Actualizing child and adolescent empowerment in participatory action research for health promotion: a six-element framework

Figures & data

Table 1. Study procedures.

	Explorative literature search	Expert recruitment	Literature review	Qualitative content analysis	Framework development
Procedure	Exploratory search, familiarization with literature regarding theoretical concept of empowerment, and children and empowerment	Identification and invitation (to join the study) of main authors publishing on empowerment, children/adolescents and participation	Literature search in four databases using PCC framework, screening of titles/abstracts and full-text, based on inclusion criteria	Coding of included articles using and deductive coding, identification (through discussion) of themes	Iterative development of framework guided by I-P-O model, Bronfenbrenner’s ecological systems theory of child development, field notes and final themes from content analysis
Participants	First author (RC)	Lead authors (RC, MA, TA)	Lead authors (RC, MA, TA), Experts	Lead authors (RC, MA, TA)	Lead authors (RC, MA, TA), Experts
Result	Understanding of the concept of empowerment of children	Establishment of an expert group consisting of 5 professors	Selection of 14 articles (out of 1.840 hits) for analysis	Identification of preliminary themes for the framework	Establishment of final framework after multiple reiterations

Abbreviations: I-P-O, Input-Process-Output; PCC, Population-Concept-Context framework.

Figure 1. Flow-diagram of article search, selection and inclusion.

Table 2. Analysed articles on empowerment theory and implementation used for framework development.

Year	Article title	Author(s)
2020	Youth participatory action research for health equity: increasing youth empowerment and decreasing physical activity access inequities in under-resourced programs and schools.	Abraczinskas and Zarrett (2020)
2018	Examining the role of youth empowerment in preventing adolescence obesity in low-income communities.	Muturi et al. (2018)
2016	Psychological empowerment among urban youth: measurement model and associations with youth outcomes.	Eisman et al. (2016)
2014	Young people and health: towards a new conceptual framework for understanding empowerment.	Spencer (2014)
2014	Examining relational empowerment for elementary school students in a YPAR program.	Langhout et al. (2014)
2010	A typology of youth participation and empowerment for child and adolescent health promotion.	Wong et al. (2010)
2007	Empowerment: a goal or means for health promotion?	Tengland (2007)
2006	Toward a critical social theory of youth empowerment.	Jennings et al. (2006)
1994	Health education and community empowerment: conceptualizing and measuring perceptions of individual, organizational, and community control.	B. A. Israel et al. (1994)

Figure 2. Six elements for child and adolescent empowerment in participatory action research for health promotion.

Table 3. Characteristics of coded articles, divided into practice-based and theory-oriented.

Practice-based articles
	Author(s) and year	Study aim	Characteristics of setting and population	Conceptualization or application of empowerment	Key insights related to the meaning of empowerment for children and adolescents
1	Abraczinskas and Zarrett (2020).	To come to a rich understanding of the feasibility of YPAR^1: (a) in aftercare and (b) paired with a physical activity intervention, to impact individual empowerment and second-order change for equitable physical activity access.	YPAR applied in two ‘typical’ medium-school aftercare programs in the southeastern U.S.A., in urban areas and low resourced communities (under-resourced facilities/equipment, no enrollment fees, attended by underserved population). In total, 64 students (64% female) aged 11–15 years (grades 6–8) participated. The majority of youth were identified as non-Hispanic Black/African American (94%).	Empowerment means individuals gain more control over their lives. Youth participation approaches can increase youth empowerment through power-sharing with adults and peers in action for changes that meet their needs.	The combination of YPAR and a (physical activity) intervention grounded in Social Determination Theory potentially provides a double ‘dose’ of empowerment.Capacity (resources) – especially of those with decision-making power – is needed for second-order change, and partner support at multiple levels (including power-sharing) are key for youth participation and empowerment.
2	Muturi et al. (2018)	Examining the influence of empowerment on preventive factors – specifically nutritional and physical activity factors – related to adolescent obesity.	A survey for measuring youth empowerment was conducted among adolescents in the 6^th to 8^th grades in three U.S.A. states; Kansas, Ohio and South Dakota. In total, 410 students (56% female) aged 11–15 years from six medium schools participated. The majority was Hispanic (40%), followed by White (22%), African American (16.1%) and Other (22%).	By giving youth information on how to adopt and maintain a healthy lifestyle, youth can enhance their decision-making role and overcome barriers to behaviour change. Empowerment is thus achieved through information and communication.	Youth empowerment may influence attitudes and beliefs in favor of making healthier nutritional decisions and being more physically active. Empowerment has the potential to cultivate skills and contribute to enhanced motivation to adopt a healthier lifestyle within a certain context.
3	Langhout et al. (2014)	Examining forms of relational empowerment among children who participated in an YPAR program.	Study took place in Maplewood Elementary School which serves primarily low-income students. In total 12 students in the 4^th and 5^th grade (9–10 years) who completed 2 years of the YPAR program participated (70% female). Participants’ ethnicity included Latin (n=9), African American (n=1), African American/white (n=1) and Latino/white (n=1).	The concept of relational empowerment is central, which holds that empowerment happens through relationships because power is relational. How social divisions are bridged and how social capital is shared is central to relational empowerment.	Children who participated in the YPAR setting showed stronger correlation with relational empowerment factors such as collaborative competence, bridging social divisions, and facilitating others’ empowerment.
Theory-oriented papers
	Author(s) and year	Study aim	Characteristics of setting and population	Conceptualization or application of empowerment	Key insights related to the meaning of empowerment for children and adolescents
4	Eisman et al. (2016).	Empirically testing a multi-dimensional, higher-order model of psychological empowerment and investigating if psychological empowerment is associated with positive and negative outcomes among youth.	Measures were conducted among adolescents in the City of Flint and Genesee County, U.S.A. which is characterized by extreme economic and health challenges, and high unemployment and crime rates. In total, 367 students (60% female) aged 11–16 years from six medium schools participated. The majority identified as White (46%), African-American (46%) or Other (22%).	Zimmerman’s conceptual framework of psychological empowerment is used, including its three components: intrapersonal, interactional and behavioral. The validity of the threefold divide of psychological empowerment was assessed.	Intrapersonal, interactional and behavioural components of psychological empowerment are distinctive in nature and need to be targeted separately when designing health promotion activities with youth.
5	Spencer (2014).	Proposing a (critical) conceptual framework for understanding empowerment with regard to youth health, informed by Lukes’ multidimensional perspective of the notion of power.	Secondary school with a diverse socio-economic catchment area in central UK, including surrounding community settings. In total 55 young people (47% females) aged 15–16 years participated.	Empowerment is conceptualized by taking different conceptions of power as a starting point, including ‘power to … ’, ‘power over … ’ and ‘power through … ’. Following this, six forms of empowerment are identified: impositional, dispositional, concessional, oppositional, normative and transformative.	Perceiving empowerment as a linear process that leads to positive health outcomes and social change disregards the complexity with which power shapes social structures and contexts in which health is enacted and experienced. Dominant health discourses propagated by ‘official institutions’ are embraced by adults but are not always in line with youth’s framings and priorities of health.
6	Wong et al. (2010)	Offering a conceptual typology for identifying youth-adult participation using an empowerment framework.	Youth participation for health promotion. The article strongly links empowerment to participation, positive youth development and PAR.	The use of an empowerment framework is described as rooted in evidence-based findings, drawing heavily on the concept of critical consciousness as formulated by Freire. An empowerment framework is used to build the TYPE Pyramid, which focuses on youth and adult involvement and consists of five participation types (vessel, symbolic, pluralistic, independent, autonomous).	Youth empowerment does not reach its potential if adults are not providing support, guidance and resources in a co-learning, safe and welcoming environment. The degree and quality (i.e. education) of adult involvement affects youth empowerment. Youth participation, youth development and youth empowerment are intertwined concepts and reinforce each other. Pluralistic youth-adult partnerships sustain healthy youth development and empowerment.
7	Jennings et al. (2006).	Contributing to the development of a critical social theory and model guidelines for youth empowerment, which emphasizes collective efforts to create sociopolitical change.	This study builds on four existing empowerment models, including: Adolescent Empowerment Circle, Youth Development and Empowerment Program Model, Transactional Partnering Model, Empowerment Education Model.	Critical youth empowerment encompasses those processes and contexts through which youth engage in actions that create change in organizational, institutional, and societal policies, structures, values, norms, and images, aiming at supporting and fostering youth contributions to positive community development and sociopolitical change, resulting in youth who are critical citizens, actively participating in day-to-day building of stronger, more equitable communities.	Empowerment is a multi-level construct (where both individuals and communities play a part) aimed at creating social justice that requires action from multiple agents and is fueled by critical reflection. Power-sharing by adults needs time so that youth are given time to learn how to handle power, and is most likely achieved within small, localized sites where youth are fully engaged. Education and training is a powerful yet under-estimated tool for enabling empowerment, and needs to be facilitated especially among adult facilitators.
8	Tengland (2007).	Clarifying the meaning of empowerment in relations to the goals of health promotion.	Theoretical explanation of the role of empowerment in health promotion and vice versa.	Empowerment has to do with the individual’s ability to control health, life, and changing the world. Empowerment is also related to the acquirement or nourishment of mental or internal resources, such as knowledge, self-esteem, self-confidence (and self-efficacy) and autonomy.	Empowerment is perceived both a goal and a process and is aligned with the principles of health promotion. Empowerment as a process requires sharing of power and control and involvement of participants in decision-making.
9	Israel et al. (1994)	Providing a definition of community empowerment that includes individual, organizational and community levels of analysis. Describing how empowerment fits within a broader conceptual model of stress and its relationship to health status. Examining a series of scales that measure perceptions of individual, organizational, community and multiple levels of control.	Literature review and measurement analysis through the Detroit Area Study, U.S.A.. 916 adults from 47 communities participated.	Empowerment refers to the ability of people to gain understanding and control over personal, social, economic, and political forces in order to take action to improve their life situations, and the concept is positive and proactive. Empowerment occurs at the individual, organizational, and community level. Although they have important independent properties, they are not mutually exclusive.	Improving health and wellbeing through individual empowerment disregards the influence of social, structural and physical factors in shaping health. Empowerment is meaningful when cultural, historical, social, economic and political context of the individual is recognized. Empowerment is both a process and an outcome, and is dynamic and ever-changing. The process of empowerment requires time and commitment to a long-term process. PAR, in which community members are involved in all aspects of the action and research, is a befitting method for realizing community empowerment.

Abraczinskas, M., & Zarrett, N. (2020). Youth participatory action research for health equity: Increasing youth empowerment and decreasing physical activity access inequities in under‐resourced programs and schools. American Journal of Community Psychology, 66(3–4), 232–20. https://doi.org/10.1002/ajcp.12433

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Muturi, N., Kidd, T., Daniels, A. M., Kattelmann, K. K., Khan, T., Lindshield, E., Zies S., & Adhikari, K. (2018). Examining the role of youth empowerment in preventing adolescence obesity in low-income communities. Journal of Adolescence, 68(1), 242–251. https://doi.org/10.1016/j.adolescence.2018.08.001

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Eisman, A. B., Zimmerman, M. A., Kruger, D., Reischl, T. M., Miller, A. L., Franzen, S. P., & Morrel‐Samuels, S. (2016). Psychological empowerment among urban youth: Measurement model and associations with youth outcomes. American Journal of Community Psychology, 58(3–4), 410–421. https://doi.org/10.1002/ajcp.12094

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Spencer, G. (2014). Young people and health: Towards a new conceptual framework for understanding empowerment. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, 18(1), 3–22. https://doi.org/10.1177/1363459312473616

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Langhout, R. D., Collins, C., & Ellison, E. R. (2014). Examining relational empowerment for elementary school students in a yPAR program. American Journal of Community Psychology, 53(3–4), 369–381. https://doi.org/10.1007/s10464-013-9617-z

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Wong, N. T., Zimmerman, M. A., & Parker, E. A. (2010). A typology of youth participation and empowerment for child and adolescent health promotion. American Journal of Community Psychology, 46(1–2), 100–114. https://doi.org/10.1007/s10464-010-9330-0

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Tengland, P. A. (2007). Empowerment: A goal or a means for health promotion? Medicine, Health Care and Philosophy, 10(2), 197. https://doi.org/10.1007/s11019-006-9027-1

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Jennings, L. B., Parra-Medina, D. M., Hilfinger-Messias, D. K., & McLoughlin, K. (2006). Toward a critical social theory of youth empowerment. Journal of Community Practice, 14(1–2), 31–55. https://doi.org/10.1300/J125v14n01_03

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Israel, B. A., Checkoway, B., Schulz, A., & Zimmerman, M. (1994). Health education and community empowerment: Conceptualizing and measuring perceptions of individual, organizational, and community control. Health Education Quarterly, 21(2), 149–170. https://doi.org/10.1177/109019819402100203

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Data availability statement

The articles included in the analysis are presented in Table 3 of the manuscript. The analysis are available from the corresponding author upon reasonable request.