Empowerment in primary care and psychiatric settings: a psychometric evaluation of the Swedish version of the empowerment scale

Abstract

Background: There has recently been an increased emphasis on patient empowerment and collaboration within their healthcare. However, there is widely a lack of clarity to the concept of empowerment and existing measurement tools lack uniformity, covering diverse domains and related concepts.

Objectives: This study aims to conduct a psychometric evaluation of the Swedish version of the Empowerment Scale- Making Decisions, focusing on its structural validity and reliability in assessing patient empowerment. This includes a detailed examination of the factor structure across two different contexts, psychiatric care (n = 211) and primary care (n = 210). We will compare several confirmatory factor analysis (CFA) models proposed in previous research to identify the best fit. If no models provide a good fit, we intend to suggest a new scale for further evaluation.

Method: The dimensionality of the scale was tested by comparing four CFA models, together with a one-factor solution, to identify the best fit for the two samples. Reliability measures were determined by coefficient Omega (ω) as well as Cronbach's alpha (α).

Results: There was limited support for the one-factor solution in both samples, challenging the scale's assumed unidimensionality (primary care sample: x²(350) = 1074, p <.001, CFI = 0.58, TLI = 0.54, RMSEA = 0.10 (90% CI: 0.09 - 0.11), SRMR = 0.11; psychiatric care sample: (x²(350) = 1307, p = < 0.001, CFI = 0.66, TLI = 0.63, RMSEA = 0.11 (90% CI:0.11;0.12), SRMR = 0.10). None of the previously suggested factor solutions demonstrated satisfactory fit. However, a three factor-solution entailed the less complexity and best model fit (primary care sample: (x²(270) = 503, p = < 0.001),CFI = 0.85, TLI = 0.84, RMSEA = 0.06 (90% CI 0.06;0.07), SRMR = 0.07; psychiatric care sample: (x²(270) = 622, p <.001), CFI = 0.87, TLI = 0.86, RMSEA = 0.08 (90% CI 0.07;0.09), SRMR = 0.07). Based on this, we continued with exploratory refinements of this solution and arrived at two adjusted three-factor models based on each sample. These two adjusted models displayed only slight differences, and in a last step we removed the items that differed between the samples to arrive at one solution appropriate for use in health care settings in general. As a result, an improved and shortened adaptation of the scale was put forward that included 18 items targeting the subscales Self-Esteem, Powerlessness and Activism. This solution remained relatively clear to the previously proposed solutions (primary care sample:(x²(131) = 240, p <.001), CFI = 0.91, TLI = 0.90, RMSEA = 0.06 (90% CI 0.05;0.08), SRMR = 0.07; psychiatric care sample: (x²(131) = 379, p <.001), CFI = 0.88, TLI = 0.86, RMSEA = 0.09 (90% CI 0.08;0.10), SRMR = 0.07; combined sample: (x²(131) = 432, p <.001), CFI = 0.91, TLI = 0.90, RMSEA = 0.07 (90% CI 0.07;0.08), SRMR = 0.06).

Conclusion: The results reinforce the difficulties in measuring empowerment given the complexity of this concept. The improved and shortened adaptation of the scale could potentially be used within health care settings to measure empowerment, but further research is needed to conceptualize and measure empowerment in patients with mental health problems. Given scarce support for the scale's unidimensionallity, future research should explore using multiple instruments targeting different constructs to measure patient empowerment more comprehensively.

Keywords: Measurement instruments; Patient empowerment; Person-centered care; Primary care; Psychiatric care.