Public Health

Power, Empowerment and

Professional Practice

Glenn Laverack
Public Health
Also by Glenn Laverack

HEALTH PROMOTION PRACTICE: Power and Empowerment

 Public Health
Power, Empowerment and
Professional Practice

Glenn Laverack
© Glenn Laverack 2005
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Contents

List of tables, figures and boxes viii

Acknowledgements x
Preface xi
An overview of the book xiii

1 Power and public health practice 1

An empowering approach to public health practice 1
Helping individuals to gain power 4
Helping groups and communities to gain power 5
Public health programming 7
‘Parallel-tracking’ empowerment in public health programming 10

2 Public health in context 14

Public health Practitioners and their clients 14
Power and public health practice in bureaucratic settings 15
Professional versus lay interpretations of health 17
Empowerment and public health discourse 21
Public health and social movement theory 23

3 Power and empowerment 27

What is power? 27
Power-from-within 28
Power-over 29
Hegemonic power 30
Power-with 30
Zero-sum and non-zero-sum forms of power 31
What is powerlessness? 33
What is the means to attaining power? 35
Cultural and contextual interpretations of power and empowerment 36

4 Helping individuals to gain power 40

Practitioners as more effective communicators 40
One-to-one communication 41
Learning to listen 43
Combining communication channels 45
Increasing the critical self-awareness of clients 47
Mapping positions of power 47
Ranking complex issues 48

v
vi · Contents

Strategies for decision making 49

Developing a strategic plan for decision making 50
Fostering an empowering professional–client relationship 52
The power of language 53

5 Helping groups and communities to gain power 57

What is a ‘community’? 57
Community empowerment as a 5-point continuum 58
The ‘domains’ of community empowerment 60
A framework for helping groups and communities to gain power 63
Empowering individuals for action 64
Empowering groups 66
Empowering groups for the development of community
organisations 69
Empowering community organisations to develop partnerships 72
Empowering communities to take social and political action 73

6 Helping marginalised groups to gain power 75

Introduction 75
A case study of helping marginalised groups to gain power 77
The public health context 78
An approach to promote health and empowerment 78
Strengthening community empowerment 79
Building healthy public policy and creating a supportive
environment 82
Dealing with conflict 85

7 The measurement and visual representation of

empowerment 89
Developing a working definition of power and empowerment 89
Collecting and analysing qualitative information 89
Collecting and analysing qualitative information in a
cross-cultural context 94
The measurement of empowerment 97
Visual representations of community empowerment 102
The interpretation and visual representation of community
empowerment 103

8 Power, empowerment and professional practice 110

Introduction 110
Addressing the constraints in public health practice 112
Building a better understanding of the meaning of power and
empowerment 113
Addressing the bureaucratic constraints 113
Using an empowering approach to public health programming 115
 Contents · vii

Using measurement to empower others 116

Understanding the means to empower individual clients,
groups and communities 117
The practical application of the ideas in the book 118

References 120
Index 126
List of tables, figures and boxes

䊏 Tables
4.1 Communication skills checklist 44
4.2 The decision-making matrix 52
4.3 Empowering and non-empowering professional language 56
5.1 The overlap of empowering concepts 61
5.2 The empowerment domains 62
5.3 Role of the Practitioner to strengthen the process
of empowerment 63
7.1 The ranking for each generic empowerment descriptor 99

䊏 Figures
1.1 Parallel-tracking public health programming 9
4.1 Combining communication channels 46
5.1 Combining the empowerment continuum and
empowerment ‘domains’ 59
6.1 Applying the parallel-track approach 84
7.1 Developing a working definition for community empowerment 91
7.2 Facilitator role types 96
7.3 Spider web for Naloto 104
7.4 Spider web for Nasikawa 105
7.5 Spider web for Orto 107
7.6 Spider web for Kyzil Oi community 108

䊏 Boxes
1.1 Helping Individuals to Gain Power in Canada 5
1.2 Helping Groups to Gain Power in Canada 6
2.1 The Origins of the WHO Definition of ‘Health’ 19
2.2 Social Movement Theory and Partnerships in Brazil 25
3.1 Experiencing Powerlessness 33
3.2 Surplus Powerlessness and Women Living in Inner-city
Housing in Canada 34
4.1 Developing Individual Skills in Canada 42
4.2 The GATHER Approach to One-to-one Communication 42
4.3 Learning to Listen 43

viii
 List of tables, figures and boxes · ix

4.4 Guidelines for Using Teaching Aids 45

4.5 Mapping Positions of Power 48
4.6 Individual Expressions of Health 49
4.7 Public Health Practitioners as ‘Enablers’ for Empowerment 53
4.8 Language and the Professional–Client Relationship 55
5.1 The Key Characteristics of ‘Community’ 58
5.2 The Characteristics of Participation in Empowering Others 65
5.3 Participation and Personal Action in Australia 65
5.4 Problem Identification through Community Stories 68
5.5 Resource Mobilisation and Empowerment in South Asia 71
6.1 Defining Minority Groups 76
6.2 Positions of Power and Conflict 86
6.3 Defining the Issues of Conflict 87
7.1 Developing a Working Definition for Empowerment in Fiji 90
Acknowledgements

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

x
Preface

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

xi
xii · Preface

The book builds on my earlier work and in particular on the publication

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

This book has three main purposes:

1 To provide the reader with an understanding of the concepts of power and

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

䊏 Chapter 1 Power and public health practice

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

䊏 Chapter 2 Public health in context

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

䊏 Chapter 3 Power and empowerment

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

xiii
xiv · An overview of the book

䊏 Chapter 4 Helping individuals to gain power

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

䊏 Chapter 5 Helping groups and communities to

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

䊏 Chapter 6 Helping marginalised groups to gain power

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

䊏 Chapter 7 The measurement and visual representation

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

䊏 Chapter 8 Power, empowerment and professional practice

The final chapter brings together the central themes of power and empowerment
and discusses the main conclusions as a number of questions in regard to public
health practice. Chapter 8 also discusses the major constraints that must be
addressed in order to help clients to gain power and for the public health profession
to embrace a more empowering practice.
Chapter 1

Power and public health

practice

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

䊏 An empowering approach to public health practice

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

1
2 · Public health

through ‘top-down’ programming and controlling working practices whilst at the

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

1 Practitioners have a superficial understanding of the meaning of power and

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

Plainly put, many Practitioners do not have a clear understanding of how the
empowerment of individuals, groups and communities can be practically accom-
modated within public health practice. However, the situation is more complicated
than this and to simply blame the Practitioners would be to underestimate the
important role that they can have in empowering their clients.
One of the main tensions that Practitioners face in an empowering approach to
public health practice is whether their clients actually want to be empowered.
Public health practice is traditionally professionally led, for example, it is the
Practitioners or their agency that chooses the clients to be empowered and the
methods to be used to empower them. The initiation of the empowerment process
and the enthusiasm for its direction and progress is often led by the Practitioner.
This is contradictory to an empowering approach in which the issue to be
addressed and the means of reaching an empowered solution are the responsibility
of the client(s) and not an outside agent such as the Practitioner.
Some clients may not want to be empowered. People, especially if they have
lived in oppressive or powerless circumstances, may feel that they do not have the
right or do not possess the motivation to empower themselves. Kieffer (1984,
p. 16) provides an example of the individual experience of powerlessness by
Sharon, a Native American living in Harlem: ‘It would never have occurred to me
to have expressed an opinion on anything … It was inconceivable that my opinion
had any value … that’s lower than powerlessness … You don’t even know the
word “power” exists.’ Some clients may not want the responsibility of making
important decisions and to avoid the regret of making a misjudgement may wish
to ‘delegate’ this type of authority to a health professional in whom they have trust
 Power and public health practice · 3

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

in Chapter 7) to help promote transparency so that everyone in the programme can

establish what was done, by whom and at what cost ( Jones and Laverack, 2003).
Whilst Practitioners cannot be expected to have an influence on transforming
power relationships across all sectors and at all levels of their everyday work there
are two areas of importance in which they do have a role:

1 Practitioners are involved in influencing policies and practices that affect

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

In practice, an empowering approach to public health involves helping individu-

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

䊏 Helping individuals to gain power

Gaining a greater sense of self-confidence is an important step towards individuals
becoming more involved with others who share their concerns in interest groups
and organisations. This is important because, by participating, individuals can
become more critically aware of the issues concerning how they can gain more
power. The Practitioner can help individuals by giving advice, connecting them
with others in, for example, self-help groups and by sharing his/her power with
clients in a way that involves the provision of both services and resources.
An example of a how a Practitioner helped individuals to gain more power is
 Power and public health practice · 5

Box 1.1 Helping Individuals to Gain Power in Canada

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

provided by Ronald Labonte (1998), a veteran community development

practitioner, in Box 1.1.
In Chapter 4, I describe three approaches and a number of practical exercises
that can be effectively used in public health practice to help individual clients to
gain power:

1 Becoming a more effective communicator. This approach includes using com-

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

䊏 Helping groups and communities to gain power

In this book, the term ‘community’ comprises heterogeneous individuals involving
themselves in groups that share common needs and interests. Community
6 · Public health

empowerment, the means by which groups of individuals can attain power, is a

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

Box 1.2 Helping Groups to Gain Power in Canada

Ronald Labonte (1998) discusses a fatal fire in a rooming house that led to
renewed efforts by community service agencies to mobilise roomers around
housing issues and tenants rights. Early community organising efforts, intent
on creating tenants’ unions and possible rent strikes, had failed. Roomers
felt that their own concerns were not being respected in the rush towards
social action and felt anger towards their landlords. At the same time, Public
Health Nurses were welcomed for the one-to-one personal care they
offered. For many of the male roomers, the idea of groups was intimidating
and a reminder of forced groups in psychiatric institutions and prisons.
However, some roomers decided that a community kitchen would be a good
idea. Staples and food were provided by a local service agency and church.
As time passed, trust developed between the Public Health Nurses and the
male roomers. This increase in trust allowed the Public Health Nurses to
provide individual counselling and to offer short educational programs on
health-related topics. This led to a dramatic personal growth in some of the
men, who developed good social, organisational and leadership skills. In one
nurse’s own words, ‘We cannot expect people to do this “social action”
process just because we can see a need for social change. They may see the
need themselves, or simply wish for life to be better. But to expect them to
work through a complex organizing process for major social change is
grossly unfair and inappropriate. We can support the individual and group
building work. We can help people build some small base amongst them-
selves, and support them in going as far along an empowerment process as
they are willing and able to go.’
 Power and public health practice · 7

Practitioner helps individuals to increase their self-esteem and to become more

critically aware eventually linking with groups that share their concerns. As small
mutual groups and community organisations are built around the programme
issue (or other topic of concern to the participants), key capacities that can be
enhanced by the Practitioners are skills in problem assessment, greater participa-
tion in programme activities and the development of local leadership. As partici-
pants progress into forming partnerships, their abilities to mobilise internal and
external resources for their work, ensuring the democratic accountability of their
own community organisations and creating effective links with other groups,
become more central.
The second approach, developed more recently, uses nine ‘domains’ to
strengthen the process of community empowerment within a programme context
(Laverack, 2001):
● Participation;
● Problem assessment capacities;
● Local leadership;
● Organisational structures;
● Resource mobilisation;
● Links to other organisations and people;
● Ability to ‘ask why’;
● Control over programme management; and
● An equitable relationship with outside agents.
A domain is a significant area of influence on the process of community empow-
erment and together they represent those aspects that allow individuals and
groups to better organise and mobilise themselves towards social and political
action. Chapter 5 discusses a new framework that combines these two approaches
to help to strengthen the process of empowerment.

䊏 Public health programming

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

objects of the programme, and the outputs and inputs needed to achieve them.
Across the top are three columns headed indicators of progress, how these indica-
tors are to be quantified or assessed and the risks and assumptions involved. The
basic concepts underlying the logical framework system are the clear statement of
objectives, identifying in advance suitable indicators of progress and the prior
assessment of risks and assumptions towards the success of the programme.
The strengths of using the logical framework system are that its design has
validity, having already been widely employed as a ‘tool’ for programme manage-
ment and evaluation. The logical framework also provides a simple and systematic
approach to strategic planning. The design of the methodology will, therefore,
have a better chance of being understood and utilised by all the programme stake-
holders. The major weakness of utilising a logical framework system is that it is
ethnocentric. The approach is a Westernised model and yet it is often superim-
posed upon non-Westernised cultural contexts. The logical framework system has
also been criticised for the inflexible nature of its design that does not allow
changes to evolve with the programme, and the necessity to ensure that findings at
the policy level are fed back into the system.
The way in which public health ‘problems’ are to be addressed and are defined
in a programme is one of the most important issues in programming and can take
two main forms: ‘top-down’ and ‘bottom-up’. ‘Top-down’ describes programmes
where problem identification comes from the top structures in the system down to
the community, while ‘bottom-up’ is the reverse, where the community identifies
its own problems and communicates these to the top structures. I intentionally use
these two terms in this book because they help to illustrate the power relationship
that exists in public health programming: The outside agent (the Practitioner) who
uses the power-over to push down a predefined agenda onto the community.
Top-down and bottom-up approaches are ideal types of best practice that
demonstrate the important differences in relation to programme design. These
differences can be distinguished by whether
● The programme has a fixed timeframe or is flexible and long-term;
● It is the outside agent or the community who identifies the objectives to be
addressed;
● It is the outside agent or the community who has control over the implementation
and management of the programme;
● The type of terminology used to describe the programme is top-down or
bottom-up; and
● The evaluation is concerned with targets and outcomes and is carried out by
the outside agent or is concerned with capacity building and processes that
actively involve the community. (Laverack and Labonte, 2000)
The two types of programming are often viewed as having different agendas
that create a bottom-up versus top-down ‘tension’. However, public health pro-
grammes do not have to be viewed as a top-down versus bottom-up situation
because practice often moves between the two approaches.
Public health programmes are not usually designed with the aim of building
community empowerment. At best, community empowerment is seen as a lower
 Power and public health practice · 9

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

Programme Design Phase: Identification; Appraisal; Approval

Public health track Empowerment track

2. Programme objectives
Empowerment objectives
How are the programme
objectives and empowerment Objectives Level of control and choice
objectives accommodated to over health and life decisions
gether within the programme?

3. Strategic approach Strategic approach

How does the strategic Individual empowerment – small

approach of the programme Strategy groups – organisations –
link and strengthen the strategic networks – social and political action
approach for empowerment?

Empowerment domains
4. Strategic implementation
and management
Planned and positive changes in the
operational domains: Participation,
How does the implementation of the
Manage organisational structures, links with
programme achieve positive and
others, resource mobilisation,
planned changes in the operational
leadership, outside agents, programme
domains?
management, asking why, problem
assessment

5. Evaluation of the
programme outcomes
How is the programme evaluation
appropriate for community
empowerment?
Evaluation of empowerment
outcomes
Evaluate
Participatory evaluation techniques
used for community empowerment

Figure 1.1 Parallel-tracking public health programming (Laverack and

Labonte, 2000, p. 257)
10 · Public health

䊏 ‘Parallel-tracking’ empowerment in public

health programming

䊐 The design phase

The first opportunity where the ‘top-down’ and ‘bottom-up’ tension can begin to
be resolved is in the design phase of the programme which can be made more
empowering by using strategic and participatory planning approaches. Such
approaches allow the involvement of the participants and help to resolve conflicts
that may arise later during implementation and management. It is at the design
phase that the power relationship is established between the outside agents, the
Practitioners or their agency, and the other stakeholders of the programme, in
particular, the intended beneficiaries.
Top-down programming is a manifestation of power-over, in which the
Practitioner exercises control of financial and other material resources over the
beneficiaries of the programme. It is a form of dominance and authority in which
control is exerted through the design, implementation and evaluation of the
programme. One assumption of top-down approaches is that power can be given
to the community simply through education, resource allocation or ‘expert’
assistance from outside. Whilst these are important elements in an empowering
public health practice, they can also create a dependency on the Practitioner.
The important issue is: Who has the power-over (access to resources, technical
expertise and political influence) on the implementation and management of the
programme? ‘Parallel-tracking’ empowerment in public health programming
assumes a more precise role for the Practitioner to help the clients to gain power.
The Practitioner must first allow his/her clients to define the issues to be
addressed and then through their own actions to resolve these issues. To achieve
this within a programme context the issues to be addressed are identified in the
design phase. The Practitioners assist their clients to gain better access to
resources, technical expertise and political influence.
The programming issue at stake is how the public health track and the empow-
erment track become linked during the progressive stages of the programme
cycle. Through ‘parallel-tracking’ financial, material, human and knowledge
resources can be made available to the community, at their request, through the
design of the programme. The concept of the programme itself changes and
becomes essentially a vehicle through which community empowerment is gradu-
ally built as a process.
The time necessary to move from a relatively powerless to a more empowered
position involves building competencies that can typically take five years at the
individual level and, for a community, up to seven years or longer (Raeburn, 1993).
Therefore, a long time frame is necessary in programmes using empowerment
approaches. Too short a programme time frame runs the real risk of initiating
community-level changes, only to end before such changes have reached some
degree of sustainability within the community. Community empowerment
 Power and public health practice · 11

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

䊐 Setting programme objectives

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

䊐 Developing the strategic approach

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

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

䊐 Programme management and implementation

The programme management process is traditionally concerned with planning,
organising, leading and controlling the utilisation of resources, both human and
material, to achieve its objectives (O’Connor and Parker, 1995). The person who
controls, or has power-over, this process determines the direction and the chance
of success in achieving the objectives. In more general terms, management is
concerned with effectiveness, the extent to which objectives are achieved, and
efficiency, the way in which the objectives are achieved as compared to other means
(Ewles and Simnett, 2003). Management is not only concerned with achieving
tasks but also involves the people, personalities and politics of a programme.
The role of the Practitioner is to be sympathetic to stakeholder ownership and
involvement, and to help make the management process an empowering experi-
ence for the participants. This can be achieved by encouraging participants to take
on greater responsibility for programme management, for example, activities
like reporting, budgeting and the procurement of resources. In order to have the
confidence to undertake these responsibilities the participants may require generic
skills training in writing, interpersonal communication, research and public pre-
sentation. However, critical management skills are also very important and
include developing self-awareness, managing stress and conflict, creative problem
solving, delegation and decision making and conducting effective group meetings.
Jan Smithies and Georgina Webster (1998, p. 94) provide a case study example
of community involvement in managing the Hutson Street Health Project in
Bradford, England. The Project covered a deprived inner-city area and was estab-
lished to work on community health through a number of interconnecting ways,
such as establishing networks and group activities. An evaluation of the Project
found that community involvement was promoted through ‘word of mouth’
rather than through official channels. Community confidence was built up
through small group activities such as cooking and exercise classes, a credit union
and playgroup for children. The Project was steered by the expressed needs and
involvement of the community, facilitated by the sympathetic role of the
Practitioner, and this allowed the community to develop its own action plans and
activities for implementation as well as being involved in the day-to-day running
of the project. The evaluation of the Project also showed that it had a strong
positive affect on the confidence of the community members who felt that this in
turn had a positive influence on their health.
In order to build the capacity and confidence of their clients it is necessary that
they are initially involved in short-term tasks that are realistic and achievable. To
do this, the Practitioner can ask the participants to set ambitious short-term
performance goals, for example, the establishment of self-directed teams to achieve
specific tasks and activities. This is important because short-term successes can help
 Power and public health practice · 13

to motivate people towards the achievement of long-term objectives. The progress

should be periodically reviewed with the participants to reflect on the success and
failures. For example, how quickly are tasks achieved when set against their own
time frame? What further support do they need or what changes to work practices
can they adopt? The practices that do work should be built into the management
and implementation of the programme (O’Connor and Parker, 1995).

䊐 Evaluation of the programme

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

Public health in context

䊏 Public health Practitioners and their clients

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

14
 Public health in context · 15

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

䊏 Power and public health practice in bureaucratic settings

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

‘expert’ language used by Practitioners (discussed in Chapter 4). Public health as

a bureaucratic activity also provides a measure of the well-being of populations,
documenting and establishing trends based on its ‘expert’ and ‘legitimate’ power.
This sets standards of ‘normality’ that can be compared in relation to other
population groups. In this way, public health practice can build upon political
concerns and create issues that they show can be overcome by using their ‘expert’
knowledge and power. Public health as a bureaucratic activity can therefore be
used in a coercive and manipulative way to influence the way people think and act
(Lupton, 1995).
If it is true that public health is a bureaucratic activity, carried out by or within
governmental organisations or government funded agencies, it is also true that
many of these organisations remain chained to traditional ways of thinking and
acting, ways which inhibit the effective inclusion of empowering approaches.
Various studies of both government and NGO agencies have found that the
concept of empowerment used in policy and in practice are often quite different
(Grace, 1991; Turbyne, 1996). Despite the intent to ‘empower’ communities, the
organisations and their staff tended to retain control over programming rather
than to relinquish power to others. The agencies operated within a contradiction
between discourse and practice; many Practitioners continued to exert power-over
(control) the community through top-down programming whilst at the same time
using an emancipatory discourse.
Judith Turbyne (1996), a researcher who looked at the transformation of
concepts in policy-making processes, found that, although NGOs, which were
conservative and traditional in their programming (top-down), used a strongly
empowering discourse. However, this was transformed before it reached the
programme interface with the community. Turbyne uses the interesting analogy of
a glass prism to represent the policy-making process which refracts and alters the
concept, dependent on the history, resultant ideology and internal structure of the
organisation. Although this refraction of the concept of empowerment was found
to be more problematic in large bureaucratic settings almost all organisations used
a Weberian notion of bureaucracy as a ‘tool’ of the authorities to implement their
political decisions by translating them into policy and by delivering them through
programmes.
To build a more empowering practice, public health must redress the
constraints placed on the profession by its bureaucratic nature. This can become
compounded in such a broad profession when Practitioners collaborate with other
professional groups who do not necessarily share an ideology of empowerment.
As I discuss in Chapter 3, before Practitioners can empower others they must first
be themselves empowered and understand the sources of their own power. This
includes a bureaucratic setting in which they feel valued and which provides them
with the resources, skills and knowledge to empower others.
But governments and the bureaucracies that they create, at least in democratic
countries, are not monolithic entities. Not only are there often contradictions
between the policies and actions of different government agencies but different
Practitioners with differing ideas often exist and work together. Practitioners working
 Public health in context · 17

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

䊏 Professional versus lay interpretations of health

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

held by those who are usually the recipients of health interventions, the public.
Practitioners have largely used official interpretations because these are easier to
define and measure, rather than lay interpretations of health, which are subjective,
being based on the experiences of the individual. In particular, the medical or
bio-medical interpretation of health has established itself as the most dominant
official interpretation. It is the medical profession, which has been the champion
of this model of health, based on the absence of disease and illness, and upon
which other health professions have modelled themselves including the field of
public health.
The bio-medical model evolved as a result of scientific discoveries and techno-
logical advances in the eighteenth and nineteenth centuries and this led to a
greater understanding of the structure and functioning of the human body. As
knowledge and understanding about the functioning of the human body
increased, health took on an increasingly mechanistic meaning. The body was
viewed as a machine that needed to be fixed. A professional split between the body
and mind developed, the body and its physical illness was the responsibility of
physicians while psychologists and psychiatrists looked after the psyche and its
illnesses. However, the focus remained on the external causes of ill health and was
reinforced by the constant threat of disease and death from epidemics such as
polio and scarlet fever.
Peter Aggleton (1991), a commentator on public health and health promotion
issues, divides the official interpretations of health into two main types: those,
which define health negatively, and those, which adopt a more positive stance.
There are two main ways of viewing health negatively. The first equates with the
absence of disease or bodily abnormality, the second with the absence of illness or
the feelings of anxiety, pain or distress that may or may not accompany the
disease. Aggleton points to the importance of recognising that some people may
be diseased without knowing it. People are unaware of their illnesses until they
start to suffer pain and discomfort, when the person is said to be ill. Negative
definitions of health emphasise the absence of disease or illness and are the basis
for the medical model. A number of problems have been raised concerning the
negative definition of health. In particular, the notion of abnormality or pathol-
ogy implies that certain universal ‘norms’ exist against which an individual can be
assessed when making a judgement as to whether or not they are healthy. This
assumes that such standards actually exist in human anatomy and physiology.
Positive interpretations of health have also been widely used by health profes-
sionals. The first modern positive definition of health came in 1948 when the
World Health Organisation (WHO) stated that health was ‘a state of complete
physical, social and mental well-being, and not merely the absence of disease or
infirmity’ ( Jackson et al., 1989). Physical well-being is concerned with concepts
such as the proper functioning of the body, biological normality, physical fitness
and capacity to perform tasks. Social well-being includes interpersonal relation-
ships as well as wider social issues such as marital satisfaction, employability and
community involvement. The role of relations, the family and status at work are
important to a person’s social well-being. Mental well-being involves concepts
 Public health in context · 19

Box 2.1 The Origins of the WHO Definition of ‘Health’

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

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

own experiences, for example of health, overlap sufficiently so that we can

communicate and share these with others (Labonte, 1993).
The importance of personal interpretations of health is becoming increasing
well recognised, for example, the link between individual control and health has
been demonstrated in several studies (Brunner, 1996; Everson et al., 1997).
Everson et al. (1997) undertook a study of Finnish middle-aged white males and
concluded that stress induced from job demands and feelings of a lack of control
was the strongest predictor of arterial heart disease. A review of heart health
inequalities in Canada found that people who experience low income, less control
in their lives and at work and who had a poor education are more likely to experi-
ence morbidity and mortality. In other words, the higher one’s position in the
workplace or society, one’s power (control), wealth and status, the better one’s
health and sense of self-esteem (Labonte, 1993).
Self-esteem is actually a social phenomenon and not an individual creation.
A person’s self-regard and sense of coherence is not grounded in ‘the self ’, but in
relation to friends, family, colleagues, the communities and settings in which they
live and work. In turn, these relationships, communities and settings are influ-
enced by the political, cultural, social and economic context that privilege some
and oppress others. This illustrates one of the dilemmas when implementing
public health interventions that include self-esteem interventions targeted at
individuals, the socially excluded or marginalised groups. The intervention focuses
on the individual and the sense of self without critically assessing the deeper
causes of political and social inequalities.
Social support is therefore also generally accepted as having a beneficial effect
on health, both at home or in the community; for example, by sharing problems
people are better able to cope with stressful events. Social support is connected to
other similar overlapping concepts such as social capital, social inclusiveness,
social exclusiveness and social cohesion. These concepts fundamentally address a
sense of connection to a ‘community’ and the involvement and trust between its
members manifested through customs, rituals and traditional groupings such as
weddings.
Official definitions of health can differ significantly from lay definitions but
both are ideal types and in practice coexist and inform one another. Practitioners
have embraced a discourse that uses an official definition that goes beyond health
care and lifestyle to feelings of well-being. Health is considered to be a means to
an end that can be expressed in functional terms as a resource which permits
people to lead an individually, socially and economically productive life. However,
in practice, public health programming has increasingly been concerned with
accountability to funders, effectiveness and value for money (Boutilier, 1993).
Budgetary constraints, competition for funding and priorities for health have also
had a strong influence on the way in which health has been interpreted. The
public health profession has taken the pragmatic view that whatever interpretation
of health is used it must be measurable and accountable, otherwise programmes
employing its ideology and strategies will be in jeopardy of being unable to justify
their economic and quantifiable effectiveness. This being the case, the measurement
 Public health in context · 21

of health has focussed on the bio-medical approach that is concerned with

demonstrating a relationship between a health status measure and a behaviour
such as smoking or a condition such as morbidity and mortality. The boundaries
for public health practice and discourse have consequently been defined by the
interpretations of illness and disease rather than by the way in which most people
generally view their own health.

䊏 Empowerment and public health discourse

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

Internationally, the need for social justice in the challenge to improve health was
increasingly recognised and became the subject of professional discourse, for
example, the 30th World Health Assembly, held in Geneva in May 1977, which set
the target of health for all by the year 2000. The following year, an international
conference on primary health care in Alma Ata in the former USSR endorsed this
and strongly affirmed the WHO’s positive definition of health (World Health
Organisation, 1986), noting that it was a fundamental human right. The Alma
Ata declaration of 1978 recognised that the gross inequalities in the health status
between and within countries was unacceptable and identified primary health
care as the key to attaining health for all by the year 2000. The declaration recog-
nised that people must be actively involved in the process of development and
states: ‘The people have the right and duty to participate individually and collec-
tively in the planning and implementation of their health care’ (World Health
Organisation, 1978, p. 1). The declaration goes beyond participation to imply that
empowerment is a necessary component to primary health care and public health.
The Alma Ata Declaration does not use the term empowerment but many of its
points imply involvement by individuals and the community. This is in part a
reflection of the discourse in the early 1970s when the concept of empowerment
had not become fully legitimised. The concept of community participation was
viewed as a means to target people as beneficiaries of development by involving
them in the process. The discourse argued that participation would allow local
knowledge and needs to be incorporated into a programme and would give the
people more control in decision making. In practice, this depends on the power
relationships between Practitioners and their clients. If Practitioners use their
power-over and take a paternalistic stance, this can lead to community control or
coercion in programme planning and implementation.
Since the early 1980s there has been a shift within public health discourse
towards empowerment and community participation embodied in the socio-
environmental approach (Robertson and Minkler, 1994). This shift was guided by
key strategic documents, such as the Ottawa Charter for Health Promotion
(WHO, 1986), but was also due to other contributory factors of a social nature.
One of these factors was an increased awareness of growing inequalities in health
status between different social groups and the narrowness of the focus on individ-
ual behaviour that ignored the psychosocial and physical environments, commu-
nity and culture. For example, it was recognised that the individualistic nature of
public health education campaigns did not recognise the social and environmen-
tal contexts in which personal behaviours are embedded and which were, in
themselves, important health determinants. Another significant factor was the
maturing of many pressure groups and social movements such as the environment
movements including Friends of the Earth and the gay rights and public health
movements, who challenged the notion of the medical and behavioural approaches
to health and raised concerns for social justice and environmental sustainability
(Freeman, 1983). Social movements can provide a bridge between the ideology
that they espouse and the established discourses and practices of bureaucracies
and it is this, in relation to public health, which I next explore.
 Public health in context · 23

䊏 Public health and social movement theory

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

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

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

Social movements therefore have a structure, a pattern of inter-relations between

individuals and groups. This pattern evolves through its processes of mobilisation,
participation and organisation. Formal social movements may possess bureau-
cratic procedures but they do not operate from within bureaucracies. Social move-
ments exist within civil society as community-based groups, developed by the
people, against systematic structures and ideologies held by those in authority
(Pakulski, 1991), for example, social clubs, pressure groups and community organ-
isations. To illustrate this, Box 2.2 provides an example of social movement theory
and community partnerships in Brazil.
Ron Eyerman, a sociologist, and Andrew Jamison, an academic interested in
social and political policy (1991), add to the discussion on social movements by
examining their intellectual activities. Eyerman and Jamison argue that these
activities can change societal values and norms, for example, public values
towards health issues such as smoking and air pollution. In particular, there
are two main concepts in the approaches that they discuss that are relevant to
the evolution of empowerment in public health discourse: cognitive praxis; and
movement intellectuals.
Cognitive praxis is the ‘knowledge interests’ that are held by a movement and
the ‘dynamic and mediating role that movements play in the shaping of knowl-
edge’ (Eyerman and Jamison, 1991, p. 47). This is the origin of new knowledge
generated by a movement and to do this intellectuals within the movement draw
 Public health in context · 25

Box 2.2 Social Movement Theory and Partnerships in Brazil

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

upon and reinterpret established intellectual concepts. Cognitive praxis plays

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

justice, have relevance to an empowering public health practice. NSMT has an

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

Power and empowerment

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

䊏 What is power?
The most common interpretation of power used in the literature is in the form of
one person having power-over and mastery of others or ‘the capacity of some
persons to produce intended and foreseen effects on others’ (Wrong, 1988, p. 2).
The anthropologist, Richard Adams (1977) further discusses the idea that power
can be a social phenomenon, one that can be vested in both individuals and social
groups. As social organisations and communities develop, they are better able to
identify and control the basis of their power. The concept of power can be viewed
as both a limited, finite entity (zero-sum) and as an expanding, infinite entity (non-
zero-sum). These are important distinctions for public health practice that I will
discuss later in this chapter.
Bertram Raven and Tchia Litman-Adizes (1986) considered the resources that
Practitioners may bring to bear on their client in order to change their beliefs, atti-
tudes and behaviours. These are identified as six bases of social power-over (the
relationship between people in which a powerful person has power-over on
others): coercion; reward; legitimacy; expertise; reference and information.
● In coercive power, the Practitioner may bring about negative consequences
or punishment for the clients if they do not comply, for example, through
prosecution.
● In reward power, the Practitioner may bring about positive consequences for
the client upon compliance, for example by awarding a certificate of good
practice. Both the coercive and reward bases of social power depend upon the
Practitioner’s ability and readiness to mediate the consequences for the client
by the way in which the power-over is used.
● Legitimate power stems from the client accepting a social role relationship with
the Practitioner, a structural relationship that grants him/her the right to pre-
scribe behaviour for the client, while the client accepts an obligation to comply
with the requests of the Practitioner.

27
28 · Public health

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

It is important to note that the term ‘knowledge is power’ can be misleading

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

䊏 Power-from-within
Power-from-within can be described as an experience of ‘self ’, a personal power
or some inner sense of self-knowledge, self-discipline and self-esteem (Labonte,
1996). Power-from-within is also known as individual, personal or psychological
empowerment, the means of gaining (a sense of ) control over one’s life (Rissel,
1994). The goal of psychological empowerment is to increase feelings of value
 Power and empowerment · 29

and a sense of personal mastery. Thomas Wartenberg (1990), a writer on the

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

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

Power-over is resource dependant and is viewed as being ‘capacity’ reliant on

some type of a material product. However, it essentially ignores that power must
also be a property of social relations including the relationship one has with
oneself (power-from-within) (Clegg, 1989).

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

䊏 Power-with
Power-with describes a different set of social relationships, in which power-over is
used carefully and deliberately to increase other people’s power-from-within,
rather than to dominate or exploit them. Power-over transforms to power-with
only when it has effectively reached its end, when the submissive person in the
relationship has accrued enough power-from-within to exercise his or her own
 Power and empowerment · 31

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

䊏 Zero-sum and non-zero-sum forms of power

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

zero (thus the term, ‘zero-sum’). I win and you lose. For you to gain power, you
must seize it from me. If you can, you win and I lose. Power is used as leverage to
raise the position of one person or group, while simultaneously lowering it for
another person or group. However, at any one time there will be only so much
leverage (wealth, control, resources, etc.) possessed within a society. This distribution
and the decision-making authority that goes with it is zero-sum. At the same time,
there are dominant forms of status or privilege, such as class, gender, education
and ethnic background that tend to structure power-over relations in most social
situations. The role of the Practitioner in this zero-sum construction of power is
to assist individuals, groups and communities to gain power, meaning here more
control over resources or decision making that influence their health and lives,
from other individuals, groups and communities.
There is another important concept of power, one that is regarded not as fixed
and finite, but as infinite and expanding. These ‘non-zero-sum’ forms of power
are ‘win/win’, since they are based on the idea that if any one person or group
gains, everyone else also gains. Trust, caring and other aspects of our social
relationships with one another are examples of non-zero-sum power. To be more
empowering in their work, Practitioners should gravitate towards the non-zero-sum
formulation. Power is no longer seen as a finite commodity, such as wealth, or as
the comparative status and authority that this might confer. Rather, non-zero-sum
power takes the form of relationship behaviours based on respect, generosity,
service to others, a free flow of information and the commitment to the ethics of
caring and justice. The role of the Practitioner in this construction of power is to
use these attributes to engender them in others and to transfer power by encour-
aging individuals to access information by themselves, in part by providing better
access to resources and information (Laverack, 2004).
In practice, public health simultaneously involves zero-sum and non-zero-sum
formulations of power. Power cannot be given but communities can be enabled by
Practitioners to gain or seize power from others. Practitioners must first identify
their own power bases and then through the professional–client relationship
enable others to share these to develop their ability to gain control over the influ-
ences on their lives and health. Practitioners need to know both how to use their
own power to help themselves into a position of more control and how to help
others to gain power. Practitioners generally do have more power or a stronger
power base than their clients, for example, their education level and professional
training, higher incomes, expert status and social class, access to information and
resources, influence over decision makers, familiarity with systems of bureaucracy
and control over budget allocations.
A Practitioner can have many clients; individuals, groups and communities, who
are not homogeneous but consist of competing interests and therefore in the course
of their work it is unavoidable to empower some whilst not others. This raises the
ethical dilemma: Which groups, at the expense of others, should get priority of
the limited resources and assistance from the Practitioner? What criteria should be
used to select one group or community in preference to another group or commu-
nity? Poverty indices and scores have been used, for example, the Jarman score and
 Power and empowerment · 33

the Index of Local Conditions, to identify particular areas of social deprivation.

However, these measures are based on census variables and can only be updated
every ten years. Focussing limited resources on only a few deprived populations
may be neither the most effective or equitable approach to public health, which has
a responsibility to maintain the health and well-being of everyone.

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

Box 3.1 Experiencing Powerlessness

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

Box 3.2 Surplus Powerlessness and Women Living in

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

barrier to empowering action. They do not even engage in activities that meet
their real needs. They begin to accept aspects of their world that are self-destructive
to their own health and well-being, thinking that these are unalterable features of
what they take to be ‘reality’. An example of the effect of powerlessness can be
seen amongst communities which are subject to sudden catastrophes such as the
Aberfan coal waste disaster. ‘People who feel their humanity violated and
unrecognised by others internalise that diminished sense of themselves in ways
that impair their capacity for recovery or even hope.’ Part of this internalising
process is isolation, removing oneself from active group participation because of
low self-esteem and high self-blame (Couto, 1989, p. 238).
The challenge is to strengthen individuals’ power-from-within, partly by helping
them to identify their own sources of power-over. People’s power or powerless-
ness, for example, is always relative to that of others in their community. One has
authority or social status by virtue of others not having it. There is a degree of
flexibility here, however, since someone may have authority or status in one
situation, relative to others, but not in another. For example, an immigrant man
may hold the position of a leader or hereditary chief within his own community,
 Power and empowerment · 35

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

䊏 What is the means to attaining power?

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

Community empowerment is a synergistic interaction between individual

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

䊏 Cultural and contextual interpretations of

power and empowerment
Many of the definitions of power and empowerment have been developed by
psychologists in industrialised countries in the areas of neighbourhood empower-
ment and community mental health (Rappaport, 1987; Swift and Levin, 1987),
for example:

Empowerment may be generally described as the connection between a sense

of personal competence, a desire for and a willingness to take action in the
public domain. (Zimmerman and Rappaport, 1988, p. 725)
The ability to act collectively to solve problems and influence important issues.
(Kari and Michels, 1991, p. 719)

Empowerment may hold a very different connotation for people living in different
cultural contexts, for example, what might be perceived as empowering by women
in an industrialised country may be very different for women in a developing
country. This includes the degree of, or expectation of, power-over the events in
life such as choosing who to marry, where and with whom to live, what to be
employed as, what to wear or even if enough control is permissible, to leave the
house alone.
John Raeburn (1993), a veteran commentator on health and community organ-
isation, provides an interpretation of power, one that has a spiritual meaning to the
Maori people of New Zealand. This meaning is embodied in the term ‘mana’
combined with dignity, humility and the status gained from one’s presence.
Raeburn argues that being involved in empowering community processes can lead
to the attainment of this cultural sense of power. Sharry Erzinger (1994), a health
consultant in Latin America, explains the meaning of empowerment in Ecuador
where poverty, religion, superstition and political dominance all function to maintain
‘power-over’ authority and control in most people’s lives. Erzinger points out that
 Power and empowerment · 37

in the Spanish language empowerment is not an individual or solitary phenomenon

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

had led to the need to develop sexual relationships as a means of income but this
was maintained because of the social acceptability of this practice. This has had
dire consequences for the families of the Krobo people who provide the support
and care necessary once the young women develop AIDS.
In a zero-sum political context, power-over access to resources is finite and
creates a win/lose situation: my power-over you, plus your absence of that power
means that I win and you lose. In these circumstances, it is in the interest of the
community groups to either work with the political context taking a strategic
approach for empowerment or to work against it to agitate for reform. In a
supportive political context, those in governance support the self-determination of
some groups and communities over others but may place the needs of the majority
into a national agenda. If a supportive political context does not exist, the onus is
on the community to gain power through whatever leverage it can use to raise
their position over others. This usually involves empowering themselves through
legitimate localised action, for example, by writing a petition and raising the issue
with government representatives, leading eventually to broader social and political
change. However in certain political contexts (undemocratic, totalitarian), the
legitimate means to empowerment do not exist and groups and communities may
have to take more radical action to bring about social and political change, for
example, mass protests, riots and strikes.
The historical context of community action may determine future involvement,
set precedents or predetermined assumptions about power and empowerment. A
history of resistance between the church in Latin America and the land-owning
aristocracy provides the backdrop for a major empowering force through critical
reflection. Church activists, inspired by their own theology, rejected the elitist and
corrupt practices of the landowners and pioneered resistance movements against
those in power. In Latin America, the church continues to promote community
action among the poor through co-operative solutions, self-help and participatory
approaches (Asthana, 1994).
Knowledge of the historical context of the community can help identify poten-
tial barriers to community empowerment such as experiences of conflict or feelings
of helplessness. Goodman et al. (1998) argue that communities with access to
information about their history, verbal or written, have a better chance of affect-
ing change, than those that do not have access. However a historical context of
colonialism has been shown to generate an atmosphere in which empowerment is
difficult to achieve. Serrano-Garcia (1984) uses Puerto Rico as a case study and
argues that an ideology of conservatism and pro-American values has been forced
into the culture. The weakening of this ideology was one of the main goals of the
Esfuerazo project in order to gain cultural identity, independence and collective
empowerment. However, Serrano-Garcia argues that this has only created an
illusion of empowerment because newly gained control over a person’s life still
exists within an oppressive colonial context, which continues to determine the
physical and physiological well-being of the population.
Historically the extent of colonialism has been widespread in the world and the
definition provided in Blair and Bernard (1998, p. 205) as ‘the practice or idea of
 Power and empowerment · 39

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

Helping individuals to
gain power

Helping individuals to gain power involves building their power-from-within and

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

1 Practitioners as more effective communicators;

2 Increasing the critical self-awareness of clients; and
3 Fostering an empowering professional–client relationship.

䊏 Practitioners as more effective communicators

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

40
 Helping individuals to gain power · 41

behalf of their clients or to mediate between conflicting interest groups. Health

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

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

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

Box 4.1 Developing Individual Skills in Canada

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

Box 4.2 The GATHER Approach to One-to-one

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

Situations where one-to-one communication takes place include:

● a health worker talking to a patient at a clinic;
● providing physiotherapy advice to an individual;
● counselling someone on a sensitive issue such as the result of a medical test;
● helping someone to cope with a difficult situation such as a bereavement.
 Helping individuals to gain power · 43

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

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

Box 4.3 Learning to Listen

Work in groups of 3–6 people. Appoint someone as a timekeeper.
1 Person A speaks for 2 minutes, without interruption, on a subject of
choice to do with work or a personal interest. Everyone else in the group
listens without taking notes.
2 Person B repeats as much as can be remembered accurately, without
anyone else interrupting, using the same words and phrases as person A.
3 A and the rest of the group, identify and agree to what was actually said.
4 The group then discusses what helped them to listen, what helped them
to remember, what hindered them from listening and how could they
become better listeners?
5 The exercise can be repeated until all members of the group have had a
turn to speak and to listen.
(Ewles and Simnett, 2003, p. 189)
44 · Public health

knowledge) while the client accepts an obligation to comply with the advice. This
can relate to a range of different types of information and behaviour change for a
healthier lifestyle, for example, a reduction in body mass (nutritional advice). The
Practitioner may have to use power-over in a form of dominance to control peo-
ple’s choices. This is sometimes a necessary communication style when, for exam-
ple, giving precise instruction such as the self-treatment of a wound by the patient.
Obtaining and giving feedback enables the Practitioner to clarify what the
client wants, that they have understood previous communication or retained skills.
This may mean obtaining feedback based on specific information using closed
questions that require short factual (yes/no) answers or based on an open form of
questioning to provide fuller answers.
Giving feedback is important for the achievement of effective communication
and in particular positive feedback that reinforces the strengths of the client’s
knowledge or skills level. The client is encouraged to share his/her concerns,
feelings and opinions but the discussion is directed by the Practitioner. To facilitate
this process the Practitioner can use ‘people centred’ approaches such as role play
and story-telling or the use of participatory materials such as three pile sorting
cards, discussion posters and flipcharts to help people to learn.
An assessment of the procedure of communication involving listening, giving
advice and obtaining and providing feedback can be an important part of
the learning process for the Practitioner. A communication skills checklist is

Table 4.1 Communication skills checklist (adapted from Lloyd and

Bor, 2004, p. 190)

Did the Practitioners Yes No Comments

Introduce themselves
Use the client’s name
Greet the client
Explain their role and purpose
Ensure that the client was comfortable
Establish and maintain eye contact
Listen to what the client was saying
Use open-ended questions
Inform the client that information would
be recorded
Maintain interest in what the client was saying
during note taking
Identify and respond to verbal and non-verbal
cues
Give appropriate and accurate advice
Provide a summary of what was said and
agreed
Obtain feedback from the client
Give a pleasant thank you and farewell
 Helping individuals to gain power · 45

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

䊏 Combining communication channels

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

Box 4.4 Guidelines for Using Teaching Aids

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

A mass medium
Television and radio

Popular
media,
puppets,
songs,
stories

One-to-one communication Printed materials

Counselling and direct discussion Leaflets and flashcards

Figure 4.1 Combining communication channels (adapted from Laverack

and Dao, 2003, p. 367)

with their clients. Popular media include drama, songs and puppets and these are
often used because of their entertainment value and ability to address sensitive
topics with humour, such as the use of condoms. School-based activities include
participatory exercises for life skills, competitions and contests and counselling
(one-to-one communication) covering a range of issues.
Communication strategies used in public health programmes have traditionally
been implemented as interventions relying on only one or two channels, for
example, a mass media campaign on road safety. This is because the frequency and
design of communication activities has been largely determined by the availability
of resources. Figure 4.1 offers a methodology that illustrates how different com-
munication channels can be combined as a part of the same intervention. The
communication intervention is represented as a triangle. Each point of the triangle
represents a different communication channel that is implemented on a regular
basis as part of the intervention, for example, weekly radio broadcasts, the distrib-
ution of leaflets and counselling sessions between the Practitioner and a client.
The centre of the triangle represents an ‘opportunistic channel’, such as commu-
nity theatre, one that is used when the opportunity arises, usually when people
congregate in a public place, for example, at out-reach clinics, in shopping malls
or at open-air markets. The combination of channels can be changed, to develop
different communication interventions, and are designed to be used together to
strengthen the approach. For example, formal didactic methods can be made
 Helping individuals to gain power · 47

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

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

䊏 Increasing the critical self-awareness of clients

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

䊏 Mapping positions of power

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

Box 4.5 Mapping Positions of Power

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

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

䊏 Ranking complex issues

Ranking is a simple exercise by which individuals can ‘unpack’ complex issues or
concepts, such as health, into its different elements so that they can be placed into
a specific order and then further analysed. An example of this is provided by
Ronald Labonte (1993) who asked several individuals to (rank) ‘Think of the last
time you experienced yourself as healthy’, and then to write down a few phrases
(categorise) that described the feeling, and the context. Box 4.6 provides a number
of these individual expressions of feeling healthy. Noticeably absent from this
list is any reference to disease or wellness, and the minimal attention given to phys-
ical evaluations such as fitness levels. Instead, the individuals often identified feel-
ings of power as being closely associated with experiences of health, for example,
 Helping individuals to gain power · 49

Box 4.6 Individual Expressions of Health

being loved, loving
being in control
fitting in, doing
relaxed, stress-free
giving/receiving, sharing
outdoors, nature
friends, belonging, meaning in life
able to do things I enjoy
happiness, wholeness
(Labonte, 1993)

power-from-within, feelings of ‘loving’, ‘being loved’, ‘giving’ and ‘belonging’ and

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

䊏 Strategies for decision making

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

individuals. Decision making is a highly complex procedure and a practical

approach to promote the basic principles of this process is outlined below.

䊏 Developing a strategic plan for decision making

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

䊐 Step 1. Ranking key options

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

1 To stop smoking in the next six months;

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

䊐 Step 2. A discussion on how to improve the present situation

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

● Remove all cigarettes from the home and workplace;

● To attend motivation classes to help to stop smoking;
● To use a substitute for smoking such as chewing gum or nicotine patches.
 Helping individuals to gain power · 51

䊐 Step 3. Developing a strategy to improve the present situation

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

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

䊐 Step 4. Assessing resources

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

● The availability of local self-motivation class;

● Money to pay for classes and time to attend the classes;
● Access to a pharmacy or Practitioner to discuss the best options for a smoking
substitute and;
● Money to purchase substitute products.

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

Table 4.2 The decision-making matrix

Ranking or priority How to improve Strategy to improve Resources necessary

Stop smoking Remove all Collect all cigarettes None

in the next cigarettes in house and dispose
6 months
Do not purchase any
more cigarettes
Attend Identify local classes Local classes or self-
motivation motivation class via
Make time to attend
classes internet or postage
Identify friend to
Finance to pay for
attend initial classes
classes
for support
Time to attend classes
Purchase Discuss best product Pharmacy
substitute gum with doctor or
GP
pharmacist
Finance to purchase
Buy gum from chemist
gum
Take on prescribed basis

䊏 Fostering an empowering professional–client relationship

Fostering an empowering professional–client relationship describes a process in
which power-over is used carefully and deliberately by the Practitioner to increase
the power-from-within of their client. This is the transformative use of power-
with as described in Chapter 3. The qualities of an empowering relationship
include a non-coercive dialogue between the Practitioner and the client in the
identification of needs or problems and practical actions, such as developing a
decision-making matrix, to address and resolve the problems. The key role of the
Practitioner is that of an ‘enabler’ and in Box 4.7 I provide some of the main char-
acteristics of this type of an empowering practice. However, these characteristics
do not apply to all public health work, for example, Practitioners involved in
enforcement, licensing and legal proceedings will have fewer opportunities to
empower others than those professionals working in an advisory role with individ-
uals, groups and communities.
This is because enforcement uses a power-over approach to maintain authority
in contrast to an advisory and educational role that uses a power-with approach
that can be used to build the power-from-within of other people.
An empowering professional–client relationship when working with individu-
als, groups and communities also involves many of the characteristics and skills
discussed in this book. For example, the ability to be a good communicator, a good
listener, helping people to become more critically aware, dealing with conflict,
linking individuals to groups that share their interests and building the capacity of
these groups to develop into functional organisations and partnerships.
 Helping individuals to gain power · 53

Box 4.7 Public Health Practitioners as ‘Enablers’ for

Empowerment

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

An empowering professional–client relationship in public health also involves

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

䊏 The power of language

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

necessary to make it possible for power to be gained. In a professional–client

relationship, this is a mutual role played out by the Practitioner who facilitates
change, and the client who identifies and executes the change.
The language used in public health largely uses the meaning of power in the
transitive interpretation: bestowing it upon others. However in practice, public
health simultaneously involves both interpretations of power. Power cannot be
given but clients can be enabled by Practitioners using the intransitive meaning to
gain or seize power from others. It is the relationship between the Practitioners
and their clients that is the empowering mechanism to achieve control over the
influences on their lives.
‘Empowerment’ has become a fashionable term. It is possible to be an ‘empow-
ered’ consumer by buying a particular product, to be an ‘empowered’ customer by
using a particular service or to be an ‘empowered’ viewer by watching a particu-
lar television show. What this language tells us is that the individual could gain
more control (over decisions, resources, information) by partaking in a particular
relationship. The ‘empowering’ relationship is cast between the different people,
those with the power-over particular information or services and those without or
with relatively less knowledge.
In public health practice, the advantage is often held by the one with the power-
over (the Practitioner) and the language that they choose to use can either
strengthen or weaken the professional–client relationship. Box 4.8 shows how the
use of language can have both an empowering and a non-empowering effect on
the professional–client relationship. The first account of Beatrice uses a power-
over approach in which the Practitioner presents a series of negative and non-
empowering statements about the client.
For example, Beatrice is described as being ‘unemployed’, ‘undernourished’
and having ‘a low birth weight’ child. The account implies a person who is
unhealthy and powerless and when confronted by such a description, through her
contact with different Practitioners and institutions, Beatrice may begin to inter-
nalise it as being true about herself. This process is called learned helplessness or
surplus powerlessness, discussed in Chapter 3, and is a manifestation of power-
over the client by the Practitioners or by the agency with which they work.
In the second account of Beatrice she is portrayed by using positive language
centred around her own capacities or power-base, for example, ‘trying to give up
smoking’, ‘fluent in French and Spanish’ and ‘trained laboratory technician’. The
account also provides opportunities for the Practitioner to have a role in helping
the client to gain power, for example, providing Beatrice with baby-sitting facilities
or referring her case to the housing department. This provides the basis for an
empowering professional–client relationship, discussed earlier in this chapter, and
is a manifestation of power-with the client.
Technical terms are a part of the everyday language of Practitioners, for
example, medical diagnostic vocabulary, and have evolved as knowledge and skills
develop within a profession’s ‘subculture’ (other subcultures include ethnic groups,
social class, sexuality). However the use of specialist language is often confusing to
lay people or to professionals not part of the ‘subculture’. This can contribute to
 Helping individuals to gain power · 55

Box 4.8 Language and the Professional–Client

Relationship
Which account of Beatrice is more empowering?
Beatrice is:
●
a low income, single mother;
●
unemployed;
●
is undernourished and anaemic;
●
is living in a one room basement apartment;
●
looking after two children, her first child was of low birth weight;
●
not able to speak English well;
●
a smoker and drinks alcohol.
Beatrice is:
●
looking for work that will fit her skills as a trained laboratory technician;
●
is trying to find ways to supplement her diet but is unable to afford extra
money for food shopping;
●
living in a small tidy apartment but is looking for better accommodation;
●
looking after her two healthy and happy children;
●
learning English at night-class but finds it difficult to get a baby sitter;
●
fluent in Spanish and French;
●
trying to give up smoking.
(Adapted from Labonte, 1998, p. 46)

their sense of powerlessness by emphasising a lack of access to knowledge and the

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

Table 4.3 Empowering and non-empowering professional language

Empowering language Non-empowering language

Uses simple technical terms Uses complex technical terms

Focuses on the problem and solution
seeking of the client
Uses local language, for example, shit
sample rather than ‘stool sample’
Uses positive words to build the power-
from-within of the client, for example,
‘Good, well done, try again’
Encourages participation, involvement
and control by the client
Promotes the idea of a partnership
between the client and the Practitioner
Uses words that are non-patronising and
non-paternalistic
Encourages feedback from the client to
share his/her ideas and experiences
Language is open, respectful, non-
coercive and two way. Practitioner
maintains eye contact and open body
language
Focuses on the problems faced by
the Practitioner
Uses technical terms
Uses negative words that undermine the
client, for example, ‘Not good enough,
poor work’
Words that assume control will be used
by the Practitioner
Promotes the idea that the Practitioner
has power-over the client in the
relationship
Uses patronising and paternalistic
language that treats the client like a child
Language does not seek feedback from
the client
Language is coercive and didactic (one
way). Body language is defensive, for
example, Practitioner does not face client

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

Helping groups and

communities to gain power

Helping groups and communities to gain power involves a process of capacity

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

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

57
58 · Public health

Box 5.1 The Key Characteristics of ‘Community’

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

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

䊏 Community empowerment as a 5-point continuum

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

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

Labonte (1990) claims that the continuum was first developed in Australia in
workshops with health and social service workers in 1988. Labonte subsequently
published his version of the continuum for community empowerment followed by
Jackson et al. (1989) who published their version for community development in
1989 using a similar 5-point continuum. Rissel (1994) later adapted these two
interpretations of the continuum to explain how psychological empowerment
relates to the process of community empowerment. These three authors use
slightly different terminologies that essentially hold the same meaning and repre-
sent the same conceptual design: the potential of people to progress from individual
to collective action along a continuum.
The continuum model has remained unchallenged in the literature and
explains how collective action can potentially be maximised as people progress
 Helping groups and communities to gain power · 59

The continuum model

1 2 3 4 5
Personal Small mutual Community Partnerships Social and
action groups organisations political
action

The empowerment domains

Participation
Problem
assessment skills

Leadership skills

Organisational structures
Resource mobilisation

Links to others

Asking why

Figure 5.1 Combining the empowerment continuum and

empowerment ‘domains’

from individual to community empowerment. The continuum model offers a

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

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

䊏 The ‘domains’ of community empowerment

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

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

A summary of each domain is given in Table 5.2.

Research was carried out to identify the empowerment ‘domains’ using:

● a review of the relevant literature;

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

A review of relevant literature, with particular reference to the fields of health,

social sciences and education, provided an in-depth understanding of programmes
which sought to achieve the same empowerment goals: to bring about social and
political change. The ‘domains’ were categorised from a textual analysis of the lit-
erature and the validity of this data was cross-checked by two other researchers
using a confusion matrix approach as discussed by Robson (1993, p. 222).
Although these nine domains have been used individually by Practitioners, both
explicitly and implicitly in empowerment approaches, for many years, their pur-
poseful integration in a public health programme context is more recent. The role
of the Practitioner in empowering others has been traditionally concerned with
facilitating the movement of people along the 5-point continuum as discussed above.
 Table 5.1 The overlap of empowering concepts (adapted from Laverack, 2001)

Community participation Community competence Community participation Community empowerment Community capacity
Rifkin et al. (1988) Eng et al. (1994) Shrimpton (1995) Laverack (2001) Goodman et al. (1998)
Factors Dimensions Indicators Domains Dimensions

Participation Machinery for Participation Participation

participant interaction and
decision making
Leadership Leadership Leadership Leadership
Organisation Social support Organisation Organisational Sense of community,
structures an understanding of
community history
and values
Resource mobilisation Resource mobilisation Resource mobilisation Resources
Needs assessment Needs assessment/ Problem assessment
action choice
Self-awareness, clarity of Asking why Critical reflection
definitions
Management of relations Links with others Social and inter-
with wider society organisational networks
Outside agents
Management Management (programme) Programme management
programmes Conflict containment Training Skills
Articulation Orientation of actions Community power
Commitment Monitoring and evaluation

61
62 · Public health

Table 5.2 The empowerment domains (Laverack and Labonte, 2000)

Domain Description

Participation Only by participating in small groups or larger organisations

can individual community members act on issues of general
concern to the broader community
Leadership Participation and leadership are closely connected.
Leadership requires a strong participant base just as
participation requires the direction and structure of strong
leadership
Organisational Organisational structures in a community represent the ways
structures in which people come together in order to socialise and to
address their concerns and problems
Problem assessment Empowerment presumes that the identification of problems,
solutions to the problems and actions to resolve the
problems are carried out by the community
Resource mobilisation The ability of the community to mobilise resources both from
within and the ability to negotiate resources from beyond
itself is an important factor in its ability to achieve success in
its efforts
‘Asking why’ The ability of the community to critically assess the causes
of its own inequalities
Links with others Links with people and organisations, including partnerships,
coalitions and voluntary alliances between the community
and others, can assist the community in addressing its
issues
Role of the outside The outside agent increasingly transforms power
agents relationships such that the community assumes increasing
programme authority
Programme Programme management that empowers the community
management includes the control by the primary stakeholders over
decisions on planning, implementation, evaluation, finances,
reporting and conflict resolution

A ‘domains approach’ gives a slightly different, and more precise, way of develop-
ing strategies whilst at the same time progressing along the continuum.
The key question Practitioners need to ask themselves is: How has the pro-
gramme, from its planning through its implementation, through its evaluation,
intentionally sought to enhance community empowerment through each domain
and at each stage of the continuum? (Laverack, 2004).
I will now discuss a new framework to explain how Practitioners can combine the
continuum model and ‘domains’ approach to build more empowered communities
and relate this to the theory on power and empowerment discussed in Chapter 3.
 Helping groups and communities to gain power · 63

䊏 A framework for helping groups and communities

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

Table 5.3 Role of the Practitioner to strengthen the process

of empowerment

Continuum model Domain Key role of the Practitioner

1. Personal action Participation Build a greater sense of control

in peoples’ lives and bring them
together in small groups around
issues of mutual concern

2. Small mutual Problem assessment skills Assist the community to

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

3. Community Leadership skills Strengthen organisational

organisations Organisational structures structures. Link organisations
Resource mobilisation to resources and develop skills
Asking why to identify, mobilise and access
resources. Promote critical
awareness (asking why)

4. Partnerships Organisational structures To develop a shared agenda

Resource mobilisation with other organisations and
Links to others build local partnerships and
alliances between groups.
Provide access to resources
outside the community

5. Social and political Links to others Provide legitimacy to the

action Asking why issues and concerns raised by
the community by using their own
expert power and political
influence
64 · Public health

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

䊏 Empowering individuals for action

䊐 Continuum point 1 and empowerment domain: Participation
A personal action to improve health can begin when individuals feel powerless
about a situation, feel the desire to rectify, what they perceive as, an unjust situation
or want to take action in response to an emotive experience in their lives. Kieffer
(1984) provides an example of how this happened to one woman who became
active in a small community support group for neighbourhood safety following an
assault on her way home. The self-help group was working towards addressing the
issues of her concern, for example, improved policing in her neighbourhood. In a
programme context, the basis for personal action is most often developed during
the planning phase through an identification of participants’ own needs and
problems, and later developed as the aims and objectives.
Individuals have a better chance of achieving their goals if they can share
their concern with other people who are affected by the same or similar circum-
stances. By participating in groups and organisations, individuals can better define,
analyse and then, through the support of others, act on their concerns. Zakus and
Lysack (1998, p. 2) provide a useful definition of participation set in this context as:

the process by which members of the community, either individually or collec-

tively and with varying degrees of commitment: develop the capability to
assume greater responsibility for assessing their health needs and problems;
plan and then act to implement their solutions and create and maintain organ-
isations in support of these efforts.

Bracht and Tsouros (1990) and Goodman et al. (1998) address the issue of how
individuals participate and agree in their conclusions that it is a combination of
involvement in decision-making mechanisms, accessibility to community organi-
sations and the development of appropriate skills such as planning and resource
mobilisation. The advantage of participation is that community-based organisa-
tions are better at strengthening social networks, competing for limited resources
and increasing the necessary skills and competencies of its members. Empowering
individuals for action must therefore involve helping them to participate in group
and community activities.
Box 5.2 provides some of the main characteristics of participation in empowering
others for personal action.
Box 5.3 provides an example of how the participation in a group activity led to
a direct personal action.
 Helping groups and communities to gain power · 65

Box 5.2 The Characteristics of Participation in

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

Box 5.3 Participation and Personal Action in Australia

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

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

1 ‘Self-help’ or ‘interest’ groups organised around a specific problem such as

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

Andrew Jones and Glenn Laverack (2003) identify a number of characteristics

of small, functional ‘interest’ groups:
● Had a membership of elected representatives;
● The majority of its members met on a regular basis;
● Had an agreed membership structure (chairperson, secretary, core members, etc.);
● All members actively participated in the meetings;
● The group met with a Practitioner to discuss issues on a regular basis;
● Kept records of previous meetings;
● Kept financial accounts;
 Helping groups and communities to gain power · 67

● Were able to identify and resolve conflicts quickly; and

● Were able to identify the ‘problems’ of and the resources available to the ‘interest
group’.

Each interest group had achieved a number of successes, such as repairs to a

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

Box 5.4 Problem Identification through

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

coalition of welfare advocates, organisations, church and labour groups. A com-

munity health centre in a small neighbourhood, providing public health care and
health promotion services, all managed by an elected board of residents, got heavily
involved. The neighbourhood it served had a high ratio of single mothers on
welfare who came to the centre for their medical services because the Practitioners
spent time with them, listening to their concerns about money, counselling them
on their stresses and hearing about their loneliness.
But these services were not enough. The Practitioners knew that these women’s
health problems were less rooted in their bodies, and even in their health behaviours,
than in the structured inadequacies of the welfare system. These Practitioners
created small groups on health exploration that offered a supportive learning
experience, breaking through some of the isolation and learned helplessness
engendered by poverty. The Practitioners used community stories as a practical
 Helping groups and communities to gain power · 69

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

䊏 Empowering groups for the development of

community organisations

䊐 Continuum point 3 and empowerment domains: Organisational structures,

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

creates those needs in the first place, or offers the means (resources, opportunities)
to resolving them. Once the community has become more critically aware of the
underlying causes of its powerlessness they can take the necessary steps to develop
actions to redress the situation and to try to gain more power for themselves.
There are many strategies that Practitioners can use to help to develop the
ability of their clients to be more critically aware and many of these are based on
the work of educationalist Paulo Freire (Freire, 1973). Freire originally developed
his ideas on building awareness through learning or education in literacy
programmes in the 1950s for slum dwellers and peasants in Brazil. The central
premise is that education is not neutral but is influenced by the context of one’s
life. People become the subjects of their own learning involving critical reflection
and analysis of their personal circumstances.
To achieve this, Freire proposed a group dialogue approach to share ideas and
experiences and to promote critical thinking by posing problems to allow people
to uncover the root causes of their powerlessness. This is an on-going interaction
between the Practitioner and their client in a cycle of action/reflection/action
and often leads to a collective social and political activity (Freire, 1973). This
approach does involve a considerable commitment from the client to be able to
gradually understand the causes of their powerlessness and to develop realistic
actions to begin to resolve the situation.
Caroline Wang and Mary Ann Burris (1994) discuss the application of Freire’s
approach using a simple exercise called ‘Photo-novella’. In this exercise, the
clients, women and children in rural communities, were given cameras to visually
document their life conditions as they saw them. These images were then used to
stimulate a dialogue to share ideas and experiences, facilitated by the Practitioner,
to promote critical thinking to identify the actual causes of their powerless-
ness. This process of empowerment involves the education of the clients by the
Practitioner who provides answers to their questions and access to supporting
sources of information. The clients were encouraged to develop a strategy for
action to resolve their identified problems towards greater control.
Community organisations enable people to progress along the empowerment
continuum by improving the ability of small groups to raise internal resources and
to access external resources. Internal resources are those raised within the com-
munity and include land, food, money, people skills and local knowledge. External
resources are those brought into the community by, for example, the Practitioner,
and include financial assistance, technical expertise, ‘new’ knowledge and equip-
ment. The ability of the community to mobilise resources from within and to
negotiate resources from beyond itself is an indication of a high degree of skill and
organisation. The role of the Practitioner is that of a link between appropriate
resources and the community. Box 5.5 provides an example of how Practitioners
can help groups and communities to mobilise resources.
The development of community organisations and local leadership are closely
connected. Leadership requires a strong participant base just as commu-
nity organisations require the direction and structure of strong leadership
(Goodman et al., 1998). Where leaders appear to have a limited vision of their
 Helping groups and communities to gain power · 71

Box 5.5 Resource Mobilisation and Empowerment

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

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

䊏 Empowering community organisations to develop

partnerships

䊐 Continuum point 4 and empowerment domain: Links to others

To be effective in influencing ‘higher level’ policy decision making, community
organisations need to link with others sharing similar concerns. The purpose of
partnerships is to allow community organisations to grow beyond their own local
concerns and to take a stronger position on broader issues through networking
and resource mobilisation.
The key empowerment issue is to remain focussed on the shared concern that
brings the groups together, and not on the individual needs or issues of the differ-
ent groups in the partnership. Ronald Labonte (1993) provides an example of the
role of a Practitioner who convened a committee on housing standards with local
activists who wanted safer, better heated homes and more affordable living condi-
tions. The Practitioner desired her agency to be more relevant to the issues
expressed by community groups. The committee met for a year, documenting that
the activists’ concerns were legitimate. The report then went through a prolonged
process of internal review by the management. Eventually, the recommendations
were rewritten, watered down in a completely non-challenging, non-committal
way. By this time, the community groups had withdrawn from the partnership,
feeling that their demands had not been honoured. The mistake was in confusing
partnership in a bureaucratic process (putting the health agency and local author-
ity in the centre) with participation in a social change process (where the problem
of ensuring policies for healthy housing are central). Instead of asking ‘How can
I involve community groups in my policy work?’, the partnership question the
practitioner should have been asking herself is ‘What activities are best suited to
effecting political change in housing policy.’
Korsching and Borich (1997, p. 342) provide another useful account of how
small rural communities in Iowa, America have started to empower themselves
by forming cluster communities. A cluster community is defined as ‘voluntary
alliances between two or more communities to address common problems, needs
and interests’. The communities were faced with concerns common to many rural
populations: a lack of resources; a decline in employment; loss of young people
and the closing of businesses and institutions caused by sweeping social and eco-
nomic changes in society. In response, many community groups have adopted a
similar strategy of creating partnerships to pool resources, discuss issues and plan
for action. Korsching and Borich (1997) argue that the emergence of cluster
communities follows a familiar pattern; initiation by a concerned individual or
organisation, establishment of meetings with other groups, formal organisation,
development of further links and partnerships through an expansion of com-
munity concerns to address broader issues. To be successful, the clusters initially
remained small scale but soon became legal entities and developed links with pri-
vate and public organisations such as companies and universities. The strength of
the cluster concept lies in its ability to establish productive links with others whilst
 Helping groups and communities to gain power · 73

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

䊏 Empowering communities to take social and

political action

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

can be supported as part of the everyday work of Practitioners. The framework

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

Helping marginalised groups

to gain power

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

75
76 · Public health

Box 6.1 Defining Minority Groups

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

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

● What are the circumstances that cause the marginalisation of their clients, for
example, inequalities in access to education or health facilities, prejudicial
policies, negative societal attitudes or hegemonic political power structures.
These structures can exclude others in society, predicate inequality and
contribute to the powerlessness of marginalised groups. They refer to a hierarchy
of social and political power that can exclude those who do not conform to
societal values and can occur directly, for example, a government policy that
makes homosexual practices illegal, or indirectly, for example, structures
that provide low socio-economic children with poorer educational facilities thus
restricting later opportunities for employment. This incorporates the concept
of social inclusion/exclusion and raises the question: How do Practitioners
include individuals and groups into a set of social and political power structures
that are responsible for excluding them in the first place? It also raises the ques-
tion: To what extent do the efforts of Practitioners to include marginalised
groups only situate them in a position of relative powerlessness without actually
challenging the hierarchical structures that created it;
● How material powerlessness can lead to internalised psychological powerless-
ness, for example, the distress experienced with the unfairness of their lack of
material power (access to resources, wealth) is internalised as aspects of their
own ‘badness’ or ‘failure’ and adds to their sense of powerlessness and low self-
esteem. Jim Ward (1987, p. 21), a Practitioner with experience of working with
skid row populations (concentrations of unemployed males), provides an
example of their internalised sense of ‘badness’: ‘we are where we are because
of what we are … bums are bums because they are lazy, stupid etc.’. The mem-
bers of this marginalised group did not recognise that their circumstances were
the result of wider structural reasons such as a weak economic policy leading to
a high level of unemployment. Their sense of uselessness was reinforced every
time they came into contact with a ‘non-marginal’, including government
workers such as the staff at the social services department. This raises the issue
of what should get a greater priority: using resources to work directly with
marginalized groups or working to change the policies that create the circum-
stances that exclude them.
 Helping marginalised groups to gain power · 77

Indigenous communities are a marginalised group to whom Simpson and Yinger’s

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

䊏 A case study of helping marginalised groups

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

including better access to recreational facilities. The central argument of the

strategy was that a swimming pool would provide the focus to improve public
health, safety and the cohesion of the community.

䊏 The public health context

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

䊏 An approach to promote health and empowerment

To promote the health and empowerment of the community through the
swimming pool, the principles of the Ottawa Charter for Health Promotion
 Helping marginalised groups to gain power · 79

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

䊏 Strengthening community empowerment

The area ‘strengthening community action (empowerment)’ is referred to in the
Charter as follows:

Health promotion works through concrete and effective community action in

setting priorities, making decisions, planning strategies and implementing them
to achieve better health. At the heart of this process is the empowerment of
communities, their ownership and control of their own endeavours and
destinies. (World Health Organisation, 1986, p. 2)

The Charter describes an empowered community as one in which individuals and

organisations apply their skills and resources in collective efforts to address health
priorities and meet their respective health needs. A distinction can be made
between individual and community empowerment. Community empowerment
involves individuals acting collectively to gain greater influence and control over
their health. In the programme this translates to the community increasing control
over, and improving the health of its members through the swimming pool. The
‘domains approach’ is specifically designed to strengthen community action
through each of the nine empowerment domains as follows:

Participation: Special efforts are made to ensure that representatives from all
the clans in the community participate in group discussions during the preparation
of the programme. People are encouraged to take an active interest in the
programme through raising their awareness in regard to the public health benefits
of utilising the pool and how these extend into the home. Regular meetings are
held in the community centre to discuss the programme, facilitated by the
Practitioners, Public Health Officers and Aboriginal Health Promotion Officers.
80 · Public health

Leadership: The Council of Elders are responsible for the development of the pool
but other local leaders should also be involved in the planning and administration
of the programme, for example, the representatives of youth groups. These leaders
can receive training and instruction in management skills to allow them to take
more control of and to plan to run the pool. At the beginning of the programme
the leadership is guided by the Practitioners who hold regular consultations with
the local leaders. This process can be facilitated by providing specific technical
support, for example, to undertake a cost–benefit analysis of the pool programme,
to help guide the Council of Elders. The purpose is to increasingly devolve
responsibility for the pool to the community, even if this is in a small way such as
facilitating a meeting.
Problem assessment: The Council of Elders (the people representing the community)
are encouraged to map and prioritise the immediate (short-term) ‘problems’ in
developing the pool. These might include a lack of community support, lack of
money and low skill level in managing a programme of this size. These issues then
become the basis for the planning of strategies for decision-making activities
and for the identification of the resources necessary to support these new roles
(discussed in Chapter 4).
Asking why: Discussions during the problem assessment exercise can lead the
participants to begin to identify the underlying causes of their powerlessness and
poor health, for example, youth unemployment and social conflict between clan
groups. Community development can be constrained by a bureaucratic or politi-
cal system that does not always address these circumstances. It was a ‘critical
awareness’ of, what the community representatives had felt to be, the injustice of
their circumstances that had led to the inception of the swimming pool proposal.
The Council of Elders had recognised that it was essential to increase the
self-esteem and cohesion of the community in order to also begin to improve
public health.
Organisational structures: The Council of Elders gave responsibility to an existing
community organisation, the Community Management Board, to manage the
pool programme. Other organisational groups within the community can also be
involved in the discussion of key issues in regard to the pool, for example, the
women’s centre. To enable people to increase control of, and improve health
through the management and supervision of the swimming pool it is necessary to
develop an understanding of the key issues. For example, the health and safety
issues in relation to the pool, the need to keep the pool area clean including the
toilets, showers and pool surround and the prevention of potential accidents.
The health promotion action area ‘developing personal skills’ provides opportu-
nities for better access to information and education through the development of
personal skills. Skill development increases the options available to people to exer-
cise more control over their own health and environment. This can be facilitated
in the school, the Community Management Board, the women’s group or at the
swimming pool and would involve technical and management skills training,
 Helping marginalised groups to gain power · 81

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

䊏 Building healthy public policy and creating a

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

䊐 Building healthy public policy

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

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

䊐 Creating a supportive environment

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

● The pool facilities should cater for all sectors of the community, for example,
water play for children, swimming for youth and adults, wading and leisure
areas for the elderly and screened areas for women.
● The pool area should cater for out of water activities, for example, shaded
areas for sitting, grassed areas to play ball games and a barbecue.
● Proper supervision by pool staff should be carried out at all times and this must
be supported with established rules and regulations regarding conduct in the
pool area.
 Helping marginalised groups to gain power · 83

䊐 Reorienting health services

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

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

The public health outcome of the pool programme is an improvement in the

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

The accommodation of empowerment as an outcome within the swimming pool

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

1. Programme Design Phase: Identification; Appraisal; Approval

Public health track Empowerment track

2. Programme objectives Empowerment objectives

To improve the health and well-being To empower the community

of the community i.e. epidemiological Objectives to be able to manage the pool
data facility

3. Strategic approach Strategic approach

Combining the principles of the Following the empowerment continuum:

Ottawa Charter for Health Promotion Strategy Individual empowerment – small groups –
and the nine empowerment domains organisations – networks – social and
political action

4. Strategic Implementation Empowerment domains

and Management
Phased release of responsibility for
management of the programme to the
Community Management Board
Planned and positive changes in the
domains: Participation, organisational
Manage structures, links with others, resource
mobilisation, leadership, outside agents,
programme management, asking why,
problem assessment

5. Evaluation of the Evaluation of empowerment

programme outcomes outcomes

Participatory approaches to Evaluate Evaluation techniques used for each

include community members and domain including visual representation
morbidity and mortality indicators (Chapter 7)

Figure 6.1 Applying the parallel-track approach (adapted from Laverack and
Labonte, 2000, p. 257)
 Helping marginalised groups to gain power · 85

As discussed in Chapter 3, power in its simplest form is about control over

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

䊏 Dealing with conflict

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

Box 6.2 Positions of Power and Conflict

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

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

1 Providing leadership training to include the identification and analysis of

potentially controversial issues;
2 Providing training for conflict management;
3 Developing communication tools to better disseminate information (discussed
in Chapter 4 and Boxes 4.4 and 5.4);
4 Using listening to clarify understanding (discussed in Box 4.3);
5 Eliminating power-over to build power-with others (discussed in Chapter 3);
6 Providing a facilitated dialogue to resolve issues (discussed in Chapter 7);
7 Defining or mapping the issues needed to chart needs, concerns and positions
of power (discussed in Chapter 4 and Box 4.5);
8 Naming personal issues that cloud the picture and assess the problem in its
broader context by using approaches of critical thinking (discussed in Chapter 5);
 Helping marginalised groups to gain power · 87

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

An example of an activity to promote personal and group reflection among

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

Box 6.3 Defining the Issues of Conflict

To carry out this exercise the Practitioner should have some prior idea about
the key questions that will be asked and some of the solutions that can be
discussed. This will help the Practitioner to focus the discussion on the
practical and not on the personal points. The Practitioner should be able to
firstly define the issues and the problem areas of the conflict in neutral terms
that all participants can agree upon.
1 The participants are asked to construct a list of key questions about the
conflict, the potential solutions to the questions.
2 The participants and the Practitioner next identify sources of the infor-
mation regarding each of the key questions, for example, web sites, local
leaders, government officials, that are necessary to move into a problem-
solving stage.
3 The participants are asked to prepare a summary of the conflict by
comparing each question with a possible solution and a source of infor-
mation. This can be usefully summarised in a table in a compact format.
4 After a period of discussion between the different parties the table can
be rewritten to highlight how major changes in one conflict alters over
time as circumstances change.
It is necessary to note that this type of a problem-solving exercise is not a
negotiation or a political commitment, it is merely a commitment to further
analysis and discussion.
(Adapted from Mitchell and Banks, 1998, p. 31)
88 · Public health

personal differences to be resolved through an open and facilitated discussion

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

The measurement and visual

representation of empowerment

䊏 Developing a working definition of power and

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

䊏 Collecting and analysing qualitative information

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

89
90 · Public health

Box 7.1 Developing a Working Definition for

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

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

䊐 Qualitative interviewing
Two main interview types can be used; unstructured and semi-structured.
Unstructured interviews may cover only one or two issues and whilst semi-structured
interviews are also conducted on a loose structure consisting of open-ended ques-
tions that define the area to be explored, the interviewer may diverge in order to
pursue an idea in more detail and depth.
The less structured the interview, the less the questions are determined and
standardised in advance of the interview. However, most interviews will have a list
 The measurement of empowerment · 91

Starting the inquiry with unstructured

interviews. Key informant, one-to-one
interviews around themes of power and
empowerment

Identification of main headings for further

discussion:
‘Lewa’ or power-from-within and
‘Kaukauwa’ or power-with

Gaining in-depth information with

semi-structured interviews. Focus group
discussions with a cross section of
community members and some one-
to-one interviews

Chiefly Power-over Power-over Unity and Kaukauwa Links to lewa

power-over at work in the home disunity as strength and Kaukauwa

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

Figure 7.1 Developing a working definition for community empowerment

(Laverack, 1999, p. 211)

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

䊐 Starting the inquiry to collect qualitative information

The initial part of the inquiry uses unstructured interviews with key informants to
identify the main themes of power and empowerment in the specific cultural
92 · Public health

context. Unstructured one-to-one interviews are used to discover the interviewee’s

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

䊐 Gaining in-depth information

The findings of the unstructured interviews provide the main headings for the
next part of the inquiry, semi-structured group interviews. The questions do not
have a fixed order or wording, but act as a guide to the interviewer who uses them
in small groups consisting of stakeholders of similar characteristics. The purpose
of the interviews is to provide more depth and comprehension to the main head-
ings and to provide anecdotal information to highlight the findings. Questions are
developed in regard to the key terms to determine who has power and how the
different forms of power interrelate. The sample selection for the interviews
is undertaken to ensure a representative range of age and socio-economic
background of the interviewees in the community.
Group interviews are a quick and convenient way to simultaneously collect data
from several people. This means that instead of the interviewer asking each
person to respond to a question in turn, there is some interaction and people are
encouraged to talk, ask questions, exchange anecdotes and to comment on each
others’ experiences. Some of the potential advantages are that the technique does
not discriminate against people who cannot read or write and encourages partici-
pation and discussion especially from those who might normally feel that they
have nothing to say. However, the articulation of group norms may silence
individual voices of dissent and it is these contradictions that the interviewer may
want to gain access to as a part of the findings. The presence of other interviewees
 The measurement of empowerment · 93

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

䊐 Keeping a record of the inquiry

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

䊐 Analysing the qualitative information

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

1 The process of disaggregation begins when photocopies are made of the

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

䊏 Collecting and analysing qualitative information in

a cross-cultural context
Public health programmes can be targeted at different cultural, socio-economic
and marginalised groups where the clients are often quite distinct from the
Practitioner. Public health programmes can also be set within a country context in
which the Practitioners are from a different cultural background or country.
Before collecting qualitative information in a cross cultural context there are issues
which need to be taken into account, for example, the unfamiliarity with a specific
cultural context makes it more difficult for a Practitioner to reflect the reality of
the situation. This means that important information might be lost during the
interpretation across cultures (Cuthbert, 1985). The most significant difficulties
faced by external Practitioners have been their inability to speak the local
language, holding a different belief and value system, poor communication and
different styles of interaction, social relationships, attitudes towards time, infra-
structure and political sensitivities (Merryfield, 1985). It is recognised that knowl-
edge of the local language, whilst important, is not essential, and that building
a rapport with potential clients is more a function of time spent on site and of
interpersonal skills than it is of cultural identity and linguistics (Ginsberg, 1988).
 The measurement of empowerment · 95

Collecting qualitative information can be improved by taking the cultural

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

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

High-level facilitator direction

Engagement Railroading

High rapport Low rapport

Empathy Disengagement

Low-level facilitator direction

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

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

Stewart and Shamdasani (1990) point out that personal bias by facilitators in focus
groups, who tend to direct the discussion and reinforce certain points of view, is a
phenomenon common to Westernised cultures. Apparently, this also occurs in
non-Westernised cultures.
Skilful facilitation is an issue common to qualitative approaches and the
question; ‘how to ensure proper facilitation?’ constantly needs to be addressed.
This includes the maintenance of a good standard of facilitation skills in order to
aim consistently for a successful balance between direction and rapport. Possessing
the necessary skills and experience does not guarantee against facilitator bias but
proper training may reduce unintentional influences.
While high rapport is always the goal of skilful facilitation, in a cross-cultural
context this may have to be achieved through roles embodying lower levels of
rapport and differing levels of engagement. The purpose of this approach is to
better position the facilitators to achieve an empathetic understanding of the
participants. Cross-cultural contexts can provide essentially novel or unique issues
and problems. The facilitators may have to be prepared to be more and less direc-
tive and engaged when collecting qualitative information, adapting their
approach to the specific requirements of the participants. This can be described
as an ‘inward’ and ‘outward’ movement by the facilitators towards a terrain of
empathy conveying a similar pattern to those noted in qualitative and participant
observatory research (Glesne and Peshkin, 1992). A key feature, and therefore a
key skill of facilitation, in these circumstances is the ability of the facilitator to
 The measurement of empowerment · 97

correctly identify the moments of transition and apply an empowering language

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

䊏 The measurement of empowerment

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

● improves stakeholder participation;

● increases problem assessment and evaluation capacities;
98 · Public health

● develops local leadership;

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

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

Domain 1 2 3 4 5

Community Not all community Community Community Community Participation in

participation members and members are members involved members involved decision making
groups are attending meetings in discussions but in decisions on has been
participating in but not involved in not in decisions on planning and maintained
community discussion and planning and implementation Community
activities and helping implementation Mechanism exists members involved
meetings Limited to activities to share in activities outside
such as women,
such as voluntary information the community
youth and men
labour and between members
financial donations

Problem No problem Community lacks Community has Community Community

assessment assessment skills and skills identified continues to
capacities undertaken by awareness to carry Problems and problems, solutions identify and is the
the community out an assessment priorities identified and actions owner of
by the community Assessment used to problems, solutions
strengthen and actions
Did not involve
participation of all community
sectors of the planning
community
Local leadership Some community Leaders exist for all Community Leaders are taking Leaders taking full
organisations community organisations initiative with initiative
without a leader organisations functioning under support from their Organisations in
Some organisations leaders organisations full support
not functioning Some organisations Leaders require Leaders work with
under their leaders do not have the skills training outside groups to
support of leaders gain resources

99
outside the community
Table 7.1 Continued

100
Domain 1 2 3 4 5

Organisational Community has no Organisations have More than one Many organisations Organisations
structures organisational been established by organisation which have established actively involved in
structures such as the community but are active links with each and outside the
committees are not active Organisations have other within the community
mechanism to community Community
allow their members committed to its
to provide meaningful own and to other
participation organisations

Resource Resources are not Only rich and Community has Resources raised Considerable
mobilisation being mobilised by influential people increasingly also used for resources raised
the community mobilise resources supplied resources, activities outside and community
raised by but no collective the community decide on
community decision about Discussion by distribution
Community distribution community on Resources fairly
members are made Resources raised distribution but not distributed
to give resources have had limited fairly distributed
benefits

Links to others None Community has Community has Links inter Links generating
informal links with agreed links but not dependant, defined resources, finances
other organisations involved in and involved in and recruiting new
and people community community members
Does not have a activities and development Decisions resulting in
well-defined development Based on mutual improvements for
purpose respect the community

Ability to ‘ask why’ No group Small group Groups held to listen Dialogue between Community groups
discussions held to discussions are about community community groups have ability to self
 ask why about being held to ask issues. These have to identify analyse and
community issues ‘why’ about the ability to reflect solutions, self-test improve its efforts
community issues on assumptions and analyse overtime. This is
and to challenge underlying their Some experience leading towards
received wisdom ideas and actions of testing solutions collective change
Are able to
challenge received
wisdom

Programme By agent By agent in By community By community in Community self-

management discussion with supervised by planning, policy manage
community agent and evaluation independent of
Decision-making with limited agent
mechanisms assistance from Management is
mutually agreed agent accountable
Roles and Developing sense of
responsibility community
clearly defined ownership

Community has not

received skills
training in programme
management

Relationship with Agents in control of Agents in control Agents and Community makes Agents facilitate
outside agent policy, finances, but discuss with community make decisions with change at request of
resources and community joint decisions support from community who
evaluation of the No decision making Role of agent mutually agents makes the
programme by community agreed Agent facilitates decisions

Agent acting on behalf change by training Agent acts on behalf

of agency to produce and support of the community to

101
outputs build capacity
102 · Public health

statement is rated by the facilitator, following the measurement, to give it a

quantitative value that can then be used to plot the data. For example, for the
domain ‘leadership’ the ranking descriptors are:

1 Some community organisations without a leader.

2 Leaders exist for all community organisations. Some organisations not func-
tioning under their leaders.
3 Community organisations functioning under leaders. Some organisations do
not have the support of leaders outside the community.
4 Leaders are taking initiative with support from their organisations. Leaders
require skills training.
5 Leaders taking full initiative. Organisations in full support. Leaders work with
outside groups to gain resources.

If the participants choose the descriptor ‘Leaders exist for all community organi-
sations. Some organisations not functioning under their leaders’, this domain will
be given a rating of 2.
The measurement, analysis and interpretation of this information need to be
shared with all stakeholders, from policy makers ‘down’ to the community mem-
bers. The information may also have to be compared over a specific time frame
and between the different components of a programme. For this purpose, visual
representations of the measurement of community empowerment can be an
appropriate way to interpret and share qualitative information.

䊏 Visual representations of community empowerment

Several authors have used visual representations as a ‘tool’ to compare changes in
the factors or domains that can influence the process of community empowerment.
For example, John Roughan (1986), a community development practitioner, devel-
oped a wheel configuration and used rating scales to measure three areas: personal
growth; material growth and social growth for village development in the Solomon
Islands. The rating scale had ten points that radiated outwards like the spokes of a
wheel for each indicator of the three growth areas. Each scale was plotted follow-
ing an evaluation by the village members to provide a visual representation of
growth and development. The approach used a total of 18 complex, interrelated
indicators such as equity and solidarity to evaluate village development.
Rifkin et al. (1988) in Nepal and later Bjaras et al. (1991) in Sweden, were the
first commentators on the use of the ‘spider web’ configuration for the visual
representation of community participation. Their approach identifies five factors:
leadership; needs evaluation; management; organisation and resource mobilisation,
and uses a similar simple rating scale. The approach was not carried out as a self-
evaluation by the community and did not promote strategic planning. However,
these early experiences of measurement have provided the basis for subsequent
attempts with visual representation. For example, Marion Gibbon (1999), a
 The measurement of empowerment · 103

community development practitioner, in her measurement of community capacity

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

䊏 The interpretation and visual representation of

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

䊐 Measuring empowerment in the Naloto community

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

Participation
4.0

3.0
Critical assessment Organisational
2.0 structures

1.0

External linkages Leadership

Problem assessment Resource mobilisation

Figure 7.3 Spider web for Naloto

Participation, given a low rating of 1.0, was identified as being weak because of
the failure of local leaders to communicate information to other members of the
community. Traditional protocol in Fiji maintains that the approval of the village
chief must be sought before holding a community meeting. Individuals may be
reluctant to defer to the chief or to ask for a particular favour, such as organising
a meeting, if they lack respect for the chief or if they are not on good terms with
the chief at the time. In the Naloto community this situation had led to a reduction
in the number of village meetings and in a poor level of participation in decision
making by its members.
Interestingly, the interpretation of the spider web in Figure 7.3 gives ‘leader-
ship’ a high rating of 3.5. A Fijian chief is always accorded the outward signs of
respect. Even though another person may gain prominence, respect and authority
within the community because of his/her personal qualities or through the acqui-
sition of wealth, he/she would have to defer to the chief on matters of tradition
and culture. Local leaders are rarely challenged and community members abide
by traditional views. In these circumstances, it is important that the participants
engage in a ‘facilitated dialogue’, through a person such as the Practitioner, to
reach a consensus on the selection of each domain that represents the actual
situation in their community.
Following the measurement exercise in Naloto community its members decided
to establish a new protocol and to first gain the approval of the village chief to
meet on a regular basis and on predetermined dates. This overcame the constraint
of having to follow the previous protocol of asking the chief for his approval before
 The measurement of empowerment · 105

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

䊐 Measuring empowerment in the Nasikawa community

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

Participation
4.0

Agents 3.0 Organisational structures

2.0

1.0
Critical Leadership
assessment
-

Project Resource
management mobilisation

External linkages Problem assessment

Figure 7.4 Spider web for Nasikawa

106 · Public health

Fiji: participation; the outside agents; critical awareness; programme manage-

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

䊐 Measuring empowerment in the Orto community

Figure 7.5 provides a ‘small’ spider web configuration in which all the domain
ratings have been given a low value by the participants of the community of Orto
in Kyrgyzstan. The community decided to combine the domain ‘outside agents’
with the domain ‘programme management’ because they felt that the Practitioner
already worked for the community-based programme. The small spider web is an
indication that the overall level of empowerment is weak and that there is a need
for the community to prioritise which domains they want to begin to strengthen.
Prioritisation is necessary because communities do not usually have the resources
at their disposal to address all the domains as a part of the same strategy, even if
assisted by a Practitioner.
The community decided that it would prioritise the domains ‘resource mobili-
sation’ and ‘participation’ because these were traditionally seen as two important
 The measurement of empowerment · 107

Participation
4.0

Critical assessment 3.0 Organisational

structures
2.0

1.0

SLLPC - Leadership
Project management

External linkages Resource

mobilisation

Problem assessment

Figure 7.5 Spider web for Orto

elements of a strong and functional village. The ability of the community to

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

䊐 Measuring empowerment in the Kyzil Oi community

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

Participation
1.0
0.8
Critical assessment Organisational structures
0.6
0.4
0.2

SLLPC - Leadership
Project management

External linkages Resource mobilisation

Problem assessment

Pilot assessment 2003

Figure 7.6 Spider web for Kyzil Oi community

 The measurement of empowerment · 109

membership of people as earlier activities and participation had therefore not

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

Power, empowerment and

professional practice

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

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

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

䊐 Can Practitioners empower their clients?

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

110
 Power, empowerment and professional practice · 111

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

䊐 Do clients have a right not to be empowered?

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

䊐 Should some individuals, groups and communities, at the expense of others,

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

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

䊏 Addressing the constraints in public health practice

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

1 A superficial understanding of the meaning of power and how the relation-

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

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

● A superficial understanding of the meaning of power and empowerment;

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

The way in which professional practice addresses these constraints is crucial to

the development of future public health policy and a professional practice that
are more empowering. Each constraint has a different set of implications for
professional practice and I now discuss ways in which these can be addressed.
 Power, empowerment and professional practice · 113

䊏 Building a better understanding of the meaning of

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

䊏 Addressing the bureaucratic constraints

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

the health and well-being of people. To achieve this Practitioners work with
individual clients and the groups and communities that they occupy ‘out there’ in
civil society. The goal of their clients, who are seeking to gain power, is to bring
about a change in the social and political order and this can challenge the bureau-
cracies that provide the funding for their development. Hence the problematic
relationship that can exist between bureaucratic organisations, the Practitioners
that they employ and their clients. The constraint of bureaucratic settings is that
many of these organisations remain governed by traditional ways of thinking and
acting, ways that inhibit the effective inclusion of empowering approaches. For
example, the dominance of top-down approaches and rigid funding cycles in
public health programming, the use of coercive and manipulative methods to
influence the way people think and act and the reluctance of Practitioners to
relinquish control to their clients.
This book has been written to encourage public health agencies to embrace
strategies to help their Practitioners and their clients to gain power. What this
means is that agencies will be moving away from a power-over agenda concerned
with disease prevention and reductions in morbidity and mortality to enable their
clients to address their own concerns. Without this type of flexibility public health
runs the risk of being seen only to involve their clients without taking the respon-
sibility of assisting people to gain power towards improving their own lives and
health.
An example of the need for a change in the constraints placed on public health
by its bureaucratic nature and by the problematic power relationship that this can
create is provided by the Multiple Risk Factors Intervention Trial (MRFIT) and
the Community Intervention Trials for Smoking Cessation (COMMIT). Both
MRFIT and COMMIT were designed as top-down public health programmes
implemented by Practitioners employed by bureaucratic agencies. MRFIT was a
10-year programme designed to reduce mortality from heart disease in the top
10 per cent male risk group. The trial undertook a massive survey of 400,000 men
in 22 cities and randomly selected 6000 for the intervention and 6000 for the
control group. The trial was the most ambitious, expensive and intensive
anywhere tried at the time in 1971. The trial failed and after six years the men in
the intervention group did not achieve a lower mortality level from coronary heart
disease than men in the control group. The COMMIT consisted of nationwide
studies involving over 10,000 heavy smokers in 11 cities with a matched control
group. At the end of this trial there was only a modest difference in the rate of
people stopping smoking between the intervention and control groups. The trial,
which cost millions of dollars and used a team of highly motivated and trained
‘experts’ to implement, similarly failed (Laverack, 2004).
Leonard Syme, an eminent public health practitioner who carried out an analysis
of the MRFIT and COMMIT programmes, points the finger at the Practitioners
and the agencies they worked for as a major contributing factor towards failure.
The motivation to change one’s behaviour, to gain control or power, must come
from within the client. However, the idea of relinquishing control to their clients
or even accepting the expertise that they may already possess such as lay health
 Power, empowerment and professional practice · 115

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

䊏 Using an empowering approach to public health

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

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

䊏 Using measurement to empower others

The measurement of community empowerment has traditionally used qualitative
information to provide ‘thick’ descriptive accounts, based on the experiences of
the participants, which produce a large quantity of data such as transcribed inter-
views. This type of data is difficult and time consuming for Practitioners to analyse
and for other stakeholders to interpret.
Developments in the monitoring and evaluation of programmes have supported
the use of locally specific approaches such as Participatory Rural Appraisal. The
trade off is between the use of timely but not so in-depth generic approaches such
as standardised checklists with the more locally appropriate information procured
from participatory ‘tools’ which are potentially time consuming. The practical
application of the approaches discussed in this book, some of which are generic in
design, are discussed later in this chapter. The aim of an empowering approach to
 Power, empowerment and professional practice · 117

measurement is to strengthen the design, to provide all stakeholders with a mutual

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

䊏 Understanding the means to empower individual clients,

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

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

䊏 The practical application of the ideas in the book

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

1 A widely accepted understanding of the process of community empowerment

as a 5-point continuum, supported by many years of field work experience
(Chapter 5);
2 A widely accepted understanding of the interpretation of ‘community’,
supported by the work of other authors, that heterogeneous individuals are
able to achieve community empowerment based on their shared needs and
interests (Chapter 5);
3 The use of established principles of participatory and empowering
approaches and practical programme ‘tools’ such as the logical framework sys-
tem and strategic planning (Chapters 1, 4–7);
4 The use of the ‘domains’ of community empowerment which have been
drawn from a broad range of case study data (Chapter 5);
5 A field tested methodology for the planning, implementation and measure-
ment of community empowerment, using parallel-tracking and a ‘domains’
approach (Chapters 1 and 5);
 Power, empowerment and professional practice · 119

6 A field-tested approach for the visual representation and interpretation of the

domains of community empowerment using the spider web configuration
(Chapter 7).

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

Aboriginal communities legitimisation of 25

and empowerment 79–85 professional discourse 112
and public health 77, 78 domains of community empowerment
Alma Ata declaration 22 60–2
asking ‘why’; see also critical definition 7
awareness 62, 70 use of 118–19

behavioural/Lifestyle approaches 21, 22 empowerment

bottom-up programming 8–10, 17, 49, 67, community 36
112, 116 descriptors 99–101
family 35
civil society, 23, 24, 114 organisational 35
definition 15, 17 psychological 35
cluster communities 72, 73 working definition of 89
cognitive praxis 24, 25
communication facilitator role types 95, 96
and the GATHER approach 42 false consciousness 33
combining channels 45 Freire, Paulo 70
one to one 41
community health
characteristics of 58 and individual control 20
interpretations of 57 expressions of 62, 63
community capacity inequalities 33, 76, 79
definitions 61 lay interpretations 17, 18
community development 5, 25, 37, 58, 66, official interpretations 17, 18
71, 80, 102–3, 116 WHO definition of 19
community empowerment 2, 4, 6 health determinants 22, 55
bottom-up programmes 8, 10, 17 health education 28, 40–1, 83, 110
continuum 6, 59 and health promotion 21
definition 35, 36, 79 health promotion 18, 21–2, 68
domains 7, 60, 62 definition 41
economic context 37, 115 helping groups and communities to gain
language 37, 53, 113 power 5–7, 57–74
measurement 97, 116 helping individuals to gain power 4–5,
methodology to build 98 40–56
overlap with concepts 61 helping marginalised groups to gain power
parallel-tracking 9 75–88
as a process 58
visual representations 102–8 Information, Education and
community organising 6, 34 Communication (IEC) 40, 41
conflict
dealing with 85–8 leadership skills 6, 59, 63, 69
critical-self awareness 5, 47–52, 70, 80, 108 learned helplessness 33, 54, 68
links with other people and organisations
discourse 15–16, 20, 26, 53, 55, 113, 115 7, 9, 61, 62, 72, 81, 84, 109;
definition 2 see also partnerships
empowerment and public health 21–2 listening skills 43

126
 Index · 127

mapping positions of power 47–8, 117 professional-client relationship 5, 32, 40,

marginalized groups 20, 30, 53, 65, 71, 52–3, 54–5, 65, 119
75–88, 94 programme management 12, 62, 81
definition 75 public health
medical approach 21 and bureaucratic settings 15–17
minority groups, defining 76–7 definition 14
New Social Movement Theory 25
New Social Movement Theory 23 versus discourse and practice 2, 16, 112
and partnerships in Brazil 25 public health programming 7
movement intellectuals 25 bottom-up programming 8
social justice 22 evaluation 13
Not In My Back Yard (NIMBY’s) 66 management 12
marginalised populations 78
organisational structures 6, 9, 59–60, parallel tracking 9, 10
62–3, 69, 83–4, 104–8 size 12
Ottawa Charter for Health Promotion timeframe 10
22, 78, 84 top-down programming 8, 10
outside agents
as enablers 53 qualitative information
collecting 89–94
parallel-tracking 9, 10, 119 in cross-cultural context 94–7
participation 62, 64, 65
partnerships; see also links to others 25, radical relativism 19
59, 62, 72
personal action self-help groups 4, 25, 37, 64
and participation 64, 65 spider web configuration 3, 88, 102–9,
photo-novella 70 117, 119
political action 35, 59, 73 stakeholders 7–10, 62, 65, 82, 89, 92,
power 115–17
definition 27 definition 1
different cultural interpretations strategies for decision making 49–51, 80
36–9, 90 matrix 51
hegemonic 30 surplus powerlessness 33
and language 53 and women 34
non-zero-sum, zero-sum 31
power-from-within 5, 15, 28–9 top-down programming 2, 10, 11, 16,
powerlessness 33 112–13, 116
power-over 29–30
power-with 30 World Health Organisation 18, 22, 79
problem assessment 59–63, 66–8, 80, 84 definition of health 19