How to empower a community? Helping communities take control of their health destiny

Highlights

• •Engaged Empowerment Town Halls promote self-actualization through collective agency.
• •Optimal collective agency may promote participation in clinical trials.
• •Distrust in institutions may correlate with participation in research studies.

Knowledge is power. Therefore, the transfer of knowledge from one to another is by definition the essence of empowerment. One of the most enduring problems in the scientific community is how to transfer knowledge generated from research findings to citizens. This is especially critical in communities that have little power, where the economic, social, and political milieu contributes to disparities in health services and health outcomes. It is in these places where the knowledge produced through the exchange of information is most beneficial. The purpose of this paper is to introduce the Engaged Empowerment Town Hall method and to analyze its efficacy as a mechanism of empowerment.

For some time now, the research community has known that place matters, but just as important are the socioeconomic determinants of place and how they affect health outcomes (Swanstrom et al., 2002; Williams and Collins, 1995). The determinants of place are socioeconomic factors such as income, education and occupation that influence the presence of resources that affect life quality. Communities that are more affluent tend to have more health advantages with the inverse being true for low-income communities (Ross and Mirowsky, 2001; Wilson, 1996). Neighborhoods with high levels of disadvantage have a preponderance of residents who lack such resources. But if place matters, it must not be forgotten that the individuals who make up “place” matter as well. Indeed, what makes neighborhoods affluent or not are residents' level of occupational, institutional, and social capital resources that can be translated into social, financial, and health outcomes.

Thus, it is established that neighborhood and individual socioeconomic status affects health outcomes. By examining levels of crime (Ross and Mirowsky, 2001; Sampson et al., 1997); housing and employment (Hannon et al., 2012), single parent homes and residential segregation (Massey, 1996), and social environment (Wang et al., 2017) one can get a good idea of the likelihood of residents engaging in outdoor physical activity, the proximity of high quality food, the proximity of health care providers, chronic stress, pollution in the environment, smoking cessation, and the quality of psychosocial health among residents.

Other studies suggest that individual poverty has a direct impact on health. This is specifically true when it comes to the ability of residents to afford high quality insurance, which is critical to residents receiving important screening and preventive care (Smith et al., 2017). Also, low-income residents tend to have less geographic access to primary care physicians, physician assistants, and chiropractors. This facet of neighborhood disadvantage reflects healthcare professionals' preference to locate in affluent communities given that many of them operate as small businesses (Davis et al., 2018). Just as any profit-driven business, their location reflects their market. In this case, they may choose to operate in areas where residents can afford high-priced medical services.

Similarly, grocers and restaurants are very sensitive to where they locate their stores. They too pay close attention to the market characteristics of particular areas. Thus, being poor affects individuals in their direct ability to access health-enhancing resources, but it also affects where they live and low-income areas are often secluded from factors that confer high life quality.

1. Engaged Empowerment Town Halls

The Tuskegee Community Engagement Core (CEC) developed the Engaged Empowerment campaign to counter the negative impact of socioeconomic status on the individual-place nexus and the subsequent health disparities that result. The CEC operates in low-income, resource poor communities across the Southeast, which includes poor urban communities in Birmingham and Atlanta, as well as rural areas in the Black Belt. The Engaged Empowerment movement seeks to distribute high-quality knowledge to communities that typically have little access to such resources. It uses information exchange and knowledge distribution as mechanisms to build collective agency with the goal of helping residents gain control of their economic, social, and health destiny. In accomplishing this, Engaged Empowerment first addresses individual self-interest then provides knowledge for attaining empowerment on the institutional level where tangible economic, political, and health management resources exist. The primary mechanism for knowledge distribution is the Engaged Empowerment Town Hall meetings where ideas between researchers and community residents are shared. A council of community representatives called HEROs (Health Equity Resource Officers) were selected and asked to specify a knowledge dissemination strategy that encompassed topics that would be materially beneficial to residents.

The Town Halls are inherently democratic. Furthermore, as demonstrated by the mass meetings of the Civil Rights era, they are powerful methods of developing collective agency. In this case, the Town Halls are effective in democratically engaging residents in modern issues concerning economics, scientific research, and health disparities. This is a process rarely afforded to geographically and economically isolated low-income populations in the Black Belt.

The Tuskegee CEC produced two Town Hall meetings in the Spring of 2018 and one in the Fall of 2018. The Town Halls took place at the Southern Christian Leadership Foundation national headquarters in Tuskegee, Alabama. During both Spring Town Halls, we had an in-person audience exceeding 75 people. Our Fall Town Hall had an audience of over 160 residents. Town Hall physical attendance was over represented by low-income, African American females. A broad age range was represented during the pilots with the mean age being 31.8.

The Town Hall meetings are streamed via Twitter and Facebook live to a national audience which enhances our ability to reach underserved communities. The innovative capacity of streaming is its ability to project the opinions, thoughts, and information of rural citizens in the Black Belt, a group rarely seen or heard outside of the immediate area, to a national audience. Rarely will people from Maine or Oregon have an opportunity to get a glimpse of the socioeconomic factors that engender economic decline and subsequent health disparities among African Americans from the Black Belt. People around the country also have an opportunity to retrieve the knowledge disseminated by residents and researchers through the live streaming.

The live streaming proved to be effective as we received a large nationwide audience viewing the Town Hall on social media. What this suggests is that the Engaged Empowerment campaign generated significant impressions and views for the Town Halls. Table 1 provides a breakdown of the streaming numbers for both Town Halls. The live steaming also is beneficial because it is a way for Black Belt residents to share their issues with a broad audience external to their region, which is extremely rare. This empowers them as their voices are amplified. The information exchange at the Town Halls not only amplifies voices, but it also enhances efforts to build collective agency and subsequent community empowerment by increasing institutional participation.

Table 1.

Town Hall viewership.

	Live audience	Twitter sites	Impressions	Facebook live sites
Town Hall 1	>100	202	722	2006
Town Hall 2	75	139	821	841
Town Hall 3	>160	347	1835	2027

2. Empowered individual voices

Self-interest is a fundamental component of collective agency. Indeed, self-interest drives an individual's participation in a group. He or she joins and participates based on what they believe can be attained for them or for those close to them. Likewise, as George et al. (2014) suggest, people are more likely to participate in research studies if they see some personal benefit. The Engaged Empowerment Town Halls taps in to the human condition of self-interest by giving them a voice to express their concerns and opinions. Similar to talk radio, the Town Halls provide everyday people with the power to affect opinion and thought as they speak their mind to a receptive audience.

3. Institutional participation

Boulware et al. (2016), Williams et al. (1997) and many others suggest that the legacy of discrimination explains lower levels of trust in biomedical research. The scientific enterprise has a dubious history in the African American community, which the Town Halls attempt to mitigate by allowing for open exchange between residents and African American scientists who communicate the overall benefit of participating in research. Trust affects participation. If discrimination is the catalyst for distrust, then the proclivity to participate in research should correlate with distrust in other discriminatory institutions. For example, discriminatory laws and policies have hurt Africans Americans economically causing higher levels of distrust in government policy and economics and subsequent lower level of participation. Therefore, trust in government and economics should correlate with participation in medical research studies with discrimination as the intervening variable of both.

Thus, by providing knowledge on economic empowerment we are easing the sting of historical discrimination in this area. Such empowerment then correlates with higher levels of trust in not only resident's ability to shape their economic and political futures, but also their ability to affect medical research through their participation. What is being promoted here is empowerment through participation.

Moreover, if discrimination is the catalyst for distrust, then their likelihood of trusting similar institutions that are discriminatory should correlate with their likelihood of participating in research studies. Engaged Empowerment Town Halls seek to address trust issues in the overall system first, which should lead to subsequent trust in the research process. Therefore, providing knowledge on the factors that residents feel will empower them economically and socially should be associated with greater desire to participate in research.

4. Evaluation methodology

The most informative methodology will determine if the Town Halls are an effective method of information exchange and knowledge distribution to the point where residents feel empowered. To address this, the CEC developed the Southeast Black Belt Health Empowerment Survey. The survey is a 27-item research instrument divided into four parts 1) sociodemographic, 2) collective empowerment, 3) preventive lifestyle activities (do you regularly engage in physical activity, screenings), and 4) institutional access and trust.

The survey is a mixture of Likert-style, interval numeric, and qualitative questions. It was piloted to a sample of participants (n = 32) viewing the first two Town Halls. The sample included physical attendees as well as members of the streaming audience.

Of specific interest, is the collective empowerment index – which relates to the Town Hall's ability to amplify resident voices – and the questions regarding institutional access and trust. Both give an indication of the effectiveness of the Town Halls as a mechanism of information exchange and knowledge distribution. The collective empowerment index averages the responses of three questions into a simple factor analysis measuring impact: How confident are you that 1) as a community, we have the power to develop economic opportunities, 2) as a community, we have the power to gain political influence, and 3) as a community, we have the power to unify around positive goals. Respondents were asked to rank how they feel on a Likert scale with not confident = 4, a little confident = 3, confident = 2, and very confident = 1. The scores for each respondent were averaged with higher scores representing lower confidence. The sample was split among respondents who experienced the Town Hall (n = 22) and those who did not (n = 10) (Table 2). The pilot revealed an internal consistency (Cronbach's α) of 0.943. There was a medium effect size between those who viewed the Town Hall and those who did not (d = 0.43).

Table 2.

Frequency table of resident views on their collective empowerment among those who did or did not experience an Engaged Empowerment Town Hall. (Did not experience Town Hall n = 11, experienced Town Hall n = 29) Index mean 1.7(SD.85).

		Frequency
		Not confident	A little confident	Confident	Very confident
Confidence in the power to develop economic opportunities	Not experience	0	4	1	6	64% confident or very confident
	Experience	1	7	5	16	72% confident or very confident
Confidence in the power to gain political influence	Not experience	1	3	3	4	64% confident or very confident
	Experience	2	4	4	19	79% confident or very confident
Confidence in the power to unify around positive goals	Not experience	0	3	3	5	73% confident or very confident
	Experience	1	4	3	21	83% confident or very confident

The collective empowerment index can also be expressed as an interval numeric variable where participants are asked to rank each question from 1 to 100, which facilitates regression analyses. This will allow for controls such as the effect of Town Halls on empowering residents while adjusting for age, sociodemographic variables (employment, income, education), levels of trust in institutions, and health-lifestyle practices (exercise, physical activity, diet).

The study also investigates institutional access and trust as a form of empowerment. As Williams and Rucker (2000) have argued, distrust in institutions is a function of historical discriminatory practices. Thus, distrust in research has the same origin as distrust in the criminal justice system or politics. By exchanging information on how to overcome such discrimination, levels of trust should increase. A part of this information exchange involves a discussion on how participation in these institutions empowers the group. So, like sitting on a jury or voting, participating in clinical research studies is a form of empowerment. Therefore, we included the question: How likely are you to participate in a government funded, health-related study that requires you to give blood? 1 = Not likely at all, 2 = somewhat not likely, 3 = neither likely or not, 4 = somewhat likely, and 5 = very likely (Table 3). In this case, the pilot revealed a medium to large effect size (d = 0.76) suggesting that the Town Halls may be doing a good job of empowering residents by encouraging empowerment through institutional participation, specifically in clinical trials.

Table 3.

Frequency table cross tabulating likelihood of participating in a clinical trial among those who are optimally confident in their community's power to develop economic opportunities, gain political influence, and unify around positive goals (optimally empowered respondents report a mean of 1 on the collective empowerment index).

		Not likely at all	Somewhat unlikely	Somewhat likely	Very likely
How likely are you to participate in a government funded research study/clinical trial?	Optimally empowered	6	1	0	4	36% Somewhat or very likely to participate
	Less than optimally empowered	10	3	0	4	24% Somewhat or very likely to participate

5. Conclusion

More sophisticated analyses will be conducted during future Town Halls, but the foundation for accomplishing useful data collection is present. Importantly, the Engaged Empowerment campaign is earnest in its mission to empower residents through information-exchange and subsequent knowledge distribution. The subject matter at Town Halls will be guided by HEROs who serve as liaisons between resource-granting institutions and the community. By continuing to build a following on social media, we plan to grow our streaming audience, which in turn will provide greater amplification of resident voices. By providing an outlet for residents to voice their thoughts, we are tapping into their self-interest which is expected to provide a higher degree of collective empowerment than what was displayed in the pilot. Furthermore, we will focus on increasing the participation rate of African American males in future meetings. Nonetheless, the overall context of community, engagement, and information exchange has been visible facets of the qualitative empowerment experienced by Town Hall attendees.