SEE ALSO asset-based community development; community; empowerment; health networks; inequality agenda; participatory rural appraisal; power; volunteerism
Participation builds the interaction of people so that they can address a broad range of common needs by sharing their ideas and experiences (Rifkin, 2011).
Participation implies people taking an active rather than a passive role, essentially by being involved in the decisions that affect their health and well-being. Participation alone does not lead to action or empowerment, does not lead to improved health outcomes and does not lead to improved health care (Rifkin, 2011). Participation is often facilitated through a representation of the majority by a few members of a community. This is because it is not usually possible for everyone to participate in community meetings. Representation may be through an elected individual of the community but the diversity of interests can create problems. Participation can become empty and frustrating for those whose role is passive, lacking in authority and is therefore not to their advantage.
The contribution of communities in meeting health goals has not received sufficient attention within policy and public health practice. The emphasis has been on collecting evidence at a population level and on working through health sector organizations to deliver interventions supported by professionals. Governments have placed an emphasis on professionally led interventions to improve health rather than on solutions designed and delivered by the communities themselves. At best this has failed to mitigate the effect of inequalities and at worst it may have contributed to the unfair distribution of resources within society (South, White and Gamsu, 2013).
Participation and public health include community involvement at all levels. However whilst individuals are able to influence the direction and implementation of a programme through their participation, this alone does not constitute empowerment. People must also choose to become more politically involved to influence, for example, policy outcomes, as well as how public health interventions are designed and delivered. Participation can then go beyond the benefits of the programme to extend to broader issues such as the structural causes of health inequalities. There is evidence to suggest that people are reluctant to engage in more direct forms of participation: for example, in New Zealand one study showed that of the 89% of respondents to a petition only 19% attended a demonstration, 17% joined a boycott, 4% joined in a strike and only 1% were willing to take action (Perry and Webster 1999) to try and influence a policy issue. This is a particular pattern with young people, members of ethnic minorities and those with the lowest level of education and income who are the least likely to be involved (Hayward 2006). Yet, marginalized groups are most likely to be affected by policy decisions because they have less of an economic and social buffer to protect them from changes in, for example, opportunities for employment and in changes to welfare policies.
Voluntary work or lay health work can be an important role for people to participate in public health programmes although this poses the challenge of how to effectively utilize them in a meaningful manner. For example, there have been few large-scaled, well-resourced programmes that have systematically involved communities in the United Kingdom (South, White and Gamsu, 2013). The reasons for this are varied but certainly the deficit approach used by governments, the idea that communities lack the knowledge and skills to solve their problems, a lack of trust between government and civil society and an unequal distribution of control over decision-making (being largely from the top-down) have contributed to this situation.
There are a range of participatory methodologies, such as participatory rural appraisal (Narayansamy, 2009), that can be used to actively involve people in public health programmes, for example, for the gathering of information. The advantages of using a participatory approach over a conventional top-down approach in public health programmes are that it is self-educative and self-improving by building upon and improving skills. A limitation of using participatory approaches in a programme context is that they require skilled facilitation that may not be available because of a lack of professional competence and confidence.
KEY TEXTS
•Chambers, R. and Somesh, K. (2003) Methods for Community Participation: A Complete Guide for Practitioners (London: ITDG Publishing)
•Rifkin, S. B. and Pridmore, P. (2001) Partners in Planning: Information, Participation and Empowerment (London: Macmillan Education)
•Zakus, J. D. L. and Lysack, C. L. (1998) ‘Revisiting Community Participation’, Health Policy and Planning, 13 (1): pp. 1–12
SEE ALSO activism; asset-based community development; evidence-based; needs assessment; upstream and downstream
Participatory rural appraisal (PRA) is an approach that aims to incorporate the knowledge and opinions of people in the planning, evaluation and management of projects and programmes (Chambers, 1997).
A range of methodologies have been developed to assist communities to undertake assessments, including rapid rural appraisal, participatory learning and action and participatory action research. Participatory rural appraisal is an approach that is commonly used in public health and enables people to collect, share and analyse information that they have identified as being important. PRA became a popular tool to assess and monitor improvements in the health and development of communities in the 1990s. It is not a single technique but a collection of participatory and non-participatory approaches and methods. PRA has also been used for its potential to help empower communities on the basis that it actively involves the marginalized, assesses their needs, builds capacities and includes them in decision-making processes.
PRA does not have to be carried out in a rural context and the large range of techniques that have been developed for its implementation can be divided into four categories (Chambers, 1997): group dynamics such as learning contracts, role reversals, feedback sessions; sampling such as transect walks, wealth ranking, social mapping; interviewing such as focus group discussions, semi-structured interviews, triangulation; and visualization such as diagrams, matrix scoring and timelines.
To ensure that people are not excluded from the participatory process the PRA techniques largely use oral and visual communication such as pictures, symbols, physical objects and group memory. Community stories, for example, are a tried and tested way to involve others and to promote participation and empowerment. Community stories can be used to identify important needs and to help build a mutual understanding of the outcomes of an evaluation (Wood, Sawyer and Simpson-Hebert, 1998). Storytelling can be initiated through group discussions and then various techniques can be used to stimulate this process including using photographs, encouraging the participants to draw a picture or to create a song. People describe the stories that they create and this in turn provides more meaning and context. Three techniques that have been successfully used for developing community stories are: (1) ‘unserialised posters’; (2) the ‘three pile sorting cards’; and (3) ‘story with a gap’ (Srinivasan, 1993).
Whilst PRA can produce a large amount of information it does not always offer a means to transform this into action, a crucial stage in evaluation that promotes empowerment. Validity in using participatory techniques can also be problematic because personal perceptions are prone to recall bias or the assessment may be influenced by the dynamics of the group, the evaluator or the techniques used (Nutbeam and Bauman, 2011). A new paradigm of professionalism has therefore emerged in the use of PRA techniques in which the key focus is decentralization and empowerment. Decentralization means that resources and discretion are devolved or bottom-up. Empowerment means that people, especially poorer people, are enabled to take more control over their lives, and secure a better livelihood with ownership and control of productive assets (Chambers, 1997).
Participatory action research (PAR) is an approach to research in communities that also places an emphasis on participation and action. It seeks to understand the world by trying to change it, collaboratively and following reflection. PAR emphasizes collective enquiry and experimentation grounded in experience and social history. Within a PAR process communities of enquiry and action evolve and address questions and issues that are significant for those who participate as co-researchers (Reason and Bradbury, 2008). PAR makes a concerted effort to integrate three basic aspects: (1) participation (life in society and democracy), (2) action (engagement with experience and history) and (3) research (soundness in thought and the growth of knowledge) (Chevalier and Buckles, 2013). PAR is not a single method but rather a pluralistic orientation to creating new knowledge and social change.
The challenges of using a PRA approach include its inclusion in large-scale public health programmes in which the agenda becomes externally driven, by the practitioner, rather community-driven and is used to create legitimacy for the programme aims. Whilst PRA can produce information that is related to the physical and social elements of a programme it has been criticized (James 1995) for not addressing the underlying structural causes of powerlessness such as resource control. This is important because community expectations can be raised and then disappointed by a lack of means to translate information into action. The process of PRA becomes one of needs assessment and participation rather than an empowering experience. A limitation of using any participatory technique is that it will require skilled facilitation and within a programme context this may sometimes not be realistic to achieve because of a poor professional capacity.
KEY TEXTS
•Chambers, R. (1997) Whose Reality Counts? Putting the First Last (London: Intermediate Technology Publications)
•Narayansamy, N. (2009) Participatory Rural Appraisal: Principles, Methods and Application (London: Sage)
•Reason, P. and Bradbury, H. (eds) (2008) The Sage Handbook of Action Research: Participative Inquiry and Practice (Thousand Oaks, CA: Sage)
SEE ALSO behaviour change; health promotion; knowledge, attitude and practice; schools; sexual health; volunteerism; youth
Peer education supports people to promote health-enhancing change among their peers. Rather than health professionals educating members of the public, lay persons are felt to be in the best position to encourage healthy behaviour amongst each other (Kelly et al., 1992).
Peer education has been used in HIV prevention, especially involving young people, with sex workers, men who have sex with men and intravenous drug users. Youth peer educators have shown in some cases to be more effective than adults in establishing norms and in changing attitudes related to sexual behaviour. Peer education is also associated with efforts to prevent substance abuse among young people, teenage pregnancy and with the homeless. Peer education is usually initiated by practitioners who recruit members of the target community to serve as educators. Peer educators are typically about the same age group as the people with whom they are working. The recruited peer educators are trained in relevant communication skills and then engage their peers in conversations about the issue of concern, seeking to promote health-enhancing behaviour change. The intention is that familiar people, giving locally relevant and meaningful suggestions, in a local language and taking account of the local context, will be more likely to promote health. They may work alongside the health practitioner, run educational activities on their own or actually take the lead in organizing and implementing activities (UNICEF, 2013).
The My Future Is My Choice was a peer education project in Namibia designed to counter the growing threat of HIV and aimed to reach thousands of young people, through other young people, with relevant information. The peer educators, aged between 14 and 21 years, received training, information and skills to help others to make choices about their future sexual health. Each peer educator aimed to reach at least ten friends and/or become a member of an AIDS drama, role play or debating club. The Ministries of Youth and Sports, Health and Social Services and Basic Education and Culture, the National Youth Council and religious organizations also took part in the project. Peer education sessions were divided into different activities, including games to teach skills in a fun way, activities to practice what they had learned and helping young people to think critically (UNICEF, 2013).
The evidence about peer education is mixed, seemingly working in some contexts but not in others. One study, for example, that covered eight secondary schools in Kenya, in which peer education clubs had been operational for two years, found a key difference between club members and non-members. The peer education project was able to encourage the adoption of preventive behaviours including abstinence, faithfulness to a partner, condom use and voluntary HIV testing only in peer education club members (Odundo, Anjuri and Odhiambo, 2013). Befriending is an internationally recognized approach similar to peer education that offers supportive, reliable relationships through peers to people who would otherwise be socially isolated. Befriending work can be emotionally demanding and volunteers do leave peer education programmes even though they are given an opportunity to discuss problems with one another or with a mentor (Falkirk Council and Healthprom, 2013).
All forms of peer education can have a high attrition rate and therefore need regular intensive training, multiple incentives for the educators and the monitoring of their duties. This means that peer education is not necessarily a cheap or easy option for public health programmes and should be seen as a strategy that can be best used alongside others; for example, it has been used effectively to complement skills-based health education on condom promotion and youth-friendly health services (UNICEF, 2013).
KEY TEXTS
•Robertson, J., Catanzarite, J. and Hong, L. (2010) Peer Health Education: Concepts and Content (San Diego: University Readers)
•UNAIDS (1999) Peer Education and HIV/AIDS: Concepts, Uses and Challenges (Geneva: UNAIDS)
•UNICEF (2013) Peer Education. Available at http://www.unicef.org/lifeskills/index_12078.html. Accessed 21 January 2014
SEE ALSO activism; Health in All Policies; health policy; inequalities agenda; social movements
Policy is made up of a combination of agendas and actions rather than just one simple decision and is usually the result of governing processes that can be subject to negotiations between a wide range of public, civil society and private actors (Sorensen and Torfing 2007).
Several useful frameworks have been developed to conceptualize how decision-makers, planners and other policymakers can act to change policy development (Lindquist, 2001). Although they primarily reflect processes in a democratic political system, they also provide conceptualizations about how the process to influence policy development works within two broad paradigms: rationalist and political. The rationalist paradigm includes linear and interactive models as representations of the policy process. It originates from classical economic theory which presumes that actors have full information and are able to establish priorities to achieve a desired and largely uncontested goal. It is driven by the production and consideration of different forms of evidence such as public health research, as well as the input from experts and academics as a valued part of the process. The political paradigm generates policy models adapted from political economy theory and derived from comparative politics and international relations. These theories stress the importance of agenda setting, policy networks, policy narratives and the policy transfer in shaping final decisions. Policy decisions, in turn, are made on the basis of bargaining and negotiation between the different stakeholders who employ a range of approaches to have an influence on each stage of the policy process (Neilson 2001).
From the vantage of policymakers, the most effective approach to policy combines elements from both the rational and political paradigms. For example, the introduction of policy to ban smoking in public places was initially based on strong epidemiological evidence regarding second-hand smoke. The best strategy to reduce death and illness from second-hand smoke would have been a total ban on smoking including in homes. Obviously such a policy would be very difficult to regulate as well as creating opposition from civil libertarian groups. The policy decision was therefore a compromise based on the available evidence and on the opposing interests of different stakeholders to reach an achievable goal rather than an optimal goal (Neilson 2001).
Government action on policy can be seen as a democratic enterprise that, in theory, reflects the needs or wants of a significant proportion of the public. The Multiple Streams model attempts to explain agenda change, how and why some issues move onto and up the decision agenda of political parties, while others do not. In the Multiple Streams model the government is viewed as an arena through which three streams of separate, simultaneous activity occur: (1) The problem stream consists of those conditions which policymakers have chosen to interpret as problems. (2) The policy stream consists of the various solutions developed by specialists. (3) The politics stream consists of developments involving macro political conditions, the public mood, interest group politics and turnover in the administrative and legislative stakeholders. The three streams of problems, policies, and politics flow through the governmental system largely independent of one another and each according to its own set of dynamics. As a result, change within one stream may occur independently of change in the other streams. An issue gains traction on the policy agenda only when stream-convergence occurs, when a window of opportunity opens, allowing a chance to push attention towards a specific agenda. People wishing to influence the policymaking process therefore have to wait for a development in the political stream so that they can use it to their advantage (Cohen-Vogel and McLendon, 2009).
Most policy development is undertaken internally and in confidence and the level of public involvement, professional and researcher consultation is limited. Policymakers are savvy and somewhat cynical operators in a political arena who use research for their own means. This depends on the role and position of the researcher, the current stage of policy development in which they are engaged, the level of contention about the policy and the researchers’ credibility. For example, high-profile researchers with a vision of their field and rhetorical skills are used to persuade relevant ministers, stakeholders and the public during policy agenda setting and formation. Researchers with a narrower expertise, such as specialists in clinical trials, are used to advise on intervention design and evaluation once overall policy directions had been agreed (Haynes et al., 2011).
The success of influencing the policy process is increased when it is technically simple and necessitates only marginal changes in any existing policy. This is further increased when it is delivered by one agency, has clear objectives, a short duration (Walt, 1994) and addresses medically defined problems rather than those residing in the complex social determinants of health.
KEY TEXTS
•Baggott, R. (2010) Public Health: Policy and Politics. 2nd edn (Basingstoke: Palgrave Macmillan)
•Edwards, M. Howard, C. and Miller, R. (2001) Social Policy, Public Policy: From Problem to Practice (Sydney: Allen & Unwin)
•Hunter, D. (2003) Public Health Policy (Cambridge: Polity Press)
SEE ALSO climate change; communicable disease; globalization; human resources for health; injury; malnutrition; Maternal, Newborn and Child Health
Population growth refers to the increase in the number of members of a population estimated over a given time period, such as on a yearly basis (United Nations, 2014).
Globally, population growth is about 81 million people annually with a total estimated population of seven billion people in 2012. Although contested, if population continues at the present rate of 1.2% per annum it will reach 11 billion by the end of the twenty-first century. Most population growth occurs in low- and middle-income countries whilst countries with high standards of living typically have low or negative rates of population growth (United Nations, 2014).
The population growth rate is the rate at which the number of individuals in a population increases in a given time period as a fraction of the initial population. If the size of a population decreases over time it is called negative population growth. Overpopulation occurs when a population level exceeds the physical capacity of the environment to support it and is a function of the number of individuals compared to the required resources including water supply, food and available land. If population growth exceeds the expansion of social and physical capacity to cope with the needs of additional people, then development is slowed, or even reversed, with profound consequences for health (Campbell et al., 2007).
Four factors can be used to determine population growth: births, deaths, immigration rate and the emigration rate. These factors can be used to calculate the population growth over a period in which social and economic factors also play a role. Australia, for example, has a population growth rate that is nearly double the global average, caused by a high level of immigration. Accurate information about population growth, information about the trends, size and structure of a country’s population is important for the development of policies and programmes. The Population Division of the Department of Economic and Social Affairs (DESA) of the United Nations Secretariat provides projected trends of populations for all countries as well as related demographic indicators, such as fertility, mortality and migration levels provided, for example, in the World Population Prospects (United Nations, 2014).
Urbanization refers to the increasing number of people that live in urban areas resulting from population growth. Urbanization can represent the level of urban development relative to the overall population or it can represent the rate at which the urban proportion is increasing. Urbanization is associated with shifts from an agriculture-based economy to an industrial, technological and service-based economy. More than 50% of the world’s population now lives in an urban context and by 2050, 70% of the world’s population will be living in towns and cities with half of all people living in large cities with between 100,000 to 500,000 inhabitants (Bulletin of the World Health Organization, 2010). People move to urban areas for better work opportunities and better access to health and education facilities. However, rapid urbanization can create pressure on transport, health, water supply, food and housing services resulting in potential health risks associated with overcrowding and poor sanitation (United Nations, 2006).
Many developing countries are characterized by rapid population growth and face adverse social, economic and environmental pressures. Population growth has traditionally been controlled through the implementation of voluntary family planning programmes and the promotion of contraception. Other factors that can control the population growth rate include morbidity resulting from disease, greater gender equity and migration patterns (Ezeh, Bongaarts and Mberu, 2012).
Public health challenges posed by rapid population growth and urbanization relate to water supply, the environment, violence and injury, non-communicable diseases resulting from an unhealthy diet and physical inactivity, harmful effects from using addictive substances and the risks associated with communicable disease epidemics. Public health authorities and government policy can take specific actions to meet these challenges including promoting a healthy urban infrastructure, improving sanitation and waste disposal and by controlling the spread of diseases in overcrowded conditions. Urban environments tend to have poorer air quality, a high flow of traffic and a lack of safe public spaces and recreation facilities. Government policy could, for example, target the prevention of risks associated with road traffic injuries, create green spaces and better regulate the causes of pollution (Bulletin of the World Health Organization, 2010). Population growth is expected to remain a critical determinant of public health (Haddock and Leahy, 2008) given its impact on service and resource availability.
KEY TEXTS
•Ezeh, A., Bongaarts, J. and Mberu, B. (2012) ‘Global Population Trends and Policy Options’, The Lancet, 380 (9837): pp. 142–148
•May, J. (2014) Word Population Policies: Their Origin, Evolution and Impact (New York: Springer)
•United Nations, Department of Economic and Social Affairs, Population Division (2014) ‘World Population Prospects: The 2012 Revision’. Methodology of the United Nations Population Estimates and Projections. ESA/P/WP.235
SEE ALSO activism; counter tactics; empowerment; inequalities agenda; social movements; zero-sum
Power can be hard or soft and defines the capacity of some people to produce intended effects on others (Wrong, 1988).
Soft power is the ability to obtain what one wants through indirect and long term actions such as co-option and attraction.
The purpose of soft power is to persuade others to voluntarily do what you want them to do but by avoiding conflict and tension. Soft power uses values, culture and agenda control to be able to attract or repel others. The media is regularly identified as a source of soft power as is the spread of a national language or a particular set of normative values (Gallarotti, 2011). In contrast, hard power achieves compliance through direct and coercive methods to force others to do what you want them to do, whether they want to do it or not.
To better understand how power is exercised either positively (the sharing of control with others) or negatively (the use of control to exert influence over others against their will), it is helpful to consider three of its simplest forms: ‘power-from-within’, ‘power-over’ and ‘power-with’.
Power-from-within can be described as an experience of self, a personal level of power and as gaining a sense of control over one’s life (Rissel, 1994). Starhawk’s (1990, p. 10) description of power-from-within likens it to ‘our sense of mastery we develop as young children’, but also to something deeper ‘our sense of bonding with other human beings, and with the environment’. Feminist theory holds that even in the most male-dominated societies, women have power, their power-from-within. Once one has accepted this, the argument that people can both have and lack power in society can be seen to be important. The goal of power-from-within is to increase feelings of value and a sense of individual control over one’s life and health. Individuals can therefore gain power-from-within without necessarily having to accumulate power as money, or status or authority.
Power-over describes social relationships in which one party is made to do what another party wishes them to despite their resistance and even if it may not be in their best interests. However, the exercise of power-over does not have to be negative. State legislation to control the spread of diseases, to impose fines for unhealthy behaviour, such as smoking in a public place, or even to redistribute market income to prevent poverty, are examples of healthy power-over. Power-over can take different forms and has three functionally distinct operations: dominance, or the direct power to control people’s choices, usually by force or its threat; exploitation, or the indirect power to control people’s choices through economic relations, in which those who control capital also have control over those who do not; and hegemony, or the ability of a dominant group to control the actions and behaviours of others by intense persuasion (Wrong, 1988).
Power-with describes a different set of social relationships, in which power-over is deliberately used to increase other peoples power-from-within, rather than to dominate or exploit them. Power-over transforms to power-with only when it has effectively reached its end, when the submissive person in the relationship has accrued enough power-from-within to exercise his or her own choices. To enable others to empower themselves can begin from the perspective to look for, and work from, areas in peoples’ lives in which they are relatively powerful. This can mean areas in people’s lives where they have some control or power-from-within and can use this to influence their lives and health. Rather than a simple transfer of resources and information the relationship involves an offering of advice and strategies to develop both the power-from-within of individuals and the collective empowerment of communities.
The role of public health is to strive to help others to gain more power-from-within, as well as power-over, so that they can empower themselves and share this through their power-with.
KEY TEXTS
•Gallarotti, G. (2011) ‘Soft Power: What Is It, Why Is It Important and the Conditions for Its Effective Use’, Journal of Political Power, 4 (1): pp. 25–47
•Laverack, G. (2009) Public Health: Power, Empowerment and Professional Practice. 2nd edn (Basingstoke: Palgrave Macmillan), Chapter 2
•Scott, J. (2001) Power (Cambridge: Polity Press)
SEE ALSO behaviour change; epidemiology; health; peer education; risk factors
The prevention paradox describes the seemingly contradictory situation when the majority of cases of a disease come from a population at low or moderate risk, and only a minority of cases come from the high-risk population of the same disease (Rose, 1985).
The prevention paradox, first described by the epidemiologist Dr Geoffrey Rose, demonstrated that for one person to benefit, many people have to change their behaviour, even though they will receive no benefit through the intervention. For example, in downs syndrome the maternal age is a risk factor yet most cases will be born to younger, low-risk mothers. This situation is paradoxical because it is logical to equate high-risk populations with making up the majority of the cases. Another example is reducing dietary fat consumption for the whole population to reduce coronary heart disease whilst it is difficult to change the behaviour of those whose risk is only low to medium. This can be further compounded by public health programmes that have chosen to use simple messaging that exaggerates the risks of a particular behaviour or the benefits of changing that behaviour. People have also recognized that health messages can change, for example, in regard to safe limits for alcohol consumption. This has led to mistrust in the public; people feel that risk does not apply to them, and they reject the advice (Hunt and Emslie, 2001). People also have cultural and personal values that undermine the meaning of health messages, for example, a person can choose not to give up smoking when he or she believes that the benefits of pleasure or to reduce stress outweigh the health risk. People may view a particular health behaviour as being bad but desirable or bad in some ways but good in others. People’s perception of risk depends on their circumstances, culture and values (Allmark and Tod, 2006).
People are influenced by the information that they receive, although sometimes conflicting, and can feel at risk, coerced or manipulated which can then create mistrust. For example, in the United Kingdom public concerns were raised about the measles, mumps and rubella (MMR) vaccine. The public health authorities saw this as an effective option with few side effects. Following media reports of conflicting scientific evidence the public became increasingly concerned that the vaccine could lead to bowel cancer and autism (Smith, 2002) and refused to have their children immunized.
A major implication of the prevention paradox is when it is used to shape prevention strategies as there may be substantial benefits to the community but relatively small gains to specific individuals. For example, from a public health perspective, targeting the entire population, including non-extreme drinkers, is both logical and likely to yield substantial community-wide reductions in harmful behaviours and poor health outcomes. Encouraging small reductions in consumption among the majority of drinkers may be a more feasible goal rather than dramatically changing consumption among frequent heavy drinkers. Primary prevention interventions targeting low-to-moderate drinkers can achieve maximum alcohol-related harm-reduction using, for example, environmental strategies such as outlet density, price and advertising. More extreme drinkers may best be reached using individually based secondary or tertiary treatment-related approaches (Weitzman and Nelson, 2004).
The prevention paradox illustrates how mainstream public health interventions can have a relatively small benefit on individual members of the general population. Public health strategies that encompass the prevention paradox can therefore be controversial because they seek to change the behaviour of a majority who may correctly perceive they are at low individual risk of harm while seemingly ignoring those persons at higher risk, with more acute symptoms of the disease.
KEY TEXTS
•Allmark, P. and Tod, A. (2006) ‘How Should Public Health Professionals Engage with Lay Epidemiology?’ Journal of Medical Ethics, 32: pp. 460–463
•Hunt, K. and Emslie, C. (2001) ‘Commentary: The Prevention Paradox in Lay Epidemiology – Rose Revisited’, International Journal of Epidemiology, 30 (3): pp. 442–446
•Rose, G. (1985) ‘Sick Individuals and Sick Populations’, International Journal of Epidemiology, 14 (1): pp. 32–38
SEE ALSO child protection; injury; lesbian, gay, bisexual and transgender; peer education; sexual health; violence
The term ‘prostitution’ has taken on a meaning of ‘sex for sale by force’, such as child sexual exploitation, whilst ‘sex work’ denotes an industry of work by choice. However, the terms prostitution (prostitutes) and sex work (sex workers) are often used synonymously (Laverack and Whipple, 2010).
Sex work can be a dangerous profession as sex workers are sometimes exposed to drug use, communicable diseases, violence, discrimination, criminalization and exploitation (Rekart, 2005). A systematic review and meta-analysis of HIV infection amongst female sex workers in low- and middle-income countries, for example, showed that they are 14 times more likely to be infected than are women in the general population (Baral et al., 2012). Discriminatory laws and policies, poor funding, stigma, violence and social exclusion, it has been suggested, have all impeded efforts to reach both sex workers and their clients with effective HIV prevention, treatment, care and support (The Lancet, 2012a). The ambiguity of the law regarding prostitution in many countries, police harassment and the covert nature of work settings, such as massage parlours and brothels, have meant that prostitutes are vulnerable to exploitation. Prostitution is forced underground and sex workers are then further exploited, for example, through working conditions that are unclean and unsafe (Clarke and MacFarlane, 2005). Prostitutes can be easy targets for exploitation resulting in a stigmatization which can lead to situations of abuse, coercion, violence and low self-esteem, all of which can have a negative effect on their health and well-being (Cornish, 2006).
In public health programmes the use of harm-reduction has been successful for training in condom-negotiating skills, safety tips for street-based sex workers, occupational health and safety guidelines for brothels, self-help organizations and community-based child protection networks (Rekart, 2005). Traditional forms of peer education, condom promotion and screening for sexually transmitted infections only work if they are accompanied by substantial community mobilization and the active participation of sex workers to tackle the social and structural factors that influence their vulnerability.
The evidence shows that the criminalization of prostitutes directly contributes to violence, police harassment and an increase in sexually transmitted infections (Rekart, 2005). The decriminalization of prostitution as well as an individual’s right to free choice, even if that choice is sex work, giving prostitutes more control over their lives and how the sex industry is managed and regulated are important aspects of empowerment. The empowerment of prostitutes through the decriminalization of their profession can be an effective approach to improve health, well-being and human rights. For example, the New Zealand Prostitutes Collective (NZPC) was established because of the laws that limited the freedom of prostitution and to combat the harassment and violence that a large proportion of prostitutes were experiencing. The NZPC is a non-government organization comprising past and present sex workers advocating for the human rights, health and well-being of all prostitutes (NZPC, 2008). The NZPC was committed to working for the empowerment of sex workers, so that they may have more control over all aspects of their work and lives. For example, to be able to make informed choices to access services that enhanced their occupational safety and right to work in a supportive environment. The NZPC was legally formed in 1989 when they registered as a charitable trust (NZPC, 2008). Its ability to identify partners, such as sympathetic politicians, who were willing to support its cause, based on a mutual respect and understanding, significantly helped to support decriminalization. A study of the impact of the Prostitution Reform Act (Abel, Fitzgerald and Brunton, 2007) several years after it was implemented showed how both better equity and health for sex workers can result from decriminalization: 87% of all survey participants had a regular doctor, sex workers were less likely to report that they felt pressured to accept a client when they did not want to do so, sex workers were more likely to report having refused to do a client in the past 12 months and spoke of the support that they now had from management when it came to refusing clients. Most survey participants reported telling clients that it was the law that they had to use condoms and over half reported refusing to do the job if the client persisted.
In many countries sex work is stigmatized and sex workers are prosecuted and harassed. Prostitutes are seen as immoral people or as victims of traffickers and as having unfortunate lives in which they have to use sex to earn a living. Clearly the choices of men and women to be involved in sex work should be respected and interventions developed to prevent health risks with a rights-based, participatory approach. Public health programmes should focus on the promotion of the health of sex workers and not just as a way to slow down the cross-infection from sexually transmitted diseases. It is the conditions, rather than the nature, of sex work that should be addressed by public health and interventions policy (Woolfers and Van Beelen, 2003).
KEY TEXTS
•Ho, J. (2000) ‘Self-Empowerment and “Professionalism”: Conversations with Taiwanese Sex Workers’, Inter-Asia Cultural Studies, 1 (2): pp. 283–299
•Laverack, G. and Whipple, A. (2010) ‘The Sirens’ Song of Empowerment: A Case Study of Health Promotion and the New Zealand Prostitutes Collective’, Global Health Promotion, 17 (1): pp. 33–38
•Rekart, M. (2005) ‘Sex-Work Harm Reduction’, The Lancet, 366 (9503): pp. 2123–2134