Self-help group participation and empowerment in Hong Kong.

This paper reports on the first comprehensive study of self-help groups in Hong Kong. Initial findings from the quantative and qualitative data suggest that self-help group participation has an impact on intrapersonal, interpersonal and community/political empowerment. Based on existing data, this study has resulted in the development of a hypothetical model encompassing the interrelationships among self-help group participation, social support, social learning, leadership and empowerment, for testing in future research.

Key words: intrapersonal empowerment, interpersonal empowerment, community/political empowerment, social support, social learning, leadership

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Participation empowers! When participants interact with each other to make meaningful changes and to assert influences individually and collectively, empowerment occurs. Past research has shown that participation and empowerment are closely related (Berger & Neuhaus, 1977; Schulz et al., 1995; Rappaport, 1987; Zimmerman & Rappaport, 1988). However, this relationship may be complex and complicated. Itzhaky and Schwartz (1988) found that not all the elements of empowerment are affected by all the elements of participation. Itzhaky and York (2000) further suggest that the relationship between participation and empowerment can be erratic, although the former can well be an antecedent of the latter. When participation affects empowerment, the path can be direct, indirect or combined (Zimrnerman, 1990; Prestby et al., 1990; Chavis & Wandersman, 1990; Speer & Hughes, 1995).

Participation in self-help groups certainly help members to empower themselves (Chesler, 1991; Nylund, 2000; Mok, 2001). Self-help group activities empower members to cope with problems and stresses, and they also empower members in their relations with the organizations that serve them, and with the community where they live. Empirically, it was found that participation in self-help group activities is instrumental in reducing family burden, loneliness, and guilt-feeling, and at a macro-level, self-help group members' advocacy activities can affect government policies (Citron, et al., 1999; Medvene & Krauss, 1989). The strong correlation between self-help group participation and self-confidence, self-efficacy, civil responsibility, and political efficacy has also been supported in research studies (Florin & Wandersman, 1984; Zimmerman & Rappaport, 1988).

Various social science theories, such as the theories of affiliation, attribution, change, coping, deviance and social exchange provide some explanation of why participation in self-help groups empowers members. Steward (1990) concluded, after synthesizing some theoretical and empirical studies, that the provision of social support and social learning in self-help groups is the major factor in self-help group effectiveness. In a study of three organizations (one of which was a mutual help organization for persons with severe mental illness), Maton and Salem (1995) found that the reason why they are so empowering is because they have a belief system that inspires growth; an opportunity role structure that is pervasive, highly accessible and multi-functional; a support system that is encompassing, peer-based, and cohesive; and leadership that is inspiring, talented and shared.

The relationship between self-help group participation and empowerment has been widely discussed, but very few studies have been conducted in a Chinese context. Are self-help group members in Chinese communities empowered individually and collectively after joining these groups? What are the covariates of self-help group empowerment in such contexts? This paper explores and analyses these questions, based on a pioneering and comprehensive study of self-help groups in Hong Kong. It is contended that self-help group participation in Chinese communities should lead to individual and collective empowerment, as is the case in Western communities. It is further argued that participating in self-help groups will enable members to obtain social support and social learning opportunities which have a direct and indirect effect on empowerment. Finally, the author believes that the leadership of self-help groups could have an impact on empowerment. A hypothetical model with regard to the interrelationships among self-help group participation, social support, social learning, leadership and empowerment is developed for testing in future research.

In Hong Kong, self-help groups for vulnerable populations proliferated in the 1980's. They have been formed to serve a wide range of populations, including the mentally ill and their families (Ma, 1992), battered women (Ko & Chang, 1994), persons with disabilities and their care-givers (Chan, 1991), single parents (Cheung & Ng, 1989), and senior citizens (Mok & Mui, 1996). Patient self-help groups were also established by medical social workers, or other medical professionals to provide support and assistance for people with various chronic illnesses (Wong, 1996; Liu, 1997; Chan et al., 1996). Although self-help groups in Hong Kong have grown in an unprecedented speed, there has been little knowledge about their nature and operation. One of the reasons may be attributed to the lack of systematic research and solid methodological foundations. Little was known about how helpful self-help groups are to members, and what kind of social impact they have produced. The research component of the self-help phenomenon has clearly been eclipsed by the self-help movement itself.

Method

Using a simple random sampling method, 100 out of the 211 self-help groups that have been identified in a previous study (Mok et al., 2002) were selected and all members of the selected groups were invited to participate in this study during the period of December, 1999 to April, 2000. They were requested to fill out a structured, self-administered questionnaire in a group with the help of one or two research assistants, depending on the size of the group. These group interviews were normally arranged on the same day as the groups' regular meetings (before, during or after the meeting, according to their preference). If this was inconvenient or impossible, a special meeting for the purpose of this research was organized. The questionnaire was completed in about 30-45 minutes. Each participant was given a small souvenir of HK$15 (about US$2) as appreciation for their participation in the study. A total of 719 valid questionnaires were finally completed.

In addition to the questionnaire survey, in-depth interviews and participant observation were carried out with 10 groups, which were purposively selected to represent different types of self-help group. The aim of the in-depth interviews and participant observation, among others, was to understand how the groups empower the members, and why they succeed or fail to achieve their group goals.

In this study, the empowerment effect of self-help groups was studied from the members' perspective. Data collected was basically subjective, and the research adopted a cross-sectional survey design, supplemented by qualitative, in-depth interviews and participant observation. Ideally, objective data from a more rigorous design such as experimental or quasi-experimental design would yield more reliable and valid findings. However, given the exploratory--descriptive nature of this study (the first Hong Kong-wide research), the present design and method of data collection are viable and realistic approaches. It is also noted that in the self-help research literature, the use of subjective measurements and a cross-sectional survey design are acceptable, although not necessarily conventional practices.

Background of Respondents 

There are many different self-help groups in Hong Kong based on the types of common problem that members share. In this study, respondents participated in a variety of these groups, ranging from groups for the chronically ill, groups for persons with mental illness, groups for the physically and mentally disabled, to other social/marginal groups such as single parents, families on welfare, divorced women, new arrivals from Mainland China, and rehabilitated drug abusers. The findings show that most respondents belong to the chronically ill groups (46.7%) followed by those who are members of the physically/mentally disabled groups (21.8%), the social/marginal groups (16.6%) and the mentally ill groups (14.9%). There were more female than male members in all groups, especially in the social/marginal groups which had many single parents, families on welfare and new arrivals from Mainland China. Most respondents were between 30-60 years old, indicating that most self-help group members are normally adults or older persons. The majority of respondents had a low educational level, ranging from primary level or below (34.8%), to lower secondary education (24.9%). This is especially true for the social/marginal groups, with 76% of the members having an educational level of lower secondary or below. Over 60% of the respondents were married, but a substantial number were divorced (9.2%) and widowed (7.9%). Again, the figures for the social/marginal group members (34% and 13% respectively) were significantly higher than those of other groups. On employment status, about one third of the respondents were employed in one way or another and 12% were unemployed. It was noted that over half of the respondents were either housewives (31.8%) or retired (19.2%).

The findings also show that respondents' participation in their self-help groups is not particularly long; three quarters of them remained with their group for four years or less. Their participation in the groups, however, is regular and for some members, quite frequent. Most of them (37%) attended group meetings/activities monthly, while some did so weekly (10 %) and bi-weekly (18%).

Self-help Group Participation and Empowerment

As pointed out rightly by Rappaport (1985), the absence of empowerment is easy to notice, but its presence is difficult to define. Over the years, researchers have attempted to operationalize the concept of empowerment in various ways (Rappaport, 1987; Zimmerman, 1996; Dunst et al., 1992; Zimmerman, 1995; Rich et al., 1995). In this study, empowerment is conceptualized as a process through which members of self-help groups gain power at intrapersonal, interpersonal and political/community levels (Parsons, 1995; Gutierrez et al., 1998). Intrapersonal empowerment was measured by the self-help group members' perception of their ability to make personal changes or choices. Measures of interpersonal empowerment include the extent to which members can relate positively to others. Political/community empowerment was measured by members' perception of their ability to influence community attitudes and social policies.

A total of 14 statements / questions on the three levels of empowerment were posed to the respondents, and their answers are summarized below.

The findings clearly indicate that members of the self-help groups surveyed had a rather strong perception of being empowered as a result of self-help group participation. At the intrapersonal level, an overwhelming majority of the respondents felt that since joining the self-help group, they had became more positive (95%), more hopeful (92.6%), more open (91.2%), more gregarious (93.3%), more decisive in taking action (88.5%) and most importantly, more confident in solving their problems (93.7%). At the interpersonal level of empowerment, there was also a great majority who responded that since joining their self-help group, they had become more capable of helping others (93.1%), had learnt to care for others (95.6%), to get along well with others (95.2%), and to understand more about their rights (94.6%) and obligations (92.7%) in society. In terms of political/community empowerment, a substantial number of respondents (53.1%) agreed that their self-help group could help to change society's attitudes towards vulnerable populations, to become more understanding and accepting, and less discriminating. However, when asked about whether their self-help group could impact on social policies, such as welfare, health and housing policies, only one third of them agreed. This finding indicates that members' sense of community/political empowerment is not as strong as their sense of intrapersonal and interpersonal empowerment.

Members' feeling of being empowered in the self-help groups was further supported by the data obtained in the in-depth interviews. As an example, a stoma cancer patient used to be very dependent on the advice of his doctor but later developed strong confidence in problem solving by means of sharing and joint effort in the group. He said: "The doctors give you theory, that is, they talk about how things can be theoretically. But on a practical level, it can be our problem. An example is farting. As long as we move our body, there will be gas. Then the bag will be inflated. The doctor's advice is that you go to the toilet and let go of the air. But how can you go to the toilet all day to let go of the air? So we teach them to pin a hole in the bag and tape it. Then we just have to take off the tape and put it back, then the smell will not go out as much."

This feeling of empowerment did not stop at the individual level, but extended to the interpersonal level. A member of a pneumoconiosis self-help group recalled an unforgettable experience when he visited another group member who was admitted to the hospital because of breathing difficulty: "When he saw me, he started crying and holding my hands with his hands tightly. He was a quiet member in the group, but this time I saw him, he had so much to talk to me about. I felt that my sheer presence there was so warm, so helpful and so therapeutic to him. I felt that I could help others and could make a difference."

In some instances, the self-help groups acted collectively to express their concern on matters affecting their lives, to change community attitudes and to fight for their rights. For example, a self-help group for the physically handicapped complained to the Equal Opportunity Commission about the lack of public facilities in the building of their office to cater for their special needs. They also met with officials of the Transport Department and bus companies to voice their concern on the mass transportation system with regard to the needs of the physically handicapped. A parent group (with cleft lip and palate children) has actively organized exhibitions, media interviews and community education programs to eliminate community misunderstanding towards, and discrimination against cleft lip and palate patients, and to seek support and acceptance from the general public.

In short, responses from the questionnaire and in-depth interviews pointed to the same conclusion: Self-help group participation has an empowerment effect, intrapersonally, interpersonally and collectively.

Social Support and Social Learning in the Self-help Groups

Why are self-help groups so empowering? Two possible factors were identified in this study: Social support and social learning.

Members of self-help groups perceive that they obtain a great deal of benefit from their groups in terms of receiving help from others (94.4%), meeting others with similar problems (98.5%), developing coping strategies (96.9%), knowing more about social resources (96.8%) and fostering a sense of belonging to the group (96.6%). The support they experienced through the self-help group was overwhelming as evidenced by their highly positive answers to the statements in the questionnaire.

Indeed, one of the biggest benefits of joining self-help groups is meeting people who have the same condition when feelings of pain and suffering can be shared, and mutual support developed. The following statements from members of self-help groups are revealing:

"Very often when you are sick, the most important thing is fear. How do I care for myself? There are a lot of worries. Even relatives and friends may not be able to help because they may not understand. When patients get in touch with cancer self-help groups, they find many peers here. They feel a strong sense of identification and support. They often see many friends here. So many people give their testimonials and everyone is sitting here. If they ask around, they will find this one got the disease so many years ago, the other one so many years ago, etc. Somehow they feel some kind of encouragement indirectly."

"The treatment is a huge challenge to cancer patients because the process is quite tough and painful, both physically and mentally. They are really tough. But very often they get support from other patients here. Sometimes the treatment is hard and they would call here. When we exchange greetings, we already feel the support. Sometimes we talk about how badly we throw up, or how many times we throw up. Oh yeah, that time I threw up eight times. If you throw up five times it is not that bad. Sometimes it is fun. Sometimes just these conversations can make us feel better."

"We feel that this group of people are all waiting at the specialty clinic because this is a special clinic for cleft lip and palate children ... When us parents sit together, we would talk. As long as we are carrying a child with cleft lip and palate, we would sit together and talk and share our care for the kid. Then we would feel better."

In addition to social support, the self-help group provides ample opportunities for social learning for its members. As recalled by members, there were many activities related to formal and informal instruction, and role modeling. For example, the single parents' group regularly held training courses on personal development, parenting skills, household maintenance and voluntary social services; the group for families of mental patients organized medical and health seminars and communication workshops to enable group members to take care of their loved ones at home; and the parents' group of cleft lip and palate children held medical seminars with topics surrounding reconstructive surgery, dentistry, orthodontics, and speech theory. The cancer self-help group, on the other hand, conducted activities that were of a more philosophical nature. The chairman of the group said: "Our education: The ultimate fear of a cancer patient is death. Everyone is afraid to die. We teach them to accept death. To put it simply, of course we cannot name the topic to be death. We have had a large-scale lecture for three weeks in a row. The title is the value of life. That is, we use different names to describe these seminars, hoping to educate our members. We welcome people from outside too. We would like them to accept this matter of death ... that it is something unavoidable. So if you can accept death, what else are you afraid of? That's the only fear you have ... Right? The worst is you are going to die. If you are not even afraid of death, we hope ... that is, the time you have now is precious."

The regular self-help group meetings are important events for members to listen to others and learn to cope with their own problems. This type of informal learning occurred all the time in each of the 10 self-help groups under study. More significantly, members' social learning was not limited to dealing with their personal and emotional problems. They also learned more about their rights and the social resources that are instrumental to promoting their well-being.

Role modeling was common according to those members involved in the in-depth interviews. In the parents' group of cleft lip and palate children, experienced members were responsible to guide the incoming parents of affected newborns in all aspects. They exchange phone numbers so that immediate advice and help can be provided. The parents' group for the mentally ill children identified some senior members to teach the new members the best ways to take care of their children.

The preceding analysis indicates that self-help groups provide tremendous social support for members and they create ample opportunities for social learning in the group. Attaining social support and the benefit of learning from others appears to make members feel stronger, help them foster a spirit of hope and enable them to develop a higher level of social consciousness.

Leadership and Empowerment

The findings from the in-depth interviews show that strong leaders have a formidable impact on the formation, development and survival of the self-help groups.

The cancer self-help group is a typical example: Its founder was a breast cancer survivor. After recovering from breast cancer, she intended to do something to help breast cancer patients. As a result, she opened a shop selling products to breast cancer patients such as artificial breasts and special bras to suit their special needs. Every time she did business with the customers, she showed concern for their health condition and had much to share with them about her own rehabilitation experience. Her conviction that she could provide information on cancer rehabilitation and give emotional support to her customers, convinced her that she should set up a sharing group for breast cancer patients. The first meeting was held in a corner of the shop and attended by nine people. However, as the meetings continued, progressively more people were attracted to join the group.

As the group grew bigger, the shop became too small for the meetings. With the help of a social worker, the group was able to secure financial support from the Hong Kong Cancer Fund to rent a place for regular meetings and to hire a full-time staff officer to implement its services. At this point, the founder believes that in helping others, the group members were actually helping themselves in building up their confidence and ability to solve their own problems. She encouraged group members to visit other cancer patients in the hospital to give them support and encouragement.

Under the strong leadership of the founder, the group has grown from a small group of 9 people to a larger group consisting of over 1,000 members. The founder, together with other leaders in the group, have decided to join the Alliance for Patient's Mutual Help organizations which is renowned for its social action activities. In so doing, they believe that they could further benefit members by influencing social policies and fighting for their rights.

Conclusion and Discussion

In this study, a major finding from the quantative and qualitative data indicates that self-help group participation has an empowerment effect on participants individually, interpersonally and collectively. However, the finding also shows that while an overwhelming majority of respondents have attained a high degree of intrapersonal and interpersonal empowerment, a remarkably smaller number of them felt that they could impact on social policies or public attitudes. This is in contrast with the situation of self-help groups in Western countries. In the United States of America, for example, self-help groups have been in the forefront of social change they not only empower individuals, but also lead to political activism. Gartner & Riessman (1998) pointed at that the self-help movement has become an important part of the social fabric of American life and that self-help represents a new political potential. In Finland, a study (Nylund, 2000) shows that over 40% of self-help groups have socially oriented goals, including collective goals to promote employment, prevent social exclusion and raise the status of single parents; welfare reform goals to provide better welfare and unemployment benefits and promote cooperation between patients and professionals; and advocacy goals to influence legislation and alter public attitudes.

Why then, have Hong Kong self-help group members felt relatively powerless in influencing social policies? First, self-help groups in Hong Kong are still in the early stage of development. Most groups devote their energy and resources to helping members cope with their personal problems, and impacting on social policy is not seen as their priority. Secondly, most self-help groups in Hong Kong serve the vulnerable populations--the chronically ill, the disabled, and the socially handicapped. It is not surprising to find that they often feel powerless and consumed with low-esteem. Finally, the small size of most self-help groups in Hong Kong is a significant negative factor affecting their ability to influence social policies. Therefore, it is important for self-help groups in Hong Kong to organize and form links with each other, so that they can impact on policies that affect their lives.

Another major finding in this study suggests that social support, social learning, and leadership are closely linked with empowerment. While social support and social learning were identified as possible contributing factors to self-help group empowerment, strong leaders were considered instrumental in empowering members individually and the group as a whole. This finding is consistent with the theories and empirical findings in the self-help literature (Bloom et al., 1991; Caplan, 1979; Cohen & Wills, 1985; Bandura, 1986; Katz, 1993; Kurtz, 1997; Maton & Salem, 1995; King et al., 2000). However, the linkage among the major variables as shown in this study is preliminary. The interrelationships of self-help group participation, social support, social learning, leadership and empowerment have been explored but not yet firmly substantiated. Based on existing data, a hypothetical model of self-help group participation and empowerment is presented below:

The model proposes that social support and social learning are two important social/psychological processes affected by self-help group participation and self-help group leadership, and both processes are believed to bolster empowerment. Specifically, self-help group participation and self-help group leadership have a direct effect on empowerment, social support and social learning, and they also have an indirect effect on empowerment through their interaction with social support and social learning. In turn, social support and social learning affect empowerment directly.

Implicit in this model is a set of research questions that need to be asked and answered. For example: To what extent does the length and intensity of self-help group participation affect different levels of empowerment (intrapersonal, interpersonal and collective/community/ political levels)? What is the impact of leadership style (democratic vs. autocratic) and nature of leadership (lay vs. professional) on empowerment? How do SHG participation and leadership interact with social support and social learning in producing an indirect effect on empowerment? What degree of impact do social support and social learning have on empowerment?

This model is intended to be hypothetical as the relationships among the major variables requires further empirical evidence if firm conclusions are to be drawn. Though hypothetical, it provides direction for future self-help research in Hong Kong. Findings from this study indicate that self-help group participation empowers participants, but further and more specific analyses of self-help group effects are warranted.

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BONG-HO MOK

The Chinese University of Hong Kong

Department of Social Work