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EDITORIAL
Year : 2015  |  Volume : 59  |  Issue : 3  |  Page : 163-166  

Community empowerment: Holistic approach for sustainable improvements in population health


1 Professor and Head, Department of Community Medicine, NRI Medical College, Guntur, Andhra Pradesh, India
2 Associate Professor, Department of Community Medicine, Konaseema Institute of Medical Sciences and Research Foundation (KIMS and RF), Amalapuram, Andhra Pradesh, India

Date of Web Publication7-Sep-2015

Correspondence Address:
Sai Shankar Prathap
Associate Professor, Department of Community Medicine, Konaseema Institute of Medical Sciences and Research Foundation (KIMS and RF), Amalapuram, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.164647

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How to cite this article:
Sai TS, Prathap SS. Community empowerment: Holistic approach for sustainable improvements in population health. Indian J Public Health 2015;59:163-6

How to cite this URL:
Sai TS, Prathap SS. Community empowerment: Holistic approach for sustainable improvements in population health. Indian J Public Health [serial online] 2015 [cited 2019 May 20];59:163-6. Available from: http://www.ijph.in/text.asp?2015/59/3/163/164647

A state of good health and well-being improves the lives of everyone and is essential for development. Communities are groups of people who may or may not be spatially connected but share common interests, concerns, or identities. Communities may be local, national, international, or even global in nature, and may have either specific or broad interests. [1]

The determinants of health are diverse, and their distribution varies within the community. This brings about disparities within the community, putting some people in a more advantageous position than others. This results in differences in the health status of the people in the community, with some disadvantaged groups of people having little control over factors and events that determine their conditions and health. This relative state of powerlessness is a core social determinant of health and acts as a broad risk factor for ill-health; it can be addressed by strategies collectively termed as "empowerment."

Community empowerment is a process of enabling communities to increase control over their lives by renegotiating power. The strategies used in the process of community empowerment are legitimate mechanisms for targeting social determinants. By addressing the socioeconomic, political, and cultural determinants of health and development, community ownership and action are brought about. Empowerment strategies enable individuals and their communities to access appropriate information, raise their assets, develop critical thinking and decision-making capabilities, build capacities themselves in this process, plan and engage in appropriate collective action on issues of importance, and also monitor and evaluate an empowerment program to solve their own problems. This process is facilitated by an external agent that acts as a catalyst in bringing about the change. Thus the communities are empowered to identify and solve their own problems and take charge of their lives.

Community empowerment is a multilevel construct described for individuals, the organizations where they work, and their community settings. Individual empowerment, also referred to as psychological empowerment, refers to individuals gaining control over their lives with building up of self-confidence, boosting up of their self-esteem, critical awareness of their social context, and better decision-making capacity, leading to participation in change for improvement. Organizational empowerment deals with the potential ability of the organizations to influence societal change for improvement. Community empowerment deals with power relations and intervention strategies that enable communities to take control of the decisions that influence their lives and health.

India is currently facing a triple burden of health problems: infectious diseases, noncommunicable diseases, and injuries. These diseases and their consequences are avoidable to a large extent. By addressing the socioeconomic as well as political and cultural barriers in accessing health information and services, empowerment can play a role as a potentially sustainable solution for these problems.

Community empowerment has been reported to be a successful strategy complementing the strategies in a routine vector-borne disease control program, an important component in the program for prevention and control of highly pathogenic avian influenza, a promising human rights-based solution to overcoming the persistent burden of human immunodeficiency virus (HIV) among female sex workers across epidemic settings, and as a strategy to reduce the impact of infectious diseases. [2],[3],[4],[5] Community empowerment has also been reported as a successful model for prevention of noncommunicable diseases in India and also for early detection of cancer. [6],[7] The importance of community empowerment has been well recognized in the context of injury prevention and safety promotion also. [8]

To protect and promote health, the joint efforts of those across the whole social fabric must be involved, i.e., the individual, the community, and the state. Health is everybody's business, and the responsibilities for health lie at the individual level, the community level, the state level, and the international level. Empowerment plays a key role in enabling these components to take control and act in order to improve health. The Ottawa Charter for Health Promotion and The Bangkok Charter for Health Promotion in a Globalized World identified community empowerment as being a central theme of health promotion. [9],[10] Empowerment brings about active participation of the people in service planning, delivery, and evaluation, and thus helps in shaping services for the benefit of the community.

Community empowerment can be viewed both as a process and an outcome. As a process, community empowerment is "…a social-action process that promotes participation of people, organizations and communities towards the goals of increased individual and community control, political efficacy, improved quality of life and social justice." [11] As an outcome, community empowerment is an interplay between individual and community change that usually takes a long time and results in changes in government policy or legislation in favor of those involved in the programs and community actions. Community empowerment is most often viewed as a five-point continuum comprising:

  1. Personal action,
  2. Development of small interest groups,
  3. Community organizations,
  4. Partnerships, and
  5. Social and political action. [12]


Domains are often used in empowerment strategies and this helps in understanding the pathways through which the empowerment approach is related to health outcomes. Participation forms the backbone of empowering strategies. Individuals have a better chance of achieving their health goals if they can participate and have discussions with other people facing similar problems or circumstances. Participatory discussions result in a higher level of critical thinking. Through participation, they can define and analyze their concerns better, can understand the interplay of factors affecting their health, and are likely to come with a joint solution to their issues, thus enabling them to take their own decisions. Participation also strengthens social networks and improves social support.

The establishment of community-based organizations brings together people with common concerns. The members of such organizations have an opportunity to gain skills and competencies, which can address their concerns and help them in achieving their health goals. These organizations can also enter into partnerships, alliances, and coalitions with other people and organizations to address the community's health needs. The Self Employed Women's Association (SEWA) is the largest trade union of informal workers in India with about one million women members. The members organized themselves into cooperatives and increased their ability to bargain with middlemen and contractors. To meet their needs, the members started their own cooperative SEWA Bank, negotiated with government and non-governmental organizations for access to preventive and curative health care at low cost, health insurance cooperative, and also a Mahila Housing Trust. It has also entered into partnerships with other organizations including the government to help its members and lobby for favorable policies and legislations. [13]

Community organizations and groups also require strong leadership to move toward achieving health outcomes. However, it is important that the leaders work for the true benefit of the community without any vested interests. In addition, there may be formal and informal leaders, and all of them have their own influence. The capacity of the community to mobilize resources from within and to negotiate resources from beyond is itself important in meeting health needs and concerns.

Addressing health outcomes does not essentially start with the community dealing with the health problems. It may begin a wide range of factors such as personal, economic, environmental, social factors, and issues that are "close to the heart" of the communities, all of which may not be directly related to health.

Capacity-building at the community level by involving local people as partners in improving local health and well-being is important, and can have a greater long-term impact and enable more inclusive participation. Joint training with community members, professionals from non-governmental organizations, and health staff will help people get to know each other better, understand various perspectives, and help in establishing linkages and partnerships. Capacity-building is needed not only in specific skills and competencies to meet health concerns but also in program management, including the management of resources, documentation, and evaluation. Continued support by the program also increases people's knowledge and skills, which help them in broader sociopolitical action such as lobbying for better policies and legislations.

Empowerment evaluation is an integral part of the program where the participants analyze the program and discuss the objectives, interventions, and results to foster improvement. This is a continuous, ongoing process and the approach is strengths-based. The chief output of empowerment evaluation is organizational learning.

Measuring empowerment is a challenging process with many limitations because of the multidimensional nature of empowerment. Scales have been developed to measure psychological empowerment and organizational empowerment. [14],[15] When measuring community empowerment as a process, it is possible to keep track of capacities, skills, and resources as well as changes in health status and policies during the time frame of the program. However, the self-reported information and scales have their own limitations because of subjective factors. The longer time frame makes measurement of community empowerment as an outcome even more challenging. Moreover, the range of experience of an individual or community may change over a period of time, as empowerment is a dynamic process and the effects should not be construed as static. The outcomes also vary with time and settings, making it more difficult to measure. Use of qualitative approaches can improve the understanding of the empowerment process and outcomes and help in better measurement.

The vertical disease-control programs are non-sustainable and hence there is a need to emphasize community-based strategies. A community-empowerment approach has been found to play an important role in tackling infectious diseases, noncommunicable diseases, and also injuries, and therefore should complement and supplement the strategies used in all disease-prevention and control programs. For this to happen, community empowerment has to be mandatorily incorporated in all the public health programs and policies. Since communities are enabled to take charge of their health and lives, a holistic community-empowerment approach can play an important role in sustainable improvements being made in population health.

 
   References Top

1.
Laverack G. Health Promotion Practice: Building Empowered Communities. London: Open University Press; 2007. p. 17-19.   Back to cited text no. 1
    
2.
Castro M, Sánchez L, Pérez D, Carbonell N, Lefèvre P, Vanlerberghe V, et al. A community empowerment strategy embedded in a routine dengue vector control programme: A cluster randomised controlled trial. Trans R Soc Trop Med Hyg 2012;106:315-21.  Back to cited text no. 2
    
3.
Available from: ftp://ftp.fao.org/docrep/fao/011/ai336e/ai336e00.pdf. [Last accessed on 2015 May 2].  Back to cited text no. 3
    
4.
Wirtz AL, Pretorius C, Beyrer C, Baral S, Decker MR, Sherman SG, et al. Epidemic impacts of a community empowerment intervention for hiv prevention among female sex workers in generalized and concentrated epidemics. PLoS One 2014;9:e88047.  Back to cited text no. 4
    
5.
6.
Mohan V, Shanthirani CS, Deepa M, Datta M, Williams OD, Deepa R. Community empowerment-a successful model for prevention of non-communicable diseases in India - The Chennai Urban Population Study (CUPS-17). J Assoc Physicians India 2006;54:858-62.  Back to cited text no. 6
    
7.
Jose R, Augustine P, Lal AA, GK L, Haran JC, Abraham B. Empowering the community for early detection of cancer: A rural community intervention programme in Kerala, India. Int Surg J 2014;1:17-20.  Back to cited text no. 7
    
8.
Hanson DW, Finch CF, Allegrante JP, Sleet D. Closing the gap between injury prevention research and community safety promotion practice: Revisiting the public health model. Public Health Rep 2012;127:147-55.  Back to cited text no. 8
    
9.
World Health Organisation. Ottawa Charter for Health Promotion. 1986 in Milestones in Health Promotion: Statements from Global Conferences. World Health Organization 2009. p. 1-5  Back to cited text no. 9
    
10.
World Health Organisation. The Bangkok Charter for Health Promotion in a Globalized World. 2005 in Milestones in Health Promotion: Statements from Global Conferences. World Health Organization 2009. p 24-28.   Back to cited text no. 10
    
11.
Wallerstein N. Powerlessness, empowerment and health: Implications for health promotion programs. Am J Health Promot 1992;6:197-205.  Back to cited text no. 11
    
12.
Labonte R. Health promotion and empowerment: Reflections on professional practice. Health Educ Q 1994;21:253-68.  Back to cited text no. 12
    
13.
Munodawafa D, Agarwal S, Chatterjee M. Women′s Empowerment to Address Social and Economic Determinants of Health: A Self-Employed Women′s Association (SEWA) Experience. Working Document on Community Empowerment for discussion at the 7 th Global Conference on Health Promotion. Nairobi, Kenya: Promoting Health and Development: Closing the Implementation Gap; 2009. p. 9-16.   Back to cited text no. 13
    
14.
Kraimer ML, Seibert SE, Liden RC. Psychological empowerment as a multidimensional construct: A test of construct validity. Educ Psychol Meas 1999;59:127-42.  Back to cited text no. 14
    
15.
Matthews RA, Diaz WM, Cole SG. The organizational empowerment scale. Personnel Review 2003;32:297-318.  Back to cited text no. 15
    



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