The issue

Within the last decades, social exclusion, disparities, and absolute poverty - almost 3 billion people living on less than US $2.00 per day - have grown despite globalization and rising per-capita income in many developing nations. Income ratios of the richest 20% of the population to the poorest 20% are now at 82 to 1 compared to 30 to 1 in 1960. World-wide health disparities are increasing due to vulnerability to disease from severe malnutrition, rapid re-emergence of water and blood-borne infectious diseases, environmental degradation, disinvestment in the health infrastructure and violence. Within this same period, empowerment strategies, participation, and other bottom-up approaches have become prominent paradigms within public health and the development aid for reducing these disparities. As "empowerment" increasingly enters mainstream discourse, those using the term need to clarify definitions, dimensions and outcomes of the range of interventions called empowering.

Findings

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. Empowerment is recognized both as an outcome by itself, and as an intermediate step to long-term health status and disparity outcomes. Within the first pathway, a range of outcomes have been identified on multiple levels and domains: psychological, organizational, and community-levels; and within household/family, economic, political, programs and services (such as health, water systems, education), and legal spheres. Only a few researchers have used designs resulting in evidence ranked as strong in the traditional evidence grading systems. Yet there is evidence based on multi-level research designs that empowering initiatives can lead to health outcomes and that empowerment is a viable public health strategy.

Much research has been focused on empowerment of socially excluded populations (e.g., women, youth, people at risk for HIV/AIDS, and the poor), though application of empowerment crosses to other populations and issues in public health. Youth empowerment interventions have produced multiple empowerment and health outcomes: strengthened self- and collective efficacy, stronger group bonding, formation of sustainable youth groups, increased participation in structured activities including youth social action, and policy changes, leading to improved mental health and school performance. 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, and 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-organizational partnerships that promote empowerment through enhanced participation and environmental and policy changes have led to diverse health outcomes.

Policy considerations

In light of the evidence and other information available up to now, effective empowerment strategies are needed for socially excluded populations. While participatory processes make up the base of empowerment, participation alone is insufficient if strategies do not also build capacity of community organizations and individuals in decision-making and advocacy. The policy considerations based on this narrative literature review include the following:

• Successful empowering interventions can not be fully shared or "standardized" across multiple populations, but must be created within or adapted to local contexts (e.g., culture and gender appropriateness).
• 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 organizational capacity development;
  • strengthening healthy public policy by organizational and inter-organizational 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.