In this season of posts, I am sharing the results of my research into the link between community power and health as reported in the medical literature. I’ve covered how we found the articles (post one), a synthesis of the many theories (post two), what the high-quality research tells us (post three), and some of the things that stood out from the rest of the research (post four).
In this post, I’ll relate the findings from the 93 articles that we identified (briefly summarized in posts three and four) to the synthesis of the many theories (that I described in post two). The diagram below is that synthesis and the blue numbers are explained in the text that follows.
To remind you, the upper branch illustrates how community power might be health protective and the lower branch illustrates how a lack of it might be a risk to health.
Based on the findings from the 93 articles, the start of the path to health improvement seems to be a change in the skills and perceptions of the community members involved. The confidence, positivity, and pride that are part of this give people a sense of their individual and collective power (1), alternatively described as a community feeling empowered (2).
Focusing on the risks to health (the lower branch), the findings support the hypotheses that this sense of individual and collective power (1) not only reduces distress directly (3) but also diminishes collective mistrust (4), which, in turn, further reduces distress (3).
Turning to health protection (the upper branch), the findings also support the theories that communities with power (called collective control in the diagram) not only feel empowered (2) but also have more trust between people and between people and organizations/systems (5). And there were numerous examples of communities with power deflecting threats to the environment (6), maintaining and enhancing the local environment (7), and resisting the “hollowing out” of services and facilities (8) – three of the four direct pathways from community power (collective control) to better community health.
Staying with health protection (the upper branch), the findings also supported the theories that ‘social protective factors’ are often present in communities that have power (9). This was especially true of social cohesion (to remind you, in post two I said other social protective factors are things like community capacity, ontological security, a sense of continuity, and community assets).
Finally, returning to risks to health (the lower branch), the findings also supported the theories that communities with power are able to make their neighborhoods safer (10).
In identifying the parts of the above diagram supported by the articles that we identified I’m not saying that they are ‘right’ and that the rest of the diagram is ‘wrong’. I’m just saying that on the basis of the articles that we found in the medical literature, those are the parts for which there is empirical evidence. For instance, if a community comes together to deflect threats and enhance the local environment (6), why would it not also attract resources to create a better place to live (the fourth of the four direct pathways)? It probably would, it’s just that we did not see it reported in the articles that we identified.
The other thing to note is that ‘evidence’ is not just what is studied and written up, it’s also what has been learnt through experience. I am sure there are readers that can think of examples to support some or all of the other parts of the diagram. Again, it is not my job to say what is ‘right’; I’m just mapping what we found in the medical literature.
So, where does this leave us? To my mind, the empirical evidence supports (some of) the theories and the theories help to make sense of the findings from empirical research. The way I summarized that in my research is that there is “an encouraging evidence base” (see the Executive Summary).
When Whitehead and colleagues synthesized the many theories on community power and health, they did so with the aim of providing new frameworks for the design and conduct of theory-led evaluations. With some luck, what I have done in my research and this series of posts is build on that so that you – a leader in health looking for new ways to address health inequity – are encouraged to embrace the building of community power as part of your health improvement strategies.
In a forthcoming post, I’ll propose a model based on the results of my research. It connects community engagement, health improvement, and the building of community power (see the third note below). But before that, in my next post, I’ll share some of the things that I learnt from the key informants that I interviewed as part of this work (see the fourth note below). Their insights go beyond what is in the medical literature.
Until next time.
Pritpal S Tamber
- The report of my research contains a more in-depth look at how the findings from the 93 articles that we identified might be mapped to the synthesis of theories.
- The image above is a screen shot of the article by Whitehead and colleagues (with numbers overlaid by me). My use of the screen shot is in line with the terms of the article.
- We’re sketching that model as part of an article for a health journal based on the results of my research and the experience of The California Endowment, which, since 2010, has sought to build the power of 14 low-income communities so that they can improve their conditions and hence their health (see here).
- The key informants were (alphabetically by surname): Michael Little; Michael Marmot; Mahasin Mujahid; john a powell (who prefers his name to be written all lower case); Shannon Sanchez-Youngman; Rebeca Sandu; Richard Smith; Paul W Speer; Nina Wallerstein (who was only available by email); and Margaret Whitehead.
- The research being described in this season of posts was in partnership with the Insight Center for Community Economic Development, and I thank Brad Caftel of the Center for overseeing the administrative details involved.