In my last post, I explained how I’ve been reviewing the research exploring the link between community power and health, and how that led to finding 93 articles. Unfortunately, although some of the research is good, much of it failed to begin with an initial hypothesis. As a consequence, it’s difficult to draw a pathway from community power to the results being reported.
Some of the authors use their results to theorize the pathway or pathways. This is perfectly acceptable when the research is in a new field but ‘community power and health’ is not remotely new. Numerous theories have been proposed for at least the last 30 years.
In many ways, however, that’s part of the problem. There are so many theories, often using very different terms, that it can be difficult to pinpoint a theory to test in one’s research.
Thankfully, in 2017, Margaret Whitehead and colleagues at the University of Liverpool synthesized the numerous theories. Rather than ‘power’, they used the term ‘control over destiny’, which they took from one of the first articles written about the importance of power to health. They organized the theories into three levels – individual, community and societal – and only included those that made some attempt to explain inequities in health (not just health outcomes).
In this post, I’m focusing on the community level, although one of the things I learnt from this work is that all three levels influence each other. Below is their logic model of the theories connecting community power to health. I have to be honest and say that I first found it hard to read, mainly because I expected community power to be the starting point (i.e., on the very left). Instead, and quite reasonably, they start where the theories start, which is on how powerlessness occurs. They describe this as the interaction of disadvantaged people living in disadvantaged places, which they call ‘concentrated disadvantaged environments’.
Broadly speaking, the upper pathway is about health protection and the lower pathway is about risks to health. I’m going to start with the lower pathway because I think most of us are used to thinking about risk factors more than protective factors.
Concentrated disadvantaged environments have the potential to create neighborhood disorder. Residents experience these neighborhoods as dangerous and threatening, and the collective threat leads to collective mistrust and a sense of powerlessness. The sense powerlessness has the potential to amplify the collective mistrust, especially if the environment is threatening. All of this causes distress, which leads to poorer mental and physical health.
The upper (health protective) pathway asks what’s present in communities that have the power (or ‘collective control’ as they call it) to challenge the neighborhood disorder. The theories posit that it’s things like social cohesion, community capacity, ontological security, a sense of continuity, and community assets. Whitehead and colleagues call these things social protective factors.
Community power (collective control) operates in direct and indirect ways. An example of the direct way is when a community prevents a toxic waste facility from being placed in its neighborhood. The indirect way relates to the reduction in social isolation that occurs through community participation, which has been shown to increase social support and inclusion and improve mental health.
With these theories mapped out, it becomes possible to see how the upper pathway protects from the risks depicted in the lower pathway. A community with power can address the neighborhood disorder by, for instance, improving safety and attracting resources, such as more investment in services and facilities. This would reduce the collective threat and mistrust, which, in turn, would reduce distress and hence improve mental and physical health.
The theories are not all positive, however. While not depicted in the above diagram, Whitehead and colleagues mention that some researchers have suggested that community power can lead to an increase in distress and ill-health. This is because there is only so much communities can do in the face of political, socioeconomic and cultural forces. Trying to work against these forces can lead to burn out, disillusionment and distress.
We owe a debt of gratitude to Whitehead and colleagues. By my count, they have considered theories from 22 articles in their synthesis. As they say, their aim was to provide new frameworks for the design and conduct of theory-led evaluations. Given the paucity of hypothesis-based research on community power and health, I hope to see their work cited repeatedly in future projects and research.
Armed with Popay’s model (to help us identify research that’s genuinely about community power) and Whitehead’s synthesis (to help us make sense of the results), we analyzed the link between community power and health. I’ll start describing that link in my next post but if you can’t wait remember that our full report is available online.
Until next time.
Pritpal S Tamber
- Whitehead and colleagues use the term inequalities rather than inequities but I know from their other work that they see them as the same thing. I double-checked this with Margaret Whitehead, and she confirmed that using inequities was ok.
- The image is a screen shot of the article, the use of which is in line with the terms 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 Amir Saboury on Unsplash