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Action on social determinants of health

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For a long period, health practitioners have developed different strategies to improve the health of people and the whole communities. The health practitioners have devoted on focusing on social determinants of health, and deal with them in order to improve health of their clients, as well as that of the whole community. According to World Health organization, social determinants of health are the conditions where people are born, work and live, and these factors determine the quality of life. These factors are influenced by the distribution of power, money, as well as resources in global, national, as well as local level (Laliberté, Perreault, Damestoy and Lalonde 2012, p. 192) The social determinants of health significantly affect health inequities. Health inequities refer to avoidable and unfair health inequalities. On the other hand, health inequalities refer to differences in health status, or the distribution of health determinants between different groups.

The public health practitioners focus on improving the health of their clients and the community through improving accessibility of the social determinants of health. In other words, they provide equality in terms of providing social determinants of health to communities on order to improve their health outcomes (Keleher, Murphy and MacDougall, 2007, p 45). As a result, Laverack asks the key question regarding this approach. The question of whether health practitioners are there to empower their clients or whether they are there to change their client remain in order to improve health.

This rhetoric remains controversial, and the lack of answer to this question rest on the fact there is little knowledge on the theoretical background, as well as practical skills on empowerment and change. This paper is a review of empowerment and change literature and provides relevant examples to answer whether public health practitioners are empowering or changing their clients and community (Keleher, Murphy and MacDougall, 2007, p 45). Empowerment and change

Empowerment refers to give power, or authority, or authorize using a legal means or official way. In public health, community empowerment refers to the process of enabling community to have control over their lives. Empowerment refers to the process in which people gain controls over the factors, as well as decisions that shape their lives. It is the same process by which they gain assets, have a voice and attributes, build capacities and networks in order to gain control (Keleher, Murphy and MacDougall, 2007, p. 45). According to Laverack (2007, p. 23), empowerment is more than enabling. In this case, in enabling, people cannot be empowered by others and can empower themselves. Therefore, community empowerment is more than participation, involvement or engagement of communities, and it implies that community ownership and actions that focus on social and political change.

Change, is different to empowerment because it refers to making something different (Laverack 2007, p. 23). Different initiatives have been provided by the public health practitioners to empower rather, as well as change their clients and the whole community. Various research conducted on strategies of health promotion in communities have shown that empowerment as an important strategy in health promotion in communities. Public health practitioners have been on the verge of finding a solution regarding health inequities. Primary health strategy is one of the strategies they have used to promote health (Laverack 2007, p. 23). Case description

Wilkinson and Pickett (2010, p. 236) argue that sustainability of a social movement for equality depends on the direction, as well on how the necessary changes in the economy and social lives rather than waiting for the government to intervene. As a result, every person requires starting improving his or her social status by any means in the society, and in the institutions. For instance, individuals should engage in income generating activities and creating stable ecosystem as part of prerequisites for health (Keleher & MacDougall, p. 6). There is no big revolution required, but a stream of continuous change in the right direction can bring change. Following the same, public health promoters, leaders and practitioners in Oregon, United States have initiated a programme to promote health equity in the whole region.

The initiative is a state-wide collaboration health improvement initiative taken by the public health practitioners and the key leaders in the state of Oregon in the United States (Oregon Health authority, 2013 p. 4). The plan focuses on the providing health equity among the people in the regions through establishment of policies, and practices to prevent chronic disease that were declared a threat to the state. The initiative envisions a state which is health equitable through accomplishment of four priorities, including preventing and reducing tobacco use, slow the increase of obesity, improve oral health, and reduce substance use and untreated behavioural issues (Oregon Health authority, 2013, p. 4).

According to Oregon Health authority (2013 p. 5), the communities are empowered to improve the lifelong of other people, whereby, the vision is that all the people are capable of reaching their full potential of health. In reducing tobacco intake, the programme initiators focus on raising the cost of cigarettes, and amount of the money gained from the tax is used to develop rehabilitation centres. Slowing obesity, they focus on providing access to healthy foods to low-income population especially among the youth, and providing legislative that allow the adoption of nutritional standard in cafeteria and food outlets. Improving oral health is by encouraging public water district to fluoridate water. Finally, to reduce substance and related issue behavioural issue, the programme focuses on conducting baseline line study to evaluate the availability of culturally and competent health providers (Oregon Health authority, 2013, p. 7).

Blue = Tobacco use
Light green = Obesity
Grey = Oral health
Light Blue = Substance abuse

Analysis of initiative
The actions taken from the case relate much with health promotion literature because there is a promotion of equitable health among the people of Oregon through health practitioners and public health practitioners. A Programme must take a design in which will be used to provide the relevant outcome. A design shows the way the people are empowered. According to Laverack (2005, p. 188), on power and knowledge theory, people get power in two ways, through zero-sum and non-zero-sum. As seen from the case study, people are given power in using the two designs, zero-sum power and non-zero-sum.

Zero-sum power creates a win/lose scenario, whereby the public health practitioners bring the beneficiaries of the health promotion a programme that bring a great deal of power in the form of authority and control (Laverack (2005, p. 189). In zero-sum, for a person to gain power another has to lose. In this case, the community is given power to decide on what they should have thus implying the producer, or the supplier will no longer decide on what the community should use (Manojlovich, 2007, p. 2). On the other hand, non-zero sum power provides win/win situation whereby it is based on the idea that if one person or group gain thus all the others gain (McHoul and Grace 1995, p. 34).

Oregon’s Healthy Future programme has also taken non-zero-sum since the health practitioners also provide information to youths through counselling, as well as nutritional information (Oregon Health authority, 2013, p. 7). As Laverack (2007, p. 76), indicates, community health promotion employs both zero-sum and now-zero source of power. In this regard, power cannot be given, but community can be enabled, or empowered by health promoters to take the power they need from others (McHoul and Grace 1995, p. 34).

1st Qtr and 3rd Qtr > Non-zero sum
2nd Qtr and 4th Qtr > Zero sum
Health promotion programmes require using a model of approach, or strategy in order to effectively achieve its goal. While there are a number of strategies used in different programmes, research indicates each model depends on the design of the programme, as well as the goals of the programmes. These strategies include the community development, community education, primary health care, and personal skills development. Strategy refers to the way or formula to achieve something. Oregon’s health promotion programme employs a primary health as the main strategy to provide health equality in the state. Effective co-ordination of primary health strategy goes beyond treatment and prevention, and includes comprehensive disease prevention and health promotion.

Laverack (2006, p. 115) indicates that health promotion is at the heart of the primary health care strategy, and for the strategy to work efficiently, primary health care practitioner must work together with the public health practitioner. The strategy is wider than what is provided in practice, and include some population-based services that are well delivered in the primary care setting. The primary health care strategy requires new skills, as well as coordination across the entire health sector than it was previously achieved (Webb, Danaher and Schirato 2002, p. 14). As Clark and Krupa (2002, p. 12) indicate, primary health care is a critical “strategy of public health derived from the social model of health” and designed specifically to deal with determinant of health. Thus, it is a system to reduce health inequities (Keleher, Murphy and MacDougall 2007, p. 6).

A primary health care provides change rather than providing empowerment to the community. The Oregon’s Healthy Future programme aims at changing the environment to provide equitable health for all people. The health promotion model by Pender (1982; revised, 1996) shows that the health professionals constitute an interpersonal environment that influence a person throughout their life. On the other hand, the programme also shows minimal empowerment to the community.

In this case, people are given power through provision of nutrition, tobacco prevention and education programmes, and counselling knowledge on how to deal with behaviour problems (Webb, Danaher and Schirato 2002, p. 14). However, the tension still exists on the meaning of empowerment in health promotion, individual or community empowerment share psychological empowerment, which relates to a number of attributes needed for the realisation of personal capacity. In the case study, psychological empowerment is seen through the provision of educational and counselling programmes for the people (Webb, Danaher and Schirato 2002, p. 14). Arguments

Laverack asks the key question regarding this approach used in health promotion. The question is whether health practitioners are there to empower their clients or whether they are there to change their client. The question remains controversial, and this case study cannot provide a concrete answer to the question. However, the case implies that the health practitioners use both empowerment and change as a strategy to promote health in their clients. As seen from the health promotion model by Pender (1982; revised, 1996), health professional constitute an interpersonal environment that influence people throughout their life. Therefore, they can influence through change or empowerment.

The element of empowerment is seen when the health practitioner uses non-zero sum power design, which is characterised by providing knowledge on nutrition, tobacco prevention and education programmes, and counselling knowledge on how to deal with behaviour problems. The element of change appears because of the provision of new policies that provide power through zero-sum design. Furthermore, the leaders and the health practitioners also introduce policies of increasing the cost of food with high sugar content and increase surveillance to regulate the abuse of drugs.

Therefore, in this case, the public health practitioners are changing the behaviour of their clients, as well as those of the community. Empowerment in state of Oregon can be ineffective because of the multiculturalism nature of the community. Laverack (2007, p. 23) argues that empowerment model faces challenges of social difference and truth claims, as the factors changes with the community. Therefore, it can be concluded that the health practitioners use either change or empowerment to promote health to their clients and the community (Laverack, 2007, pp. 23-26). Conclusion

This paper answers Laverack question of whether health professional help to empower the clients or help to change the client in order to promote health. Using the Oregon’s Healthy Future initiative as a case study of the analysis, the study found that health professional uses both strategies to promote health. For example, the health professional and leaders enacted policies aimed to change the behaviour, as well as empower the people. In the case, the increment of price on unhealthy foods and tobacco aimed at changing the behaviour of the people. On the other hand, educational programmes and counselling programmes aimed at empowering people.

Reference List

Clark, C. C., & Krupa, T. 2002. Reflections on empowerment in community mental health: Giving shape to an elusive idea. Psychiatric Rehabilitation Journal, 25(4), 341-349. Keleher, H., Murphy, B., & MacDougall, C. 2007. Understanding health promotion. South Melbourne, Victoria: Oxford University Press. Laliberté, M. C., Perreault, S., Damestoy, N., & Lalonde, L. 2012. Ideal and actual involvement of community pharmacists in health promotion
and prevention: a cross-sectional study in Quebec, Canada. BMC public health, 12(1), 192. Laverack, G. 2005. Public health: Power, empowerment and professional practice. New York: Palgrave Macmillan. Laverack, G. 2006. Improving health outcomes through community empowerment: a review of the literature. Journal of Health, Population and Nutrition, 113-120. Laverack, G. 2007. Health promotion practice: Building empowered communities. Maidenhead: Open University Press. Manojlovich, M. 2007. Power and empowerment in nursing: Looking backward to inform the future. Online Journal of Issues in Nursing, 12(1). McHoul, A. W., & Grace, W. 1995. A Foucault primer: Discourse, power, and the subject. London: UCL Press. Oregon Health authority, 2013. Oregon’s Healthy Future: A Plan for Empowering Communities. Retrieved on August 23, 2014 from http://public.health.oregon.gov/About/Documents/oregons-healthy-future.pdf Webb, J., Danaher, G., & Schirato, T. 2002. Understanding Bourdieu. London [u.a.: SAGE. Wilkinson, R. G., & Pickett, K. (2010). The spirit level: Why greater equality makes societies stronger. New York: Bloomsbury Press. Pender 1986; revised 1996. Health promotion model. Nursing theorists and their work, 7, 434-453.

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