Health Promotion Practice 1st Edition

Visit the link below to download the full version of this book:

https://medipdf.com/product/health-promotion-practice-1st-edition/

Click Download Now

Health Promotion
Practice
Building Empowered
Communities

Glenn Laverack

Open University Press

Open University Press
McGraw-Hill Education
McGraw-Hill House
Shoppenhangers Road
Maidenhead
Berkshire
England
SL6 2QL

email: [email protected]
world wide web: www.openup.co.uk

and Two Penn Plaza, New York, NY 10121–2289, USA

First published 2007

Copyright # Glenn Laverack 2007

All rights reserved. Except for the quotation of short passages for the purposes of
criticism and review, no part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form, or by any means, electronic,
mechanical, photocopying, recording or otherwise, without the prior permission of
the publisher or a licence from the Copyright Licensing Agency Limited. Details of
such licences (for reprographic reproduction) may be obtained from the Copyright
Licensing Agency Ltd of 90 Tottenham Court Road, London, W1T 4LP.

A catalogue record of this book is available from the British Library

ISBN– 10: 0335 220 576 (pb) 0335 220 584 (hb)
ISBN- 13: 978 0 335 220 571 (pb) 978 0 335 220 588 (hb)

Library of Congress Cataloguing-in-Publication Data

CIP data applied for

Typeset by YHT Ltd, London

Printed by Printed in Poland by OZ Graf. S. A.
www.polskabook.pl
 Contents

Tables, Figures and Boxes viii

Preface x
Acknowledgements xii

Introduction: an overview of the book 1

1 Health promotion practice 3

Health promotion in context 3
Health promotion and public health 7
Health promotion and health education 9
Power and powerlessness 9
Power over 9
Power-from within 11
Power with 12
Powerlessness 13
Professional practice and empowerment 13

2 Communities and community-based interaction 17

What is a community? 17
What is civil society? 18
What are community-based concepts? 19
Community-based interaction 21
The ladder of community-based interaction 24
Community readiness 24
Community participation 24
Community engagement 25
Community organisation 27
Community development 27
Community capacity 28
Community action 28
Community empowerment 29

3 Health and empowerment 31

Interpreting the meaning of health 31
The link between empowerment and improved health outcomes 32
Participation and improved health outcomes 35
Organizational structures and improved health outcomes 35
vi CONTENTS

Resource moblization and improved health outcomes 37

‘Asking why’ and improved health outcomes 37
Problem assessment and improved health outcomes 39
Links with others and improved health outcomes 39
The roles of the outside agents and improved health outcomes 40
Empowering people to address the determinants of health 41
This Boy’s Life: the everydayness of the determinants of health 42

4 Empowerment and health promotion programming 46

Health promotion programming and parallel tracking 47
Does the programme have a fixed time frame or a flexible timeframe? 48
Is the outside agent or the community who identifies the concerns to be
addressed? 48
Is it the outside agent or the community who has control over the
management of the programme? 49
How is the programme evaluated? 49
Accommodating empowerment approaches into chronic disease
programmes 51
The programme design phase 51
Settling programme objectives 54
Developing the strategic approach 55
Programme management and implementation 56
Evaluation 58

5 ‘Unpacking’ community empowerment for strategic planning 60

The ‘domains’ of community empowerment 60
Improves participation 62
Develops local leadership 63
Builds empowering organizational structures 64
Increases problem assessment capacities 64
Enhances the ability of the community to ‘ask why’ 65
Improves resource mobilization 66
Strengthens links with other people and organisations 66
Creates an equitable relationship with the outside agents 67
Increases control over programme management 68
Strategic planning for community empowerment 68
Step 1. preparation 69
Step 2. setting a baseline for each domain 70
Step 3. strategic planning and the assessment of resources 77
Step 4. evaluation and visual representation 83

6 Evaluating community empowerment 84

The purpose of evaluation in a programme context 84
Design considerations 85
 CONTENTS vii

Selecting an appropriate paradigm 86

Ethical and practical considerations 88
Methodological considerations 91
Defining and measuring an inclusive community 91
Creation of valid knowledge from diverse perspectives 91
The problematic use of rating scales to measure empowerment 91
The visual representation of the evaluation of empowerment 93
The spider-web configuration 94
Adapting the spider-web configuration 98

7 Empowerment in action: an issues-based approach 102

Case study 1: improving health outcomes and community
capacity in Canada 102
The Saskatan ‘In Motion Programme’ 102
The impact of the SIMP 104
Case study 2: improving housing standards in an inner-city area
in England 107
Applying the empowerment domains to the community issue 108

8 Empowerment in action: a community-based approach 115

Case study 1: improving health and hygiene in a remote
community in Northern Australia 115
The health promotion context 116
A community-based approach to promote health and hygiene 119
Case study 2: improving livelihoods in rural communities in
Kyrgyzstan 122
The cultural context 123
The community empowerment approach 124
Evaluating community empowerment 127

9 Building empowered communities 129

Lessons learnt 129
Address community concerns 129
Build partnerships 131
Build community capacity 132
Evaluate to share ideas and visions 133
The social perspective 134
The structural perspective 136
The structural perspective and the determinants of health 137
The radical perspective 140
The ultra radical 142
Bibliography 144
Index 155
 Tables, Figures and Boxes

Tables

2.1 Three Community Based Concepts and their Relationship to

Empowerment.
2.2 An Interpretation of Community Based Concepts.
4.1 Skills Training in Health Promotion Programmes.
5.1 The ‘Domains’ of three Community Based Concepts.
5.2 The Generic Statements for each ‘Domain’ and Ranking.
5.3 The Framework for Assessment and Strategic Planning for the Naloto
Community in Fiji.
6.1 An example of the EAR scale for ‘problem assessment’.
7.1 An example of a domain definition and indicators.
7.2 Capacity Assessment of the Community of Saskatoon.

Figures

1.1 Community Empowerment as a Continuum.

2.1 A Ladder of Community Based Interaction.
4.1 Parallel-Tracking Empowerment in Chronic Disease Programmes.
5.1 Statements used for ‘Increases problem assessment capacities’ in Fiji
6.1 Measurement for Bukara Village.
6.2 Measurements for the Tokbai-Talaa village.
6.3 Spider-web for Ak-Terek Village.
6.4 Spider web for Aral and Chech Dobo Villages.
6.5 Cross-checking the Measurement of Community Empowerment.
6.6 Spider diagram for Empowerment in Mwangane .
6.7 Spider diagram for Participation in Mwangane.
8.1 Spider-web for Kopura Bazar community.

Boxes

1.1 Core Competencies for Health Promotion Programming

1.2 A New Definition of Health Promotion
1.3 What is Health Promotion?
 TABLE, FIGURES AND BOXES ix

1.4 The Transformative use of Power-Over

1.5 Examining Positions of Powerlessness
3.1 Empowerment for health outcomes in Samoa
3.2 Photovoice for Maternal and Newborn Health
4.1 The Definition of Stakeholders
4.2 Mapping and Ranking Community Concerns
5.1 Participation and health promotion in a traditional Fijian context
5.2 Developing a working definition for empowerment in Fiji
6.1 Empowerment Evaluation
6.2 Key Characteristics for the Evaluation of Community Empowerment
 Preface

I grew up in a single-parent family at the bottom of the social and economic

gradient and draw on my personal experiences in Chapter 3. My work in
public health and health promotion over the past 25 years has always been
with those who have to suffer the consequences of poverty and inequality.
Throughout my life I have observed the powerlessness of others or have
myself been directly affected by those who have power over my health and its
determinants. This will continue to motivate me to write about and to work
with people who struggle to gain power.

The idea for this book began when I was working on a school health pro-
motion programme in southern India. It was typically top-down with control
over decisions and resources taken by an outside agent that also
designed, implemented and evaluated the programme. This created an
imbalance in power and a continual struggle for control between the Indian
authorities and the outside agent. The parties involved were bound by the
bureaucratic procedures imposed by the conditions of funding, lines of
management and the ‘milestones’ imposed for meeting outcomes. The out-
side agent would not relinquish control because it was concerned with the
effectiveness (costs and targets met) and accountability of the programme.
This situation increasingly frustrated the Indian counterparts, who as the
recipients felt that they already had the necessary skills and competencies to
implement the programme.
At the time I strongly believed that there had to be a practical solution
to reconcile these differences and my opportunity came when I went to
Australia to begin my research on empowerment. My aim was to understand
how programmes could be an empowering experience for the intended
beneficiaries by strengthening their capacity. To achieve this I would have
to tread a fine line between theory (academic excellence) and practice
(pragmatism), to produce something that was rigorous and useful to the
stakeholders of health promotion programmes. I began by unpacking the
concept of community empowerment into its individual components. This
involved a rigorous process of review and led to the categorization of what I
termed the ‘empowerment domains’, discussed in Chapter 5.
I now had a theoretically and empirically ‘rich’ basis for the development
of an approach to empower communities and carried out its field-testing in
Fiji. This worked well and I was also able to develop the idea of ‘parallel
 PREFACE xi

tracking’ to accommodate empowerment approaches into top-down pro-

gramming. This involves the strengthening of the links between the ‘health
promotion track’ and the ‘empowerment track’ of the programme and pro-
vides a broader framework in which to situate the tool. I discuss this in
Chapter 4. The approaches discussed in this book are now being adapted and
applied in Asia, North America, the Pacific and Africa and I refer to some of
these experiences in Chapters 7 and 8.
It is hoped that the book will inspire practitioners to work in more em-
powering ways in health promotion and to contemplate how they can
influence the way others gain power.

Glenn Laverack, Auckland, New Zealand

 Acknowledgements

I would like to acknowledge the many people with whom I have had the
privilege of working during the course of writing this book.
In particular I would like to thank Dr Peter Adams, Dr Chris Bullen,
Dr Susan Rifkin, Dr Kirsten Havemann, Dr Janine Wiles and Dr Pat Neuwelt.
In Canada, Georgia Bell-Woodard, Ronald Labonte, Karen Chad and Lori
Littlejohns and the staff of the SLLP project in Kyrgyzstan.
I owe much thanks to my family, Elizabeth, Ben, Holly and Rebecca, for
their continued love and to my mother, Barbara, who provided the motiva-
tion for writing this book.
 Introduction: an overview of
the book

This book is the third in a series of publications that focus on power and
empowerment in professional practice. The first two books, Health Promotion:
Power and Empowerment (Laverack 2004) and Public Health: Power, Empower-
ment and Professional Practice (Laverack 2005) were written to provide a the-
oretical understanding of the subject area. This book goes further by
providing a special focus on communities and is illustrated throughout with
useful case study experiences. The book is written for health promotion
students and practitioners who want to learn more about practical
approaches that they can use to build empowered communities.
The book has three main purposes:

1 Chapters 1 to 3 provide the reader with an understanding of the key

concepts used in the book and the link to improved health outcomes
in the context of health promotion programmes.
2 Chapters 4 to 6 provide the reader with an understanding of practical
approaches that can be used in health promotion programming to
build and evaluate empowered communities.
3 Chapters 7 to 9 provide the reader with case study examples of how
communities can be empowered in practice and a conclusion of the
main issues discussed in the book.

Chapter 1 introduces the reader to the key concepts used in the book,
including health promotion, power and empowerment, and how they are
used to develop an empowering professional practice.
Chapter 2 defines and discusses, in a practical sense, the concepts of
community, civil society and community-based interaction. This chapter
clarifies the overlap between the key community-based concepts such as
community participation, community development and community capacity
and situates them in relation to community empowerment. The complexity
of the difference between these and other concepts is explained, for the first
time, as a ladder of community based interaction.
Chapter 3 begins with an interpretation of the different meanings of
health and then provides a discussion of the link between empowerment and
improved health outcomes. The chapter also examines the link between the
2 HEALTH PROMOTION PRACTICE

determinants of health and empowerment and the relevance of this to health

promotion practice.
Chapter 4 provides a discussion of the tensions that exist in health pro-
motion between bottom-up and top-down styles of programming. Readers are
introduced to a methodology for accommodating these two styles together
within the same programme through the use of ‘parallel tracking’. The ap-
plication of this approach is explained by using a practical case study example
of chronic disease prevention in Polynesian people in New Zealand.
Chapter 5 provides a detailed description of the nine ‘domains’ of com-
munity empowerment and uses case study examples to illustrate their im-
portance to health promotion. The chapter describes a step-by-step approach
for building empowered communities within health promotion program-
ming including setting a baseline, strategic planning, implementing a
strategic approach and evaluation.
Chapter 6 discusses the importance of, and provides the means to,
evaluate community empowerment. It discusses the key areas of considera-
tion when designing an evaluation methodology and offers a practical
method of visual representation using the spidergram configuration.
Examples of the practical use of the spidergram are given to show how this
approach can be used to share information between stakeholders.
Chapter 7 provides two case study examples of how, within an issue-based
approach, to build empowered communities by using the nine domains dis-
cussed in Chapter 5. The examples consider improving health outcomes and
community capacity in Canada, and improving housing standards in an
inner-city area in England.
Chapter 8 provides two case study examples of how, in a community-based
approach, to build empowered communities by using the nine ‘domains’
discussed in Chapter 5. The case studies consider improving health and hy-
giene in a remote community in Northern Australia, and improving liveli-
hoods in rural communities in Kyrgyzstan.
The final chapter brings together the central themes of the book, dis-
cusses the main lessons learnt from empowerment approaches and examines
three different contexts in which health promoters can build empowered
communities: social, structural and radical.
1 Health promotion practice

Health promotion in context

While there is no singularly accepted definition of health promotion, the

term is generally regarded as a multi-faceted process involving individuals,
‘interest’ groups and communities. The operational purpose of health pro-
motion is to enable people to increase control over, and to improve, their
health and its determinants. This is embodied in the Ottawa Charter for Health
Promotion (WHO 1986) and the Bangkok Charter for Health Promotion in a
Globalized World (WHO 2005):
The Ottawa Charter states:

Health promotion is the process of enabling people to increase

control over, and to improve, their health. To reach a state of com-
plete physical, mental and social well-being, an individual or group
must be able to identify and to realize aspirations, to satisfy needs
and to change or cope with the environment. Health is, therefore,
seen as a resource for everyday life, not the objective of living. Health
is a positive concept emphasizing social and personal resources, as
well as physical capacities. Therefore, health promotion is not just
the responsibility of the health sector, but goes beyond healthy
lifestyles to well-being.
(WHO 1986: 1)
The Bangkok Charter states:

The United Nations recognizes that the enjoyment of the highest

attainable standard of health is one of the fundamental rights of
everyday human being without discrimination. Health promotion is
based on this critical human right and offers a positive and inclusive
concept of health as a determinant of the quality of life and en-
compassing mental and spiritual well-being. Health promotion is the
process of enabling people to increase control over their health and
its determinants, and thereby improve their health. It is a core
function of public health and contributes to the work of tackling
communicable and non-communicable diseases and other threats to
health.
(WHO 2005: 1)