Colegio Henry Wallon

Empowerment is inherent to modern health promotion, though it has roots in multiple disciplines including sociopolitical theory (Freire, 1972), health promotion and education (Labonte, 1990; Wallerstein, 1992; Wallerstein & Bernstein, 1988) and psychology (Rappaport, 1987; Zimmerman, 2000). Empowerment is a complex concept that can be understood as both a process and an aim (Tengland, 2007). Furthermore, empowerment can occur at the individual level or collectively among communities (Green et al., 2015; Labonte, 1994; Laverack & Labonte, 2000; Zimmerman, 2000; Zimmerman & Rappaport, 1988). Broadly, empowerment is conceptualised as people gaining greater control over their lives. Increased control has been described as increased competency (Labonte, 1990; Rappaport, 1987), power (Laverack, 2016; Taylor et al., 2014) and self-esteem (Zimmerman & Rappaport, 1988). Specific to health promotion, the WHO defines empowerment as enabling people to increase control over the decisions and actions that affect their health (World Health Organization, 1998). An empowerment approach is distinct in that people actively participate in the decision making process to define their goals (Tengland, 2007). Empowerment can be understood as a “bottom- up” approach that requires health entities to work with people to negotiate solutions aligned to people’s existing values and beliefs (Laverack & Labonte, 2000). However, others contend that empowerment can successfully occur from either direction – bottom-up or top-down as long as one’s existing values align with health promoting activities (Spencer, 2013). Thus, empowerment

is most centrally focused on enabling others to gain control through shared values, rather than conceptualised by the ‘direction’ it is achieved. The concept of empowerment differs between individual and community empowerment. However, these concepts overlap given that community empowerment involves empowered individuals with a shared goal.

Individual empowerment, also known as psychological empowerment, centres on enhancing one’s personal power, such as self-confidence or self-esteem (Zimmerman & Rappaport, 1988). Self-empowerment is relatable to the psychological theory of self-actualisation such that a person realises their greater capacity or potential (Maslow, 1970). Health empowerment theory extends our understanding of individual empowerment by positioning the concept as a relational process between a person and their environment such that greater wellbeing is achieved through recognising one’s personal and social-contextual resources (Shearer, 2009; Shearer & Reed, 2004). Thus, a person’s achievement of their goals depends upon the interaction between one’s psychological factors and their influencing environment (Shearer, 2009). Consequently, empowerment assumes that a person desires to improve their situation and that one’s circumstances are conducive for their decision-making. More specifically, in order for individual empowerment to occur, a person must be motivated to seek change and their participation facilitated at the environmental level (Green et al., 2015). A person can reach a state of self-empowerment where they hold a high degree of power over their lives enabled by heightened self-esteem and capacity for life-skills that subsidize this power (Tones & Tilford, 2001). Essentially, individual empowerment amounts to a person’s increased sense of control over their life. Evidence supports that individual empowerment can have a positive impact on people mental and physical wellbeing such as improvements to self-efficacy and self-esteem, sense of control, knowledge and awareness, behaviour change and connectedness with others (Wallerstein, 1992; Woodall, Raine, South, & Warwick-Booth, 2010).

Community empowerment differs from individual empowerment because it is a social- action process towards gaining greater control over the determinants that influence their lives (Wallerstein, 1992). Community empowerment often requires challenging social and political

18 Chapter 1 – Background institutions in order to obtain greater control (Wallerstein, 2006). Thus, context plays a key role in determining the efforts of community empowerment. For instance, in NZ, community empowerment may likely target issues common in a democratic, Western society such as inequities between social groups, disempowering obesity discourse and value of the thin ideal. Community empowerment in another context, such as a more oppressive society may have much different aims such as woman’s reproductive rights. Community empowerment can be conceptualised as a spectrum that increases from individual assertions to organised community efforts in an effort for people to gain greater control through social and political action (Laverack, 2016). Figure 3 depicts a model that situates individual and community empowerment in health promotion.

The empowerment model identifies education as a principal contributor to individual action and awareness, the building block of both individual and community empowerment. Therefore, education that is supportive of individual and community empowerment holds the potential to not only improve health outcomes at the individual and community level, but also influence healthy public policy towards much wider health impacts. The diagram also emphasises the importance of health promotion efforts directed at both the macro level via healthy public policy and the individual (or community) level via education and training. While both approaches are equally important, this thesis approaches empowerment in health promotion at the individual level.

Empowerment is however not without criticism. Since the concept relies on people to realise their goals and aspirations, empowerment can be a lengthy process to achieve health aims (Tengland, 2012). Additionally, facilitative methods that involve participants in the learning process require the educator to realise their own power and sacrifice a portion of their power to others (Laverack, 2016). Empowerment may also require further training for health practitioners to implement an empowering approach and understand the worldview of others in order to develop shared understanding (Tengland, 2007). Furthermore, empowerment is a difficult concept to evaluate given its complexity and varied definitions (Lindacher, Curbach, Warrelmann, Brandstetter, & Loss, 2018). However, an empowerment approach is advantageous for involving people at the heart of decision making to uphold their beliefs and values, which avoid common ethical harms such as victim blaming and stigmatisation (Tengland, 2007).

In summary, a holistic concept of health is advantageous for its ability to address complex issues yet maintain alignment with moral principles. A holistic model of health is embraced by modern health promotion, an ecological and strengths-based discipline driven by values of empowerment, social justice, participation, salutogenesis and a holistic paradigm. Health promotion positions empowerment as a necessary strategy to disseminate health work for its alignment to health promotion values and to ultimately enable people to gain greater control over their health.

20 Chapter 1 – Background