Control and empowerment in social determinants of Aboriginal and Torres Strait Islander health

Researching the control factor and empowerment in addressing the social determinants of Aboriginal and Torres Strait Islander health

Empowerment interventions can bring about powerful changes in individuals and communities, enabling them to take control of their lives and forming a base for other learning. However, empowerment is a concept often used in the context of Indigenous health without clear articulation of what it actually means and involves. Simply enhancing knowledge about a social or health issue does not equal behaviour change. This is particularly the case in the context of post-colonial societies such as Indigenous Australia where people experience trans-generational grief and loss resulting from racism and other discriminatory government policies. Without this understanding it is difficult to effectively operationalise empowerment, let alone evaluate its effectiveness.

In this project, a 10-year collaborative Empowerment Research Program (ERP) was designed to assess the contribution of empowerment to addressing the social determinants of Indigenous health and wellbeing using two Indigenous-instigated community empowerment initiatives: Men’s Support Groups, and a 50-hour Family Wellbeing (FWB) empowerment education program. The ERP represents one of the few attempts to systematically understand the nature of empowerment from the point of view of Indigenous-developed activities that aim to empower.

Evidence is building that empowerment interventions should be the first step in initiatives aimed at helping people engage and benefit from health and other capacity building programs, and to take advantage of any reforms made within macro policy environments. The development of tools to measure the impact of empowerment interventions, such as the Family Wellbeing Program (FWB) and Men’s and Women’s Groups, are crucial to validate the embedding of such programs in core service provision, thus enabling evaluation of outcomes to meet government requirements for accountability.

Qualitative research to date suggests that through promoting empowerment, wellbeing and social cohesion, participation in men’s support groups and FWB education programs may be saving financial outlays through:

• reduced expenditure on health and welfare;
• lower rates of imprisonment; and
• higher employment.

The ERP has also helped build skills among both Indigenous and non-Indigenous team members, delivering 50 TAFE level accreditations in Family Wellbeing Facilitation and five graduate diplomas in Indigenous Health Promotion, while recruiting seven higher degree research candidates since 2005, with two PhDs and one Masters by research completed through JCU in 2009. Recent uptake of FWB work throughout Australia and overseas in Papua New Guinea also demonstrates the transferability of the research to other contexts and settings.

Project key steps are as follows:

• Phase one of the program focused on defining and theorising empowerment from the point of view of Indigenous Australians, while phase two explores how to measure and determine cost effectiveness of empowerment. Ten-year research objectives (comprising short, medium and longer term) were developed to guide the ERP.
• The ERP has attracted a range of short-term funding, including five NHMRC project grants as building blocks to address the objectives, with the findings of one objective informing the next.
• A commitment to longer-term partnership research arrangements with relevant Indigenous community organisations and other agencies based on the concept of ‘phased approach’ to evaluating complex community health programs.
• A strategy that actively promotes Indigenous employment and participation at all levels of the research, from community-based research worker through to chief investigator.

Findings to date have confirmed international evidence regarding empowerment as a social action process promoting:

• participation of people and communities towards goals of increased individual and community control;
• expanded choices and autonomy; and
• improved quality of life and social justice.

However, there was a greater focus in the Indigenous Australian context on beliefs, personal values and the skills and desires to help others, reflecting Indigenous concepts of spirituality and holism in health. Significantly, the empowerment and related social and emotional wellbeing attributes and outcomes qualitatively described in the ERP findings to date resonate strongly with Australian (Grew et el 2007) and internationally identified evidence-based cost effective or ‘best buy’ mental health promotion programs (UK Dept. of Health 2009).

After 10 years of developmental research adapting and refining the FWB program in a wide variety of settings, an understanding of the dimensions and benefits of empowerment and the potential of these benefits to contribute nationally to improving Indigenous health has emerged.

The empowerment program has significant implications for health promotion and community development project design. Collaborative approaches that creatively integrate micro community empowerment initiatives such as FWB with macro policies and programs can maximise health gains at population levels. This requires partnerships with other agencies and organisations, and adapting and embedding FWB as the foundation for health and social programs. These include:

• child and maternal health
• drug and alcohol
• sexual health including HIV/AIDS
• change management in organisations
• workforce development
• pre-employment training for Indigenous job seekers.

In the context of organisational change, the potential benefits of empowerment programs are twofold:

• a positive impact on the organisation’s effectiveness
• enhancements in staff health, wellbeing and sense of control.

It is also possible to integrate the spiritual dimensions of health into social and emotional wellbeing programs, and this is an important way to support Indigenous families and communities make positive change and take greater control of their futures.

Among the factors that have contributed to the success of the FWB program are self determination and control over program conceptualisation and development, and the Indigenous notion of holism that addresses the physical, emotional, mental and spiritual dimensions of health. For instance, Aboriginal community men’s groups promote participation and social inclusion and community cohesion, and work to shift social norms towards respect for self and others, responsibility and improved wellbeing for men and their families.

A key challenge in the use of psychosocial empowerment programs such as FWB relates to the time and resources required to achieve change at a population level. A long-term partnership approach to empowerment research that creatively integrates micro community empowerment initiatives with macro policies and programs are vital if health gains are to be maximised.

Related resources:

• Bainbridge, R. 2009, ‘Cast all Imaginations: Umbi speak’, unpublished PhD thesis, James Cook University, Cairns.
• Griew, R. 2007, ‘Family Centred Primary Health Care: Review of evidence and models’, paper prepared for Office of Aboriginal and Torres Strait Islander Health, Department of Health and Ageing, Canberra.
• Mayo, K. & Tsey, K. 2008, ‘The Research Dance: University and community research collaborations at Yarrabah, North Queensland‘, Health and Social Care in the Community, vol. 17(2), pp. 133–40.
• McCalman, J. et al 2009, ‘Indigenous Men’s Support Groups and Social and Emotional Wellbeing: A meta-synthesis of the evidence‘, Australian Journal of Primary Health
• Tsey, K. 2008, ‘The ‘Control Factor’: Important but neglected social determinant of health‘ (correspondence), The Lancet, vol. 372(9650), p. 1629.
• Tsey, K. et al. 2003, ‘Social Determinants of Health, the “Control Factor”, and the Family Wellbeing Empowerment Program‘, Australasian Psychiatry, vol. 11(supplement), pp. 34–9.
• Tsey, K. et al. 2005, ‘The Role of Empowerment through Life Skills Development in Building Comprehensive Primary Health Care Systems in Indigenous Australia‘, Australian Journal of Primary Health, vol. 11(2), pp. 16–25.
• Tsey, K. et al. 2005, ‘Adapting the “Family Wellbeing” Empowerment Program to the Needs of Remote Indigenous School Children‘, Australian and New Zealand Journal of Public Health, vol. 29(2), pp. 112–16.
• Tsey, K. et al. 2007, ‘Empowerment-based Research Methods: A 10 year approach to enhancing indigenous social and emotional wellbeing‘, Australasian Psychiatry, vol. 15 (supplement), pp. 34–8.
• Tsey, K. et al. 2009, ‘Empowerment and Indigenous Australian Health: A synthesis of findings from Family Wellbeing formative research’, Health and Social Care in the Community (in press). United Kingdom Department of Health 2009, Executive Summary, New Horizons: Towards a Shared Vision for Mental Health.
• Wallerstein, N. (ed.) 2006, What Is the Evidence on Effectiveness of Empowerment to Improve Health?, World Health Organization, Regional Office for Europe.
• Whiteside, M. 2009, ‘A Grounded Theory of Empowerment in the Context of Indigenous Australia’, unpublished PhD thesis, James Cook University, Cairns, Qld.
• Whiteside, M. et al. 2006, ‘Empowerment as a Framework for Indigenous Workforce Development and Organisational Change’, Australian Social Work, vol. 59(4), pp. 422–34.