Empowerment in old age: A ladder of user participation in social services for older people

Abstract

Summary

This article indicates how to achieve empowerment in old age by promoting user participation in social services for older people. Common empowerment strategies include promoting community and political participation, the seniors’ power movement, and policy advocacy. More effective strategies for empowering older people need to be identified and explored to respond effectively to increasing global aging problems. The article discusses user participation in social services for older people as another valuable strategy and presents the values and core beliefs for promoting user participation in social services for older people.

Theoretical advances

It proposes a ladder of user participation to provide social workers with clear guidelines for creating suitable channels for involving older people in meaningful and greater participation. The proposed ladder comprises seven levels including (1) being consulted and giving feedback; (2) increasing opportunities for service users to make choices; (3) involvement in daily service management and implementation; (4) assisting in running programs and activities; (5) assuming an active role in groups and projects; (6) working in partnership and sharing power; and (7) involvement in decision-making and control over services.

Applications

It provides examples of effective ways of promoting the ladder of user participation in centers for older people at each level and discusses principles of practice in implementation.

Keywords

Social work user participation older people a ladder of user participation empowerment

Introduction

There has been increasing concern among social workers about empowering older people (Baur & Amba, 2012; Kam, 2002; Thompson & Thompson, 2001; Toofany, 2007). The aim of empowerment is to assist older people to develop the capacity and competence to achieve a greater measure of control of their later life and to experience “an internal transformation from a state of powerlessness to a state of self-efficacy, self-worth and self-esteem” (Kam, 1997, p. 52). A commonly-adopted strategy is to promote older people's community and political participation. Through expressing their views and needs for solving community problems and improving community facilities, older people can raise social consciousness and find their role in contributing to community development (Kam, 2021b). By exerting political influence on their elected representatives in the local and central political systems, older people can increase their sense of political significance and competence (Goerres, 2009; Kam, 2000; Walker, 2006). Another strategy used by social workers is promoting the seniors’ power movement that aims to raise older people's age consciousness and awareness of senior power (Beard & Williamson, 2011). Policy advocacy also promotes older people's empowerment (HelpAge International, 2000; Pardasani & Goldkind, 2012) by articulating their power to combat ageism and “feel able to take part and the capacity to develop new policy discourses which can challenge official perspectives and assumptions” (Barnes, 2005, p. 245). Older people are organized to form action groups or age-based organizations to act on social structures or institutions which oppress and disempower them (Kam, 1997).

While recognizing the merits of using the above strategies to enhance older people's empowerment, social workers are likely to confront difficulties involving or mobilizing a broad cross-section of older people, particularly individuals who are vulnerable because of low income, physical and health impairment, low self-image, or a passive personality. More alternative strategies for empowering older people need to be identified and explored to respond effectively to increasing global aging problems. This article proposes user participation in social services for older people as another useful empowerment strategy (Barnes, 2005; Bowers & Wilkins, 2012; Carey, 2019; Righi et al., 2018).

This article points out that user participation should not only be considered a concern of social work administrators as a management issue but also as a form of daily social work practice with older people. User participation in social services is not limited simply to service users’ uptake of services but also their involvement in expressing opinions and participating in service planning, implementation, and decision-making, thus reducing their dependency on professionals, weakening their belief in the myth in professional authority, and teaching them to share power and responsibilities with social workers. According to the International Association of Schools of Social Work (2018) Global Social Work Statement of Ethical Principles, social workers are required to promote users’ rights to participation by working “toward building the self-esteem and capabilities of people, promoting their full involvement and participation in all aspects of decisions and actions that affect their lives” (p. 6). The British Association of Social Workers (2014) Code of Ethics includes a similar statement requiring social workers to “promote the full involvement and participation of people using their services in ways that enable them to be empowered in all aspects of decisions and actions affecting their lives” (p. 7). Furthermore, the National Association of Social Workers (2021) Code of Ethics urges social workers to “seek to promote the responsiveness of organizations, communities, and other social institutions to individuals’ needs and social problems” (p. 1). Social workers’ professional bodies thus expect social workers to exercise a duty to work collaboratively with social work administrators to promote user participation in service units, including those serving older people. While taking responsibility for promoting service user participation in its unique sphere of activity, the social workers and the social work profession collectively are not solely accountable for righting society's wrongs. There is a clear need for social workers to work with others, including service users, to ensure that other influential social agents, including government, play their part in promoting user participation in all aspects of society.

This article outlines the rationale for promoting user participation in social services for older people, advocating a seven-level ladder of user participation that provides social workers and social work administrators with clear guidelines for implementing user participation as a form of empowerment practice. The proposed ladder comprises seven levels: (1) being consulted and giving feedback; (2) increasing opportunities for service users to make choices; (3) involvement in daily service management and implementation; (4) assisting in running programs and activities; (5) assuming an active role in groups and projects; (6) working in partnership and sharing power; and (7) involvement in decision-making and control over services. It also highlights examples of effective user participation and the principles of practice in implementation at each level.

User participation: A neglected empowerment strategy

Concern about the value of service users’ perspectives, opinions, and participation in the social service sector is increasing. Contemporary social work literature provides extensive discussion of the importance of listening to service users’ perspectives and promoting their participation in the delivery of social services (Beresford & Carr, 2012; Bohem & Staples, 2002; Shaping Our Lives, 2003). Research increasingly shows that social workers who pay more attention to service users’ perspectives can better understand and identify service users’ real needs (Beresford & Croft, 2004; Braye, 2000). The service user perspective helps social workers understand service users’ opinions, recognize their contribution to the design and delivery of services to fit their specific needs, and develop an egalitarian and partnership relationship with them (Barnes, 2012; Fleming, 2012).

User participation has been increasingly recognized as an important goal in designing social welfare policies in European countries (Askheim et al., 2017; Barnes & Cotterell, 2012; Christensen & Pilling, 2019). In the UK, service users’ and carers’ involvement has been a central theme in the government's modernization agenda in health and social care development (Bochel et al., 2007; Carr, 2007; Department of Health, 2000). In Hong Kong, the lump sum grant subvention system requires social welfare agencies to set up and implement service quality standards in service provision, one of which is to promote service users’ participation and increase their opportunities to give feedback and comment on services received (Social Welfare Department, 2001).

Despite increasing emphasis on service user participation, social welfare organizations’ adoption of a consumerist approach to participation as a kind of supermarket or consumerist model of involvement has been criticized. Service users are conceived as consumers or customers (Askheim et al., 2017; Carter & Beresford, 2000). The emphasis of this approach is not to meet the needs of older people and facilitate change but rather to improve the management, economy, and effectiveness of the service. This approach limits older service users’ participation to consultation and access to information and is criticized as service- and service-provider-oriented and merely a token effort to involve older service users. Consultation is usually restricted to minor issues, and professionals retain most decision-making. Service user participation is used to give the appearance of their agreement and consent to pre-determined decisions and plans, thus simply serving as a public relations and window-dressing exercise. It fails to divulge essential and full information to service users and confines discussion to professionally set agendas, using professional jargon and protocols. This approach tends to seek users’ views on existing services rather than service development innovation. Support for promoting service users’ participation, such as paying for their time and offering suitable channels for participation or providing training, is largely neglected, thus rendering user participation under-used as an effective strategy for achieving empowerment (Carter & Beresford, 2000; Taylor, 2006).

Empowerment and older people's participation

However, many scholars have identified user participation's potential to generate empowerment effects (Barnes, 2005; Carey, 2019; Taylor, 2006; Thompson & Thompson, 2001). The empowerment approach to user participation needs to be adopted instead to achieve meaningful participation (Barnes & Walker, 1996; Beresford & Croft, 1993). Unlike the consumerist approach, the empowerment approach adopts the user-oriented, needs-led, and power-sharing approach to promote the service users’ participation with the principal objective to help service users empower themselves through speaking directly for themselves and having a right to direct say in agencies and services to gain greater control of their lives. It encourages service users to express their views and opinions and influences implementation and decision-making in service delivery. The empowerment approach involves service users in needs assessment and the development, management, and operation of services, providing them with a range of opportunities to define their own needs and the services they require to meet them. This approach can help change “managed user participation” to real “user-managed participation” (Braye & Preston-Shoot, 1995).

Based on the empowerment approach, older people's participation in social services provides them with opportunities to influence and manage the implementation of services. Since older people are often exposed to a social environment over which they have little control or choice, their ability to choose and decide for themselves can be enhanced through involvement. An environment that encourages participation helps older people learn skills, gain personal control, and exert influence over their daily lives. It can also mobilize their abilities and resources to solve their own problems and help others.

Core beliefs in facilitating older people's participation

Social workers and social work administrators need to adopt a rights-based perspective of participation as an older service users’ right (Davies et al., 2014) rather than a functionalist perspective of user participation that emphasizes the utility of involving older service users in task achievement. The social welfare sector not only comprises social welfare agencies and social work professionals but also includes older service users. User participation is thus about more than having a voice in services and is more concerned with how older service users are treated and regarded throughout their lives. Participation does not only mean initiatives designed and controlled by service providers. It is not what social workers want them to do but is about older people's rights to have more say and represent themselves to facilitate greater peer participation in service units.

A strengths perspective also needs to be adopted regarding older people to increase their confidence and commitment to promoting older people's participation. Social workers and social work administrators need to believe that once they start with the strengths of older people, older people can be encouraged to participate and uplift their involvement (Kam, 2021b). It may take some time to facilitate and train older people to become involved, but when more older people are involved, more manpower can be secured to increase the planned programs’ or activities’ effectiveness and efficiency.

Social workers and social work administrators need to recognize that older people are very good at caring for and appreciating others, have a higher sense of responsibility and accountability, have many talents in managing domestic chores, are funnier and humorous in leading games and activities for their peers, have more leisure time, know their community and older people's needs best, have a strong sense of community identity and have very good community networks. All these strengths can be maximized and further developed to enhance older people's motivation, confidence, and abilities to work with social workers in user participation initiatives or projects. Social work administrators also need to encourage social workers to develop a professional culture that “acknowledges authority of users’ experiences in the constitution of knowledge in social work practice” (Leung, 2011, p. 51).

A ladder of user participation in services for older people

Since user participation should not be tokenistic, some practical guidelines are needed to involve service users in meaningful participation. Carter and Beresford (2000) point out that access and support are two key components for effective involvement. Thus service users need to be adequately supported to access different ways or channels of participation. Goss and Miller (1995) suggest five levels of user participation: (1) no involvement; (2) passive involvement; (3) limited or organization-centered involvement; (4) listening and responsive involvement; and (5) partnership. Mackay (2002) adapted Arnstein's ladder of citizen participation (Arnstein, 1969) to propose eight levels of service user and carer involvement: (1) not involved; (2) informed; (3) consulted; (4) attended working groups; (5) influence on action; (6) shared action; (7) delegated function; and (8) controlled decisions and actions. Tsang (2013) also suggests that social workers need to help service users advance their participation from negative or non-responses to passive and active responses, then to passive and active participation, and eventually help them become task and organization leaders.

These suggestions show that promoting user participation is a progressive process. However, they do not address the specific situations of older service users. There is also a little discussion on the effective means and channels to promote older service users’ participation (Casado et al., 2020). To fill this gap, this article proposes a ladder of user participation that provides older people with suitable channels and platforms for effective involvement in greater participation. This proposed ladder draws on the above suggestions and the author's extensive experience in direct social work practice, teaching social work courses, supervising social work students in fieldwork practicum, offering training workshops for frontline social workers, providing consultation for gerontological social workers, and conducting knowledge transfer projects with social service agencies. Since centers for older people are the most common and popular places frequented by older people to receive services, suggested examples in services provided by such centers are presented below to illustrate the application of the ladder of user participation and the empowerment effects on older people. These examples only serve for illustration purposes and do not mean that the ladder is only applicable to this specific service setting. Other service settings in social service for older people can also adopt this ladder, modified as necessary, to promote older service users’ participation.

The proposed ladder comprises seven levels: (1) being consulted and giving feedback; (2) increasing opportunities for service users to make choices; (3) involvement in daily service management and implementation; (4) assisting in running programs and activities; (5) assuming an active role in groups and projects; (6) working in partnership and sharing power; and (7) involvement in decision-making and control over services. Older people's involvement in seven levels of participation is facilitated based on their personal circumstances (such as older people's interests, personal strengths, health and other personal limitations, and experiences in using the services) without necessarily following the progressive steps in the ladder (Kam, 2021a).

Level 1: Being consulted and giving feedback

The first level is to increase older people's opportunities to be consulted and give feedback on service delivery. Social workers need to release more relevant information about the center's services to help older people and their family members understand what serves them best. Information needs to be presented in ways that can be easily comprehended.

Different methods are used to collect older peoples’ views on center services and activities, such as setting up a users’ feedback collection box, posting users’ feedback on the center's notice board, and regularly conducting focus group meetings with service users and their family members. Following programs and group sessions, social workers allow time for evaluation meetings or sharing sessions to collect service users’ feedback and comments. Once their views and feedback are truly and genuinely recognized, older people will be empowered by being accorded a sense of respect, thus enhancing their self-worth, self-value, and self-esteem.

Level 2: Increasing opportunities for service users to make choices

Since making choices is power, centers for older people need to maximize older service users’ opportunities to participate in activities and programs. If the center provides meal services, service users need to be offered extensive choices of menus. Social workers are recommended to collect the views of older service users and their family members on their preferred choices and options for community support services, such as the time and frequency of the service. More opportunities to make choices in utilizing services can empower older people to increase their self-confidence and learn how to gain personal control and influence in their daily lives.

Level 3: Involvement in daily service management and implementation

Service users are encouraged to contribute to the center's daily service management and implementation, such as participating in the center's reception counter service. They can also help social workers to communicate with service members, such as regularly maintaining phone contact with members who live alone or whose active participation in the center's activities is limited by health conditions or other reasons. They can also help arrange the mailing of the center bulletin to members. Since older people generally have plenty of leisure time, they can be encouraged to attend the center daily to help with routine maintenance tasks such as feeding the fish in the aquarium or watering plants. At times of seasonal festivals, service users can be involved in buying decorating materials and working with social workers to decorate the center. They can be trained to become ambassadors for the center to receive visiting guests as they know the center best.

Giving older service users the opportunity to be helpful affords them a sense of control and a feeling of being capable rather than impotent. Research shows that participation enables service users to “develop more of an allegiance to shared goals, a sense of community and shared values” (Birchall & Simmons, 2004, p. 3). Thus, the more older people participate in facilitating center services, the higher their sense of belonging to the center can be strengthened. Older people empowered to become contributing members in the center are likely to experience a reduced sense of uselessness and helplessness.

Level 4: Assisting in running programs and activities

Older people can be encouraged to assist in providing services in the center. They can be facilitated and trained to become masters of ceremonies in mass activities. Since older people know the personalities and characteristics of center members best, they can be trained to lead games in mass and recreational activities more funnily and humorously. Social workers can encourage older service users to buy and pack presents for activities as they are best-placed to tell what center members need and like. More effort needs to be expended to involve older people as volunteers in running volunteer services, such as home-visiting, blood-pressure measurement, leading daily physical and health exercises, and activities for other needy groups in the community.

Social workers are recommended to use volunteerism as an empowering process to help older people counteract their powerlessness and enhance a sense of self-worth and self-efficacy (Kam, 2002). Social workers do not only need to recruit volunteers from among active, healthy, well-off, and educated older people with professional backgrounds. Instead, they need to open up opportunities for older people who belong to a helpless or powerless group, such as those on a low income, who live alone, have a chronic illness, or have a low self-image and passive personality. This level of participation helps social workers adopt a new paradigm that changes their view of older people from problem-bearers to potential help-givers. It can also empower older people to become prosumers (Toffler, 1980), that is, that they are both producers and consumers of services. Providing older people with more channels to assist in services vastly reduces the number of older people regarded as helpees and correspondingly increases the number taking up helper roles. The help-giving power of the service unit can also be expanded because of the greater involvement of many older people in playing the helping role.

Level 5: Assuming an active role in groups and projects

Older people involved in this level are encouraged to change their role from assisting to assuming an active or core position in running groups or projects in the center. Social workers need to facilitate the establishment of service user groups that enable older people to work together to run group activities or their preferred community projects. Social workers need to encourage joint decision-making with service users in planning and implementation. They need to step back and assist older people in setting agendas, chairing and taking records in group meetings, and enhancing their contribution to democratizing the group process. This also helps increase resources in service provision quantitatively but qualitatively. This level of participation can help older people discover their capacity and potential for helping themselves and others. It can help empower older people by developing their positive life goals and deconstructing the negative stereotypical image of old age.

Level 6: Working in partnership and sharing power

At this level, older people are empowered to work in partnership with and learn how to share power with social workers. An egalitarian relationship between social workers and older people needs to be emphasized. Older people are encouraged to co-design and co-produce the center's services and facilities with social workers (Bowers & Wilkins, 2012; Righi et al., 2018). Older people are encouraged to work in partnership with social workers to discuss and identify community issues related to older people's wellbeing and take collective and campaign actions for making community and policy changes.

Centers for older people need to set up user councils and allow older people to elect representatives to the council. Center managers and administrators hold regular meetings with council representatives in which service users enjoy equal status to discuss the running of services, improving the center's facilities, and future planning. This can promote democracy, status, and power equality within the center, shared leadership, and cooperation in decision-making among service users. Social workers are also encouraged to form carer or family member groups to assist the center's services and activities. Regular sharing meetings need to be conducted to collect carers’ or family members’ feedback and suggestions for improving the service. This level of participation helps ensure a quality service for older people and improves professional knowledge of the issues that concern older service users and their carers or family members.

Level 7: Involvement in decision-making and control over services

Social workers can further help older people exercise the power of decision-making and control. A good way is to transform older people's groups into self-programming or self-help groups. By taking responsibility for running or managing the groups on their own, older people can learn and experience self-determination, self-reliance, self-production, and self-empowerment. This level of participation contributes to a significant power shift, enabling older people to make their own decisions, control the services, discover, and maximize their internal resources or inner strengths rather than relying on external intervention by social workers. These user-led initiatives are “more likely to have credibility with older people” and “less likely to be swayed by the interests of the agency” (Carter & Beresford, 2000, p. 18).

It is helpful to avoid hierarchical and bureaucratic patterns of organization. It can also create alternative services devised by older people to induce change in the dominant social institutions and policies. Older people, carers, or family members can also be encouraged to become significant stakeholders as members of the center's Board/Executive/Advisory Committee and thus influence or control the center's decision-making processes. Forming district or territory-wide old age coalitions or linking older members to these coalitions can also be considered an effective empowerment strategy for strengthening older people's political power and influence on policy changes.

Principles of practice

Adopting the ladder of user participation is likely to generate cultural changes in social service organizations and social workers’ practices. Therefore, some practice principles are required to guide social workers and social work administrators to work together to induce or respond to these changes effectively. The following six principles are suggested for enhancing the empowerment effects of implementing the ladder of user participation in services for older people.

First, user participation is a voluntary and bottom-up process. It involves a gradual process that needs sufficient preparation and transition. During the process, older people's choice in participation needs to be respected. Second, older people's participation needs to start from small tasks as it is important to let older people firstly gain successful and rewarding experiences. Since older people may lack experience, it is helpful to arrange exchanges with other user groups with successful experience of user participation to enrich their understanding of involvement in different levels of the ladder. Third, changes in social service organizations are required to provide favorable conditions to promote older people's participation. Social work administrators need to develop a culture of user participation in service units and emphasize the importance of staff participation in the daily operation of services. They need to support frontline social workers to listen to older people's voices and offer a personal touch and humanistic contact with older people. Social work administrators also need to ensure social workers’ sensitivity to the avoidance of discriminatory, ageist, and depersonalized language.

Fourth, social workers and social work administrators are encouraged to facilitate “cooperative power” with older people by developing capacities and skills to work with older people in collaborative decision-making (Leung, 2016). Fifth, social work administrators need to identify the specific training needs of social workers and older people, provide them with the necessary training and support their involvement in a participatory process of joint learning, and consolidate participation experiences together. Social workers need to be supported with appropriate supervision. There should be regular sharing among staff in different service units.

Sixth, social workers need to be psychologically prepared for older people's passive or negative responses to user participation. Social work administrators need to provide social workers with adequate support to learn effective ways of handling possible difficulties and limitations. The following are some common examples of older people's passive or negative responses and methods for social workers to handle these.

Older people lack the confidence to become involved . Social workers emphasize that older people are experts on their problems and find other experienced service users to assist and work with them.

Older people worry that they cannot handle the task . Social workers involve service users in tasks based on their strengths and utilize their capacity.

Older people are unwilling or unmotivated to take up responsibility . Social workers need to let service users understand that their needs can only be fully met by their taking responsibility and that the social workers will support them by working with them as partners.

Older people are afraid of receiving unfavorable comments and being the subject of gossip. Social workers need to let service users understand that unfavorable comments or gossip will be avoided if their participation involves a democratic, open, and transparent process.

Older people worry about power conflicts with social workers . Social workers need to let service users know that participation is their right and that they share power and responsibility with social workers and do not take over the power from social workers.

Older people may perceive that social workers are lazy and deny their responsibilities . Social workers need to gradually involve older people and avoid pushing too fast, letting them understand the values and meaning of participation and helping them reflect on their personal growth from participation.

Conclusion

The United Nations Report on World Population Ageing (United Nations, 2020) reveals that population aging continues to be a global phenomenon. The global population aged 65 years or over is projected to double in the coming 30 years. This population will increase from 703 million to 1.5 billion between 2019 and 2050, from 9% to 16% of the total global population. This change draws attention to the need to identify effective strategies to empower older people to respond to the challenges of global aging. This article suggests that user participation is regarded as a useful empowerment strategy since promoting user participation in service units is less demanding for older people and is more suitable for different groups of older people with different personal capacities and limitations. A shift from the prevailing consumerist approach to the empowerment approach in user participation can significantly impact older people's empowerment.

Involving older people in user participation is a progressive process. The ladder of user participation proposed in this article offers social workers and social work administrators clear directions and practical guidelines to progressively promote older people's participation in social services for older people. This is particularly important and beneficial in the context of rapid global population aging. Thus social service development and policy changes are not just decided by younger decision-makers. Promoting older people's participation is imperative to enable older people's voices to be heard and taken into consideration in the planning and development of social services. It makes services more responsive to their particular needs, thus protecting older people's rights and providing them with more choices.

Rapid global population aging should not be viewed from a problem-oriented perspective only; an asset-based perspective should also be adopted. An increasing population of older people implies an increase in the number of people with rich life experiences and wisdom, different talents and skills, plenty of leisure time, and good social networks. They should be regarded as precious community assets and resources. Promoting user participation in services for older people is helpful and timely to tap or maximize these assets and resources. It is expected that older people, particularly the “young olds,” are looking for opportunities to have a productive and meaningful later life. These opportunities can be expanded by shifting social work professionals’ focus from directly providing services to actively involving older people's participation and working closely with them in service delivery. The better use of the ladder of user participation in their practice, the greater the chance that older service users will experience empowerment in their later life. Success in making user participation an empowerment process in social services for older people depends on the commitment and concerted efforts of social workers and social work administrators to emphasize empowerment as the ultimate goal of social services that create different channels of participation for developing an empowered generation of older people.

The proposed ladder of user participation helps enhance the theoretical understanding of the inter-relationship between user participation and the empowerment of older people. It also helps fill the practice gap of applying user participation in social services for older people. It will nonetheless have to be further developed and operationalized in different practice settings for older people and other service users’ groups. More modifications will also be required to make it applicable in different countries with specific cultural contexts and socio-political structures. To date, there has been limited research into the effectiveness of its application. Further research will then be necessary to examine and determine its effects on facilitating older service users to achieve empowerment in old age.

Footnotes

Ethical Approval

No ethical approval was required for this nonempirical study.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Declarations of Conflict of Interests

The author declare that there is no conflict of interest.

ORCID iD

Ping Kwong Kam

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