SELF EMPOWERMENT IN PATIENT WITH CHRONIC DISEASE: A LITERATURE REVIEW

Chronic disease is the highest cause of death in the world and Indonesia which can affect patient's quality of life. One of the key factors for a good patient's quality of life is empowerment. Self-empowerment is important for patients in making decisions with health professionals regarding the patient's health. The aim study was to explore self empowerment in patient with chronic disease. The methods was a narrative literature. The selection process of articles using PRISMA flow diagram. The databases used Science Direct, Pubmed, and Google Scholar. This literature review revealed five (5) articles focus on patient empowerment and six (6) articles about intervention related to empowerment. Patients empowerment develops in line with the increasing of self-efficacy and selfmanagement. Empowerment can also improve the relationship between patients and health professionals. The interventions related to empowerment, including health education, empowerment based on experiential learning, energy conservation, mobile-health technology. Patients with chronic disease have a responsibility in managing their disease. Therefore, empowerment becomes important in patients with chronic disease. In addition, empowerment can also improve health outcomes. An effective intervention in increasing empowerment is to provide health education to patients and families about the illness.

in joint decision making and empowerment can occur when patients accept responsibility for their health. Patients can learn to solve problems with information and support from health professionals. Patient empowerment begins when health professionals believe that patients can control their care and aims to increase the patient's capacity to think critically and make their own decisions about their health (Kambhampati et al., 2016). However, the existing research mostly examines empowerment in a single disease. Therefore, examining empowerment in different conditions and populations will allow for an increase in information and understanding about the empowerment of these patients. This literature review aimed to analyze the self empowerment of patient with chronic disease.

METHODS
The databases used to search for literature were Science Direct, Pubmed, and Google Scholar. The keywords were empowerment OR self empowerment OR patient empowerment, and chronic disease OR chronic illness. The inclusion criteria for this study were chronic disease patients, articles published in 2015-2020, indexed by SINTA or SCIMAGO, using Indonesian or English. This study excludes research that uses the method of Meta-analysis, Systematic review, literature review. A literature search using the PRISMA flowchart ( fig.1). There are 4 stages in the search: identification, screening, eligibility, and included. At the identification stage, about 2700 journals were identified. After the screening and eligibility stages were carried out, finally there were 11 journals included.

RESULTS
This literature study contains 11 journals used, 5 of which discuss empowerment, and 6 journals discuss interventions related to empowerment. Chronic diseases discussed include coronary heart disease, chronic disease, diabetes mellitus, chronic kidney failure, liver cirrhosis, and cancer. Journal publications from 2015-2020 with different place settings, namely Southeast Sweden, Sub-Saharan Africa, Turkey, Ireland, China, Italy, and Indonesia. The highest number of respondents was 242 and the lowest was 20 respondents aged over 18 years.
Research by Kärner Köhler, et al. (2018) stated that the self-empowerment of patients with coronary heart disease had an average score of 3.69 (149 participants) with a range of 1-5 values. Em-powerment correlates with marital status, self-assessment of health, well-being, gender, and age (Kärner Köhler et al., 2018). In addition, empowerment also has a correlation with employment status, education status, diabetes education, diabetes complications, chronic diseases other than diabetes and social support (Arda Sürücü and Büyükkaya Besen, 2017). Empowerment also correlates with the frequency of selfcare behavior of diabetic patients (Eyüboglu and Schulz, 2016).
Empowerment can also improve the relationship between patients and health care providers. The patient's active attitude is also needed in managing patient's active attitude is also needed in managing his condition better (Bailo et al., 2019). In HIV patients, the role of support for fellow survivors in the form of exchanging experiences, education about daily activities, and discussing intimate matters can make a person have self-identity, self-esteem, a positive life, and self-acceptance, especially for their disease (Angwenyi et al., 2019). ).
Efforts to increase empowerment are considered important to do. Therefore, several interventions can increase empowerment, including health tions can increase empowerment, including health education that can increase the value of empowerment in coronary heart patients (Wahyuni and Rezkiki, 2015). In addition, health education using empowerment theory can also improve knowledge and health behavior in liver cirrhosis patients for the better (Zhang et al., 2019).
Another intervention carried out in patients with diabetes mellitus is experiential learning-based empowerment that can improve patients in managing their disease (Ernawati et al., 2015). In addition, empowerment-based self-management interventions empowerment-based self-management interventions also provide impact on increasing the value of empowerment in patients with diabetes mellitus (Cheng et al., 2019). The intervention carried out by Ritianingsih and Nurhayati (2019) regarding energy conservation techniques with self-empowerment in conservation techniques with self-empowerment in chronic kidney failure patients influences on improving the quality of life of patients. In addition, the research of Doyle et al. (2019) regarding the application of the Mikidney application in supporting the empowerment of chronic kidney failure patients in handling patients' health conditions. Patients are more aware of their condition and have more information about new diseases, diet, and exercise that can be done after implementing this application on their cellphone.

DISCUSSION
Self-empowerment is defined as the ability of individuals to control themselves over decisions related to health (Woodall et al., 2010). This increase in self-empowerment goes hand in hand with increasing self-management and self-efficacy.
Empowerment is a modern and latest research to activate the role of the patient and with patient-centered care, the patient will be more independent at home. The support of people around both families and health workers provides benefits to individuals in being responsible for their care (Bailo et al., 2019). This is supported by research by Riyadi and Muflihatin (2021) which states that family support can provide positive energy and individual motivation in self-management.
Self-empowerment can be influenced by several factors, one of which is education and educational background. This is supported by research conducted by Ramadhan (2019) that education can increase patient knowledge which will affect the patient's belief in therapy and self-efficacy, both of which can affect self-management. In addition, social support and age can also affect empowerment. This is supported by research by Toar (2020)  Cross sectional 167 1. Patient empowerment influence patient health behavior. 2. Health literacy has no effect on health behavior because selfcare in diabetic patients is easy to understand, therefore it does not require higher cognitive abilities to understand advice from health professionals. 3. Selfempowerment more effective than health literacy 4. Health literacy give positive impact to clinical decision, meanwhilepatient empowerment give the impact to health behavior

CONCLUSION
Self-empowerment is a key factor in improving health outcomes, communication between patients and health care providers, and medication adherence. Interventions that are considered effective in increasing empowerment are by providing health education or education to patients and families with the help of health service providers. Several methods applied in providing health education are considered effective, including discussion methods, exchanging experiences, and health education with empowerment.