Ijerph 18 02247 v2 1

International Journal of
Environmental Research
and Public Health
Article
Enablers of Patient Knowledge Empowerment for
Self-Management of Chronic Disease: An Integrative Review
Vestina Vainauskienė * and Rimgailė Vaitkienė
School of Economics and Business, Kaunas University of Technology, 44239 Kaunas, Lithuania;
rimgaile.vaitkiene@ktu.lt
* Correspondence: vestina.vainauskiene@ktu.lt; Tel.: +3-706-204-0281
Abstract: The non-development of the concept of patient knowledge empowerment for disease
self-management and the non-development of the theory of patient knowledge empowerment
in patients with chronic diseases, cause methodological inconsistency of patient empowerment
theory and does not provide a methodological basis to present patient knowledge empowerment
preconditions. Therefore, the aim of the present integrative review was to synthesize and critically
analyze the patient knowledge enablers distinguished in the public health management theory,
the knowledge sharing enablers presented in the knowledge management theory and to integrate
them by providing a comprehensive framework of patient knowledge enablers. To implement the
purpose of the study, in answering the study question of what patient knowledge empowerments
are and across which levels of patient knowledge empowerment they operate, an integrative review
approach was applied as proposed by Cronin and George. A screening process resulted in a final
sample of 78 papers published in open access, peer-review journals in the fields of public health
management and knowledge management theories. Based on the results of the study, the Enablers

of Patient Knowledge Empowerment for Self-Management of Chronic Disease Framework was
Citation: Vainauskienė, V.; Vaitkienė,
created. It revealed that it is important to look at patient knowledge empowerment as a pathway
R. Enablers of Patient Knowledge across the empowerment levels through which both knowledge enablers identified in public health
Empowerment for Self-Management management theory and knowledge sharing enablers singled out in knowledge management theory
of Chronic Disease: An Integrative operate. The integration of these two perspectives across patient empowerment levels uncovers a
Review. Int. J. Environ. Res. Public holistic framework for patient knowledge empowerment.
Health 2021, 18, 2247. https://
doi.org/10.3390/ijerph18052247 Keywords: patient knowledge empowerment; patient knowledge enablers; empowerment levels;
self-management; chronic disease; health management; knowledge management; integrative review
Academic Editor: Paulo Santos
Received: 23 January 2021

Accepted: 19 February 2021
1. Introduction
Published: 24 February 2021
The mission of the modern public health system is to improve the health of the
Publisher’s Note: MDPI stays neutral
population and reduce health inequalities through organized institutional and community
with regard to jurisdictional claims in
effort. Chronic diseases are identified as a sustainability challenge for European health
published maps and institutional affil- systems, as the growing scale of chronic diseases due to an aging population and increasing
iations. life expectancy requires increased financial investment and an effective response to patient
needs and expectations. Meanwhile, research agrees that the paradigmatic shift in approach
to chronic disease patients from disease-oriented to patient-oriented, as an active healthcare
partner is important in this context [1]. The patient, as an active partner, could self-
Copyright: © 2021 by the authors.
manage the disease, make rational, day-to-day decisions related to their health condition to
Licensee MDPI, Basel, Switzerland.
ensure health behavior [2,3]. Health behavior in patients with chronic diseases reduces the
This article is an open access article
financial burden on the healthcare sector [1,4], and active collaboration between patients
distributed under the terms and and healthcare institutions facilitates the identification of patients’ needs and expectations.
conditions of the Creative Commons An essential precondition for patient self-management of the disease is patient em-
Attribution (CC BY) license (https:// powerment [3,5]. Patients are empowered to make independent disease management
creativecommons.org/licenses/by/ decisions and to be responsible, primarily when they have knowledge about their dis-
4.0/). ease [3,5] and can use it purposefully in taking these decisions. However, the purposeful
Int. J. Environ. Res. Public Health 2021, 18, 2247. https://doi.org/10.3390/ijerph18052247 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 2247 2 of 24
use of empowered patients’ knowledge needs specific preconditions called knowledge

enablers.
There are several areas in the scientific debate on patient knowledge empowerment for
self-management of disease. The concept of patient empowerment is still being developed;
this highlights its heterogeneity and multidimensionality. In particular, the concept of pa-
tient empowerment is being developed in the contexts of different chronic diseases [2,4–7],
which presupposes that the context of patient empowerment determines different means
of patient empowerment to achieve long-term rational disease management solutions.
In the scientific discussion of concept development, a significant place is occupied
by the isolation and analysis of patient empowerment results. Empowering patients
for disease self-management also has a positive effect on the patient’s psychological
state [3,4,8,9] interpersonal relationships [5,10–13] and ultimately manifests itself through
health behavior. To achieve the results of patient empowerment in the healthcare system
discussed above, it is important to create preconditions for patient empowerment for
disease self-management.
Research on patient empowerment to date from a public health management perspec-
tive has focused on individual patient enablers without substantiating them as potential
patient knowledge enablers: digital health technologies [14,15], availability of reliable
information, digital health communities, and others. Knowledge management theory
discusses knowledge sharing extensively and in detail, distinguishing preconditions that
ensure knowledge sharing: supportive organizational culture [16], organizational member
motivation [17], mutual trust [18], less centralized organizational culture [19], etc. In this
context, Ippolito et al.’s (2020) systematic literature study and Scharf’s (2014) Knowledge
Management Model of Patient Learning stand out [13,20].
Ippolito et al. (2020) distinguished common, but not knowledge-related, groups
of enablers of patients with chronic diseases: patient learning and knowledge, social
support and counseling, developing and maintaining relationships with patient ecosystem
stakeholders, and patient-centered healthcare models [13]. Scharf’s (2014) knowledge
management model for patient learning identifies and integrates interorganizational and
environmental enablers and critical knowledge management processes based on and
developed by classic knowledge management theory: active and passive knowledge
discovery, explicit and implicit knowledge sharing, and knowledge creation [20]. However,
it remains unclear whether the identified knowledge enablers are relevant to the knowledge
empowerment of patients with chronic diseases.
It should be noted that one of the latest directions in research is the development of
a conceptual model of the Learning Health System [21–24]. A key value proposition of
the learning health system is patient-centeredness through rational and health-friendly
decision-making in the lifelong learning process involving patients themselves and key
stakeholders of their ecosystem [21]. Despite the fact that the continuous knowledge
creation and its effective empowerment are reflected in the whole concept of the learning
health system, neither the concept of patient knowledge nor that of patient knowledge
empowerment is developed in scientific works.
Knowledge is multidimensional in its nature because, from a classical theory of
knowledge management, knowledge includes explicit, tacit, and dormant knowledge [25].
In order to create knowledge, a continuous cyclical process takes place, integrating various
knowledge management activities that stimulate the processes of knowledge acquisition,
conversion, and use and in knowledge management theory these activities are widely
analyzed and developed as knowledge enablers [26,27].
Thus, the field of research in public health management theory develops patient
empowerment more from a patient perspective, while the field of knowledge manage-
ment theory presents enablers who stimulate knowledge management processes from an
organizational perspective.
To date, patient empowerment research faces problems of fragmented approach and
insufficient conceptualization, as the lack of a framework for patient empowerment in
patients with chronic diseases causes methodological inconsistencies in patient empow-

erment theory and does not provide a methodological basis for presenting knowledge
empowerment preconditions. However, the integration of public health management and
knowledge management theories would provide a comprehensive framework for patient
knowledge enablers.
The objective of the present integrative review was to synthesize and critically analyze
the patient knowledge enablers presented in the publications on public health management,
the knowledge enablers presented in the knowledge management theory and to integrate
them by presenting the enablers of patient knowledge empowerment for self-management
of chronic disease framework. Thus, the integrated approach of the two different fields
applied in this study significantly contributes to the consistent development of the topic
of patient empowerment, as the results obtained capture the depth and breadth of the
patient empowerment theory and contribute to a new understanding of the phenomenon
of concern.
2. Materials and Methods

In order to fulfill the goal of the integrative review, primarily, the approaches of patient
knowledge enablers are selected and substantiated, and the methodological choices of the
integrative review are substantiated.
2.1. Patient Knowledge Enablers: Theoretical Background

In order to theoretically substantiate knowledge enablers for patients with chronic
diseases, first, it is important to reveal the aspects of empowerment in its broad sense and
the levels across which patient empowerment develops, then to understand the mechanism
by which the patient, across the levels of empowerment, acquires the power to purposefully
use their knowledge in their day-to-day decisions to achieve health behavior. Finally, to
identify why, in addition to patient knowledge enablers emerging from the field of public
health theory research, the knowledge enabler, widely analyzed in the field of knowledge
management theory research, driven by the interaction of members of the organization
knowledge sharing is particularly important.
2.1.1. Patient Empowerment and Its Levels

In the theory of empowerment, one of the main keywords is power, and its concept
is revealed through the ability to get what is needed; to influence how others think, feel,
behave, and what they believe in; to allocate resources in social systems such as family,
organization, community, and society [28]. Gutiérrez et al., (1995), summarizing the insights
of a number of authors, present essential aspects of the concept of empowerment [28]:
• Empowerment is both theory and practice that deals with aspects of power, powerless-
ness, and oppression and how they contribute to the problems of individuals, families,
or communities and affect helping relationships.
• Empowerment aims to increase personal, interpersonal, or political power in such a
way that individuals, families, or communities can take action to improve their situa-
tion.
• Empowerment is a process that takes place at the individual, interpersonal, and/or
community levels and includes subprocesses such as developing group awareness,
reducing self-blame, accepting personal responsibility for change, and improving
self-efficacy.
• Empowerment occurs through intervention methods, basing help relationships on
cooperation, trust and shared power, awareness raising, individual involvement in
the process of change, training in special skills, and mobilization of resources.
Thus, effective empowerment practices are not fighting or adapting, but increas-
ing real power so that individuals are able to protect themselves from the problem or
change it. As Peterson (2014) emphasizes, empowerment is an active, participatory process
through which individuals gain greater control over their lives, acquire rights, and reduce
marginalization [29].
Scientific discussions reveal that patients are empowered when they have the knowl-
edge, skills, attitudes, and a certain level of self-awareness to influence their behavior and
to cooperate effectively with stakeholders to achieve optimal wellbeing [30]. The context of
chronic diseases means that the specific expertise of patients is formed simply because they
are forced to live every day with the symptoms and consequences of their disease and to
communicate periodically with healthcare professionals (passive involvement, the knowl-
edge is rather tacit here). According to Bate and Robert (2006), patient engagement in their
disease management evolves: first, patients take on the role of those who complain, then
provide information about their conditions, listen and respond, counsel, and advise until
they finally fully participate and become involved in taking chronic disease management
decisions [31].
Empowering patients for independent disease management also has a positive ef-
fect on the patient’s psychological state through patient self-confidence [4,8,9], positive
self-perception [9], and self-esteem [3]. Research also highlights the results of patient
empowerment via the social dimension, as empowering the patient to act independently
has a positive effect on his interpersonal relationships with relatives, healthcare profes-
sionals [5,10–13], and communities of patients with the same disease [32]. Finally, the
empowerment of a patient with chronic illness manifests itself in their behavior through
conscious internal control of behavior self-efficacy, which allows them to make rational
decisions for self-management of chronic illness and is a key precondition for health
behaviors [9,33]. Wagstaff (2006) distinguishes three models of patient involvement in
decision-making [34]. In the traditional paternalistic model, decisions related to patient‘s
health are made by the healthcare professional with minimal information to the patient.
In the shared decision model, the patient participates in the decision-making process by
expressing their preferences among the possible solutions. In the informative model, the
healthcare professional provides all the necessary information for the patient to make a
choice. In this context, it is important to emphasize that the pursuit of patient knowledge is
dissociated from the involvement in the decision-making process in a patient-centered ap-
proach, the pursuit of patient consultation does not imply a shared decision-making model.
As patients are actively involved in decision-making related to their health, there is
a need to identify existing knowledge, acquire new knowledge, develop it, share it with
stakeholders in the ecosystem, and use it to make effective disease management decisions.
Patient empowerment can take two forms: at the individual level, when a patient
identifies themselves with a chronic illness, has the necessary knowledge and control, and
can make decisions; at the community level, where patients can empower other patients
in the community by disseminating their knowledge, experience, etc. [35]. However, the
perception of the community varies depending on the level of empowerment.
Rissel (1994), like many other authors, takes the view that maintaining community
health is inseparable from community empowerment. Above all, however, empowerment
begins and develops at the individual level, is characterized by participation in informal
patient communities, raising awareness, and ultimately concrete social action in community
organizations [36]. Rissel (1994) presents Torre’s (1986) view that community empowerment
develops through three main components, and that without at least one of them, community
empowerment is not possible [36]:
• A microcomponent covering such intrapersonal aspects as patient self-esteem and
self-efficacy;
• Mediating structures characterized by mechanisms specific to groups of individuals
and active participation of group members in sharing knowledge and growing their
critical consciousness.
• A macrocomponent that encompasses social and political activities as mediating
structures become community organizations capable of changing or creating new
social conditions.
The isolated levels of patient empowerment presuppose that the microcomponent of

patient empowerment reflects the psychological empowerment of patients, which, when
the patient identifies themselves with a chronic disease, has the necessary knowledge
and control and can make informed decisions and for which participation in collective
political action is unnecessary. Meanwhile, the empowerment of community, first through
mediating structures, and later through community organizations, is possible with raised
level of psychological empowerment among individual members of the community.
In the context of modern organizational theory, an organization is treated as a system
of interrelated components such as individuals, their formal and informal groups, and their
patterns of behavior arising from the needs of the organization; perception of personal
role within the organization and physical environment in which individuals act to achieve
organizational goals. All these components are combined by linking processes, which
are aimed at the most effective interaction of the mentioned components to achieve the
goals of the organization: communication, balancing between the components for balanced
operation and decision analysis [37].
Dizon (2012) presents a definition of community organization by Kramer and Specht
(1975): “Various methods of intervention, whereby a professional change agent helps a
community action system composed of individuals, groups, or organizations to engage
in planned collective action in order to deal with social problems within a democratic
system of values. It is concerned with programs aimed at social change with primary
reference to environmental conditions and social institutions” [38]. In the context of
patient empowerment, community organizations are based on an active participatory
decision-making model to achieve community-important goals in the perspective of health
improvement. Communities devise various programs to implement health-related goals
by concentrating on their strengths and using collective effort. Based on this perception, it
can be argued that community organization is a system characterized by the components
of the organization singled out in the context of modern organizational theory and the
processes that connect them, aimed at achieving a common goal.
Thus, the levels of patient empowerment discussed above by Rissel (1994) can be
identified with the distinct components isolated by modern organizational theory (first,
there is an individual, then under specific preconditions informal (usually) patient groups
form until a formal organization is finally set up) and therefore are ensured by the same
linking processes [36].
Patient empowerment takes place across levels of empowerment, and the result of
patient empowerment is primarily the psychological empowerment of individuals and
then that of community by creating organizations involving stakeholders, which operate
through interaction to achieve health-related goals.
2.1.2. Patient Knowledge Formation for Patient Empowerment

Paulo Freire, who coined the concept of patient empowerment, has linked patient
empowerment primarily to a process where educational intervention focuses on shaping
patients’ ability to think critically and act autonomously [4]. Thus, from a patient perspec-
tive, their empowerment can be interpreted as a process of empowering the patient to
make independent decisions about their illness in routine situations [10]. Small et al. (2013)
look more globally, arguing that the empowerment process is the patient’s participation in
healthcare [2]. Through the empowerment process, the patient, from the passive recipient
of information becomes an active healthcare partner, able to select from the abundance of
information and make the most appropriate decisions for the course and condition of his
disease [5]. In other words, it is in the process of empowering the patient that the patient’s
knowledge is created and used by the patient to implement effective decisions related to his
or her health. There are three main implementation-oriented approaches in research [39]:
• Promoting Action on Research Implementation in Health Services (PARIHS);
• Consolidated Framework for Implementation Research (CFIR);
• Knowledge to Action Framework (KTA).
All of these approaches concentrate on and interpret the process of implementation in

their own way, but only the core of the KTA approach is the knowledge with which specific
actions can be effectively implemented in practice.
The KTA approach provides conceptual guidance on how to integrate the stages
of knowledge creation with knowledge implementation [40]. In the process of funnel-
shaped knowledge creation, knowledge is as if distilled (knowledge inquiry, knowledge
synthesis, and knowledge tools/products) until clinical practice recommendations or
patient decision aids are created. The action cycle consists of seven stages and provides for
the use of distilled knowledge: (1) identify the problem and determine the know/do gap;
identify, review, and select knowledge; (2) adapt knowledge to the local context; (3) assess
barriers/facilitators to knowledge use; (4) select, tailor, and implement interventions; (5)
monitor knowledge use; (6) evaluate outcomes; and (7) sustain knowledge use.
The stages of the action cycle can occur sequentially or overlap, and the cycle of
knowledge formation can influence the action cycle at any stage. The elements of the action
cycle focus on deliberately bringing about change in healthcare systems and groups [32,33].
Based on the discussed approach and the above insights on empowerment in general
and patient empowerment, it can be stated that patients’ knowledge is formed in a process
that includes the search for knowledge about their disease, its synthesis and the use of spe-
cific knowledge. Meanwhile, the action cycle is a process of knowledge empowerment, in
which the patient, through the levels of empowerment, acquires the power to purposefully
use their knowledge in everyday decisions to achieve health behavior.
2.1.3. Patient Knowledge Enablers: The Importance of Integrating Public Health

Management and Knowledge Management Theories
Knowledge enablers are generally defined as processes, inputs or sources facilitating
the manipulation of knowledge. The concept of the health system is inseparable from the
concept of patient empowerment. The health system includes all organizations, people,
resources, and actions whose primary goal is to promote, restore, and maintain health at
the individual or population levels [41]. Both the structures and processes of the health
system (as supply factors) and patient choices (as demand factors) determine the progress
of patient health. The patient’s movement through the health system is identified with a
pathway that describes the patient’s progress through the health system to avoid side effects
and complications in the context of chronic disease. According to Brathwaite et al. (2020),
the patient uses a variety of enablers on their path through the health system to achieve
health behavior [41]. From the perspective of conceptualizing patient knowledge, patient
knowledge enablers create context and provide stimulating preconditions for patients
to use knowledge through empowerment levels in the knowledge to action framework
action cycle to make a specific decision. In addition to these enablers, it is particularly
important in the context of patient empowerment that as a patient travels through levels of
empowerment, the use of their knowledge is stimulated by purposeful interactions with
other patients with chronic illness.
Classical knowledge management theory assumes that the creation of knowledge
involves a continuous cyclical process that integrates a variety of knowledge management
activities and solutions focused on the use and continuous updating of knowledge. As
already mentioned, in order to enable patients to self-manage chronic disease in daily life,
it is important not only to develop the necessary knowledge but also to develop cognitive
abilities to use knowledge for rational routine decision-making and constantly update it.
The essence of knowledge creation is to generate new solutions, form, develop, and use
competencies using knowledge management tools [25]. Knowledge management theory
provides management solutions that can be adapted to empower patients’ knowledge to
create preconditions for independent disease management.
Enabling factors for knowledge management are vital infrastructure for the effective-
ness of knowledge management activities. According to Kale and Karaman (2011), these
are organizational mechanisms that stimulate the creation and development of knowl-
edge in an organization and facilitate the creation, conversion, use, and protection of
knowledge [27]. In knowledge management theory, knowledge empowerment has been

developed through different knowledge management processes in an organization, which
have been singled out by Gold et al. (2001) and whose enablers are extensively studied in
knowledge management theory [42]:
• The process of knowledge acquisition, which includes knowledge creation, search,
and collaboration activities [43,44];
• The process of knowledge conversion involving activities of knowledge organization,
storage, integration, and coordination [45,46];
• The process of knowledge use/application, including retrieving and knowledge
sharing [20,47];
• The knowledge protection process that manifests itself through knowledge storage
activities [42].
An organization’s knowledge management capabilities, helpful to adapt to an uncer-
tain external environment, are shown in how effectively an organization can acquire, retain,
and distribute knowledge. In other words, knowledge management skills are related to
the development of specific enablers that create the context for knowledge management
activities knowledge exploration and knowledge exploitation. Knowledge sharing is at
the heart of the classic spiral SECI model, which encompasses the following knowledge
creation processes that take place in the interaction of members of an organization: in
the process of socialization through shared experience without the use of language tacit
knowledge is created; externalization is directed at the conversion of tacit knowledge into
explicit knowledge; the process of combination involves the sharing and coordination of the
explicit knowledge, thus creating new knowledge; the process of internalization is the con-
version of explicit knowledge into tacit knowledge and reflects the essence of learning [44].
Thus, in knowledge management theory, the preconditions of knowledge sharing in an
organization are widely discussed because the authors unanimously agree that knowledge
sharing is a critical organizational capability integrating other knowledge management
practices and processes that result in organizational sustainability [17,26,48–51]. Therefore,
this article assumes that in addition to patient knowledge enablers emerging from the field
of public health theory research, the knowledge enabler, widely analyzed in the field of
knowledge management theory research, is especially important, driven by the interaction
of the organization’s members knowledge sharing.
Keeping this view in mind, the present review paper mainly focused on two theories
public health management and knowledge management and on the interdisciplinary
approach provided by these theories. The synergy of these theories would lead to a fulfilled
framework of patient knowledge enablers, answering the research question What are
patient knowledge enablers and through which levels of patient knowledge empowerment
do they operate?
2.2. Methodology of Literature Review

To answer the research question, Cronin and George’s (2020) integrative review ap-
proach was used as one of the most recent one, generalizing many previous integrative
review approaches, and, according to the authors of this article, easily adaptable to synthe-
size scientific literature from different scientific theories to capture a phenomenon evolving
in the context of different perspectives [52]. The authors of the article also followed the
stages of integrative review as suggested by Cronin and George (2020): (1) choice of syn-
thesis vehicle, which can be adjudication and redirection; (2) literature review; and (3)
thematic synthesis [52]. The following describes all integrative review decisions that were
made in gathering the data.
2.2.1. Choice of Synthesis Vehicle

According to the above-mentioned authors, adjudication is the most adequate to
use not for meta-analyzes but for systemic analyzes, where the aim is to reveal causal
relationships based on objective quantitative constructs and systematization standards.
The essence of this research question lies in the desire to unite multiple communities of
practice. Therefore, to answer the research question addressed in this article, redirection
is a more appropriate strategy because, according to the authors mentioned above, it
is applied when seeking to find a new insight about a topic through a juxtaposition of
several studies, including “disciplined imagination to develop new kinds of ideas that
are necessarily speculative out of current domain knowledge, and it foregrounds aspects
of the domain in need of more frontline empirical work ” [52]. Thus, the application of
redirection vehicle provides space to raise new questions and thus steer future research in
unexpected directions.
2.2.2. Literature Review

According to Cronin and George (2020), in the literature review phase, it is important
to ensure the completeness and balance criteria of the selected literature [52]. In the context
of an integrative review, a complete review is important, i.e., it is important for researchers
to analyze all literature that met the search criteria, including previously unexplored and
unknown concepts and methodologies. Having ensured the completeness criterion, both a
quantitative and a qualitative balance between different paradigms is sought after, as each
of the paradigms is based on a different social–scientific reality.
To ensure both criteria of the literature review, the selection of research papers was
performed in two databases of research covering different scientific theories. The Sci-
enceDirect database includes scientific journals from a variety of disciplines, including
Health Sciences (public health management); The Emerald Management database includes
full-text journals in the field of social sciences (management science).
Both of the authors of the present study independently carried out a search in these
two databases. The search string used in the present study was the following:
• ScienceDirect database search string: “patient empowerment” AND “knowledge”
AND “enablers”.
• Emerald Management database search string: “knowledge management enablers”
AND “empowerment”.
It should be noted that keywords related to chronic diseases were not included in the
search string because of the tradition in public health management work that the concept
of patient empowerment is inseparable from the context of chronic diseases.
The search strings were modified slightly in several cases to function properly on
some search platforms. When searching for research papers in the ScienceDirect database,
it was chosen to include scientific articles from 2008 to September 2020. The year 2008 was
chosen as a starting point because it was noticed that it was from that period that the
topic of patient empowerment began to appear in this database. Meanwhile, knowledge
sharing, as one of the knowledge management activities, has a long research tradition, so
the starting point of the year in the Emerald Management database was the emergence of
the database, and research papers were sought until September 2020.
It should be mentioned that since the research papers were searched for in two
databases on different fields of science, no duplicate articles were found. After making
sure that there were no duplicate research papers, the authors of the article independently
screened the titles, abstracts, and keywords of the selected research papers and if no
connection was found with patient empowerment, knowledge, enablers (in case of search
a.), and with knowledge management enablers, empowerment (in the case of search b.),
they were eliminated from further analysis. When there was no clarity as to whether the
article could be included, it was read in full. Careful reading was done of the articles
that were chosen as eligible, and those not relevant were not included in further analysis.
Figure 1 presents a step-by-step representation of our screening process.
nection was found with patient empowerment, knowledge, enablers (in case of search a.)
and with knowledge management enablers, empowerment (in the case of search b.), they
were eliminated from further analysis. When there was no clarity as to whether the article
could be included, it was read in full. Careful reading was done of the articles that were
Int. J. Environ. Res. Public Health 2021,chosen
18, 2247 as eligible, and those not relevant were not included in further analysis.
9 of 24Figure 1
presents a step‐by‐step representation of our screening process.
Figure 1.Article
Figure 1. Articlescreening
screening and
and inclusion
inclusion procedure.
procedure.
Studies
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wereincluded in the
included analysis
in the if they
analysis met the
if they meteligibility criteria:criteria:
the eligibility
• As the aim of the study was to find a new approach that integrates two different
 As the aim of the study was to find a new approach that integrates two different
research traditions, to reveal the holistic approach and ensure the completeness cri-
research traditions,
terion, it was important to to
reveal
find athe holistic
wide rangeapproach
of knowledgeandenablers;
ensure the completeness
therefore, the cri‐
terion, itthat
research wasconceptually
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a wide range of knowledge
develops the aboveenablers;
keywordstherefore,
from the
research
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• various
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Emerald Management were considered
database does notsuitable;
detail search results and only provides
 research papers. In order to ensure
The Emerald Management database does not a balance between the tworesults
detail search disciplines whenprovides
and only
analyzing only scientific publications, the types of publications such as
research papers. In order to ensure a balance between the two disciplines when ana‐ conference
abstracts,
lyzing onlyminiscientific
reviews, short communications,
publications, the typesandofEncyclopedia
publicationswere
suchnotasincluded
conference ab‐
in the data analysis from the results obtained in the ScienceDirect database. From
stracts, mini reviews, short communications, and Encyclopedia were not included in
both databases, the research included in the integrative review met the peer-review
the data analysis from the results obtained in the ScienceDirect database. From both
and open access criteria. The application of the peer review filter in the search of both
databases,
databases the research
resulted included
in the entry inresearch
of valid the integrative review
papers into met the peer‐review
the integrative review. and
open
The access
total numbercriteria. The that
of articles application of the
matched the peer
search review
string from filter in the search
each database is pre- of both
sented in Table 1. A similar number of publications were selected in both databases, whichreview.
databases resulted in the entry of valid research papers into the integrative
suggests that the applied search string combinations and eligibility criteria allowed one
to balance the literature review results both quantitatively (article type) and qualitatively
(peer review).
Table 1. Search sources and results.
Number of Access Type,

Databases Article Type Subject Areas
Articles Found Review Type
Medicine and Dentistry (29)
Computer Science (6)
Review articles (14)
Nursing and Health Professionals (9)
Research articles (34) Open Access,
ScienceDirect 51 Biochemistry, Genetics and Molecular
Discussion (2) Peer-review
Biology (3)
Editorials (1)
Immunology and Microbiology (2)
Neuroscience (2)
Open Access,
Emerald Management 56 Articles (56) Social Sciences (56)
Peer-review
2.2.3. Thematic Synthesis

According to Cronin and George (2020), at the thematic synthesis stage, broader
themes from the different perspectives were abstracted and integrated to support the
goals of the review (adjudication or redirection) [52]. By abstracting themes in different
perspectives, it is important for the researcher to discover ones that connect different
research traditions, because only in this way they can be combined into a single whole,
i.e., integrated. When integrating themes from different research traditions, it is important
to highlight the connections between the themes, iterating as much as necessary to find
a “maximally elegant framework” that highlights relationships among themes more than
within them.
The computer-assisted qualitative data analysis software MAXQDA 2020 (VERBI
GmbH, Berlin, Germany) was used to analytically summarize the qualitative data by
distinguishing the themes relevant to this study and the relationships that integrate them.
The developers of this program identify its numerous benefits and especially wide range of
useful functions: qualitative data interrogation, reflection, integrity, and exploration [53]).
Given that the research object has not been studied, an inductive coding approach
has been applied, where research themes arise from qualitative data by constantly reading
and thinking about it in an iterative process of qualitative data analysis, which, according
to Seidel (1998) has characteristics such as repeatability and progression, recursivity, and
holography [54].
3. Results
The thematic synthesis of the selected research papers took place in the following
sequence: first, the research papers on public health management selected in the Science Di-
rect database and the research papers on knowledge management selected in the Emerald
Management database were coded separately. With the help of computer-assisted qualita-
tive data analysis software, in identifying the relationships between patient knowledge
enablers and patient empowerment levels, the themes from the research of both theories
integrated through patient empowerment levels were identified.
3.1. Overview of Identified Themes

From the synthesis of reviewed articles, the following important themes were identi-
fied as shown in Tables 2 and 3. As can be seen in the tables, the literature on both theories
is dominated by specific subthemes.
Table 2. Synthesis of identified themes in public health management literature (source: own elaboration).
Themes Subthemes Number of Citations

Autonomy 8
Motivation 3
Involvement in the search for a health-related decision 4
Individual enablers
Involvement of a partner 3
Self-esteem 2
Clear available information about the chronic disease 2
Digital information 11
Digital self-care via empowering healthcare forms 36
Health technologies
Accessibility of reliable information 11
Creation of e-communities 10
Patient-centeredness model Characteristics of patient-centered model 12
Multicomponentiality of disease management programs 8
Disease management programs
Interaction between the patient and a healthcare professional 4
Mission of learning health system 9
Learning health system
World Health Organization 5
Table 3. Synthesis of identified themes in knowledge management literature (source: own elaboration).
Themes Subthemes Number of Citations

Web 2.0 12
Technological enablers of knowledge sharing
Systems of knowledge sharing 5
Supportive organizational culture 38
Systemic enablers of knowledge sharing Transformative leadership 15
Less formalized and centralized organizational structure 7
Openness to experience 3
Satisfaction arising from helping others 3
Enablers of individual knowledge sharing Self-efficacy 1
Attitudes, subjective norms and conscious self-control 2
Internal motivation for knowledge sharing 7
The analyzed public health management research papers widely discuss patients’
self-care through empowering forms of healthcare. This subtheme is closely related to
healthcare technologies, which are a particularly important part of modern health care and
a dominant and transforming trend in the health care system of the future.
In the analyzed knowledge management research papers, the subtheme of organiza-
tional culture supporting knowledge sharing was especially distinct. Unsurprisingly, the
authors pay a lot of attention to organizational culture, as it is identified in the management
paradigm as one of the most important factors in ensuring organizational sustainability in
the context of transformational change caused by industry 4.0.
In the qualitative analysis of the selected research papers, the levels of patient empow-
erment were coded as the subthemes, and the literature of both disciplines were combined
through the above-mentioned subthemes. As can be seen in Table 4, most citations were
coded to justify empowerment through mediating structures and empowerment at the
macrolevel. This suggests that the research analyzed in both theories focuses more on
formal and/or informal groups of individuals as components of the organizational system.
Table 4. Synthesis of topics for patient empowerment levels (source: own elaboration).
Number of Citations:
Theme Subthemes In Public Health In Knowledge
Management Literature Management Literature
Microlevel 11 6
Levels of patient Empowerment through
empowerment 15 23
mediating structures
Macrolevel 9 19
3.2. Patient Knowledge Enablers: A Public Health Management Perspective

3.2.1. Individual Patient Knowledge Enablers
Patient autonomy is a subtheme based on the highest number of citations in the theme
of patient individual knowledge enablers. In the context of patient empowerment, it is
important to emphasize that patient autonomy in making health-related decisions does
not mean that the patient has complete independence and the healthcare professional or
other stakeholders are not involved in decision-making [55,56]. Meis et al. (2014) explain
this by the term “autonomously dependent”, arguing that the positive effect of patient
empowerment also occurs when the patient knows that in situations where a risk-free
health-related decision is needed, their knowledge ensures optimal decision-making [56].
However, the patient is also aware that in a more risky situation, they are not left alone
and can turn to a healthcare professional to apply a shared decision-making model and
reduce the risk to the patient. Patient autonomy allows them to feel confident in their
knowledge, motivated to obtain even more knowledge from a healthcare professional [57],
and therefore encourages involvement in formal and informal patient organizations that
ensure the uptake of digital health-related information through knowledge sharing [57] and
the transition from the level of microempowerment to empowerment through mediating
structures [58].
According to Meis et al. (2014), involving the patient in the search for and making
a health-related decision essentially means that the patient will not only face the final,
likely a good outcome of the decision-making, but will also experience barriers in the
decision-making process, and will not avoid unforeseen constraints and thus will learn to
look for alternatives and tackle barriers, i.e., discover knowledge and share it with those
involved in the decision-making process [56]. In the context of empowerment theory, equal
participation of patients in the decision-making process is like a means of encouragement
and self-efficacy.
In the research papers analyzed, the subtheme of the patient‘s partner‘s involvement
as an enabler of knowledge sharing was singled out. With certain chronic diseases, day-to-
day healthcare decisions are inseparable not only from the patient but also from those close
to them, who often not only share information about the patient’s physical environment
and daily conditions to maintain the effectiveness of the treatment, strengthen patient and
healthcare professional‘s therapeutic relationships, and reassure patients [14].
The effective participation of the patient in shared decision-making is also ensured
by the available clear information on the nature of the disease and the treatment offered,
preconditions for medical success, risks and side effects, reasonable treatment alterna-
tives, their risks and side effects and possible consequences if not treated with the best
alternatives. Having clear and structured information enables the patient to apply the
available knowledge in making the best treatment decision and behaving healthily in daily
activities. According to Menon and George (2018), patient empowerment increases the
level of patient self-esteem that can be treated as an enabler of patient knowledge because
a patient’s awareness that he has sufficient knowledge and can apply it determines their
confidence in the treatment, which directly affects the effectiveness of the treatment [59].
3.2.2. Health Technologies

The importance attributed to health technologies in the research analyzed can be
explained by the digital transformation in many areas and the consequent digitization of
medical and public health and the empowerment of patients through digitization.
Digital self-care through empowering forms of healthcare: The digitalization of
medicine and healthcare allows for the development and implementation of new forms
of healthcare (e.g., Mobile Health Tools, Clinical Decision Support Systems, Health In-
formation Systems, and Do It Yourself Technologies) in which patients themselves are
actively involved and which require active patient participation in both the development
and application of the tools in day-to-day healthcare. In other words, the digitalization of
healthcare is shaping the trend of digital self-care, where patients have the opportunity
to play an active role in the day-to-day management of chronic disease through interac-
tions with digital forms of healthcare [60]. The use of digital devices increases patients’
ability to follow a medical regime and recommended lifestyle through the integration of
these forms into the daily activities of the patient [57] while supporting the functions of
reminder, feedback, knowledge creation, and self-care [14]. As a result, patients’ routine
decision-making becomes smoother, building patients’ self-confidence [14,15,59–63] and
highly dynamic [63–65].
Enabling forms of healthcare are closely linked to patients ’access to personal health
data. Health technology means that medical information about a patient becomes available
not only to healthcare professionals but also to patients. The availability of personal
information supports the patient’s empowerment to manage their health [66] and the
interactions between health professionals in different fields [64,66]. Thus, the emergence
of the digital revolution in medicine and new self-care technologies are narrowing the
boundaries between expert and patient practice [67].
Availability of reliable information: There is a clear consensus in the analyzed research
that certified and high-quality digital health technologies provide patients with reliable
information about their disease [14,59,64,65,68]. The availability of reliable information
leads to the consistent development of knowledge by empowered patients and is therefore
more insightful about their health, leading to more informed decisions, early diagnosis,
and faster recovery.
Creating e-communities. According to Menon and George (2018), one of the most
essential tools to effectively empower a patient for chronic disease management is the
ability to access and participate in virtual patient communities [59]. The accessibility of
these communities allows for communication with patients with the same disease and
health professionals when all three essential processes of knowledge management take
place: knowledge acquisition, knowledge conversion, and knowledge use [60,67,68].
Health technologies can be seen as enablers of patient knowledge because their use to
self-manage chronic disease in the daily lives of patients not only facilitates the process
of building patient knowledge, but also enables the patient to actually act using their
knowledge in everyday decisions for health behavior.
3.2.3. Patient-Centered Healthcare Model

The paradigm shift from disease-orientation to patient-orientation is identified in
research as a patient-centeredness model, which is defined as healthcare that respects
the individual patient and responds to the individual patient’s preferences, needs, and
values and ensures that patient values guide all clinical decisions [69]. In essence, the goal
of this model is to engage the patient in their chronic disease treatment and day-to-day
management decisions in the way that is most acceptable to them.
The Picker Institute singled out assumptions that together define the essence of
patient-centered care, and one of these dimensions focuses on the importance of timely
information and patient education. The research emphasizes that it is particularly important
for healthcare professionals to provide more than enough knowledge to patients with
chronic diseases that will help them understand the treatment scenario and how much
effort is needed to treat the disease [59]. Van der Heide et al. (2018) emphasize that in the
patient-centered care model, patient resources are particularly important: patients with
strong self- efficacy, high levels of health literacy, and a broad social network are more able
to manage their health conditions and care situations [69].
The active involvement of the patient in their healthcare can be seen as an enabler of
patient knowledge, because in such a healthcare model, patient knowledge is managed on
a continuum basis: patient knowledge that enables the patient to act effectively in their
everyday life by utilizing the knowledge when it is necessary is continuously created (i.e.,
facilitates manipulation of knowledge).
3.2.4. Disease Management Programs

Disease management programs are structured treatment plans designed to help chron-
ically ill patients manage their chronic disease and maintain and improve quality of life.
Pimouguet et al. (2011) define disease management programs as an ongoing process
and proactive patient monitoring involving at least two of the following components:
patient education (nutrition and physical activity recommendations and self-monitoring
and knowledge related to disease and medication), coaching (providing tools to the patient
to overcome psychological and social barriers to independence or adherence to treatment),
adjustment of treatment (disease manager can start a new treatment or modify an existing
one without/with the prior consent of the primary care physician), monitoring (health
professional receives medical data from the patient), and care coordination (the health
professional reminds the patient about upcoming visits or important aspects of their health-
care and informs the physician of complications, treatment adjustments, or therapeutic
recommendations) [35,70,71],
Executing a disease management program essentially means that a patient in constant
interaction with a healthcare professional constantly acquires knowledge, converts it, uses
it, and evaluates it. The evolving ability of patients to evaluate means that they are not
only able to evaluate knowledge from a variety of perspectives, but, above all, to apply and
analyze it in everyday decisions disease-related. Thus, through the disease management
program, the patient, as an enabler of knowledge, becomes an active healthcare partner,
able to select from the abundance of information and make the most appropriate decisions
for the course and condition of their disease.
3.2.5. Learning Health System

Despite its broad coverage, the healthcare system has emerged in the research papers
analyzed as a context that facilitates patient manipulation of available knowledge. Accord-
ing to the analysis of the research, the mission of the healthcare system in the context of
chronic diseases is to create and maintain access to evidence-based resources for health care
professionals and patients, develop the necessary knowledge and skills, reduce emotional
stress, maintain combat and self-efficacy skills, and the application of health technology
tools, thereby creating and maintaining patients’ quality of life [15,59,72,73]. This insight
presupposes that, without naming it specifically, the authors are talking about the learning
health system. The core value of a learning health system is patient orientation through
rational and health-friendly decision-making in lifelong learning, involving patients them-
selves and key stakeholders in their ecosystem (e.g., family, patient communities with the
same disease, treating physicians, etc.), thus ensuring continuous improvement of and
innovation in healthcare. The learning health system uses the latest technological advances
to achieve these goals to ensure dynamic collection and implementation of medical evi-
dence (confirmation), rapid learning based on daily patient care data and thus leading to
higher quality, safety, and innovation in healthcare. Thus, the continuous development of
knowledge and its effective use in this way empowering patients is reflected in the whole
concept of the learning health system [21].
Patient activation by enabling knowledge for day-to-day decisions related to chronic
disease management takes place in the context of the learning health system dominated
by the patient-centered healthcare model where the patient is an active partner whose
preferences, needs and values are taken into account; forms of healthcare based on digitized
health technologies are used and chronic disease management programs are in place, which
help to respond to the patient proactively and ensure the processes of patient knowledge
acquisition, conversion, and use.
Summarizing the themes reflecting the enablers of patient knowledge from the per-
spective of public health management, it can be stated that, in principle, the empowerment
of patients takes place through the process of knowledge sharing, applying technological
solutions. The process of harnessing knowledge involves the rapid discovery and sharing
of existing knowledge. Knowledge discovery activities, as its use activities, are less relevant
in the context of knowledge empowerment for patients with chronic diseases than knowl-
edge sharing, since patients can quickly discover the required knowledge through health
technology solutions. Health technologies create mechanisms and knowledge repositories
to ensure that the knowledge needed to make a decision is accessed quickly. Isolated
chronic patient knowledge enablers act as prerequisites to facilitate patient knowledge
empowerment through direct (e.g., disease management programs) and indirect (e.g.,
digitized forms of healthcare) interaction between patients, healthcare professionals, and
patient e-communities through knowledge sharing. The process of knowledge sharing is
the transfer of knowledge to another individual as needed for proper decision-making [51].
It is a two-way process patients communicate through health technology tools with health-
care professionals and other patients, provide knowledge about their disease, and receive
the response they need, thus expressing knowledge and combining it to make a specific
health-related decision [18,74].
3.3. Patient Knowledge Enablers: A Knowledge Management Perspective

3.3.1. Technological Knowledge Sharing Enablers
In order to share knowledge, it must first be codified, i.e., tacit knowledge is translated
into explicit knowledge and this, in the context of digitization trends, is made fast using
such technologies [51,75,76] Qandah et al., 2020), as Web 2.0 [17,51,74] and knowledge
sharing systems [16,26,50]. In the analyzed management literature, Web 2.0 as a knowl-
edge sharing tool is related to social networking, blogs within the organization, virtual
communities of practice, expert profile systems, and the intranet [53]. According to the
classical theory of knowledge management based on Nonaka and Takeuchi (1995), tacit
knowledge, which is usually developed in organizations over many years, is extremely dif-
ficult to codify and therefore sharing it at horizontal and vertical organizational levels [77]
requires a shared social process and informal face-to-face interaction between members
of the organization, which is activated by the members of the organization acting in a
specific environment created for knowledge sharing. If such an environment is not created,
knowledge management in an organization simply cannot exist [50].
The analyzed research papers found a connection between the specific environment
necessary for knowledge sharing and the use of Web 2.0 tools. According to Arif et al.
(2015), social networks create an informal knowledge-sharing environment that encourages
interpersonal relationships and collaboration among members of an organization that does
not restrict communication due to differing social norms, cultural values, and interests [17].
Malik and Kaval (2018) emphasize that information technology support and application
intensity fundamentally and drastically change knowledge-sharing behavior [75].
Thus, the main purpose of the technology-based tools discussed is not simply to access
data and information, but to support the interaction between members of the organization
and, as a result, the transformation of individual tacit knowledge into organizationally
explicit knowledge and vice versa.
3.3.2. Systematic Knowledge Sharing Enablers

The study of research has revealed that knowledge sharing in an organization does
not happen by chance specific preconditions must be created in the organization to ensure
the process of knowledge use through knowledge sharing.
Supportive organizational culture: Organizational culture is a critical precondition for
securing knowledge management activities, but one of the biggest challenges is to develop
a type of organizational culture that promotes knowledge management activities [49].
There is a relationship between the culture of the supportive organizational culture and the
attitudes of the members of the organization towards knowledge sharing within the orga-
nization [51,78]. It should be noted that in this theme there are distinctive characteristics
of the supportive organizational culture that have a positive effect on knowledge sharing
practices: openness to change, promotion of innovation, trust, teamwork, high moral
standards, information flows, involvement, supervision, customer service, and orientation
to reward [16]. In the analyzed research, the following characteristics of the supportive
organizational culture promoting knowledge sharing stood out.
Despite the fact that organizational culture and the origin of organizational climate
concepts are different methodological traditions, in the management paradigm several
theoretical and empirical tests to combine the two concepts can be found: both organi-
zational culture and climate reveal the macroperspective of the organizational context
where shared experiences develop that affect the end result sought by the organization [79]
If an organization does not create a context suitable for knowledge sharing, knowledge
management activities will simply fail [50].The analyzed scientific works highlight the
separation of organizational culture and climate, as a context that promotes knowledge
sharing, through the dimension of individual perception. Organizational climate is the
result of the interaction of individuals and their environment, shaping individual behavior
and influencing intentions to share or not to share knowledge [78,80]. and it is therefore
important to understand that the climate perceived by organizational members can vary
radically [81,82]. Thus, it can be stated that in the perspective of knowledge sharing, the au-
thors follow the approach formed by Zohar and Hofmann (2012) when the organizational
climate is treated as the perception of individuals’ organizational values and priorities,
i.e., the culture of the organization reflects what the organization believes in, and the
climate of the organization expresses how individual employees perceive the culture of the
organization.
Research reveals that organizations with a culture of team-oriented work are more
successful in sharing knowledge than those that are more focused on fully technology-
based decision-making [74]. This insight confirms that the externalization of knowledge
from tacit to explicit knowledge takes place in close (physical) interaction of the members
of the organization, engaging in knowledge sharing to achieve common goals. An integral
part of the social sharing process is the shared language between the members of the
organization, expressing the various subtleties, acronyms, and hidden meanings, formed
by the members of the organization acting in the same context and enabling members
to acquire, convert, and apply new knowledge in the context in which it has a specific
meaning [74].
External motivation of members of the organization as a supportive characteristic of
knowledge sharing encourages members of the organization to participate in knowledge
management activities and stimulates not only the sharing of goals, visions, and tasks, but
also knowledge-sharing activities [17].
A culture of knowledge sharing is characterized by a high level of trust among mem-
bers of an organization [19]. Interpersonal trust between members of an organization is
the basis of their relationship, creating an opportunity for socialization [83] and a positive
effect on knowledge sharing, as members of an organization tend to share knowledge
only with those they trust [17,51]. A higher level of trust creates stronger relationships not
only between members of the organization but also between members of the organization
and the organization [18]. The positive relationship of the members of the organization
with the organization is expressed by their commitment to the organization, which in the
organizational culture perspective is defined as the emotional attachment of the organiza-
tion members to the organization and identification with the organization’s values, which
leads to a member feeling responsibility to help the organization to achieve its goals [18]
empowering their self-efficacy and dedicating themselves to the task [84].
Transformational leadership: The role of a leader in an organization is one of the keys
to creating the preconditions for knowledge management activities through management
support, focused on inspiring employees to share knowledge and support actions that
ensure such activities [51,83]. Qualitative analysis of the research revealed that knowledge
management activities in an organization are ensured by a transformational leadership
style characterized by motivating members of the organization for autonomy, mutual trust
and “cultivation” of the commitment to the organization [50,85]. Transformational leaders
create a supportive environment and, through charisma and special attention to employees,
promote their intellectual development, motivate the creation and sharing of knowledge,
develop a learning culture and discipline, and create mechanisms for knowledge manage-
ment activities [17,80,84,86].Some authors identify transformational leadership styles with
knowledge-oriented leadership, thus emphasizing the importance of this leadership style
for ensuring knowledge management activities in an organization [86,87].
Less formalized and centralized organizational structure. The organizational struc-
ture is “responsible” for formalizing the explicit knowledge, the level of autonomy of the
members of the organization, uniting them by specific means, desertification, and selection
of effective communication channels for knowledge flows [49]. According Arif et al. (2015),
organizational structures are most often categorized by formality, centrality, and integra-
tion [17]. Effective knowledge sharing requires a more flexible organizational structure,
diversified teams of organization’s members, and common goals that link them [19]. When
the organizational structure is less formalized and centralized and more integrated, a
higher level of social interaction between members of the organization is achieved and
the conductivity of knowledge sharing between functionally and hierarchically different
members of the organization is ensured [83].
3.3.3. Individual Enablers

Knowledge sharing is not possible in any organization without interacting individuals
pursuing a goal that unites them. In particular, in the absence of individuals with tacit
knowledge who at the individual level do not show knowledge-sharing behavior, an orga-
nization’s knowledge management skills are not possible. Qualitative analysis of research
papers revealed that the following personal characteristics are important for individual
behavior of knowledge sharing: openness to experience [78], satisfaction with helping
others [26,51].; self-efficacy [26]; attitudes, subjective norms, and conscious behavior con-
trol [51].; internal motivation to share knowledge [26,51,88,89].
3.4. Integration
During the integrative review, having isolated patient knowledge enablers from public
health management and knowledge management research papers, they were integrated
through patient empowerment levels. Based on the relationships between patient empow-
erment levels and patient knowledge enablers identified during the integrative literature
review, propositions were formulated and substantiated, illustrating them by Enablers of
Patient Knowledge Empowerment for Self-Management of Chronic Disease Framework
(see Figure 2).
Int. J. Environ. Res. Public Health 2021, 18, x 18 of 24
Figure2.
Figure 2. Enablers
Enablers of
of patient
patientknowledge
knowledgeempowerment
empowermentfor self‐management
for self-management of of
chronic disease
chronic disease
framework. Note: P1a and P1b relationships are grounded by Proposition 1; P2a, P2b, P2c,
framework. Note: P1a and P1b relationships are grounded by Proposition 1; P2a, P2b, P2c, P2d, P2d,
P2e,
P2e, and P2f relationships are grounded by Proposition 2; P3 relationship is grounded by Proposi‐
and P2f relationships are grounded by Proposition 2; P3 relationship is grounded by Proposition 3;
tion 3; P4a and P4b relationships grounded by Proposition 4; and P5a and P5b relationships
P4a and P4b relationships grounded by Proposition 4; and P5a and P5b relationships grounded by
grounded by Proposition 5.
Proposition 5.
Proposition 1. Patient empowerment through mediating structures mediates the relation between
Proposition 1. Patient empowerment through mediating structures mediates the relation between
the patient empowerment micro level (P1a) and the empowerment macro level (P1b).
the patient empowerment micro level (P1a) and the empowerment macro level (P1b).
Qualitative analysis of the research revealed that patient empowerment evolves
Qualitative analysis of the research revealed that patient empowerment evolves
through three levels of empowerment, in which the patient becomes increasingly empow‐
through three levels of empowerment, in which the patient becomes increasingly em-
ered to use
powered theirtheir
to use knowledge
knowledge in everyday
in everyday decisions to pursue
decisions to pursuenot not
onlyonly
theirtheir
ownown but but
also
community health behaviors [14,18,51,60,74,90,91].
also community health behaviors [14,18,51,60,74,90,91].
Patientprogress
Patient progressacrossacrossempowerment
empowermentlevels levelscan
canbebeequated
equatedwithwiththethetrajectory
trajectorythatthat
defines the patient empowerment process when a patient from a
defines the patient empowerment process when a patient from a passive recipient of infor- passive recipient of in‐
formation becomes an active healthcare partner. First of all, the
mation becomes an active healthcare partner. First of all, the microlevel of empowerment microlevel of empower‐
isment is formed,
formed, whichwhich
includes includes the patient’s
the patient’s psychological
psychological empowerment,
empowerment, manifested
manifested in thein
the patient’s perception of themself as being able to consciously
patient’s perception of themself as being able to consciously influence their behavior ininfluence their behavior
ainhealth-friendly
a health‐friendly direction.
direction. Patient’s
Patient’s self‐efficacy
self-efficacy has ahas a positive
positive effecteffect on confidence
on their their confi‐
dence
to to objectively
objectively assess
assess their their knowledge
knowledge and cognitive
and cognitive abilities abilities in the
in the areas areas of
of health health
literacy.
literacy. On this basis, the interactive element of patient empowerment
On this basis, the interactive element of patient empowerment is beginning to emerge, is beginning to
emerge, with the aim of transferring existing knowledge and cognitive
with the aim of transferring existing knowledge and cognitive abilities to a community of abilities to a com‐
munity with
patients of patients
the same with the same
chronic chronic
disease disease
through throughstructures
mediating mediating structures
such, such, for
for example, as
example,patient
informal as informal patient organizations/groups.
organizations/groups. Active participation
Active participation of patients in of patientsgroups
different in dif‐
ferent
in groups
sharing their in sharing their
knowledge knowledge critical
and developing and developing
awareness critical awareness
of chronic of chronic
illness and health,
illness andtohealth,
according Menon according
and George to Menon
(2018),and Georgein(2018),
is crucial is crucial
harnessing in harnessing
patient knowledge patient
and
knowledge
thus shapingand thussatisfaction
patient shaping patient
so that satisfaction so that theytoare
they are empowered empowered
take to take
daily decisions daily
related
decisions
to related
their illness [59].to their illness [59].
Accordingto
According toRissel
Rissel(1996)
(1996)provisions
provisionson oncontinuum
continuumempowerment,
empowerment,ititcan canbebeargued
argued
that having
that having empowered
empowered patientspatientsthrough
throughmediating
mediatingstructures,
structures,patient
patientempowerment
empowerment
evolvesfrom
evolves from thethe
fieldfield of psychological
of psychological empowerment
empowerment to the
to the field field of community
of community empower-
ment when mediating structures become community organizations embracing the expertise
of empowered patients on the basis of which social conditions are created and changed [36].
Proposition 2. Health technologies (P2a, P2b, and P2c) and the patient-centered healthcare model
(P2d, P2e, and P2f) act as enablers of patient knowledge across all levels of patient empowerment.
As can be seen in Figure 2, qualitative analysis of the research revealed a link be-
tween patient knowledge enablers such as preconditions created by health technology
(e-communities and accessibility of reliable information) [16,51,59,60,68,74] the patient-
centered healthcare model [14,92] and all levels of patient empowerment.
Health technologies create the preconditions for e-communities to appear, for patients
to access reliable information related to their chronic disease and create an effective en-
vironment for face-to-face interaction. The accessibility of reliable information increases
patients’ self-efficacy and self-confidence in decision-making, and e-communities ensure
knowledge sharing through patient interaction with healthcare professionals and other
patients. At all levels of patient empowerment, the availability of reliable information
about a chronic disease is very important to the patient, because whether they are in the
field of psychological empowerment or already in the community empowerment, they face
their chronic disease on a daily basis and have to make health decisions on the basis of
reliable, related, and relevant information. Meanwhile, interaction through e-communities
varies depending on the level of empowerment the patient is at. At the microlevel of
patient empowerment, patient knowledge empowerment is dominated through interaction
with sharing knowledge with the healthcare professional and passive monitoring of the
activities of virtual patient communities. At other levels of patient empowerment, knowl-
edge is empowered through active interaction not only with the healthcare professional,
but also the transfer of existing knowledge to members of (informal) virtual communities
and community organizations.
Given that the goal of the patient-centered healthcare model is to involve the patient
in the treatment and day-to-day management of the chronic disease in the most acceptable
way, qualitative analysis of the research revealed that this patient knowledge enabler
operates across all levels of patient empowerment because as patient empowerment evolves,
patient engagement unequivocally increases.
Proposition 3. Patient knowledge empowerment at the microempowerment level is stimulated by

technological knowledge sharing enablers (P3).
The analysis of selected research papers revealed that there is a link between techno-
logical knowledge-sharing enablers such as Web 2.0 and the knowledge-sharing systems
and the microlevel of patient empowerment [65].The latest finding of the study suggests
that at the microlevel of patient empowerment, the above-mentioned technological knowl-
edge enablers, acting on the basis of already discussed health technologies, stimulate
codification of patient and healthcare professional knowledge in order for the patient
to express accumulated knowledge, experience in everyday life struggling with chronic
disease and objective information on health parameters; and the healthcare professional,
after assessing the knowledge expressed by the patient, could convey recommendations
based on knowledge and experience for making daily decisions in the most understandable
and acceptable way for the patient.
Proposition 4. Patient knowledge empowerment through mediating structures (P4a) and at the
macrolevel (P4b) is stimulated by systemic knowledge sharing enablers.
The study revealed that to stimulate knowledge sharing in mediating structures and at
macro level for patient knowledge empowerment transformational leadership manifestations
are important [17,51,84,93], supportive culture of these organizations [16,18,51,74,91,93], and
a less formalized and centralized structure of the organizations [17,74,93]. Regardless of
the fact that mediating patient structures are mostly informal and patient community
organizations are formalized, through a less formalized and centralized organizational
structure, active social interaction between members of the organization is created to
ensure knowledge sharing. The supportive organizational culture and the manifestation of
transformational leadership in the organization are aimed at changing the behavior of the
members of the organization, stimulating patients’ orientation to continuous learning, and
sharing knowledge, skills, and competencies in the context of learning health system.
Proposition 5. Patient knowledge empowerment through mediating structures (P5a) and at the
macrolevel (P5b) is stimulated by the individual knowledge sharing enabler–internal patient moti-
vation.
An integrated analysis of research reveals that knowledge sharing enabled by patients

through mediating structures and at the macrolevel is stimulated by their internal moti-
vation [51]. In other words, as patient empowerment evolves across the levels discussed
above, patient‘s awareness of the importance of knowledge sharing in the interpersonal
dimension is built, where an internal stimulus is felt to transfer existing knowledge and
cognitive skills to the same chronic disease community and later to address related so-
cial issues.
3.5. Limitations
The limitations of the performed integrative review, which could potentially influence
the results of the research, can be related to the following methodological choices:
• Given the time and physical resources of the researchers, a relatively limited number
of databases for the identification of potentially eligible studies were used.
• The choice to analyze only open access publications due to limited financial resources
may have led to insufficient identification of themes of knowledge enablers for chronic
patients from public health management and knowledge management perspectives
and thus may have affected the results of the integration of these two perspectives.
4. Conclusions
Patient empowerment takes place across the levels of empowerment, and the result
of patient empowerment primarily is the psychological empowerment of individuals and
then that of community, creating organizations involving stakeholders, which operate
through interactions to achieve health-related goals. Patients’ knowledge is formed in a
process that includes the search for knowledge about their disease, its synthesis, and the
use of specific knowledge. Knowledge empowerment also takes place in a process in which
the patient, across the levels of empowerment, acquires the power to purposefully use their
knowledge in everyday decisions to achieve health behavior.
Enablers of patient knowledge empowerment for self-management of chronic disease
framework confirms the importance of looking at patient knowledge empowerment as
a process, as patient empowerment evolves consistently across patient empowerment
levels. The above-mentioned model also reveals that at all levels of patient empowerment
there are both knowledge enablers distinguished in public health management theory and
knowledge enablers distinguished in knowledge management theory. Thus, in the context
of patient empowerment, it is important to look at patient knowledge empowerment from
both a patient perspective and an organizational perspective when searching for solutions
to stimulate the use of knowledge, as the integration of these two perspectives provides a
holistic frame for patient knowledge empowerment.
Author Contributions: Conceptualization, V.V.; methodology, V.V. and R.V.; formal analysis, V.V.;
investigation, V.V.; data curation, V.V.; writing original draft preparation, V.V.; writing—review and
editing, V.V. and R.V.; visualization, V.V.; supervision, R.V.; project administration, V.V.; funding
acquisition, V.V. and R.V. All authors have read and agreed to the published version of the manuscript.
Funding: This research is funded by the European Social Fund under the No 09.3.3-LMT-K-712
“Development of Competences of Scientists, other Researchers and Students through Practical
Research Activities” measure. This research is funded by School of Economics and Business, Kaunas
university of technology.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The study materials and the detail of all analyses are available from
the corresponding author upon reasonable request.
Conflicts of Interest: The authors declare no conflict of interest.
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International Journal of

Received: 23 January 2021

use of empowered patients’ knowledge needs specific preconditions called knowledge

patients with chronic diseases causes methodological inconsistencies in patient empow-

2. Materials and Methods

2.1. Patient Knowledge Enablers: Theoretical Background

2.1.1. Patient Empowerment and Its Levels

The isolated levels of patient empowerment presuppose that the microcomponent of

2.1.2. Patient Knowledge Formation for Patient Empowerment

All of these approaches concentrate on and interpret the process of implementation in

2.1.3. Patient Knowledge Enablers: The Importance of Integrating Public Health

knowledge [27]. In knowledge management theory, knowledge empowerment has been

2.2. Methodology of Literature Review

2.2.1. Choice of Synthesis Vehicle

2.2.2. Literature Review

Table 1. Search sources and results.

Number of Access Type,

2.2.3. Thematic Synthesis

3.1. Overview of Identified Themes

Themes Subthemes Number of Citations

Themes Subthemes Number of Citations

3.2. Patient Knowledge Enablers: A Public Health Management Perspective

3.2.2. Health Technologies

3.2.3. Patient-Centered Healthcare Model

3.2.4. Disease Management Programs

3.2.5. Learning Health System

3.3. Patient Knowledge Enablers: A Knowledge Management Perspective

3.3.2. Systematic Knowledge Sharing Enablers

3.3.3. Individual Enablers

Proposition 3. Patient knowledge empowerment at the microempowerment level is stimulated by

An integrated analysis of research reveals that knowledge sharing enabled by patients

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