Empowerment interventions designed for persons living with chronic disease - a systematic review and meta-analysis of the components and efficacy of format on patient-reported outcomes

Abstract

Background: Empowerment approaches are essential for building the capacity of individuals with chronic disease to be in control of their health. Reviews of empowerment interventions have been focused on specific chronic diseases, thereby limiting the scope of findings. This study had three aims: 1) to describe the characteristics of empowerment interventions covering a broad range of chronic diseases, 2) to clarify consistency with the World Health Organization`s (WHO) definition of empowerment as a process composed of four fundamental components and 3) to summarize outcome measures and estimate the effects in group and individual intervention formats.

Methods: Systematic literature review and meta-analysis. CINAHL, Medline, Embase, PsycINFO, Web of Science, COCHRANE and Central Register of Controlled Trials were searched using Chronic Disease, NCD, Empowerment, as MeSH terms. Eligible randomized and quasi randomized controlled trials were included. Review Manager 5.4 was used to conduct the meta-analysis. Risk of bias was assessed with the Cochrane risk-of-bias tool (ROB 2).

Results: Thirty-nine articles representing 8,011 participants were included in the review. A majority (82%) of studies reported robust evidence for changes on study-defined outcome measures in favor of interventions. Intervention content was assessed against WHO's four fundamental components of empowerment, showing that all studies incorporated one component, but none targeted all components. Components reflecting knowledge acquisition, patient engagement with their health care providers and facilitating environment were scarcely reported. Meta-analyses found evidence for positive effects of group-format interventions measuring empowerment, HbA1c, and self-efficacy. Effects on empowerment were also found in some individual-format interventions. High levels of heterogeneity and variability among the conceptual frameworks were identified.

Conclusion: Empowerment interventions in group-format were most efficient, however, considerable conceptual inconsistencies were identified. Future studies should consolidate conceptual understandings by using WHO's empowerment framework to ensure that fundamental components of empowerment are explicitly included in intervention design. Furthermore, there is a need to clarify the role of empowerment through pathways that include patient activation, self- management, and clinical outcomes. This systematic review will inform the clinicians and researchers who aim to develop novel empowerment interventions to assist patients in the process of gaining control of their health.

Trial registration: PROSPERO: International Prospective register of systematic reviews ID=CRD42020178286.

Keywords: Chronic disease; Empowerment; Interventions; Meta-analysis; Person-centered care; Self-management; Systematic review.

Fig. 1

PRISMA flow chart. The figure details our search and selection process applied during the systematic review

Fig. 2

Forest plot of the meta-analysis of group-format empowerment interventions versus control using the Empowerment Scale (2A), HbA1c (2B), self-efficacy (2C) and Self-Management / self-care (2D)

Fig. 3

Forest plot of the meta-analysis of individual-format empowerment interventions versus control using HbA1c (E)

Fig. 4

Risk of Bias Domains for individual randomized studies using Rob2 tool. Domains: D1: bias arising from the randomization process, D2: bias due to deviations from intended intervention, D3: bias due to missing outcome data, D4: bias in the measurement of the outcome, and D5: bias in the selection of the reported result. Legend: Red (x) = high risk of bias; Yellow (-) = unknown risk of bias; Green ( +) = low risk of bias

Fig. 5

Risk of Bias Domains for cluster randomized studies using Rob2 tool. Domains: D1: bias arising from the randomization process, D1b: Bias arising from the timing of identification and recruitment of individual participants in relation to the timing of randomization. D2: bias due to deviations from the intended intervention, D3: bias due to missing outcome data, D4: bias in the measurement of the outcome, and D5: bias in the selection of the reported result. Red (x) = high risk of bias; Yellow (-) = unknown risk of bias; Green ( +) = low risk of bias