For some years now, the term empowerment has been used frequently in care models for patients with chronic diseases. The Real Academia de la Lengua Española defines the Spanish verb empoderar as an archaic variant of the verb apoderar and as a form derived from the English verb to empower. The dictionary definition of the Spanish term is “To make an individual or a group stronger or more powerful”.1 The literal meaning would be to “give power”, which is not the same as to strengthen or to encourage. Consequently, the correct Spanish term is and should be empoderar (to empower).

The origins of empowerment philosophy can be found in the approach to popular education developed in the 1960s on the basis of the work of Paulo Freire.2 The participatory approach, which emerged in the field of development in the 1970s, is a process that seeks to reduce the vulnerability and enhance the capacities of poor and marginalized populations in order to promote sustainable human development in these communities.3 In the mid-1980s, a network of women's groups and academics (DAWN) were the first people to use the term to refer to the process through which women could gain control over symbolic and material resources and strengthen their capabilities and roles in all areas.

Initially, the term was used to frame the rights and needs of groups that were vulnerable due to discrimination on the grounds of sex, race, or sexual orientation. Although the term empowerment is applicable to all vulnerable social groups or any group that is a victim of marginalization, both its origin and its broadest practical application are found in the field of women's rights.

Today, the concept of empowerment is used in a wide range of contexts. The interpretations of the term come from different disciplines, ranging from psychology and philosophy to the health sciences.

In health care, the term empowerment refers to a process that facilitates behavioral change and helps patients to take responsibility for their own health and to make informed choices—mainly in the areas of nutrition, physical activity and adherence to treatment—in order to achieve treatment goals.4 The aim of empowering patients is to foster self-care and self-efficacy.

The World Health Organization (WHO) defines empowerment as “a process through which people gain greater control over decisions and actions affecting their health”. They go on to say: “To achieve this, individuals and communities need to develop skills, have access to information, and resources, and opportunities to have a voice and influence the factors affecting their health and well-being”.5

In 2012, the WHO Regional Office for Europe published Health 2020,5 a policy framework document that establishes the strategy and identifies the priority areas for policy action for Europe in health matters up to the year 2020. One of the goals defined by this policy document is to empower citizens and patients.

In the context of health care, the term empowerment was first used as a guiding principle that should inform all interventions that promote better health. Later, the approach was used as a way to increase patients’ autonomy and participation in decisions about their health. More recently, however, some authors have started using the term to refer to strategies designed to help patients with chronic diseases to participate in and take responsibility for their own care and treatment, in order to improve health outcomes and, as a secondary goal, to control healthcare costs.6

Numerous definitions of empowerment exist in the context of health economics (Table 1). They define empowerment as the social process of recognizing, promoting, and enhancing the patients’ ability to meet their own needs, solve their own problems, and feel that they are in control of their own lives.

Empowerment is achieved by way of 5 principal steps:

• 1.

  Explore which aspects of the condition represent a problem for the patient.

• 2.

  Clarify the patient's feelings and the implications of their emotions: What does the patient think and feel about his or her situation?

• 3.

  Develop a plan: What needs to change? What options or resources are available to the patient?

• 4.

  Commit to action. Help the patient to understand the effort they will have to make and assess their commitment: What will the patient do and when?

• 5.

  Evaluate the process. Discuss the results and what the patient learned. Find out whether they encountered obstacles. Decide on the course of action for future interventions.7

Through these 5 steps, the empowerment process explores the patient's emotional response to their situation, works on ways to resolve the problems identified, and sets behavioral goals and targets. Obviously, there are certain prerequisites to success in this process and it will not be possible to empower a patient if these are not met:

• -

  The patients must have certain abilities8,9: They must accept their condition and have the necessary intellectual capacity to understand and engage with the disease process as a whole (prognosis, risks, treatment options, etc.).

• -

  Empowerment is both a process and an outcome.10,11 The empowerment process is a collaborative partnership between health professionals and patients in which the patient acquires capacities and skills through the transfer of knowledge and resources. At the end of the process, patients are better equipped to control and manage their disease and make informed decisions. The process should be guided by an exchange of information through which knowledge and skills are shared.12 This goal can be achieved in many different ways: through a verbal exchange of information during a visit with the specialist; by creating materials designed to inform and train patients to correctly interpret clinical information; by teaching patients to cope more effectively with their disease and to improve their quality of life (and enabling them to pass on their knowledge to other patients); by fostering healthy behaviors that will reduce clinical risks.

Today, on-line resources are very important and, when properly selected, they can and should be an essential resource for patients. In Spain, there are a number of “patient schools” (patient education websites), where patients who have certain diseases or are taking certain drugs share their knowledge and experience with others in similar situations.13 To cite just a few, there are “schools” dealing with diabetes, fibromyalgia, anticoagulation therapy, breast cancer, colorectal cancer, Parkinson disease, epilepsy, Alzheimer disease, childhood asthma, food allergies, chronic kidney disease, serious mental illness, and ostomies).

The ultimate aim of the empowerment process is to change the patients’ situation by encouraging them to play an active and responsible role and to participate in the decision-making process.

A patient can be said to be empowered when:

• –

  They understand and have mastered their disease and understand the effects it has on their personal, family, and professional life—in short, its impact on their quality of life and future.

• –

  They are capable of effective self-care measures and of adjusting their treatment regimen as needed, and are aware of the limits that must be respected in their therapy.

• –

  They are capable of making decisions and are satisfied with their health professionals and treatment.

• –

  They are well informed enough to avoid the most common risks and complications of their treatment and know how to minimize those risks.

• –

  They play an active role in their own care, engaging with health professionals to learn more about their disease and its treatment.

Patient empowerment implies making a paradigm shift in care; the challenge is how to introduce this approach into routine practice. It implies changing the current model of patient-physician relationship from the old paternalistic model, in which the patient is excluded from medical decisions, to a model based on an empowered patient. Designing strategies that enhance the patients’ knowledge and understanding is not enough to empower them; if the ultimate goal is to enable the patient to change his or her behavior, motivational strategies will probably also be necessary.14

Patient empowerment will become an integral part of the management of chronic diseases because it helps to maximize efficiency and value in health care systems.21 An active and empowered patient is able to make decisions, satisfy his or her own needs, and resolve problems. Empowered patients think critically and are in control of their lives and health. In order to achieve this goal, the patient must first acquire the necessary knowledge. An empowered patient has to be well informed and trained and must have a sufficient knowledge to understand the disease and its treatment and to feel capable of carrying out the therapy.22 Health professionals must keep their own professional knowledge up-to-date, avoid clinical inertia, respect the patient's needs, offer their patients the best therapeutic options available, and guide them in their choices. Health professionals are responsible for collaborating in the task of providing the best knowledge and skills (advising their patients on appropriate on-line resources and sharing links to webs or blogs offering reliable information in everyday language).This will empower their patients and enable them to make informed decisions about the options available to them and act accordingly.

The authors declare that they have no conflicts of interest.