Power, control, communities and health inequalities I: theories, concepts and analytical frameworks

Abstract

Summary This is Part I of a three-part series on community empowerment as a route to greater health equity. We argue that community ‘empowerment’ approaches in the health field are increasingly restricted to an inward gaze on community psycho-social capacities and proximal neighbourhood conditions, neglecting the outward gaze on political and social transformation for greater equity embedded in foundational statements on health promotion. We suggest there are three imperatives if these approaches are to contribute to increased equity. First, to understand pathways from empowerment to health equity and drivers of the depoliticisation of contemporary empowerment practices. Second, to return to the original concept of empowerment processes that support communities of place/interest to develop capabilities needed to exercise collective control over decisions and actions in the pursuit of social justice. Third, to understand, and engage with, power dynamics in community settings. Based on our longitudinal evaluation of a major English community empowerment initiative and research on neighbourhood resilience, we propose two complementary frameworks to support these shifts. The Emancipatory Power Framework presents collective control capabilities as forms of positive power. The Limiting Power Framework elaborates negative forms of power that restrict the development and exercise of a community’s capabilities for collective control. Parts II and III of this series present empirical findings on the operationalization of these frameworks. Part II focuses on qualitative markers of shifts in emancipatory power in BL communities and Part III explores how power dynamics unfolded in these neighbourhoods.

Lessons from community participation in primary health care and water resource governance in South Africa: a narrative review

“…In this scenario, participation may do more harm than good when they are ‘equivocal’ and ‘disorderly’ [ 68 , 69 ]. Popay et al (2020) argued that for community participation to achieve its potential and reduce inequities, there is need to support disadvantaged communities through capacity building to exercise greater control over decisions and actions [ 70 ]. This can be achieved when the ‘empowerment process actively engage[s] with power dynamics operating in community settings’ for sustainability’ [ 70 ].…”

“…Lack of clarity on roles and responsibility has been a challenge in other countries [ 62 , 71–73 ]. The literature reflected the importance of community empowerment through capacity building and access to information [ 64 , 70 , 74 , 75 ].…”

“…These results support findings by Meier et al (2012), who identified that communities are often required to participate in highly structured activities, without sufficient knowledge of the health systems, nor the skills to challenge powerful stakeholders and institutional processes on board and make their voice heard [ 9 ]. Under such circumstances, participants cannot take advantage of opportunities to impact decision-making, central to the success of community participation programmes [ 30 , 70 , 71 ].…”

Covid-19 and pathways to health inequities for families in a socioeconomically disadvantaged area of Sweden – qualitative analysis of home visitors’ observations

“…Although the community level pathways to health inequities may not be the one first identified by practitioners and the population itself, they enhance our understanding of the critical need to consider the complex interrelation of the social determinants on all levels without forgetting or ignoring the structural determinants and only focus on those more visible on the individual level. In recent years British researchers have reinforced the argument that in order to combat socio economic health inequities it is necessary to consider how macro political and economic structures influence both the communities/place and the health of the individuals living there [ 33 – 35 ], as well as increasing understanding of the mechanisms of power and control on all levels in order to promote community empowerment in favour of health equity [ 34 , 35 ]. Mackenzie et al demonstrated that policymakers and practitioners tend to underplay the role of power and politics in favour of material and behavioural explanations in their assessments of the problem of health inequities [ 36 ].…”

Building back fairer in public health policy requires collective action with and for the most vulnerable in society

“…6 Nevertheless, the pandemic is forcing renewed acknowledgement of power as the fundamental driver of health inequalities. There have been new calls: to reclaim comprehensive public health rooted in public interest, focused on cooperation, participatory decision-making, and action that supports dignity, rights and social justice 7 ; to ensure that community empowerment focuses on systems and structural transformation 8 ; and…”