Community Empowerment and Health Equity
- Jennie PopayJennie PopayLancaster University, Division of Health Research
Empowerment features prominently in public health and health promotion policy and practice aimed at improving the social determinants of health that impact communities and groups that are experiencing disadvantage and discrimination. This raises two important questions. How should empowerment be understood from the perspective of health and health equity and how can public health practitioners support empowerment for greater health equity?
Many contemporary definitions link empowerment to improvements in individual self-care and/or the adoption of “healthier” lifestyles. In contrast, from a health equity perspective community empowerment is understood as sociopolitical processes that engage with power dynamics and result in people bearing the brunt of social injustice exercising greater collective control over decisions and actions that impact their lives and health. There is growing evidence that increased collective control at the population level is associated with improved social determinants of health and population health outcomes. But alongside this, there is also evidence that many contemporary community interventions are not “empowering” for the people targeted and may actually be having negative impacts. To achieve more positive outcomes, existing frameworks need to be used to recenter power in the design, implementation, and evaluation of local community initiatives in the health field. In addition, health professionals and agencies must act to remove barriers to the empowerment of disadvantaged communities and groups. They can do this by taking experiential knowledge more seriously, by challenging processes that stigmatize disadvantaged groups, and by developing sustainable spaces for the authentic participation of lay communities of interest and place in decisions that have an impact on their lives.
The Alma Ata Declaration on primary health care in 1978 triggered the rapid growth of community empowerment initiatives around the globe. By 1986, the World Health Organization (WHO) had recognized community empowerment for health and health equity as a core component of professional practice in the Ottawa Charter. In 2015, a commitment to empowerment was woven into the UN Sustainable Development Goals. It is embedded in many national and local health strategies and public health and health promotion professionals are widely accepted to have a role in advocating for policies to remove structural barriers to empowerment.1 As the COVID-19 pandemic spread around the globe, the significance of working “with” communities was further emphasized in health policy and practice.
But this focus on community empowerment in public health policy and practice raises two important questions. How should empowerment be understood from the perspective of health and health equity, and how can public health practitioners support empowerment for greater health equity? This article aims to provide some answers to these questions. First, the meaning of “community empowerment” and its link to the concept of “collective control” are considered. This is followed by a brief review of research evidence on the impact on health, health equity, and the wider social determinants of the increased control people individually and/or collectively can gain from successful empowerment processes. The focus then shifts to consider whether contemporary community initiatives in the health and other sectors are “empowering” for the people who are targeted. The article concludes by arguing that public health practice needs to shift the focus from “assets to power” and describes two frameworks that can help recenter power in local community initiatives and three practical ways in which health professionals and agencies can remove barriers to the empowerment of disadvantaged communities/groups. The article draws particularly on the author’s experience of empowerment initiatives in public health in the Global North and on the English-language literature. Although the issues raised are relevant to global public health, it is possible that some salience to the wider field of international development is neglected.
Defining Community Empowerment and Collective Control
In the third decade of the 21st century, approaches to promoting public participation in decision-making and to empowering “disadvantaged” groups to have more control over their lives have become mainstream: featuring in global, national, and local health and social policies (e.g., UN Economic and Social Council, 2019). Importantly, this is happening as social and health inequalities are increasing, life expectancy improvements in many countries have stalled, and, in some countries, for some groups, life expectancy is falling (Hiam et al., 2018; Marmot, 2020; Stuckler et al., 2017). As with all previous pandemics, COVID-19 exacerbated these inequalities as those already living in the most difficult circumstances are at greatest risk of acquiring and dying from the infection.
Against this backdrop, there are growing calls for greater clarity about the meaning of community empowerment and for practical approaches to assess the impact of empowerment processes on the social conditions and health experiences of communities bearing the brunt of social injustice (see, for example, Cyril et al., 2016; Freeman et al., 2016; Lawson & Kearn, 2014; Newman & Clarke, 2016; Rolfe, 2018).
How should empowerment be understood from a health equity perspective? Many contemporary definitions in the health field link empowerment to improvements in individual self-management of chronic conditions and/or the adoption of “healthier” behaviors and lifestyles. These definitions have lost the intellectual and practice roots of empowerment in the work of writers and activists like Freire and Gramsci (Ledwith, 2001), Alinsky (1971), and the civil rights and feminist movements of the 1960s and 1970s. In these original understandings, community empowerment involves sociopolitical processes that engage with power dynamics and result in people bearing the brunt of social injustice exercising greater collective control over decisions and actions that impact their lives and health. As Eyben (2011) puts it:
Empowerment happens when individuals and organised groups are able to imagine their world differently and to realise that vision by changing the relations of power that have kept them in poverty, restricted their voice and deprived them of their autonomy. (p. 2)
Basically, successful empowerment processes can release, and further develop, the collective capabilities people need to challenge the structural drivers of social and health inequities. As the World Health Organization (1997) has highlighted, the pursuit of changes in the political environment to improve equity should be a central objective of empowerment in the health field. From a health equity perspective, this understanding holds out the most promise: In essence, empowered communities are better able to work alone and with others for the social transformation and political change needed to deliver greater social justice.
What of the vexed concept of “community.” Some 50 years ago Bell and Newby (1971) identified 98 definitions of community, which related to groups of people sharing an affinity to a particular place, interest, or identity. Communities are self-defined. Located at the international, national, or local level and acting to provide a sense of belonging, they are experienced as inclusive by “members” but exclusive by those who do not “meet” the membership criteria. As Dominelli (2019, pp. 8–9) notes, communities “are constantly changing entities with shifting and contested boundaries . . . affiliations constituted by geography, identity and interests are multi-dimensional, interactive and fluid because individuals belong to more than one community simultaneously.” They are also profoundly gendered. As Dominelli goes on to argue, neighborhood-based “communities” are popularly seen to be women’s spaces, though the work they do in these “communities” often remains invisible. The concept of place-based communities dominates public health policy and practice: Groups with shared interests and identities that are not defined in geographical terms are typically not understood to be communities. Notwithstanding this complexity, the concept of community is used here to capture the central importance to successful empowerment processes of people recognizing their shared experience of structural inequalities, the negative impacts these have on their lives and health (individually and collectively) and acting together to challenge the power dynamics that create and sustain these inequities.
Empowerment processes operate through diverse routes, but three are particularly important.
Groups of people may come together spontaneously to resist a shared threat to their well-being. Since the 1980s, for instance, American sociologist Phil Brown (2007) has studied local people’s resistance to exposure to toxic waste: activities he termed “popular epidemiology.” One example of the emergence of bottom-up empowerment processes described by Brown (1992) was the action by residents in Woburn, Massachusetts to try to prove a link between industrial toxins in their water supply and high rates of childhood leukemia. Civil society organizations have also sought to hold commercial companies to account using the legal system (e.g., challenging the licensing of the Monsanto company products containing the controversial weed killer glyphosate).
Government agencies can support empowerment by removing structural obstacles (Laverack & Pratley, 2018). Approaches to mainstreaming gender equality and the empowerment of women and girls through education and antidiscrimination legislation provide important learning about the empowerment potential of actions by national governments. Local government can also act to empower marginalized groups. Mayors in Italy, for example, have led local initiatives to help facilitate the integration of migrants.
Agencies, usually in the public or not-for-profit sectors, can establish local community-based initiatives that aim to be “empowering,” although not all of them are experienced as such by the groups targeted. In the Global North, these are often described as community development projects; in low- to middle-income countries, the phrase “community-led development initiative” is increasingly used.
The Impact of Empowerment and Collective Control on Health
The concept of “control” is a ubiquitous feature of definitions of empowerment. And increasing control at the individual and collective level has been long advocated as a means of improving health and reducing health inequalities. Syme (1989) has termed the theory underpinning these approaches “control over one’s destiny.” In a recent review, Whitehead et al. (2016) described a number of pathways embedded in theories linking inequities in “control over destiny” to inequities in health.
Living in disadvantaged neighborhoods can produce a sense of collective threat and powerlessness. Over time, these chronic stressors can lead to anxiety, anger, or depression—all known to damage mental and physical health (Ross, 2011).
Empowerment processes may lead to increased political understanding and engagement (e.g., increasing voting rates). This could increase public pressure for more accountability in politics and more socially just policies.
High-quality empirical evidence testing these theoretical pathways demonstrates that the level of control a person has over their life circumstances is a significant determinant of individual-level health outcomes (Bosma et al., 1997; Orton et al., 2019; Siegrist & Marmot, 2004; Woodall et al., 2010). There is also growing evidence on the impact of “collective” control on population health and on unequal collective control across diverse communities as a determinant of health inequities. For example, research has found positive impacts of collective control on the social determinants of health (e.g., social cohesion and environmental improvements) (Laverack, 2006; Milton et al., 2011; Pennington et al., 2018; Wallerstein, 2006; Whitehead et al., 2016). Evidence for direct impacts on health outcomes is more limited, but longitudinal studies have reported a positive association between collective control and health improvement. Similarly, Chandler and Lalonde (2008) found that lower rates of youth suicide among First Nations in Canada were significantly associated with increased “cultural continuity” measured in terms of the success of land claims, degree of self-government, community control of local services, and access to dedicated cultural facilities.
Though limited in number, there are also some high-quality evaluations of the impacts of interventions that aim to increase collective control. Orton et al. (2016), for instance, identified direct health benefits arising from microfinance interventions that increased collective control among women in South Africa, Peru, and Bangladesh, including reduced violence against women, reductions in infant mortality that were greater for those in the scheme compared with poor and richer women outside the scheme, and improved nutritional status in children, especially girls. Similarly, an evaluation of New Deal for Communities, a regeneration program in 39 disadvantaged neighborhoods in England implemented between 1998 and 2011, suggests there were greater improvement in mental health/well-being and social cohesion in areas that adopted structures and processes that gave local people significant control over decisions (Popay et al., 2015).
The Politics of Community Interventions
The evidence summarized in the previous section shows that increasing people’s collective control over decisions and actions that impact on their lives improves some of the determinants of health and health inequalities and can directly impact health outcomes. But are local community-based initiatives in the health and other sectors around the globe empowering?
Typically, these initiatives are located in places/neighborhoods characterized by poor socioeconomic conditions, and many espouse an empowering ethos. However, the approaches are very diverse, sitting along a continuum from those focused narrowly on changing individual behaviors, without attending to upstream determinants of these behaviors, to those focusing on action to achieve wider social transformation and political change for greater equity. Newman and Clarke (2016) argue that these potentially contradictory community initiatives have emerged over recent decades as a result of a “politics of translation,” that is, a political process whereby diverse “mediators and translators of change [including international, national and state actors, private corporations, third sector ‘voluntary’ agencies and public services] seek out, interpret and enroll ideas in new settings” (p. 20). In parallel, they argue the “politics of articulation” enable notions such as “community” and “empowerment” to be “recruited to and positioned in different chains of meanings . . . with other concepts . . . [and] come to take on new associations [leading to] ….often antagonistic political projects” (pp. 40–41).
Processes driven by the “politics of translation” have influenced community-based initiatives in the health field in ways that could be impacting negatively on their empowerment potential. Over the past two decades, for example, new concepts, such as “social capital” (Aiyer et al., 2015; Ansari et al., 2012; Putnam, 1995), “community capacity and competency” (Eng & Parker, 1994; Geyer, 1997), “asset-based community development” (Morgan & Ziglio, 2007), and “community resilience” (Ziglio et al., 2017) have been widely accepted as both integral to and defining of “empowering” approaches to work with disadvantaged communities/groups. Significantly, as others have argued (e.g., Wallerstein, 2002), the ways in which at least some of these concepts have been implemented in practice lack the radical edge inherent in the original understanding of community empowerment. At the same time, however, “organizational” aspects, mostly internal to communities, are widely accepted as the most appropriate and/or feasible markers of the success of empowerment processes. Laverack’s (1999) much referenced framework developed in his dissertation in 1999 is a good example of this, comprising (a) participation, (b) leadership, (c) problem assessment, (d) organizational structures, (e) resource mobilization, (f) links to others, (g) “asking why,” (h) program management, and (i) the role of outside agents. Laverack and Wallerstein (2001, p. 183) have argued that these organizational domains “present a straightforward way to define and measure [community empowerment] as a process” and “may act as a proxy measure” for outcomes of this process. Arguably, the focus on organizational aspects of empowering processes, on “strengthening the internal social and economic fabric of the neighbourhood itself” (Smock, 2004, p. 17), and on subjective perceptions of [increased] control and influence among communities members, risks diverting attention from engagement with external structures of power and authority (Newman & Clarke, 2016, p. 35).
The “politics of articulation” may also be changing community-based work in ways that undermine empowerment processes—at least for some. Community “participation” and “empowerment” have become ubiquitous features of a wide-ranging policy landscape across the globe (health and social care, antipoverty programs, urban regeneration, economic development, environment, etc.). These initiatives are targeted at all social groups, not just the disadvantaged, in what Rose (1999, pp. 188–189) has described as a move to “governing through community” that has been interpreted in very different ways. On the one hand, it is argued to be an opportunity for “citizens” to gain power as governments work with them to address the complexity of contemporary social and economic problems (Taylor, 2007). On the other hand, some commentators argue that it is a way for governments to shift responsibility for solving the problems of social injustice from the national and/or local state to local communities (Bulley & Sokhi-Bulley, 2014) and in so doing shift the focus from macrostructural determinants of inequities to individual behaviors.
There is some evidence to support both positions, but the important point from the perspective of this article is that the move to “governing through community” may be increasing inequities by enhancing collective control over decisions in more affluent communities, while undermining capabilities for collective control in more disadvantaged groups. As Rolfe (2018, p. 16) concluded on the basis of an evaluation of four local empowerment initiatives in the United Kingdom:
[Although] communities can have significant agency in making decisions about responsibility, risk and power, the level of agency in each situation is shaped by community capacity [which] seems to demonstrate a distinct socio-economic gradient, reinforcing concerns that community participation policies can become regressive, imposing greater risks and responsibilities upon more disadvantaged communities in return for lower levels of power.
Similarly, it is undeniable that millions of local community health projects around the world embrace an empowerment ethos, while focusing narrowly on increasing health “literacy” and/or changing individual behavior or lifestyles and neglecting the wider socioeconomic, commercial, and/or political determinants of individual lifestyles. These include, for example, community-based projects that seek to reduce the incidences of being overweight and being obese by increasing individual levels of physical activity while failing to address problems in local food systems, including the cost and availability of nutritious food. These types of initiatives risk increasing the exclusion and social stigma already associated with poverty and disadvantage and undermining the capabilities these communities need to challenge these.
Newman and Clarke (2016, p. 43) warn that claims that community initiatives are being incorporated and co-opted by powerful institutions in ways that are not empowering for the people targeted can be “politically immobilizing.” They argue that practitioners do not necessarily become depoliticized because they are required to deliver government agendas or are socially distanced from those they seek to represent and/or mobilize. Many in and beyond the health field are already developing strategies to “resist the depoliticisation of community as a site for struggle” (Newman & Clarke, 2016, p. 44). However, given the complex political environments within which local initiatives with disadvantaged groups/communities are being implemented, those committed to work for greater health equity need to be vigilant about the top-down use of approaches that, while espousing to be empowering, are potentially disempowering. As Gaventa (2006, pp. 23–24) has argued, the adoption and translation of the discourse of “community empowerment” and “participation” by powerful agencies and institutions are “reconfiguring the spatial dynamics of power.” In this context, health practitioners and academics need to attend to how to influence these changing power dynamics in ways that generate greater social and health equity.
Conceptualizing Power Dynamics in Community Initiatives
From a health equity perspective, community empowerment is best understood as a social and political process aimed at increasing the collective control disadvantaged groups have over actions that have the potential to increase social justice. The aim of local community initiatives should be to help create the conditions in which this is possible. This framing requires those involved in designing, delivering, and/or evaluating community initiatives in the health field to clearly identify the forms of power operating in particular contexts to limit the exercise of collective control by communities and the forms of power—or collective control capabilities—communities need to shift these power dynamics.
Traditionally, two main forms of power have been identified: conflictual and consensual, which are in turn closely linked to the relationship between social structure and individual or collective agency. Conflictual “power over” exercised by one “group” to dominate another underpins Karl Marx’s theory of class domination (Miller, 1984). The three “faces” of conflictual power (Lukes, 1974) distinguish between coercive “overt power over,” “covert power over” (the ability to keep issues off the political agenda), and “latent power over” (the ability to implant ideas in people’s minds that are contrary to their interests, through ideology or propaganda).
Different “forms” of consensual power have also been described. According to Parsons (1982), power is exercised by “leaders” with the agreement of society members, to achieve collective goals based on common values. In contrast, Arendt (1970, p. 44) coined the term “power with” to describe the capacity to act together with others for the common good, whereas Starhawk (1987) argued that “power from within” (personal ability and spiritual integrity) and “power with” (power among equals) are forms of resistance to dominating “power over.” These forms of emancipatory power have been combined into a tripartite model encompassing power within, power with, and power to (Allen, 1998; Townsend et al., 1999). Usually applied at the individual level, this model has been widely used in studies of female empowerment and asset-based community development (e.g., Kim et al., 2007; Mathie et al., 2017; Rowlands, 1997).
Social theorists, such as Giddens (1984) and Bourdieu (1986), have sought to link conflictual and consensual understandings of power through the relational lens of social structure and agency. According to Bourdieu’s theories, social structures distribute economic, social, and cultural capital (or resources), differentially privileging some groups over others, whereas “habitus” is the physical manifestation of processes whereby cultural capital—social norms and preferences—is embedded in a society and shapes individual and collective agency. According to structuration theory (Giddens, 1984), people derive power to act—transformative capacity—from hierarchical social structures of, for example, class, gender, and ethnicity, which provide “rules” that shape action and distribute resources that support action. As with Bourdieu’s capitals, in Giddens’s theory, although some groups gain greater transformative capacity/power, enabling them to dominate others, widely accepted social norms may mean people accept—consciously or not—the exercise of power over them.
Foucault (1998, p. 93) argues that “conflictual power over” and “consensual power with” have been replaced by constitutive power, which “comes from everywhere” operating through social discourses and systems of knowledge at the level of the state, civil society, the microrelationships of everyday life, and individual consciousness. He argues that constitutive power produces social reality and social subjects by giving meanings to social identities and defining what action is possible for them. As Foucault (1971, p. 170) puts it, “humans are not only power’s intended targets, but also its effect.”
Elsewhere, a series of three papers have described two complementary frameworks that draw on these multiple understandings of power and report on their use (Ponsford et al., 2020; Popay et al., 2020; Powell et al., 2020). These frameworks are offered as resources that can help recenter power and collective control in the design and delivery of work with disadvantaged communities and strengthen the focus on social and political change for greater equity.
The Emancipatory Power Framework (EPF) comprises a power lens through which capabilities for collective control, and changes in these within a community, can be identified. This framework draws upon the emancipatory concepts of “power within,” “power with,” and “power to” described earlier. These are adapted to the community level and reflect the different capabilities (as understood by Sen, 1999) that develop in communities during empowerment processes and that are required for them to exercise greater collective control.
From a capabilities perspective, power within in the EPF refers to collective capabilities internal to a community, including recognition of shared values and interests. Power with refers to the power emerging when a community acts with other agencies or communities to achieve common ends. Power to refers to the implementation of community action, including opportunities for collective decisions/action and the consequences of these.
Power over is also included in the EPF, recognizing communities may exercise “zero sum” power: when, for example, a community seeks to stop an organization from doing something perceived as negative in their neighborhood. Importantly, groups within the same community may also seek to exercise power over others within the same community.
The Limiting Power Framework (LPF) comprises four forms of power that are known to restrict the collective control communities, particularly the more disadvantaged, can exercise over their lives and health. The LPF is based on a typology developed by Barnett and Duvall (2005) in response to what they perceived as too narrow an understanding of power in the international development field.
“Compulsory power” involves the direct visible use of physical, psychological, or economic force, for example, punitive restrictions on eligibility for welfare payments in the United Kingdom resulting in increased suicide rates (Barr et al., 2015). “Institutional power” operates through formal rules, procedures, and norms that marginalize the concerns of disadvantaged communities, controlling what information is publicly available, who is involved in decision-making, and so on (Popay, 2018). “Structural power” works invisibly through institutions such as the law, the labor market, and education, creating and sustaining hierarchies of social class, gender/sexuality, race/ethnicity, and so forth, which distribute resources, opportunities, and social status. “Productive power,” in contrast, operates through social discourses and practices to construct social identities and appropriate actions (e.g., good mothering = breastfeeding).
As figure 1 illustrates, these multiple forms of power are simultaneously interacting in all social situations.
Forms of limiting power operate in context-specific ways to restrict a community’s ability to collectively control their destiny: Structural power, working through intersecting structures of class, gender, race, sexuality, age, disability, and so on, creates and sustains inequities in access to material resources, opportunities, and social status between and within communities. These inequities are compounded by “institutional power,” which marginalizes the experiential knowledge disadvantaged groups have about the risks they face in daily lives. At the same time, “productive power” creates stigmatized identities for people experiencing poverty and disadvantage and for the places in which they live. Communities of interest and place can use emancipatory forms of power to resist and move beyond the constraints these forms of limiting power impose on them.
From Theory to Action: How Can the Health Sector Support Empowerment Processes?
The LPF and EPF can be used to map power dynamics operating in the local context when community initiatives are being designed, implemented, and/or evaluated. Existing capabilities for collective control in the groups/communities involved can be assessed, action to strengthen and expand these developed, strategies of resistance identified, and change over time measured. The frameworks can be used by and with communities and in participative action research. Box 1 lists other resources that can help strengthen the focus on power and collective control in local public health initiatives that aim to empower disadvantaged groups and communities.
Box 1. Resources to Help Strengthen the Focus on Power and Collective in Public Health Practice and Policy
World health Organization, 2010: Commission on the Social Determinants of Health Discussion Paper 2: Conceptual framework for Action.
Quantitative and Qualitative Methods to Measures Community Empowerment, WHO Health Evidence Network Synthesis Report 59, 2018.
The Communities in Control emancipatory power markers (Ponsford et al., 2020) describe a set of markers that can be used to assess changes in capabilities for collective control associated with community empowerment initiatives based on the three dimensions of emancipatory power: “power within,” “power with,” and “power to.”
The Communities in Control Participatory Spaces Framework (Powell et al., 2020) aims to help community members and professionals to better understand, probe, and track how different participative spaces, and the power dynamics operating within them, affect the development of the capabilities that are prerequisites for collective influence and/or action by communities.
The Scottish government Power Inequalities Resources: developed to support the health community to address the fundamental social and commercial determinants of health inequities by understanding and acting on different forms of power.
The Power Cube: developed by John Gaventa Institute of Development Studies at Sussex to help people understand and analyze the way power “works” in governance processes, organizations, and social relations; combines three dimensions of power (visible, hidden, and invisible), three types of spaces (closed, invited, claimed/created), and three levels at which power works: local, national, and global
Principles of Community Engagement for Empowerment (2019 Public Health Wales NHS Trust)
In this section, the focus moves from local community-based initiatives to three more general ways in which those involved in health policy, practice, and research can contribute to shifting power dynamics in ways that increase the collective control disadvantaged groups/communities can exercise over decisions and actions that impact their lives: (a) revaluing the knowledge and experience of disadvantaged people, (b) maximizing the empowerment potential of participatory spaces, and (c) challenging the social production of stigma.
Valuing the Knowledge of Experience
In all fields, some forms of knowledge are more powerful than others and are used to privilege particular understandings of issues and their solutions and marginalize others. In most “modern” societies, there is relatively little power attaching to the “experiential” knowledge people acquire in their daily lives, compared with professional and/or research-based knowledge, and the more disadvantaged the group, the less socially valued their experiential knowledge. Galison (2004, p. 237) has written about the “art of how knowledge is deleted, covered, and obscured by political and social practices” that suppress some forms of knowledge. Similarly, McGoey (2012, p.13) argues that considerable political labor goes into maintaining “a convenient fiction” of expert knowledge and its opposite: ignorance. These knowledge hierarchies have been described as matters of “epistemic justice and rights” (Fricker, 2012) and they give rise to three questions about knowledge, authority and power: Who knows? Who decides who knows? Who decides who decides who knows? (Zuboff, 2019).
There are many reasons why knowledge acquired through experience, particularly the experiential knowledge of people who are disadvantaged, stigmatized, and/or excluded from the mainstream of societies, is devalued in policy, practice, and research (Fraser, 1989; Pickin et al., 2002). But ignoring this knowledge has had grave consequences for health equity. In July 2017, for example, a fire destroyed the 25-storey Grenfell Tower in London, killing 72 social housing tenants and traumatizing hundreds more. The tragedy would not have happened if the local government and housing management agency had acted on tenants’ warnings, over the previous five years or more, about fire hazards in and around the block.
An important way for those in health policy, practice, and research to support the empowerment of disadvantaged people/communities is therefore to find ways to increase the status and impact of their “experiential” knowledge. This means challenging the long-standing dominance of research-based evidence and professional “expertise” in the health field. It means advocating for knowledge based on the lived experience of inequality and injustice to be treated as equal to, albeit different from, professional expertise and research evidence in decision-making processes. It means that policymakers and practitioners should respond constructively to the challenges experiential knowledge frequently embodies. As a report from the UK Health Foundation (2018) concludes:
Conceptualising personal narratives as evidence, acknowledging the motivations and context of decision making, then testing and re-testing with people ensures that their problems are addressed, or their wellbeing is improved. This contrasts to the evidence-producing practices in health sciences that abstract away from people and contexts . . . our current and impending health challenges seem to demand we work more closely with the people involved and understand their lived reality. (p. 5)
Maximizing the Empowerment Potential of Participatory Spaces
Local and national policy processes typically involve the use of existing participatory spaces or the creation of new spaces for dialogue, debate, and/or collaborative decision-making with community members. The nature of these participatory spaces, and the relationships between different types of spaces, will influence the opportunities a community has to develop and exercise their capabilities for collective control over decisions and actions that impact on their lives. Health agencies and their staff can create and/or shape participatory spaces in ways that increase the empowerment potential. But to do this effectively requires an understanding of how power operates in different types of participatory spaces to determine who can become involved, how they become involved, with what interests, what issues are able to be addressed, and what can be said and done about them (Renedo & Marston, 2014). Powell et al. (2020) identify three dimensions of participative spaces that are particularly important from the perspective of community empowerment processes: relational, temporal, and material. These dimensions shape the power dynamics that operate within particular participatory spaces and the extent to which communities can develop and/or use their capabilities to influence decisions and actions.
A key element of the relational dimension is who establishes the space and for what purpose. In the context of public/community participation, an important distinction has been drawn between “closed,” “invited,” and “claimed” spaces (Cornwall, 2002). Closed spaces are usually decision-making spaces established by institutions (e.g., local government committees or board meetings of a health agency or private company) and institutional power is often used to limit or prevent public involvement. Invited spaces are those in which the public/community members are invited to participate by people in established positions of power. These spaces may be established specifically to engage with the public/communities or comprise a period of time for public/community participation on the agenda of meetings that are otherwise “closed.” In invited spaces, institutional power may be used to discriminate against some groups and/or to define the terms on which community members can participate such that there are limited opportunities for their voices to be heard. This could, for example, involve strictly enforced time slots for community participation or a requirement for prior notice of an intention to speak. However, if disadvantaged groups/communities with relatively little power can gain access to closed spaces or participate effectively in invited spaces they can assert their interests and rights to those with more power, enhancing their visibility and voice within decision-making. “Claimed” spaces are created by communities/groups or may be invited spaces over which a community has gained control. In these spaces, the terms of participation are set by those with less power and potentially they offer greater scope for disadvantaged communities to develop the capabilities necessary for them to act collectively in the pursuit of greater equity, such as trust and alliances, enhanced knowledge and skills, and shared interests.
Previous experience of spaces with an established history in a neighborhood (e.g., open sessions in council committee or activities at a community center) will shape whether community members participate and if so, how. “Regularized spaces” such as neighborhood committees or social clubs are more likely to have formal “rules” of membership, which can be exclusionary, but they may also provide greater opportunities than “fleeting spaces” for shared understandings about local issues to develop or for those participating to influence decisions. Fleeting spaces (such as festivals) typically have open participation (though there may be an entry fee), and they can work to broaden and deepen social relationships across a community and between the community and local agencies and to provide opportunities for conversations to be opened up, potentially contributing to the development of positive shared narratives about a community and/or neighborhood.
The influence of the most obvious “material” dimension of space (e.g., buildings and facilities) on opportunities for communities to develop capabilities for, and to exercise, collective control over decisions and actions is well documented. A less obvious material dimension of participatory spaces is the positive narratives about a community and/or neighborhood that can be shared and valued. Positive narrative-building has been identified as an important aspect of the empowerment process and can be an effective form of resistance to the stigma attaching to poverty and disadvantage and to low-income neighborhoods.
The diversity of available participatory spaces and the ability of community members to move between them will also shape the effectiveness of empowerment processes. Different spaces offer different entry points for people with different interests, identities, skills, and experiences. “Community claimed spaces” are more likely to provide opportunities for communities to build their power within—to grow confidence in their collective ability to act to change the conditions in which they live through the sharing of new skills and knowledge, the development of shared interests, and positive narratives about the community and the neighborhood. These capabilities can be used to enter and affect changes in other spaces, particularly in invited spaces, where people in established positions of power may attempt to limit the influence a community can have, and in closed spaces, where people in established positions of power may seek to prevent communities from participating in decisions that could impact on their lives. As Gaventa (2006, p. 24) argues, disadvantaged groups need to be able to operate in diverse spaces in order to “challenge power by denying its legitimacy” and “to move citizen action from access, to presence, to influence.”
Challenging the Social Production of Stigma and Powerlessness
Research has shown that in most societies, people and communities experiencing poverty and disadvantage, and the places in which they live, are stigmatized, and this contributes to social and health inequities (Halliday et al., 2020). Stigma is associated with internal feelings of shame and moral inferiority. It can cause psychological stress, poorer self-reported health and life satisfaction, and lower levels of well-being and social trust. It can fragment social relationships and create barriers to receiving services, finding jobs, or accessing resources. As Amartya Sen has argued, “shame” is at the “irreducible absolutist core” of the concept and experience of poverty and disadvantage.
The stigmatized identities associated with poverty and disadvantage are inaccurate, misrepresenting both the nature and scale of the “problems” they highlight. Despite this, many institutions and individuals play a role in generating and maintaining this stigma, including the local, national, and international media; politicians and public officials; a wide range of public and private agencies and their staff; and the public in general. Even well-intentioned professionals, community activists, and academics working to reduce social and health inequities can inadvertently contribute to stigmatizing processes. Many images associated with health inequalities (e.g., those portraying alcohol and tobacco consumption and obesity) reflect stereotypes of people “behaving badly” and neglect of the difficult social and economic conditions that shape these behaviors.
The health community can challenge these stigmatizing processes by
Avoiding language, images, and/or engagement activities that inadvertently create or compound the stigmatization of disadvantaged people or communities and the places in which they live.
Drawing wider attention to the positive things that people living in disadvantaged circumstances do individually and collectively, in and beyond their neighborhoods to challenge narratives of low-income people as irresponsible, uninvolved, and/or lacking social capital and social connectedness.
Supporting disadvantaged communities to construct and disseminate alternative positive images and/or stories that privilege their perspectives and knowledge.
Responding to and/or challenging stigmatizing coverage in national and local media, official documents, and other sources; encouraging and/or producing more positive narratives; and giving greater attention in local initiatives to action to purposefully address negative reputation.
Giving more prominence to the upstream social and commercial determinants of health inequities in policy and practice, including the ways in which these shape behaviors, as these are less likely to lead to inappropriate and unhelpful labels being applied to an area or people.
Public health and health promotion policy, practice, and research that supports the empowerment of people carrying the burden of social and health inequalities can contribute to improved population health and reduced health inequalities. But to do that, practitioners need to reclaim the radical agenda. As Ledwith (2020, p. 13) argues, this “involves situating practice in its political context, it is about understanding the structures of power that reach into people’s personal lives to determine their life chances.” An analysis of these power dynamics and ways to challenge them must be integrated into the design and delivery of local initiatives: plotting power dynamics before mapping community assets (Friedli, 2013). It is also important to design and implement policies and practices that positively support the release and/or development of the capabilities—forms of power—disadvantaged people need to exercise greater collective control over the decisions and actions that impact their lives and health in the pursuit of social justice.
This article draws on findings from an evaluation of a major English Empowerment program: the Communities in Control Study (CIC Study). I would like to thank Local Trust and Big Local partnerships for their support for that research. I am grateful also to the wider membership of the CIC study research team, a partnership of researchers based at the Universities Lancaster, Liverpool, Exeter, Sheffield, London School for Hygiene and Tropical Medicine, and Fuse (a collaboration between Newcastle, Durham, Northumbria, Sunderland, and Teesside Universities). In particular, I would like to acknowledge the influence of work led by the following members of the team: Professor Margaret Whitehead, Dr. Emma Halliday, Dr. Matt Egan, Dr. Ruth Ponsford, Dr. Anne Townsend, Dr. Katie Powell and Dr Amy Barnes.
The research has been supported and funded by the NIHR School for Public Health Research (SPHR) [Project reference: SPHR-SWP-IEQ-CIC] NIHR Public Health Research Programme (Project Reference: PHR study 16/09/13. The views expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care.
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1. In this article, the phrase “public health” is used to refer to both public health and health promotion.