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Measuring Empowerment in Families Whose Children Have Emotional Disorders: a Brief Questionnaire.

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Assessment tools measuring health-related empowerment in psychosocially vulnerable populations: a systematic review

  • Jianxia Zhai2,
  • Jing-Yu Tan1,
  • Mursal Azami1,
  • Kym Cunninghami &
  • Sue Kruskeiii

International Journal for Disinterestedness in Health volume 20, Article number:246 (2021) Cite this article

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Abstract

Groundwork

Many programs are undertaken to facilitate the empowerment of vulnerable populations across the earth. However, an overview of appropriate empowerment measurements to evaluate such initiatives remains incomplete to date. This systematic review aims to describe and summarise psychometric backdrop, feasibility and clinical utility of the available tools for measuring empowerment in psychosocially vulnerable populations.

Methods

A systematic literature review post-obit the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was completed. A descriptive arroyo was used for information analysis. Papers were eligible if they explored the development, validation, cross-cultural translation or the utility of an empowerment measurement tool in the context of psychosocially vulnerable populations.

Results

Twenty-six included manufactures described twenty-6 separate studies in which xvi empowerment measurement tools were developed, validated/translated, or used. There was heterogeneity in empowerment constructs, samples targeted, and psychometric properties measured. The measurement of reliability of the included instruments was satisfactory in nigh cases. Still, the validity, responsiveness, interpretability, feasibility and clinical utility of the identified measurement tools were often not adequately described or measured.

Conclusion

This systematic review provides a useful snapshot of the strengths too every bit limitations of existing health related empowerment measurement tools used with psychosocially vulnerable populations in terms of their measurement properties, and constructs captured. It highlights significant gaps in empowerment tool measurement, development and evaluation processes. In particular, the results suggest that in addition to systematic assessments of psychometric properties, the inclusion of feasibility and clinical utility as event measures are important to assess relevance to clinical practice.

Background

Empowerment of individuals refers to a participatory process of condign stronger and more confident enabling them to have more than control over their lives [i]. An empowered individual may brandish characteristics of increased self-esteem, self-efficacy, responsibility and self-determination [i]. However, the term empowerment has also been used with various populations and in a wide range of contexts to illustrate aspects of a broader concept [ii]. Every bit such it has been described as a multi-level construct, which comprises organisational, community or group and individual domains [iii].

Empowerment has been viewed as a cardinal value or goal in health promotion and an integral chemical element of social equity and social welfare policy [4, five]. Empowerment-related research tends to identify and highlight participants' strengths and abilities rather than focusing on risk factors and deficits [3]. Internationally, in varied wellness promotion programs researchers are endeavoring to conceptualise and measure empowerment, and aiming to inform theory edifice and policy advocacy [6,7,viii].

In healthcare, vulnerable populations are those individuals at risk of unequal access to healthcare services and desirable health outcomes because they meet barriers due to their cultural, indigenous, health or economic status [9]. Vulnerabilities tin be further categorised into iii domains: physical, psychological, and social [9]. Psychosocially vulnerable populations within the context of this review are characterised every bit those susceptible to poor health outcomes generated or exacerbated by the presence of detail psychosocial factors. Factors may include, merely are not express to, belonging to a racial or ethnic minority or being an ethnic person, being pregnant, a kid, elderly or homeless, or having human immunodeficiency virus (HIV) or a severe mental affliction. Psychosocially vulnerable populations are those at risk of disparate healthcare access and outcomes due to stigmatisation and prejudice [x]. Hence, empowerment that promotes independence and enables self-determination is ofttimes a goal for the holistic wellbeing of individuals from vulnerable populations [11].

Initiatives funded by WHO, USAID, the World Bank and other agencies, seek to build empowerment among vulnerable or disadvantaged groups and communities to eliminate stigma and wellness disparities [12]. Studies have shown that empowerment programs can lead to positive wellness-related outcomes such as improved coping skills, self-efficacy, self-mastery, more admission to wellness services and other resources, and enable disadvantaged groups to drive positive structural and organisational modify [xiii,14,15,16,17].

Every bit the concept of empowerment has gained recognition as a core tenet in health promotion by patients, professionals, and policy makers, there has been increasing interest in the utility of implementing empowerment programs [18]. Endeavors to evaluate such interventions are largely dependent on effective and robust measurements of the empowerment concept [xix]. Nevertheless, to date, measurement has been complicated considering there is no universally accustomed definition of empowerment, and it is argued that the empowerment construct may be both context-dependent and population-specific [20].

Cyril et al. [four] stated that although there have been extensive studies on empowerment in the final decades, at that place remains a scarcity of literature adequately reporting on associated psychometrics. Whilst varied empowerment measurement tools and scales have been developed, their quality has non been rigorously or systematically appraised. Those studies that have appraised the reliability and validity of scales measuring empowerment have tended to focus on participants with specific diseases, limiting their generalisability to wider populations [21,22,23]. Because populations with psychosocial vulnerabilities tend to be at higher risk of social exclusion and reduced access to healthcare than the general population, it is important to determine the potential for well-measured empowerment interventions to exist used in these groups.

To the best of our knowledge, in that location has been no published systematic review with regard to empowerment measurement tools available to evaluate and monitor benefits of health promotion programs for psychosocially vulnerable populations. Systematic test of reliability, validity, feasibility and clinical utility of empowerment tools is required to inform the selection of appropriate instruments to evaluate empowerment programs and address outstanding issues on how to effectively raise empowerment in individuals and groups. The purpose of the report was to systematically review and appraise the properties of empowerment measures and their applicability for utilize with empowerment programs for psychosocially vulnerable populations.

Methods

Search strategy

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-assay (PRISMA) guidelines [24]. Nosotros searched MEDLINE, CINAHL, PsycINFO, PubMed, Informit Indigenous Collection, and the Australian Ethnic WellnessInfoNet electronic databases. The Australian database was included in addition to the international Informit Indigenous research resources collection considering of the authors' awareness of ongoing Australian-based research almost empowerment assessment in Aboriginal and Torres Strait Islander communities. The searches used relevant Medical Field of study Headings (MeSH) and keywords listed beneath (Pubmed example). To identify additional eligible studies that may have been missed by the electronic search, the reference lists of the retrieved articles were too reviewed, supplemented by citation tracking using Google scholar. Papers published between January 1990 and January 2021 were eligible for inclusion. The database search inception date of January 1990 was selected because the publication of health-related empowerment studies has increased dramatically since the early 1990s [1]. We conducted the database searches for the review between 4 Dec 2020 and 31 January 2021. Retrieved literature from the combined database searches was imported into bibliographic citation management software, Endnote X9.

#one empowerment [MeSH Terms]
#2 empowerment measurement* [Title/Abstract]
#three empowerment calibration*[Championship/Abstruse]
#4 empowerment tool*[Title/Abstruse]
#v empowerment survey*[Title/Abstract]
#six empowerment questionnaires*[Title/Abstract]
#7 #1OR #two OR #3OR #4 OR #5 OR #6
#viii vulnerable population* [MeSH Terms]
#9 sensitive population* [Championship/Abstract]
#10 underserved population* [Title/Abstract]
#xi #8 OR #9 OR #10
#12 #seven AND #11

Study inclusion and exclusion criteria

Manufactures were included if the study aims focused on empowerment measurement tool evolution, or the implementation, validation or translation of existing empowerment measurement tools in the context of psychosocially vulnerable populations. Studies investigating empowerment as a health upshot mensurate to evaluate the utility of empowerment measurement tools contextualised with psychosocially vulnerable individuals were likewise eligible. Only manufactures available in English linguistic communication were included. In that location were no restrictions on study quality. Studies that were published in dissertations, books, reports, and other non-peer-reviewed resources were also eligible for inclusion. Studies were excluded if empowerment was explored using just qualitative research methods (eastward.yard. face up to face interviews or focus groups), they did not focus on empowerment in a health-related context, or they did not report whatsoever psychometric assessment results from measuring empowerment.

Data extraction and data items

Data extraction comprised general information about the study including author, year, written report design, setting and written report aims, and participant characteristics. We extracted further detailed information with regard to characteristics of empowerment measurement tools, the empowerment domains under exam, measurement tool item development, number of items included in each tool, how the measurement tool was administered, tool response scales, and whether exploratory factor analysis (EFA) and/or confirmatory factor analysis (CFA) was conducted.

We adhered to the guidelines for instrument measurement backdrop suggested by Rostad et al. [25]. The psychometric properties of the empowerment measurement tools were appraised beyond four dimensions: reliability, validity, responsiveness and interpretability. In addition, we appraised feasibility and clinical utility of the tools. In this review, reliability refers to the consistency of a measurement, which normally includes test-retest reliability, internal consistency, and inter-rater reliability [26]. Validity refers to the extent to which a measurement tool represents the variable/s it is intended to measure [26]. Responsiveness reflects the capacity of an instrument to measure alter over time, and interpretability of measurement scores is important to differentiate between clinically of import modify and measurement error [27]. Feasibility refers to the resources needed to administer and procedure a participant cess using the measurement tool, for example, who completed the assessment, time taken, and amount of staff training required [25, 28]. Clinical utility explores 'usefulness to practice' and whether the result of the cess can inform clinical and industry conclusion making [29].

Data synthesis and presentation

A descriptive analysis was utilised in this report to illustrate the range of empowerment measurement tools used with psychosocially vulnerable populations, and evaluate their psychometric properties, feasibility of apply and clinical utility. The report results were tabulated and presented using descriptive summaries.

Results

Included studies

Electronic searches yielded 1316 articles and the secondary reference listing search generated 12 additional papers (Fig. 1). After removing 1011 indistinguishable publications, 305 records remained for title and abstruse review. Screening of titles and abstracts excluded 244 papers. The remaining 61 full-text records were reviewed for inclusion eligibility. A farther 35 articles were excluded. At that place was terminal inclusion of 26 papers focusing on empowerment measurement tool evolution, or the validation, translation or application of existing empowerment measurement tools.

Fig. ane
figure 1

PRISMA flow diagram of study choice. Adjusted from: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, et al. The PRISMA 2020 argument: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71

Full size image

Overview of the studies

In total, the 26 included articles reported 26 distinct studies and xvi different empowerment measurement tools (Table ane). Viii of the studies were undertaken in the US, five in Australia, two in Republic of india, and 2 in Nippon. One study was in both the US and Australia, and ane each were undertaken in Nepal, Iran, the Netherlands, China, United mexican states, Bolivia, Sweden and Africa. With regard to the empowerment measurement tools, the number of response items included in the tools ranged from eight to 34. A bulk of the studies used a measurement tool with a four or five-point Likert calibration. Written report sample sizes ranged from 15 to 1824 participants. Characteristics indicating psychosocial vulnerability among study participants included pregnancy, mental health disorders (including families of children with mental health disorders), Indigenous populations, ethnic minorities, people infected with HIV, and people who were members of self-help groups. Across the 26 included studies, seven articles focused on initial development of an empowerment measurement tool (tool development studies), 5 articles reported how the tools were validated or translated when used in a cross-cultural or new language setting (tool validation/translation report), and the remaining 14 manufactures used an empowerment measurement tool to assess health outcomes following an intervention (empowerment study).

Table one Characteristics of the empowerment measurement adopted in the review

Total size table

Measurement properties

Reliability

Internal consistency of the empowerment measurement tools was tested in xviii studies and most demonstrated medium to moderately skillful internal consistency across settings (Tabular array 2) with iii reporting poor internal consistency of sub-scales [39, 42, 48]. Test-retest reliability was assessed in 4 studies [20, forty, 41, 44]. Only one study by Contreras-Yáñez et al. [20] reported intra-class coefficients (ICC). The written report assessed adaption of a Spanish version of the Wellness Empowerment Calibration for utilise with Latin American participants with rheumatoid arthritis and the ICC showed moderately skillful reliability across settings.

Tabular array two Measurement properties of the scales included in the review

Full size table

Validity

Content validity

The various methods of assessing content validity reported in 6 of the studies included brief descriptions of content revision [31, 45], calculation of the content validity ratio and content validity index [32], rating of measurement tool calibration items by practiced panels [20, 43], and contained particular ratings and participants readability and clarity [44]. The face validity of measurement tools, for example, difficulty and relevance of response items, was assessed with a participant feedback approach in only two studies [20, 32].

Benchmark-related validity

A comparative Locus of Control scale was used past Kameda and Shimada [42] to assess criterion-related validity in their evolution of an empowerment measurement tool for Japanese significant women. There was a strong positive correlation institute betwixt the original scale scores and the newly developed calibration. Afterward, in a 2015 written report measuring empowerment among Iranian pregnant women, Borghei et al. [32] used Kameda'southward pregnancy empowerment scale, equally well equally the Spritzer psychological empowerment scale equally gold standards to evaluate the criterion-related validity of their new empowerment measurement tool (the Persian-language Cocky-Structured Pregnancy Empowerment Questionnaire), and showed a strong positive correlation between the gold standards and their new tool.

Construct validity

Construct validity was assessed past a number of different approaches in the studies in this review, including assessment of structural validity, internal and external construct validity, discriminant/convergent validity and cross-cultural validity. Structural validity was tested using an EFA method for determining number of factors of the scale in 6 studies. Klima et al. [43] used an expert panel to constitute content validity of dimensions of pregnancy-related empowerment in an initial development phase of their empowerment measurement tool. A subsequent CFA was consistent with the adept panel'southward 4 dimensions: provider connectedness, peer connexion, skilful controlling and gaining voice. Discriminant and convergent validity was assessed in two studies with fair results [41, 48]. Of five empowerment validation/translation studies, iii considered an test of cantankerous-cultural validity. In developing a pregnancy-related empowerment scale, Klima et al. (2015) used a committee of bilingual translators to achieve conceptual rather than literal equivalence validation. Contreras-Yáñez et al. [xx] conducted cultural sematic validation in a cross-cultural adaptation, and Hansson and Björkman [39] briefly mentioned cultural validation in the context of testing reliability and validity of the Swedish version of an English-language empowerment scale for people with a mental illness. Cross-cultural validity was not reported in the remaining two validation/translation studies [42, 48].

Responsiveness and interpretability

Responsiveness, or the power of a measurement tool to detect changes over time, was examined in three studies [31, 46, 50]. Specifically, Nishita et al. [46] reported that a participant-driven direction intervention enhanced diabetes cocky-efficacy with a medium to large effect size at follow-upwardly after 12 months. Berry et al. [50] reported that effect sizes for iv subscales of the Growth and Empowerment Mensurate (GEM) between baseline and 8 weeks were large, indicating that the GEM was sensitive to empowerment changes in the targeted substance abuse handling population. Bhatta et al. [31] demonstrated sustained increased empowerment from a social self-value intervention for people with HIV after 6 months. None of the included studies reported interpretability.

Feasibility and clinical utility

Of the 26 studies reviewed, seven reported one or more aspects of measurement tool feasibility and/or clinical utility in terms of who carried out the assessment [15, 45], the number of missing responses [17, 20, 48], participants cocky-reported experiences of using the tool [20, 39, 43, 48], besides as the amount of time needed to complete an assessment [20, 39, 43].

Castelein et al. [48] in a comparison of iii instruments, evaluated their clinical usefulness for people with psychotic disorders. They found grammatical and lexical considerations were important and that clinical usefulness was dependent on cerebral abilities of participants. Additionally, in feedback from participants, musical instrument items that were not applicative to all had the potential to confuse users during information drove and issue in unanswered items [17, 48]. The average participant time needed was reported in iii studies and ranged from 7 min to xxx min. Feedback related to the participant time burden showed that vii min was regarded as convenient [20], whereas the 30-min timeframe required to complete the GEM [17] was considered also long for use with pregnant women in fourth dimension-express appointments with competing clinical priorities [49]. None of the studies reported whether staff grooming was provided alee of measurement tool administration. Only Contreras-Yáñez et al. [20] assessed a majority of these features related to feasibility and clinical utility.

Discussion

This systematic review has examined the measurement of empowerment in psychosocially vulnerable populations from 1990 to 2021. Since the early 1990s, empowerment every bit a general concept has gained pregnant entreatment demonstrated past an exponential increase in literature, peculiarly that exploring its theoretical underpinnings [one]. The term is now entrenched among many of the health professions, however, over fourth dimension efforts to develop robust empowerment measures have lagged [one, 44]. This review adds to this important field of inquiry by identifying empowerment measurement tools as they relate to psychosocially vulnerable populations, and reported on available assessments of psychometric backdrop of the tools, their feasibility and clinical utility.

Shortcomings in comprehensive testing of of import measurement tool properties have been identified in the review. In assessments of reliability, or consistency of the measurement tools, well-nigh of the included studies appraised internal consistency as fair or good for the total scale making upward the tool, but failed to assess or written report on reliability of its subscales. Additionally, test-retest reliability or the degree to which results are repeatable has been reported as beingness a necessary testing component for fairly assessing full general reliability [4], nonetheless, this step was documented in only four of the 26 included papers. Construct validity of a tool is one of the most significant measurement properties since it determines how well the tool measures what it claims to exam [19]. Overall, this review identified a general lack of adequate investigation of this property with less than half of the studies (10/26) reporting results of an assessment.

With regard to v studies that included validation/translation, three examined cross-cultural validity, albeit one briefly, in the process of translating an existing empowerment tool to a new cultural and linguistic communication grouping. Validating a tool in a culturally different population is non merely a thing of direct translation and dorsum translation into respective language and cultural settings. Importantly, it is also necessary to ensure conceptual, operational, measurement, functional and particular equivalence, in parallel with creating semantic equivalence [12, 51]. The application of standard scales without adequate adaptation inappropriately 'presumes a universality of definition and understanding' (Brownish et al., 2013, p.six). For case, the pregnancy-related empowerment scale (PRES) was validated and widely used across America including African American populations [43]. However, for use in sub-Saharan African settings, translation was not considered and possible affect of cultural differences was absent in the study's results [fourteen]. Although there are varied available tools for assessing empowerment amidst pregnant women, information technology remains challenging to identify advisable instruments that are applicative for the civilisation and experiences of each target population [43].

Responsiveness and interpretability of empowerment tools were described and reported in very few studies, which is consequent with findings of Terwee et al. [52]. Without insight about responsiveness, or 'longitudinal validity', it is difficult to empathize whether clinically important changes in levels of participants' empowerment are sustained over time. None of the studies included in this review tested interpretability which is useful in distinguishing clinically important alter from measurement error. It is highlighted that responsiveness and interpretability, and flooring/ceiling effect were often missing in measurement tool evaluations [xix, 52]. Validation/translation studies could exist more informative if they were able to examination these of import measurement qualities. Without full assessment of psychometric properties, the validity and reliability of results generated by utilize of that measure remain uncertain.

Well-nigh of the studies included in the review did not report enough information to assess feasibility and clinical utility of the empowerment tools. In detail, there was oft a lack of data regarding time and effort needed for participants to complete assessments, or for those who administer them. Measurement tool evaluations should also provide an indication of training or professional expertise and experience needed past staff who administer instruments. As matters of practicality, decisions based on the respondent and administrative burden of a measurement tool are likely to be linked to available resources in both clinical and research environments. Additional musical instrument attributes related to feasibility of apply and clinical utility include the needed literacy levels of intended participants and user acceptability [53]. High participant refusal rates and levels of missing information are likely indicators that an instrument or items in information technology were unacceptable or not applicable. Missing responses are particularly important for clinical utility if the full score from an empowerment measurement tool is influenced by unanswered items [25].

Whilst some empowerment scales have been successfully validated across populations, settings and cultures, they may not measure up in a cursory assessment of their feasibility or clinical application. For example, the GEM was adult and validated with Ancient Australians and studies have reported that it effectively captured changes within Indigenous people participating in specific empowerment programs [13, 17, 45]. The Gem requires meaning investment for implementation as it encourages participants to reflect on their life experiences and requires an average of xxx min to complete the scale [49]. Empowerment is inherently circuitous and subjective, context dependent, and definitionally imprecise [17]. As such, it could be argued that as a construct regarded with increasing importance and value, its measurement is deserving of additional participant and authoritative burden. Although a shortened version of the Jewel reducing the instrument from 12 to vi core detail scales has been trialed and successfully detected the most consistent empowerment change in two groups of participants [54], it was concluded that using the full tool gave maximum analytical power for understanding the nuances of personal modify. Evolution and rigorous validation of short-form scales may enhance the routine use of empowerment measurement tools [55], however, the advantages of this should be weighed against potential loss of intent and utility of the original tools.

Every bit with many literature reviews, relevant articles may accept been missed by our search strategy or overlooked in error during the championship and abstract review phase. Information technology is possible that an important simply unpublished torso of work related to empowerment of psychosocially vulnerable populations exists. For example, projects undertaken in Indigenous community-controlled sectors internationally may exist underreported in the peer-reviewed literature. This review is likewise subject field to potential bias including errors in translation of information from original research papers. Due to the time lag betwixt research completion and subsequent publication recent literature may have been missed. A further possible bias was introduced considering this review has excluded literature published in languages other than English.

Decision

This review synthesizes and assesses bachelor studies on the measurement properties, feasibility, and clinical utility of empowerment measurement tools used in psychosocially vulnerable populations. Few studies provided a comprehensive assessment of the properties of interest. In that location were pregnant shortcomings in testing of psychometric qualities, particularly with regard to evidence to support responsiveness and interpretability of the measurement tools. The results highlight that development, translation and validation of empowerment measurement tools is not a straightforward process [56]. At that place are many steps that tin can be costly, fourth dimension consuming and requiring complex statistical analyses. Notwithstanding, the work is important because well-designed and tested measurement tools are primal to increasing our understanding of the complex empowerment construct. Detailed and importantly, systematic assessments of the psychometric properties of measurement tools are needed to create reliable, valid and responsive measures of empowerment. Additionally, future research will do good from including feasibility and clinical utility as issue measures in assessments of the effectiveness of empowerment programs for psychosocially vulnerable populations.

Availability of data and materials

Non applicable.

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Acknowledgements

The authors would similar to acknowledge the Australian Nurse-Family unit Partnership Programme teams who deliver the plan across 13 sites working with women and communities.

Funding

This systematic literature review was supported by the Australian Nurse-Family unit Partnership Program National Support Service funded past the Australian Section of Health.

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Affiliations

  1. College of Nursing & Midwifery, Charles Darwin University, Brisbane, Queensland, Commonwealth of australia

    Sandy Campbell, Jing-Yu Tan, Mursal Azami & Kym Cunningham

  2. College of Nursing & Midwifery, Charles Darwin University, Melbourne, Victoria, Australia

    Jianxia Zhai

  3. College of Nursing & Midwifery, Charles Darwin University, Alice Springs, Northern Territory, Australia

    Sue Kruske

Contributions

SK, SC JT, KC and MA conceived the written report concept and design. JZ conducted the literature searches and conducted initial screening of papers. JZ and SC screened, reviewed and extracted information from papers and prepared the manuscript. All authors reviewed typhoon versions of the paper and critically revised them for intellectual content and gave last approval of the published version.

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Correspondence to Sandy Campbell.

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Campbell, S., Zhai, J., Tan, JY. et al. Cess tools measuring health-related empowerment in psychosocially vulnerable populations: a systematic review. Int J Equity Health 20, 246 (2021). https://doi.org/10.1186/s12939-021-01585-1

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Keywords

  • Empowerment
  • Tools
  • Psychometric properties
  • Vulnerable populations
  • Systematic review

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