Empowering Women in the Face of Body Ideals: A Scoping Review of Health Promotion Programs

Abstract

Achieving women’s health equity and empowerment is a global priority. In a Western context, women are often disempowered by the value society places on body size, shape or weight, which can create a barrier to health. Health promotion programs can exacerbate women’s preoccupations with their bodies by focusing outcomes toward achieving an “ideal” body size. Women’s health promotion activities should be empowering if the desired outcomes are to improve their health and well-being long-term. This review sought to identify key elements from health promotion programs that aimed to empower women. A search was conducted in PubMed, MEDLINE, Web of Science, Scopus, CINAHL complete, and Academic Search Premiere databases. The search yielded 27 articles that collectively reported on 10 different programs. Through thematic synthesis, each article was analyzed for (1) key program features employed to empower women and (2) how such programs evaluated women’s health. Seven themes resulted, of which five describe key empowering features (active participation, social support, sustainable change, holistic health perspective, strength-based approach) and two evaluation characteristics (assessment across multiple health domains and a mixed-method design). The findings from this review can assist health promoters to design and improve initiatives that aim to empower women.

Keywords

empowerment well-being health promotion program women

Addressing women’s health inequity is a global priority (Peters et al., 2016; United Nations, 2015), with gender recognized as an independent health determinant (Sen & Östlin, 2009). Women have unique physiological, biological, and psychological needs compared with men (Östlin et al., 2006) and experience health inequities shaped by gendered norms, values, and practices; differential exposures and vulnerabilities; and biases in research and healthcare (Sen et al., 2007). In a Western context, strong cultural value is placed on women’s attainment of an “ideal body” that corresponds with desirable attributes including health, beauty, and success. An “ideal body” is considered thin, tone, and below a body mass index (BMI) of 25 kg/m². This image typically requires restrictive eating and disciplined exercise and is often unattainable for many creating a disempowering pursuit that is detrimental to women’s mental, social, physical, and spiritual dimensions of health. Yet, these pressures are structurally embedded and perpetuated by popular media, health professionals, and government organizations (O’Hara & Taylor, 2018). These structural biases counter women’s right to good health and well-being and warrant gender-specific approaches to health promotion and research. Gender-specific programs offer a useful approach to promote women’s health (Pederson et al., 2014). Health promotion programs support personal skill and critical thinking development, which are essential components preceding collective action to address inequities (Green et al., 2019; Zimmerman et al., 2017). According to the Ottawa Charter, health promotion should empower those it aims to serve (World Health Organization, 1986). In relation to gender-specific health promotion programs, an empowering approach means that women should be involved in the design of health-promoting activities and supported to increase their autonomy for making decisions that affect their health and well-being (Taylor et al., 2014).

Yet, health promotion programs are often not empowering and can risk achieving the opposite outcome (Pederson et al., 2014). The dominant health discourse, also known as the “weight-centered health paradigm,” prioritizes a body within the BMI category of 18.5 to 24.9 kg/m² as the cornerstone of health achievement, with diet and exercise as the primary tools to accomplish this goal (O’Hara & Taylor, 2018; Schuette et al., 2017). Such narrowly defined parameters for “health success” often predispose women to “failure” and can impede the wider benefits of health promoting actions (Mensinger, Calogero, Stranges, & Tylka, 2016; Tylka et al., 2014). Moreover, the weight-centered health paradigm normalizes “fat phobic” environments, which fosters body concern and simultaneously damages the health and well-being of those concerned with their body size (O’Hara & Taylor, 2018). Women’s participation in dieting, fasting, and appearance-driven exercise demonstrate how the preoccupation with body size can take precedence over health (Leong et al., 2016). The disempowering effects of weight-targeted approaches necessitate a shift toward programs that seek to empower women with a broader vision of health success.

Despite empowerment being an essential strategy for women’s health promotion (Pederson et al., 2014; World Health Organization, 1986), an empowerment approach is rarely adopted in explicit terms. Barriers to adopting an empowering approach in health promotion programs include conceptual and contextual variation (Lindacher et al., 2018; Richardson, 2018). One notable example of women’s health promotion that successfully implements empowerment is the Health at Every Size (HAES) movement. HAES prioritizes well-being and health-promoting behaviors irrespective of a person’s body size or weight (Association for Size Diversity and Health, 2017). The movement is driven by values of weight inclusivity, health enhancement, respectful care, eating for well-being, and life-enhancing movement (Association for Size Diversity and Health, 2017). Values such as “health enhancement” or “eating for well-being” can only be realized through the exchange of dialogue between service providers and users to define health activities. Therefore, by embracing these values, a HAES program exemplifies how empowerment can be enacted to promote women’s health.

This review sought to identify health promotion programs that aimed to empower women and answer the following research questions:

Research Question 1: What are key features of health promotion programs that aim to empower women in the face of Western body ideals?

Research Question 2: How do researchers evaluate women’s success in such programs?

Method

The research questions guided the methodology for this review. Since this study sought to explore the programs by their features and methods for evaluation, the method of this review followed a thematic synthesis approach where key program features and evaluation strategies were identified as themes across the included articles (Thomas & Harden, 2008). This review aligns with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist (Tricco et al., 2018).

Search Strategy

A search was conducted to identify health promotion programs that aimed to empower women. The focus of this review was narrowed to programs delivered in Western context given the focus on Western societal values and the variation of body ideals that exists between contexts.

The search included PubMed, Web of Science, Scopus, CINAHL Complete, Academic Search Premier, and MEDLINE databases. Only articles published in peer-reviewed journals were considered. The search terms were: “women,” “girl*,” “female*,” “body image,” “self-acceptance,” “self-worth,” “self-esteem*,” “empower*,” “health at every size,” “program*,” “intervention*,” “campaign*,” and “trial*.” More specifically, the search was conducted as follows: TITLE-ABS-KEY (“girl*” OR “women” OR “woman” OR “female*”) AND (“empower*” OR “health at every size”) AND (“body image” OR “self-acceptance” OR “self-worth” OR “self-esteem”) AND (“intervention*” OR “program*” OR “campaign*” OR “trial*”).

Inclusion and Exclusion Criteria

Articles were included if they were peer-reviewed, English, published in scholarly peer-reviewed journals between 2005 and 2020, reported on a health promotion program, named empowerment as an aim or characteristic of the program, involved a non-clinical female population, adopted a health-enhancing approach (as opposed to prevention of illness), and occurred in a Western context. A weight-inclusive perspective was embraced, such that all bodies have the ability to be healthy independent of weight, given the aims of this review (Tylka et al., 2014). Therefore, women with a BMI > 24.9 kg/m² were not considered a clinical population based on body size alone. Programs that adopted a HAES approach were also considered in the place of stating “empowerment” given the alignment between the HAES principles and an empowerment approach (Association for Size Diversity and Health, 2017).

Articles were excluded if the full text was unavailable, a description of the program was not provided, or if the study focused on a specific subpopulation (e.g., pregnant, menopausal). Articles were also excluded if program aims focused on weight control or illness prevention.

Search results from all databases were exported to Endnote X9 by the first author. After duplicate removal, V.C. and M.T. independently scanned the article titles and abstracts for inclusion and exclusion criteria. Then, each of the authors examined the remaining articles by full-text to determine eligible investigations for the review. Any discrepancies between the authors were discussed prior to final article inclusion. The references of the included articles were further examined for eligible research articles. In some cases, an additional search was conducted to gather more detail about the pertinent program.

Data Synthesis

Each article was analyzed using thematic synthesis driven by the research questions. The thematic synthesis followed the three-step approach described by Thomas and Harden (2008): coding of text “line-by-line,” refining the codes to “descriptive themes,” and then producing higher level “analytical themes.” Thus, the resultant themes generated in the review described (1) the key program features embedded in the design of empowering health promotion programs and (2) how researchers evaluated women’s success in such programs. Each round of coding was corroborated with E.N. and M.T. for consistency of argument. An example of how codes were merged to create themes can be found in Figure 1.

Figure 1.

Example of thematic coding of empowerment programs.

Results and Discussion

The search results from all databases (n = 1,070) yielded 433 unique research articles. Following article screening, 13 articles met eligibility criteria. The references of the selected articles and program-specific searches produced 14 additional articles that met the inclusion criteria. Thus, 27 articles were included in the review. A flow diagram detailing the article selection process for this review can be found in Figure 2.

Figure 2.

Flow chart of article selection process.

Empowering Health Promotion Programs for Women

The 27 articles collectively reported on 10 different health promotion programs. A summary of each program is provided in Table 1.

Table 1.

Summary of Empowering Health Promotion Programs for Women.

	Program name	Program aims	Empowerment in program philosophy	Related investigations	Setting	N	Participants	Study design	Program length	Contact sessions (duration/frequency)	Adherence at postintervention
1	Choisir de maigrir? (Choose to Lose Weight?)	To develop well-being and a healthy lifestyle through positive change to physical activity, eating behavior, and body acceptance	Empowerment as a driving value in HAES principles: weight inclusivity, health enhancement, respectful care, eating for well-being, life-enhancing movement (ASDAH, 2017).	Provencher et al. (2007); Provencher et al. (2009); Gagnon-Girouard et al. (2010); Leblanc et al. (2012)	Health and social service centers, Canada	48	Overweight or obese; 28–51 years old	RCT; Quantitative evaluation	16 Weeks	3–6 Hours/weekly	91.7%
1	Choisir de maigrir? (Choose to Lose Weight?)			Carbonneau et al. (2017); Bégin et al. (2019)	Health and social service centers, Canada	216	Normal, overweight and obese; 21–83 years old	RCT; Quantitative evaluation	16 Weeks	3–6 Hours/weekly	79.2%
2	HUGS (Health-focused, Understanding lifestyle, Group supported, and Self-esteem building)	To promote a healthy lifestyle by encouraging positive change to physical activity, eating, and body size acceptance	Empowerment as a driving value in HAES principles: eating for well-being and pleasure, size acceptance, and physical activity for enjoyment (ASDAH, 2017).	Mensinger, Calogero, Stranges, and Tylka (2016); Mensinger, Calogero, and Tylka (2016); Mensinger and Meadows (2017)	Health center, The United States	40	Physically inactive, obese; 30–45 years old	RCT; Quantitative evaluation	24 Weeks	1.5 Hours/weekly	97.5% (42.5% attended at least 2/3 of the meetings)
3	Girls on the Go!	To improve body satisfaction, self-efficacy, and positive approaches to healthy eating and physical activity through enhanced self-esteem.	Conceptualized empowerment under a social model of health. “ . . . it [the program] empowers them [young girls] to identify important factors that influence their own health depending on their specific context” (Tirlea et al., 2013, p. 5).	Tirlea et al. (2013); Tirlea et al. (2016)	Community setting, Australia	62	At-risk for poor self-esteem; 13–16 years old	RCT; Quantitative evaluation	10 Weeks	1–3 Hours/weekly	95.2%
3	Girls on the Go!			Tirlea et al. (2013); Tirlea et al. (2016)	Community setting, Australia	60	At-risk for poor self-esteem; 10–13 years old	RCT; Quantitative evaluation	10 Weeks	1–3 Hours/weekly	98.4%
4	Stress management course	Stress management through building body- and self-awareness through a gendered perspective toward a salutogenic approach to themselves and their bodies	Embraces an empowerment approach under a gender-theoretical perspective. “ . . . the gender-sensitive approach aimed to empower girls as a group to listen to and base the content on their own thoughts and experiences, and to facilitate a salutogenic approach to their bodies” (Strömbäck et al., 2013, p. 5).	Strömbäck et al. (2013); Strömbäck et al. (2016)	Youth health center, Sweden	54	Self-reported stress; 17–25 years old	Pretest/posttest; Mixed-method evaluation	Not reported	2 Hours/not reported	85.2%
5	Women Bound to be Active	To improve women’s physical activity, self-efficacy, and self-worth	States aims of “ . . . empowering women to be more active” (Huberty et al., 2008, p. 84). Empowerment theory not explicitly discussed, but observed in program strategies (e.g., consciousness raising, identifying personal resources, and building social connections).	Huberty et al. (2008); Huberty et al. (2009)	University or community setting, The United States	45	Physically inactive, mean age 48.1 years old (SD = 10.8)	Pretest/posttest; Mixed-method evaluation	32 Weeks	1 Hour/weekly to fortnightly	53.3% (attended at least 75% of meetings)
5	Women Bound to be Active			Huberty et al. (2010); Huberty et al. (2013)	University or community setting, The United States	81	Physically inactive; mean age 51.9 years (SD = 10.1)	CT; Mixed-method evaluation	32 Weeks	1 Hour/weekly to fortnightly	63.0%
6	She Hits Hard	To build positive body image and foster body empowerment in young girls	Program promotes “body empowerment” among girls. Empowerment theory not explicitly discussed, but mentions specific body empowerment strategies including: intentional language, open discussion, deep reflection, and processing experiences with interviews.	Fuerniss and Jacobs (2020)	Middle school setting, The United States	20	Low engagement, body dissatisfaction or by invitation from a peer experiencing the above criteria; 11–14 years old	Not specified (article reports on program description, not evaluation)	3 Semesters	75 Minutes/twice weekly	Not specified
7	The GIRL Curriculum	Engaging girls to critically analyze the “ideal female body” and navigate possible perceived barriers to physical activity	States aims of empowering young girls through increasing confidence and body satisfaction; Empowerment theory not explicitly discussed, but observed in program approach (e.g., cocreating the curriculum, open discussion and reflection).	Meza and Marttinen (2019)	School setting, The United States	11	10–11 Years	Case study design; Qualitative evaluation	28 Weeks	20–30 Minutes/weekly to twice weekly	Not specified
8	The Way Forward	A gender-specific intervention with a focus on holistic improvement to promote the health of young women at risk of disadvantage	States aims of empowering young women and embraces empowerment as a core driving value of the program	Warwick-Booth et al. (2015)^a; Warwick-Booth and Cross (2017)^a; Warwick-Booth and Cross (2018)	Voluntary gender-specific provider (Women Centre), England	165	Health-related issues (e.g., low self-esteem, family difficulties, alcohol/substance misuse); 15–26 years	Qualitative evaluation	Indefinite	Dependent on individual needs	N/A
9	Exercise intervention program	Increase physical activity, physical, improve self-perception, and body image through developing self-empowerment	Program based on the empowerment process to inform positive development in participants	Lindwall and Lindgren (2005)	7 Schools; Sweden	56	Nonphysically active girls; 13–20 years	RCT pretest/posttest; Quantitative evaluation	24 Weeks	1 Hour/twice weekly	48.2% (on average, participants attended 56% of sessions)
10	Girls on the Run^b	Aims to enhance girls’ social, psychological, and physical competencies to successfully navigate life experiences.	States aims of empowering girls and describes empowerment as underpinning theory for positive youth development	Debate et al. (2007)	School settings, The United States	193	8–11 Years	Pretest/posttest; Quantitative evaluation	12 Weeks	1 Hour/twice weekly	95%
				Martin et al. (2009)	School settings, The United States	21	8–12 Years	Pretest/posttest; Quantitative evaluation	12 Weeks	1 Hour/twice weekly	95%
				Gabriel et al. (2011)	School settings, The United States	287	8–11 Years	Quasi-experimental longitudinal; Quantitative evaluation	12 Weeks	1 Hour/twice weekly	Not specified
				Weiss et al. (2019) Other related studies: Iachini et al. (2014); Galeotti (2015)	School settings, The United States	203	8–11 Years	Longitudinal; Mixed-method evaluation	12 Weeks	1 Hour/twice weekly	82.3%

Note. HAES = Health at Every Size; RCT = randomized-controlled trial; CT = controlled trial.

Source provides greater detail for program summary. Not peer-reviewed article and, therefore, not included in article count or thematic synthesis. ^bGirls on the Run is implemented across Canada and the United States and has been delivered to over 2,000,000 girls to date. Details reported in the table are specific to the studies included in the review.

Empowerment was theorized differently across the 10 programs (Table 1). Empowerment tended to be embraced as a core driving value discussed either explicitly (8, 10) or implicitly by adopting a HAES approach (1–2). One program mentioned empowerment specifically as the theory of change (9) and others conceptualized empowerment in conjunction with other theoretical models, such as the social model of health (3) and gender-theoretical perspectives (4, 8, 10). Other programs were less clear about how empowerment was applied to the program, but relevant strategies were observed (5–7).

Key Features of Empowering Health Promotion Programs for Women

Seven themes arose from the thematic synthesis, which are summarized in Table 2. In response to the first research question, the first five themes described program features that were pertinent to empowering women: active participation, social support, sustainable change, holistic health perspective, and strength-based approach. The remaining two themes identified key features for evaluating women’s health success in such programs: assessment across multiple health domains and a mixed-method design. Greater detail regarding the program strategies and evaluation tactics obtained from each of the 27 articles is provided as supplemental material (Table S1 and Table S2).

Table 2.

The Seven Themes Outlining Key Features of Empowering Health Promotion Programs for Women.

Program features for . . .	Components
Empowering women
Women’s active participation in the program	• Discussing and reflecting on personal experience • Defining program components • Engaging in practical activities
Fostering social support	• Exchanging personal experiences with others in a safe space • Group discussion • Building a supportive network and social connectedness
Focusing on sustainable change	• Self-defined goal setting • Emphasizing intrinsic motivation • Supporting independence and autonomy • Improving knowledge of self and body
Utilizing a holistic health perspective	• Promoting mental health Self-/body-acceptance, stress management, self-esteem, self-confidence • Promoting physical health Awareness of body and physiological cues, eating behavior, nutrition, and physical activity • Promoting social health Social support, building connectedness with others, evaluating existing relationships • Realizing a broad range of health behavior benefits
Adopting a strength-based approach	• Supporting holistic awareness of health behaviors, motivation and body • Supporting acceptance of body/self • Promoting positive health behaviors • Weight inclusive
Evaluating women’s health
Assessment across multiple health domains	• Behavioral Eating for well-being, physical activity, and behavioral determinants • Psychosocial Psychological well-being, psychological distress, self-perception, and body awareness • Physical Anthropometric, cardiometabolic, and fitness parameters
Mixed-method design	• Evaluating women’s health outcomes using both qualitative and quantitative methods

Active Participation

Women’s active participation in the programs was evident through their role in defining program aspects (1–7, 9), engaging in practical activities (1–7, 9, 10), and reflecting on personal experiences (1–10). Supporting women to reflect on and discuss personal experiences was the most common form of active participation. Topics for conversation included personal circumstances, thought patterns and/or behaviors (1, 3–4, 6–10), bodily sensations (1, 2, 5, 6), goals and motivations (1, 10), and challenges and achievements (3, 5–6, 10). Programs also involved women’s active engagement by supporting them to define course aspects, such as devising their own health goals (1, 3, 5) and electing topics for discussion and/or activities (3, 4, 6, 7, 9). Additionally, women engaged in a wide range of practical activities, from progressive muscular relaxation (4) to boxing (6). The practical activities served various purposes, such as improving body awareness and/or body empowerment (1, 4, 6, 7, 9, 10), strengthening interpersonal relationships (1, 3, 6, 7, 9, 10), and skill development (3–6, 9, 10).

Participation is a central tenet of the empowerment process (Wallerstein & Bernstein, 1988). Women’s ongoing involvement in defining, participating, and reflecting on program activities engages them in a problem-posing learning style, comparable to critical education (Wiggins, 2011). This active form of learning promotes outcomes that are co-created through exchange and dialogue, such as improved health literacy and self-confidence, which contributes to greater control and agency over health (Strömbäck et al., 2013). Active participation is further empowering by acknowledging women as valuable sources of knowledge, who hold expertise of their own thoughts, bodies, and experiences. Thus, women exercise power through active participation by drawing on existing knowledge throughout the program (Tengland, 2007), and shifting power to women so they can deprioritize external goals (e.g., fad dieting, weight loss).

Social Support

Another key empowering theme was fostering social support. The majority of programs were conducted in a group format and facilitated women to share their experiences with each other through discussion (1–7, 9, 10). Group discussions tended to concentrate on set themes, personal experiences, and the insights women gained during the course. Other programs developed relational support between the facilitator and participant (6–8). Several programs fostered social connections between the participants through practical activities (3–7, 9, 10), community projects (3, 10), or creating a supportive social network after the program ended (1).

Social support is central to collective dimensions of empowerment, such as community empowerment (Laverack, 2016). In the stress management course (4), women received “confirmation” from one another through sharing their experiences and support with one another. More specifically, Strömbäck et al. (2013) elaborate that women’s collective recognition of stressors enabled them to transform their individualized experiences of stress and barriers into a shared experience. A similar effect was reported by women who received relational support from their engagement worker (8), which enabled them to feel stronger through their connection (Warwick-Booth & Cross, 2018). These findings are consistent with community empowerment—a social action process—in which people unite to challenge social and political ideals to gain greater control over the determinants that influence their lives (Wallerstein, 1992, 2006). Within this context, the social support between women in the programs enabled them to challenge disempowering societal norms (e.g., body ideals, gendered expectations) toward gaining greater control over their lives. Empowerment through social connection may provide insight into why social support among women was highlighted as key indicator of continued health behaviors beyond program completion (5). Thus, fostering social support between women is empowering by forming connections through shared values and collectively challenging sociocultural pressures to create more space for themselves and prioritize their well-being.

Sustainable Change

A further theme across the programs was a focus on sustainable change. In particular, four programs (1–3, 5) encouraged women to make adjustments to their lifestyle that were realistic, gradual, manageable, and aligned to their values. Women were supported to design personalized health goals tailored to their individual preferences, abilities, and long-term intentions (1, 5). Additionally, women were encouraged to explore intrinsic factors to support sustainable behavior change as opposed to extrinsic aims. For example, the programs guided women to explore physical activity and/or healthy eating as a source of enjoyment (1–3, 5, 7, 9, 10), manage their eating behaviors based on internal physiological cues (1, 2), and identify individual triggers and reactions to stress (4, 10).

A focus on sustainable change is an empowering program feature because it inherently allows women to tailor change to their needs. In particular, facilitators must understand individual contexts, experiences, and aspirations to help formulate realistic ambitions that are sustainable. Therefore, working toward sustainable change requires health professionals and women to engage in dialogue; a distinguishing feature of the empowerment process that allows for the creation of shared understanding and “true” learning (Freire, 1973). This exchange is critical to women’s empowerment because it integrates women’s personal circumstances into health ambitions and simultaneously challenges societal pressures to adopt short-term and failure-prone aims, such as the idealized body, intensive fitness plans, fad dieting, and gendered perfectionism (Harman & Burrows, 2019; Pfister et al., 2017; Strömbäck et al., 2014). Accordingly, programs that emphasize sustainable change have demonstrated promising outcomes for women, such as increased control over health through the improved ability to set realistic health goals (Huberty et al., 2009).

Holistic Health Perspective

All empowerment programs embraced a holistic health perspective by promoting multiple dimensions of health and their interconnectivity. The programs primarily concentrated on promoting women’s mental, physical, and social health (1–10); however, some of the programs were more explicit about their aims of promoting women’s social health (3–6, 9, 10). Spiritual development was also noted as an important aspect (10). Moreover, program activities often emphasized the interconnectivity between these dimensions; for instance, encouraging women to participate in practical activities as a group that concentrated on enjoyable movement, therefore drawing on physical, mental, and social health dimensions.

The partnership between a holistic health perspective and an empowerment approach is well-recognized and fundamental to health promotion (World Health Organization, 1986). In this context, embracing a holistic health perspective enabled women to address their health using a broader lens beyond a weight focus. This expanded view of health widens women’s notion of how they can define their health and attribute value to multiple facets of well-being. Strömbäck et al. (2013) describe how women became “bodily empowered” on completing the stress management course through deepening their understanding of the interplay between their physical body and emotional stress. Furthermore, women’s increased holistic awareness of their bodies supported them to become more autonomous from disempowering sociocultural norms like dieting and body ideals (Strömbäck et al., 2013). A holistic paradigm enabled programs to empower women by broadening women’s potential for health success, fostering their embodied knowledge, and emphasizing well-being as a fundamental aspect of health.

Strength-based Approach

All of the programs embraced a strength-based approach by creating an inclusive environment and focusing on one’s assets as opposed to the avoidance of risk behaviors. Women were supported to realize a wider range of health benefits and behaviors, such as enjoyable physical activity (1–3, 5, 7, 9, 10), eating for well-being (1–3) self-esteem (3–5, 7, 9, 10), self-awareness/body awareness (1–2, 4, 6, 7, 10), and self-acceptance/body acceptance (1–4, 7, 9, 10). Another way the programs supported a strength-based approach was by explicitly creating a weight-inclusive environment by accepting body size diversity and abstaining from weight loss or other appearance-related goals. One program intentionally used language as a means to build body empowerment by refraining from using the word “fat” and reframing how girls talked about their bodies through open discussion (6).

A strength-based approach is an empowering program feature for women because it removes the constraints of a narrowed definition of health. For example, weight-targeted approaches rely on the assumption that a person’s body size is indicative of their health status (Bacon & Aphramor, 2011; Tomiyama et al., 2013; Tylka et al., 2014). This assumption disempowers women by stigmatizing bodies that exceed a BMI of 24.9 kg/m², creating a narrow window for health success, and perpetuating the societal value of an “ideal” body size and the many associated health-damaging consequences (Bacon & Aphramor, 2011; Pfister et al., 2017; Tylka et al., 2014). Alternatively, a strength-based approach emphasizes weight-inclusivity recognizing that all bodies have the ability to be healthy independent of illness or weight. Consequently, a strength-based approach avoids the pitfalls of deficit-based tactics and fosters a broader vision for health success that encourages behaviors that foster health and well-being informed by personal experience and circumstances. Huberty et al. (2009) found that women who focused on a wide range of physical activity benefits (e.g., social support, enjoyment, and self-worth) maintained greater motivation to participate in physical activity following the program compared with women adopting a deficit approach, such as emphasizing weight loss and/or appearance (5). Therefore, a strength-based approach emerges as an empowering program feature by people of all shapes and sizes to participate in health-promoting activities and discovering the many ways good health can be experienced and achieved.

Assessment Across Multiple Health Domains

While the outcome assessments varied considerably between the programs, women’s health success tended to be evaluated using quantitative methods across multiple dimensions including psychosocial (1–5, 9, 10), behavioral (1–3, 5, 10), and physical (1, 2, 5, 9) health factors. Three of the programs (1, 2, 5) assessed women’s health across psychosocial, physical, and behavioral parameters. The stress management course (4) only assessed women’s outcomes under a psychosocial dimension using quantitative methods, however, researchers also employed qualitative methods that provided a broader evaluation of women’s outcomes. Briefly, psychosocial outcomes included measures related to psychological well-being (1–3, 5), psychological distress (1, 2, 4) and self-perception (1–4, 9, 10). Physical assessments were either anthropometric (1, 2, 5, 9), cardiometabolic (1, 2) or fitness parameters (9). Behavioral evaluations largely concentrated on assessment related to eating (1–3) and physical activity (1, 2, 5, 9, 10). Some of the programs also assessed behavioral determinants such as benefits and barriers to exercise and self-efficacy (3, 5, 10).

Assessment across multiple dimensions enabled researchers to detect a variety of ways that women exhibited health improvement (or lack thereof). Sometimes women improved psychosocial and behavioral outcomes without making significant changes to physical health parameters (1, 5, 9). Traditionally, researchers and funding bodies have favored randomized research designs to generate empirical evidence based on causal relationships between one or two variables (Van Belle et al., 2017). Yet, under a well-being paradigm, such designs are less suited to evaluate complex health promotion programs that involve multiple variables and their interactions (Dooris et al., 2017; Van Belle et al., 2017). Thus, assessment across multiple domains provided researchers with a more complete picture of women’s health by defining health success in broader terms. Encouraging women to identify health indicators beyond the traditional markers of diet, exercise and body size, may help break detrimental cycles associated with weight loss aims, such as guilt-driven exercise (Harman & Burrows, 2019) and weight cycling (Tylka et al., 2014).

Mixed-method Design

Both quantitative and qualitative methods were employed to evaluate program success. Seven programs used quantitative assessments including surveys and/or scales (1–5, 9, 10), physical assessments (1, 2, 5, 9), physical activity diaries (1, 5), pedometers (5), and food records (1). Six programs adopted qualitative methods consisting of open-ended interviews (4–8, 10) and/or focus groups (8, 10). Three programs used a combination of qualitative and quantitative methods (4, 5, 10).

The programs that adopted mixed or qualitative only methods uncovered deeper insights regarding women’s health success. The programs utilizing a mixed-method design (4, 5, 10) yielded a more complete picture where qualitative data enabled interpretation of the outcomes observed in the quantitative data. For example, women who completed the stress management course (4) exhibited increased perception of their bodies in the quantitative data (Strömbäck et al., 2016). The qualitative data revealed that through increased awareness of their bodies, women felt empowered by viewing their body as a resource as opposed to focusing on its deficiencies (Strömbäck et al., 2013).

Using a mix of methods was also advantageous for capturing outcomes when one method was not enough to capture change. For example, Huberty et al. (2013) explain that women reported changes to their perceptions of physical activity despite modest increases to time spent being physically active. In other instances, the qualitative data enabled the discovery of unanticipated forms of success that women experienced, such as changes to motivation, barriers, and perceptions of health (4, 5). Strömbäck et al. (2013) exemplify this point by describing how women became empowered by transitioning from an individualized to a collective view of stress. Such insights provided the added benefit of identifying key program aspects that contributed to women’s success (e.g., social support, active participation). Lindacher et al. (2018) and Richardson (2018) corroborate the value of employing a mixed-method design when evaluating complex concepts such as empowerment that are multidimensional and heavily influenced by context. Thus, a mixed-method approach becomes necessary as moral health promotion requires a shift from corporeal notions of health to identifying women’s health success under a holistic lens. Given the complex and holistic nature of these programs, future studies should utilize mixed-method approaches to provide a more complete picture of program outcomes and enabling program features. Providing comprehensive evaluations of empowering health promotion programs would enable broader implementation and thereby benefit the advancement of women’s health promotion.

Strengths and Limitations

The programs reviewed were highly varied based on the specificity of aims, groups of women studied, program delivery methods and outcome assessment. The programs focused on a range of young girls and adult women whose health needs and attitudes change across the life course. For example, while body dissatisfaction remains relatively stable across the lifespan (Tiggemann, 2004), women’s concerns with body weight and shape change with age. Variability of program lengths can also have an impact on women’s outcomes. The ability to examine empowering approaches to promoting women’s health by specific parameters (e.g., age group, methods used) is limited by the paucity of literature highlighting a need for further work in this field. This review takes an initial step at collating evidence on empowering approaches for women’s health. Accordingly, the breadth of the included programs should be considered when interpreting the findings from this review.

Despite their diversity, the themes arising from this review strongly coincide with the values that underpin health promotion, namely active participation, social support, sustainable change, holistic health perspective, strength-based approach and assessment across multiple domains (consistent with a holistic health perspective; Taylor et al., 2014). The holistic and sustained improvements to women’s health and well-being reported by these programs are promising evidence, not only for the use of empowering approaches women’s health promotion, but values-driven health promotion as a broader field. Further research to build a larger evidence base in this area is necessary given the prevalent and increasing rates of women who experience poor health within a disempowering environment (Appelman et al., 2015; Peters et al., 2016; Sen & Östlin, 2009).

The programs were often vague and heterogeneous in their use of empowerment and its evaluation. In one program (5), empowering women was stated as an aim, yet there was no explicit mention of empowering strategies. The inconsistency of empowerment conceptualization and implementation is acknowledged as a common barrier to progressing empowerment in health promotion programs (Lindacher et al., 2018; Richardson, 2018). Thus, clearer definition of empowerment in health promotion program research is needed. This review adds a first step toward synthesizing what we know about empowering health promotion programs for women living in a Western context.

Implications for Practice

The findings from this review help address the gender-equity health gap by offering strategies specific to women’s health promotion (Peters et al., 2016). The seven themes contribute guidance for professionals on the design of health promotion programs for women living in a Western context. However, empowering program characteristics are not universally appropriate. Context variation is an ongoing barrier to implementing empowerment as an approach. This variation requires health professionals to be reflective and conscious of their context of practice and transparent in the way empowerment is defined and embedded into program design. This transparency is necessary to advance the evidence-base for values-driven health promotion that supports a paradigm shift toward a broader and more inclusive vision of health success.

Supplemental Material

sj-docx-1-heb-10.1177_10901981211050571 – Supplemental material for Empowering Women in the Face of Body Ideals: A Scoping Review of Health Promotion Programs

Supplemental material, sj-docx-1-heb-10.1177_10901981211050571 for Empowering Women in the Face of Body Ideals: A Scoping Review of Health Promotion Programs by Victoria Chinn, Eva Neely, Sarah Shultz, Rozanne Kruger, Roger Hughes and Michelle Thunders in Health Education & Behavior

Supplemental Material

sj-docx-2-heb-10.1177_10901981211050571 – Supplemental material for Empowering Women in the Face of Body Ideals: A Scoping Review of Health Promotion Programs

Supplemental material, sj-docx-2-heb-10.1177_10901981211050571 for Empowering Women in the Face of Body Ideals: A Scoping Review of Health Promotion Programs by Victoria Chinn, Eva Neely, Sarah Shultz, Rozanne Kruger, Roger Hughes and Michelle Thunders in Health Education & Behavior

Footnotes

Acknowledgements

The authors would like to thank Massey University for funding this project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This review was supported by Massey University under a Doctoral Scholarship.

ORCID iD

Victoria Chinn

Supplemental Material

Supplemental material for this article is available online.

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