What is the Evidence on Effectiveness of Empowerment to Improve Health?

This synthesis report from the Health Evidence Network (HEN), an information service for public health and health care initiated and coordinated by the World Health Organisation (WHO) Regional Office for Europe, discusses the effectiveness of empowerment strategies on health outcomes. It finds that empowerment is a complex strategy that can lead to improved health outcomes but is dependent on the agencies, leadership, and context in which they are implemented. The paper includes discussions on youth empowerment, women's empowerment, and empowerment of people at risk for HIV/AIDS.

According to the report, research on the effectiveness of empowerment strategies has identified two major pathways: the processes by which it is generated and its effects in improving health and reducing health disparities. The research findings include discussions on participatory empowering strategies, empowerment outcomes and health and development outcomes.

• Evidence on participatory empowering strategies - the research found that citizen participation seems critical in reducing dependency on health professionals, ensuring cultural and local sensitivity of programmes, facilitating capacity and sustainability of change efforts, enlisting community stakeholders in programme improvement, enhancing the productivity, effectiveness and efficiency of programmes and enhancing health in its own right. Key facilitators to participation were identified as the use of local opinion leaders, lay health workers and social movements, political will and use of culturally based and culturally competent interventions. Participation can be constrained by development experts’ unwillingness to challenge internal power relations, lack of knowledge about empowerment, or unwillingness to extend beyond engaging key informants in order to genuinely facilitate community decision-making. While participation forms the backbone of empowering strategies, participation alone is insufficient and can be manipulative and passive, rather than active, empowering and based on community control. The World Bank has identified four characteristics to ensure that participation is empowering: people’s access to information on public health issues, their inclusion in decision-making, local organisational capacity to make demands on institutions and governing structures and accountability of institutions to the public. While specific empowering interventions differ, the majority of the interventions worldwide support participatory strategies that are based on group dialogue, collective action, advocacy and leadership
  training, organisational development, and transfer of power to participants.
• Empowerment outcomes - the report explains that much of empowerment literature focuses on participatory empowering strategies that lead to outcomes as ends in themselves, yet they are also intermediate steps to health and development outcomes. Aggregated regional and national data must be used with caution as empowerment outcome measures. Exclusive reliance on national
  and regional data also can lead to false interpretation of the success or failure of an empowerment
  initiative that may be facing intransigent national bureaucratic and political structures. Empowerment
  outcomes, therefore, must be assessed at many levels simultaneously and over time for an accurate
  picture.
• Health and development outcomes - the research found that interventions that have been most integrated with the economic, education, and/or political sectors have resulted in greater psychological empowerment, autonomy and authority, and have substantially affected a range of health outcomes. For example, multi-level empowerment strategies for HIV/AIDS prevention which address gender inequities have improved health status and reduced HIV infection rates. Women’s empowering
  interventions, integrated with the economic, educational, and political sectors, have shown the greatest impact on women’s quality of life, autonomy and authority and on policy changes, as well as on improved
  child and family health. Patient and family empowerment strategies have increased patients’ abilities to manage their disease, adopt healthier behaviours, and use health services more effectively, as well as increasing care-giver coping skills and efficacy. Coalitions and inter-organisational partnerships that promote empowerment through enhanced participation and environmental and policy changes have led to diverse health outcomes.

The policy considerations suggested by this narrative literature review include the following:

• Specific population programmes to overcome the larger political, social, racial, and economic forces that produce and maintain inequities need to be developed and further evaluated;
• Structural barriers and facilitators to empowerment interventions need to be identified locally;
• Empowerment strategies, including community-wide participation, seem worthwhile to be
  integrated into local, regional and national policies and economic, legal, and human rights
  initiatives;
• Health promotion should address effective empowerment strategies, such as:
• increasing citizens’ skills, control over resources and access to information relevant
  to public health development;
• using small group efforts, which enhance critical consciousness on public health
  issues, to build supportive environments and a deeper sense of community;
• promoting community action through collective involvement in decision-making
  and participation in all phases of public health planning, implementation and
  evaluation, use of lay helpers and leaders, advocacy and leadership training and
  organisational capacity development;
• strengthening healthy public policy by organisational and inter-organisational
  actions, transfer of power and decision-making authority to participants of
  interventions, and promotion of governmental and institutional accountability and
  transparency; and
• being sensitive to the health care needs defined by community members
  themselves.
• The most effective empowerment strategies are those that build on and reinforce authentic
  participation ensuring autonomy in decision-making, sense of community and local bonding,
  and psychological empowerment of the community members themselves.
• Government investment in multiple-method research and evaluation designs to collect
  evidence on the impact of empowerment strategies over time is needed.

The report concludes that empowerment strategies are promising in their ability to produce both empowerment and health impacts. Empowerment strategies are more likely to be successful if integrated within macro-economic and policy strategies aimed at creating greater equity. While participatory processes are at the base of empowerment, participation alone is insufficient if strategies don’t also build capacity to challenge non-responsive or oppressive institutions and to redress power imbalances. The key message from this review is that "empowerment is a complex strategy that sits within complex environments. Effective empowerment strategies may depend as much on the agency and leadership of the people involved, as the overall context in which they take place."