SEE ALSO indigenous peoples; inequalities agenda; power; zero-sum
Empowerment in the broadest sense is the process by which people work together to increase control over events that determine their lives and health (Werner, 1988).
The definitions of empowerment mostly give the term a positive value and have been developed in Western value systems, which place a strong emphasis on individual and community responsibility. The definitions also embody the notion that empowerment should come from within an individual, group or community and cannot be given to them.
Individual empowerment (personal or psychological) can be difficult to define because in itself it is not consistent with any particular goal and takes on a different form at the individual level in different contexts. Zimmerman (1995, p. 1; emphasis added) defines psychological empowerment as ‘a process by which people gain greater control over their lives, democratic participation in the life of their community, and a critical understanding of their environment’. Rappaport (1987, p. 122) places more emphasis on individual control in psychological empowerment as ‘a mechanism by which people gain mastery over their lives and affairs’.
Patient empowerment enables individuals to take control of their own health and well-being on disease management and to participate in decisions affecting their care. Patient empowerment is also about respecting patients’ rights and participating in making health systems more user friendly and information more accessible (The Lancet, 2012). Giving patients more control over their recovery can, for example, occur as part of home-based treatment. One study (Bassett and Prapavessis, 2007) on physical therapy for ankle sprains showed that the home-based groups had similar outcome scores for post-treatment ankle function, adherence and motivation to a standard physical therapy intervention. In contrast, the home-based group had significantly better attendance at clinic appointments and a better physical therapy completion rate. Patients were helped to set goals and to develop personal action plans to complete the therapy as well as education and training on treatment such as strapping techniques. The patients had more control and were better informed about their recovery and this sharing of knowledge and skills led to a viable home-based option. The patient-centred clinical method, for example, provides a focus on the practitioner–patient relationship as follows:
1.The illness and the patient’s experience of being ill are explored at the same time;
2.Understanding the person as a whole places the illness into context by considering: How does the illness affect the person? How does the person interact with his or her immediate environment? How does the wider environment influence this interaction?
3.The patient and doctor reach a mutual understanding on the nature of the illness, its causes and its goals for management, and who is responsible for what;
4.The desirability and applicability to undertake broader health promoting and illness prevention tasks, for example, providing the patient with information or skills about how he/she can dress a wound at home;
5.Gaining a better understanding of the patient–doctor relationship in order to enhance it, for example, placing a value on the contribution being made by both sides and forming a ‘partnership’ to address the illness rather than a traditional paternalistic approach;
6.Making a realistic assessment of what can be done to help the patient given, for example, the constraints in understanding, time and skill level (Stewart et al., 2003).
It is through the process of collective empowerment that people are best able to achieve the broader social and political change that is necessary to improve their lives and health. The collective empowerment of patients, for example, enables them to have an influence on the health system through networking and pressure groups. Collective empowerment includes personal empowerment, family empowerment and organizational empowerment. It is a dynamic process involving continual shifts in power relations between different individuals, groups and decision-makers in society (Laverack, 2004). Collective empowerment outcomes include the redistribution of resources, a decrease in powerlessness or success in achieving changes in health or social norms about a health behaviour. Powerlessness, or the absence of power, whether imagined or real is a concept with the expectancy that the behaviour of a person or group cannot determine the outcomes they seek (Kieffer, 1984).
The role of the public health practitioner in empowerment approaches is to build individual and collective capacity, to provide resources and to help others to gain greater control in their lives. Working in an empowering way is also a political activity because the structures of authority that sometimes create health inequality and social injustice can remain dominant. Empowerment should therefore involve both collective and individual actions, to enable people, for example, to be proactive about the health care that they receive and, more importantly, to be able to take action if this does not meet their needs and expectations.
KEY TEXTS
•Godbold, N. and Vaccarella, M. (2012) Autonomous, Responsible, Alone: The Complexities of Patient Empowerment (Freeland, Oxfordshire: Inter-Disciplinary Press)
•Laverack, G. (2009) Public Health: Power, Empowerment and Professional Practice. 2nd edn (Basingstoke: Palgrave Macmillan)
•Wallerstein, N. (2006) ‘What Is the Evidence on Effectiveness of Empowerment to Improve Health?’ Health Evidence Network Report (Copenhagen: WHO Regional Office for Europe)
SEE ALSO communicable disease; definition; empowerment; Health Impact Assessment; hygiene; reformers
Environmental health is concerned with the way that the natural and built environment including air, food, water, radiation, chemicals, disease vectors and housing can affect our health and well-being (Friis, 2010).
Environmental health is considered as a branch of public health. It is concerned with the natural and built environment but differs from environmental protection, which is concerned with protecting the natural environment mainly for the benefit of ecosystems. Environmental health encompasses the assessment and control of those environmental factors that can potentially affect health as well as preventing disease and creating health-supportive environments. It includes the theory and practice of the direct effects of chemicals, radiation and some biological agents, and the effects (often indirect) on health and well-being of the broad physical, psychological, social and cultural environment, which includes housing, urban development, land use and transport (Friis, 2010).
Environmental health professionals are sometimes called environmental health officers as well as environmental protection officers, public health inspectors and environmental health specialists. Environmental health professionals are responsible for a wide range of duties including monitoring water and air quality, control of toxic substances, food hygiene inspections, housing standards, health and safety and pollution control. The Chartered Institute of Environmental Health, for example, is a registered charity and the professional voice for environmental health in the United Kingdom. It sets standards, accredits courses and qualifications for environmental health officers and provides advice to local and national governments and the private sectors (Chartered Institute of Environmental Health, 2012).
Environmental health has its roots, for example, in the United Kingdom, in the political liberalism of the Victorian period which led to public pressure to promote sanitary reform in areas of urban industrialization. This helped environmental health reformers, such as Edwin Chadwick, to achieve their aim of bringing about legislation including the Public Health Act 1848 and to be more active in mobilizing sectors of the population who in turn had an influence on government policy (Berridge, 2007). Sir Edwin Chadwick (1800–1890) was an English public health reformer, noted for his work on the improvement of sanitary conditions. In 1832 Chadwick was employed to enquire into the reform of the poor and in 1834 individual parishes were formed into Poor Law Unions each with a union workhouse. While still officially working with the Poor Law, Chadwick also took up the question of poor sanitation. Chadwick was a commissioner of the Metropolitan Commission of Sewers in London from 1848 to 1849 and a commissioner of the General Board of Health from its establishment in 1848 to its abolition in 1854. In January 1884 he was appointed as the first president of the Association of Public Sanitary Inspectors, later to become the Chartered Institute of Environmental Health (Chartered Institute of Environmental Health, 2012).
An important role of the environmental health officer today is as an enforcer of public health law concerned with food inspection, licensing, complaint investigations and legal proceedings. An enforcement of the wide range of public health, health protection and food safety legislation has been seen to be necessary to maintain a healthy and safe environment in the home, at work and during recreation. The enforcement role has helped to establish the image of environmental health professionals as having the power of legislative controls. There is a further role, one that has developed more recently and that is complementary to the role as enforcers, educators and specialists. It is an important role that involves helping others to gain greater control over decision-making and access to available resources to help improve their health and well-being through education, training and specialist technical services.
KEY TEXTS
•Battersby, S. (2011) Clay’s Handbook of Environmental Health. 20th edn (London: Routledge)
•Friis, R. (2010) Essentials of Environmental Health. 2nd edn (Boston: Jones & Bartlett Learning)
•Frumkin, H. (2010) Environmental Health: From Global to Local. 2nd edn (San Francisco: John Wiley & sons)
SEE ALSO communicable disease; definition; health information systems; non-communicable disease; risk communication
Epidemiology is the study (or the science of the study) of the patterns, causes and effects of health and disease conditions in defined populations. Epidemiology informs policy decisions and an evidence-based practice by identifying risk factors for disease and preventive health care goals (Porta and Last, 2008).
Epidemiological studies aim to identify causal relationships between exposure to risks, such as alcohol consumption or smoking, and health outcomes. Epidemiologists employ a range of study techniques that can be categorized as (1) Observational studies that have two components: descriptive and analytical. Descriptive observations pertain to who, what, where and when in regard to a health-related event. Analytical observations deal more with the how of a health-related event. (2) Experimental epidemiology covering randomized control trials, field trials and community trials (Adetunji, 2008).
John Snow (1813–1858) was one of the first people to systematically use epidemiological techniques in London in 1849. He investigated data on cholera mortality using a new numeric method that revealed the rate was much higher in certain areas which drew its water from heavily polluted sections of the River Thames. His investigations in the Broad Street district were able to show that there was a marked difference in cholera rates when one company moved its water intake source to a less-polluted section of the river whereas another company did not. When another epidemic occurred in 1854 his detailed house-to-house investigation provided conclusive evidence that the water supplied by one company to the Broad Street pump was the source of the cholera. The pump was sealed to stop it from being used by residents and the epidemic slowed down. Legislation in 1857 later required all companies to filter their water supply and a greater appreciation developed that environmental factors could have an impact on the health of the public (Crosier, 2012).
Lay epidemiology describes the processes by which people in their everyday life interpret risks (Allmark and Tod, 2006), including risks to their health. To reach conclusions about risks, people access information from a variety of sources including the mass media, the internet, friends and family. Lay epidemiology poses a challenge to those in authority because it does not accept that professional information is the dominant perspective (Brown and Zavestoski, 2004). For example, in India, the People’s Health Movement has conducted a number of people’s tribunals in which evidence of the lack of access to health care and its damaging effects have combined with court actions to hold the government accountable to its legal obligations to maintain health services (People’s Health Movement, 2012).
Social epidemiology is the systematic study of health, well-being, social conditions or problems and diseases and their determinants, using epidemiology and social science methods to develop interventions, programmes and policies that can lead to a reduction in adverse impacts on populations (Cwikel, 2006). Social epidemiology emphasizes that it is the study, by qualified researchers, of social problems in combination with traditional epidemiology that sets standards of ‘normality’ that can be compared across population groups. In this way, health practice can build upon political concerns and create issues that they show can be overcome by using their expert knowledge. The public is open to rational discussion and practitioners can engage with communities to offer advice that is based on sound scientific evidence. Health experts can play a mediating role between those in authority and those in civil society by helping to shape their daily conduct through rationality, research and self-regulation.
Health profiles are a summary of health information for a particular population, for example, for a country subdivided into regions, provinces, towns and communities. Health profiles are usually produced annually by the government and show how one geographical area compares to the national and regional average. This comparative information then helps to make decisions to prioritize and plan services to improve people’s health and to address health inequalities (Network of Public Health Observatories, 2013).
Epidemiological evidence and other information from, for example, health profiles can be used by the general public to make informed decisions about their health. However, if the information about health risks is not communicated well it can create confusion or can be misinterpreted. Epidemiology has proved effective in establishing the major causes of diseases such as malaria but continues to experience difficulty in regard to more subtle health issues where causation is complex such as with immunization, hormone replacement therapy and alcohol consumption.
KEY TEXTS
•Cwikel, J. G. (2006) Social Epidemiology: Strategies for Public Health Activism (New York: Columbia University Press)
•Porta, M. and Last, J. (2008) A Dictionary of Epidemiology. 5th edn (USA: Open University Press)
•Somerville, K., Kumaran, K. and Anderson, R. (2012) Public Health and Epidemiology at a Glance (London: Wiley-Blackwell)
SEE ALSO definition; epidemiology; health information systems; knowledge, attitude and practice; prevention paradox; social determinants of health
Evidence-based practice, in whatever professional context, involves not only evidence but the judgement (knowledge and experience) of the practitioner and also of their professional partners including members of the community (Craig and Smyth, 2002).
The movement to develop an evidence-based practice began in the field of medicine but quickly spread to other parts of the health sector to address the development, implementation and evaluation of effective programmes and policies including the appraisal of research. However, an evidence-based practice should go beyond research as it consists of the education, skills and experience of the professional alongside values that inform decision-making, client situation and context such as the availability of resources (Hoffman, Bennett and Del Mar, 2013). Evidence-based practice is an adaptation of epistemology, ontology and methodology derived from the natural sciences. Ontological assumptions are about the way in which the world is, the nature of reality. Epistemological assumptions are about what we can know about that reality. Methodological assumptions are about how we come to know that reality and the strategies we employ in order to discover the way in which the world functions. An evidence-based approach has been applied to a range of technical procedures, settings, management and health technologies and to a range of fields including clinical medicine, health care, public health and education (Marks, 2002).
The movement to develop an evidence-based practice has consistently employed a scientific discourse derived from the epistemologies of positivism. The information from randomized controlled trials (RCTs) has been the most highly rated; for example, the evidence hierarchy rates the categories of evidence as follows: (1) the meta-analysis of RCTs; (2) at least one RCT; (3) one randomized study without randomization; (4) one other type of quasi-experimental study; (5) non-experimental descriptive studies (comparative, case control); and (6) expert committees or the opinions or clinical experience of respected authorities (Marks, 2002). The choice of evidence has favoured the quasi-experiment of the RCT although this is not always considered to be the most appropriate for fields such as public health, health promotion and social care.
Public health programmes are increasingly expected to justify what they do by being able to provide evidence of their effectiveness. However, what counts as evidence can be a contested issue, partly because it is not always possible to measure the impact of public health work. There are several organizations that are involved in the assessment of the effectiveness of public health interventions including the Cochrane Collaboration (www.cochrane.org) that facilitates accessibility to systematic reviews of the effects of health care and population health and the National Institute for Health and Clinical Excellence (NICE) that supports evidence-based practice in clinical and population health (www.nice.org.uk).
A broader issue for the development of an evidence-based practice is in the light of the growing impetus for interventions that address the determinants of health in addition to addressing individual behavioural risk factors (Rychetnik and Wise, 2004). For example, practitioners working with smokers in low-income communities need to understand the importance that smoking plays in some people’s lives. Even when the person understands the health risks associated with smoking this behaviour can be important to help them cope with living in poverty (Craig and Smyth, 2002).
The challenges of an evidence-based practice include having the availability of information from existing research and evaluation, statistical sources, expert and lay knowledge. Evidence-based practice also relies on the findings of research to be transferable into the work setting but this is not necessarily the case – neither are practitioners always skilled to appraise what works and what does not work for their professional context. The approach to an evidence-based practice has been criticized for being overly prescriptive, restrictive and narrow in scope. In order to improve an evidence-based practice it will be necessary to: (1) broaden the evidence base; (2) create more inclusive methods for evidence synthesis; (3) clarify principles and assumptions to make them coherent and consistent with the evidence about decision-related behaviour from psychology and the social sciences; (4) differentiate more clearly between the dissemination of evidence and its implementation; (5) take into account the social, organizational and psychological barriers to behaviour change (Marks, 2002).
KEY TEXTS
•Fink, A. G. (2012) Evidence Based Public Health Practice (London: Sage)
•Hoffman, T., Bennett, S. and Del Mar, C. (2013) Evidence-Based Practice across the Health Professions. 2nd edn (Edinburgh: Churchill Livingstone)
•Smith, K. (2013) Beyond Evidence Based Policy in Public Health (Basingstoke: Palgrave Macmillan)