Evaluating the Methodological Approaches of Cross-Cultural Adaptation of the Bedside Handover Attitudes and Behaviours Questionnaire into Portuguese.

Nurse managers need culturally adapted assessment instruments to support the implementation of change to Nursing Bedside Handover (NBH) in healthcare institutions. This study aimed to cross-culturally adapt the Bedside Handover Attitudes and Behaviours (BHAB) questionnaire to the Portuguese context and evaluate the methodological approaches used for this purpose. To guide this study, we followed a guideline for cross-cultural translation and adaptation measurement instruments in healthcare. The results of the content validity testing suggested that the BHAB questionnaire is a valid instrument for use in the Portuguese context. To obtain these results we showed 1) using of a new methodological approach, the dual focus, to resolve the divergences and ambiguities in the translators' committee and the multi-professional committee; 2) the lack of a conceptual definition of the construct of the instrument as a requirement to retain items with I-CVI <0.70 after validity relevance pretesting and 3) the cognitive debriefing and relevance pretesting as methodological approaches which can be used alone or together to reinforce the evaluation of cultural relevance of the items. We concluded there is a need for guidelines to support the decision-making process of healthcare researchers with comprehensive information about the different methodological approaches they can follow.

The Nursing Practice Environment and Patients' Satisfaction with Nursing Care in a Hospital Context.

Nursing, being a profession in health, aims to improve the quality of the response to patients' demands, which have repercussions on the attitudes, behaviors and performance of nurses. BACKGROUND: The aim of the study was to evaluate the relationships among the nursing practice environment, nurse-patient interactions and patients' satisfaction with nursing care in a hospital context. METHODS: The study applied a descriptive analysis. Based on the initial exploration of the data, we decided to perform a simple linear regression of the dimensions of the scales. RESULTS: The latent variables and interactions between the different dimensions of the three constructs (the nursing practice environment (PES-NWI), nurse-patient interactions (NPIS-22-PT) and patients' satisfaction in the hospital context (SAPSNC-18)) were submitted to confirmatory analysis. The model was statistically significant, with a good fit with the data (χ2/gl = 128.6/41 (0.000); GFI = 0.900; AGFI = 0.831; TLI = 0.910; CFI = 0.907; RMSEA = 0.102). CONCLUSIONS: The study showed favorable rates of overall satisfaction on the part of patients, such as the nurses' skills in dealing with their illness/health situation, ability to solve problems in a timely manner, responsiveness to patients' needs and technical competence.

Influencing Factors of Nurses' Practice during the Bedside Handover: A Qualitative Evidence Synthesis Protocol.

Nursing Bedside Handover (NBH) is acknowledged as a nursing practice implemented at the patient's bedside to improve communication safety during the shift change, but it is vulnerable due to inconsistent application among nurses. This synthesis of qualitative evidence aims to review and synthesize the perceptions and experiences of nurses regarding the factors that, in their perspective, influence NBH practice. We will follow the thematic synthesis methodology of Thomas and Harden and the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) Statement guidelines. A search will be conducted through the databases of MEDLINE, CINAHL, Web of Science, and Scopus, and we will follow the three-step search process to identify primary studies with qualitative or mixed-method research designs and projects of quality improvement. The screening and selection of the studies will be carried out by two independent reviewers. We will use the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) to report the screening, search, and selection of studies. To assess its methodological quality, two reviewers will independently use the CASM Tool. The extracted data will be reviewed, categorized, and summarized in tabular and narrative formats. The findings obtained will allow us to inform future research and change management led by nurse managers.

Translation and Validation of the Individual Workload Perception Scale-Revised for Portuguese Nurses.

(1) Background: In Portugal, there is no scale to assess nurses' satisfaction with their workload. Therefore, this study aimed to culturally/linguistically adapt and validate the IWPS-R scale, with 29 items, to produce a Portuguese version. (2) Methods: A quantitative, descriptive and cross-sectional study was conducted in two phases: translation and adaptation of the IWPS-R into Portuguese, following the steps recommended by Beaton; and evaluation of its psychometric properties in a non-probability sample of 323 nurses working in a hospital centre of reference in Portugal. (3) Results: The final scale obtained a total explained variance of 62.3% and a KMO of 0.88. The reliability was assured through the determination of an internal consistency of 0.88. The construct validity was determined through confirmatory factor analysis. The factorial model presented a good quality fit (X2/df = 2.118; CFI = 0.925; GFI = 0.900; RMSEA = 0.059; p (RMSEA ≤ 0.05) = 0.041; RMR = 0.078; MECVI = 1.525; SRMR = 0.0631) with five factors. (4) Conclusions: The Individual Workload Perception Scale-Revised-Portuguese version (IWPS-R-PT) is a 21-item tool with five dimensions: Nurse Manager Support, Team Support, Workload, Organizational Resources and Intent to Stay. The IWPS-R-PT was found suitable for hospital-based nurses and may be useful in other settings where nurses work.

Translation and Validation of the Indicators of Quality Nursing Work Environments in the Portuguese Cultural Context.

The Indicators of Quality Nursing Work Environment scale (IQN-WE) with 65 items, developed by Chiou-Fen Lin, Meei-Shiow Lu, and Hsiu-Ying Huang in 2016, aimed to create a set of quality indicators of the nursing work environment. The translation and validation for the Portuguese cultural context of the IQN-WE scale was performed in this study. OBJECTIVES: culturally and linguistically adapt the IQN-WE scale, originating from the Portuguese version, and evaluate its psychometric characteristics. METHODS: it is a descriptive, cross-sectional, observational and quantitative study. The IQN-WE scale was validated in a sample of 542 nurses belonging to a hospital center in Portugal. The study obtained a response of 21.69%, of whom 78.0% were women and 22% men. The mean age of the sample was 39 years and a standard deviation of 8.1 years. All nurses who work have a bachelor's degree, and 13.5% have a master's degree. RESULTS: the study obtained an instrument with a total explained variance of 52.67% and KMO = 0.843. It found a strong-to-moderate linear correlation matrix between the dimensions. The pre-test and the team of experts ensured the content validity. The determination of internal consistency guaranteed reliability, with 0.95. Confirmatory factor analysis validated the construct. The factorial model presented a goodness of fit index, with five factors. CONCLUSION: the study achieved an instrument with 50 items in five dimensions: Team Support and Professional Development; Team Organization and Management; Safe Nursing Work Environment; Information Systems and Risk Control; Salary and Welfare. The IQN-WE-PT scale proved to be an appropriate instrument to be applied in health organizations in Portugal.

International Portuguese Nurse Leaders' Insights for Multicultural Nursing.

Cultural diversity among patients and healthcare workers in the Portuguese healthcare organizations will increasingly challenge nurse managers to develop favorable nursing work environments and to improve culturally congruent care. AIM: This study aimed to identify nurse managers' interventions that improve favorable nursing work environments in multicultural nursing teams and culturally congruent care for patients, based on Portuguese nurse leaders' experience in international settings. METHODS: A qualitative and exploratory study was conducted as the first stage of a sequential exploratory mixed study design. A convenience sample of Portuguese nurses with leadership experience of multicultural teams was recruited to participate in one focus group. Qualitative data were recorded and transcribed for content analysis. Text segments were organized into themes and categories with the support of the qualitative software IRaMuTeQ. RESULTS: Nurse managers' interventions, such as adapting the leadership style, thanking nurses for their work, adjusting the unit to attend to patients' worship practices, and supporting foreign nurses in learning the local language, were categorized into three main themes and five categories-transcultural nursing leadership assumptions, capitalizing nurses, improving culturally congruent care, team problems and strategies, and improving effective communication. CONCLUSIONS: These findings corroborate international studies, advocate for capable nurse managers to lead in a globalized world, and are suitable to develop a transcultural nursing leadership questionnaire.

Translation, Adaptation, and Validation of the Self-Efficacy Scale for Clinical Nurse Leaders for the Portuguese Culture.

Studies related to the competencies of clinical nurse leaders as an advanced practice demonstrate that they are an asset to health organizations. However, it is pertinent to use an instrument to measure the self-efficacy of clinical nurse leaders in Portugal to facilitate managers' decision-making. In this study, we aimed to translate, adapt, and validate the Clinical Nurse Leader Self-Efficacy Scale for the Portuguese cultural context. This is a quantitative, observational, and descriptive cross-sectional study. The sample of this study was non-probabilistic and intentional, consisting of 329 nurses responsible for shift and specialist nurses. The translation and validation process followed the internationally recognized guidelines on the psychometric properties of measurement instruments. The factor analysis explained 62.1% of the variance and had a seven-dimensional structure. The seven factors were: Patient-Centred Care; Unit Management; Clinical Leadership; Strategic Leadership; Team Management; Cost Reduction; and Care Planning. The confirmatory analysis showed that the seven-factor model achieved a suitable adjustment in the Portuguese context. The self-efficacy scale for clinical nurse leaders can be considered a valid and reliable instrument for application in Portugal in any care context. This scale allows the assessment of the nurse's perception of their ability to intervene effectively as a clinical leader in their care team.

Validation of Psychometric Properties of the Nursing Work Index-Revised Scale in Portugal.

The use of instruments designed to assess the nursing practice environment is crucial to improve the quality of nursing care, to anticipate problems and difficulties that may arise in organizations, and allow nurse managers to implement changes and improvements in key areas. In this study, we aimed to evaluate the psychometric properties of the Nursing Work Index-Revised Portuguese version (NWI-R-PT) scale. A quantitative, observational, descriptive, and cross-sectional study was conducted. METHODS: The sample consisted of 767 nurses from 4 public Portuguese hospitals. Exploratory and confirmatory factor analysis techniques were used to test the distinct structural models. The scale's accuracy was evaluated through internal consistency, using Cronbach's alpha. RESULTS: NWI-R-PT internal consistency was 0.91. The NWI-R-PT model with six factors, namely "Management Support," "Professional Development," "Fundamentals of Nursing," "Nurse-Physician Relationship," "Endowments," and "Organization of Nursing Care," was supported by exploratory and confirmatory factor analysis. The NWI-R-PT scale presents adequate goodness-of-fit indices concerning the final factorial model and the convergent validity. CONCLUSIONS: The NWI-R-PT scale has a competent and reliable structure. The scale's validity is confirmed; therefore, it may be employed in all contexts in clinical practice, research, and nursing management. The NWI-R-PT is a useful and valid instrument to assess the nursing environment in hospitals, primary care, long-term care, and nursing homes. The scale has significance in improving the quality of nursing care and patient safety, the professional development of nurses, and organizational results.

Graduating Nursing Students' Empowerment and Related Factors: Comparative Study in Six European Countries.

New nurses are needed in healthcare. To meet the role expectations of a registered nurse, nursing students must feel empowered at graduation. However, there are only a few studies focusing on nursing students' empowerment. This study aims to describe and analyze graduating nursing students' level of empowerment in six European countries and potential related factors. A comparative and cross-sectional study was performed in the Czech Republic, Finland, Italy, Portugal, Slovakia, and Spain with graduating nursing students (n = 1746) using the Essential Elements of Nurse Empowerment scale. Potentially related factors included age, gender, a previous degree in health care, work experience in health care, graduation to first-choice profession, intention to leave the nursing profession, level of study achievements, satisfaction with the current nursing programme, clinical practicums, theoretical education, and generic competence measured with the Nurse Competence Scale. The data were analysed statistically. Graduating nursing students' self-assessed level of empowerment was moderate, with statistical differences between countries. Those with high empowerment had no intention to leave the nursing profession, had a higher level of study achievements, and a higher self-assessed generic competence level. The results suggest that empowerment needs to be enhanced during nursing education. Further research is needed to understand the development of empowerment during the early years of a nursing career.

Translation, Adaptation, and Validation of the L'Échelle d'Interactions Infirmière-Patient-23 for the Portuguese Culture: The Multidimensional Nature of Nursing Care.

Nursing care is based on the interaction between nurse and patient. The L'Échelle d'Interactions Infirmière-Patient-23 (EIIP-23) is used to evaluate and understand the perception of nurses about their interventions in the practice of care, to reach better health results. The present study aims to validate the questionnaire EIIP-23 to Portuguese, evaluating its psychometric properties. METHODS: This is methodological research for the process of cross-cultural translation and adaptation. RESULTS: The process of cross-cultural translation and adaptation were satisfactory. The committee of experts reached an agreement of more than 90% in the first evaluation for all the items. The internal consistency of the nurse-patient interaction scale 22-PT (NPIS-22-PT) was 0.864. Exploratory and confirmatory factor analyses were carried out in the NPIS-22-PT model, with three factors. The results show that the final factorial solution presents acceptable goodness of fit indexes and adequate convergent validity. CONCLUSION: The translated version produced a good quality psychometric evaluation, and can be considered a valid, trustworthy, and useful instrument to evaluate the nurse-patient interactions in Portugal. It showed acceptable reliability and validity in psychometric tests. In the context of nursing, the NPIS-22-PT is a relevant instrument.

Association between treatment adherence and quality of life among overweight adolescents.

Overweight is an extra burden for adolescent development and can trigger severe physical and psychosocial problems. This cross-sectional correlational study aimed to analyze the association between treatment adherence and obesity-related quality of life among overweight adolescents. The sample consisted of 94 adolescents attending a specialized Pediatric Obesity Clinic in Portugal, 48.94% of whom were boys and 51.06% girls, with a median age of 14.17 years (SD = 1.51). A positive correlation was found between obesity-related quality of life and adherence to weight control. The influence of parents and caregivers on the adherence to weight control is significantly associated with increased physical comfort, better social life and family relations. These results highlight the importance of behavioral change and adherence to weight control as pillars of a better quality of life among overweight adolescents. Obesity management programs need to focus on multiple criteria of treatment effectiveness, such as obesity-related quality of life.

Association between treatment adherence and quality of life among overweight adolescents / Associação entre adesão terapêutica e qualidade de vida em adolescentes com sobrepeso / Asociación entre adhesión terapéutica y calidad de vida en adolescentes con sobrepeso

Overweight is an extra burden for adolescent development and can trigger severe physical and psychosocial problems. This cross-sectional correlational study aimed to analyze the association between treatment adherence and obesity-related quality of life among overweight adolescents. The sample consisted of 94 adolescents attending a specialized Pediatric Obesity Clinic in Portugal, 48.94% of whom were boys and 51.06% girls, with a median age of 14.17 years (SD = 1.51). A positive correlation was found between obesity-related quality of life and adherence to weight control. The influence of parents and caregivers on the adherence to weight control is significantly associated with increased physical comfort, better social life and family relations. These results highlight the importance of behavioral change and adherence to weight control as pillars of a better quality of life among overweight adolescents. Obesity management programs need to focus on multiple criteria of treatment effectiveness, such as obesity-related quality of life.

O sobrepeso representa um ônus adicional para o desenvolvimento do adolescente e pode provocar problemas físicos de psicossociais. Este estudo correlacional transversal teve como objetivo analisar a associação entre adesão terapêutica e qualidade de vida associada à obesidade entre adolescentes com sobrepeso. A amostra consistia em 94 adolescentes que frequentavam uma clínica pediátrica especializada em obesidade em Portugal (48,94% meninos; 51,06% meninas), com mediana de idade de 14,17 anos (DP = 1,51). Foi demonstrada uma correlação positiva entre qualidade de vida relacionada à obesidade e adesão ao controle de peso. O estudo mostra uma associação positiva entre a influência dos pais e cuidadores sobre a adesão ao controle de peso e o aumento do conforto físico e a vida social e relações familiares. Os resultados destacam a importância de mudanças comportamentais e adesão ao controle de peso como pilares para uma melhor qualidade de vida entre adolescentes com sobrepeso. Os programas para o manejo da obesidade devem priorizar múltiplos critérios de efetividade terapêutica, tais como qualidade de vida relacionada à obesidade.

El sobrepeso representa una carga adicional para el desarrollo del adolescente y puede provocar problemas físicos y psicosociales. Este estudio correlacional transversal tuvo como objetivo analizar la asociación entre adhesión terapéutica y calidad de vida, asociada a la obesidad entre adolescentes con sobrepeso. La muestra consistía en 94 adolescentes que frecuentaban una clínica pediátrica, especializada en obesidad en Portugal (48,94% niños; 51,06% niñas), con una media de edad de 14,17 años (DP = 1,51). Se demostró una correlación positiva entre calidad de vida relacionada con la obesidad y adhesión al control de peso. El estudio muestra una asociación positiva entre la influencia de los padres y cuidadores sobre la adhesión al control de peso y el aumento de confort físico, la vida social y relaciones familiares. Los resultados destacan la importancia de cambios comportamentales y de adhesión al control de peso como pilares para una mejor calidad de vida entre adolescentes con sobrepeso. Los programas para el manejo de la obesidad deben priorizar múltiples criterios de efectividad terapéutica, tales como calidad de vida relacionada con la obesidad.

Lifestyle and treatment adherence among overweight adolescents.

This study evaluated the influence of overweight adolescents' lifestyle on the adherence to weight control, and identifies their predictors. Participants were 94 adolescents, aged 12-18 years, attending a Paediatric Obesity Clinic. Lifestyle was assessed using the "Adolescent Lifestyle Profile" and treatment adherence through the "Therapeutic Adherence to Weight Control Questionnaire." Adherence to weight control was associated with various lifestyle domains. Several predictors were identified for lifestyle and adherence to weight control among overweight adolescents. A broad array of inter-correlations and predictors were identified and should be taken into account when designing adolescent weight control interventions.

Controlled trial of an Internet-based intervention for overweight teens (Next.Step): effectiveness analysis.

Adolescent obesity is a major health problem. The need for effective adolescent weight management programs is of high clinical and public health relevance. This study evaluates the effectiveness of an e-therapeutic platform (Next.Step), aiming to promote weight management skills and the adoption of health-promoting lifestyles. This nonrandomized clinical trial with control group uses a sample of 94 adolescents who attended a paediatric obesity clinic. The experimental group was invited to access the platform Next.Step during 24 weeks, in addition to the standard treatment program. The control group followed the standard treatment protocol and joined a waiting list. Overall, the outcomes of the e-therapeutic program were not substantially better than those obtained with a traditional kind of intervention despite the intervention being associated with an improved health responsibility score (d = 0.51; p = 0.014). Several predictors of the Next.Step effectiveness were found. CONCLUSION: Although the e-therapeutic program led to a significant increase in health responsibility, inconclusive results were found regarding the program effectiveness compared to the standard multidisciplinary intervention. The lack of significant differences between groups may be due to the reduced rates of program adherence and the high dropout rate. WHAT IS KNOWN: • Adolescent obesity has reached epidemic proportions, and standard treatment programs have been unable to achieve the desired adherence so far. • Internet-based programs have already shown positive results in the adult obese population, but information is scarce regarding adolescents. WHAT IS NEW: • This study assesses the effectiveness of a structured case management program including communication technologies on both the behavioural change and the health of obese adolescents. • The e-therapeutic program led to an increase in health responsibility.

Usability of an internet-based platform (Next.Step) for adolescent weight management / Usabilidade de uma plataforma na internet (Next.Step) no controle de peso de adolescentes

OBJECTIVE: The current study evaluates the usability perception of an e-therapeutic platform (supported by electronic processes and communication), aiming to promote the behavior change and to improve the adolescent health status through increased and interactive contact between the adolescent and the clinical staff. METHODS: This was a correlational study with a sample of 48 adolescents (12-18 years) who attended a Pediatric Obesity Clinic between January and August of 2012. Participants were invited to access, during 24 weeks, the e-therapeutic multidisciplinary platform (Next.Step) in addition to the standard treatment program. A usability questionnaire was administered and the platform performance and utilization indicators were analyzed. RESULTS: The users' perception of satisfaction, efficiency, and effectiveness regarding the Next.Step platform was clearly positive. However, only 54.17% of the enrolled adolescents accessed the platform, with a mean task-completion rate of 14.55% (SD = 18.853). The higher the number of the platform consulted resources, the greater the tendency to enjoy the platform, to consider it exciting and quick, to consider that the time spent in it was useful, to consider the access to information easy, and to login easier. Post-intervention assessment revealed a significant reduction in anthropometric and behavioral variables, including body mass index z-score, waist circumference percentile, hip circumference, and weekly screen time. CONCLUSION: These results highlight the importance of information and communication technologies in the health information access and the healthcare provision. Despite the limited adherence rate, platform users expressed a positive overall perception of its usability and presented a positive anthropometric and behavioral progress. .

OBJETIVO: O estudo atual avalia a percepção de usabilidade de uma plataforma e-terapêutica (apoiada por processos e comunicação eletrônicos), com vistas a promover a mudança comportamental e melhorar o estado de saúde dos adolescentes por meio do contato aumentado e interativo entre o adolescente e a equipe clínica. MÉTODOS: Estudo correlacional com uma amostra de 48 adolescentes (12-18 anos) que frequentaram uma clínica de obesidade infantil entre janeiro e agosto de 2012. Os participantes foram convidados a aceder, durante 24 semanas, à plataforma multidisciplinar e-terapêutica (Next.Step) e, além disso, a participar do programa de tratamento padrão. Um questionário de usabilidade foi administrado e foram analisados os indicadores de desempenho e uso da plataforma. RESULTADOS: A percepção de satisfação, eficiência e eficácia dos usuários com relação à plataforma Next.Step foi claramente positiva. Contudo, apenas 54,17% dos adolescentes inscritos acederam à plataforma, com uma taxa média de conclusão das tarefas de 14,55% (DP = 18,853). Quando maior o número de recursos consultados na plataforma, maior a tendência de gostar da plataforma e considerá-la excitante e rápida, pois o tempo gasto nela é útil e o acesso a informações e ao registro é mais fácil. A avaliação pós-intervenção mostrou uma redução significativa nas variáveis antropométricas e comportamentais, inclusive no z-score do Índice de Massa Corporal, no percentil de circunferência da cintura, na circunferência do quadril e no tempo de tela semanal. CONCLUSÃO: Esses resultados destacam a importância das tecnologias de informação e comunicação no acesso a informações sobre saúde e prestação de cuidados. Apesar da limitada taxa de adesão, os usuários da plataforma expressaram uma percepção geral positiva de sua usabilidade e apresentaram um progresso antropométrico e comportamental positivo. .

Usability of an internet-based platform (Next.Step) for adolescent weight management.

OBJECTIVE: The current study evaluates the usability perception of an e-therapeutic platform (supported by electronic processes and communication), aiming to promote the behavior change and to improve the adolescent health status through increased and interactive contact between the adolescent and the clinical staff. METHODS: This was a correlational study with a sample of 48 adolescents (12-18 years) who attended a Pediatric Obesity Clinic between January and August of 2012. Participants were invited to access, during 24 weeks, the e-therapeutic multidisciplinary platform (Next.Step) in addition to the standard treatment program. A usability questionnaire was administered and the platform performance and utilization indicators were analyzed. RESULTS: The users' perception of satisfaction, efficiency, and effectiveness regarding the Next.Step platform was clearly positive. However, only 54.17% of the enrolled adolescents accessed the platform, with a mean task-completion rate of 14.55% (SD=18.853). The higher the number of the platform consulted resources, the greater the tendency to enjoy the platform, to consider it exciting and quick, to consider that the time spent in it was useful, to consider the access to information easy, and to login easier. Post-intervention assessment revealed a significant reduction in anthropometric and behavioral variables, including body mass index z-score, waist circumference percentile, hip circumference, and weekly screen time. CONCLUSION: These results highlight the importance of information and communication technologies in the health information access and the healthcare provision. Despite the limited adherence rate, platform users expressed a positive overall perception of its usability and presented a positive anthropometric and behavioral progress.

Internet-based intervention programme for obese adolescents and their families (Next.Step): research protocol of a controlled trial.

AIM: This paper describes the design and rationale of a controlled trial that aims to determine the effectiveness of an intervention programme in which the internet is used. BACKGROUND: Adolescent obesity is a major health problem, there being urgency to find effective interventions that induce behavioural change. The inclusion of the internet in the intervention may improve adolescents' adherence to the weight management programme and lead to adoption of healthier lifestyles. DESIGN: A clinical trial with a control group (non-randomized). METHODS: Participants are adolescents with appointments at a paediatric obesity clinic (Portugal). Sample size was calculated according to the power analysis. The experimental group will follow the standard treatment protocol and receive free access to the e-therapeutic platform. The control group will follow the standard treatment protocol and join a waiting list. Intervention length will be 36 weeks (24 weeks of direct intervention with a follow-up for 12 weeks). This study was approved by the Ethical Committee for Health (Lisbon, Portugal) in January 2012 and funded by the Foundation for Science and Technology (Portugal) in December 2012. DISCUSSION: The results of this research will promote reflection on new approaches directed to treat adolescent obesity and on the promotion of healthy behaviours. We expect to gather empirical evidence of the intervention programme effectiveness. The expectations lie on the population health gains, empowerment in decision-making and adoption of healthier lifestyles.