Since February 2020, I have been reviewing the research exploring the link between agency, belonging and health. The idea of the project, which is in collaboration with The California Endowment, is to see whether there is empirical evidence to support what many community-focused practitioners know – that individuals and communities with agency are able to change their odds on health, and that this change is all the greater if they have a sense of belonging.
We spent the first few months getting to grips with the medical literature by speaking with ten key informants (listed in the notes below). In response to their insights, we decided to focus on the link between community agency and health – leaving aside individual agency and belonging – partly because there was good theoretical and empirical information to work with and partly because it aligned with the Endowment’s theory of change.
Agency is an awkward term. Although I have gotten used to it, I find it always needs explaining. Many people think of government bodies or companies when they hear ‘agency’, so ‘community agency’ makes no sense to them. But agency also means being able to act to produce an effect, and it’s that definition that I’m using. Synonyms are ‘influence’ and ‘power’, and from here on I’m going to use ‘community power’ because I think it’s less awkward and more communicative.
Health researchers don’t tend to talk about community power but they do often talk about community empowerment. This is especially true in public health where practitioners often feel as though a community’s health would improve if its members were ‘empowered’ to make changes to their lives. Public health tends to interface with communities through community engagement, and sometimes the aim of that engagement is community empowerment.
It’s for that reason that much of the research we found came from public health.
Unfortunately, the term ‘community empowerment’ is often used vaguely. We came across a lot of research claiming that communities had been empowered but on closer inspection had merely been consulted with – usually to make a health intervention more ‘culturally acceptable’. In order to ensure that the research we looked at was genuinely about community power, we used a 2006 model on the link between community engagement and health improvement.
The model is by Jennifer Popay, now a distinguished professor of sociology and public health at Lancaster University in the UK. As well as helping to delineate the different types of community engagement, it also incorporated what we thought to be a plausible theory of change – that the type of outcomes possible depend on the depth of the engagement.
At the shallow end (informing, consultation), only service and health outcomes are possible, and both are modest (indicated by the width of the triangles). However, as engagement deepens and communities are encouraged to take more and more control (a way of describing having power), intermediate outcomes surface. These intermediate outcomes are important in and of themselves but also have the potential to enhance the service and health outcomes.
On the basis of Popay’s model, we looked for research in which power was delegated to communities or in which communities had control. We first looked in review articles recommended by the key informants, and then in two other review articles that we found ourselves. We found 93 research articles in those reviews in which communities either had power delegated to them or were in control. We then pulled out the results from the 93, whether positive, negative or neutral.
The problem with a list of results, however, is that it doesn’t tell you how the thing you’re looking at – in our case, community power – led to those outcomes. Thankfully, we were able to lean on another model, this time one that mapped all of the theories on how community power influences health, which was put together by Margaret Whitehead and colleagues at the University of Liverpool. I’ll be describing that in my next post.
If you want to see the full results of our research into community power and health, our report is online. It lists all 93 articles, describes their results (broken down by the quality of the research), suggests how we’d update Popay’s model, and has a narrative on what we learnt from the key informants. But I’ll be covering the same ground over the next few months in these fortnightly posts.
Until next time.
Pritpal S Tamber
- The ten 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 global health literature also has a fair amount of research on community empowerment. Global health, of course, incorporates public health but tends to be broader.
- Popay’s model was first published in 2006 as a background paper for the National Institute for Clinical Excellence in England. The paper is no longer available but the model was published again in 2010 as part of a book chapter entitled, ‘Community Engagement for Health Improvement: The English Experience.’ The book was ‘Health Assets in a Global Context’, and is available here.
- The image of Popay’s model was taken from a 2013 article by O’Mara-Eves and colleagues (because it was more readable than the version in the abovementioned book). My use of the image is in line with the terms of publication of the article.
- 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.
The photo behind the title is by PIXNIO.