Empowerment can be defined in a number of different ways and circumstances.
Definitions can apply to whole communities or to individuals. The commonalities within definitions of empowerment involve the ability to take control, effect change
32 Factors affecting health promotion
and improve the quality of life for those involved (Becker et al. 2004). At a community level, empowerment may lead to environmental or service change. An example of this might be a local community coming together to lobby the local primary care trust for a birth centre in their area. On an individual level,
empowerment may allow an individual to develop her own way of exercising control over her thoughts, feelings and actions, and begin to acquire a perceived self-efficacy (Becker et al. 2004). This means that a person develops a belief in her own ability to make changes in her life, moving from an external to an internal locus of control. An example of this could be a woman deciding to approach her general practitioner about a long-standing medical problem.
Empowerment is acknowledged as being part of health promotion. Empowerment can work alongside practical changes to promote the achievement of more positive health choices (Peterson and Hughey 2004), e.g. within a community health promotion initiative a community should identify its own health needs. Therefore the initiative that is put in place will reflect the priorities of that community and may achieve more. However, there may be difficulties in implementing community involvement. The process of communities empowering themselves involves service providers allowing decision-making and problem-solving to be a shared
responsibility. It may be difficult for health-care providers to appreciate the expertise and abilities of women and their communities. Health-care providers may also struggle with not being the one who automatically provides the solutions (Portela and Santarelli 2003).
The Sure-Start initiative is an example of an attempt to involve a community in local health initiatives and health promotion. In the way the initiative is set up currently, Sure-Start projects involve elements of community empowerment.
Although the projects have Government set targets, the way in which these targets are implemented is decided by a board of local parents, voluntary organizations and other interested parties. Indeed one of the Sure-Start principles is that the projects should be community driven but professionally coordinated. The majority of the Sure-Start services have concentrated their efforts on health and education promotion for women and children, although there is an increasing inclusion of partners and other carers in the projects. Many of the services include groups led not by professionals but by the participants themselves. One example is a teenage mothers’ club in the north-west of England (Gostling 2003). Midwives noticed that teenagers were not attending the existing groups for pregnant women or mothers and babies. By talking to the young women, the midwives discovered that some of the pregnant teenagers were meeting at each other’s houses because they felt that the existing services did not cater for their needs. Many young women in the area were missing out on health promotion while pregnant or as new mothers. In addition young women were under-using the services on offer. In response to this, funding was found to set up the teenage club. Once set up, the club was client led, with an emphasis on peer support and education. The club has also formed links with the local teenage pregnancy working group and has proved the catalyst for an increased profile for the needs of pregnant teenagers within the maternity services.
The experience in the north-west illustrates how a community (in this case pregnant teenagers) can begin empowering themselves given the appropriate tools, such as funding, a venue and support from health professionals.
Not only do groups, such as the teenager group discussed above, encourage empowerment; they can also improve social capital in areas where the local
Finding ways to reach women 33
populations may have changed profile and social capital may be reduced. Social capital is defined as:
Both formal and informal reciprocal links among people in all sorts of family, friendship, business and community networks.
Lynch et al. (2000, p. 404) It is felt by some that increased social capital, characterized by bonding, linking, participation and trust, within a community setting can have benefits for health and can increase the impact of health promotion (Lynch et al. 2000). However, there is also some debate about the characteristics of social capital and the different potentials for the various forms of social capital to improve the uptake of healthier choices (Baum and Ziersch 2003). But, overall, an increase in social networks and social support appears to benefit women.
For some women involvement in groups can increase their feelings of empowerment and possibly contribute to social capital in their community. It appears that empowerment is fostered for women in group situations, which include participation and connectedness, rather than just activities (Peterson and Hughey 2004). Groups that include peer support and/or a sense of a group working together will therefore be more suited to women’s empowerment. However, empowerment can also take place at an individual level. As joining groups is not an option for some women, whether through choice, isolation or illness, empowerment for these women can be facilitated individually. The MOMobile programme in the USA utilizes local advocates to work with low-income mothers in the local community (Becker et al.
2004). The aim of the project is for the advocates to provide support, health promotion and referrals where needed. The advocates identified themselves as helping to empower women through the encouragement of self-determination, decision-making and self-sufficiency:
A client comes with no ideas what her rights are, about everything, and then you educate them or teach them and that’s when we are making a
difference. And then afterwards when we form a relationship and watch them on their own strengthen themselves and use resources that they have and sometimes teach you a little bit …
Becker et al. (2004, p. 336) It is interesting to note that the advocates themselves were local women and they believed that the process of being advocates and working with local women empowered both participants.
In the UK, there are various buddying projects or projects where local women are recruited as advocates to promote health in their local community. There is potential for many of the projects to work in a similar way to the MOMobile scheme, although there has been little research into the women’s experience of being involved in such projects. A research project has been evaluated that offered social support in pregnancy to a group of women who had given birth to a low-birthweight baby in a previous pregnancy (Oakley et al. 1996). Social support was given by research midwives, in addition to the usual midwifery care. The support took the form of home visits, when the research midwife provided a listening ear for the women. The research midwife was also available for 24-hour contact by the women. The physical and psychosocial outcomes for the group of women who were given extra support
34 Factors affecting health promotion
were better at 6 weeks, 1 year and 7 years after the birth of the child. The results of the research project appear to confirm that social support by midwives does promote health. Although empowerment is not specifically discussed in Oakley et al.’s research, it is possible that the social support offered by the research midwives facilitated the empowerment of the women included in the study through the support by the midwives of the women in making decisions.
As illustrated empowerment is a major influence on the ability to make healthier choices. Midwives have the potential to help women (and their partners) empower themselves through both group work and individual encounters.
SUMMARY OF KEY POINTS
The factors that mediate women’s ability to make healthier choices include:
■ The impact of family and home life. Domestic responsibilities and expectations may limit a woman’s ability to care for her own health.
■ The influence of power and control may prevent women accessing facilities or making choices.
■ Being poor will make it harder for women to afford healthier options and more difficult to access facilities. Poverty may also mean that a woman’s priorities may be at odds with the priorities of the Government or health agencies.
■ Women from black and ethnic minority groups will have both the mediating factors of all women plus the additional constraints arising from their situation in the UK.
■ There are a number of possible ways forward for engaging women in health promotion and facilitating healthy choices. There is a need to:
– examine the practical restrictions on women making healthier choices
– foster an environment that helps women empower themselves to make healthier choices in their lives.
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