SEE ALSO advocacy; child protection; counter tactics; empowerment; health; power; social movements
Activism is action on behalf of a cause, action that goes beyond what is considered to be routine in society (Martin, 2007).
What constitutes as activism depends on what is conventional in society as any action is relative to others used by individuals, groups and organizations. In practice, activist organizations employ a combination of both conventional and unconventional strategies to achieve their goals (Laverack, 2013a). Activism has an explicit purpose to help to empower others and this is embodied in actions that are typically energetic, passionate, innovative and committed. It has played a major role in protecting workers from exploitation, protecting the environment, promoting equality for women and opposing racism. However, activism is not always used positively as the actions of some minority groups can oppose human rights and the beliefs of the majority.
The types of actions that activist organizations engage in can be broadly subdivided into two categories: indirect and direct.
1.Indirect actions are non-violent and often require a minimum of effort including voting, signing a petition, taking part in a ‘virtual (online) sit-in’ and sending an email to protest your cause;
2.Direct actions can range from peaceful protests to inflicting intentional physical damage to persons and property. For most activists their focus is on short-term, reactive and direct action with the intention of having an immediate effect. Direct actions can be further subdivided into non-violent and violent actions.
2.1.Non-violent, direct actions include protests, picketing, vigils, marches, publicity campaigns and taking legal action. Consumer boycotts are an example of non-violent, direct actions focused on the long-term change of buying habits and the reform of consumer markets. Consumer boycotting was an early tactic of activists to try and punish corporations but by the 1990s the trend was more towards developing standards and accrediting retail products that would be rewarded by consumers. Concerns have been raised that boycotting products may force the people involved in the labour of manufacture to turn to more dangerous sources of income (UNICEF, 2001).
2.2.Direct violent actions include physical tactics against people or property, placing oneself in a position of manufactured vulnerability to prevent action or taking part in a civil disobedience.
Direct action can be used in a symbolic way to send a message to the general public, and/or to the owners, shareholders and employees of a specific company, and/or to policymakers, about specific grievances. Some organizations use a dual strategic approach: one which is moderate and conventional whilst also using unconventional and more radical tactics. The radical strategy can be carried out by individuals or covert affinity groups, independent of the organization, whilst the conventional tactics form its official actions. The dynamics of this relationship are often unclear, but a strategy that employs both tactics can have a dramatic influence on public opinion. The risk is that the unconventional tactics can result in negative publicity and impact on future resource allocation and recruitment (Martin, 2007).
Health activism is a combination of two key concepts: activism and health and involves a challenge to the existing order whenever it is perceived to influence peoples’ health negatively or has led to an injustice or an inequity. The tactics of health activism have continued to evolve along with new developments in technology. Cell phone messaging, for example, is extensively used to communicate and to organize rallies. Health activism also continues to raise new issues including sexual harassment, bullying and domestic violence by campaigning about them and by developing techniques to address the inequities that these issues create (Plows, 2007).
The strategic approach used by activists is a dynamic process because organizations can use a variety of tactics, culturally informed and to some extent shaped by local laws, political opportunity, culture and technology.
KEY TEXTS
•Andersen, G. L. and Herr, K. G. (eds) (2007) Encyclopaedia of Activism and Social Justice (London: Sage)
•Laverack, G. (2013a) Health Activism: Foundations and Strategies (London: Sage)
•Pakulski, J. (1991) Social Movements: The Politics of Moral Protest (Sydney: Longman)
SEE ALSO injury; non-communicable disease; peer education; tobacco control; youth
Addiction is the continuation of a behaviour despite adverse consequences and is characterized by an inability to consistently abstain, to control personal behaviour, cravings, the diminished recognition of significant problems or dysfunctional emotional responses (Angres and Bettinard-Angres, 2008).
Substance dependence, also called drug addiction and drug misuse, is a compulsive need to use drugs in order to function normally including the use of sedatives, barbiturates and opiates. The addictive potential of a drug varies from substance to substance, from individual to individual, by dose and frequency of use. When there are no prevention, treatment or recovery activities, addiction can result in disability or premature death. There are several theories of drug addiction including having a genetic predisposition, self-medication, theories involved with social and economic development and the association between poverty and addiction. Drugs can be legal and delivered as prescriptions as well as being available as stimulants that cause a psychological addiction with mild physical symptoms when withdrawal occurs; for example, withdrawing from caffeine can cause headaches (Galea, Nandi and Vlahov, 2004).
Public health interventions for addiction vary according to the types of drugs involved, the amount of drugs used, duration of the drug addiction, medical complications and the social needs of the individual. Determining the best type of an intervention also depends upon the personality, spirituality or religion, mental or physical illness and the social support of the individual with the addiction. Addictions targeted by public health agencies include drug and alcohol abuse involving interventions such as needle exchange, opioid substitution therapies, self-help, counselling and therapy. Alcohol, for example, is a psychoactive and potentially dependence producing substance with severe health and social consequences. It is estimated that 2.5 million people died worldwide of alcohol-related causes in 2004 and is the third leading risk factor for premature death in the world (Blas and Kurup, 2010). Community mobilization is an approach that has proven successful in responding to the differential marketing of alcohol to vulnerable groups. In the United States it has been used to strengthen the enforcement of public drunkenness and alcohol outlet zoning in low-income communities. Prevention specialists target community leaders in a campaign to raise awareness of problems associated with drinking and to develop specific solutions that involve the community. Community action in Surfers Paradise, Australia, led to increased regulation of licensed alcohol premises and the implementation of policies and a code of practice for bar staff, and as a consequence alcohol-related violence were reduced (Homel et al., 1997). Elsewhere, community action projects on alcohol regulation have resulted in bar staff training, shortening of hours of operation of licensed premises, increased age verification checks and highly visible drink driving enforcement, resulting in reductions in injury (Holder et al., 1997). Although these types of interventions often have an immediate impact, the sustainability of community action remains unclear.
As a chronic, relapsing disease, addiction may require continued treatment to increase the intervals between relapses and to diminish their intensity. The goal of addiction treatment is to enable an individual to manage his or her substance misuse and can include abstinence. More immediate goals reduce substance abuse, improve the patient’s ability to function and minimize the medical and social complications of substance abuse. Harm reduction is an approach used in public health to reduce the harmful consequences of high-risk behaviours such as addiction by incorporating strategies that cover safer use, managed use and abstinence (Ritter and Cameron 2006). The goal is to work with the individual or community to minimize the harmful effects of a given behaviour (Marlatt and Witkiewitz, 2010). Counselling is also a common strategy used to help people who have an addiction to recover. Counselling refers to any form of interaction where someone seeks to explore, understand or resolve a problem or a troubling personal issue that is preventing them from living their lives in a way that they would wish to do so (McLeod and McLeod, 2011). Counsellors help clients to explore and understand their worlds and so discover better ways of coping with addiction. Whilst the boundaries are not always clear regarding the differences between counselling and therapy, the latter can be used in a more clinical context whilst counselling tends to have a social focus (Dryden and Feltham, 1993). Residential drug treatment is also an intervention for substance dependence and can be broadly divided into 12 step programmes or Therapeutic Communities. Other rehabilitation programmes use cognitive-behavioural theory and SMART recovery to examine the relationship between thoughts, feelings and behaviours, recognizing that a change in any of these areas can affect the whole (Galea, Nandi and Vlahov, 2004).
Public health interventions that address addiction are often based on acceptance and the willingness of the provider to collaborate with clients involved in high-risk behaviours in the course of reducing harmful consequences. This can be made complicated if the individual or group in question is involved in illegal or unpalatable activities. The ethical issue here is whether or not public health practitioners should be allowed to choose with whom they work, can they apply their personal judgement and should they be excluded to work with others based on their own personal preferences.
KEY TEXTS
•Angres, D. and Bettinard-Angres, K. (2008) ‘The Disease of Addiction: Origins, Treatment and Recovery’, Disease-a-Month, 54 (10): pp. 696–721
•Marlatt, G. A., Larimer, M. E. and Witkiewitz, K. (2011) Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors. 2nd edn (London: Guildford Press)
•Wilson, R. and Kolander, C. (2010) Drug Abuse Prevention. 3rd edn (Boston, USA: Jones & Bartlett Learning)
SEE ALSO gender mainstreaming; inequalities agenda; lifestyle; men’s health; mental health; non-communicable disease; women’s health; youth
The adult lifespan covers an age range from about 18 to 60 years. Most societies determine adulthood based on reaching either biological maturity or a legally and socially specified age regarded as being independent and responsible (Hubley, Copeman and Woodall, 2013).
Definitions of adulthood can be inconsistent and contradictory; for example, a person may be biologically considered adult but still be treated as a child within society if they are under the legal age of majority. Conversely, one may legally be an adult but lack the maturity and responsibility that define adult character. Public health interventions targeting adults can therefore overlap with initiatives targeting youth groups.
Middle adulthood is a time for establishing a pattern in life, raising a family and dealing with the everyday stress of work and relationships. The role of public health is to ensure that people are supported on a range of health and parenting issues often through clinical, workplace and leisure settings. The risk of chronic disease is a particular focus as are risk factors often caused by poor lifestyle choices such as tobacco use, lack of physical activity, poor eating habits, sexually transmitted diseases and drug abuse. These risk factors can lead to overweight and obesity, hypertension, high cholesterol and increased vulnerability to stress resulting in heart disease, cancers and diabetes (WHO, 2013). To address these health issues public health interventions have typically used lifestyle and behavioural approaches and educational and motivational techniques to change individual behaviours.
Older adulthood is the start of a transition to being elderly and a period when people suffer more from chronic diseases or are affected by isolation, depression and a lower level of physical activity. The emphasis in public health is on maintaining a healthy lifestyle and coping with life-changing experiences such as bereavements and the menopause.
Later life consists of ages nearing or surpassing human life expectancy typically 60 years of age to the end of the life (WHO, 2011). Terms that are used for people in later life include old people, seniors, senior citizens, older adults, the aged, the elderly and elders. Good health is essential for people in later life to remain independent and, from a public health perspective, it is important to distinguish between the ‘well old’ and the ‘frail old’ as it is the latter group that will need more attention from health services. Key concerns are isolation, disability, osteoporosis, accidents including falls, elder abuse and poverty. Those who have an advanced disease will also need long-term care and support (Hubley, Copeman and Woodall, 2013). Disease prevention activities can delay the onset of non-communicable diseases in later life but need to be detected and treated early to minimize their consequences.
Dominant images of older people in a particular period of time and place are held by society. Today’s dominant image of ageing is of frailty and helplessness and issues of dependency and care and homelessness. People in later life often play a critical role through volunteering, helping their families with child care responsibilities and are increasingly participating in the paid labour force (WHO, 2011). One residents’ association of older people, situated in a deprived housing estate in an American city, decided to do something about their poor living conditions. The area faced problems of high unemployment, anti-social behaviour, such as vandalism and street crime, and had poor street lighting and broken lifts in some of the high-rise buildings. The older persons believed that participating in the residents’ association and sharing their concerns would be the beginning of their action towards changing their situation. Representatives of the residents’ association met on a regular basis to discuss how they could address their problems and decided to make a strategic plan to improve living conditions by having more control over their own housing (Tracy, 2007).
In reality many older people do not suffer severe ill health or disability and are not dependent on others. The discrimination of older people therefore rests on a model which focuses on social isolation, poverty, illness and unemployment. Older persons can internalize these perceptions and this can contribute to a lower self-esteem and feelings of helplessness. These negative perceptions can then inadvertently direct government policy on the distribution of resources for the aged towards a dependency model rather than support and empowerment (Onyx and Benton, 1995).
•Albert, S. and Freedman, V. (2009) Public Health and Aging: Maximising Function and Wellbeing. 2nd edn (New York. Springer)
•Gillam, S., Yates, J. and Badrinath, P. (2012) Essential Public Health: Theory and Practice. 2nd edn (Cambridge: Cambridge University Press), Chapters 13 and 14
•Prohaska, T., Anderson, L. and Binstock, R. (2012) Public Health for an Aging Society (Baltimore, USA: John Hopkins Press)
SEE ALSO activism; counter tactics; empowerment; journalism; social movements
Advocacy involves people acting on behalf of themselves or on behalf of others to argue a position and to influence the outcome of decisions (Smithies and Webster, 1998).
Advocacy can include media campaigns, public speaking and publishing research with the intention of influencing policy, resource allocation and decision-making within political and social systems. Some of the key forms of advocacy that are used in public health include:
•Health advocacy supports and promotes health care rights as well as enhancing community health and policy initiatives; for example, the availability, safety and quality of care. It focuses on education and relies on expert knowledge rather than inserting lay knowledge into expert systems (Brown et al., 2004);
•Media advocacy is the strategic use of the mass media as a resource to advance a social or public policy initiative and aims to influence the selection, framing and debate of specific topics. The goal of media advocacy is to get the media’s attention and to frame the problem and solution in an appropriate way so that policymakers, politicians and the public understand the issue. Media advocacy targets the ways in which issues come to be regarded as newsworthy and to try to influence the boundaries within which it can take place (Wallack et al., 1993);
•Mass advocacy occurs when groups and organizations campaign on issues that are important to their members, who then speak out for themselves or influence what others say in the campaign (Loue, Lloyd and O’Shea, 2003);
•Peer advocacy occurs when a person agrees to act on the behalf of another; for example, volunteers who are recruited to act on behalf of service users at a citizens’ advice bureau;
•Self-advocacy occurs when individuals or groups share the same concerns or act on their own behalf;
•Legal advocacy occurs when a qualified person is employed to act on the behalf of others as an advocate, solicitor or barrister (Smithies and Webster, 1998).
In practice, the different forms of advocacy can overlap; for example, self-advocacy groups can play an important role for supporting peer advocacy and mass advocacy can support the efforts of self-advocacy groups. Patient Involvement Action Groups (PIAG) are a way of bringing together patient comments and complaints to effect improvements in hospitals. They allow patients to voice their concerns, anonymously if they wish, and to have feedback about actions taken. Patients and their carers are given comment forms which can be returned to a member of staff or placed in a collection box. Patients nominate representatives to advocate on behalf of other patients at the PIAG meetings. Once a month all of the comments, both positive and negative, are reviewed by the PIAG and action is decided upon at an appropriate level, or a report is given about action already taken. These include side rooms fitted with curtains to act as a screening door when a patient is carrying out personal functions, frosted glass, wards which suffered from solar glare received vertical blinds to improve conditions and shelves were put up in bathrooms for personal belongings. This approach has resulted in the number of formal complaints decreasing to less than 20% of the previous level as patients gained confidence that their comments would be acted upon and the hospital environment improved (Improvement Network, 2013).
Advocacy is ineffectual as an approach if it does not challenge those in authority to force them to make systems and societies more equitable (Labonte and Laverack, 2008). It is empowerment that enables others to take more control of their lives, usually through forcing social and political change. Strategies that include advocacy must therefore also use an empowerment approach to effectively achieve improvements in the lives and health of others.
KEY TEXTS
•Chapman, D. (2007) Public Advocacy and Tobacco Control: Making Smoking History (London: Wiley-Blackwell)
•Loue, S., Lloyd, L. S. and O’shea, D. J. (2003) Community Health Advocacy (New York: Kluwer Academic/Plenum Publishers)
•Lustig, S. (2012) Advocacy Strategies for Health and Mental Health Professionals: From Patients to Policies (New York: Springer)
asset-based community development
SEE ALSO capacity building; community; evidence based; needs assessment
Asset-based community development (ABCD) is a methodology that seeks to use the strengths within communities as a means for more sustainable development (Kretzmann and McKnight, 1996).
ABCD is based on the assumption that even the poorest of neighbourhoods is a place where individuals and organizations are the resources that can be used to rebuild themselves (Kretzmann and McKnight, 1996). ABCD can be defined by three main characteristics:
1.Asset-based starts with what is present in the community, not with what is absent, needed or problematic, so it aims to use the capacities in the community;
2.It concentrates on the agenda building and problem-solving capacities of local residents, local associations and local institutions;
3.It constantly builds and re-builds linkages among local residents, local associations and local institutions.
Formal and informal associations, networks and families are treated as assets because at the core of ABCD is its focus on social relationships. Building on the skills of residents, the power and supportive functions of local institutions, ABCD aims to draw upon existing strengths. The first step in the process is to identify existing, but often unrecognized, assets and assess the resources of a community to determine what types of skills and experience are available. The key is to begin to use what is already in the community. The next step is to discover what people in the community care enough about to act on. The final step is to determine how citizens can act together to achieve their goals.
Community development is different to asset-based community development because it is used by outside agencies to assist communities to improve their lives – often linked to the distribution of resources and to economic, infrastructural and political opportunities. Community development is often an aspect of state policy and with support, sometimes from a government-appointed community worker, aims to address issues of local concern (Jones, Sidell and Douglas, 2002).
Justifying the use of an assets-based approach implies that community development has been deficit based. It implies that too much intervention focusing on what is wrong in communities, such as crime, poverty, ill health and poor housing, has been used and that this needs fixing from the outside. By presenting community development as deficit based, it gets confused with misguided top-down approaches. The ABCD approach has been criticized as being politically convenient because it shifts the focus from the practical realities of the causes of inequality, deprivation and powerlessness and therefore runs the risk of being seen as the application of a superficial approach (Harris, 2011).
Asset mapping is commonly used in ABCD to mobilize people around a common vision (Kretzmann and McKnight, 1996). Its purpose is to generate an inventory of the resources and capacities available at the individual, group and institutional level within a given community (Foot and Hopkins, 2010). Community asset mapping has received considerable attention in, for example, the United Kingdom, as a way to foster the ‘Big Society agenda’ by moving power away from central government and giving it to local communities through changing and opening up public services and promoting social action (South, White and Gamsu, 2013).
Guidance (NHS North West, 2011) to successfully undertake a community asset mapping approach in practice includes:
•The community should identify the assets which they value as these are likely to have the greatest impact. Individual and community capacities can be considered as assets only in so far as they are valuable to the community;
•It is important to consider the reasons for doing an asset mapping approach and what it is hoped to be achieved from it. These considerations are likely to determine the geographic area to be assessed, the size of the sample to be interviewed and the questions to be asked in the mapping exercise;
•It is important to consider how the surveyed assets will be used, such as using a database, as this will affect how they may be updated in the future;
•It is important to make sure that the final mapping is continually monitored to check whether it is up to date and still useful.
Asset mapping can be a time-intensive activity that requires planning and resources. The experience so far gained shows that it is important to involve a variety of volunteers who can liaise with different segments of local communities. Questionnaires can be an efficient way to systematically collect information on people’s personal assets, however, the questions must be able to reach the correct level of detail otherwise it will have limited usability. Local events can also be a successful way to undertake asset mapping and offer a context in which to identify specific and individually valued goals (Giuntoli, Kinsella and South, 2011).
KEY TEXTS
•Foot, J. and Hopkins, T. (2010) A Glass Half Full: How an Asset Approach Can Improve Community Health and Well-Being (London: Improvement and Development Agency (IDeA))
•Harris, K. (2011) ‘Isn’t All Community Development Assets Based?’ The Guardian Online. Posted 23 June 2011
•Kretzmann, J. P. and McKnight, J. L. (1993) Building Communities from the Inside Out: A Path toward Finding and Mobilizing a Community’s Assets (Evanston, IL: Institute for Policy Research)
SEE ALSO definition; empowerment; fear-based campaigns; inequalities agenda; power
Autonomy refers to the capacity to be self-governing, to making the decisions that will influence one’s life and health. It is linked to what it is to be a person, to be able to choose freely and to be able to formulate how one wants to live one’s life (Kant, Gregor and Reath, 1997).
A respect for the autonomy of the individual and the conditions in people’s lives that support such autonomy is core to an ethical and empowering approach to public health. Ethics is the branch of philosophy dealing with distinctions between right and wrong, and with the moral consequences of human actions based on the concepts of human rights, individual freedom and on doing good and not harming others (PHAC, 2013).
Autonomy and empowerment are closely connected as both relate to having the freedom and opportunities in our lives to be able to make the right choices for ourselves. The difference between delivering an empowering approach in contrast to delivering a behaviour change approach is also closely related to how much autonomy is provided in public health interventions. If the strategies that are used give the practitioner the authority to control decision-making, for example, through setting the agenda, it is less likely to be empowering. If it facilitates a process of needs assessment, planning and capacity building toward political action, it has a much better chance of being empowering. In a professional context the key question is: Do I want to help to empower people or to simply change their behaviour? Both approaches aim to achieve improvements in health; however, the advantage of empowerment is that it also strengthens autonomy, skills and control in achieving healthier and more sustainable lives. Behaviour changes do sometimes lead to more autonomy and control, but, if they do, this is usually as a secondary effect, such as a feeling of greater self-esteem following smoking cessation. The aim of public health interventions should not simply be behaviour change but the attainment of more autonomous choice and empowerment.
It is the practitioners, or their agency, that usually provide the initial enthusiasm for the public health intervention. This is contradictory to an empowering approach in which the issue to be addressed should involve the beneficiaries of the programme. Some beneficiaries may not want to be involved. People, especially if they have lived in powerless circumstances, may feel that they do not have the right or do not possess the motivation to empower themselves. For other people, health is secondary to the personal goals in their lives and they may be willing to risk their health in order to pursue these goals.
What must be remembered is that power cannot be given but people must gain it for themselves. The right to be empowered rests with the individual or group and the role of the practitioner is to facilitate and enable others to take greater responsibility and control over their lives. Some people may not want the responsibility of making decisions or fear the regret of making a misjudgement and therefore are willing to delegate this authority to another person in whom they have trust. Others, for example, the very young, the very old or people with an addiction, may not have the ability to sufficiently mobilize themselves collectively. For those people who cannot or who refuse to take responsibility then public health practice may have to intervene, for example, through policy and legislation to prevent the spread of an infectious disease, to protect population health or place an individual into care, even against his or her wishes. For example, the enforcement of speed limits to protect drivers and pedestrians and legislation to restrict the sale of alcohol and tobacco to children (Baum, 2008).
In practice, the application of a public health approach that promotes autonomy also provides opportunities to help others to empower themselves within a programme context.
KEY TEXTS
•Dawson, A. (2011) Public Health Ethics: Key Concepts and Issues in Policy and Practice (Cambridge: Cambridge University Press)
•Frankel-Paul, E., Miller, F. and Paul, J. (2003) Autonomy (Cambridge: Cambridge University Press)
•Kant, I., Gregor, M. and Reath, A. (1997) Kant: Critique of Practical Reason (Cambridge: Cambridge University Press)