Evaluation von Empowerment in der Gesundheitsförderung: Entwicklung von Kriterien methodischer Qualität auf Basis einer systematischen Übersichtsarbeit und einer Analyse des Empowerment-Projekts „GENIESSER Oberpfalz“

Obwohl Empowerment in der Perspektive der WHO als ein Kernprinzip der Gesundheitsförderung gilt, existieren keine Empfehlungen für die Evaluation dieses Konzepts im Rahmen von Interventionen. Für die Entwicklung effektiver Interventionen zur Förderung von Empowerment sind jedoch angemessene Studiendesigns, Datenerhebungsmethoden und Indikatoren zur Erfassung von Empowerment unabdingbar. Um besser zu verstehen, welche Evaluationsverfahren für Empowerment bislang genutzt wurden und welche Vor- und Nachteile mit bestimmten Verfahren verbunden sind, wurde zunächst eine systematische Übersichtsarbeit – aufgebaut nach PRISMA – zu Evaluationsverfahren in Empowerment-basierten Gesundheitsförderungsinterventionen durchgeführt. Es konnten 26 Artikel eingeschlossen werden: Die Studien variierten zwischen sechs verschiedenen Empowerment-Strategien, die sich hinsichtlich des Aktivierungsgrades voneinander unterscheiden. Die Studien setzten heterogene Studiendesigns und vielfältige quantitative, qualitative und Mixed-Methods-Datenerhebungstechniken ein. Qualitative und quantitative Verfahren dominierten. Die quantitativen Messinstrumente (ausschließlich Fragebögen) wiesen eine große Heterogenität auf, da hauptsächlich Skalen neu entwickelt wurden oder bestehende Instrumente adaptiert wurden. Alle Studien berücksichtigten Indikatoren, die individuelle Kompetenzen und Motivationen widerspiegeln, wohingegen Indikatoren, die die organisationsbezogenen und politischen Komponenten von Empowerment reflektieren, weniger häufig genutzt wurden. Die Einbeziehung von Adressaten der Intervention bei der Entwicklung des Evaluationsdesigns für Empowerment, sowie die Kombination verschiedener Datenquellen für die Erfassung des Konzeptes wurden als spezifische Instrumente für die Qualitätssicherung der Datenerhebung vorgeschlagen. Lediglich fünf Studien analysierten Veränderungen des Gesundheitsverhaltens und versuchten die theoretische Verknüpfung zwischen Empowerment und Gesundheitsverhalten mit statistischen Methoden zu belegen. Die Ergebnisse der Übersichtsarbeit zur Forschungspraxis in Bezug auf die Evaluation von Empowerment und die damit verbundenen Begründungen und Bewertungen laut der jeweiligen Autoren lieferten in einem nachfolgenden Arbeitsschritt, zusammen mit theoriebasierter Literatur zur Evaluation von Empowerment und Public-Health-Literatur aus dem Feld komplexer Interventionen, die Grundlage für die Entwicklung eines Kriterienrahmens. Dieser enthält 17 Kriterien für die qualitätsgesicherte Evaluation von Empowerment. Nach Abgleich mit einer konkreten Empowerment-Intervention (GENIESSER Oberpfalz) unter Mitarbeit der Autorin konnte die Systematik um zwei weitere Kriterien erweitert werden. Zur weiteren Überprüfung der Anwendbarkeit und Funktionsweise des Kriterienrahmens wurden abschließend qualitative Interviews mit dem Forscherteam (n=5) geführt, um einerseits zu explorieren, ob sich das gewählte Studiendesign bei GENIESSER bewährt hat, und wie bestimmte methodische Vorgehensweisen bewertet werden. Gesamtergebnis der Arbeit ist ein Kriterienrahmen für die qualitätsgesicherte Evaluation von Empowerment, der aus systematischer Übersichtsarbeit und theoriebasierter Public-Health-Literatur entwickelt wurde und auf seine Anwendbarkeit auf eine spezifische Intervention überprüft wurde. Der Kriterienrahmen funktioniert gut, manche Aspekte treffen jedoch projektspezifisch nicht immer zu. Angesichts der flexiblen und kontextabhängigen Erscheinungsform von Empowerment-Ansätzen, ist die Entwicklung eines Standards für deren Evaluation möglicherweise aber unrealistisch. Nichtsdestotrotz versucht die vorliegende Arbeit den Bereich „Evaluation von Empowerment“ weiter zu entwickeln, indem sie Wege aufzeigt qualitativ hochwertige Evaluationen dieses Konzeptes durchzuführen. Konkrete Empfehlungen bzw. Kriterien guter Praxis für die Evaluation von Empowerment wurden abgeleitet – sowohl für den Forschungs- als auch Praxisbereich der Gesundheitsförderung. Einen weiteren Anhaltspunkt liefern die Handlungsempfehlungen für wichtige Reportingbereiche bei der Evaluation von Empowerment. Als Aufgabe für die Zukunft dieses Forschungsbereiches wird in Anlehnung an Harmonisierungsprozesse in vorrangig klinischen Disziplinen hinsichtlich Kern-Outcome-Sets und Kernmessinstrumenten skizziert, wie ein methodischer Konsensusprozess zur Evaluation von Empowerment in der Gesundheitsförderung aussehen kann

How Health Promoters Can Assess Capacity Building Processes in Setting-Based Approaches—Development and Testing of a Monitoring Instrument

Background: Health promoters often use stakeholder groups to jointly plan and implement local interventions. Stakeholder groups should take over responsibility to later run the health promotion program independently. Monitoring this process of capacity building can help health promoters improve the quality of the process. Instruments for the systematic assessment of capacity building among stakeholder groups are scarce. The goal of this study was to develop, and pilot test a generic assessment instrument for setting-based capacity building. Methods: We drafted a semi-standardized monitoring instrument to be used in stakeholder groups in various settings. This "EVA-protocol" (short for evaluation protocol) was based on capacity building domains e.g., leadership, resource mobilization. It was pilot implemented in a research network on increasing an active lifestyle in various settings. The respective health promoters documented 78 meetings of 15 different stakeholder groups. We performed feedback interviews and member checking among the facilitating health promoters, asking for comprehensibility, length, usability and perceived benefits of the instrument. Findings: Data collected in the "EVA-protocol" helped the facilitating health promoters understand the development of competences and capacities in the stakeholder groups and identify factors that favor or hinder the capacity building process. The instrument was rated as user friendly, but it was remarked that it is best filled out by two persons and reflected upon by those to offer the greatest benefit. Not all projects could afford this procedure due to lack of time/staff resources. Conclusions: The drafted instrument can serve as quality management tool for health promoters who facilitate participatory stakeholder groups in different settings and intend to build capacities for sustainable health promotion structures

German senior citizens’ capabilities for physical activity: a qualitative study

Sen's capability approach (CA) has found its way into health promotion over the last few years. The approach takes both individual factors as well as social and environmental conditions into account and therefore appears to have great potential to explore opportunities for ('capabilities') and barriers to active lifestyles. Thus, our objective in this study was to investigate which capabilities senior citizens perceive to have available to them in order to be physically active. In Southern Germany, we conducted 26 semi-standardized interviews with senior citizens aged 66-97, as well as 9 interviews with key persons who have close contact to senior citizens in their work life. We identified 11 capabilities which the interviewees considered as important in leading an active lifestyle. They could be grouped into four domains: (1) individual resources, (2) social interactions and norms, (3) living conditions and (4) organizational environment. Results highlight the need for health-promoting interventions that widen the range of capabilities on social and environmental levels in a way that individuals can freely choose to be as physically active as they like. The results make clear that interventions should not only target and involve older adults themselves, but also their families, nursing home staff or community representatives, because these groups are important in shaping older adults' capabilities for an active lifestyle

Evaluation of Empowerment in Health Promotion Interventions: A Systematic Review

Although empowerment is one of the core principles of the World Health Organization's approach to health promotion, there are no standards, best practice recommendations, or guidelines for evaluating empowerment within interventions. For the development of effective empowerment promoting interventions, adequate study designs, methods, and indicators for assessing empowerment are essential. In order to better understand which evaluation procedures have been used so far, and which advantages and disadvantages are connected to them, we systematically reviewed empowerment-based health promotion interventions. We included 26 studies, which use a broad variety of quantitative, qualitative, and mixed-methods designs and various data collection methods; qualitative and mixed-methods designs predominated. The quantitative measurement instruments are heterogeneous: Mainly self-designed or modified scales are applied. All studies consider indicators reflecting individual competencies and motivations, whereas indicators capturing the organizational and political components of empowerment are less common. Involving target group members in the development of evaluation procedures and combining different data sources are mentioned as specific steps to improve the quality of data collection. Given the flexible and context-dependent nature of empowerment approaches, the development of a "gold standard" for its evaluation seems unrealistic. However, the analyzed studies can be used to deduce recommendations that may help to conduct high-quality evaluations of empowerment, for example, mixed-methods designs, participation of target groups, and reflective loops within the research team

Empowerment for healthy nutrition in German communities: a study framework

Empowerment is seen as a key strategy for sustainable health promotion efforts. However, there is only limited research on how to link the empowerment approach to the promotion of healthy eating, which is a major current public health issue. The article presents the development of a study framework for implementing and evaluating an empowerment intervention for healthy nutrition. This framework was created for a community intervention study meaning to involve elderly citizens in Bavaria, Germany. The study protocol was developed in an iterative process basing on (i) literature reviews on the topics empowerment in relation to healthy nutrition and mixed-methods evaluation, (ii) workshops with empowerment and public health experts and (iii) consultations with local community representatives. Through these measures we identified good practice criteria as well as specific challenges of integrating empowerment and healthy nutrition, e.g. engaging people in healthy nutrition, reconciling participants' nutrition preferences with public health nutrition priorities and evaluating bottom-up activities in the community. Consequences for the study design were deducted from the literature and the consultations, e.g. practical recommendations as to how power could be gradually assigned to group members. A qualitative mixed-method evaluation design was chosen to capture emergent empowerment processes. The study framework presented here is the first on empowerment and nutrition to provide explicit guidance on how empowerment may be applied to healthy nutrition and implemented and evaluated in the community context

How Older Citizens in Germany Perceive and Handle Their Food Environment—A Qualitative Exploratory Study

Apart from individual factors like knowledge or personal motivation, the environment also influences a person's eating behaviour. Food environments can be described as the collective physical, economic, policy and sociocultural surroundings, opportunities and conditions that influence people's food choices and nutritional status. In order to explore how older citizens in rural Germany perceive and handle their food environment, we conducted semi-structured face-to-face interviews with 35 older adults (71 +/- 7 years), asking about micro-, meso- and macro-level influences on eating habits. Participants reported social factors to be crucial in shaping their diets, such as preferences of family members or social expectations connected to roles (guest, host). On a physical level, structural aspects and resources in their nearby surroundings influenced shopping and eating behaviour (for example access to an own vegetable garden, local shopping facilities and restaurants). Macro-level influences such as the food industry were hardly mentioned. Participants noticed that the environment affects their diets but dealt with undesired influences using strategies of adaptation and behaviour change, rather than challenging the environmental influences. Public health projects should raise the awareness of the multiple environmental influences on eating behaviour and also help people to create healthier food environments

Empowering senior citizens for healthy nutrition in Germany: A pilot study

Main goal of this study was to analyse how empowerment processes and bottom-up activities aimed at healthier food choices and food environment could be initiated among a group of senior citizens (between 60 and 75years old). The intervention was set up as a pilot study in a rural community (15,000 inhabitants) in the federal state of Bavaria, South Eastern Germany. A process evaluation documented how group formation and empowerment processes developed during the course of the intervention. Extensive field notes were taken in 27 meetings, interviews (n=13) and focus groups (n=4) were conducted with participants and key persons at different points of the intervention. Data were analysed using content analysis. The intervention succeeded in motivating senior citizens to participate in regular meetings over 11months. During the intervention, the group members' awareness of factors influencing their eating behaviour increased. Furthermore, they developed ideas to improve the community's food environment and accomplished duties needed to implement these ideas. However, initiating empowerment processes, especially in terms of fostering leadership and transferring responsibility, took longer than expected and could be realised only partially. The findings support a further use and evaluation of the empowerment approach for addressing nutritional aspects among senior citizens