EMPOWERMENT - A KEY TO HEALTH PROMOTION

The word empowerment comes up a lot in health promotion literature. People are empowered when they have access to and can use their knowledge, selfesteem, self-confidence, self-efficacy, and autonomy to act (Tengland, 2007). Empowerment helps people gain control over and influence events and outcomes important to them. In the case of this book, empowerment means gaining mastery over the knowledge needed to influence circumstances that protect and promote the health of animals and ecosystems along with the health of people and their communities. Feelings of empowerment fuel action.

The path to empowerment begins by identifying personally meaningful goals related to a person’s or his or her communities’ power to make and implement decisions (Cattaneo and Chapman, 2010). Goals leading to empowerment cannot be imposed upon a person or a group. Imposing a goal, when it differs from another person’s, will not facilitate that person’s empowerment process. Empowerment requires a person to believe in his or her abilities to act when he or she has the power to do so (this is known as their self-efficacy). A person’s perceptions of the success or failure of an action will strongly influence his or her perceptions of self-efficacy, and thus the ability or willingness to keep acting. Once empowered, people can have some control or influence over the next steps to accomplish their goals. Helping people become empowered requires developing an understanding of the relevant social context, power dynamics at play, the possible means to achieve control over attaining goals, and the resources needed to set a course of action.

Empowering is not without its challenges. Power dynamics play a role. For example, when we give an individual more power over his or her own choices, we may decrease the power of someone else (or some organization) to determine those choices. This tension can manifest itself differently across various sectors as well as in different cultures. Actions that empower one community in one situation could disempower another community in another situation. These types of tensions have been manifested as previous colonial powers negotiate new w'ays to manage wildlife or natural resources with Indigenous governments in co-management systems. Co-management provides direct involvement for Indigenous governments and organizations in wildlife management, sharing management responsibility between governments, users, and renewable resource boards rather than retaining power in one government agency. Trying to change power dynamics can have unintended and negative consequences if it triggers actions from a repressive authority. Individuals or groups that are marginalized as power dynamics shift may not equitably benefit from actions intended to empower the entire community.

Further challenges can arise by a choice to make top-down or bottom-up decisions on priorities and actions. What if a health promoter, for example, decides the priorities for action should focus on a disease-prevention programme but the community members prioritize food security actions? Who decides who needs to be empowered and for what ? While there is significant literature exploring these tensions, questions, and challenges, there is no one best approach to empower people or communities. A careful understanding of needs, power dynamics, and the local circumstances is essential before making any decisions on who to empower, for what, and how.

STRATEGIES AND COMPETENCES FOR CROSS-SECTORAL HEALTH PROMOTION

The WHO’s Ottawa Charter for Health Promotion (1986) set five strategies that are essential for successful health promotion (Table 4.2).

TABLE 4.2

Five Strategies for Health Promotion Established in the Ottawa Charter for Health Promotion (WHO, 1986)

Build healthy public policy

Create supportive environments

Strengthen community action

Develop personal skills

Reorient health services

The first strategy, the healthy public policy approach, refers to the need to be concerned with the implications of all public policies on the social, personal, biological, and ecological influences on health (known as the determinants of health; see Chapter l) and not just health policy. The aim is to shine a health light on all policies that can influence social and natural environments affecting health and the ability to make healthy choices. (See Chapter 10 for a more detailed discussion of healthy public policy.) This supports the creation of situations and circumstances that allow people to be healthy. The Ottawa Charter recognized the need not only to create social circumstances for health but also the criticality of protecting the natural and built environments and natural resources when constructing supportive health environments. Community empowerment and actions are at the heart of health promotion, making strengthened community action a health promotion pillar. Translating community support into personal action requires people to develop the personal skills to exercise more control over their own health and over the environments where they live, work, and play. In doing so, they can create and access options to be healthy. The fifth strategy encouraged us to see health systems not as doctors, nurses, and hospitals but as a collaboration of individuals, community groups, professionals, institutions, and governments which connect the health sector with broader social, political, economic, physical, and natural environmental components, the goal is to move beyond providing clinical and curative services to partnerships in the pursuit of health. Intersectoral action, interorgani- zational partnerships, community engagement and participation, creating healthy settings, political commitment, funding and infrastructure, and awareness of the socio-environmental context are all essential for successful health promotion.

Health promoters strategically work with others to influence behaviours, decisions, and determinants of health across sectors (WHO. 1998). There have been and continue to be efforts to define essential health promotion skills, attitudes, and knowledge. Table 4.3 synthesizes some of these efforts and generalizes them for work across species.

The ideals and principles of health promotion tend to be shared across jurisdictions, but their emphasis and organization can differ with different target audiences (Hyndman, 2009). Patrick et al., (2012), for example, emphasized the need for health promotion to re-engage with the interconnectedness of humans and the

TABLE 4.3

Cross-Sectoral Health Promotion Competencies for Reciprocal Care

Attitude or Perspective

Domains of Thinking or Doing

Systems thinking

Understands the socio-ecological model of health and the determinants of health framework and can apply them to problem assessment and programme planning Integrates, assesses, and communicates complex and diverse evidence and types of knowledge in an understandable manner

Can identify the people and settings involved in an issue as well as their interrelationships and current situations

Facilitates change

Can identify, engage, and work with communities and individuals seeking or requiring help to act or make health-promoting decisions Can develop strategic action plans that are feasible, acceptable, and effective in the realities encountered in the involved circumstances, communities, and individuals Supports and enables incremental change to a healthier situation using available knowledge and resources while promoting longer-term gains coming from new knowledge and changed situations

Evidence-based and action-oriented

Can systematically and effectively bridge the knowing-to- doing gap in people and organizations Uses evidence-based approaches to planning, recognizing the diverse types of knowledge and perceptions of evidence relevant to health promotion

Adapts to local context and circumstances

Can build partnerships, alliances, and coalitions to develop accessible, feasible, and effective actions sensitive to and relevant to the local setting and local people Can identify locally relevant structural and social barriers and opportunities to equitable and just distributions of health determinants, resources, and services Can identify critical social, environmental, or behavioural factors that promote or compromise meeting health goals within a local socio-ecological system

Sources: Adapted from Allegrante et al.. 2009: Hyndman. 2009.

natural environment and adopt ideas from the sustainability field while remaining attentive to core competencies, if it aims to rise to the challenge of climate change. Hancock (2015) similarly recommended more emphasis on the “eco” side of the socio-ecological approach if population health and health promotion want to deal with the new planetary challenges emerging in the Anthropocene. Although a common language by which health promotion and its meaning can be communicated beyond the human health sector is still lacking, there is substantial overlap in lists of competencies for One Health and EcoHealth (e.g. Charron, 2012; Stephen and Stemshorn, 2016) with those of health promotion. Competencies for partnering, collaborating, leading, systems thinking, strategic planning, communicating, evaluating, and enabling action across disciplines arise whenever people seek to mobilize knowledge and resources for sustainable change.

Health promoters need leadership skills to imagine and implement strategic actions for developing policy, mobilizing, and managing resources for health promotion, and building capacity. Advocacy with and on behalf of individuals and communities or other species is part of the health promoters’ purview. Being able to assess the needs and assets in communities and systems will help to develop measurable goals and objectives that are acceptable to the community as well as target research and interventions to develop the resources, capacity, and knowledge to achieve those goals. Health promoters must be able to determine the effectiveness of actions and policies in order to enable evidence-based, culturally sensitive, and ethical actions that can effectively produce the greatest improvements of health within the available resources. In addition to these skills, an effective health promoter needs to be able to work well with others. Working collaboratively across disciplines, sectors, and partners is essential to enhance the impact and sustainability of health promotion programmes and policies (Fertman et al., 2016).

 
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