This study is concept-oriented and empirical in nature and will help to further refine interventions supporting empowerment. It is in line with the reform of the Québec health care system that calls for a transition of services from health care facilities to programs that support people in their living environment. Along with this relocation of services, there is a political debate about how important it is for individuals and their families, caregivers and communities to take responsibility for their own health and the necessary steps to improve it [
7,
8] This stance implies a modification of professional practices to support self-care. However, interventions supporting empowerment are not well documented, despite the aging of the population and the growing number of home care services following after a short hospital stay [
9]. The CSSS is the local authority at the heart of the health and social services network; it provides primary care services to the local population and ensures their accessibility, continuity and quality. It is essential that this organization use scientific knowledge to develop and deliver preventive and primary care adapted to the different needs of the population by supporting self-care initiatives and promoting autonomy.
Statement of the problem
The clients targeted in this study are adults with chronic health problems who receive home care services. The Ministère de la Santé et Services sociaux du Québec [
9] identifies chronic diseases as the most important health problem of the century: "Chronic diseases develop slowly, persist over time, are often incurable and result in a disability and, above all, they claim many victims. Four chronic diseases are responsible for more than 70% of deaths in Québec every year. They are, in order of importance, cancers, cardiovascular diseases (CVD), respiratory diseases and diabetes." In the Eastern Townships alone, 51.4% of the population suffers from at least one chronic health problem and 19.7% live with activity limitations [
10]. The main health problems found in the Eastern Townships and particularly the City of Sherbrooke are cardiovascular and respiratory diseases, diabetes and breast cancer [
11,
12]. These health problems often lead to long-term activity limitations requiring home care services [
12]. Moreover, family members (caregivers) frequently help with the care of individuals suffering from one or many chronic diseases and with the daily management required by these types of diseases. It was estimated that in 1996, 2.8 million Canadians aged 18 years and older provided help for a person with long-term limitations [
13]. In order to improve the health status of this clientele and family support, Québec's homecare services have adopted a framework that advocates interventions promoting empowerment. These interventions are aimed at enhancing clients' potential to learn and use the tools they need to live as independently as possible and to maintain or improve their own and their family's quality of life [
14,
15]. The interventions promoting empowerment can be conceptualized as being part of a process that enables the development of the capacity to choose, to make sound decisions and to act according to one's preference [
16]. This in turn, according to Dunst and Trivette [
17], increases the person's control over his or her life and is associated with various cognitive attributes, such as intrinsic motivation, self-efficacy and self-awareness. According to this perspective, it is possible for a person to learn to be more independent, to adopt healthier lifestyles and to relate better to his or her social environment and network.
Research has shown that professional home health care providers frequently mention the use of interventions promoting self-care when describing their work. Their description of the interventions indicates that their professional expertise is employed within a collaborative relationship [
1,
18]. More research is needed to examine how empowerment interventions unfold in real-life practice settings [
2]. This is particularly important since the home care sector seems to assume that their programs are empowering [
7,
9] although there is little empirical evidence supporting this claim. With the transition of health care services to the community and the ever-increasing emphasis on empowerment, the time seems right for a study observing interventions with clients suffering from chronic health problems who require home care services [
4,
5].
In the context of this study and based on prior work by members of the research team, the term
enabling interventions refer to professional interventions that promote empowerment. The terms
individual empowerment refers to the impact of these interventions on the persons receiving them [
1,
2,
4‐
6,
19,
20].
Empowerment research is first and foremost theoretical in nature and there is very little empirical information on the full extent of the phenomenon. The available data are predominantly from studies examining the process of community empowerment with groups of individuals representing extreme cases of isolation, such as persons with disabilities and persons who are economically underprivileged [
21‐
23]. Empowerment has also been studied in reference to closely related concepts such as compliance, coping and self-care. However, these concepts are limited compared to the more comprehensive approach associated with the phenomenon of empowerment. In fact, these closely related concepts could be part of a larger empowerment construct [
6]. Despite these limitations, prior studies have identified many essential attributes of enabling interventions for communities and individuals.
Among authors who have attempted to define the attributes of empowerment interventions, Gibson [
24] states that this type of intervention focuses more on the individual's strengths, rights and capabilities than on his or her shortfalls. This approach implies that people are seen not as powerless victims but as being able to identify solutions for their well-being [
25]. In addition, enabling interventions must help people develop their "self-solutions" [
26]. Cardone and Gilkerson [
27] and Dunst and Trivette [
17] maintain that considering persons as possessing knowledge rather than as recipients of professional knowledge enhances the use of their own competencies. In a study with families living in extreme poverty, Ouellet et al. [
22] observed certain characteristics that influence enabling interventions, such as follow-up duration and intensity, the availability of the health care professional and intervention flexibility. Zerwekh [
28] states that interventions promoting empowerment require a balance between the care recipient's initiatives and those of the health care professional. Strategies that foster a person's empowering capabilities include: 1) listening to concerns; 2) supporting awareness of alternatives; and 3) broadening possibilities. For their part, Paul et al. [
1] maintain that enabling interventions are founded on the latitude given to a person within the intervention and take into account the individual's experiences and perceptions of his or her reality. In a prior study, five dimensions that comprise enabling interventions were identified. They are interventions that: 1) develop and maintain a therapeutic relationship; 2) are based on a person's point of view and strengths; 3) encourage and support the decision-making process; 4) help to broaden possibilities; and 5) facilitate the learning experience [
2]. Some studies show that in order to facilitate empowerment, an egalitarian relationship must be established with the person having difficulties [
22,
28,
29], a relationship based on collaboration and that is respectful of the person's experience and ability to seek solutions to his or her problems [
30]. The relationship also implies that the person is able to define his or her own needs [
2]. To date, very few studies have described the context in which professional interventions unfold with people needing home care services.
Factors associated with empowerment interventions
Interventions that encourage empowerment are influenced by the community health care professionals' perceptions and modes of understanding and their ability to interact with the people involved [
17,
21]. According to Labonté [
31], empowerment exists as a conceptual lens through which professional practices can be revaluated. Some factors might restrain the application of enabling interventions by health care professionals and compromise their enabling effect: 1) a vision of the situation focused primarily on problems and the person's deficits [
24]; 2) a misunderstanding of the person's own resources [
32]; 3) a stereotypical attitude towards a person's abilities and limitations influenced by social class and family structure [
33]; 4) a tendency to consider the professional point of view as reliable and to disregard that of the care recipient; 5) different and sometimes opposing views on the definition of power between the help-giver and the help-seeker and on the distribution of power within the intervention [
34,
35]; and 6) the professional's experience and feelings of self-efficacy related to the intervention [
2]. When examining interactions between professionals and their clients, it is imperative to take into account clients' perceptions of their own abilities, limitations and needs as well as their vision of the interactional process.
Individual empowerment as the outcome of enabling interventions
Individual empowerment reinforces various behaviours and encourages the person to take more control over events and important situations in his or her life [
17]. Drolet [
36] mentions that individual empowerment contributes to the development of problem-solving skills and increases self-esteem and self-efficacy. St-Cyr-Tribble et al. [
2] identified several indicators of individual empowerment. These indicators are: 1) awareness of one's life situation, own strengths and needs; 2) increase in self-esteem; 3) decrease in negative feelings; 4) well informed decision-making; 5) learning and developing skills; 6) taking action; 7) developing relationships with the social support environment and network; and 8) improvement in living conditions. These dimensions of empowerment correspond to what Rissel [
35] called
psychological or individual empowerment in his community empowerment model. Empowerment is a long-term process of change [
37,
38], a dynamic phenomenon comprising a number of steps or phases, but there is no consensus between authors concerning the whole process. Usually the process starts with an awareness phase and ends with an action phase, be it individual or collective in nature [
35]. The awareness phase is often generated by a crisis or contextual change [
22,
37,
39]. Studies that have explored aspects of individual empowerment rarely did so in the context of home care services. Furthermore, most results are based on representation and not on observations of the intervention process itself. Therefore, there is almost no information concerning indicators associated with the efficacy of these interventions.