Has empowerment lost its power?

Empowerment is espoused as a flagship value of health promotion. From the bold assertions in the Ottawa Charter [1] and the Jakarta declaration [2] through to the recent commitment in Nairobi [3], the discourse of empowerment has been unwavering throughout. This short points of view paper intends to stimulate critical discussion about the continued value and use of empowerment in contemporary health promotion. While empowerment has been seen as a cornerstone of health promotion practice and philosophy [4], we argue that unresolved challenges associated with the concept may inhibit the continued primacy of empowerment within the discipline. A recent evidence review of empowerment and its application to health and well-being (conducted by two of the authors and based primarily on evidence published between 2000 and 2010) has stimulated this assertion [5]. Lengthier discussions about these issues are currently being prepared for publication; therefore, this short article intends to focus on the definition of empowerment and, in the authors’ point of view, the dilution of the concept from its original roots as a radical social movement. Empowerment, with its origins in liberatory pedagogy, is generally viewed as an approach to enable people who lack power to become more powerful and gain some degree of control over their lives and health [6]. This suggests that empowerment approaches must operate at various levels, from focussing on both the individual through to organizations and communities [7]. This perspective was captured by Rappaport [8, p. 122] who suggested that empowerment is: a process by which people, organzations and communities gain mastery over their affairs. This was further reaffirmed by Wallerstein [9, p. 198] who has referred to the concept as: … a social-action process that promotes the participation of people, organizations and communities towards the goals of increased individual and community control, political efficacy, improved quality of life and social justice. Labonte [10] describes empowerment as embodying both resistance to power structures through advocacy and processes such as community organization, as well as community building and development. Thus, it is about giving and taking power in unison. In this respect, it is a zero–sum relationship and power in essence is finite. For example, resources being directed at some people can cause the displacement of power (disempowerment) from others due to competition for the same resources [11, 12]. In its widest and most radical sense, empowerment concerns combating oppression and injustice and is a process by which communities work together to increase the control they have over events that influence their lives and health [13]. This is reflective of health promotion as it was intended to be, albeit as an idealistic vision. In the past two decades, however, the focus within public health and health promotion has increasingly moved from the macro to the micro resulting on emphasis at the individual level. This is reflective of the broader policy environment in which neo-liberal ideology has infiltrated western politics. As McGregor [14] has noted, this increasing neoliberal focus values the individual at the expense of the group or community endeavour. This clearly offers challenges to promulgating the original tenets of achieving empowerment which advocates shared experiences of powerlessness and community mobilization and organization. Wise [15] believes that the underlying philosophy of empowerment involves enabling the oppressed to understand how structural processes (e.g. gender inequality, social inequalities, etc.) impact upon them as individuals and concerns mobilizing people to take community action [16]. This clearly echoes Frieran ideas of critical consciousness raising and assumptions of liberation and action resulting from heightened awareness. We contend, however, that the use of empowerment in this way has been at best diluted and at worst lost within health promotion. This, we would suggest, has been fuelled by the broader shift within health promotion which has increasingly focused its efforts toward a reductionist individualistic enterprise focused largely on behaviour change at an individual level, rather than a discipline that focuses on addressing social justice and wider power structures through social and structural change. We would share the point made by Carey [17] that the word has been used with casual abandon, with many health promotion projects and interventions (seemingly regardless of their function) aiming to ‘empower’ the populations they are working with. The rhetoric and the reality of empowerment is, from our evidence review, quite different and does not resonate with the concept as it was used by the likes of Paulo Friere who emphasized key ideas such as critical awareness or ‘conscientization’. There are two potential explanations for this. The first is that empowerment is now seen as a buzz word, a term that needs to be present in any programme’s attempt to improve people’s health regardless of its aims and purpose. Raeburn and Rootman [18, p.64], for instance claim: Empowerment is not a word we like all that well. It is unquestionably a (if not the) current ‘buzz word’ in health promotion and community development … but like all over-used words, one can get tired of hearing it or it tends to be misused or misunderstood. Secondly, the political and radical overtones of empowerment have been diluted by concepts such as ‘individual’, ‘psychological’ or ‘self’ empowerment and thus reaffirming a neo-liberal ideology. Staples [19] suggests that individual empowerment concerns the way people think about themselves and also the knowledge, capacities, skills and mastery they actually possess. While there is good evidence showing that empowerment interventions focussing on the individual increase participants’ psychological well-being, including self-efficacy, confidence and self-esteem [13, 20–25], individual empowerment can occur without participation in collective action or political activity. It is, therefore, essentially concerned with developing attributes which are needed for people’s personal capacity to be realized [26]. The issue for us is that individual empowerment does not consider or challenge the social determinants of people’s health [23] and in our view does not constitute full empowerment in the sense of transforming the relations of power. Individual empowerment alone has a limited impact on addressing health inequalities and may be illusory in that it does not lead to an increase in actual power or resources. In reality, empowerment simply at the individual level does little to influence social change: Individual empowerment is not now, and never will be, the salvation of powerless groups. To attain social equality, power relations between ‘haves,’ ‘have-a-littles,’ and ‘have-nots’ must be transformed. This requires a change in the structure of power” [19, p.36] This is not to say that individual empowerment is unimportant, but if it remains at this level, it overlooks change in the political and social context in which people live [11]. Clearly, empowerment as a concept remains central to health promotion (certainly always in principle if not always in practice); however, the existence of problems with defining empowerment leave health promotion advocates unable to articulate what exactly it is [27]. Describing a vicious theory-practice circle, Catteneo and Chapman [28, p. 646] argue that: the lack of precise definition has made it amenable to diffuse applications, which have then exacerbated the lack of precision in its definition. Is empowerment now, for example, less about social and political change and more of an individual concept, perhaps reflecting the infiltration of neoliberal ideas within health promotion more broadly as already discussed? Within the field of health promotion, both practitioners and academics use the term casually and definitions abound [29]. As a result, the concept of empowerment is used in conjunction with other terms (such as community competence, capacity, cohesiveness and social capital [30]) somewhat interchangeably which serves to confuse its meaning even further. This for many readers may not be problematic, but the authors, like other academics [31], argue that the original meaning, i.e. the focus on ‘power’, is somewhat lost by this conflation. As noted, empowerment is a multi-construct concept about both processes and outcomes, for individuals and for communities, further limiting definitional clarity. Furthermore, the historical development of the concept can be used to explain why there is currently no universally accepted definition of empowerment [32], as the term emerges from the convergence of several different disciplines including psychology, health education, sociology and social work. Somewhat compounding this issue is that the discourse of empowerment within health promotion has not evolved consistently throughout the world, so it is little wonder that the term has been misrepresented so frequently within health promotion. For example, empowerment has been viewed by some as a ‘Eurocentric phenomenon’ [33, p. 40], perhaps because it was a central tenet in the original WHO European Healthy Cities programme in the late 1980s [12] and because of the burgeoning amount of academic writing on the issue from European authors. However, in Africa, community development and empowerment approaches have been a key strategy for some time [34], but very little academic commentary has been provided by authors from the continent. In contrast, Anme and McCall [35] argue that empowerment is a reasonably new concept in Asian countries. Despite these definitional difficulties, which are well recognized and discussed across a range of disciplines in which the concept is used, empowerment is still viewed positively as having a contribution to make within health promotion. Similar to health promotion itself, which has no universally accepted definition [36], empowerment remains a fuzzy concept within contemporary literature and research, drawing upon different disciplinary perspectives and understandings and being used differently around the world [33]. More clarity around defining the concept and analytical precision in usage in health promotion is thus required for current practitioners, in order to facilitate the more accurate measurement of empowerment for both individuals and communities. This article raises a number of critical issues surrounding the concept of empowerment and its use within health promotion. The position of the authors, as reflected, is that the concept has become diluted over time. We argue that this has occurred alongside the increasing ‘timidity’ discourse noted in the language used over the same period of time within key WHO charters [37]. As such, we note that empowerment has somewhat lost its links with its original and much more radical self as reflected in health promotion’s roots in the 1970s and 1980s. Among things, this is reflected in the move towards examining empowerment at a more individual level which we argue is detrimental to the concept. The central argument of this points of view paper is therefore that, empowerment has lost (or is at risk of losing) its power. In an effort to move beyond the rhetoric associated with empowerment, we seek debate and we anticipate academic dialogue around the issues raised.

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