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

ABSTRACT

Child and adolescent participation for health promotion can be realized through participatory action research (PAR). However, there is a lack of understanding regarding the concrete steps needed to actualize empowerment within PAR. We propose a framework that outlines six elements that need to be considered when designing a PAR study that strives to actualize child and adolescent empowerment. These are 1) Safeguarding the necessary resources; 2) Having high quality adult facilitation; 3) Enabling sense-making activities and 4) Investing in capacity building. These four elements make up an environment that may nourish children and adolescents’ social, emotional and cognitive development that may potentially lead to 5) Positive child and adolescent development and 6) Participatory competence. The proposed framework adopts a holistic approach by considering the lived reality of children and adolescents and their capabilities and characteristics. Future research is needed to assess the practical utility of the framework.

KEYWORDS:

• Empowerment
• Health promotion
• Participatory Action Research (PAR)
• Positive youth development
• Framework
• School-aged

Introduction

Growing interest of academic researchers to engage individuals and groups as active agents in the research process has resulted in the normalization of child and adolescent participation in research (Ozer & Piatt, 2017; Tsang et al., 2020; Wong et al., 2010). Considering the voices of children and adolescents is an essential part of the General Principles of the Convention on the Rights of the Child, which states that every child has the right to express their views, feelings and wishes in all matters affecting them (United Nations, 1989). Child and adolescent participation can be realized through participatory research, an umbrella term for research designs, methods, and frameworks that involves active collaboration (Cargo & Mercer, 2008; Vaughn & Jacquez, 2020). Participatory Action Research (PAR), which is closely connected to community-based participatory research (CBPR) (Israel et al., 2019), combines participation and action to understand and address societal challenges and health-related issues (Cargo & Mercer, 2008; Ozer et al., 2020; Vaughn & Jacquez, 2020).

Although it is not yet clear through which mechanisms child and adolescent participation in PAR contributes to tackling certain health issues (Frerichs et al., 2016), it is generally believed that health promotion interventions that are developed in collaboration with children and adolescents better match their needs and interests and therewith have increased effectiveness (Ballonoff Suleiman et al., 2021; Peterson et al., 2011; Wong et al., 2010). The shift towards more child and adolescent participation in health promotion is in line with the theory of positive youth development, an approach that aims to stimulate and facilitate the promotion of health and wellbeing among young people, while focusing on the development of personal competencies such as self-efficacy, resilience, and taking initiative (Christens & Peterson, 2012). Other perceived critical features of child and adolescent participation are the generation of useful knowledge for communities, and the overall empowerment of young participants (Aeschbach et al., 2022; Powers & Tiffany, 2006).

Empowerment is considered one of the key concepts of health promotion and is claimed as one of the important benefits of child and adolescent participation in PAR as they are supported to acquire skills that help them to analyse their situation and to take action for the betterment of health (Eisman et al., 2016; International Collaboration for Participatory Health Research ICPHR, 2021; Muturi et al., 2018; Wallerstein, 2002). Empowerment is a multi-level construct that consists of social action processes, individual and collective outcomes on both psychological and community levels (Jennings et al., 2006), and is geared towards the improvement of equity and quality in the lives of those concerned, through the acquirement of control and mastery within their respective contexts (Perkins & Zimmerman, 1995).

Although the importance of child and adolescent empowerment within PAR has been widely recognized and represented within the literature, a lack of understanding exists of the concrete steps needed to ‘actualize’ child and adolescent empowerment (Úcar Martínez et al., 2017). Many models have portrayed the process of participation of children and adolescents in research and beyond (Cahill & Dadvand, 2018; Cargo et al., 2003; Hart, 1992; Shier, 2001) emphasizing the dynamics of shared decision-making and youth-adult interactions, yet clarity regarding the efforts needed to work towards the actualization of empowerment remains absent.

Understanding the concrete elements needed to actualize empowerment within the context of PAR with children and adolescents is necessary to provide research facilitators with more guidance on how to design the process and what contextual factors they have to take into account (Jennings et al., 2006; Úcar Martínez et al., 2017; Wong et al., 2010). Further, clarity regarding these concrete elements is fundamental for future progress in terms of theoretical robustness, practical utility and evaluation purposes within child and adolescent PAR (Messiha et al., 2023; Ozer & Douglas, 2015). The current study aims to explore the essential elements that need to be included in the process of PAR to actualize child and adolescent empowerment and to present these visually in a framework.

Methods

Study procedures

The first author (RC) conducted an explorative literature search on empowerment, children/adolescents and participation. The rationale for the explorative search was to first understand the theoretical concept of child empowerment. RC familiarized herself with the identified articles and shortlisted relevant articles. Using this shortlist, main authors who had published on the topic of empowerment, children/adolescents and participation were identified, and subsequently approached for participating as an expert in this study. This expert group was established to contribute to the literature review and to provide consultation and feedback throughout the framework development phase. The literature review was undertaken to understand how empowerment was used within participatory projects and to what extent it aligned with the theoretical concepts of empowerment. Therefore, we aimed to include both theory-oriented and practice-based articles, which we subsequently analysed according to the qualitative content approach (Erlingsson & Brysiewicz, 2017). The qualitative content analysis resulted in a set of potential elements that formed the basis of the framework. Table 1 shows an overview of the study procedures, which are described in detail below.

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.

Expert group

In the period between June 2020 and September 2020, 12 experts were invited to participate in this study via email in which the steps and time investment of the study were outlined. Seven experts responded of which five (BC, MZ, DP, JJ, BI) agreed to participate, and to contribute as co-author to the manuscript. The experts are all professors in the fields of health behaviour and community psychology and made notable contributions to the literature regarding the topics of community and adolescent health, community engagement and participation and empowerment theory. For the literature review, experts were asked to send a maximum of four articles that met the search criteria (see ‘Data collection’). For the framework development, experts were asked to provide feedback on several drafts until consensus was reached on the final framework.

Data collection

Data collection followed a three-step procedure that was performed by the lead authors: (1) literature search, (2) article selection and (3) article inclusion. The Population-Concept-Context framework (PCC) was adopted to structure the literature search phase as it aided in constructing clear search objectives following our inquiry (Pollock et al., 2023). Our population included ‘school-aged children ^AND/OR youth ^AND/OR adolescents’, our concept ‘empowerment ^AND theory ^OR implementation ^OR conceptualization’, and finally context included ‘health interventions ^AND/OR health promotion ^AND/OR public health ^AND/OR lifestyle ^AND/OR participatory research’. The terms for population, concept and context were used in AND-combination. Literature search was carried out in PubMed, Web of Science, ERIC and PsycINFO. Articles were eligible for inclusion when they: 1) explored the concept of empowerment theoretically or 2) through the implementation of a participatory research, 3) amongst primary or secondary school aged children and adolescents, 4) with the aim of promoting health. Further, the articles had to be written in English and published in a peer-reviewed scientific journal.

Figure 1 shows the flow-diagram of article search, selection and inclusion. The literature searches resulted in 1.840 unique articles. The lead authors (RC, MA, TA) selected 39 articles based on title and abstract screening and the experts added 20 articles that met the eligibility criteria as described above. For articles to be included in the data analysis, we adopted a more detailed set of eligibility criteria for the full-text screening. As we aimed to include articles that would be a fundamental source for developing the framework, we formulated the following criteria: (1) the article focuses on improving health behaviours through PAR and explicitly aims at empowering children/adolescents and/or 2) the article describes and explains the general concept of empowerment. The lead authors independently screened the full-texts and made a selection according to perceived eligibility following the second set of criteria. Peer debriefing and reflexivity was adopted among the lead authors to discuss interpretations of the articles, their added value and methodology. Conflicts following the selection procedure were thoroughly discussed and resolved. In total, 14 articles were included in the data analysis. One author (RC) extracted the following descriptive information from the included articles: author(s) and year, study aim, characteristics of setting and population. The conceptualization or application of empowerment in the articles, and the key insights related to the meaning of empowerment for children and adolescents were extracted by RC and MA/TA and included in Table 2.

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
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)

Data analysis

A qualitative content approach was used to analyse the included articles. The objective of this approach is to systematically transform a large amount of text into a highly organized and concise summary of key results, to gradually move from lower levels of abstraction and manifest content to higher levels of abstraction to latent meaning (Erlingsson & Brysiewicz, 2017). In line with this approach, RC and MA familiarized themselves with the text by independently coding two articles in Atlas.ti inductively, creating a first exploration of ‘meaning units’ (i.e. meaningful sentences). Based on the coding of these two articles, RC drafted a coding scheme and refined it following in-depth discussions with MA and TA. The refined coding scheme functioned as a tool for deductively coding the remaining articles by RC and MA or TA. Codes (i.e. labelled meaning units) were further condensed, leading to an overview of potential themes and subthemes to be included in the framework. Data analysis continued and codes were extensively discussed in a reflective and iterative manner until no new themes emerged.

Framework development

The development of the framework was guided by: (1) the I-P-O (input-process-output) model (Ilgen et al., 2005), as it provided inspiration for drafting the process outline; (2) Bronfenbrenner’s ecological systems theory of child development (Evans, 2006; Guy-Evans, 2020), as it emphasized the importance of contextual factors (Cahill & Dadvand, 2018); (3) the authors’ field work reflections, as they have ample experience with conducting health-related PAR with children and adolescents; and (4) the final codes resulting from the data analysis. During 15 meetings amongst lead authors, the final coding scheme was discussed, and themes and subthemes were identified through and in-depth assessment of used terminology, included elements and how to logically order them within the framework. Subsequently, RC structured all elements in a first visualization of the framework, which was subsequently critically discussed. The first framework draft was sent to the experts, and discussed in an online meeting (March 2021) during which the global structure of the framework was evaluated, followed by a discussion on the included elements in two break-out rooms that were separately led by RC/TA and MA. Suggestions for improvement were formulated and afterwards incorporated in a next version of the framework. Subsequently, the experts were asked to provide feedback (multiple rounds) through email. After multiple adjustments, consensus was reached on the final framework (Figure 2).

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

Results

In total, 14 articles were included for the qualitative content analysis (see Figure 1). After analysing the first nine articles, no distinctive codes could be identified from the remaining articles, indicating that data saturation was reached (see Table 2).

Table 3 presents the characteristics of the coded articles, divided into theory-oriented and practice-based articles. Practice-based articles linked empowerment (theory) to participatory (action) research for health promotion among children and adolescents aged 9–16 (often female), and theory-oriented articles offered a broad understanding on the conceptualization of empowerment in the context of health promotion.

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

	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
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	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.

Expert input during the framework development phase

Experts suggested changes related to the conceptualization and application of empowerment throughout the framework development phase. As creating (sociopolitical) awareness through critical consciousness development is considered a key aspect of individual or psychological empowerment (Christens et al., 2016), experts made comments on the role of age with regard to the capability of developing sociopolitical awareness and the depth with which children and adolescents can do so. According to them, critical consciousness at a very young age might be hard to develop and is also hard to measure, but children from 9 years onwards are believed to be starting to develop the capacity for critical thinking. Further, experts emphasized the role of the community that the child or adolescent is part of, and explained that without community and family engagement, empowerment is hard to achieve. One of the experts mentioned that ‘unless the family talks about issues, then the critical consciousness is not there. If you don’t have conversations in classroom and family, it is hard to articulate and develop critical consciousness.’ Besides this community, the role of the larger society (policy, governments, organizations, physical environment and historical trauma) was emphasized by stating that it has ‘impact on a lot of what is in the framework (referring to the elements)’. Experts also mentioned that there are different outcomes of the empowering process, and according to them, ‘what really gives power is that those outcomes are on multiple levels; the empowering outcomes of organizations leads to empowerment for kids, and how environments interact creates an environment for a child to have agency, think critically and be successful in the world’.

The experts’ input validated the use of Bronfenbrenner’s theory as it views child development as a complex system of relationships affected by multiple levels of the surrounding environment (G. W. Evans, 2006; Guy-Evans, 2020), which may influence the extent to which children or adolescents are engaged in empowerment processes.

Points of attention

Several points of attention have to be considered when reading the framework. First, the framework is positively stated, meaning that only elements are included that contribute to child and adolescent empowerment, without elaborating too much on the potential pitfalls, risks and contextual barriers (ICPHR, 2021; Weidenstedt, 2016). Second, although the framework considers influences from the ecological system’s theory of child development (Evans, 2006; Guy-Evans, 2020), it prioritizes elements within the sphere of influence of all actors involved in the PAR process, including children, adolescents, and adult facilitators. Third, the framework depicts the process as centralized around individual children and adolescents and their ‘empowerment journey’ – although this same process journey is likely also leading to the empowerment of other actors within the direct or indirect environment.

Framework description

Figure 2 presents the final framework. The framework is placed in an Ecological context, to show the influence of contextual factors on the process of actualizing empowerment through: 1) the Macrosystem including society and the physical environment; 2) the Exosystem including community organizations and institutions, such as local governments and schools; 3) the Microsystem including the child or adolescent, friends, peers, teachers, and family. Below we describe the contextual factors that form the ecological context.

Ecological context

Unique contextual factors have to be considered with regard to the potential for developing empowerment (Wong et al., 2010) as it influences the development of children and adolescents either directly or indirectly.

Macrosystem

The macrosystem includes the society and the physical environment. The society in which the child or adolescent resides is characterized by certain attitudes, ideologies, political norms, values, images and implications with regards to the cultural, historical, social and economic context (Jennings et al., 2006). Power dynamics are part of societies’ functioning because power – often exerted by governments and official institutions – shapes social structures and contexts in which many societal aspects are enacted and experienced, including those that relate to health (Spencer, 2014). These power dynamics also influence children’s and adolescents’ perceptions on norms, values and beliefs related to health and society.

The physical environment can influence child and adolescent development directly or indirectly (Evans, 2006; Guy-Evans, 2020). The presence of natural settings contributes to motoric and social play opportunities and accounts for greater independent mobility. Also, the quality of housing, playgrounds and the neighbourhood influences behavioural conduct and academic achievements. For example, the presence of noise and crowding may affect the quality of reading (Evans, 2006; Guy-Evans, 2020) and attractive playgrounds are more likely to be used.

Exosystem

The exosystem consists of community organizations and institutions, that constitute formal and informal social structures, and may impact child and adolescent development heavily (Evans, 2006; Guy-Evans, 2020). Examples of community organizations are community centres, health services, and religious organizations, whereas institutions include schools, municipalities, and academic institutions with affiliated adult research facilitators. According to Langhout et al. (2014), these ‘intermediary’ entities that stand between society and individuals have an important function in learning about society. Besides the learning potential that exists alongside the presence of these entities, community organizations can also shape the way children and adolescents are positioned within society by providing opportunities for participation, or not (Spencer, 2014).

Microsystem

Child or adolescent characteristics including demographics such as sex, age, ethnicity, education/grade-level, and psychosocial characteristics are salient factors influencing the dynamics of key microsystems such as the immediate environment of the child, including family, friends, peers, and teachers. Both the demographic factors and psychosocial characteristics, such as the level of confidence, self-esteem, self-image, sense of belonging, current health behaviour and beliefs, contribute to the potential of developing empowerment throughout the participatory process (Muturi et al., 2018). For example, psychosocial characteristics account for the ability to think critically and to be conscious of certain societal dynamics and are linked to the developmental phase of the child or adolescent (Abraczinskas & Zarrett, 2020).

Friends and peers are of particular importance because social groups provide a space where children can demonstrate competence, self-worth, and independence (Wong et al., 2010). Teachers, who are representing schools, are critical for children and adolescents’ social, behavioural, and academic development in the classroom context (Chen et al., 2020), but are also capable of creating environments where children and adolescents are supported in developing the skills and capacities to thrive in the community. Family bonds are also important, because they can be a source of social, emotional, and cognitive support.

The process of actualizing empowerment is further divided into Short-term goals and Long-term goals, referring to the stage of the PAR study. On the short-term, an Enabling environment has to be created to secure the right conditions for the development of empowerment (Tengland, 2007). To create such an enabling environment the following elements should be considered: (1) Resources, (2) Adult facilitation, (3) Sense-making, and (4) Capacity building. On the long-term, opportunities need to be created for Moving towards empowerment and collective participation through the elements (5) Positive child and adolescent development and (6) Participatory competence. It is these two elements (5 and 6) that may indicate that child and adolescent empowerment within PAR is being actualized. Below we describe the six elements for actualizing empowerment, starting with the short-term goals of creating an enabling environment (elements 1, 2, 3, 4), followed by the long-term goals of moving towards empowerment and collective participation (elements 5, 6).

Short-term goals: enabling environment

An enabling environment can be created through efforts by involved organizations, institutions, adult facilitators, family, friends, and peers. The elements that form the enabling environment contribute to social, emotional, and cognitive development and are intrinsically linked to child and adolescent empowerment.

Element 1: resources

To enable child and adolescent empowerment, a set of resources is needed, including the involvement of relevant individuals and groups (people) that commit to the process, sufficient energy and funding (money), open governance structures, a safe and welcoming physical and psychological space, and social, emotional and cognitive support from related people, including the family.

The process of empowerment is dynamic and requires energy, space, and commitment to a long-term process (Israel et al., 1994; Jennings et al., 2006). Having open governance structures that provide children and adolescents with opportunities for understanding community needs helps them to strengthen the ties with the community (Jennings et al., 2006). A safe and welcoming space has to be provided by the adult facilitators in particular (see next section). Characteristics of such a space are that children and adolescents feel valued, respected, and supported. A safe and welcoming space functions as a learning place, where both success and failure can be experienced, and where children and adolescents can develop a sense of ownership, where they can flourish, share their views and opinions, and are encouraged to try out new skills and roles (Jennings et al., 2006). A safe and welcoming space also includes feeling and being safe in terms of physical, emotional, and social safety, both in the peer group as with the adult partners and facilitators. Support implies the motivation of relevant partners to positively influence and contribute to the project goals. Without (social, emotional, and cognitive) support, including the child’s family and social environment, empowerment is hard to achieve. It is through social support that children and adolescents can develop personal control and competence to act and develop other social skills (Israel et al., 1994). Generally, children and adolescents are not perceived as leaders and power is often ‘in the hands of adults’. Therefore, a lack of support by adults in particular, for example by school-directors, may possibly lead to proposed changes not happening (Abraczinskas & Zarrett, 2020; Spencer, 2014). Presenting the positive potential and actual achievements of children and adolescents within the community is also part of a supportive environment (Jennings et al., 2006).

Element 2: adult facilitation

The role of adult facilitators is perceived as a pivotal function in the process of empowerment through direct influence and responsibilities. The elements describe what adult facilitators ideally have to do and find important. An ideal adult facilitator shares power, understands the importance of co-learning, is trustable and respectful, has knowledge regarding the topic(s) and possesses facilitation skills.

Adults can serve as resources and collaborators instead of being the ‘experts’ by facilitating critical dialogue, awareness and building skills towards critical consciousness in partnership with children and adolescents (Wong et al., 2010). Adults have access to institutions within society that provide opportunities for children and adolescents to participate in decisions that affect their lives. Because organizations and communities are often represented by adults, sharing power is in the first place the responsibility of adults (Wong et al., 2010). Sharing power with children and adolescents takes commitment, effort, and insight about what is needed. It requires considerable flexibility to effectively facilitate, teach, guide, mentor, encourage, provide feedback, keep children and adolescents focused on a task, and yet exert authority and control when needed, without being dominant or discouraging (Jennings et al., 2006). Optimal power sharing is also linked to the quality of negotiation by adults and children and adolescents, which includes deciding on the degree and types of responsibilities by both parties, a clear understanding of the rationale and joint decision-making on which tasks are to be performed by which party (Wong et al., 2010). Depending on the ages and cognitive capacities of the children and adolescents involved, the adults together with the children and adolescents decide on the type of planning, decisions, and activities to be undertaken (Wong et al., 2010).

Whereas power sharing is the visible act of taking up and dividing roles and responsibilities, co-learning is the acknowledgement of the value that adults as well as children and adolescents can contribute to the process. It allows adults to gain insight in children’s and adolescents’ perspectives and vice versa. Power sharing and co-learning is needed, because children and adolescents may not be aware of or connected to resources that could make their planning and activities more efficient (Wong et al., 2010). Further, it requires guidance and patience as children and adolescents learn to deal with power that they may never have had before (Jennings et al., 2006).

Adults are needed for providing supervision, guidance and social support, they can serve as role models and provide connection to other influential adults. This requires from adults that they are trustable and respectful, and that they possess certain skills. These skills include that the adult facilitator is attuned to the socio-political realities of the topic at hand, and has knowledge and skills to guide children and adolescents in critical examinations (Jennings et al., 2006) – a key element of actualizing empowerment. It also requires empathy, unconditional positive regard and genuineness, trying to understand children’s and adolescents’ world view, being non-judgemental, tolerant and without pretence (Tengland, 2007). Facilitation requires training so that future facilitators become skilled in conducting these tasks (Abraczinskas & Zarrett, 2020). Adult facilitators’ attitude towards power sharing and co-learning, their upholding of values such as trust and respect towards the children and adolescents involved, and their knowledge and skills, affects the degree and quality of the facilitation and can influence child and adolescent development (Wong et al., 2010).

Element 3: sense-making

Sense-making is about meaning making for the adult facilitators, partners and children and adolescents who are involved in the process. Meaningful implies that it is helpful in the lives of participating children and adolescents, with respect to their social, emotional, and cognitive development.

Meaningful conversations with adult facilitators, teachers, and family contributes to the articulation and development of critical consciousness. Providing opportunities for feedback loops between children and adolescents and adult partners, sustains children’s and adolescents’ input and adds meaning to the process (Abraczinskas & Zarrett, 2020). Engaging in meaningful activities possibly leads to increased motivation to influence community health outcomes. These activities include engaging in community services and trying different roles and responsibilities, which results in learning and practicing of important leadership and participatory skills (Jennings et al., 2006). Adult leaders need to consider activities that appeal to children and adolescents. Activities need to engage and resonate with children and adolescents’ lived experiences to increase meaningfulness (Spencer, 2014). Voicing opinion and perspectives is a way of practicing critical thinking by formulating opinions about problems and solutions (Wong et al., 2010). Voicing opinion contributes to critical dialogue and furthering awareness about societies’ role in shaping children’s and adolescents’ life experiences and health outcomes (Wong et al., 2010). Part of voicing opinion is to share feelings, and this is more likely to occur in a safe psychological space. Further, children and adolescents are more likely to stay engaged and motivated if they have fun in the process. Including social games and ensuring enjoyable partnerships with adults adds meaning to the process. Adapting inclusive, cooperative, and collaborative play centred on friendship and informal fun is important, because it contributes to a positive social-emotional climate (Abraczinskas & Zarrett, 2020).

Element 4: capacity building

Capacity building focuses on cognitive development and social relations and includes exchanging knowledge on the topic(s) at hand, learning to build partnerships with peers and adult partners, developing research skills, critical thinking, and understanding shared decision-making.

Exchanging knowledge on the topic(s) includes both scientific and embodied knowledge. Scientific knowledge, which encompasses knowledge from research providing evidence- or theory based input regarding a topic, may be primarily shared by adult facilitators (or discovered through youth participatory action research, see Kohfeldt et al., (2011), whereas embodied knowledge can be exchanged by adults, and children and adolescents – as it involves sharing lived experiences and learning therefrom. Critical consciousness (as a central element of empowerment) is not only ‘knowing’ and ‘being aware’ of the issue but thinking of tactics to overcome the challenge. Therefore, exchanging knowledge about the topic is a first step in developing critical consciousness. Being knowledgeable equips children and adolescents to address issues, but critical thinking is needed to ‘see and understand the very structures, processes, social values and practices’ that children and adolescents seek to understand or improve (Jennings et al., 2006). Learning and applying research skills is an extension of critical thinking, and includes learning about different research methods and performing them. Building partnerships is an accelerator for developing critical thinking, as children and adolescents are provided opportunities for engagement with diverse sectors within the local community, they can acquire valuable skills for navigating adult worlds (Jennings et al., 2006). Partnership building is inevitable for capacity-building (Langhout et al., 2014). Lastly, capacity is built through the increase of developmental assets such as competence and sense of control by being involved in shared decision-making (Wong et al., 2010).

Long-term goals: towards empowerment and collective participation

The presence of essential resources, the quality of adult facilitation, the efforts in sense-making and the building of (cognitive and social) capacity may contribute to the long-term goals of positive child and adolescent development and participatory competence, which can be considered as first indicators for actualizing child and adolescent empowerment within PAR.

Element 5: positive child and adolescent development

Critical consciousness is gained through dialogue where both children and adolescents contribute their perspectives to develop an authentic understanding of the environment (Wong et al., 2010). Partaking in meaningful roles, voicing opinion and observing the results of their contributions can build confidence, competence, self-efficacy and self-esteem among children and adolescents, which may positively affect their self-concept (Abraczinskas & Zarrett, 2020; Jennings et al., 2006; Wong et al., 2010). Improvements in critical consciousness and self-concept, which fall under psychological empowerment, may also be associated with increases in prosocial behaviours (Eisman et al., 2016). Children’s and adolescents’ participation has further the potential to positively influence health behaviours, through conducting research and developing action in areas important to them (Muturi, 2018; Abraczinskas & Zarrett, 2020; Wong et al., 2010). Reflection and action on health inequities with peers and adults in a power-sharing partnership can enrich children’s and adolescents’ health-related values, with the potential of improving health knowledge and behaviour (Abraczinskas & Zarrett, 2020). Overall, critical consciousness in combination with positive self-concepts may ultimately promote healthy development of children and adolescents who are engaged in empowerment processes (Eisman et al., 2016). These processes, in turn, often target broader community health promotion through changes in systems and institutional practices.

Element 6: participatory competence

Community health is improved when a diverse representation of residents is engaged in action towards community health improvement (Israel et al., 1994). Children and adolescents represent an important segment of communities, and participatory processes therefore suffer when they are excluded. Engaging children and adolescents enables pluralistic leadership to occur and contributes to collective efficacy in working towards solutions for (health) issues (Israel et al., 1994; Jennings et al., 2006), for example by sharing perspectives about a certain community health issue and co-deciding on solutions to be implemented. In partnership and collaboration, existing cognitive and contextual divides can be bridged and strengths and assets mutually recognized (Jennings et al., 2006). When decisions are made in intergenerational groups, all participants are exposed to different ways of thinking and problem solving that may contribute to develop strategies to improve the health of those involved. This may also contribute to the creation of a vibrant ecosystem for community-based leadership development (Christens et al., 2022), while also creating contexts conducive to youth cognitive and sociopolitical development (Wong et al., 2010), such as youth learning to become critical agents of their environment and becoming motivated to enact change.

Discussion

Six elements for actualizing child and adolescent empowerment in PAR in health promotion were synthesized from literature exploration and expert consultation: 1) Safeguarding the necessary resources, 2) Having high quality adult facilitation, 3) Enabling sense-making activities, 4) Investing in capacity building. These four elements make up an environment that may nourish children’s and adolescents’ social, emotional and cognitive development that potentially lead to 5) Positive child and adolescent development, and 6) Participatory competence. All elements have to be viewed in light of the ecological context of society, community organizations and institutions, physical environment, family, relatives, friends, peers and teachers, and the personal characteristics of the child or adolescent. Below we formulate important considerations with regards to the implication of the framework in practice.

First, empowerment takes place as part of a mutual learning process in which adults, children and adolescents learn from each other in iterative ways while establishing a meaningful partnership. In line with this, the need for education and training of adult facilitators to prepare them to guide children and adolescents through the process – while adopting an attitude of co-learning – is pivotal and sufficient resources should be available to facilitate the development of competencies of adults (Akiva et al., 2022; Augsberger et al., 2023; Jennings et al., 2006; Lac et al., 2022). This learning process also emphasizes the relational nature of empowerment (Christens & Peterson, 2012). By creating value for all children, adolescents and (adult) partners involved through the connection of children and adolescents from different backgrounds in that same participatory process.

Second, aiming at the creation of educational value through the empowerment process is of direct relevance for children and adolescents and should be prioritized. Much of the literature on child and adolescent empowerment puts the achievement of social justice and the -‘fight’- against social inequalities through child and adolescent participation at the forefront, which is a natural consequence of the historical origins of empowerment in social movements that aimed to strengthen the position of ‘poor and marginalized populations’ (Calvès, 2009; O’Kane, 2002; Torres-Harding et al., 2018). However, this can unduly emphasize children as the agents that can bring social change when -‘rightly’- equipped and educated, whilst deemphasizing the roles of policy, governments, and the broader contexts. It is therefore recommended to consider children and adolescents as equal collaborators, but not as main drivers for social change. Framing empowerment as an educational reciprocity between children, adolescents and other (adult) partners, constitutes a form of power sharing that connects naturally to the developmental needs of children and adolescents. The proposed framework therefore attempts to balance the need for children and adolescents to be engaged in social and political change with an emphasis on empowerment as an educational effort that contributes to positive child and adolescent development. Furthermore, the relative emphasis on education and social action in empowerment processes depend greatly on the context and issues that they are seeking to address.

Third, it is essential to recognize the different ethical concerns that may potentially lead to disempowerment (Spencer, 2014). These concerns are linked to dynamics of power building and are very delicate in nature (Weidenstedt, 2016). A possible risk is that adult facilitators consciously or unconsciously impose a specific perspective on participants that is not initially embraced by the children and adolescents involved (Spencer, 2015). This includes the promotion of dominant health discourses and normative ideologies without taking into account children and adolescents’ perspectives on the health issue at hand nor their specific context (Spencer, 2015; Weidenstedt, 2016). According to Spencer (2015), for health promotion discourses to be effective, they need to engage and resonate with young people’s lived experiences, which may be different from dominant perspectives on health and social issues. Careful consideration should be given to questions such as who should lead, who should support and with what tools and intentions. This requires proper reflexivity and appropriate communication – again emphasizing the importance of facilitator training.

Situating the framework

Over the past two decades, several attempts have been made to conceptualize participatory processes, including the Ladder of Participation (Hart, 1992), Pathways to Participation (Shier, 2001), Transactional Partnering Process Between Adults and Youth (Cargo et al., 2003), Wong et al.’s Typology of Youth Participation and Empowerment (2010) and the P7 model (Purpose, Positioning, Perspective, Power relations, Protection, Place, Process) for youth participation (Cahill & Dadvand, 2018). Although the elements in our proposed framework have some similarities with these existing models (e.g. related to concepts such as co-learning, shared decision-making and context), our framework contributes to the literature as it outlines the process through which child and adolescent empowerment can be actualized. Despite empowerment being a key characteristic of participatory (action) research (PAR), the process of how empowerment in PAR can be actualized is currently poorly understood (ICPHR, 2021; Úcar Martínez et al., 2017). Additionally, by explaining the concrete elements in our framework, we provide practical guidance for the actualization of empowerment among children and adolescents within PAR. The explicit mention of contextual factors that may influence the overall development of children and/or adolescents contributes to a holistic view of the empowerment process and encourages research facilitators to consider these factors throughout the entire PAR process. The division of the process into short-term and long-term goals indicates that empowerment is not an ‘end station’, rather it is about ‘making a start’ for actualizing empowerment through a PAR study.

Strengths and limitations

Our framework reflects a population- and purpose-specific model, which can be considered a strength as different settings may have distinct goals with regards to empowerment (Todd, 2012). The small number of articles included in the qualitative data analysis can be considered a limitation of the study, as they do not necessarily represent the broad empowerment literature. However, the included articles are well-established, and we reached data saturation after the coding of nine articles – which was sufficient for developing a salient framework through researcher triangulation and expert input. Moreover, our study was exploratory in nature and was not aiming at systematically identifying and summarizing all relevant individual studies about empowerment among children and adolescents in PAR. Some difficulty was experienced when selecting articles that focused on empowerment as a concept within PAR, as not all articles on PAR explicitly mentioned empowerment as an aim which potentially may have led to the exclusion of relevant articles. However, clarity was provided on the link with empowerment in these articles through discussions with experienced experts in the field.

Conclusion

The proposed framework supports researchers in designing and guiding participatory processes towards actualizing empowerment. The framework is based on a holistic perspective considering the lived reality of children and adolescents and their capabilities and characteristics. The process of achieving empowerment is considered as an educational effort where children and adolescents as well as (adult) partners collectively learn through shared action to address issues of shared concern. Future research is needed to assess the practical utility of the framework.

Author contributions

RC and TA designed the study. RC, MA and TA contributed to the qualitative analysis of the included articles. RC drafted the final framework. All co-authors provided critical input during the framework development. RC wrote the manuscript. TA, BC and DP contributed to revising the manuscript. All authors approved the final version.

Ethics approval

This study did not require ethics approval.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The contributions of RC, MA and TA were funded by a grant from the Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation (ZonMw) [CVON2016-07 LIKE]. The contribution of RC was further funded by a Marie Skłodowska-Curie Innovative Training Network (Health CASCADE), funded by the European Union’s Horizon 2020 research and innovation programme under Marie Skłodowska-Curie grant agreement [n° 956501].

Notes

1. Abbreviations: PAR, Participatory Action Research; YPAR, Youth-led Participatory Action Research.