How can empowerment lead to an improvement in the health status of individuals, groups and communities? This review examines the impact of nine ‘domains’ of empowerment that have led to improvements in health outcomes: participation; community-based organisations; local leadership; resource mobilisation; asking ‘why?’; assessment of problems; links with other people and organisations; the role of outside agents; and programme management. This ‘domains approach’ helps to unpack the complex concept of empowerment and its different areas of influence on health outcomes.
Empowerment is defined as the process by which relatively powerless people work together to increase control over events that determine their lives and health. In community psychology, empowerment is seen to enhance perceptions of personal control, which has a direct effect on improving health outcomes. In community health, empowerment is viewed as a process beginning with individual action and resulting in community organisations, partnerships and ultimately social and political action. Evidence shows that community action has led to sustained change in the social and organisational environment that is linked to improvements in health.
Findings regarding the nine domains of empowerment include the following:
- Individuals have a better chance of achieving health goals if they can participate with other people affected by similar circumstances. Participation can strengthen social networks and build trust in public institutions.
- Local leaders will not always choose to use their control over resources to benefit those with the worst health inequalities. Resource mobilisation, improved literacy and education (particularly for women) can lead to improved health outcomes.
- Asking ‘why?’ involves the ability of the community to critically assess the contextual causes of powerlessness and poor health. This process of discussion, reflection and action can help people to address health issues.
- Partnerships with other people and organisations are an important step towards empowerment. Pooling limited resources and taking collective action can lead to improvements in health outcomes.
- Individual control, in part a consequence of the position of people in structural and social hierarchies, has been shown to influence their health and wellbeing. However, population health and nutrition practice are traditionally professionally-led, as is the process of empowerment. Outside agencies and programme management influence how much control communities have over health activities and programmes.
Literature on community health recognises that many health inequalities are a result of power relations. These affect the distribution of resources and the development of policy:
- A key issue is how much control the outside agent (the practitioner or agency) gives to the community in programme design, implementation, management, evaluation, financial control, administration, and reporting. The community must have a sense of ownership of the programme which, in turn, must address their concerns.
- Asking ‘why?’, or ‘critical thinking’, forms the basis for a number of approaches to learning and social change. Such approaches can help to engage people in conceptualising problems, defining goals and influencing policy.
- More research is needed to establish the evidence for links between empowerment and improvements in the health status of individuals, groups and communities.
