The clients targeted in this study are adults with chronic health problems who receive home care services. The Ministère de la Santé et Services sociaux du Québec 9 identifies chronic diseases as the most important health problem of the century: "Chronic diseases develop slowly, persist over time, are often incurable and result in a disability and, above all, they claim many victims. Four chronic diseases are responsible for more than 70% of deaths in Québec every year. They are, in order of importance, cancers, cardiovascular diseases (CVD), respiratory diseases and diabetes." In the Eastern Townships alone, 51.4% of the population suffers from at least one chronic health problem and 19.7% live with activity limitations 10. The main health problems found in the Eastern Townships and particularly the City of Sherbrooke are cardiovascular and respiratory diseases, diabetes and breast cancer 1112. These health problems often lead to long-term activity limitations requiring home care services 12. Moreover, family members (caregivers) frequently help with the care of individuals suffering from one or many chronic diseases and with the daily management required by these types of diseases. It was estimated that in 1996, 2.8 million Canadians aged 18 years and older provided help for a person with long-term limitations 13. In order to improve the health status of this clientele and family support, Québec's homecare services have adopted a framework that advocates interventions promoting empowerment. These interventions are aimed at enhancing clients' potential to learn and use the tools they need to live as independently as possible and to maintain or improve their own and their family's quality of life 1415. The interventions promoting empowerment can be conceptualized as being part of a process that enables the development of the capacity to choose, to make sound decisions and to act according to one's preference 16. This in turn, according to Dunst and Trivette 17, increases the person's control over his or her life and is associated with various cognitive attributes, such as intrinsic motivation, self-efficacy and self-awareness. According to this perspective, it is possible for a person to learn to be more independent, to adopt healthier lifestyles and to relate better to his or her social environment and network.

Research has shown that professional home health care providers frequently mention the use of interventions promoting self-care when describing their work. Their description of the interventions indicates that their professional expertise is employed within a collaborative relationship 118. More research is needed to examine how empowerment interventions unfold in real-life practice settings 2. This is particularly important since the home care sector seems to assume that their programs are empowering 79 although there is little empirical evidence supporting this claim. With the transition of health care services to the community and the ever-increasing emphasis on empowerment, the time seems right for a study observing interventions with clients suffering from chronic health problems who require home care services 45.

In the context of this study and based on prior work by members of the research team, the term enabling interventions refer to professional interventions that promote empowerment. The terms individual empowerment refers to the impact of these interventions on the persons receiving them 124561920.

Empowerment research is first and foremost theoretical in nature and there is very little empirical information on the full extent of the phenomenon. The available data are predominantly from studies examining the process of community empowerment with groups of individuals representing extreme cases of isolation, such as persons with disabilities and persons who are economically underprivileged 212223. Empowerment has also been studied in reference to closely related concepts such as compliance, coping and self-care. However, these concepts are limited compared to the more comprehensive approach associated with the phenomenon of empowerment. In fact, these closely related concepts could be part of a larger empowerment construct 6. Despite these limitations, prior studies have identified many essential attributes of enabling interventions for communities and individuals.

Among authors who have attempted to define the attributes of empowerment interventions, Gibson 24 states that this type of intervention focuses more on the individual's strengths, rights and capabilities than on his or her shortfalls. This approach implies that people are seen not as powerless victims but as being able to identify solutions for their well-being 25. In addition, enabling interventions must help people develop their "self-solutions" 26. Cardone and Gilkerson 27 and Dunst and Trivette 17 maintain that considering persons as possessing knowledge rather than as recipients of professional knowledge enhances the use of their own competencies. In a study with families living in extreme poverty, Ouellet et al. 22 observed certain characteristics that influence enabling interventions, such as follow-up duration and intensity, the availability of the health care professional and intervention flexibility. Zerwekh 28 states that interventions promoting empowerment require a balance between the care recipient's initiatives and those of the health care professional. Strategies that foster a person's empowering capabilities include: 1) listening to concerns; 2) supporting awareness of alternatives; and 3) broadening possibilities. For their part, Paul et al. 1 maintain that enabling interventions are founded on the latitude given to a person within the intervention and take into account the individual's experiences and perceptions of his or her reality. In a prior study, five dimensions that comprise enabling interventions were identified. They are interventions that: 1) develop and maintain a therapeutic relationship; 2) are based on a person's point of view and strengths; 3) encourage and support the decision-making process; 4) help to broaden possibilities; and 5) facilitate the learning experience 2. Some studies show that in order to facilitate empowerment, an egalitarian relationship must be established with the person having difficulties 222829, a relationship based on collaboration and that is respectful of the person's experience and ability to seek solutions to his or her problems 30. The relationship also implies that the person is able to define his or her own needs 2. To date, very few studies have described the context in which professional interventions unfold with people needing home care services.

Interventions that encourage empowerment are influenced by the community health care professionals' perceptions and modes of understanding and their ability to interact with the people involved 1721. According to Labonté 31, empowerment exists as a conceptual lens through which professional practices can be revaluated. Some factors might restrain the application of enabling interventions by health care professionals and compromise their enabling effect: 1) a vision of the situation focused primarily on problems and the person's deficits 24; 2) a misunderstanding of the person's own resources 32; 3) a stereotypical attitude towards a person's abilities and limitations influenced by social class and family structure 33; 4) a tendency to consider the professional point of view as reliable and to disregard that of the care recipient; 5) different and sometimes opposing views on the definition of power between the help-giver and the help-seeker and on the distribution of power within the intervention 3435; and 6) the professional's experience and feelings of self-efficacy related to the intervention 2. When examining interactions between professionals and their clients, it is imperative to take into account clients' perceptions of their own abilities, limitations and needs as well as their vision of the interactional process.

Individual empowerment reinforces various behaviours and encourages the person to take more control over events and important situations in his or her life 17. Drolet 36 mentions that individual empowerment contributes to the development of problem-solving skills and increases self-esteem and self-efficacy. St-Cyr-Tribble et al. 2 identified several indicators of individual empowerment. These indicators are: 1) awareness of one's life situation, own strengths and needs; 2) increase in self-esteem; 3) decrease in negative feelings; 4) well informed decision-making; 5) learning and developing skills; 6) taking action; 7) developing relationships with the social support environment and network; and 8) improvement in living conditions. These dimensions of empowerment correspond to what Rissel 35 called psychological or individual empowerment in his community empowerment model. Empowerment is a long-term process of change 3738, a dynamic phenomenon comprising a number of steps or phases, but there is no consensus between authors concerning the whole process. Usually the process starts with an awareness phase and ends with an action phase, be it individual or collective in nature 35. The awareness phase is often generated by a crisis or contextual change 223739. Studies that have explored aspects of individual empowerment rarely did so in the context of home care services. Furthermore, most results are based on representation and not on observations of the intervention process itself. Therefore, there is almost no information concerning indicators associated with the efficacy of these interventions.

Some authors believe there is a link between personal resources and the individual empowerment process 1938. For example, having good solid values, using available resources, being responsible, possessing internal strength, being able to improve one's self-confidence or desiring a better future are all linked to the empowerment process 21. The latter two elements have also been noted in research done by St-Cyr Tribble et al. 2. Living conditions such as poverty and the quality of the social environment, and especially social support, can hinder the individual empowerment process and maintain helplessness 2140.

A few evaluative studies on the efficacy of enabling interventions have been carried out in the field of family services. These studies mostly used data from interviews with health care professionals and their clients to gather information on the interventions and their outcomes. To our knowledge, only Gibson 41 has used participant observations to examine the process of individual empowerment in mothers with a child suffering from a chronic disease. Gibson's study did not focus on the intervention process per se. Because the intervention process can be seen as being in constant flux between the clients' individual characteristics and their particular contexts 42, it is necessary to study empowerment intervention in all its complexity. The enabling intervention should be examined in its natural context and should take into account the client's point of view. It is then possible to determine the indicators of these interventions in terms of their agreement with the literature, on the one hand, and with health care professionals' and clients' perspectives on the other.

The principal aim of the study is to document the empowerment process (empowerment interventions and individual empowerment) of adults receiving home care services and their caregivers. More specifically, the objectives of the study are to: 1) describe the modes of actualization of enabling interventions in the home care setting; 2) describe the individual empowerment process of home care clients; 3) obtain the caregivers' (professionals and lay persons) views on empowerment interventions, the process of individual empowerment and the integration of knowledge; 4) examine the relationship between empowerment interventions and the process of individual empowerment of home care clients; 5) describe the contextual elements facilitating the implementation of empowerment interventions and individual empowerment; and 6) document the transfer and integration of knowledge between the research team, health care professionals, lay persons, caregivers and home care clients of the community health division of the CSSS-IUG of Sherbrooke.

The concept of empowerment is studied from an individual perspective even though the phenomenon comprises a collective component 3543. From an individual perspective, empowerment is a social process whereby the acquisition of skills by the person to satisfy his or her needs, resolve his or her problems and mobilize the necessary resources to take control over his or her life is recognized, supported and valued 34.

A mixed qualitative design combining a fourth generation evaluation and case studies 4445. The fourth generation evaluation serves as a collaborative approach that encourages dialogue between the actors in the ongoing research. A steering committee composed of investigators, "on-site" co-investigators and administrators has been created and will be responsible for the planning and progress of the study, coordinating communications and maintaining interactions with the practice setting as well as integrating the research findings. An on-site follow-up committee composed of health care professionals will help define contact modalities with clients, and contribute to the validation of research evaluation tools, revision of the analyzed data and development of clinical tools. The case study approach will contribute to the understanding of how enabling interventions influence the individual empowerment process for clients and their caregivers receiving home care services.

A theoretical sample 46 will comprise 15 health care professionals (nurse, psychosocial professional, respiratory care therapist, etc.) working in the home care program of a CSSS and 30 individuals aged between 18 to 64 years who have chronic health problems such as diabetes, cardiovascular and respiratory disease and are receiving home care services. The age range was chosen to allow maximum variability when studying the concept of empowerment with adults. Caregivers will also be asked to participate in an interview, for a possible maximum of 30. Caregivers are defined as individuals providing long term care to a member of their family, a friend, or a neighbour suffering from a chronic disease 47. The clients will designate a person they consider as a caregiver among their social network. Participants' inclusion criteria are presented in Table 1. The decisions regarding the sample size of this theoretical and purposeful sample study are based on qualitative research's criteria 446. One of the principal criteria is that the amount and the depth of the data collected (n = 4 methods) is more important to achieve the aims of a qualitative study than the number of participants. Another criteria is saying that triangulation of multiple methods design (in this study: evaluative and cases study), types of participants (home care professionals, n = 15; clients, n = 30; caregivers, n = 30), numerous research tools (n = 9), are all insuring the rigor of the process and providing strong substantiation of constructs. Another reason has been influencing the decision making on the sample size. This study on empowerment intervention has been inspired from the results obtained and tools elaborated in other studies on the phenomenon that were conducted by the present group of investigators, thus giving room to methodological experience supporting the sample choice 234561420.

Four methods of data collection will be used: direct observations of home care visits, semi-structured interviews, focus groups and socio-demographic questionnaires (see Table 2). A non-participatory direct observation will provide in situ data during the intervention process 48 and shed new light on the integration of empowerment interventions in professional practice and provide evidence regarding the client's individual empowerment process. The strategy used to select cases for the observation of home visits is an adaptation of the critical incident and case study method 4950. Participating health care professionals will intentionally select two cases from their caseloads.