Health Psychology. Michael Murray
capital, or its lack, has been linked with health inequalities. Uphoff et al. (2013) systematically reviewed evidence on the associations and interactions between social capital and socio-economic inequalities in health. Of the 60 studies that met the inclusion criteria, 56 showed significant correlations between social capital and socio-economic inequalities in health. Twelve studies showed how social capital can act as a buffer against the negative effects of low SES on health, while five concluded that social capital has a stronger positive effect for people with a lower SES.
There has been a wide range of criticisms of social capital as an explanatory concept (e.g., Lynch et al., 2000). These include confusion over what exactly the term implies, debates over ways of measuring it, and ignorance of the broader political context. Bjørnskov and Sønderskov (2013) argued that social capital is not a good concept since contemporary research either conceptualizes it as several distinct phenomena or constructs it using other terms. Baum (2000: 410) also emphasizes caution in the use of the concept in that ‘there are dangers that the promotion of social capital may be seen as a substitute for economic investment in poor communities particularly by those governments who wish to reduce government spending’.
Community Mobilization and Power
Considering that current global economic processes restrain the capacity of grassroots organizations to respond to structural challenges in health, it is important for future interventions to develop new methods to leverage power for such organizations (Campbell, 2014; Campbell and Cornish, 2014; Speer et al., 2014). It is important to recognize the need to transform power relationships, not just at individual and community levels, but also at macro levels (Ansell, 2014). As shown in the case presented in Box 5.3, developing strategic alliances can help grassroots organizations to strengthen their political power to affect policy change. Developing partnerships for health and community development ‘must be understood not as a tool for intervention, but as part of the interventions and definition of success’ (Aveling and Jovchelovitch, 2014: 34). The process of building partnerships involves critical reflection and is influenced by institutional and socio-cultural contexts.
BOX 5.3 INTERNATIONAL CASE STUDY: Creating social alliances to influence positive policy change
Speer et al. (2014) presented the case of ISAIAH, a faith-based community organizing group based in the Minneapolis–St Paul metropolitan area. It was formed in 2000 when three faith-based groups merged after recognizing that small groups do not have sufficient political power to influence change. It is now composed of 90 different organizations and uses a social action approach to affect positive policy change to address social inequity. The group had been instrumental in preventing the elimination of three stops for a light rail line being built in Minneapolis–St Paul. The communities that would potentially benefit from these transit stops were predominantly ethnic minority groups. The group influenced planning decisions and funding legislations by collaborating with neighbourhood groups and highlighting the link between transportation and health. As the authors noted:
Pursuing a deeper appreciation of the connection between health and transportation led ISAIAH leaders to policy professionals who emphasized the role of transportation for community vitality – through access to grocery stores, employment, schools, and affordable neighborhoods. Simultaneous to this discernment, ISAIAH responded to the Governor’s vetoes by revisiting state legislators and pushing back against the Governor’s neoliberal articulation of scarcity and limited resources. (Speer et al., 2014: 165)
To maintain the momentum of the group’s efforts, ISAIAH and its allies are currently working on a health-impact assessment to explore land-use policies to prevent the negative consequences of the rail line on marginalized neighbourhoods.
Source: Speer et al. (2014)
Campbell et al. (2010) showed that it is possible for people from disadvantaged communities to mobilize themselves to demand better social and economic conditions to improve health. They presented three successful pro-poor social movements in Brazil, India and South Africa wherein social groups demanded access to land, health services and life-saving medical treatment. A similar case is presented in Box 5.4, wherein pobladores successfully mobilized themselves to demand better living and working conditions in Chile (Hadjez-Berrios, 2014). In these case studies, although enabling disadvantaged groups to make their concerns heard was an important aspect of the movement, the willingness of those in power to take these demands seriously proved crucial to the success of these campaigns. As Stephens (2010) argued, health promotion research and practice need to recognize how those in more advantaged social positions maintain and perpetuate unequal power relations in society. She noted:
Using social theories will enable us to develop research questions with a focus on making visible the practices of those with privilege that work to simultaneously preserve and increase power and access to resources while denying access to other groups. (Stephens, 2010: 997)
BOX 5.4 INTERNATIONAL CASE STUDY: Community participation in health during the Unidad Popular Government – Santiago de Chile (1970–1973)
Context
The organization and mobilization of popular classes had a significant impact on the improvement of living and working conditions in overcrowded cities in Chile. In addition to the creation of the National Health System in 1952 and its later institutional development until 1973, the active participation of disadvantaged and marginalized communities, also known as pobladores, had mobilized social action to address local health problems in poor urban settlements. Community participation in health in Chile saw its peak with the arrival of the Unidad Popular Government in 1970. This ended abruptly in September 1973 due to a military coup that lasted for 17 years.
Method
This qualitative study aimed to explore the experiences of community participation in health during the Unidad Popular Government in Santiago de Chile from 1970 to 1973. Participants included three former health government officials, three primary health care workers and six pobladores, who were directly involved with the movement.
Findings
Participants constructed community participation in health programmes from 1970 to 1973 as a multiple and dynamic response to the health and political challenges faced by communities. Three different moments in community participation in health were highlighted in the analysis. The first moment aimed to expand health care coverage, prevent diseases, educate pregnant women and prevent alcoholism through the development of ‘Health Brigades’ inside settlements. ‘Health Brigades’ were relatively autonomous organizations (mostly composed of young women) that were trained by health workers. The second moment was characterized by improvements in autonomy and widening of the scope of participation through grassroots participation in health decisions. In this context, health issues were no longer conceptualized in biomedical terms. Finally, the third moment in community participation in health was characterized by a growing understanding of the wider determinants of health and the development of comprehensive definitions of health related to the democratization of health services.
Conclusion
Community participation in health in Chile during the Unidad Popular Government contributes to a critical understanding of community participation, conceived as a dialectic and transformative action. In this context, the pobladores constituted themselves as social subjects who actively transformed Chilean health institutions by challenging the dominant and oppressive hierarchies in society.
Source: Hadjez-Berrios (2014)
In a review of what it would take to eradicate health inequalities, a report for NHS Scotland (Scott et al., 2013: 6) concluded that this can only be achieved ‘if the underlying differences in income, wealth and power across society are reduced’. In a similar report, McCartney et al. (2012) reviewed the evidence for the higher rate of mortality in Scotland. They concluded that the continued high rates of mortality, despite improvements in health care, can be accounted for by a ‘synthesis that begins from the