Sustainability and power in health promotion: community-based participatory research in a reproductive health policy case study in New Mexico

Health promotion programs are commonly viewed as value-free initiatives which seek to improve health, often through behavior change. An opposing view has begun to emerge that health promotion efforts, especially ones seeking to impact health policy and social determinants of health, are vulnerable to political contexts and may depend on who is in power at the time. This community-based participatory research study attempts to understand these interactions by applying a conceptual model focused on the power context, diverse stakeholder roles within this context, and the relationship of political levers and other change strategies to the sustainability of health promotion interventions aimed at health policy change. We present a case study of a health promotion coalition, New Mexico for Responsible Sex Education (NMRSE), as an example of power dynamics and change processes. Formed in 2005 in response to federal policies mandating abstinence-only education, NMRSE includes community activists, health promotion staff from the New Mexico Department of Health, and policy-maker allies. Applying an adapted Mayer's power analysis' instrument, we conducted semi-structured stakeholder interviews and triangulated political-context analyses from the perspective of the stakeholders. We identified multiple understandings of sustainability and health promotion policy change, including: the importance of diverse stakeholders working together in coalition and social networks; their distinct positions of power within their political contexts; the role of science versus advocacy in change processes; the particular challenges for public sector health promotion professionals; and other facilitators versus barriers to action. One problem that emerged consisted of the challenges for state employees to engage in health promotion advocacy due to limitations imposed on their activities by state and federal policies. This investigation's results include a refined conceptual model, a power-analysis instrument, and new understandings of the intersection of power and stakeholder strategies in the sustainability of health promotion and health in all policies.