Evaluation von Empowerment – Perspektiven und Konzepte von Gesundheitsförderern. Ergebnisse einer qualitativen Studie in Australien

Zusammenfassung

Hintergrund: Empowerment ist ein Kernkonzept der WHO-Vision von Gesundheitsförderung. Die Evaluation von Empowerment erweist sich aber als schwierig. Bei der Entwicklung angemessener Studiendesigns, Indikatoren und Methoden für die Messung und Bewertung von Empowerment sollten die Erfahrungen, Bedenken und alltäglichen Rahmenbedingungen von Praktikern der Gesundheitsförderung berücksichtigt werden.

Methoden: Es wurden semistandardisierte Interviews mit 17 erfahrenen Experten der gemeindenahen Gesundheitsförderung im Bundesstaat New South Wales, Australien, durchgeführt. Die Interviews behandelten Nutzen und Probleme der Evaluation von Empowerment, Schlüsselindikatoren und methodische Aspekte. Die Interviewtranskripte wurden mithilfe der thematischen Content-Analyse ausgewertet. Die Ergebnisse wurden mit den Interviewpartnern auf einem Workshop diskutiert (sog. respondent validation).

Ergebnisse und Diskussion: Die Evaluation von Empowerment wird generell von den Gesundheitsförderern unterstützt. Wesentliche Bedingung hierfür ist, dass Empowerment explizit Bestandteil der Programmlogik bzw. der zugrundeliegenden Theorie ist. Die Interviews machten deutlich, wie wichtig es ist, dass das politische Umfeld die Evaluation von Empowerment befürwortet. Die oftmals fehlende Anerkennung von Empowerment als Ergebnis einer Intervention im Vergleich zu gesundheitsbezogenen Ergebnissen ist eine große Herausforderung für die Finanzierung von Evaluationen. Gemeindemitglieder sollten in den Evaluationsprozess einbezogen werden; allerdings bestand keine Einigkeit darüber, wie Repräsentativität erreicht werden kann. Die besten Methoden zur Erfassung von Empowerment sind nach Ansicht der Interviewten qualitative Verfahren. Die positiven Erfahrungen, die die Interviewpartner mit innovativen qualitativen Methoden gemacht haben, rechtfertigen eine Investition in die Entwicklung neuer Forschungsansätze.

Abstract

Background: Although the concepts of participation and empowerment are hallmarks of the WHO vision of health promotion, it is acknowledged that they are difficult to evaluate. Devising adequate study designs, indicators and methods for the assessment of participation and empowerment should take into account the experiences, concerns, working conditions and constraints of health promotion practitioners.

Methods: Semi-structured interviews were conducted with 17 experienced practitioners in community-based health promotion in New South Wales, Australia. The interviews covered benefits of and barriers to the evaluation of empowerment, key indicators and methodological aspects. Interview transcripts were examined using thematic content analysis.

Results and Discussion: The idea of evaluating empowerment is supported by health promotion practitioners, provided that empowerment is part of the programme logic and/or programme theory. The interviews highlighted the importance of a receptive environment for evaluation of empowerment and participation to take root. The resistence of health authorities towards empowerment indicators is a great challenge for funding of evaluations. Community members are to be included in the evaluation process, al-though it is not always easy to do so in a representative way and empowering approach. The best methods to capture whether empowerment has occurred in a programme are qualitative ones. The positive experiences that the interview partners made with innovative qualitative methods encourage further investment in developing new research designs.

Schlüsselwörter

Gesundheitsförderung - Empowerment - Evaluation - qualitative Untersuchung

Key words

health promotion practice - empowerment - participation - evaluation - qualitative study

Literatur

• 1 World Health Organization .Declaration of Alma Ata (International conference on primary health care). WHO Europe, Copenhagen 1978
• 2 World Health Organization .Ottawa Charter for Health Promotion. WHO Europe, Copenhagen 1986
• 3 WHO Commission on the Social Determinants of Health .Achieving health equity: from root causes to fair outcomes. Geneva: World Health Organization, Commission on the Social Determinants of Health (CSDH) 2007
• 4 Israel BA, Checkoway B, Schulz A. et al . Health education and community empowerment: conceptualizing and measuring perceptions of individual, organizational, and community control.  Health Educ Q. 1994;  21 149-170
• 5 Wallerstein N. Powerlessness, empowerment, and health: implica-tions for health promotion programs.  Am J Health Promot. 1992;  6 197-205
• 6 Zimmerman MA. Psychological empowerment: issues and illustrations.  Am J Community Psychol. 1995;  23 581-599
• 7 Rissel C. Empowerment: the holy grail of health promotion?.  Health Promot Int. 1994;  9 39-47
• 8 Laverack G, Wallerstein N. Measuring community empowerment: a fresh look at organizational domains.  Health Promot Int. 2001;  16 179-185
• 9 Issel LM. Health Program Planning and Evaluation – A Practical, Systematic Approach for Community Health. Jones and Bartlett, London 2004
• 10 Linnan L, Steckler A. Process evaluation for public health interventions and research - an overview. In: Steckler A, Linnan L, Hrsg. Process Evaluation for Public Health Interventions and Research. Jossey-Bass, San Francisco 2004: 1-24
• 11 Potvin L, Richard L. Evaluating community health promotion programmes. WHO Reg Publ Eur Ser 2001: 213-240
• 12 Nutbeam D. Evaluating health promotion – progress, problems and solutions.  Health Promot Int. 1998;  13 27-44
• 13 Minkler M, Frantz S, Wechsler R. Social support and social action organizing in a „grey ghetto”: the tenderloin experience. 1982–83.  Int Q Community Health Educ. 2005;  25 49-61
• 14 Wallerstein N. What is the evidence on effectiveness of empowerment to improve health?.  http://www.euro.who.int/Document/E88086.pdf , abgerufen am 7.2.2007
• 15 Wallerstein N. Power between evaluator and community: research relationships within New Mexico's healthier communities.  Soc Sci Med. 1999;  49 39-53
• 16 McMillan B, Florin P, Stevenson J. et al . Empowerment praxis in community coalitions.  Am J Community Psychol. 1995;  23 699-727
• 17 Rissel CE, Perry CL, Wagenaar AC. et al . Empowerment, alcohol, 8th grade students and health promotion.  J Alc Drug Educ. 1996;  41 105-119
• 18 Zimmerman MA, Rappaport J. Citizen participation, perceived control, and psychological empowerment.  Am J Community Psychol. 1988;  16 725-743
• 19 Fawcett SB, Paine-Andrews A, Francisco VT. et al . Using empowerment theory in collaborative partnerships for community health and development.  Am J Community Psychol. 1995;  23 677-697
• 20 Rissel C, Perry C, Finnegan J. Toward the assessment of psychological empowerment in health promotion: initial tests of validity and reliability.  J R Soc Health. 1996;  116 211-218
• 21 Naylor PJ, Wharf-Higgins J, Blair L. et al . Evaluating the participatory process in a community-based heart health project.  Soc Sci Med. 2002;  55 1173-1187
• 22 Zakus JD, Lysack CL. Revisiting community participation.  Health Policy Plan. 1998;  13 1-12
• 23 Wen LM, Rissel C, Voukelatos A. et al . Community involvement and self-rated health status: findings from a cross-sectional survey in Central Sydney.  N S W Public Health Bull. 2003;  14 213-217
• 24 NSW Department of Health .A framework for building capacity to improve health. Sydney 2001
• 25 NSW Department of Health .Strengthening health promotion in NSW – a map of the work and implications for workforce planning and development. Sydney 2003
• 26 McMeeking L, Kolpakow M von. Community and consumer participation in health.  NSW Public Health Bull. 2002;  13 188
• 27 Baum F, Santich B, Craig B. et al . Evaluation of a national health promotion program in South Australia.  Aust N Z J Public Health. 1996;  20 41-49
• 28 Clavarino AM, Janda M, Hughes KL. et al . The view from two sides: a qualitative study of community and medical perspectives on screening for colorectal cancer using FOBT.  Prev Med. 2004;  39 482-490
• 29 Schofield MJ, Lynagh M, Mishra G. Evaluation of a Health Promoting Schools program to reduce smoking in Australian secondary schools.  Health Educ Res. 2003;  18 678-692
• 30 Watson L, Small R, Brown S. et al . Mounting a community-randomized trial: sample size, matching, selection, and randomization issues in PRISM.  Control Clin Trials. 2004;  25 235-250
• 31 Harvey PW, Steele J, Bruggemann JN. et al . The development and evaluation of lighten up, an Australian community-based weight management program.  Am J Health Promot. 1998;  13 8-11
• 32 Rowley KG, Daniel M, Skinner K. et al . Effectiveness of a community-directed ,healthy lifestyle‘ program in a remote Australian aboriginal community.  Aust N Z J Public Health. 2000;  24 136-144
• 33 Loss J, Wise M. Concepts, benefits and limits of empowerment and participation in community-based health promotion practice – results of a qualitative study (eingereicht).
• 34 Patton MQ. Qualitative Evaluation and Research Methods. 2. Aufl. SAGE Publications, Newbury Park 1990
• 35 Pope C, Ziebland S, Mays N. Qualitative research in health care.  Analysing qualitative data. Bmj. 2000;  320 114-116
• 36 Mays N, Pope C. Qualitative research in health care. Assessing quality in qualitative research.  Bmj. 2000;  320 50-52
• 37 Mayer SE. Building community capacity with evaluation activities that empower. In: Fetterman DE, Kaftarian SJ, Wandersman A, Hrsg. Empowerment Evaluation: Knowledge and tools for self-assessment and accountability. Thousand Oaks, London, New Delhi 1996: 332-378
• 38 Fawcett SB, Paine-Andrews AL, Francisco VT. et al .Empowering community health initiatives through evaluation. In: Fetterman DE, Kaftarian SJ, Wandersman A, Hrsg. Empowerment Evaluation: Knowledge and tools for self-assessment and accountability. Thousand Oaks, London, New Delhi 1996: 161-187
• 39 Fawcett SB, Paine-Andrews A, Francisco VT. et al .Evaluating community initiatives for health and development. WHO Reg Publ Eur Ser 2001: 241-270
• 40 Eng E, Parker E. Measuring community competence in the Mississippi Delta: the interface beween program evaluation and empowerment.  Health Educ Q. 1994;  21 199-220
• 41 Dixon J, Sindall C. Applying the logics of change to the evaluation of community development in health promotion.  Health Promot Int. 1994;  9 297-309
• 42 Davies R, Dart J. The ,Most Significant Change‘ technique: a guide to its use. http://www.mande.co.uk/docs/MSCGuide.pdf , abgerufen am 24.4.2007
• 43 Wang C, Burris MA. Photovoice: concept, methodology, and use for participatory needs assessment.  Health Educ Behav. 1997;  24 369-387
• 44 Labonte R, Feather J, Hills M. A story/dialogue method for health promotion knowledge development and evaluation.  Health Educ Res. 1999;  14 39-50
• 45 Loss J, Eichhorn C, Reisig V. et al . Qualitätsmanagement in der Gesundheitsförderung – Entwicklung eines multidimensionalen Qualitätssicherungsinstruments für eine landesweite Gesundheitsinitiative.  Präv Gesundheitsförd. 2007;  2 199-206
• 46 Loss J. Editorial.  Präv Gesundheitsförd. 2008;  3 53-55

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