empowerment interventions for older adults

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ResearchWestern Journal of Nursing

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published online 30 July 2010West J Nurs ResNelma B. C. Shearer, Julie Fleury, Kathy A. Ward and Anne-Marie O'Brien

Empowerment Interventions for Older Adults

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1Arizona State University, Phoenix

Corresponding Author:Nelma B. C. Shearer, 500 N. 3rd Street, Phoenix, AZ 85004 Email: [email protected]

Empowerment Interventions for Older Adults

Nelma B.C. Shearer1, Julie Fleury1,Kathy A. Ward1, and Anne-Marie O’Brien1

Abstract

There has been much discussion regarding the need to empower older adults to make informed health decisions and to test interventions targeting empowerment to promote health among older adults. It has been suggested that an empowerment approach may nurture an older adult’s participation in health care decisions and promote positive health outcomes. The purpose of this article is to report the findings of a critical review of published empowerment intervention studies with community-dwelling older adults. A descriptive literature review was conducted to examine how empowerment is conceptualized across interventions, the guiding theoretical frameworks, the outcomes measured, as well as the health outcomes of these interventions. Based on the findings from this review, recommendations for future empowerment intervention research with older adults as well as implications for practice are proposed.

Keywords

empowerment, interventions, older adults

Never before in our nation’s history have we experienced such a rapid and unprecedented growth in the number of older adults, defined by the American

West J Nurs Res OnlineFirst, published on July 30, 2010 as doi:10.1177/0193945910377887



2 Western Journal of Nursing Research XX(X)

Association of Retired Persons (http://www.aarp.org/) as someone aged 50 years and older. By the year 2030, approximately 20% of the U.S. popula-tion will be compromised older adults, many of whom will seek health care (Administration on Aging [AOA], United States Department of Health and Human Services, 2007; Centers for Disease Control and Prevention & The Merck Company Foundation, 2007). The aging of the U.S. population and the concomitant rise in health care needs underscore the importance of facili-tating meaningful and innovative ways to foster positive health outcomes among older adults.

There has been much discussion regarding the need to empower older adults to make informed health decisions (AOA, 2007) and to test interven-tions targeting empowerment to promote health among older adults (e.g., DeCoster & George, 2005; Keller & Fleury, 2000). It has been suggested that an empowerment approach may nurture an older adult’s participation in health care decisions and promote positive health outcomes (AOA, 2007; Toofany, 2006, 2007). The purpose of this article, therefore, is to report the findings of a critical review of published empowerment intervention studies with community-dwelling older adults. Specifically, a descriptive literature review was conducted to examine how empowerment is conceptualized across inter-ventions, the guiding theoretical frameworks, the outcomes measured, as well as the health outcomes of these interventions. Based on the findings from this review, recommendations for future empowerment intervention research with older adults as well as implications for practice are proposed.

Conceptualization of EmpowermentIn the health education and health promotion literature, empowerment has been conceptualized as a framework for understanding the process and conse-quences of efforts to exert control and influence over the decisions that affect one’s life, including perceptions of personal control as well as behaviors to realize control (Perkins & Zimmerman, 1995; Rappaport, 1984). Empowerment as a process focuses on relationships with others and the transfer of power with the outcome of “liberation, emancipation, energy and sharing power” (Leyshon, 2002, p. 467), and can be understood from several perspectives, including social and developmental (Shearer, 2004; Shearer & Reed, 2004). Such perspectives provide a basis for identifying and evaluat-ing empowerment interventions among older adults.

As a social process, empowerment is associated with external social forces that act on the person and affect his or her sense of control and feelings of power (Shearer, 2004; Shearer & Reed, 2004). Social support as an external feedback



Shearer et al. 3

mechanism has been studied as a process that can provide needed reinforce-ment, resources, assistance, and motivation (Ellis-Stoll & Popkess-Vawter, 1998; Shearer & Fleury 2006) and enable the individual to make decisions (Hawks, 1992). Other external social forces have been studied from the per-spective of emancipation from oppression. Several authors have suggested that empowerment could be promoted by addressing political constraints (Gutierrez, 1995; Labonte, 1994), environmental constraints (Ryles, 1999), and social constraints (Fulton, 1997).

Empowerment may also be understood in reference to the life span devel-opmental perspective (Lerner, 1997). Life span development is an orientation to the study of human beings who are viewed as continuously innovative, embedded in a dynamic environment, and equipped with inherent potential. Change derives from mutual influences in the personal and environmental contexts. Person–environment interactions, particularly human relationships, are central to developmental progress and well-being (Shearer & Reed, 2004). Health cannot be narrowly defined by illness or chronic conditions; rather, health must be viewed within a network of relationships and respon-sibilities. From a life span development perspective, the person is viewed as an active participant and resource in health care (Shearer & Reed, 2004). Empowerment from this approach considers the strengths and health goals of the individual rather than those of the health care provider (Baltes, Lindenberger, & Staudinger, 1998).

Theoretical frameworks underlying health empowerment interventions often address constraints in order to facilitate power. Three theories that offer a perspective on power related to empowerment include critical social theory, feminist theory, and Bandura’s theory of self-efficacy. Critical social theory emerged from Marxism and from Freire’s perspective that human beings’ “ontological vocation is to be a subject who actions upon and transforms one’s world” (Richard Shaull, as cited in Freire, 1968/1981, p. 12). Critical social theory focuses on making people aware of the social constraints under which they live, freeing their thinking, establishing unconstrained communi-cation, and facilitating empowerment through increased participation, includ-ing movement toward creating change (Shearer & Reed, 2004). Feminist theory acknowledges basic human potential and includes life experiences that may contribute to a transformation of oppressive situations, facilitating empowerment (Kane & Thomas, 2000). Empowerment from a feminist per-spective emphasizes choice and freedom (Shearer & Reed, 2004). Based on social behavior and social learning theory, Bandura’s concept of self- efficacy is often linked with empowerment. Self-efficacy refers to a per-son’s belief that they have the ability to succeed in a given situation.




Empowerment from a self-efficacy perspective focuses on enhancing per-ceived self-efficacy and movement toward positive health behaviors, sense of control and choice, and power through mastery experiences, social modeling, social persuasion, and psychological responses (Bandura, 1992, 1994).

MethodSearch Process

Computerized and manual searches were conducted of articles in the English-language literature from 1995 to 2008. Computerized searches of Academic Search Premier, Medline, and CINAHL databases were conducted using the following search terms: empowerment and elder*, empowerment approach, empowerment model, empowerment program, and empowerment + adults + intervention. Primary inclusion criteria for articles targeted (a) English lan-guage, peer-reviewed articles; (b) adults 50 years and older; (c) intervention study designed to foster older adult empowerment as stated by authors; (d) ran-domized controlled trials or quasi-experimental designs; and (e) conducted in community settings. Exclusion criteria included (a) case study, qualitative, and/or retrospective study; (b) study did not use empowerment either as an approach or an outcome; (c) study population was inpatient and/or living in group setting such as a long-term-care facility; and (d) mean age of study population was less than 50 years of age. Studies referenced by articles found in those databases were also considered. As a result of the search, 558 cita-tions were reviewed, and 11 studies were found to meet the inclusion and exclusion criteria.

Classification and Review ProcessA coding frame as described by Blue and Black (2005) was developed to record the following critical elements of the studies reviewed: (a) author’s last name(s), year published, and title of the intervention; (b) how empower-ment was defined; (c) theoretical framework guiding the intervention; (d) study methods (design/participants/outcome measures); and (e) results/conclusions. Specific coded study participant characteristics included the targeted patient population and the participants’ gender, race, age, and socioeconomic status. Specific coded design elements included randomized controlled trial versus quasi-experimental, sample size, mode of intervention delivery (i.e., in a group vs. individual setting), number of dose-weeks over which the interven-tion was delivered, coded theory elements, and intervention components.



Shearer et al. 5

Finally, coded outcomes included the targeted participant outcome vari-ables and instruments used to measure any change in the target variables over time

ResultsStudy Characteristics

Eleven empowerment intervention studies focusing on older adults were found that met eligibility criteria. Six of the reviewed studies were random-ized controlled trials (Adolfsson, Walker-Engstrom, Smide, & Wikblad, 2007; Anderson et al., 1995; Davison & Degner, 1997; Figar et al., 2006; Katula, Sipe, Rejeski, & Focht, 2006; Tsay & Hung, 2004), and five used a quasi-experimental design (Boonyasopun, Aree, & Avant, 2008; DeCoster & George, 2005; Golant, Altman, & Martin, 2003; Pibernik-Okanovic, Prasek, Poljicanin-Filipovic, Pavlic-Renar, & Metelko, 2004; Wong, Harker, Lau, Shatzel, & Port, 2004) to address the needs of older adults related to the prevention and management of chronic illness and cancer. Table 1 presents a detailed description of the studies reviewed.

Sample and SettingParticipants included community-dwelling men and women with a mean age ranging from 50 years to 74 years. Two of the 11 studies reviewed targeted adults aged 60 years and older (DeCoster & George, 2005; Katula et al., 2006); one study targeted adults aged 65 years and older (Figar et al., 2006). One study did not report the age of participants but did indicate that the sample population was “elderly” (Boonyasopun et al., 2008). In 8 of the 11 studies women comprised the majority of the study participants, two were majority men (Adolfsson et al., 2007; Pibernik-Okanovic et al., 2004), and one study comprised only men (Davison & Degner, 1997). Of note, nearly half the study samples were international (Argentina, Canada, Croatia, Sweden, Taiwan, and Thailand), and one U.S. study comprised only foreign-born Hispanics (Wong et al., 2004). The remaining studies were conducted in the United States and included either predominately Caucasian (DeCoster & George, 2005; Golant et al., 2003; Katula et al., 2006) or did not report par-ticipant race (Anderson et al., 1995). Only one study reviewed included income level of the sample (DeCoster & George, 2005) and two studies did not report either education or income level of the sample (Adolfsson et al., 2007; Golant et al., 2003). Of the nine studies that did report years of education,



6

Tabl

e 1.

Syn

thes

is o

f Hea

lth E

mpo

wer

men

t In

terv

entio

ns

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

Ado

lfsso

n, W

alke

r-En

gstr

om, &

W

ikbl

ad (

2007

)Pa

tient

Edu

catio

n in

Typ

e 2

diab

etes

—

A R

ando

miz

ed

Con

trol

led

1-Ye

ar

Follo

w-U

p St

udy

Seve

n pr

imar

y ca

re

cent

ers

loca

ted

in

cent

ral S

wed

enIn

terv

entio

n gr

oup

n =

42; c

ontr

ol

grou

p n =

46In

clus

ion

crite

ria:

rece

ivin

g di

etar

y or

ora

l ant

idia

bete

s th

erap

y; ≤7

5 ye

ars;

HgA

1c v

alue

6.5

-10;

di

abet

es fo

r at

le

ast

1 ye

ar; p

er

MD

or

RN

, abl

e to

jo

in in

edu

catio

n gr

oup

with

oth

ers;

Swed

ish

spea

king

Empo

wer

men

t vi

ewed

as

a pr

oces

s w

here

by in

divi

dual

s (a

) ga

in m

aste

ry

and

take

con

trol

ov

er t

heir

live

s an

d (b

) po

sses

s sk

ills,

reso

urce

s, op

port

unity

, and

au

thor

ity t

o ch

ange

a

situ

atio

n.N

o th

eore

tical

fr

amew

ork

iden

tifie

dPa

radi

gm s

hift

from

pr

ovid

er-c

ente

red

to p

atie

nt-c

ente

red

appr

oach

Ran

dom

ized

con

trol

led

tria

lG

roup

s of

5-8

pa

rtic

ipan

ts; 4

-5

sess

ions

(2½

-hr

sess

ions

).Se

ven

phys

icia

ns a

nd

12 d

iabe

tes

spec

ialis

t nu

rses

ser

ved

as

empo

wer

men

t ed

ucat

ion

faci

litat

ors

Educ

atio

n se

ssio

ns

focu

sed

on t

hem

es

addr

essi

ng s

elf-

care

and

dia

bete

s kn

owle

dge

Aim

of e

duca

tion

was

to

(a)

ena

ble

patie

nts

to r

each

the

ir s

hort

- an

d lo

ng-t

erm

goa

ls

and

(b)

iden

tify

barr

iers

and

res

ourc

es

nece

ssar

y to

faci

litat

e be

havi

oral

cha

nge

At

base

line

and

1-ye

ar

follo

w-u

p:M

easu

rem

ents

: (a

) co

nfid

ence

in

diab

etes

kno

wle

dge;

(b

) se

lf-ef

ficac

y; (c

) sa

tisfa

ctio

n w

ith

daily

life

Gly

cem

ic c

ontr

ol

mea

sure

d th

roug

h H

gA1C

Body

mas

s in

dex

At

1-ye

ar fo

llow

-up:

in

terv

entio

n gr

oup

sign

ifica

ntly

hig

her

conf

iden

ce in

di

abet

es k

now

ledg

e co

mpa

red

to

cont

rol g

roup

No

sign

ifica

nt

diffe

renc

es

betw

een

grou

ps o

n re

mai

ning

var

iabl

es

(con

tinue

d)



7

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

And

erso

n et

al.

(199

5)Pa

tient

Em

pow

erm

ent:

Res

ults

of a

R

ando

miz

ed

Con

trol

led

Tria

l

Dia

bete

s ed

ucat

ion

prog

ram

gra

duat

es

from

Uni

vers

ity o

f M

ichi

gan

Med

ical

C

ente

rSe

lf-se

lect

ed s

ampl

e;

N =

64;

dia

betic

pa

tient

s; 46

ra

ndom

ly a

ssig

ned;

18

not

ran

dom

ly

assi

gned

; Mea

n ag

e 50

; 70%

wom

en;

77%

with

som

e co

llege

edu

catio

n

Philo

soph

y of

em

pow

erm

ent

that

pre

sum

es

to m

aint

ain

heal

th; i

ndiv

idua

ls

mus

t po

sses

s ps

ycho

logi

cal

abili

ties

in o

rder

to

prod

uce

chan

ges

in (

a) p

erso

nal

beha

vior

, (b)

soc

ial

circ

umst

ance

s, an

d (c

) or

gani

zatio

ns t

hat

influ

ence

the

ir li

ves

No

theo

retic

al

fram

ewor

k id

entif

ied

Ran

dom

ized

con

trol

led

tria

l fol

low

ing

unco

ntro

lled

pre–

post

pi

lot

test

Six

2-hr

gro

up s

essi

ons

wee

kly

for

6 w

eeks

Dia

betic

edu

cato

rs

prov

ided

em

pow

erm

ent

prog

ram

Aim

of p

rogr

am w

as t

o (a

) en

hanc

e ab

ility

to

iden

tify

and

set

pers

onal

goa

ls,

(b)

prob

lem

-sol

ve

to r

educ

e ba

rrie

rs,

(c)

cope

with

ci

rcum

stan

ces,

(d)

man

age

stre

ss,

(e)

gain

soc

ial

supp

ort,

(f) im

prov

e se

lf-m

otiv

atio

n

Mea

sure

men

ts:

Self-

effic

acy

subs

cale

m

easu

ring

per

ceiv

ed

abili

ty t

o (a

) as

sess

sa

tisfa

ctio

n, (

b) s

et

pers

onal

goa

ls,

(c)

prob

lem

-sol

ve,

(d)

emot

iona

lly

cope

, (e)

man

age

stre

ss,

(f) o

btai

n su

ppor

t, (h

) m

otiv

ate

self,

(i)

mak

e de

cisi

ons

Dia

bete

s Att

itude

Sca

leD

iabe

tes

Car

e Pr

ofile

Bloo

d gl

ucos

e co

ntro

l m

easu

red

by H

gA1C

Inte

rven

tion

grou

p de

mon

stra

ted

(a)

sign

ifica

nt

impr

ovem

ent

over

co

ntro

l gro

up in

fo

ur s

elf-e

ffica

cy

mea

sure

s, (b

) si

gnifi

cant

de

clin

e in

neg

ativ

e at

titud

e to

war

d liv

ing

with

dia

bete

s in

tw

o su

bsca

les,

sign

ifica

nt

redu

ctio

ns in

H

gA1C

leve

ls

(Coh

en’s

d =

0.24

)

Tabl

e 1.

(co

ntin

ued)

(con

tinue

d)



8

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

Boon

yaso

pun,

Pa

tcha

rapo

rn, &

A

vant

(20

08)

Effe

ct o

f an

Empo

wer

men

t-Ba

sed

Nut

ritio

n Pr

omot

ion

Prog

ram

on

Foo

d C

onsu

mpt

ion

and

Seru

m

Lipi

d Le

vels

in

Hyp

erlip

idem

ic

Tha

i Eld

erly

Chi

ang

Mai

Pro

vinc

e,

Tha

iland

104

Tha

i eld

erly,

pa

rtic

ipat

ing

in

“Eld

erly

Hea

lth

Prom

otio

n Pr

ojec

t”

spon

sore

d by

Pub

lic

Hea

lth C

ente

rEx

peri

men

tal g

roup

n =

56; c

ontr

ol

grou

p n =

48In

clus

ion

crite

ria:

no h

isto

ry o

f co

mpl

icat

ions

or

dise

ases

rel

ated

to

lipi

d st

atus

; no

hype

rlip

idem

ic,

hype

rgly

cem

ic,

hype

rten

sive

m

edic

atio

ns

Adu

lt ed

ucat

ion

theo

ry,

empo

wer

men

t co

ncep

t, an

d ch

arac

teri

stic

s of

el

derl

y nu

triti

on

need

s, w

ants

, and

de

sire

sEm

pow

erm

ent

appr

oach

con

sist

ed

of b

eing

a g

ood

liste

ner

Qua

si-e

xper

imen

tal,

pret

est–

post

test

co

ntro

l gro

up a

ssig

ned

to e

xper

imen

tal o

r co

ntro

l gro

up b

ased

on

livi

ng a

rea

Expe

rim

enta

l gro

up

part

icip

ated

in 1

-day

em

pow

erm

ent-

base

d nu

triti

on p

rom

otio

n w

orks

hop

cond

ucte

d by

tra

ined

com

mun

ity

heal

th v

olun

teer

s; pa

rtic

ipan

ts r

ecei

ved

soyb

ean

or r

ice

bran

oi

l for

coo

king

Follo

win

g w

orks

hop,

ho

me

visi

ts c

ondu

cted

by

com

mun

ity h

ealth

vo

lunt

eers

tw

o tim

es p

er w

eek

for

2 m

onth

s.

Mea

sure

men

ts:

56-it

em fo

od fr

eque

ncy

ques

tionn

aire

de

velo

ped

by t

he

auth

ors

Expe

rim

enta

l and

co

ntro

l gro

ups:

food

co

nsum

ptio

n, li

pid

leve

ls, a

nd h

ealth

pr

oble

ms

mea

sure

d at

ba

selin

e an

d 2

mon

ths

Expe

rim

enta

l gro

up

show

ed d

ecre

ased

co

nsum

ptio

n of

hi

gh-s

atur

ated

fats

, ch

oles

tero

l, an

d si

mpl

e su

gars

at

2 m

onth

s co

mpa

red

with

con

trol

gro

upEx

peri

men

tal g

roup

sh

owed

hig

her

perc

enta

ge

chan

ges

in t

otal

se

rum

cho

lest

erol

(C

ohen

’s d =

0.64

), LD

L-C

(C

ohen

’s d =

–0.4

3), a

nd

HD

L-C

(C

ohen

’s d =

0.70

) co

mpa

red

with

con

trol

gro

upN

umbe

r of

no

rmol

ipid

emic

si

gnifi

cant

ly

incr

ease

d in

the

ex

peri

men

tal g

roup

as

com

pare

d to

the

co

ntro

l gro

up.

Tabl

e 1.

(co

ntin

ued)

(con

tinue

d)



9

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

Dav

ison

& D

egne

r (1

997)

Empo

wer

men

t of

Men

New

ly

Dia

gnos

ed W

ith

Pros

tate

Can

cer

Win

nipe

g co

mm

unity

cl

inic

N =

60

men

; new

ly

diag

nose

d pr

osta

te

canc

er; <

12th

gr

ade,

58.

3%;

mar

ried

, 86.

7%;

retir

ed, 7

1.7%

Inte

rven

tion

grou

p n

= 30

, Con

trol

gro

up

n =

30In

clus

ion

crite

ria:

men

new

ly

diag

nose

d w

ith

pros

tate

can

cer;

have

not

att

ende

d in

itial

tre

atm

ent

cons

ulta

tion;

abl

e to

rea

d, s

peak

, an

d w

rite

Eng

lish;

no

evi

denc

e of

co

gniti

ve c

hang

e

Proc

ess

theo

ry

appr

oach

to

empo

wer

men

t as

a m

otiv

atio

nal

phen

omen

on

by r

elat

ing

it to

ex

pect

ancy

and

sel

f-ef

ficac

y th

eori

esEm

pow

erm

ent

defin

ed a

s a

proc

ess

whe

reby

an

indi

vidu

al’s

belie

f in

sel

f-effi

cacy

is

enh

ance

d;

belie

f in

pers

onal

po

wer

less

ness

is

decr

ease

d.C

once

ptua

l fra

mew

ork

Empo

wer

men

t M

odel

by

Con

ger

and

Kan

ungo

Ran

dom

ized

con

trol

led

tria

lA

ll pa

rtic

ipan

ts

part

icip

ated

in a

n in

trod

ucto

ry s

essi

on

and

rece

ived

iden

tical

w

ritt

en in

form

atio

n pa

cket

s ab

out

pros

tate

ca

ncer

Inte

rven

tion

grou

p re

ceiv

ed a

dditi

onal

se

lf-ef

ficac

y in

form

atio

n pa

cket

, en

cour

aged

to

read

m

ater

ials

and

ask

qu

estio

ns, d

ecid

ing

to m

ake

deci

sion

s re

gard

ing

trea

tmen

t. G

iven

bla

nk a

udio

-tap

e to

rec

ord

phys

icia

n co

nsul

tatio

nN

urse

res

earc

hers

(a

utho

rs)

cond

ucte

d al

l int

ervi

ews

Pret

est

and

6-w

eek

post

test

Mea

sure

men

ts:

Con

trol

Pre

fere

nce

Scal

eSt

ate-

Trai

t Anx

iety

In

vent

ory

Cen

tre

for

Epid

emio

logi

c St

udie

s D

epre

ssio

n Sc

ale

Soci

odem

ogra

phic

Pro

file

Que

stio

nnai

re

Men

in in

terv

entio

n gr

oup

assu

med

si

gnifi

cant

ly m

ore

activ

e ro

le in

tr

eatm

ent

deci

sion

m

akin

g an

d lo

wer

le

vels

of a

nxie

ty.

Dep

ress

ion

was

the

sa

me

for

both

gr

oups

(con

tinue

d)

Tabl

e 1.

(co

ntin

ued)



10

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

DeC

oste

r &

G

eorg

e (2

005)

An

Empo

wer

men

t A

ppro

ach

for

Elde

rs L

ivin

g W

ith D

iabe

tes:

A P

ilot

Stud

y of

a

Com

mun

ity-

Base

d Se

lf-H

elp

Gro

up—

The

D

iabe

tes

Clu

b

Dia

bete

s C

lub,

a p

eer-

led,

sel

f-hel

p gr

oup

at a

loca

l sen

ior

cent

erN

o co

ntro

l gro

up;

N =

11;

dia

bete

s; ≥6

0 ye

ars

of a

ge; n

o co

gniti

ve o

r m

enta

l is

sues

Mea

n ag

e 73

.9 y

ears

, m

arri

ed, r

etir

ed,

Cau

casi

an w

omen

w

ith 1

0th-

grad

e ed

ucat

ion

Fem

inis

t vi

ew o

f po

wer

as

a se

nse

of

ener

gy, p

oten

tial,

and

com

pete

nce

Empo

wer

men

t pro

cess

an

d ou

tcom

e w

here

pe

ople

dem

onst

rate

so

me

leve

l of c

ontr

ol

and

invo

lvem

ent i

n lif

eEm

pow

erm

ent

appr

oach

usi

ng

tech

niqu

es t

o in

crea

se d

iabe

tic

self-

effic

acy,

self-

care

beh

avio

rs, a

nd

impr

ove

glyc

emic

co

ntro

l

Qua

si o

ne-g

roup

pr

e–po

st t

est

desi

gn.

Part

icip

ants

func

tione

d as

ow

n co

ntro

lC

lose

d-gr

oup

wee

kly

mee

ting

for

1 hr

ov

er 6

mon

ths

focu

sing

on

solv

ing

prob

lem

s, sh

arin

g se

lf-ca

re in

form

atio

n,

or a

sses

sing

im

prov

emen

tsSo

cial

wor

kers

faci

litat

ors

of s

elf-h

elp

grou

p as

sist

ing

olde

r ad

ults

in

form

atio

n an

d m

aint

enan

ce o

f clu

b

Mea

sure

men

ts:

Dia

bete

s Se

lf-M

anag

emen

t R

ecor

dSe

lf-C

are

Act

ivity

Sca

leSe

lf-Ef

ficac

y fo

r D

iabe

tes

HbA

1C

Red

uctio

n of

HgA

1c

by 1

% d

urin

g 6

mon

ths

Sign

ifica

nt in

crea

se

in s

elf-e

ffica

cy

scor

es a

nd s

elf-

man

agem

ent

beha

vior

Figa

r et

al.

(200

6)Ef

fect

of E

duca

tion

on B

lood

Pr

essu

re

Con

trol

in

Elde

rly

Pers

ons

Hyp

erte

nsiv

e m

embe

rs o

f HM

O

of t

he H

ospi

tal

Ital

iano

Inte

rven

tion

grou

p: P

atie

nt

PEM

is b

ased

on

deve

lopm

ent

and

enha

ncem

ent

of

prev

ious

ly e

xist

ing

reso

urce

s, ca

paci

ties,

and

know

ledg

e; fi

nal

Ran

dom

ized

con

trol

led

tria

lT

hree

PEM

edu

catio

nal

wor

ksho

ps fo

cusi

ng

on h

yper

tens

ion

man

agem

ent

and

Mea

sure

men

t:Sy

stol

ic b

lood

pre

ssur

e by

24-

h am

bula

tory

m

onit

orin

gD

igita

l BP

(OM

ROM

-450

) as

sess

ed a

s

PEM

was

sig

nific

antly

m

ore

effe

ctiv

e th

an

the

com

plia

nce-

base

d m

odel

in

nigh

t-tim

e BP

con

trol

(C

ohen

’s d = -0

.65)

(con

tinue

d)

Tabl

e 1.

(co

ntin

ued)



11

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

Empo

wer

men

t M

odel

(P

EM)

n =

30;

Con

trol

gro

up:

Com

plia

nce-

base

d M

odel

(C

M)

n =

30>6

5 ye

ars

of a

ge;

mor

e w

omen

in

PEM

(57

% v

s. 30

%);

ambu

lato

ry,

diab

etic

; HT

N

aim

is b

ehav

iora

l ch

ange

CM

is b

ased

on

assu

mpt

ion

that

pa

tient

s ar

e ob

liged

to

follo

w

reco

mm

enda

tions

of

heal

th c

are

prov

ider

PREC

EDE

Mod

el a

nd

com

plia

nce-

base

d m

odel

thre

e C

M e

duca

tion

wor

ksho

ps o

ffere

d si

mul

tane

ousl

yPh

ysic

ians

with

ex

peri

ence

in

hype

rten

sion

ed

ucat

ion

and

man

agem

ent

wer

e tr

aine

rs o

f the

w

orks

hops

prim

ary

and

natr

iure

sis

asse

ssed

as

seco

ndar

y at

bas

elin

e an

d fin

al

Gol

ant,

Altm

an, &

M

artin

(20

03)

Man

agin

g C

ance

r Si

de E

ffect

s to

Im

prov

e Q

ualit

y of

Life

The

Wel

lnes

s C

omm

unity

in

Sant

a M

onic

a, C

alifo

rnia

N =

32

patie

nts

com

plet

ing

pilo

t la

unch

, bas

elin

e,

follo

w-u

p as

sess

men

t; 26

w

omen

, 4 m

en;

mea

n ag

e 57

.07

Empo

wer

men

t no

t de

fined

The

Wel

lnes

s C

omm

unity

’s Pa

tient

Act

ive

Empo

wer

men

t M

odel

focu

ses

on

copi

ng w

ith il

lnes

s, pa

rtne

ring

with

ph

ysic

ian,

mak

ing

chan

ges

view

ed

One

-gro

up p

re–p

ost

test

de

sign

; pilo

t st

udy

of

a co

mm

unity

-bas

ed

psyc

hoed

ucat

ion

inte

rven

tion

in

colla

bora

tion

with

the

m

edic

al c

omm

unity

Psyc

hoed

ucat

ion

inte

rven

tion

desi

gned

to

ass

ist

and

info

rm

patie

nts

with

can

cer

Mea

sure

men

tsC

ance

r Tre

atm

ent

Side

Ef

fect

s qu

estio

nnai

re

mea

sure

d ca

ncer

sy

mpt

oms,

canc

er

side

effe

cts,

emot

iona

l di

stre

ss, a

nxie

ty, a

nd

depr

essi

onPh

ysic

al a

nd e

mot

iona

l he

alth

mea

sure

d w

ith

SF-3

6 H

ealth

Sur

vey

Dep

ress

ion

scor

es

sign

ifica

ntly

de

crea

sed

from

bas

elin

e to

follo

w-u

p as

sess

men

tsM

enta

l hea

lth a

nd

vita

lity

impr

oved

si

gnifi

cant

ly fo

r th

ose

who

wer

e w

orki

ng, a

s

Tabl

e 1.

(co

ntin

ued)

(con

tinue

d)



12

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

(47-

66)

year

s; 4

Afr

ican

Am

eric

an,

25 w

hite

; 17

mar

ried

, 13

unm

arri

ed

as im

port

ant,

and

decr

easi

ng u

nwan

ted

alon

enes

s, lo

ss o

f co

ntro

l, an

d lo

ss o

f ho

peN

o th

eore

tical

fr

amew

ork

iden

tifie

d

how

to

man

age

pain

, fa

tigue

, low

whi

te

bloo

d ce

ll co

unt,

and

infe

ctio

n in

ord

er t

o im

prov

e qu

ality

of l

ife.

Prof

essi

onal

s tr

aine

d as

co-

faci

litat

ors

of

one-

half-

day

educ

atio

n co

nfer

ence

(ba

selin

e)

and

30-d

ay fo

llow

-up

by t

elep

hone

and

mai

l

Brie

f Sym

ptom

Inve

ntor

y us

ed t

o m

easu

re

emot

iona

l dis

tres

s

com

pare

d to

tho

se

who

wer

e no

tD

ecre

ase

in p

robl

ems

with

wor

k or

ot

her

daily

ac

tiviti

es r

elat

ed t

o em

otio

nal s

tres

s

Kat

ula,

Sipe

, R

ejes

ki, &

Foc

ht

(200

6)St

reng

th T

rain

ing

in O

lder

Adu

lts:

An

Empo

wer

ing

Inte

rven

tion

Uni

vers

ity C

ente

r-ba

sed

Exer

cise

La

bora

tory

Incl

usio

n cr

iteri

a: >6

0 ye

ars

of a

ge;

sede

ntar

y; se

lf-re

port

ed d

iffic

ulty

w

ith o

ne o

r m

ore

activ

ities

of d

aily

liv

ing

requ

irin

g am

bula

tion;

sta

ble

resi

denc

e fo

r 3

mon

ths

Empo

wer

men

t no

t de

fined

Empo

wer

men

t th

eory

w

ithin

con

stru

cts

of s

ocia

l lea

rnin

g th

eory

and

sel

f-ef

ficac

y

Ran

dom

ized

con

trol

led

tria

lC

ompa

riso

n of

tr

aditi

onal

str

engt

h tr

aini

ng (

TST

) pr

ogra

m w

ith o

ne

supp

lem

ente

d w

ith

a ps

ycho

logi

cal

inte

rven

tion

(PEI

) us

ing

stra

tegi

es t

o ta

rget

par

ticip

ants

’ se

lf-ef

ficac

y an

d m

otiv

atio

n, g

uidi

ng

Phys

ical

Act

ivity

Rea

dine

ss

Que

stio

nnai

re (

PAR

-Q)

Low

er-le

g st

reng

th t

estin

gU

nide

ntifi

ed

ques

tionn

aire

s m

easu

ring

de

mog

raph

ics,

self-

effic

acy,

and

desi

re

Sign

ifica

nt in

crea

ses

in d

esir

e fo

r up

per-

body

phy

sica

l st

reng

th in

bot

h gr

oups

PEI g

roup

rep

orte

d la

rger

upp

er-b

ody

stre

ngth

effi

cacy

ga

ins

and

larg

er

gain

s in

low

er-b

ody

stre

ngth

effi

cacy

. N

eith

er b

etw

een-

grou

p

Tabl

e 1.

(co

ntin

ued)

(con

tinue

d)



13

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

Excl

usio

n cr

iteri

a: ps

ychi

atri

c ill

ness

; se

vere

sym

ptom

atic

he

art

dise

ase;

sy

stem

ic d

isea

se

activ

e ca

ncer

; he

arin

g or

vis

ual

impa

irm

ent;

cogn

itive

im

pair

men

t; al

coho

lism

; ina

bilit

y

the

feel

ing

of p

ride

in

acco

mpl

ishm

ents

, and

ap

ply

activ

ity t

o da

ily

livin

gSp

ecifi

c co

mpo

nent

s of

PEI

incl

uded

: gi

ving

indi

vidu

al

atte

ntio

n, p

rovi

ding

re

info

rcem

ent,

givi

ng

enco

urag

emen

t, fo

cusi

ng o

n po

sitiv

e

mea

n di

ffere

nces

fo

r ch

ange

in

uppe

r-bo

dy

stre

ngth

effi

cacy

or

in lo

wer

-bod

y st

reng

th e

ffica

cy

wer

e st

atis

tical

ly

diffe

rent

to w

alk

with

out

assi

stan

ce; f

ailu

re

to p

ass

the

phys

ical

ac

tivity

rea

dine

ss

ques

tionn

aire

Com

mun

ity-d

wel

ling

part

icip

ants

, n =

38 (

12 m

ales

, 26

fem

ales

); m

ean

age

70.5

yea

rs;

pred

omin

atel

y w

hite

with

mor

e th

an h

alf e

arni

ng a

co

llege

deg

ree

com

men

ts, p

rovi

ding

fe

edba

ck o

n ab

ility

and

te

chni

que,

rew

ardi

ng

effo

rt a

nd g

ivin

g pe

rfor

man

ce fe

edba

ckA

ll pa

rtic

ipat

ed in

6-

wee

k w

eigh

t tr

aini

ng r

outin

e; P

EI

supp

lem

ente

d w

ith

grou

p-m

edia

ted

coun

selin

g de

liver

ed

in e

ight

diff

eren

t m

eetin

gs fo

llow

ing

exer

cise

ses

sion

s

Tabl

e 1.

(co

ntin

ued)

(con

tinue

d)



14

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

Both

gro

ups

met

2 d

ays/

wee

k fo

r ce

nter

-bas

ed

trai

ning

and

1 d

ay/

wee

k ho

me-

base

d tr

aini

ngPi

bern

ik-O

kano

vic,

Pras

ek,

Polji

cani

n-Fi

lipov

ic, P

avlic

-R

enar

, & M

etel

ko

(200

4)

Patie

nts

trea

ted

at V

uk

Vrh

ovac

Uni

vers

ity

Clin

ic in

Cro

atia

Incl

usio

n cr

iteri

a: ty

pe

2 di

abet

es; a

ge u

p to

60

year

s, po

or

Com

pone

nts

of

empo

wer

men

t ar

e ac

cept

ance

, ex

pres

sion

of

feel

ings

, aut

onom

y, al

lianc

es, a

nd a

ctiv

e

Qua

si-e

xper

imen

tal

desi

gn w

ith r

epea

ted

mea

sure

sSi

x-w

eek

empo

wer

men

t bi

opsy

chos

ocia

l ed

ucat

ion

inte

rven

tion

Gly

cem

ic c

ontr

ol

mea

sure

d as

HgA

1cPe

rso

nal m

ode

l of

diab

etes

mea

suri

ng

belie

fs a

bout

ef

ficac

y an

d

Psyc

holo

gica

l and

so

cial

qua

lity

of

life

impr

oved

aft

er

empo

wer

men

t in

terv

entio

n:

(a)

psyc

holo

gica

lEf

fect

s of

an

Empo

wer

men

t-Ba

sed

Psyc

hoso

cial

In

terv

entio

n on

Q

ualit

y of

Life

an

d M

etab

olic

C

ontr

ol in

Ty

pe 2

Dia

betic

Pa

tient

s

glyc

emic

con

trol

(H

gA1c

>8.

5%

duri

ng la

st y

ear)

Inte

rven

tion

grou

p (n

= 7

3); c

ontr

ol

grou

p (n

= 3

5); 4

7%

fem

ale,

mea

n ag

e of

53

with

10t

h-gr

ade

educ

atio

n

part

icip

atio

n in

m

anag

ing

the

dise

ase

Bein

g em

pow

ered

m

eans

hav

ing

know

ledg

e ab

out

the

dise

ase

and

self-

awar

enes

sPa

tient

-cen

tere

d ed

ucat

iona

l m

odel

pro

vidi

ng a

bi

opsy

chol

ogic

al

appr

oach

to

diab

etes

ca

re

base

d on

Fes

te’s

empo

wer

men

t pr

ogra

mSm

all g

roup

s la

stin

g 60

-90

min

focu

sing

on

goal

set

ting,

prob

lem

so

lvin

g, co

ping

with

di

abet

es, c

opin

g w

ith

daily

str

ess,

seek

ing

soci

al s

uppo

rt, a

nd

stay

ing

mot

ivat

ed

cons

eque

nces

abo

ut

diab

etes

WH

OQ

oL-B

REF

Q

ualit

y of

Life

ques

tionn

aire

Perc

eive

d lo

cus

of h

ealth

co

ntro

lBa

selin

e as

sess

men

t, se

cond

ass

essm

ent

at 6

-wee

k co

urse

(g

lyce

mic

con

trol

and

qu

ality

of l

ife),

follo

w-u

p as

sess

men

ts a

t 3-

and

6-

mon

th p

erio

ds

(gly

cem

ic c

ontr

ol)

dom

ain

(Coh

en’s

d =

–0.1

9);

(b)

soci

al d

omai

n (C

ohen

’s d =

−0.

44);

impr

ovem

ent

in

glyc

emic

con

trol

po

stin

terv

entio

n,

3 m

onth

s, an

d 6

mon

ths

(Coh

en’s

d =

0.41

)

Tabl

e 1.

(co

ntin

ued)

(con

tinue

d)



15

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

Tsa

y &

Hun

g (2

004)

Empo

wer

men

t of

Pa

tient

s With

En

d-St

age

Ren

al

Dis

ease

—A

R

ando

miz

ed

Con

trol

led

Tria

l

Taiw

an E

xper

imen

tal

grou

p (n

= 2

5);

Con

trol

gro

up

(n =

25)

Mea

n ag

e 51

yea

rs,

maj

ority

fem

ale

(60%

), m

arri

ed

(90%

), em

ploy

ed

(64%

), an

d 36

%

elem

enta

ry s

choo

l gr

adua

te a

nd28

% h

igh

scho

ol

grad

uate

Incl

usio

n cr

iteri

a: di

agno

sis

of E

SRD

; tr

eatm

ent

with

he

mod

ialy

sis

≥3

mon

ths;

≥18

year

s of

age

; res

idin

g in

hom

e se

ttin

g; ab

le t

o re

ad a

nd

wri

te; w

illin

g to

pa

rtic

ipat

e

Empo

wer

men

t be

gins

w

ith p

ower

; pow

er

is t

he a

bilit

y to

in

fluen

ce w

hat

will

ha

ppen

to

self

Empo

wer

men

t fa

cilit

ates

de

velo

pmen

t of

inde

pend

ent

prob

lem

-sol

ving

ab

ilitie

s, pr

omot

esa

sens

e of

con

trol

, an

d su

ppor

ts v

alid

de

cisi

on-m

akin

g pr

oces

ses

Pros

pect

ive

rand

omiz

ed

cont

rolle

d tr

ial;

pret

est–

post

test

des

ign

Expe

rim

enta

l gro

up

rece

ived

info

rmat

ion

pack

et w

ith in

divi

dual

co

unse

ling

sess

ion

thre

e tim

es/w

eek

for

4 w

eeks

.Fo

cus

of in

terv

entio

n on

pa

tient

act

ive

part

icip

atio

n in

sel

f-ca

re a

nd d

ecis

ion

mak

ing.

Con

trol

gro

up g

iven

in

form

atio

n pa

cket

w

ith s

essi

on c

onte

nts

Nep

hrol

ogy

Clin

ical

N

urse

Spe

cial

ist

with

mas

ter’s

deg

ree

cond

ucte

d in

divi

dual

co

nsul

ting

sess

ions

Mea

sure

men

ts:

Empo

wer

men

t Sc

ale

Stra

tegi

es u

sed

by p

eopl

e to

pro

mot

e he

alth

m

easu

red

self-

care

and

se

lf-ef

ficac

yD

epre

ssio

n op

erat

iona

lized

Bec

k D

epre

ssio

n In

vent

ory

Sign

ifica

nt im

prov

emen

t of

per

ceiv

ed

empo

wer

men

t (C

ohen

’s d =

−0.7

8);

self-

care

sel

f-effi

cacy

(C

ohen

’s d =

−0.6

1);

depr

essio

n (C

ohen

’s d =

0.06

0) in

ex

perim

enta

l gro

up

Tabl

e 1.

(co

ntin

ued)

(con

tinue

d)



16

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

Excl

usio

n cr

iteri

a: ac

ute

illne

ss/

hosp

italiz

ed;

repo

rted

ps

ychi

atri

c/co

gniti

ve d

isor

ders

; ph

ysic

al li

mita

tions

Won

g, H

arke

r, La

u,

Shat

zel,

& P

ort

(200

4)Sp

anis

h A

rthr

itis

Empo

wer

men

t Pr

ogra

m:

A D

isse

min

atio

n an

d Ef

fect

iven

ess

Stud

y

Sout

hern

Cal

iforn

ia

Art

hriti

s Fo

unda

tion

Incl

usio

n cr

iteri

a: pe

rson

s w

ith

arth

ritis

and

acco

mpa

nyin

g fa

mily

and

frie

nds

Excl

usio

n cr

iteri

a: th

ose

with

out

arth

ritis

; <18

yea

rs

of a

ge; r

epea

ters

; de

clin

atio

n of

initi

al

surv

eyPr

etes

t/po

stte

st

com

plet

ion

n =

141

No

theo

retic

al

fram

ewor

k id

entif

ied

alth

ough

ba

sed

on t

he

Stan

ford

Art

hriti

s Se

lf-he

lp p

rogr

amEm

pow

erm

ent

not

defin

ed

Sing

le-g

roup

pr

etes

t– p

ostt

est

desi

gnSp

anis

h A

rthr

itis

Empo

wer

men

t Pr

ogra

m a

dapt

ed fr

omSt

anfo

rd A

rthr

itis

Self-

Hel

p C

ours

eSi

x w

eekl

y in

terv

entio

n se

ssio

ns (a

ppro

xim

atel

y 2

hr) f

ollo

wed

a

stan

dard

ized

pr

otoc

ol u

sing

an

inte

ract

ive

disc

ussio

n.

Empo

wer

men

t pr

ogra

m fo

cuse

d on

Gen

eral

hea

lth r

atin

g: Sh

ort

Form

-36

Pain

Rat

ing

Mod

ified

Hea

lth

Ass

essm

ent

Que

stio

nnai

reSe

lf-re

port

ing

join

t co

unt

Art

hriti

s Se

lf-ef

ficac

y Sc

ale

Self-

care

beh

avio

r an

d ar

thri

tis k

now

ledg

e

Sign

ifica

nt

impr

ovem

ent

in

mea

sure

s of

dis

ease

ac

tivity

from

pr

etes

t to

pos

ttes

t: se

lf-re

port

ed p

ain

ratin

g; se

lf-re

port

jo

int

coun

t; ar

thri

tis

impa

ct o

n sl

eep;

da

ily a

ctiv

ity

impa

irm

ent;

and

depr

essi

onSi

x-m

onth

follo

w-u

p:

mai

nten

ance

of

pos

ttes

t im

prov

emen

t

Tabl

e 1.

(co

ntin

ued)

(con

tinue

d)



17

Aut

hor/

Year

Titl

eSe

ttin

g &

Sam

ple

Cha

ract

eris

tics

Con

cept

ualiz

atio

n of

Em

pow

erm

ent

&T

heor

etic

al

Fram

ewor

kIn

terv

entio

n C

ompo

nent

s &

Dos

age

Out

com

e M

easu

res

Key

Fin

ding

s of

Hea

lth

Out

com

es

6-m

onth

follo

w-u

p ev

alua

tion

n =

118

Mea

n ag

e 50

.7 y

ears

; 92

.2%

wom

en,

60%

spo

ke o

nly

Span

ish,

60%

re

port

ed h

avin

g no

m

edic

al in

sura

nce,

m

ajor

ity e

duca

ted

at e

lem

enta

ry le

vel

or le

ssN

atio

n of

ori

gin:

M

exic

o, 8

4%;

Cen

tral

Am

eric

a, 10

%; S

outh

Am

eric

a, 5%

; Car

ibbe

an/

Cub

a 0.

7%

enha

ncin

g se

lf-ef

ficac

y an

d ac

cess

ing

heal

th

care

.To

pics

incl

uded

:(a

) se

lf-m

anag

emen

t sk

ills,

(b)

lear

ning

to

acce

ss

heal

th c

are,

(c)

find

ing

appr

opri

ate

phys

icia

n ca

re, a

nd (

d) e

ffect

ive

com

mun

icat

ion

with

ph

ysic

ian

Faci

litat

or (

prom

otor

a)

cert

ified

by

arth

ritis

fo

unda

tion

led

inte

ract

ive

disc

ussi

on

form

atM

ater

ials

: boo

k,

audi

otap

es, i

llust

rate

d ex

erci

se b

ook

Tran

slat

ions

of m

ater

ials

in

dire

ct (

refle

cted

cu

ltura

l var

iatio

ns o

f co

ncep

ts, c

onte

nt, a

nd

proc

ess)

scor

es: g

ener

al

heal

th m

ean

ratin

g im

prov

ed fr

om

pret

est

to 6

-mon

th

follo

w-u

pPr

etes

t to

6-m

onth

fo

llow

-up

show

ed

sign

ifica

nt

impr

ovem

ent:

phys

ical

func

tion

Not

e: L

DL-

C =

low

-den

sity

lipo

prot

ein

chol

este

rol;

HD

L-C

= h

igh-

dens

ity li

popr

otei

n ch

oles

tero

l; ES

RD

= e

nd-s

tage

ren

al d

isea

se.

Tabl

e 1.

(co

ntin

ued)




the levels varied, with some study populations comprising predominately elementary school–educated adults (Boonyasopun et al., 2008; Wong et al., 2004) to those with greater than 75% of the adults having some postsecond-ary education (Anderson et al., 1995; Katula et al., 2006). Sample sizes ranged from 13 to 108 participants.

The interventions were community based and ranged in approach from individually focused (Davison & Degner, 1997; Tsay & Hung, 2004) to group focused (Adolfsson et al., 2007; Anderson et al., 1995; DeCoster & George, 2005; Figar et al., 2006; Golant et al., 2003; Pibernik-Okanovic et al., 2004; Wong et al., 2004). Only Boonyasopun et al. (2008) and Katula et al. (2006) used a combination of both. The interventions were carried out in homes (Tsay & Hung, 2004), community-based organizations, schools and churches (Wong et al.), senior centers (DeCoster & George, 2005), clinics (Adolfsson et al., 2007; Anderson et al., 1995; Davison & Degner, 2005; Figar et al., 2006; Golant et al., 2003; Pibernik-Okanovic et al., 2004), and a combination of centers and homes (Boonyasopun et al., 2008; Katula et al., 2006).

Theoretical PerspectiveOf the articles reviewed, all conceptualized empowerment from a social process perspective involving relationships and social forces that act on the individual and promote a sense of control and feelings of power, including the transfer of power from one group to another. Nearly half of the studies reviewed (Adolfsson et al., 2007; Anderson et al., 1995; Boonyasopun et al., 2008; Pibernik-Okanovic et al., 2004; Tsay & Hung, 2004) were informed by Feste’s (1991) patient empowerment program (PEP), which argues that patient acquisition of knowledge and psychosocial skills empowers them to develop and implement a successful self-care plan that not only enhances their health, but also their quality of life (Anderson et al., 1995). The authors define empowerment “as one’s inherent capacity to be responsible for one’s own life” (Funnell et al., 1992, p. 55). This definition is guided by Rappaport’s (1987) perspective of empowerment as autonomous self-regulation. Empowerment is thus viewed as an outcome rather than an intervention or strategy to encourage behavior change (Anderson et al., 1995; Tsay & Hung, 2004). Although Figar and colleagues (2006) emphasized the importance of using multiple theories to develop and tailor their self-management program for blood pressure control, they also cited the PEP to explain their approach to patient empowerment. Additional theoretical frameworks included a feminist empowerment perspective to guide a peer-led, self-help Diabetes Club (DeCoster & George, 2005) and a psychological empowerment perspective



Shearer et al. 19

(based on social cognitive theory and empowerment theory) to guide a strength training intervention (Katula et al., 2006). Finally, Davison and Degner (1997) used Conger and Kanungo’s (1988) Empowerment Model for their theoreti-cal framework, which is based on management and psychology theories as well as the concept of self-efficacy. With this approach, empowerment is viewed from a motivational perspective where belief in one’s own ability to successfully execute a desired goal leads to increased sense of personal mas-tery (Davison & Degner, 1997).

Intervention Strategies and DoseAll interventions reviewed included a health education component to foster empowerment by increasing knowledge to make informed choices and facilitating disease management specific to diabetes (Adolfsson et al., 2007; Anderson et al., 1995; DeCoster & George, 2005; Pibernik-Okanovic et al., 2004), hyperlipidemia (Boonyasopun et al., 2008), hypertension (Figar et al., 2006), cancer (Davison & Degner, 1997; Golant et al., 2003), end-stage renal disease (ESRD; Tsay & Hung, 2004), or disability including sarcopenia (Katula et al., 2006) and arthritis (Wong et al., 2004). In addition to health education, intervention content targeting type 2 diabetes self-management focused on optimal diabetes management by providing psychosocial edu-cation incorporating diet, exercise, medication compliance, and self-care behavior. Anderson and colleagues (1995), Adolfsson and colleagues (2007), and Pibernik-Okanovic and colleagues (2004) used a patient-centered, empowerment-based diabetes psychosocial educational program designed by Feste (1991). Key components that guided the six program sessions in these studies included enhancing the patient’s ability to identify and set real-istic goals, applying a problem-solving process to eliminate barriers to reach goals, coping with diabetes, managing stress related to living with diabetes, identifying and obtaining social support, and improving self-motivation (Anderson et al., 1995).

These studies (Adolfsson et al., 2007; Anderson et al., 1995; Boonyasopun et al., 2008; Katula et al., 2006; Tsay & Hung, 2004) also included a social support component to foster participant empowerment, but varied in both the degree of emphasis and the rationale. For example, Katula and colleagues (2006) coupled social interaction during supervised strength training exer-cises with a group counseling psychological empowerment process targeting strength efficacy and desire for physical strength. The group counseling com-ponents of the empowerment intervention were based on previous work in the promotion of a physically active lifestyle and included topics related to




self-awareness and self-monitoring of progress, accomplishments, motiva-tion, and changes in daily life. Boonyasopun and colleagues (2008) used social support as the primary strategy for effecting change in the participants’ health behaviors. According to the authors, the community health volunteers’ biweekly home visits over the course of 2 months facilitated participant adherence through monitoring, teaching, and reinforcement. Tsay and Hung (2004) encouraged participants to identify sources of social support as a way to foster the participants’ ability to manage stress and to assume a more active role in the management of their ESRD.

Across the studies reviewed, the dosage of the interventions varied. Golant and colleagues (2003) held one half-day education program in the commu-nity, and Boonyasopun and colleagues (2008) held a full-day education program; other authors reported programs ranging from 4 to 10 sessions. Reported group attendance rates varied from 82.5% to greater than 85%. Among the 11 studies, 9 used either lay and/or health care professionals to deliver the intervention in a group format, and two used individual consulting provided by clinical nurse specialists (Davison & Degner, 1997; Tsay & Hung, 2004).

Outcome MeasuresAlthough all of the studies reviewed focused on enhancing patient empower-ment, empowerment was operationalized differently across studies. Outcome measures included self-efficacy (Adolfsson et al., 2007; Anderson et al., 1995; DeCoster & George, 2005; Katula et al., 2006; Wong et al., 2004); disease self-management (DeCoster & George, 2005; Figar et al., 2006; Golant et al., 2003; Pibernik-Okanovic et al., 2004; Wong et al., 2004); knowl-edge, attitude, behavioral, and health outcomes (Adolfsson et al., 1995; Boonyasopun et al., 2008); and taking a more active role in treatment deci-sion making (Davison & Degner, 1997). Even among those studies that conceptualized empowerment in the same way, the empirical referents var-ied. For example, self-efficacy was measured using SEDS (DeCoster & George, 2005), whereas others developed measures including confidence in lifting weights (Katula et al., 2006) and self-efficacy related to personal self-care (Adolfsson et al., 2007; Anderson et al., 1995; Wong et al., 2004).

Of note, only Tsay and Hung (2004) differentiated empowerment from self-efficacy as an outcome measure. The authors used a modified Empowerment Scale developed by Anderson, Fitzgerald, Funnell, and Marrero (2000) to evaluate the intervention’s effect on empowerment in patients with end-stage renal disease. The authors then measured self-care



Shearer et al. 21

self-efficacy using Lev and Owen’s (1996) Strategies Used by People to Promote Health (SUPPH) scale.

Targeted health outcomes also varied across the studies reviewed and included blood pressure control (Figar et al., 2006), physical and emotional health (Davison & Degner, 1997; Golant et al., 2003; Tsay & Hung, 2004), pain scores (Wong et al., 2004), physical functioning (Katula et al., 2006; Wong et al., 2004), and reduced glycated hemoglobin (Adolfsson et al., 2007; Anderson et al., 1995; Boonyasopun et al., 2008; DeCoster & George, 2005; Pibernik-Okanovic et al., 2004).

Measurement time points also varied and ranged from 30 days to 9 months. Limited rationale, however, was provided for measurement time points.

Study OutcomesAcross reviewed studies, significant effects on outcomes were varied. Interventions based on Feste’s PEP had a significant impact on outcomes, including diabetes knowledge and self-care management skills (Adolfsson et al., 2007), self-efficacy (Anderson et al., 1995; Tsay & Hung, 2004), quality of life and glycemic control (Pibernik-Okanovic et al., 2004), hyper-lipidemia and food consumption (Boonyasopun et al., 2008), and levels of depression (Tsay & Hung, 2004). Studies incorporating other empowerment models to guide the intervention also had significant effects, including increased self-efficacy (DeCoster & George, 2005; Katula et al., 2006), improved glycemic control (DeCoster & George, 2005), decreased depres-sion (Golant et al., 2003), improved blood pressure control (Figar et al., 2006), and a more active role in decision making, and lowered state anxiety levels (Davison & Degner, 1997). It is important to note that the sample size in a number of studies was small; thus this review likely included studies without adequate statistical power. Among studies that provided adequate data, effect size ranged from .19 to .78, with most studies showing small to moderate effects.

DiscussionGiven the growing numbers of older adults, a greater understanding of rele-vant and effective empowerment interventions for this population is essen-tial. The findings from this review support the efficacy of empowerment interventions to enhance management of chronic illness among older adults and improve health outcomes. However, limitations in attention to theory, specification of intervention strategies used, and outcomes measured make it




difficult to draw conclusions about the overall effectiveness of empowerment interventions in older adults.

Although a number of the studies reviewed used a theoretical perspective to guide program implementation and evaluation, often insufficient detail was provided to permit understanding of the operationalization of the major concepts in the intervention, particularly from a culturally relevant perspec-tive. Among studies that have achieved intervention effects, the mechanisms underlying treatment are not always clear, limiting the applicability of exist-ing intervention findings to practice. Ongoing research efforts are needed to better operationalize and test theoretical frameworks for empowerment inter-ventions and to evaluate the effectiveness of multilevel interventions that address cultural, contextual, and sustainability issues. Theory-based pro-grams that incorporate formative mechanisms and relevance to older adults in the community may show more promising results than those that lack a theoretical basis. A stronger theoretical approach may include specification of and program tailoring to select theoretical mediators.

Across the studies reviewed, consistency between the empowerment conceptualization and the clinical problem addressed was inferred. Few of the studies reviewed conceptualized the problem guiding the intervention from a theoretical perspective. Specification of the problem should detail defining experiences consistent with intervention theory, such as lack of self-efficacy, or low levels of perceived power, mastery, skills, or resources as part of inclusion criteria. The assumption that chronic illness or risk among older adults is associated with low levels of empowerment may result in interventions being delivered to those who do not need them, and will not benefit from them, limiting intervention effects. Continued efforts are needed to clearly specify the factors that put older adults at risk for low levels of perceived empowerment, thus more clearly targeting the causes for lack of empowerment and the design and evaluation of relevant and effective interventions.

Overall, intervention strategies were not well defined and were not clearly linked to theoretical referents. Although the majority of strategies focused on knowledge, social support, motivational factors, self-efficacy, self-management, goal setting, and education, it is not clear how these strategies comprise core empowerment components in an intervention. Without understanding the core empowerment components underpinning the interventions, includ-ing such factors as how and why the interventions worked or the conditions under which the treatment was thought to work, application to practice is limited. A greater level of specificity in construct definition as well as clear links between intervention theory and intervention strategies are needed to



Shearer et al. 23

evaluate specific predictions from theory and provide meaningful guidelines for intervention development targeting these constructs (Baranowski, 2006), strengthening the contribution of studies to the empirical literature. General statements about intervention content and delivery methods limit evaluation of the relationship between empowerment outcomes and intervention deliv-ery, including which component of multiple interventions may be responsible for an effect. Thus, greater attention is needed to intervention specification and related quantification of intervention fidelity to the planned protocol.

The conceptualization of empowerment and operationalization of empow-erment in the intervention were not consistent. Adolfsson and colleagues (2007) conceptualized empowerment as including mastery and control, oper-ationalizing empowerment in the intervention as education. Similarly, Figar and colleagues (2006) conceptualized empowerment as enhancement of capac-ities, operationalizing empowerment in the intervention as education and digital blood pressure monitoring. Davidson and Degner (1997) conceptual-ized empowerment as enhancing self-efficacy, operationalizing empowerment as information. DeCoster and George (2005) conceptualized empowerment as including control, self-efficacy, energy, potential, and competence, opera-tionalizing empowerment as a self-help group focusing on diabetes manage-ment. In some studies reviewed, empowerment was not defined, but relied on education to address problems such as quality of life among cancer patients (Golant et al., 2003). In other studies, the conceptualization of empowerment was outlined, with little information regarding operationalization in the inter-vention (Boonyasopun et al., 2008; Pibernik-Okanovic et al., 2004; Tsay & Hung, 2004; Wong et al., 2004). With any health promotion intervention or program, one of the greatest challenges is the maintenance of relevant effects over time. Many interventions within this review implemented comprehen-sive programs, but did not necessarily plan for, facilitate, or evaluate mainte-nance of program activities.

The majority of the studies reviewed conceptualized empowerment from a social perspective that involves relationships and social forces that act on the individual and promote a sense of control and feelings of power (Shearer & Reed, 2004), including the transfer of power from one group to another (Leyshon, 2002). However, a focus on individual strengths, skills, and access to needed resources may be a more sustainable approach. Empowerment may be viewed from a life span developmental perspective (Lerner, 1997) in which human beings are viewed as continuously innovative, embedded in a dynamic environment, and possessing inherent potential (Shearer & Reed, 2004). Successful intervention design from this perspective requires an inte-grative understanding of cultural and contextual perspectives, characteristics,




and resources of the target population, as well as the theoretically relevant determinants of empowerment that can be transformed into culturally sensi-tive behavior change strategies (Fleury & Lee, 2006). Interventions from a life span perspective focus on maximizing strengths and minimizing weak-nesses (Baltes et al., 1998) rather than changing behavior. The participant is a resource and active partner, and the intervention, directed less toward changing the participant and more toward optimizing human potential (Shearer & Reed, 2004). Similarly, studies reviewed tested standardized empowerment interventions primarily focused on the management of chronic illness using a one-size-fits-all approach. Further research is needed designed to facilitate the engagement of the older adult in the process of recognizing personal resources, social contextual resources including social network, and accessing social services and the identification of desired health goals and the means to attain these goals (Shearer, 2009). Indeed, researchers have called for an empowerment approach from a paradigm focused on the inherent poten-tial, skills, and resources of older adults rather than their deficits (Shearer, 2007; Shearer & Reed, 2004).

In a number of studies outcome measures were clearly linked to the con-ceptualization of empowerment (Anderson et al., 1995; Boonyasopun et al., 2008; Pibernik-Okanovic et al., 2004; Tsay & Hung, 2004; Wong et al., 2004), whereas in others the link was less clear. Adolfsson and colleagues (2007) conceptualized empowerment as including mastery and control, with outcome measures targeting knowledge, self-efficacy, HgA1C, and body mass index. Davidson and Degner (1997) conceptualized empowerment as self-efficacy, with outcome measures targeting treatment control preferences, anxiety, and depression. Figar and colleagues (2006) conceptualized empow-erment as enhancement of resources, capacity, and knowledge, with outcome as systolic blood pressure. Katula and colleagues (2006) based their interven-tion on Empowerment Theory and self-efficacy, with outcomes of physical activity readiness and lower leg strength. Outcomes evaluation was typically not comprehensive in addressing all theoretically relevant outcomes. Among outcomes addressed, effects were stronger overall for physiologic outcome variables and for outcomes measured immediately following the interven-tion. Tsay and Hung (2004) used an empowerment-specific scale to measure intervention outcomes, with an effect size of .78.

One area of concern within the studies reviewed is the lack of significant follow-up to determine the long-term impact of interventions. Although mod-est changes in health behaviors and outcomes can be achieved with empow-erment interventions, the extent to which such outcomes are lasting is less clear. With some interventions implemented for only several weeks, and an



Shearer et al. 25

overall limited time to follow up, the lasting impact of health empowerment interventions on relevant outcomes is difficult to evaluate.

In summary, a limited amount of intervention research has been conducted focusing on empowerment in older adults. This review raises many important questions regarding the definition and measurement of the concept of empow-erment, the strategies used to guide interventions, and the theory guiding the intervention. The clinical relevance and utility of empowerment-based inter-vention research is limited given the lack of clarity regarding the concept of empowerment, its measurement, and the specific interventions addressed.

Declaration of Conflicting Interests

The authors declared no conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The authors disclosed that they received the following support for their research and/or authorship of this article: The authors received funding from National Institutes of Health–National Institute of Nursing Research: 1R15 NR009225-01A2.

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