Empowerment Assessment tools in People with Disabilities ... · PDF fileDisabilities in...

REVIEW

Empowerment Assessment tools in People with

Disabilities in Developing Countries. A systematic

literature review

LUTIEN BAKKER & WIM H. VAN BRAKEL

Athena Institute, VU University Amsterdam, De Boelelaan 1085, 1081

HV Amsterdam, The Netherlands

Accepted for publication 11 June 2012

Summary

Introduction: Many initiatives are undertaken to improve the empowerment of

people with disabilities in developing countries. However, an overview of adequate

measurement tools to evaluate such activities is not available to date. This systematic

literature review aims to describe and assess the available tools to measure

empowerment in people with disability, suitable for use in developing countries.

Methods: A systematic literature review was conducted. Articles were eligible when

they described the development, validation, translation or the use of an instrument

measuring empowerment in the context of disability. The instruments were assessed on

their psychometric properties and on equivalence properties when they were translated.

Results: Thirty-six articles were found in which 17 questionnaires were developed,

validated, translated or used. The questionnaires varied in the construct of

empowerment, the target population and the psychometric properties. None of the

questionnaires were developed or validated in a developing country. The

psychometric properties and equivalence criteria were not adequately described

and measured in any article. The Empowerment Scale (ES) of Rogers was the most

often validated, translated and used questionnaire, receiving the highest number of

positive ratings for the psychometric properties.

Discussion/Conclusion: The ES is the tool most widely used to measure empower-

ment, but adequate validation in a developing country context is still lacking.

Cultural validity should be assessed in any culture before it is used. Further research

is needed to develop empowerment instruments for developing countries and to assess

the equivalence criteria, including psychometric properties of such questionnaires.

Introduction

Empowerment is a widely-used concept in many disciplines and research areas.1,2

Professionals who deal with issues of the powerlessness of disadvantaged groups, such as

Correspondence to: Lutien Bakker (e-mail: [email protected])

Lepr Rev (2012) 83, 129–153

0305-7518/12/064053+25 $1.00 q Lepra 129

women, ethnic minorities and disabled people, are increasingly interested in this concept

which is generally considered as an important objective in social-welfare policy.3

THE CONCEPT ‘EMPOWERMENT’

The verb to empower is explained both by the Merriam Webster’s dictionary4 and the Oxford

Dictionary5 as ‘giving official authority to an individual to do something and/or promoting

the self-actualisation or influence of someone by making someone stronger and more

confident.’ This dichotomy in the concept of empowerment is described by many other

investigators6 – 8 who explained that the concept of empowerment consists of an external and

internal component: the individual responsibility to control one’s own life and the broader

responsibility of the institutions, organisations or society that enable people to take

responsibility for their own life.7

The construct of empowerment can be analysed at the organisational, community and

individual level.9,10 Analysing empowerment at the organisational level means the

investigation of arrangements to provide individuals with opportunities to exert control, and

of organisational effectiveness in service delivery and the policy process.9 At the community

level of analysis, empowerment refers to the context in which organisations and individuals

interact to enhance community living, and ensure that their communities address local needs

and concerns. The individual level of analysis consists of three components.9 First, the

intrapersonal component refers to how people think about their capacity to influence social

and political systems important to them. This component treats empowerment as a

personality variable that encompasses psychological processes such as perceived control,

self-efficacy, sense of community and perceived competence. Second, the behavioural

component refers to specific actions to exercise influence through participation in

organisations and activities. Third, the interactional component includes knowledge about

needed resources and problem-solving skills.11 – 13

EMPOWERMENT IN DISABLED PEOPLE

A large minority group struggling with difficulties in gaining control of their life and claiming

their rights is the group of people with disabilities. Controlling the factors affecting their lives

may be difficult due to physical or psychological constraints. More often, however, it is due to

stigmatization and prejudice, and extrinsic factors such as institutions, organisations and

society that do not enable people with disabilities to take responsibility for their own life.

Therefore, improving empowerment is a very important goal in the rehabilitation of disabled

people as this provides them with the tools they need to attain independence and self-

determination.14

EMPOWERMENT OF DISABLED PEOPLE IN DEVELOPING COUNTRIES

Globally, it is estimated that more than a billion people are living with some form of

disability.15 Also in low-income countries there are a large number of people living with

disabilities,15 probably due to poverty, malnutrition, inadequate health care and violent

conflicts.16 Many nations in the world have accepted the Convention on the Rights of Persons

with Disabilities (2006) which aims to change the view of people with disabilities as ‘objects’

of charity, towards the view of people with disabilities as ‘subjects’ who are capable of

L. Bakker & W.H. van Brakel130

claiming their own rights and making decisions concerning their own lives.17 Even though

many nations signed this convention, still many people with disabilities experience

discrimination.18 International organisations work to improve the empowerment of disabled

and other disadvantaged people by promoting and supporting empowerment projects of local

partners. Whether those activities are effective for the people involved can be measured with

empowerment measurement tools, such as the Empowerment Scale of Rogers.2 However,

whether empowerment tools developed in Western societies are suitable in developing

countries is questionable as the concept of empowerment may differ in other cultures.

It should be adapted to the context people live in, with factors such as religion, social beliefs

and social habits being embedded. Until now, there has been no systematic review published

of measurement tools available to evaluate the effectiveness of development projects with

regard to empowerment. Such an overview is important to choose appropriate tools to

monitor and evaluate empowerment projects.

The objective of this systematic review is to critically appraise instruments available for

assessing empowerment in people with disabilities, suitable for use in developing countries.

Material & Methods

A systematic literature review has been conducted to fulfil the research objective of this

study. This review followed the PRISMA guidelines for authors reporting a meta-analysis or

systematic review.19

INFORMATION SOURCES

Studies were identified between 13 and 19 December 2010. They were selected by searching

the online databases Pubmed, Science Direct, Web of Science, PsycInfo, Cinahl, Scopus,

Search 4Dev and Google Scholar. In addition, the reference lists of the selected articles were

searched to identify other relevant studies.

ELIGIBILITY CRITERIA

Articles were eligible when they reported instrument development, validation or translation

studies of an instrument measuring empowerment in the context of disability. Studies using

empowerment as an outcome measure in the context of disability were also included to assess

how and how often particular instruments were used. Additionally, only articles written in

English and of which access to full text was available were included. Studies were considered

not eligible when empowerment was assessed with qualitative measures (e.g. open

interviews) or when empowerment was not measured in the context of disability. Letters to

the editor and opinion papers were also excluded. There was no restriction on the year of

publication.

SEARCH

The search terms were derived from the concepts in the research objective: empowerment;

people with disabilities; developing countries; assessment tools and outcome measures. We

searched in the literature and thesauruses for synonyms of these concepts to broaden the

Empowerment Assessment tools for disabilities 131

search. Because the synonyms for empowerment, like self-actualization and self-

determination resulted in a large number of articles, it was decided to narrow the search

by using only the term ‘empowerment’ in combination with the other terms. This resulted in

the following syntax.

(empower*) AND (“disabled person*” OR disabilit*) AND (“developing countr*”) AND(scale* OR measure* OR survey OR assess* OR instrument* OR questionnaire*)

AND (psychometric* OR validat* OR reliability)

To include countries which were not always considered as developing countries, a search

has been done by replacing the term “developing countri*’” by (Brazil OR “South Africa”

OR Nepal OR India OR China OR Indonesia). Potentially relevant articles were first selected

based on title and imported into Endnote. Further selection was done based on the abstract

and full-text of the articles.

ARTICLE SELECTION

An overview of the whole article selection process is shown in the PRISMA flow chart in

Appendix 1. One hundred and twenty-four articles were selected based on title. The abstracts

were analysed and 80 articles were excluded as they did not meet the eligibility criteria. The

remaining 44 articles were further assessed for eligibility by reading the full text. From these,

14 were excluded. The other 30 eligible articles were analysed as described below. In

addition, the reference lists of the 44 articles yielded another 6 articles that were eligible for

inclusion. Finally, 36 articles were included in the analysis.

DATA COLLECTION PROCESS

For every article the type of study was determined: a development study (a study in which the

development of a questionnaire is described and validated); a validation study (a study in

which an already developed instrument is validated); a translation study (a study in which an

instrument is translated into a new language and culture) or an empowerment study (a study in

which an empowerment instrument was used as an outcome measure). Following this,

information was extracted according to different templates suitable for those types of research

studies, explained in the next section.

DATA ITEMS

From each study, information was extracted with regard to the characteristics of the

population and the concept of empowerment measured by the questionnaire.

ASSESSMENT OF PSYCHOMETRIC PROPERTIES

The eight quality criteria for measurement properties of Terwee et al.20 were used to determine

the quality of the measures found in the development and validation studies. It is believed that

these criteria work well to distinguish well-developed from poorly-developed question-

naires.20 A global consensus on these criteria was achieved through the study of Mokkink

et al.21 Data was extracted from every measurement on the content, criteria and construct

validity, internal consistency, reproducibility, responsiveness, floor or ceiling effect and

interpretability. The quality criteria were rated as follows: positive (þ ), negative (2 ),

indeterminate (?) or no information available (0). These criteria are summarized in Appendix 2.


EQUIVALENCE OF TRANSLATED QUESTIONNAIRES

The equivalence criteria of Herdman et al.22 were used to assess the cultural equivalence of

translated empowerment assessment tools in the translation studies. Herdman et al.

developed a model to examine the cultural equivalence in instrument validity between source

and target culture. This model defines six types of equivalence: conceptual, item, semantic,

operational, measurement and functional. These types for equivalence were rated as follow:

very good (þþ ), good (þ ), poor (2 ) or indeterminate (?). The types of equivalence and the

rating system are explained in Appendix 3.

EMPOWERMENT ASSESSMENT TOOLS USED IN RESEARCH STUDIES

To assess how and how often particular instruments were used, information was extracted on

the empowerment scales used, the population in those studies (age, place of living, severity of

disability and method of diagnosis) and the way they were used.

SUMMARY MEASURES

To summarise the data, a list of empowerment scales was created. For each, the number of

development, validation, translation and empowerment studies was counted.

Results

Seven development studies, nine validation studies, four translation studies and 16

empowerment studies were found.

INSTRUMENT DEVELOPMENT STUDIES

Table 1 provides data of the seven development studies.

Nine questionnaires were found in the seven studies, since Segal23 described the

development of three questionnaires. All questionnaires were developed in North America or

Europe. The measurement aims of the empowerment questionnaires varied. Some

questionnaires measured the concept of empowerment in general (Empowerment

Questionnaire for Inpatients (EQuIP), the ‘Vrijbaan’ questionnaire and the Youth

Empowerment Scale-Mental Health (YES-MH), while other questionnaires were more

specific in the concept of empowerment they measured. For example, the Personal Opinions

Questionnaire (POQ) measures the intrapersonal component of psychological empowerment

and Segal assessed empowerment along three dimensions with three different questionnaires.

Most questionnaires were developed for people with mental disabilities.

The assessment of the psychometric properties of the nine questionnaires is presented in

Table 2.

No questionnaire obtained more than two positive ratings. Positive ratings were only

achieved for content validity and internal consistency. The POQ obtained a negative score for

content validity since the target population was not involved in the item selection. The

indeterminate ratings for content validity were given because the item selection was not

clearly described. Indeterminate ratings for internal consistency were given if no factor


Table

1.

The

dev

elopm

ent

studie

s:th

ech

arac

teri

stic

so

fth

eques

tionnai

res

and

the

popula

tion

Au

tho

rN

ame

Mea

sure

men

tai

mN

Ag

e(m

)D

isab

ilit

yP

lace

Bo

lto

n11

PO

QT

he

intr

aper

son

alco

mp

on

ent

of

psy

cho

log

ical

empo

wer

men

tfo

rp

eop

lew

ith

dis

abil

itie

s1

56

31

Sen

sory

(10

%),

ort

ho

pae

dic

(24

%),

chro

nic

(16

%),

psy

chia

tric

(5%

),n

euro

log

ical

(8%

),le

arn

ing

dis

abil

itie

s(2

0%

),m

issi

ng

(17

%)

US

Lo

pez

36

EQ

uIP

Em

pow

erm

ent

inold

erpsy

chia

tric

inpat

ients

87

65

Pat

ients

from

psy

chia

tric

war

dw

ith

affe

ctiv

e(n

¼5

8),

psy

cho

tic

(n¼

17

),an

xie

ty(n

¼6

)an

do

ther

(n¼

3)

dis

ord

ers.

Lo

nd

on

Sam

ooch

a37

Vri

jbaa

nE

mp

ow

erm

ent

amo

ng

peo

ple

wit

ha

long

-ter

mw

ork

dis

abil

ity

419

34

Par

tici

pan

tsof

are

hab

ilit

atio

nco

urs

e(d

isab

ilit

yn

ot

men

tio

ned

)N

eth

erla

nd

s

Seg

al23

Per

sES

Th

eam

ou

nt

of

con

tro

lth

ein

div

idual

has

ov

erco

mm

on

life

do

mai

ns

310

?P

arti

cipan

tsof

clie

nt-

run

self

-hel

pag

enci

es,

oper

ated

by

and

for

per

son

sw

ith

sev

ere

men

tal

dis

abil

itie

sU

S

Seg

al23

OE

ST

he

exte

nt

tow

hic

hin

div

idual

sar

ein

vo

lved

inin

flu

enci

ng

org

aniz

atio

nal

stru

ctu

res

wit

hw

hic

hth

eyco

me

inco

nta

ct

310

?P

arti

cipan

tsof

clie

nt-

run

self

-hel

pag

enci

es,

oper

ated

by

and

for

per

son

sw

ith

sev

ere

men

tal

dis

abil

itie

s.U

S

Seg

al23

Ex

traO

ES

Th

eex

ten

tto

wh

ich

ind

ivid

ual

sb

eco

me

par

tici

pan

tsin

the

poli

tica

lpro

cess

and

civic

acti

vit

ies

inth

ela

rger

com

munit

y

310

?P

arti

cipan

tsof

clie

nt-

run

self

-hel

pag

enci

es,

oper

ated

by

and

for

per

son

sw

ith

sev

ere

men

tal

dis

abil

itie

s.U

S

Wal

ker

38

YE

S-M

HE

mp

ow

erm

ent

amo

ng

yo

uth

con

sum

ers

wh

oex

per

ien

cesi

gn

ifica

nt

emoti

on

alo

rb

ehav

iou

ral

dif

ficu

ltie

s

18

51

4ti

ll2

1R

esp

on

den

tsw

ho

exp

erie

nce

dse

rio

us

men

tal

hea

lth

dif

ficu

ltie

s,A

DH

D(3

6%

.2%

),d

epre

ssio

n(1

9·0

%),

and

bip

ola

rd

iso

rder

(16·2

%).

US

Ro

ger

s2E

SP

erso

nal

empow

erm

ent

from

the

per

spec

tive

of

con

sum

ers,

surv

ivo

rs,

and

form

erp

atie

nts

of

men

tal

hea

lth

serv

ices

27

1?

Use

rso

fm

enta

lh

ealt

hse

rvic

esin

the

form

of

self

-hel

pp

rog

ram

s.E

xac

td

isab

ilit

ies

are

no

tm

enti

on

ed.

US

Fau

lkner

39

PaE

SP

atie

nts

empow

erm

ent

and

dis

empow

erm

ent

inhosp

ital

envir

onm

ents

cate

ring

for

old

erp

eop

le

10

26

5þ

&1

8þ

Ho

spit

aliz

edp

eop

lew

ho

had

bee

nin

pat

ien

tso

fat

leas

t3

day

s.E

ng

lan

d

Acr

onym

s:P

OQ

:P

erso

nal

Opin

ions

Ques

tionnair

e,E

QuIP

:E

mpow

erm

ent

Ques

tionnair

efo

rIn

pati

ents

,V

rijb

aan:

the

‘Vri

jbaan’

ques

tionnair

e,P

ersE

S:

Per

son

al

Em

pow

erm

ent

Sca

le,

OE

S:

Org

aniz

ati

onal

Em

pow

erm

ent

Sca

le,

Ext

raO

ES:

Ext

raO

rganiz

ati

onal

Em

pow

erm

ent

Sca

le,

YE

S-M

H:

Youth

Em

pow

erm

ent

Sca

le-M

enta

lH

ealt

h,

ES:

Em

pow

erm

ent

Sca

le,

PaE

S:

Pati

ents

Em

pow

erm

ent

Sca

le.


Table

2.

The

dev

elopm

ent

studie

s:th

epsy

chom

etri

cpro

per

ties

Ques

tionnai

res

Conte

nt

val

idit

yIn

tern

alco

nsi

sten

cyC

rite

rion

val

idit

yC

onst

ruct

val

idit

y

Rep

rod

uci

bil

ity

Res

po

nsi

ven

ess

Flo

or

or

ceil

ing

effe

ctIn

terp

reta

bil

ity

Ag

reem

ent

Rel

iab

ilit

y

PO

Q11

2þ

0?

00

00

0E

Qu

IP36

þ?

0?

0?

00

?‘V

rijb

aan

’37

þþ

00

00

00

0P

ersE

S23

??

0?

??

?0

0O

ES

23

??

0?

??

?0

0E

xtr

aOE

S23

??

0?

??

?0

0Y

ES

-MH

38

þþ

0?

00

00

?E

S2

þþ

0?

00

00

?P

aES

39

þ?

0?

00

00

?

Rat

ing

:þ

¼p

osi

tiv

era

tin

g;

?¼

indet

erm

inat

e;2

¼p

oo

r;0¼

no

info

rmat

ion

avai

lab

le.

Acr

onym

s:P

OQ

:P

erso

nal

Opin

ions

Ques

tionnair

e;E

QuIP

:E

mpow

erm

ent

Ques

tionnair

efo

rIn

pati

ents

;V

rijb

aan:

the

‘Vri

jbaan’

ques

tionnair

e;P

ersE

:P

erso

na

lE

mpow

erm

ent

Sca

le;

OE

S:

Org

aniz

ati

onal

Em

pow

erm

ent

Sca

le;

Ext

raO

ES:

Ext

raO

rganiz

ati

onal

Em

pow

erm

ent

Sca

le;

YE

S-M

H:

Youth

Em

pow

erm

ent

Sca

le-M

enta

lH

ealt

h;

ES:

Em

pow

erm

ent

Sca

le;

PaE

S:

Pati

ents

Em

pow

erm

ent

Sca

le.


analysis had been performed. No information was found in any of the development studies

concerning criterion validity and floor or ceiling effects. Furthermore, no positive ratings

could be given for interpretability and responsiveness since no minimally important change

(MIC) in scores was defined. In addition, the property of reproducibility could not be rated

positively in any of the questionnaires since some investigators did not perform a test-retest

evaluation, or when they did, no intra-class correlation coefficients or MIC were reported.

Finally, nearly all studies mentioned construct validity, but none had defined a priori

hypotheses; therefore, no positive ratings could be given for this property.

VALIDATION STUDIES OF EMPOWERMENT QUESTIONNAIRES

Table 3 provides data of the nine validation studies.

Four authors described the validation of an empowerment instrument of which the

original article could not be included as they were not accessible (the Psychological

Empowerment Scale (PsychES), the Family Empowerment Scale (FES) and the Diabetes

Empowerment Scale (DES)), or because empowerment was only a part of the whole

questionnaire (the empowerment factor of the Quality of Life Questionnaires (QOL-Q

empowerment factor). In addition, two authors validated the Mental Health Confidence Scale

(MHCS). The article developing the MHCS was not included in this review because this scale

was not meant to measure the concept of empowerment. This was later contested by Castelein

et al.1

All questionnaires were validated in North America, Europe or Australia. The

measurement aims of the questionnaires differed. For example, the DES measures diabetes-

related psychosocial self-efficacy (e.g. self-management tasks such as blood glucose

monitoring), while the FES measures empowerment of the family. The MHCS originally

aimed to measure the construct of confidence. However, Castelein1 concluded that the

MHCS, like the PersES and the ES, measures the construct of empowerment. The MHCS

focuses on the intrapersonal component of empowerment, while the ES and the PersES focus

also on the societal component of empowerment. These results were in line with the results

found by Kaczinsky et al. 24 who indicated that the ES and the MHCS possibly measured the

same construct, because the correlations between the ES and the MHCS were consistently

around the 0·70. Most of the questionnaires were validated in a population with mental

illness, except for the DES, the FES and the PsychES.

The assessment of the psychometric properties of the nine questionnaires is presented in

Table 4.

Content validity was not assessed as this property is often described in the original

developing study. None of the validated questionnaires obtained more than one positive

rating for the psychometric properties. Positive ratings were only given for the properties

internal consistency, construct validity and floor or ceiling effect. The ES validated by

Wowra25 received a negative score for internal consistency, because some subscales had a

Cronbach’s alpha below 0·70. The ES validated by other authors received an ‘indeterminate’

rating for internal consistency, because the size of the sample was inadequate1,26 or because

no alphas were presented per factor of the questionnaire.24 This was also the case in other

questionnaires that were rated ‘indeterminate’ for internal consistency. Construct validity

was rated positively for the ES and the MHCS in the study of Kaczinsky.24 However, the

construct validity of the ES, the MHCS and the PersES validated by Castelein1 and of the ES

validated by Corrigan26 were rated as ‘poor’, since the hypotheses formulated in advance


Table

3.

Th

ev

alid

atio

nst

ud

ies:

the

char

acte

rist

ics

of

the

qu

esti

on

nai

res

and

the

po

pu

lati

on

Auth

or

Val

idat

edques

tionnai

reM

easu

rem

ent

aim

NA

gem

Dis

abil

ity

Pla

ce

Akey

40

Psy

chE

S41

Psy

cholo

gic

alem

pow

erm

ent

asse

ssin

gfo

ur

dim

ensi

ons

of

psy

cholo

gic

alem

pow

erm

ent:

atti

tudes

of

contr

ol

and

com

pet

ence

s;know

ledge

and

skil

ls;

par

tici

pat

ion

info

rmal

acti

vit

ies

and

par

tici

pat

ion

inin

form

alac

tivit

ies.

293

35·4

Par

tici

pan

tsw

ere

the

par

ents

of

chil

dre

nw

ith

dis

abil

itie

ssu

chas

inte

llec

tual

impai

rmen

t,ce

rebra

lpal

sy,

hea

ring

of

vis

ion

impai

rmen

tsor

dev

elopm

enta

ldel

ays.

Sev

erit

yof

dis

abil

ity

var

ied

wid

ely

US

Bro

okin

gs4

2P

OQ

11

The

intr

aper

sonal

com

ponen

tof

psy

cholo

gic

alem

pow

erm

ent

for

peo

ple

wit

hdis

abil

itie

s473

28

Ort

hopae

dic

(31%

),C

hro

nic

illn

esse

s(2

3%

),le

arnin

gdis

abil

itie

s(1

9%

),psy

chia

tric

(19%

),se

nso

ry(4

%),

neu

rolo

gic

al(4

%).

US

Corr

igan

26

ES

2T

ote

stth

eE

Sin

apopula

tion

wit

hgre

ater

dis

abil

itie

san

dto

exam

ine

subsc

ales

of

the

ES

35

33·1

Ser

ious

and

per

sist

ent

men

tal

illn

ess

evid

ence

dby

atle

ast

thre

epsy

chia

tric

hosp

ital

izat

ions.

Sch

izophre

nia

(n¼

18),

schiz

oaf

fect

ive

dis

ord

er(n

¼13),

bip

ola

rdis

ord

er(n

¼9

)an

dm

ajor

dep

ress

ion

(n¼

5)

US

Kac

zinsk

y24

ES

2E

mpow

erm

ent

by

five

subord

inat

efa

ctors

whic

hhav

ean

over

lap

wit

hth

efa

ctors

of

the

MH

CS

.296

48·5

Sev

ere

men

tal

illn

ess

US

MH

CS

43

Confi

den

ceby

3fa

ctors

whic

hhav

ean

over

lap

wit

hth

efa

ctors

of

the

ES

.S

ingh

44

FE

S45

Afa

mil

ies

empow

erm

ent

rati

ng

scal

eth

atm

easu

res

fam

ily

empow

erm

ent

inth

eco

nte

xt

of

men

tal

hea

lth

serv

ices

for

fam

ilie

sw

ho

hav

ech

ildre

nw

ith

seri

ous

emoti

onal

dis

turb

ance

(SE

D)

228

41·2

&13·3

Par

ents

of

chil

dre

nw

ith

SE

DU

S

Sta

ncl

iffe

46

QO

L-Q

,th

eem

pow

erm

ent

fact

or4

7

The

empow

erm

ent

fact

or

asse

sses

opport

unit

ies

toex

ert

contr

ol

over

one’

sen

vir

onm

ent

and

mak

ech

oic

ein

one’

sli

fe

63

&56

34·8

Adult

shav

ing

inte

llec

tual

dis

abil

itie

sA

ust

rali

a

Ander

son

48

DE

S49

Dia

bet

es-r

elat

edpsy

choso

cial

self

-effi

cacy

375

50·4

Hav

ing

dia

bet

esU

SW

ow

ra25

ES

2P

erso

nal

empow

erm

ent

from

the

per

spec

tive

of

consu

mer

s,su

rviv

ors

,an

dfo

rmer

pat

ients

of

men

tal

hea

lth

serv

ices

283

.18

Outp

atie

nts

rece

ivin

gm

enta

lhea

lth

care

US

Cas

tele

in1

ES

2P

erso

nal

empow

erm

ent

from

the

per

spec

tive

of

consu

mer

s,su

rviv

ors

,an

dfo

rmer

pat

ients

of

men

tal

hea

lth

serv

ices

50

18

–65

Pat

ients

wit

hpsy

chia

tric

dis

ord

ers

Net

her

lands

MH

CS

43

Confi

den

ceby

3fa

ctors

whic

hhav

ean

over

lap

wit

hth

efa

ctors

of

the

ES

.P

ersE

S23

The

amount

of

contr

ol

the

indiv

idual

has

over

com

mon

life

dom

ains

Acr

onym

s:P

sych

ES:

Psy

cholo

gic

al

Em

pow

erm

ent

Sca

le;

PO

Q:

Per

sonal

Opin

ions

Ques

tionnair

e;E

S:

Em

pow

erm

ent

Sca

le;

MH

CS:

Men

tal

Hea

lth

Confiden

ceS

cale

;F

ES;

Fam

ily

Em

pow

erm

ent

Sca

le;

QO

L-Q

:Q

uali

tyo

fL

ife

Ques

tionnair

e;D

ES:

Dia

bet

esE

mpow

erm

ent

scale

;P

ersE

:P

erso

nal

Em

pow

erm

ent

Sca

le.


Table

4.

Th

ev

alid

atio

nst

ud

ies:

the

psy

cho

met

ric

pro

per

ties

Inte

rnal

consi

sten

cy*

Cri

teri

on

val

idit

yC

onst

ruct

val

idit

y

Rep

roduci

bil

ity

Flo

or

or

ceil

ing

effe

ctQ

ues

tionnai

reA

gre

emen

tR

elia

bil

ity

Res

ponsi

ven

ess

Inte

rpre

tabil

ity

Psy

chE

S40

00

?0

00

00

PO

Q42

þ0

00

00

00

ES

26

?0

20

00

00

ES

24

?0

þ0

?0

00

MH

CS

24

?0

þ0

?0

00

FE

S44

þ0

00

00

00

QO

L-Q

,T

he

emp

ow

erm

ent

fact

or4

60

20

00

0þ

0

DE

S48

þ0

?0

00

00

ES

25

20

00

00

0?

ES

1?

02

00

00

0M

HC

S1

?0

20

00

00

Per

sES

1?

02

00

00

0

*A

sth

ese

arti

cles

are

no

td

evel

op

men

tst

ud

ies

bu

tv

alid

atio

nst

ud

ies

of

qu

esti

on

nai

re,

inw

hic

ho

ften

afa

cto

ran

alysi

sis

do

ne

inth

eo

rig

inal

stu

dy

,a

po

siti

ve

rati

ng

isal

sog

iven

wh

enth

efa

cto

rsfo

un

din

the

ori

gin

alst

ud

yar

eu

sed

and

wh

enC

ronb

ach

’sA

lphas

are

mea

sure

dfo

rth

ese

fact

ors

and

are

bet

wee

nth

e0·7

0an

d0·9

5.

Rat

ing

:þ

¼p

osi

tiv

era

tin

g;

?¼

indet

erm

inat

e;2

¼p

oo

r;0¼

no

info

rmat

ion

avai

lable

.A

cronym

s:P

sych

ES:

Psy

cholo

gic

al

Em

pow

erm

ent

Sca

le,

PO

Q:

Per

sonal

Opin

ions

Ques

tionnair

e,E

S:

Em

pow

erm

ent

Sca

le,

MH

CS:

Men

tal

Hea

lth

Confiden

ceS

cale

,F

ES:

Fam

ily

Em

pow

erm

ent

Sca

le,

QO

L-Q

:Q

uali

tyof

Lif

eQ

ues

tionnair

e,D

ES:

Dia

bet

esE

mpow

erm

ent

scale

,P

ersE

S:

Per

sonal

Em

pow

erm

ent

Sca

le.


could not be confirmed. A positive rating for ceiling effect was obtained by the QOL-Q, the

Empowerment factor, because only 14% of the respondents obtained the highest possible

scores. The QOL-Q, the Empowerment factor was the only questionnaire tested on criterion

validity. This was rated negatively as the correlation found between the scores and the proxy

(the criterion) was below 0·70. We could not find relevant information on reproducibility,

responsiveness and interpretability of the validated questionnaires in any of the validation

studies.

TRANSLATION STUDIES OF EMPOWERMENT QUESTIONNAIRES

Table 5 provides data for the four translation studies. Two authors (Shiu27 and Hansson28)

presented the development of the translated version of the DES and the ES, respectively

in Chinese and Swedish. The equivalence ratings29 of those translations are presented in

Table 6.

The other two studies did not describe the development of the translated version of the

questionnaire but validated an already translated version.30,31

The Chinese version of the DES developed by Shiu27 was rated ‘good’ for conceptual

equivalence, item equivalence and semantic equivalence, as they applied the correct

methodology. The measurement equivalence was rated as ‘indeterminate’ since only the

internal consistency was found the same in the original validation study and translation study.

For the other psychometric properties insufficient information was available to assess the

equivalence. The Swedish version of the ES developed by Hansson28 obtained indeterminate

ratings for conceptual, item and semantic equivalence as no clear information was found on

these criteria. Also, the measurement equivalence was rated as indeterminate, since internal

consistency was found to be good in the original study, but poor in the Swedish version. For

the other psychometric properties insufficient information was available for a comparison.

The psychometric properties of the translated questionnaires are presented in Table 7.

Good internal consistency was found in the Chinese version of the DES in both articles of

Shiu.27,30 Poor internal consistency was found in the Swedish version of the ES as the

subscales of the questionnaires had low Cronbach’s alphas. Poor criterion validity of the DES

was found in the Chinese version of the DES in both articles of Shiu27,30 as the correlation

with the HbA1c level (the criterion) was low. The Swedish version of the ES showed good

construct validity as more than 75% of the results were in accordance with predefined

hypotheses. Indeterminate ratings were given for the construct validity in the Chinese version

of the DES27 and the Japanese version of the ES31 as no hypotheses were formulated in

advance. Shiu27 was the only author who did a test-retest study in which the reliability of the

Chinese version of the DES was rated positively. No information was found in the studies

about responsiveness and the floor or ceiling effects. Although Hansson28 and Shiu30 both

analysed the scores of subgroups, interpretability was rated indeterminate as no MIC was

defined.

EMPOWERMENT STUDIES

Sixteen articles were included in which an empowerment scale was used. Information on the

type of empowerment scale used and the population can be found in Table 8.

Almost half of the articles used the ES of Rogers2 and they all used it in people with

mental illnesses. The FES was used twice: one author used it in persons with disabilities3


Table

5.

The

tran

slat

ion

studie

s:th

ech

arac

teri

stic

so

fth

eques

tionnai

res

and

the

popula

tion

Au

tho

rN

ame

Mea

sure

men

tai

mN

Ag

eD

isab

ilit

yP

lace

of

liv

ing

Sh

iu27

DE

S48

Tra

nsl

ate

the

DE

Sin

toC

hin

ese

and

esta

bli

shit

sp

sych

om

etri

cp

rop

erti

esam

on

gH

on

kK

ong

Chin

ese

peo

ple

20

75

3(m

ean

)P

atie

nts

wit

hd

iab

etes

type

1an

d2

Ho

ng

Ko

ng

Sh

iu30

DE

S48

To

exam

ine

the

psy

cho

met

ric

pro

per

ties

of

the

Chin

ese

ver

sion

of

the

DE

S

18

95

3·0

5(m

ean

fem

ales

)P

atie

nts

wit

hd

iab

etes

type

1an

d2

Ho

ng

Ko

ng

51·

43

mea

nm

ales

)

Han

sso

n28

ES

50

Mea

suri

ng

the

psy

cho

met

ric

pro

per

ties

of

the

Sw

edis

hv

ersi

on

of

the

ES

92

47

(mea

n)

Sch

izo

ph

renia

(46

),o

ther

psy

cho

sis

(14

),N

on

psy

cho

sis

(17

)S

wed

en

Yam

ada3

1E

S50

To

exam

ine

the

psy

cho

met

ric

pro

per

ties

of

the

Jap

anes

ev

ersi

on

of

the

ES

,th

eE

S-J

,d

evel

op

edb

yH

ata

etal

.(2

00

3)

72

25

–6

5y

ears

Hav

ing

sch

izo

ph

ren

iaac

cord

ing

toth

eD

SM

-4Ja

pan

Acr

onym

s:D

ES

:D

iab

etes

Em

po

wer

men

tsc

ale,

ES

:E

mp

ow

erm

ent

Sca

le.


while the other used it with parents of ill children.32 In the remaining articles, empowerment

was measured with a scale for which no development or validation study was accessible.

Table 9 lists all 17 questionnaires used to measure empowerment in the context of disability

for which quality measures were available and the frequency of their use.

Discussion

Many instruments have been developed to measure the concept of empowerment. When

using a questionnaire it is important that it is relevant to the target population.20 The majority

of the questionnaires were developed to measure empowerment in people with mental illness.

Although most of the questionnaires were meant to measure empowerment in the disabled

people themselves, others measured empowerment of family members or caregivers. As the

construct of empowerment has a different meaning for family members or caregivers, those

questionnaires cannot be used interchangeably. Most questionnaires were developed for a

population aged 30–50. The concept of empowerment in this age group may not always be

the same as in, for example, the elderly or the young, as their needs will be different.

Therefore, adaptations in the questionnaires may have to be made when using the

questionnaire in another population. It is noteworthy that all questionnaires in this review

were developed and/or validated in a developed country, most of them in the United States.

This suggests that most of the questionnaires are measuring the construct of empowerment

based on a Western worldview.

The validity of a research project depends on whether the instrument, used to measure the

outcome, adequately measures the construct it intends to measure. The empowerment

questionnaires found in this review cannot be used interchangeably as they differ in their

construct of empowerment. All questionnaires assessed empowerment at the individual level

as the measurement of empowerment in people with disabilities was the focus point of this

systematic review. When reviewing the constructs of empowerment, we found that the POQ,

EQuIP, PaES, MHCS and the FraES measure the intrapersonal component of empowerment

since their items measure the feelings of the subjects. The OES and the ExtraOES measure

the behavioural component of empowerment as they focus on the extent to which the person

is involved in organisations or in political processes. The ES, the ‘Vrijbaan’, the PersES and

the DES measure the intrapersonal component of empowerment, but also the interactional

component as they include questions about the knowledge of the subjects on how they can

influence their own life. The YES-MH, the PsychES, the FES and the FEQ measure

Table 6. The translation studies: the equivalence ratings

AuthorsConceptualequivalence

Itemequivalence

Semanticequivalence

Operationalequivalence

Measurementequivalence*

Functionalequivalence

Shiu27 þ þ þ 2 ? þHansson28 ? ? ? 2 ? - -

* This is assessed according to the psychometric criteria of Terwee (20).Rating: þþ ¼ very good, þ ¼ good, 2 ¼ poor, - - ¼ very poor, ? ¼ indeterminate and 0 ¼ no information.


Table

7.

The

tran

slat

ion

studie

s:th

epsc

yhom

etri

cpro

per

ties

Rep

rod

uci

bil

ity

Ques

tionnai

res

Inte

rnal

consi

sten

cyC

rite

rion

val

idit

yC

onst

ruct

val

idit

yA

gre

emen

tR

elia

bil

ity

Res

ponsi

ven

ess

Flo

or

or

ceil

ing

effe

ctIn

terp

reta

bil

ity

ES

(Han

sso

n28)

20

þ0

00

0?

DE

S(S

hiu

27)

þ2

?0

þ0

00

DE

S(S

hiu

30)

þ2

00

00

0?

ES

(Yam

ada3

1)

00

?0

00

00

Rat

ing

:þ

¼p

osi

tiv

era

tin

g;

?¼

indet

erm

inat

e;2

¼p

oo

r;0¼

no

info

rmat

ion

avai

lab

le.

Acr

onym

s:D

ES

:D

iab

etes

Em

po

wer

men

tsc

ale,

ES

:E

mp

ow

erm

ent

Sca

le.


empowerment by assessing all three components of empowerment. An overview of the

constructs measured by each questionnaire is presented in Figure 1.

The empowerment questionnaires were rated according to the quality criteria for

psychometric properties of Terwee et al.20 It should be kept in mind that a questionnaire with

many ‘indeterminate’ scores is not necessarily a poor questionnaire. The rating is partly

dependent on the availability of information and the quality of reporting, which is different

from the quality of the questionnaire itself.

Content validity is considered to be one of the most important measurement properties

since this determines whether the construct is adequately measured by the questionnaire.20

Unfortunately, a good description of this property is often lacking, as authors do not describe

the concepts being measured, the item selection process or the involvement of experts and

target population. In addition, internal consistency is a very important property. But also in

assessing this property, authors fail to apply adequate methodology. Many authors only

described internal consistency of the whole scale, but not per sub-scale. Furthermore, many

authors failed to specify hypotheses in advance for the assessment of construct validity.

Hypotheses formulated in advance are needed to lower the risk of bias, since retrospectively it

is tempting to think up alternative explanations for low correlations, instead of concluding

that the questionnaire may not be valid.20 Very few authors described the reproducibility,

responsiveness, floor or ceiling effects and interpretability of the questionnaires. This is in

line with findings of Terwee et al.20 and Stevelink et al.33 regarding health status

questionnaires. They also found that assessments of these properties were often missing. This

demonstrates that validation research needs to be carried out more extensively to assess the

quality of all relevant psychometric properties.

Empowerment

Community level Individual level Organizational level

CaregiverDisabled personFamily member

Intrapersonal Intrapersonal Intrapersonal

InteractionalInteractionalInteractional

Behavioural Behavioural Behavioural

ExtraOES

OES

DES PersES Vrijbaan ES

MHCS FraESPaESEQuIP

YES-MHFESFEQ PsychES

POQQOL-Q QOL-Q

QOL-Q

Figure 1. The constructs of empowerment measured by the seventeen questionnaires.


Table

8.

Art

icle

sin

wh

ich

anem

po

wer

men

tq

ues

tion

nai

reis

use

d

Au

tho

rQ

ues

tio

nn

aire

use

dN

Ag

em

Dis

abil

ity

Pla

ce

Ch

eun

g51

Sel

f-dev

elo

ped

stru

ctu

red

qu

esti

on

nai

re6

92

23·1

Sev

ere

gra

de

of

dev

elo

pm

enta

ld

isab

ilit

y(1

7·2

%),

mo

der

ate

gra

de

(49·9

%)

and

am

ild

gra

de

(33·4

%)

Ch

ina

Co

ok

52

ES

21

08

46·6

Pat

ien

tsw

ith

sch

izo

ph

ren

ia,

bip

ola

rd

iso

rder

s,d

epre

ssiv

ed

iso

rder

and

per

son

alit

yd

iso

rder

US

Co

rrig

an53

ES

21

82

44

1·8

Dia

gno

ses

wit

hse

rio

us

men

tal

illn

ess,

such

assc

hiz

op

hre

nia

,b

ipo

lar

dis

ord

ero

ra

maj

or

dep

ress

ion

.

US

Dan

iels

54

Fra

ES

78

39

Men

tal

hea

lth

cou

nse

llo

rsU

SV

anU

den

-Kra

an55

Sel

f-dev

elo

ped

stru

ctu

red

qu

esti

on

nai

re5

28

43

/47

Mem

ber

so

fa

Du

tch

on

lin

esu

ppo

rtg

rou

pfo

rp

atie

nts

wit

hb

reas

tca

nce

r,fi

bro

my

alg

iaan

dar

thri

tis.

Net

her

lan

ds

Fri

edm

an56

Aco

mb

inat

ion

of

sev

eral

qu

esti

on

nai

re1605

77

Ben

efici

arie

sw

ith

dis

abil

ity

whic

hnee

dor

rece

ive

hel

pw

ith

two

or

more

acti

vit

ies

of

dai

lyli

vin

g.

US

Heb

ert5

7H

CE

Q58

92

08

3In

div

idu

als

atri

sko

ffu

nct

ion

ald

ecli

ne

Can

ada

Itza

hk

y3

FE

S45

85

38

Per

sons

wit

hdis

abil

itie

s:hea

ring

impai

red

(23%

),b

lin

d(1

5%

)o

ther

var

iou

sp

hy

sica

ld

isab

ilit

ies

(22

%)

and

tho

seim

pai

red

du

ring

thei

rar

my

serv

ice

(40

%)

Isra

el

Kap

lan

59

ES

23

00

47

Pat

ien

tsd

iagn

ose

dw

ith

Sch

izo

phre

nia

or

anaf

fect

ive

dis

ord

erU

S

Ko

sciu

lek

60

ES

21

59

40

Ind

ivid

ual

sw

ith

men

tal

illn

ess

US

Lu

nd

ber

g61

ES

2200

40·6

Par

tici

pan

tsin

conta

ctw

ith

men

tal

hea

lth

serv

ices

.H

avin

gpsy

chosi

s,af

fect

ive

dis

ord

ers

or

oth

erm

enta

lh

ealt

hd

iso

rder

s

Sw

eden

Man

62

FE

Q62

22

13

5–

54

Fam

ily

mem

ber

so

fp

erso

ns

wit

htr

aum

atic

bra

inin

jury

(TB

I)C

hin

a

Seg

al63

Per

sES

&O

ES

23

22

53

8·8

Pat

ien

tsin

men

tal

hea

lth

care

serv

ices

US

Str

ack

64

ES

27

14

1·6

Pat

ien

tso

fm

enta

lh

ealt

htr

eatm

ent

cen

tres

US

Vau

th65

ES

2172

39·6

Pat

ients

wit

hsc

hiz

ophre

nia

Sw

itze

rlan

dW

alsh

66

FE

S45

19

?P

aren

tso

fch

ild

ren

adm

itte

dto

the

ho

spit

alfo

rg

ener

alsu

rgic

alo

rm

edic

alca

rew

ho

wer

ere

ferr

edto

So

cial

Wo

rk

Au

stra

lia

Acr

onym

s:E

S:E

mp

ow

erm

entS

cale

,Fra

ES

:F

ran

s’E

mp

ow

erm

entS

cale

,HC

EQ

:H

ealt

hC

are

Em

po

wer

men

tQ

ues

tio

nn

aire

,FE

S:F

amil

yE

mp

ow

erm

entS

cale

,FE

Q:F

amil

yE

mp

ow

erm

ent

Qu

esti

on

nai

re,

Per

sES

:P

erso

nal

Em

po

wer

men

tS

cale

,O

ES

:O

rgan

izat

ion

alE

mp

ow

erm

ent

Sca

le.


Table

9.

Ov

erv

iew

of

the

qu

esti

on

nai

res

Qu

esti

on

nai

res

Mea

sure

men

tai

mT

arg

etg

rou

pN

Dev

elop

men

tst

ud

ies

NV

alid

atio

nst

ud

ies

NT

ran

slat

ion

stu

die

sN

Em

po

wer

men

tst

ud

ies

ES

2P

erso

nal

empo

wer

men

tM

enta

lil

lnes

s1

42

7P

OQ

11

Intr

aper

sonal

empow

erm

ent

Psy

cholo

gic

alan

dphysi

cal

dis

abil

itie

s1

1–

–E

Qu

IP36

Em

po

wer

men

tO

lder

psy

chia

tric

inp

atie

nts

1–

––

Th

e‘V

rijb

aan

’37

Em

po

wer

men

tL

on

g-t

erm

wo

rkd

isab

ilit

ies

1–

––

Per

sES

23

Per

sonal

empo

wer

men

tM

enta

lil

lnes

s1

1–

1O

ES

23

Org

aniz

atio

nal

der

ived

emp

ow

erm

ent

Men

tal

illn

ess

1–

–1

Ex

traO

ES

23

Ex

tra

org

aniz

atio

nal

der

ived

emp

ow

erm

ent

Men

tal

illn

ess

1–

––

YE

S-M

H38

Em

po

wer

men

tM

enta

lil

lnes

s1

––

–P

aES

39

Em

po

wer

men

tO

lder

ho

spit

aliz

edp

eop

le1

––

–P

sych

ES

41

Psy

cholo

gic

alem

pow

erm

ent

Par

ents

of

chil

dre

nw

ith

psy

cholo

gic

alan

dp

hy

sica

ld

isab

ilit

ies

–1

––

MH

CS

43

Co

nfi

den

ceM

enta

lil

lnes

s–

2–

–F

ES

45

Fam

ily

empow

erm

ent

Par

ents

of

chil

dre

nw

ith

men

tal

illn

ess

–1

–2

QO

L-Q

-T

he

emp

ow

erm

ent

fact

or4

6E

mpow

erm

ent

Inte

llec

tual

dis

abil

itie

s–

1–

–

DE

S48

Psy

cho

soci

alse

lf-e

ffica

cyP

atie

nts

of

dia

bet

esty

pe

1an

d2

–1

2–

Fra

ES

54

Em

po

wer

men

tM

enta

lh

ealt

hco

un

sell

or

––

–1

HC

EQ

58

Em

po

wer

men

tF

rail

old

peo

ple

––

–1

FE

Q62

Fam

ily

empow

erm

ent

Fam

ily

mem

ber

sof

pat

ients

wit

htr

aum

atic

bra

inin

juri

es–

––

1


In the light of the above results, it is difficult to determine which questionnaire is the most

reliable and valid to measure empowerment. Nonetheless, from all the seventeen

questionnaires, the ES is the best rated according to the quality criteria of Terwee, as

positive ratings were found for content validity,2 internal consistency2 and construct

validity.24,28 Because there was more information available about the ES, also more poor

ratings were found. The DES was also rated ‘good’ according to some quality criteria. Good

internal consistency was found by three authors for the original version and translated

version27,28,30 and good reliability was found in the translated version.27 However, this

questionnaire is specifically applicable in patients with diabetes and therefore not suitable to

measure empowerment in another population.

The cultural equivalence of translated empowerment assessment tools could only be

assessed in two questionnaires: the DES and the ES. The Chinese version of the DES was

found to be translated adequately as the authors described the adaptation of this questionnaire

in the Chinese culture perfectly.27 The adaptation of the ES in the Swedish culture was not

described adequately and therefore rated poorly.28 The authors found poor internal

consistency in the Swedish version, while good internal consistency was found in the original

study in the US. This might demonstrate that, despite the fact that both cultures have a

Western ideology, they differ enough to make the questionnaire not directly suitable in the

Swedish culture. This highlights the need to take cultural differences between countries into

account when adapting a questionnaire.

In the scientific literature, the ES was the most validated, translated and used

questionnaire. This indicates that many scientists consider this questionnaire a useful tool to

assess empowerment in patients with mental illness. Whether this scale can be used in a

population with other disabilities should be further investigated.1

The exclusion of non-English articles and articles of which no full text was available may

have created bias and is a limitation of this study. These articles may have described relevant

questionnaires or translations of questionnaires relevant to this study. However, these

exclusions were unavoidable. The main strength of a systematic review is that the investigators

are transparent about the methods used and that these are described in sufficient details. This we

attempted to do and we acknowledge the potential bias created by the excluded articles. A list of

the articles excluded is available from the corresponding author on request.

Furthermore, it is important to realize that this review focused on quantitative methods

and therefore excluded articles describing qualitative methods for assessing empowerment.

This does not in any way mean we disregard the importance of qualitative methods, but

reflects a conscious decision to limit the scope of this review. Finally, in this study the quality

criteria were assessed by one reviewer, making the rating subject to information bias.

However, most of the criteria are objective and based on numeric results. Therefore, the

influence of this type of bias is likely to be limited.

Conclusions

No questionnaires were found which were developed, validated or translated in developing

countries. As a consequence, no appropriate evidence exists about which questionnaire is

1An unpublished thesis of Evelien Rosens et al. (35) demonstrates that the ES in its current form is notrecommended to assess empowerment in people with a range of disabilities in Tamil Nadu, South India.


suitable to use in developing countries with regard to quality of psychometric properties and

cultural equivalence.

A generic measurement of the concept of empowerment is difficult since empowerment

manifests itself in different perceptions, skills, and behaviours in different groups of people.34

Therefore, the construct of empowerment is not easily reduced to a universal set of

operational rules and definitions.34 It may be that no global empowerment measure can be

developed. Zimmerman34 suggests that the measurement of empowerment in a specific

setting for a particular sample of individuals is possible, but it must be connected to the

experience of the research participants and must be contextually grounded in the culture in

which it is used. However, further research is needed before a definitive conclusion can be

drawn about generic measurement of empowerment.

With the above limitations in view, we suggest that the Empowerment Scale of Rogers is

currently the best validated tool to measure empowerment. The ES is the most widely

validated and used empowerment scale and many scientists consider this scale reliable and

valid, based on the studies of Rogers,2 Corrigan,26 Wowra25 and Hansson.28 Although this

scale was originally developed to measure intrapersonal and interactional empowerment in

patients with mental illness in the US, the items are also applicable in people with other

disabilities. Other scales may be relevant when other constructs of empowerment are

measured (see Figure 1). Further research is needed to validate the properties of the various

instruments that have not yet been tested.

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Appendices

Appendix 1: Overview of the study selection process demonstrated in a PRISMA

diagram

Iden

tific

atio

n Recordsidentifiedthrough

PsychInfo(n = 62)

RecordsidentifiedthroughPubmed(n = 33)

Recordsidentifiedthrough

Science Direct(n = 17)

Recordsidentified

through Webof Science

(n = 23)

Recordsidentifiedthrough

WorldCat(n = 25)

Scr

eeni

ng

Records after duplicates removed(n = 124)

Records excluded(n = 80)

Recordsidentified

through othersearching

(n = 1)

Full-text articlesassessed for eligibility

(n = 44)

Elig

ibili

ty

Articles in which anempowerment scale is developed,

validated, translated or used inthe context of disabilities (n = 30)

Records excluded(n = 14)

Incl

uded

Studies included in the analysis(n = 36)

Records included byreference list

selection(n = 6 )

Records screened onabstract(n = 124)

Recordsidentified

through Cinahl(n = 12)


Appendix 2: Quality criteria for measurement properties of health status questionnaires

The content validity assesses the extent to which the concepts of interest are adequately

represented by the items in the questionnaire (20). This criterion is rated positively (þ ) when

there is a clear description of the measurement aim, target population, the concepts that are

being measured and the item selection plus target population and experts are involved in the

item selection,. The criteria is rated as indeterminate (?) when a clear description is lacking or

only target population is involved. The criteria is rated negatively (2 ) when there was no

target population.

Internal consistency is the extent to which items in a scale are intercorrelated and thus

measuring the same construct (20). A factor analysis is needed in order to determine whether

the scale is measuring one or more constructs and Cronbach’s alphas need to be calculated.

Therefore, this criteria is rated positively (þ ) when a factor analyses has been performed and

when the Cronbach’s alpha’s are between 0·70 and 0·95. It is rated as indeterminate (?) when

there is no factor analysis or doubtful design and rated negatively (2 ) when the Cronbach’s

alpha is below the 0·70 or above the 0·95 despite adequate methodology.

The criterion validity is the extent to which scores on the questionnaires relate to a gold

standard (20). A positive rating (þ ) is given when in the article it is explained that the ‘gold’

standard is gold and that the correlation with the gold standard is at least 0·70. This criterion is

rated as indeterminate (?) when there are no convincing arguments that the golden standard is

‘gold’ or a doubtful design. The criteria is rated negatively (2 ) when the correlation is below

the 0·70.

The extent to which scores on a particular questionnaire relate to other measures in a way

that is consistent with the theory is called construct validity (20). This criterion is rated

positively (þ ) when specific hypotheses were formulated in advance and when at least 75%

of the hypotheses could be accepted according to the results. The criterion is rated

indeterminate (?) when the design was doubtful, for example by not having hypotheses. The

criteria is rated negatively (2 ) when less than 75% of the hypotheses could be accepted

according to the results.

Reproducibility (reliability and agreement) is the extent to which repeated measures in

stable persons provided similar answers (20). Reliability concerns the degree to which

patients can be distinguished from each other, despite measurement error. The intra-class

correlation coefficient (ICC) is the most suitable and most commonly used reliability

parameter for continuous measures and often 0·70 is recommended as a minimum standard

for reliability. This criterion is rated positively (þ ) when the ICC or weighted Kappa is at

least 0·70 in a sample size of at least 50 patients. It is rated indeterminate when the design is

doubtful (e.g. no time intervals mentioned). The criteria is rated negatively (2 ) when the ICC

or weighted Kappa is below 0·70 despite adequate design and method. Agreement concerns

the absolute measurement error; it demonstrates the extent to which the scores on repeated

measures are close to each other. To assess this, the minimally important change (MIC)

should be defined in the article. The absolute measurement error should be smaller than the

MIC. Therefore, a positive mark will be given (þ ) when the smallest detectable change

(SDC) (reflects the smallest within-person change in score) is smaller than the MIC or when

there are convincing arguments that agreement is acceptable. An indeterminate mark (?) is

given when there is a doubtful design or when the MIC is not defined. A negative mark (2 ) is

given when the smallest detectable change is found to be higher than the MIC.


Responsiveness is defined as the ability of a questionnaire to detect clinical important

changes over time and can be assessed by testing predefined hypotheses for example about

expected correlations between changes in measures. Responsiveness is tested by relating the

SDC to the MIC (20).

Floor or ceiling effects demonstrates the number of respondents who achieved the lowest

or highest possible score (20). A positive rating (þ ) is given when less than 15% of the

respondents achieved the highest or lowest possible scores. An indeterminate mark (?) is

given when there is a doubtful design or method and a negative mark (2 ) is given when more

than 15% of the respondents achieved the highest of lowest possible scores.

The last criterion is the interpretability, which assesses the degree to which one can

assign qualitative meaning to quantitative scores (20). A positive ranking (þ ) is given when

the mean and the SD scores are presented of at least four relevant subgroups of patients and

the MIC is defined. An indeterminate rating (?) is given when there are less than four relevant

subgroups or patients, when no MIC is defined or when there is a doubtful design.

In all criteria, when no information was found it was rated with a 0.

Appendix 3: The types of equivalence and the rating system

Conceptual equivalence is the way in which different populations conceptualize the

measured concept. It is achieved when the questionnaire has the same relationship to the

underlying concept in both cultures (22). The conceptual equivalence is rated as ‘very good’

(þþ ) when the concept of the questionnaire in both cultures is examined by literature,

experts opinions and opinions of the population. This equivalence is rated ‘good’ (þ ) when

the concept of the questionnaire is examined by one or two of the different methods

(literature, experts and population). The equivalence is rated as ‘poor’ (2 ) when the concept

in the cultures is not examined and described and not taken into account in the translation.

The equivalence is rated as ‘indeterminate’ (?) when the methodology to assess the

conceptual equivalence is not clear.

Item equivalence is the way in which the domains are sampled and exists when the items

estimate the same parameters on the construct being measured and when they are equally

relevant and acceptable in both cultures. It is assessed by an initial qualitative examination of

the relevance of items (22). When this is performed by a literature research and consulting

expert’s opinions and members of the target population itself, this equivalence is rated as

‘very good’ (þþ ). This equivalence is rated as ‘good’ (þ ) when the items of the

questionnaire are examined, but not by all three methods. When an initial qualitative

examination of the relevance of items has not been performed and described, this equivalence

is rated as ‘poor’ (2 ). The equivalence is rated as ‘indeterminate’(?) when the methodology

to assess the item equivalence is not clear.

Semantic equivalence concerns whether language has the same effect on the respondent

in different languages (22). This equivalence is rated as ‘very good’ (þþ ) when the semantic

equivalence is achieved by obtaining a more detailed description about the items to show the

range of ideas within the key words, when good translators are involved and when a sample of

the target population is asked to paraphrase the translated items. This equivalence is rated as

‘good’ (þ ) when translation quality is assessed by some of the methodology described above

but not all. It is rated as ‘poor’ (2 ) when assessment of the translation quality is not


performed or described and rated as ‘indeterminate’(?) when the methodology for this

equivalence is not clear.

Operational equivalence means the possibility of using a similar questionnaire format,

instructions, mode of administration and measurement methods of the current scale in the

target population. This is important as the operation of the questionnaire should not affect the

results in another culture (22). Whether this is taken into account in the article is assessed by

rating this equivalence as ‘very good’ when this is taken into account by reading literature

reviews regarding instrument use, looking to the type of instrument used by other researchers

in other fields or by anthropological data on cultural norms. It is rated as ‘good’ (þ ) when

operational equivalence is taken into account but not by all methods described in the previous

classification. This equivalence is given a ‘poor’ (2 ) rate when operational equivalence is not

taken into account. It is rated as ‘indeterminate’ (?) when the methodology assessing this

equivalence is not clear.

The rating ‘no information’ (0) is not applicable in the above mentioned equivalence

types, because when there is no information in the article it is assumed that this equivalence is

not taken into account and consequently should be rated as ‘poor’.

Measurement equivalence is the extent to which the psychometric properties of different

language versions of the same instrument are similar (22). For examining the psychometric

properties of the translated versions, the quality criteria of Terwee et al. (20) were used from

the original development study and the translation study. The psychometric properties which

were found only in one study are not taken into account, as the equivalence cannot be

assessed. Also quality criteria who were rated as indeterminate (?) or as unknown (0) by using

the rating of Terwee et al. were not taken into account in this assessment. Measurement

equivalence is rated as ‘very good’ (þþ ) when found four or more psychometric properties

the same in the original study and the current study. It is rated as ‘good’ (þ ) when two or

three psychometric properties are the same in the original study and the current study. These

above mentioned ratings were only given when in the other psychometric measures no

inequalities between the two studies were found. Measurement equivalence is rated ‘very

poor’ (- -) when found four or more psychometric properties unequal in the original study and

the current study. It is rated ‘poor’ when found two or three psychometric properties being

unequal in the original study and the current study. These above mentioned ratings were only

given when in the other psychometric measures no equivalence was found. It is rated as

‘indeterminate’ (?) when there were psychometric properties found being equal and unequal

in the studies or when there was only one psychometric property found the same or not the

same. It is rated as ‘no information’(0) when psychometric properties were not available in

the original study or in the current study.

Functional equivalence summarizes all parts of the process of equivalence and

demonstrates the extent to which an instrument does what it is supposed to do equally well in

two or more cultures. Therefore, this summarizing equivalence is rated as ‘very good’ (þþ )

when four to five equivalence types are assessed with þ or þþ . It is rated ‘good’ (þ ) when

three equivalence types are assessed with þ or þþ . It is rated ‘medium’ (þ /2 ) when

two equivalence types are assessed with þ or þþ and it is rated ‘poor’ when only one

equivalence type is assessed with þ or þþ . Finally, it is rated ‘very poor’ when there was

no equivalence type rated with þ or þþ .


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