohol abuse, the most dramatic and health-promoting changes have resulted from policy enactments governing product pricing and availability, or restrictions such as smoking bans in the workplace. These policy initiatives usually arise from partnerships between advocacy-oriented citizens’ groups and public health professionals. When concern shifts from individual health behaviours to broader health conditions, such as poverty, inequality or discrimination, the role of community organizing and policy advocacy becomes even more important.

There are two other lessons for health promotion that can be taken from Virchow’s story. First, Virchow was dismayed by how the poverty of the Silesian miners induced a sort of apathy or resignation and recognized that ‘inciting the people to a united effort’ is not easy work. While oppressed peoples often produce their own leaders and organizers, there is also an important ‘outside’ role that health promoters can play in this process. This role might include the specific knowledge, material and financial resources or organizing skills that the health promoter offers; for example, the health promoter represents a link between less powerful groups and more powerful public institutions, political and economic leaders. But central to this role is a motivational and power-transforming presence.

Second, Virchow’s argument that the Silesian problem was not simply typhoid, but a whole range of diseases that shared in common an aetiology in people’s living and working conditions, draws attention to a conundrum that still characterizes health promotion debate. Is it a practice intended to galvanize people into action around a specific set of risk factors associated with a specific disease? Or is it something larger and less easy to define that involves efforts by citizens, professionals and public institutions to make healthier, more deeply structured social conditions such as poverty, inequality and powerlessness? This raises important questions about evaluation and accountability; for example, Virchow’s report on the plight of Silesian miners fell on deaf political ears. Does that mean his work failed? Or, to the extent that it played some small part in motivating new forms of organization amongst the miners, did his work provide political reformers with a potent health argument for their work and serve as an inspiration for public health activists? Might we then as easily conclude that Virchow’s work succeeded? In other words, the process of empowerment that is central to health promotion change can be as important a success as the change itself.

What is health promotion?

Health promotion is not a new idea, if one takes it to mean any or all activities that improve the health of individuals and communities. Health promotion as a named practice, however, is more recent, with its steady rise in the health sectors of most industrialized countries following Canada’s landmark 1974 publication A New Perspective on the Health of Canadians (Lalonde, 1974). Following in the tradition of earlier public health measures to curb the spread of infectious diseases, health promotion emphasized the importance of interventions to prevent disease and promote wellbeing rather than relying upon remedial efforts to treat their damaging effects. This emphasis, given the deliberate contrast many of its proponents make to costly medical care, has helped to make health promotion politically legitimate (World Health Organisation, 2002c). Despite its legitimacy, there remains a lot of disagreement amongst writers and practitioners about what health promotion ‘really is’. These disagreements are illustrated by the three short stories in Box 1.1.

Box 1.1: Three faces of health promotion

Story 1: Sharon the nurse educator

Sharon is a nurse educator in a large teaching hospital. She runs groups for people who have been treated for serious heart disease. The goal of her education is to help people understand the importance of compliance with follow-up care (drugs, return check-ups) and the value of changing certain lifestyles (smoking, diet, exercise). Patients (which is how she thinks of them) are in the programme for as long as they are under formal hospital care Success for her is an indication that the patients will comply with their treatment, that they have made an appointment with a local health centre after discharge and that, as Sharon puts it, ‘They’ve had some fun in the group, since fun is a great healer.’

Story 2: Bob the nutritionist

Bob works for a local health department running nutrition and physical activity programmes tailored to low-income groups. Holding an advanced health promotion university degree, he appreciates the need for careful planning of his programmes; goals, objectives, activities, measurable and time-specific outcomes. He also appreciates the importance of a ‘multifaceted’ approach to health promotion. He supplements his education groups with some personal lobbying to make physical activity centres free to people on low incomes. His big concern is intervening early into, even preventing the onset of, diabetes, which his reading tells him is on the cusp of becoming a major epidemic amongst ‘high risk’ groups.

Story 3: Jill the social worker

Jill, a social worker by training, is part of a community health team employed by a local Health Trust. The Trust serves a severely disadvantaged area. A group was formed around timely access to health services and lack of safety and maintenance in the council housing. Jill was a key organizing resource in their work. She is attempting to get the group formalized in structure, and better linked to outside groups and other agencies that will add more political weight to their efforts. She has also formed a local chapter of the recently created Equity in Health Society and has published a few articles on her community empowerment approach to health promotion in practitioner journals.

In practice, the people in all three stories are right in claiming that they are doing health promotion. Health promotion is an idea that still belongs primarily to people employed in the health sector, in the sense that it provides these workers with some conceptual models, professional legitimacy and programmatic resources. Some of these workers may be titled ‘health promoters’ or ‘community developers’, others ‘health educators’, while many more who look to the idea of health promotion occupy more traditional job roles such as nurses, health visitors, physicians and social workers.

What the three stories also illustrate is that health promotion is best thought of as a ‘situated practice’ rather than as some universal theory of or approach to health. By this I mean that people, largely employed by (situated in) state agencies or state-funded non-governmental organizations (NGOs), engage in activities or programmes that are intended to improve or maintain the health of individuals and groups. Increasingly, such activities are undertaken with the cooperation of these groups and in collaboration with persons working in other sectors, both public and private. To a lesser extent, activities have broadened to include changing public policies that condition individual or group choices and behaviours, for example, pricing mechanisms to reduce tobacco consumption or new regulations to make housing healthier.

In broad terms, health promotion describes a relationship between the state (which regulates health opportunities), market economies (which create both health opportunities and health hazards) and community groups (which, through individual choices or collective action, influence both the state and market economies as well as their own health). More particularly, health promotion works to create some change in that relationship. This change could be defined as increasing citizen compliance with state health advice on fitness activities. Or it could be defined as improving the ability of marginalized groups to voice their concerns and influence political decision-making. By considering health promotion as a ‘situated practice’, our concern shifts away from any one particular health goal or target to the role of health promoters in making a valuable contribution to the attainment of that goal. Sharon, Bob and Jill all want to change people’s health. But if we commit to the idea that health promotion is about increasing people’s control over their health, we need to pay attention to how they define their own health goals, and how we, as practitioners, contribute to their goal attainment. This brings us to consider two variations in contemporary health promotion theory and practice.

Health promotion: two variations on a theme

If the single theme of health promotion is ensuring that people enjoy better health, there are two main variations in how theorists and practitioners interpret it. Andrew Tannahill (1985), a leading UK health promotion theorist, provides the term’s more conventional usage as ‘a realm of health-enhancing activities which differ in focus from currently dominant “curative”, “high technology” or “acute” health services’. Like many others, Tannahill favours a precise definition of health...

Table of contents

• Cover Page
• Title
• Copyright
• Contents
• List of Figures, Tables and Boxes
• Foreword by Ronald Labonte
• Preface
• Acknowledgements
• An Overview of the Book
• 1 Health Promotion in Context
• 2 Promoting Health: it all Depends on What we Mean by ‘Health’
• 3 Power Transformation Promotion Practice
• 4 Community Empowerment Promotion Practice
• 5 Addressing the Tensions in Health Promotion Programming
• 6 ‘Parallel-tracking’ Community Empowerment into Health Promotion Programming
• 7 The Domains of Community Empowerment
• 8 Building Community Empowerment Approaches in Health Promotion
• 9 Evaluating Community Empowerment Approaches
• 10 Implications for an Empowering Health Promotion Practice
• Bibliography
• Index