Empowerment: the holy grail of health promotion?
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HEALTH PROMOTION INTERNATIONAL Vol. 9, No. 1
C Oxford University Pros 1994 Printed in Great Britain
Empowerment: the holy grail of health promotion?
CHRISTOPHER RISSEL
School of Public Health, Division of Epidemiology, University of Minnesota, Minneapolis, MN, USA
SUMMARY
Potentially, empowerment has much to offer health further discussion, th is paper proposes several assertions
promotion. However, some caution needs to be exer- about the definition, components, process and outcome
cised before the notion is wholeheartedly embraced as of 'empowerment', including the need for a distinction
the major goal of health promotion. The lack of a clear between psychological and community empowerment.
theoretical underpinning, distortion of the concept by These assertions and a model of community empower-
different users, measurement ambiguities, and structural ment are offered in an attempt to clarify an important
barriers make 'empowerment' difficult to attain. To issue for health promotion.
Key words: community health; community organization; empowerment
INTRODUCTION
Health promotion advocates have not well articu- between psychological empowerment and com-
lated what exactly is meant by 'empowerment' in munity empowerment, where psychological
the health promotion context, and the ambiguity empowerment is considered at an individual
surrounding the concept is a major stumbling level, and community empowerment is con-
block for the field. Being practical and problem- sidered a collective phenomenon but including a
oriented, and largely atheoretical, health promo- psychological component. This distinction is dis-
tion (and public health) tends to borrow cussed below. The paper is organized in four main
somewhat haphazardly from more theory-based sections. First, the major obstacles to the whole-
disciplines such as political science, psychology sale use of empowerment in health promotion are
and sociology (Bunton and Macdonald, 1992). considered. Second, the diverse literature is
As a result, theory laden terms are used in health reviewed for agreement on what empowerment
promotion without considering the tradition constitutes. Third, the process of empowerment is
behind these terms—empowerment being one of explored and a model of psychological and com-
the latest in fashion. munity empowerment presented. Finally, issues
For example, a majority difficulty for the for health promotion are discussed, and some
development and application of empowerment assertions made for discussion.
theory in health promotion has been the lack of
clarity regarding the focus of empowerment
(Tones, 1984a, b, 1992). The dynamics of indi- OBSTACLES TO 'EMPOWERMENT' IN
vidual psychological empowerment are very HEALTH PROMOTION
different from those of political action and com-
munity empowerment, and the difference has A closer look at the literature on empowerment
implications for health promotion practice. reveals some major obstacles to its wholesale use
This paper proposes that a distinction be made in health promotion. Primarily, empowerment
3940 C. Rissel still lacks a clear theoretical underpinning with capitalist cultures that subscribe to the zero-sum key elements articulated and supported by concept of power. research findings. Health promotion needs to address these This absence of theory and definition in a obstacles before empowerment is widely used as health promotion context has no doubt contri- the yardstick by which health promotion judges buted to the fact that empowerment has often itself. The following section reviews the em- been discussed but not been well quantified or powerment literature, and builds the case for measured. Virtually all the major writers about distinguishing between psychological and com- empowerment lament this deficit, except Rappa- munity empowerment. port(1987) who argued that empowerment could not be measured, but could only be considered case by case in its own unique context. Unfortun- EVOLVING DEFINITIONS OF ately for health promotion advocates skirmishing EMPOWERMENT with medical epidemiologists and hospital administrators over resources, an inability to There are a few concepts in health promotion document positive (or negative) impacts associ- with as much potential as that termed 'empower- ated with 'empowerment' is a serious drawback. ment'. It embodies the raison d'etre of health The lack of a clear concept and definition of promotion, 'the process of enabling people to empowerment also allows for the misappropria- increase control over, and to improve their health' tion of the term. Grace (1991) argues that (World Health Organization, 1986) and arguably empowerment is the health establishment's should be a major goal of every health promotion response to community demands for increased program (Braithwaite and Lythcott, 1989; Bres- control over their own health, and that low, 1992). Unfortunately, it is also a greatly approaches that aim to empower communities abused term, with many papers from a range of mask a priori controlling attempts by health disciplines describing programs asserting the professionals. Health promotion is essentially empowering nature of projects (e.g. McKay et al, bureaucratically based (Stevenson and Burke, 1990; Fleury, 1991; Pizzi, 1992; Lower et al, 1992) and, therefore, represents some form of 1992) without appearing to consider what authority, so that vigilance must be exercised empowerment means or entails. against using empowerment strategies in top- Empowerment is a complex notion, borrowing down disempowering ways. Some critics question from many bodies of literature. It is an idea shown whether empowerment is possible in situations to be rooted in the civilrightsand women's move- where power is bestowed to those without power, ments, the 'social action' ideology of the 1960s, without addressing the structural inequality of and the 'self-help' perspectives of the 1970s power represented in this interaction. According (Kieffer, 1984; Eng etai, 1992). Promoted in the to Gruber and Tricket (1987) there is a funda- 1980s as a principal theory of community mental paradox in the idea of people empowering psychology (Rappaport, 1981; Rappaport et al, others because the very institutional structure 1984; Rappaport, 1987), empowerment was that puts one group in a position to empower also significant for community psychology in that it works to undermine the act of empowerment'. acknowledged the person as a 'citizen' within a Swift and Levin (1987) argued that there is political as well as social environment. In the nothing in the psychological definition of em- 1990s it can be seen as part of the growing general powerment that requires the increase of power of movement towards greater control by citizens in one group to decrease the power of another many areas of life, including medicine (Illich, group, and that power does not have to be seen as 1976), health education (Brown and Margo, a zero-sum commodity, but as a 'win-win' situa- 1978), the self-help movement (Rappaport, tion. Whilst this may be true in a psychological 1985), the physical environment (Auer, 1989) sense, it does not apply in a political sense where and nursing homes (Kari and Michels, 1991). resources are scarce. It is unlikely that entrenched Rappaport (1981, p. 15) described the aim of groups will relinquish control of resources with- empowerment as 'to enhance the possibility for out some degree of conflict (Baum, 1990). Swift people to control their own lives'. No distinction and Levin did conclude that empowerment was made between 'people' as individuals or programs directed at system-change will be collective groups. Similarities with the World extremely difficult to implement in western Health Organization (WHO) (1986) definition of
Empowerment: the holy grail of health promotion? 41
health promotion are obvious. Since 1981 the at the expense of others. It might be expected that
definition has altered slightly to reflect the notion groups with actual control over resources have a
that empowerment must come from within a high level of reported psychological empower-
group and can not be given to a group or com- ment, although the reverse is not necessarily true.
munity. More recent definitions capture this Groups with high levels of reported psychological
aspect: empowerment may not have much control over
resources.
Empowerment is viewed as a process: the mechanism
by which people, organizations and communities gain
mastery over their lives (Rappaport et al, 1984);
THE PROCESS OF EMPOWERMENT
A process through which people become strong enough
to participate within, share in the control of and influ- Several recent reviews have identified the work of
ence, events and institutions affecting their lives (Torre,
1986); Saul Alinsky, Paulo Friere, and Jack Rothman as
the intellectual and practical basis of the concept
Psychological empowerment may be generally de- of community empowerment (Swift and Levin,
scribed as the connection between a sense of personal 1987; Wallerstein and Bernstein, 1988; Gibson,
competence, a desire for, and a willingness to take
action in the public domain (Zimmerman and Rappa- 1991; Fahlberg et al., 1991; Eng et al, 1992;
port, 1988); Wallerstein, 1992). Looking at the descriptions of
empowerment provided in the literature, it seems
The ability to act collectively to solve problems and
influence important issues (Kari and Michels, 1991); that a common process of personal development,
participation, consciousness raising and social
A social-action process that promotes participation of action is evident. A few key examples are sum-
people, organizations and communities towards the
goals of increased individual and community control, marized below.
political efficacy, improved quality of life and social Kieffer (1984) studied 15 grassroots citizen
justice (Wallerstein, 1992). leaders of community organizations and looked
at the process by which these people became
The more recent definitions begin to reflect an psychologically empowered. He identified four
important distinction made by Swift and Levin stages in the empowerment process. Thefirst,the
(1987) between the subjective experience of 'era of entry' covers the initial tentative explora-
psychological empowerment and the objective tion of authority and power. The second stage, the
reality of modified structural conditions for the 'era of advancement', is characterized by a men-
purpose of reallocating resources. As will be toring relationship and supportive peer relation-
argued below both of these components are neces- ships, where dialogue and mutual problem
sary for community empowerment, although a solving contribute to an increase in critical
distinction should be made between psychological understanding. The third stage, the 'era of incor-
empowerment and community empowerment. poration' covers the development of organiza-
It is important to make this distinction. Psycho- tional and political skills and confronting activity.
logical empowerment can be defined as a feeling The fourth stage, the 'era of commitment' is a time
of greater control over their own lives which of integration of these social actions into the
individuals experience following active member- reality and structure of everyday life.
ship in groups or organizations, and may occur Torre (1986) proposed that there were three
without participation in collective political action. essential components of community empower-
Community empowerment includes a raised level ment, micro factors [referring to intra-personal
of psychological empowerment among its mem- aspects such as developments of self-esteem and
bers, a political action component in which self-efficacy (Bandura, 1982, 1986)|, mediating
members have actively participated, and the structures [referring to the group mechanism
achievement of some redistribution of resources whereby members through their active participa-
or decision making favorable to the community or tion shared knowledge and raised their critical
group in question. An increase in a sense of consciousness (Friere, 1973)), and macro factors
psychological empowerment does not need to be (referring to the social and political activities).
at the expense of others. However, by the above According to Torre, unless all three components
definition, community empowerment means that are present then community empowerment can-
control over resources (which are limited) is not occur. For example, in circumstances where
redistributed, which means that some people gain community self-help groups are formed for the42 C. Rissel
purpose of increasing self-efficacy or self-esteem, action (see Figure 1), although the process need
no matter how much the group members particip- not be simply linear with one stage automatically
ate in the process, there could not be community following the other.
empowerment unless there was a social action The process of community empowerment
component addressed at increasing the power of begins with an assumption that a power deficit or
the group. Participants could experience an an unattended social problem exists, despite the
increase in psychological empowerment in this presence of some competencies. By contrast, an
example. empowered community logically should include
Swift and Levin (1987) proposed a three stage groups of individuals who have a raised sense of
model from a class consciousness perspective, empowerment. Psychological empowerment may
where each stage was a pre-requisite for the next. require some individual personal development,
According to this view, to become empowered a such as increases in self-esteem or self-efficacy
person would first reach some critical conscious- (Bandura, 1982), at least to the point where that
ness of their powerlessness. Second, this person individual is willing and able to join a group and
would feel strongly about this inequity, and function effectively within it.
through social interaction begin to feel comrade- Joining mutual support, self-help or action
ship with like-minded persons. Finally, the group groups, builds and expands social networks and
would then engage in deliberate action addressed provides an opportunity for a personal mentor
at changing the social conditions creating the (Kieffer, 1984) or group to support a personal
powerlessness. The combination of all three development process. At the same time, indi-
stages are needed for community empowerment viduals may become critically aware of how
(Swift and Levin, 1987). political structures operate and affect them and
Community organization and community their groups, or this critical consciousness raising
development are closely related to the process of may occur through participation in a group or
community empowerment. Minkler has compre- other mediating social structure. Participation in
hensively described the principles of community and influence of a group or organization is an
organization (Minkler and Cox, 1980; Minkler, important stage of both psychological and com-
1990, 1992). Chavis and Newbrough (1986) munity empowerment (Green, 1986; Florin and
essentially equate community development with Wandersman, 1990). It is often the means by
the process of psychological and community which people learn skills which they may then be
empowerment. In many ways it would seem that able to transfer to other situations (Wandersman,
community development or organization are the 1981), and how communities develop their prob-
means by which communities or groups might lem solving capacity (Batten, 1967).
become empowered, perhaps with the assistance Participation in collective action is also funda-
of an organizer who facilitates this process. mental to the successful redistribution of
Therefore, the community health development resources, which is necessary before a community
continuum, developed almost simultaneously on or group can be said to be empowered. The
two continents (Jackson et ai, 1989; Labonte, emphasis on community action as a core com-
1989a, b), is a useful schema for representing the ponent of community empowerment (Brown,
community empowerment process. The potential 1991) is also consistent with the principles of
of community empowerment is maximized as the health promotion (Miner and Ward, 1992) and
focus shifts from the individual to collective social voluntary organizations (O'Connell,1978). Issues
Personal Mutual Issue identification Participation in Collective political and
development support and campaigns/ organizations/ social action
groups community coalition
organization advocacy
— I'sychological empowerment deficit Community empowerment —
Fig. 1: Conceptual stages of community development for maximizing community empowerment potential (adapted
from Jackson et al., 1989; Labonte, 1989a, b)Empowerment: the holy grail of health promotion ? 43
being addressed by the group or community powerment is presented in Figure 2. It can be seen
should be or have been identified by the group. that the process of psychological empowerment is
Ideally, the outcome of the community empower- enhanced by the sense of community, and that
ment process is a greater degree of psychological psychological empowerment plus collective
empowerment among community members than political or social action plus an actual increase in
before the process, and an actual increase in control over resources (to some degree) con-
control over resources. stitute community empowerment.
Another concept which has been linked to
community empowerment is 'sense of commun-
ity' (Wallerstein, 1992). A theory of the concept ISSUES FOR HEALTH PROMOTION
of sense of community expanded by McCillan and
Chavis (1986) and Chavis etal. (1986) has been How does empowerment relate to health?
linked to an increase in participation in block While there is no specific research documenting
organizations (Wandersman and Giamartino, an increase in a psychological state of empower-
1980; Florin and Wandersman, 1984) and ment leading to improvements in physical health,
political participation (Davidson and Cotter, there is ample evidence that groups without power,
1989), such that an increase in sense of com- or who reported feeling powerless, experience
munity leads to an increase in participation worse health. However power is measured, those
(Chavis and Wandersman, 1990) and problem- with more power are healthier (Smith, 1990;
focusing coping behaviors (Bachrach and Zautra, Labonte, 1992). Wallerstein (1992) cites some
1985). evidence that social support contributes to health
In the broader sense of the word 'community' in a non-specific way, and it is conceivable that
(for example, a professional community of scien- the psychological state of empowerment may
tists), a community and its cohesiveness seems to effect physical health in the same way. From a
have some parallel with group cohesiveness. mental health perspective, individuals or groups
indeed, the words 'community' and 'group' are reporting increased levels of psychological
often used interchangeably in the community empowerment is the goal of community psycho-
psychology literature. Pressure to conform in logy.
groups or communities may be the mechanism by Community empowerment offers possibilities
which groups exert influence on members to for demonstrating direct physical health improve-
participate and act socially, although McMillan ments through the effects of structural changes
and Chavis (1986) acknowledge that community achieved through collective political action.
members also are attracted to communities where However, consequences of community empower-
they feel they are influential and that these forces ment may not be attributable to specific compo-
operate concurrently. nents. It may be the synergy of components that
A visual representation of the preceding dis- leads to possible health gains. Also, it is not yet pos-
cussion of the components of community em- sible to determine what degree of control over
Community
empowerment
Psychological empowerment
Empowerment
deficit teuc identification Health
and campaign^
community
organization
Sense of
community
Fig. 2: Model of the critical components of community empowerment and the process by which it may be achieved44 C. Rissel
resources might be necessary for health improve- Generalizability and maintenance
ments, and whether new or more resources are To expect a psychological state of empowerment
necessary, or whether mobilizing existing generated from activity on a single issue to
resources is sufficient. transfer to all areas of life leading to better health
seems optimistic. The ability to transfer skills
Process or outcome? learned during an empowering process may
It has been generally assumed that 'empower- contribute to greater power in another life
ment' is both a process and an outcome. When the domain, but there is no particular reason why the
distinction is made between psychological and psychological state should transfer. Also, once a
community empowerment it is readily seen that certain level of psychological empowerment is
both are an outcome, although a process of per- achieved there is no reason to expect that it
sonal and community development operates should remain at that level.
simultaneously to lead to a psychological sense of With regard to community empowerment, it
empowerment. As discussed above community seems possible that a group may be empowered
empowerment includes the state of psychological on one issue, but not another. Therefore, the
empowerment, as well as some change in the degree of empowerment may vary depending on
structural environment (social action may be the issue being considered. This suggests that
successful in varying degrees). At this time there community empowerment is topic specific. The
are no clear criteria for determining what degree more issues in which a given group has influence
of psychological empowerment has been attained or control of resources, the more powerful that
and, therefore, how empowered a community group or community is likely to be. However,
may have become. Assessing changes in the circumstances may change such that the group
socio-political environment, as recommended by experiences a set-back, even though the level of
Wallerstein (1992) and Zimmerman (1990), to resource control achieved is unaltered. Groups
evaluate community empowerment is also not yet that pay attention to group maintenance issues
well developed (Bunton etaL, 1991). and sub-production systems (achievement of
tasks and objectives) increase their prospects of
Individual or group phenomena? longer-term viability (Prestby and Wandersman,
If one accepts that all three components of com- 1985).
munity empowerment are necessary before a pro-
cess can be said to have been empowering for a
group or community, then the process and out- Special populations?
come of community empowerment must be a Different sub-groups, such as children (Kalnins et
group phenomenon, not an individual one. This ai, 1992), isolated rural communities (Hughes,
also applies to psychological empowerment. 1987; Jenkins, 1991) and the chronically poor
Typically, if an individual felt in control of him/ and homeless (Winkle and Ward-Chene, 1992),
herself, participated in a group of some kind and are particularly powerless or dependent on others
performed a political action that person would be and so present significant barriers for community
considered to be empowered. However, this empowerment. On the one hand, these are exactly
hypothetical individual performs these actions the groups with the largest empowerment deficit,
within a social and group context, and is depend- but also the groups with the most barriers to
ent on others. If one person were to benefit at the empowerment. Such special populations may
expense of others, the process could hardly be require more active encouragement to work
said to be empowering! towards psychological and community empower-
Community leaders often contribute a great ment, by establishing frameworks that at least set
deal toward community empowerment, and the process in motion, and support it to some
receive some personal rewards in the process degree (Jenkins, 1991).
(Rich, 1980). In circumstances where individual
leaders are socially or politically active they What is the role of the health promoter?
would also be traditionally thought of as em- 'Enabling' people to increase control over their
powered, but it should be remembered that they health suggests some action on behalf of the
are representationally powerful, i.e. are powerful health professional. But 'taking over' any com-
because they represent a group of supporters, and munity development activity is the antithesis of
are dependent on this support. any empowering process (Batten, 1967). TheEmpowerment: the holy grail of health promotion? 45
major contribution of health promoters is, then, 5. Community empowerment through the syn-
one of facilitation not direction. Health profes- ergy of its critical components is related to
sionals might contribute to the process by en- physical health in a non-specific way.
couraging and supporting community initiatives, 6. A change in the level of psychological em-
and the establishment of infrastructure and
systems which promote political activity. Efforts powerment or control over resources for one
within mediating structures, perhaps in a mentor- issue is unlikely to transfer to other areas.
ing role or by building membership or mainten- Therefore, both psychological and community
ance activities, while not reported as the most empowerment are topic specific.
personally rewarding of tasks (Revenson and For work in the area of community empower-
Cassel, 1991) may contribute a great deal. Profes- ment to proceed, common use of terms and
sionally initiated projects may become empower- language would make communication easier.
ing if communities or groups can organize them- Common understanding of the theoretical back-
selves and act politically to take control of the ground of the construct, keeping clear the distinc-
effort. tion between psychological and community
empowerment, and including all the critical com-
ponents of community empowerment when using
the concept might avoid loose usage of the term.
CONCLUSIONS Consideration of the disciplinary history of con-
cepts used in health promotion might assist
Several proposals have been asserted in this common understanding (Bunton and Macdonald,
paper. They are summarized here. 1992; Nutbeam, 1986).
Better quantification of the psychological
1. There is an important distinction between empowerment construct and means of assessing
psychological empowerment and community changes in the socio-political environment should
empowerment. Psychological empowerment be a high priority for health promotion research.
is a feeling of greater control over their own Better quantification would also allow better
lives which individuals experience through study of the relation of empowerment to health
group membership, and may occur without measures. Longitudinal studies are also needed,
participation in collective political action. looking not only at end-points, but at the process
Community empowerment includes a raised and elements necessary for achieving community
level of psychological empowerment among empowerment. Funding agencies will need to be
the community members, a political action convinced of this necessity.
component in which members have actively
participated, and the achievement of some
redistribution of resources favorable to the
community or group in question. ACKNOWLEDGEMENTS
2. Both psychological and community empower- The author would like to acknowledge the helpful
ment are an outcome, although processes of discussions and comments regarding earlier
personal and community development oper- drafts of this paper made by John Finnegan and
ate simultaneously to contribute to the Kim Miner.
attainment of a psychological sense of Address for correspondence:
empowerment, and participation in collective Christopher Rissel
political action. Division of Epidemiology
3. An increase in the control over resources (the School of Public Health
attainment of actual power) or a positive University of Minnesota
change in the socio-political environment, Suite 300
1300 South Second Street
plus an increase in the reported level of Minneapolis
psychological empowerment are the appropri- MN 55454-1015
ate end-points for evaluating an empower- USA
ment program.
4. Community empowerment is a group pheno-
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