Ronald Labonte (2001) shares a scenario where a group of women living in a boarding house complain that the male residents are asking for sexual favours before allowing the women to use the bathroom. The women approach a community health worker seeking assistance and she supports them in advocating for improved dignity and safety. From this beginning, a small group forms and the women begin to meet weekly to share their burdens, identify their strengths and plan collective actions. Laverack (2004) uses the same case study, identifying how the practitioner agreed to mentor the women and support them in building their personal power. I have recently been approached by a group of women in a similar situation, where the male residents of their rooming house are demanding favours and money before allowing the women to use the bathroom. In this paper, I will consider the issues that must be addressed and the approach that I will take to support these women.
Prior to meeting with the group of women, I will prepare myself by considering the issues that they may be facing, and the factors I may need to address in supporting them to achieve a greater sense of control over their lives and their health. By doing this, I do not seek to ignore the felt needs of the women but rather to ensure I am adequately prepared. By familiarising myself with the needs of women in similar situations and the processes used to empower them, I add to the tools already in my kete and increase my ability to support these women.
Feindel (2001) identifies a number of elements that inform a women-centred approach to health (see Figure 1) of these, the need for respect and safety, the importance of empowering women, women’s decision-making processes, women’s forms of communication and interaction, and the involvement and participation of women stand out as of particular importance.
Hager & Baxter (2006) suggest that a home is free from physical, sexual and emotional abuse where a person can feel secure and make the decisions that influence their space. The rooming house clearly does not live up to this definition and, as such, I believe that many of the issues being faced by these women will be similar to those experienced by other homeless women. They are vulnerable, often having to contend with experiences of low self-esteem, mental illness, disability, family violence, sexual abuse, drug and alcohol abuse and poverty (Bridgman, 2002; Clover et al, 2005; Hager & Baxter, 2006). The women will all face different issues in their lives, they have however come together around a common purpose and this is where our work begins.
Health promotion is about process and change, it is an upstream approach to enabling individuals and communities to improve their wellness or sense of wellness through a process of personal and community empowerment and systemic change (Downie et al., 1991; Labonte & Reid, 1997; Laverack, 2004; Raeburn & Rootman, 1998). The Ottawa Charter for Health Promotion (World Health Organization, 1986) defines health promotion as a “process of enabling people to increase control over, and to improve their health” through a process of:
* Building healthy public policy;
* Creating environments that support and protect health;
* Strengthening community empowerment, development and organisation;
* Supporting personal and social development through information and enhanced life skills;
* Reorienting health services to meet the needs of communities and individuals.
These five themes provide an effective framework for health promotion action however the Charter fails to recognise the social contracts of indigenous peoples (Lane & Gardiner, 2003), and as such must be viewed in the light of Te Tiriti o Waitangi. That is to say, we must consider the participation of Maori, the development of partnerships with Maori and the improvement of Maori health status (Health Promotion Forum, 2002, Ministry of Health, 2002).
Empowerment is central to health promotion (Clover et al., 2005; Downie et al., 1991; Durie, 1999; Ewles & Simnett, 2003; Jones & Naidoo, 1997; Labonte, 1996, 2001; Labonte & Reid, 1997; Laverack, 2004, 2006; Lord & Hutchison, 1993; Nutbeam & Harris, 2004; Raeburn & Rootman, 1998; Rissel, 1994; Robertson & Minkler, 1994; World Health Organization, 1986), and to enable the women in the rooming house to gain control of their lives and their health requires me to work with them within an empowerment framework – to support them in developing power-from-within (Laverack, 2004).
A working definition of empowerment is provided by Minkler (cited in Nutbeam & Harris, 2004): a social action process in which organisations, communities and individuals gain control of their lives within a complex social and political system, thereby improving equity and quality of life.
Torre (cited in Rissel, 1994) proposed three essential components of community empowerment: (1) intrapersonal factors, (2) mediating structures, and (3) social and political activities. Labonte (2001) presents a more comprehensive model of empowerment, identifying five strategy areas (see Figure 2), each of which represent a different level of social organization and relationships – interpersonal, intra-group, inter-group and inter-organizational. Laverack (2004) presents similar elements within a continuum (see Figure 3). Given the similar concepts I have detailed the two models side by side in Table 1.
Both approaches are useful tools in understanding the various empowerment strategies available to health promoters. However, Laverack’s continuum presents a more useful approach in that it clearly demonstrates the incremental process of empowerment. In considering how to work with the women, I shall embrace the content of both models within the framework provided by Laverack.
Laverack (2004; 2006) goes on to present nine domains to be considered in the process and measurement of community empowerment:
* Organisational structures;
* Problem assessment;
* Resource mobilisation;
* Asking why;
* Links with other people and organisations;
* The role of outside agencies;
* Programme management.
He notes that the domains influence the practice of empowerment in health promotion from both independent and inter-dependent perspectives. The domains approach provides further tools in ensuring that my activities are effective in empowering my clients.
Before considering how I will go about helping to empower this group of women, I also need to consider how I will measure the efficacy of my approach. What tools will I use to evaluate either my practice or the benefits experienced by my clients?
Fetterman ; Wandersman (2005) suggest 10 principles to guide empowerment evaluation, the evaluation should:
* improve practice;
* be owned by the community;
* involve all stakeholders;
* be a democratic process;
* support social justice;
* respect community knowledge;
* be linked to the evidence base;
* be accountable;
* build organisational knowledge;
* build skills and knowledge within the community.
These principles must underpin the evaluation in order to ensure that the evaluation supports our process. Indicators must be developed to measure any changes in wellness or quality of life. Laverack (2004) discusses empowerment indicators and how they can be used to measure changes in the various empowerment domains. He uses Empowerment Assessment Rating Scales to rank where a group or community places itself on a five point scale (see Figure 4) for each of the nine empowerment domains.
Laverack suggests working with the group or community to assign ranks to each of the nine empowerment domains at various points over the life of a programme. This will allow changes to be measured and represented in a manner that means something to those involved.
Raeburn ; Rootman (1998) present subjective measures of health and wellbeing as a useful means of considering the effectiveness of a health promotion programme. They suggest that using an “Impact Questionnaire” will provide a useful measure in considering how people rate their health and wellbeing, how they rated this before the programme, if there has been any changes and whether they attribute these to the programme and, finally, how satisfied are they with the programme.
Whilst I think Laverack’s approach is more useful in the longer term as a group or community move through the empowerment continuum, I think Raeburn & Rootman’s approach will be of greater value in the short term. I propose therefore to work with the women within Fetterman ; Wandersman’s principles to develop an approach to evaluation that draws on both Laverack and Raeburn & Rootman. The complexity and tools of evaluation will, I hope, build as their sense of empowerment builds.
A plan for action
From my experience with stopping violence groups, I believe it would be necessary for me to recruit a female co-worker to act as a role model for the group and to share a sense of their experience as women. In selecting a co-worker, I will need to consider the demography of the group and whether there is already someone within the group that might be in a position to take on this role. Once a co-worker has been selected we will need to arrange a meeting with the women, this will need to be held in a safe and comfortable location where the women may feel able to share their concerns and develop an initial agenda for action.
Returning to Laverack’s (2004) continuum of community empowerment, we need to begin by identifying and analysing the key issues for the women. This will require a group work process that remains aware of the needs and capabilities of the women (for example, we would need to gauge literacy levels within the group before using activities that require a high level of literacy) whilst also drawing out their strengths and building their self-confidence. We will need to identify the common concerns of the groups and work with the women to identify possible solutions. It may be appropriate to use Laverack’s Empowerment Assessment Rating Scales to support this process. Given the background to their initial approach, it is likely that the first issue to be identified and addressed would be safety. One possible approach here will be to support the women in advocating for improved safety thus adding our expert power (Smith, 1982) to the situation. Throughout the initial group-work we will need to work with the women to build their skill bases, increase their access to resources and information, and create opportunities for action.
Building the women’s sense of power-from-within will require an ongoing process with many small personal and group successes. Developing their strength both individually and as a group will enable them to take greater roles in leading the group, developing more supportive relationships and undertaking action to address their concerns. Throughout this process, my co-worker and I must use our power-over (Labonte ; Reid, 1997) to increase the women’s power-from-within. We must also move from leaders and educators to facilitators, nurturing the group as the members pull together and support one another around their issues.
Whilst recognising the long process of group formation, it is also important to keep a clear sense of direction. The development of a small mutual group will have increased the women’s sense of achievement and power however there is still scope for further empowerment. By bringing the group of women together with other groups in similar situations we can begin to move into a community development approach. The groups can pull together about common issues and look beyond their immediate situation (for example, when I was working in a suburb of Sunderland, a city of approximately 300,000 people in the Northeast of England, a number of groups came together to organise around crime, housing, employment and youth issues). Through combining their mass with other groups it will also be possible to access greater resources and be seen as legitimate by decision-makers (in Sunderland we were able to secure initial funding from a local employer and a philanthropic trust, office space in a local advice centre and support from local Councillors).
Raeburn ; Rootman (1998) suggest that it is most appropriate to form a new organisation to drive community action however with the existing resources and skills located within women’s organisations in Auckland it may be more appropriate to develop partnerships. Supporting the women in working with the other groups to develop partnerships with other organizations will allow them to strengthen their existing networks, increase their access to resources and give them still greater access to decision-makers. It will also allow them to gain from the knowledge held within different organisations.
Ideally, from the partnership building would come a commitment to making change at a societal level and the women that are still involved would work with their colleagues to influence policy at a wider level, this may be around accommodation for women, employment and training opportunities, violence, crime and so on. By this point the role of my co-worker and I would probably have disappeared as the skills, knowledge and direction of those involved has moved to a point where they have a high level of power-from-within and are using this to support other women (in Sunderland, local people took on significant roles in the community resulting in the development of a community owned training organisation and youth service along with increased investment in social housing stock, provision of local services including a supermarket and GP, and increased use of local people by local employers).
The process I have outlined here is a guide as to how I might work with the group of women. It is important to remember that if the process is to be truly empowering then much of it must be led by the group. I can present a framework for action but it is up to them as to the direction they take and the level of their commitment and participation. It is also important to recognise that not everyone will continue in the process to the end (if indeed it reaches the end point I have suggested), that is not a mark of failure but of the different needs and aspirations of the women involved. Measuring success, or lack of it, must be integral to the health promotion process and as such an evaluation path also needs to be considered in this process. This would also involve working with the women to develop an approach that embraces the principles of Fetterman & Wandersman (2005) and the methods of Raeburn & Rootman (1998) and Laverack (2004).