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Abstract
Introduction Community empowerment is a core concept in health promotion theory and practice. Several authors have defined and conceptualised the term differently. However, we did not find any synthesis of the various definitions of, and meanings attached to, community empowerment and the various conceptualisations, operationalisations, and the indicators for measuring community empowerment in the health promotion literature. The aim of this scoping review is to characterise and synthesise various definitions, conceptualisations, operationalisations and indicators for measuring community empowerment in the literature.
Methods and analysis This scoping review will follow scoping review methods outlined by Arksey and O’Malley. We will identify relevant studies from 1986 onwards, written in any language, conducted anywhere in the world, and published in PubMed, PsycINFO, CINAHL, Web of Science and Medline. Two reviewers will independently screen titles, abstracts and full-text articles, after which they will carry out data extraction and analysis. We will develop a numerical and narrative synthesis of the definitions, conceptualisations, operationalisations and measurements of community empowerment in relation to health promotion and/health outcomes.
Ethics and dissemination This scoping review does not require ethics approval, as we will only include information from previously conducted studies and we will not involve human participants.
- community empowerment
- citizen empowerment
- health promotion
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Strengths and limitations of this study
To our knowledge, this is the first review that will synthesise the definitions, conceptualisations and operationalisations of community empowerment in both the published and grey literature.
We anticipate that the scoping review findings will reveal gaps for further syntheses and/or primary research on community empowerment, which are up to now not obvious.
We plan to contact experts in the field to request additional relevant studies from grey literature, but we are aware that we may not receive responses from all those that we contact and our list of experts may not be comprehensive. Additionally, we will search five databases, but we are aware that we may miss some relevant articles captured in other databases.
Introduction
The 1978 Alma Ata declaration described individual empowerment and citizenship as a critical element for achieving community empowerment, which is a crucial component of primary healthcare.1 Additionally, the declaration emphasised the importance of involving the community in planning and implementing interventions that affect their health. Following the Alma Ata declaration, there was a consistent emphasis on community action in the Ottawa Charter on Health Promotion.2 This was reaffirmed in the Jakarta Declaration,3 and subsequent declarations on health promotion legitimised the empowerment discourse, making it a core element of health promotion theory and practice.
Despite these developments, empowerment remains an ambiguous concept yet to be well articulated in the health promotion field.4 Various authors have noted that the varying use of this term may minimise the continued significance of empowerment within the health promotion discipline.4–6 One aspect of the conceptualisation of community empowerment that has received considerable attention in the health promotion literature is the question of whether community empowerment is a process or an outcome. Although Rissel4 has argued that most people agree that community empowerment is both a process and outcome, measuring community empowerment as a process or outcome is fraught. There is no consensus about which is easier to measure and how to measure them.7 8 Various authors weighing in on this question have described community empowerment as a multilevel construct, a process with three levels starting with individual development and psychological empowerment at the individual level, moving on to community empowerment and ending with social and/or political empowerment.4 8–10
Turning to individual and psychological empowerment, both terms are often used interchangeably in the empowerment literature. But Christens5 argues that they differ and highlighted contextual considerations as the primary distinguishing factors between the two concepts. Individual empowerment focuses on a single personality without considering other contextual factors. It increases psychological well-being, self-efficacy and self-esteem and can be achieved without participating in collective action.6 However, individual empowerment cannot sufficiently address inequalities and may not produce the amount of actual power or resources required to influence political and social change. On the other hand, psychological empowerment evolves from active participation in collective action and capacity building and is therefore inseparable from the community and organisational empowerment processes.5 Yet, most of the literature on empowerment in the health promotion field focus on individual empowerment. A recent systematic review of empowerment measures in health promotion revealed that about 85% of the articles reviewed focused on individual empowerment, highlighting the paucity of studies focusing on organisational and community empowerment.7
Popay et al,11 in one of a recent trilogy of papers, offered an insightful perspective to the discourse. They argued that community ‘empowerment’ interventions have become more focused on psychological and social empowerment with less attention paid to social and political action. The authors contend that social and political action is necessary in order to achieve transformation and equity, which are the basis of health promotion practice. According to the authors, it is crucial to identify the factors responsible for the depoliticisation of community empowerment and return to the original essence of the empowerment concept, which is to build capabilities required to exercise collective control for decision making and social action.
A more detailed examination of the community empowerment literature and its related constructs reveals different barriers to its extensive use in health promotion practice.4–6 Although community empowerment is central to community development and health promotion, it is difficult to apply and measure due to the lack of a clear theoretical underpinning and definition.4 6 Further, various authors have argued that there has been a dilution of the concept over the years with the replacement of community empowerment with other concepts.5 6 Laverack and Wallerstein8 note that the increasing emphasis on discussions that present concepts such as community capacity, community competence, community cohesiveness and social capital as critical for promoting improved quality of life and health outcomes have tended to overshadow the significance of community empowerment in transforming power relations and facilitating social change in health promotion practice. These constructs are often described as having as much potential as the term ‘community empowerment’. Different authors across a range of disciplines assert that they increase individuals’ abilities to take control of their lives and health, which is the underlying principle of community empowerment.4 12 13 Unfortunately, the use of these terms has tended to devalue the core goal of empowerment which is social or political change.
Several authors have attempted to operationalise community empowerment as well as develop indicators for measuring community empowerment. Laverack and Wallerstein8 describe nine domains through which empowerment can be measured. According to the authors, programmes aimed at achieving community empowerment should strive to ‘facilitate participation, build local leadership, increase problem assessment capacities, enhance the ability to ‘ask why’, develop empowering organisational structures, improve resource mobilisation, strengthen links to other organisations and people, create an equitable relationship with outside agents; and increase control over programme management”. These domains also provide insight into possible ways of progressing along the empowerment continuum, which involves moving from personal action to political action.14 Although the authors attempt to strengthen the community empowerment discourse, community empowerment remains a complex term due to the absence of clear conceptualisation and indicators for measuring the concept.
There is a scarcity of relevant systematic reviews on community empowerment. When we scoped for reviews on community empowerment, we identified only five major ones over the past 20 years. One was a literature review, another a rapid review, and the other three were systematic reviews. The literature review by Laverack examined various conceptualisations and operationalisations of community empowerment.15 However, this review was conducted over 15 years ago and did not follow systematic methods to identify the included studies. The more recent rapid review was conducted by Laverack and Pratley16 to strengthen policy-making in the WHO European Region. The review explored the existing knowledge on the conceptualisation and measurement of community empowerment at the national level. The authors, proposed that the use of mixed methods, a range of indicators and variables and accessing databases as the ideal approach for measuring community empowerment. However, the authors noted that the technical and organisational skills required to effectively integrate qualitative and quantitative methods might be unavailable in many settings.16 Of the three systematic reviews, the most recently published one focused on empowerment measures in health promotion.7 The other two systematic reviews focused on empowerment for health nutrition17 and evaluation procedures and their advantages and disadvantages.18 We also found a scoping review on community empowerment, focusing on water, sanitation and hygiene.19
While these reviews have enhanced our understanding of community empowerment interventions, none of these reviews offered a critical synthesis of the meanings attached to community empowerment and the diverse approaches for operationalising and measuring the concept. Yet, for health promotion practitioners and researchers seeking to improve community members’ ability to gain resources or achieve resource redistribution through community action, a clear understanding of concepts and indicators remains elusive.
Ponsford et al20 argue that for the outcome of any community empowerment initiative to benefit health policy and practice, health promotion researchers must identify and measure local capabilities (various forms of power) at the collective level. The lack of a critical synthesis of how community empowerment is conceptualised, operationalised and measured highlights a gap in our knowledge yearning to be filled. Therefore, this study seeks to characterise and provide a critical synthesis of the various definitions and conceptualisations of community empowerment. The synthesis will also document the diverse approaches for measuring community empowerment in the literature. The study findings could engender discussions and debates in the health promotion field.
Objectives
To identify and synthesise the various definitions and concepts (ie, activities, processes and components) used to describe community empowerment in the context of health promotion.
To identify and synthesise descriptions and assessments of how community empowerment is operationalised (ie, indicators and interventions of community empowerment) in the context of health promotion.
To describe the relationship between community empowerment and health promotion and/health outcomes.
Methods
Protocol
This scoping review protocol was developed using the scoping review methods outlined by Arksey and O’Malley.21 We will follow the proposed steps for conducting a scoping review: identifying the research question, identifying relevant studies, study selection, charting the data, collating, summarising, and reporting the results, and consultation. We will report the findings from our scoping review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews: Checklist and Explanation.22
Eligibility
We will include any published qualitative, quantitative and mixed-methods studies, whether on empirical or conceptual research in the health sector. Eligible studies must provide: (1) a definition and/or conceptualisation of community empowerment (eg, activities, processes and components); or (2) a description or assessment of the operationalisation of community empowerment (eg, indicators and interventions of community empowerment); and/or (3) a description, explanation or assessment of the relationship between community empowerment and health promotion and/or health outcomes.
Information sources
We will conduct a systematic search of published literature within the health sector. We will search the following electronic databases: PubMed, PsycINFO, CINAHL, Web of Science and Medline. We will also carry out a hand search of unpublished reports and key websites (eg, the WHO), check the reference lists of all included studies and contact authors and/or experts in the field for additional references.
Search strategy
Our search strings will combine keywords and Medical Subject Headings (MeSH) terms such as community empowerment, community participation, community engagement, empowerment education, health promotion, health education, community critical consciousness, community critical awareness, citizen empowerment, citizen participation, community capital, collective action, collective control, collective control capability(ies), collective involvement, collective empowerment, group-based empowerment, group morale, group cohesion and camaraderie. We have developed a preliminary search strategy using PubMed (online supplemental file 1), which we will finalise using an iterative approach of checking whether known articles that meet our eligibility were found by the search. The search will not be limited by language and geography, but we will limit our search to start from 1986, when the Ottawa Charter for Health Promotion was first launched.2
Supplemental material
Study selection
The review team will pilot the eligibility criteria by screening a sample of the first titles, abstracts and full-text articles together (using online supplemental file 2). The screening process will start off with at least two review authors independently assessing the titles and abstracts. Full-text articles will be retrieved for all the titles and abstracts that potentially meet the eligibility criteria. At least two review authors will again independently assess the full-text articles to make a final decision about which studies to include in the review.
Supplemental material
Data extraction and data items
Once we have a final list of all included studies, one review author will extract and sort relevant data from individual studies according to the objectives of the review. The review author will extract general information on the study and author details; research type and study design; and research setting and participants into an Excel spreadsheet. In terms of the synthesis, extracted data will be classified into three categories: (1) definitions and concepts of community empowerment; (2) indicators, interventions or evaluations of community empowerment and (3) relationship between community empowerment and health promotion. Additional categories may be identified during the data extraction process and in consultation with the entire review team. We will not assess the methodological quality of the included studies, as that is the convention for such scoping reviews.21 22
Data synthesis
We will use both qualitative and quantitative methods to synthesise the data. We will conduct a numerical analysis to provide an overview of the basic characteristics of the included studies (eg, study design and country setting). For objective 1, we will conduct a qualitative analysis to provide a narrative synthesis of the different definitions and concepts of community empowerment, including its activities, processes and components. For objective 2, we will provide a narrative synthesis of key indicators and interventions of community engagement and provide a quantitative summary (eg, in a table or as harvest plots) of the effectiveness of interventions (objective 2). For objective 3, we will also provide a narrative synthesis of any descriptions or explanations of the relationship between community empowerment and health promotion (objective 3).
Patient and public involvement
There was no patient or public involvement in the design of this protocol.
Discussion
The concept of empowerment is the core value of health promotion practice, but wide use of the empowerment construct across several fields has resulted in varying scopes, approaches and definitions.7 23 This has led to varying conceptualisations, operationalisations and indicators for measurement.24 To our knowledge, this is the first review that will synthesise the definitions, conceptualisations and operationalisations of community empowerment in both the published and grey literature. The review will provide a critical synthesis of the definitions of community empowerment and the meanings attached to the concept in the health promotion field to enable discussions and debates in the health promotion field.
In conducting the review, we expect to conceptually grapple with different authors’ definitions, conceptualisations and operationalisations of community empowerment. We will grapple with delineating issues related to individual empowerment versus psychological empowerment. We will also grapple with delineating issues related to how community empowerment is conceptualised versus operationalised. Similarly, we will be challenged when distinguishing between issues relating to the operationalisation vs the measurement of community empowerment. We will consider how authors define, conceptualise, describe and distinguish these issues in the included studies and agree within our team on a way for interpreting differences and understanding various definitions, conceptualisations, operationalisations and indicators for measurement.
We anticipate that the scoping review will reveal gaps for further syntheses and/or primary research on community empowerment which are up to now not obvious. The scoping review will present the different definitions, conceptualisations and operationalisations that exist in the literature and illuminate key conceptual and ideological differences in the various approaches to measuring community empowerment. Further, the review will contribute to the debate on the definition, conceptualisation, operationalisation and measurement of community empowerment, which will elevate the discourse within the health promotion field. Finally, the scoping review will serve as a foundation for future studies; we hope that as a start, there will be scope for us to conduct a qualitative evidence synthesis on the barriers, facilitators and strategies of community empowerment.
Our scoping review has the following strengths. First, we will search several databases that capture relevant studies on community empowerment. Second, we chose to include articles published from 1986 when the Ottawa Charter on Health Promotion, the major international document that elevated the centrality and importance of community empowerment in health promotion, was developed. Third, we will contact policy-makers, practitioners and other experts working in the field of health promotion to request additional grey literature that are not available in the public domain. And lastly, we will not restrict our searches by language or geography, meaning we will retrieve and screen a wide range of articles on this topic.
We envisage a few limitations. Although we intend to contact experts in the field to request additional publications from grey literature, we understand that we may not receive responses from all of them. In addition, our list of experts may not be comprehensive. We will search five databases, but we are aware that we may miss some relevant articles captured in other databases. While our strategy will ensure that we include all articles published in all languages with a plan to use expert translators, some of the meanings may be lost during translation.
Ethics and dissemination
This is a scoping review of completed studies. As such, our research does not require ethics approval, as we do not involve human participants. The results will be submitted to a peer-reviewed scientific journal for publication and as conference presentations.
Study status
Authors are finalising the search strategy and preparing to conduct the review. The aim is to complete the review by mid-2022.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors OA conceptualised the protocol together with BS and GBB. GBB and BS drafted the protocol and OA and NBG provided feedback. All authors reviewed and approved the final manuscript before final submission for peer review.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.