Review Article Diabetes empowerment related to Pender’s Health Promotion Model: A meta-synthesis Agnes Yin Kwan Ho, rn, mnsc, 1 Ingela Berggren, rn, drpolit 1 and Elisabeth Dahlborg-Lyckhage, rn, phd 1,2 1 Department of Nursing, Health and Culture, University West,Trollhättan and 2 Institute of Health and Caring Science, Sahlgrenska Academy, Gothenburg, Sweden Abstract Diabetes self-management is a challenge for both clients and health-care professionals. Empowerment plays a vital role in helping clients to achieve successful self-management. This study adopted a meta-ethnographic approach. Nine qualitative studies were synthesized in order to contribute to a deeper understanding of what clients perceive as being important in an effective empowerment strategy for diabetes self-management. Four central metaphors that influenced empowerment were identified: trust in nurses’ competence and awareness, striving for control, a desire to share experiences, and nurses’ attitudes and ability to personalize. The lines-of-argument synthesis suggested the need for an evaluation system to appraise clients’ diabetes knowl- edge, health beliefs, and negative emotions, as well as the outcome of interventions. Based on Pender’s Health Promotion Model, this study emphasizes the fact that health-care professionals need to understand and address modifiable behavior-specific variables. The study suggests that an effective empowerment strategy would be to use activity-related affect, as well as interpersonal and situational influences, as a means of facilitating and enhancing clients’ health-promoting behaviors. Key words diabetes, empowerment, Health Promotion Model, meta-ethnography, self-management. INTRODUCTION Diabetes is a global public health concern for many nations in the 21st century and ~ 246 million people worldwide have diabetes, almost 6% of the world’s adult population (IDF, 2006a). About 80% of these clients live in developing coun- tries and suffer from type 2 diabetes, of whom 46% are in the 40–59 year age group. The eastern Mediterranean and the Middle East are the regions with the highest diabetes preva- lence rates. In 2007, India had the world’s largest diabetes population, followed by China, the USA, Russia, Germany, Japan, Pakistan, Brazil, Mexico, and Egypt (IDF, 2006a).The highest prediabetes prevalence is in the European region, with 9% of the adult population being at significant risk of developing type 2 diabetes (IDF, 2006b).The escalating dia- betes prevalence is underpinned by factors such as an aging population, unhealthy diet, overweight, and obesity, as well as physical inactivity (IDF, 2009). Diabetes self-management is a lifelong commitment. An effective self-care regimen and a multidisciplinary team approach are required to avoid or delay the serious chronic complications of the disease. Acquiring diabetes knowledge through education plays an essential role in diabetes self- management, as improved knowledge will lead to an effective change in self-management behaviors (Booker et al., 2008). In recent years, the empowerment concept has been adopted in modern diabetes care. Rodwell (1996: 309) defined empowerment as a helping process “. . . whereby groups or individuals are enabled to change a situation, given skills, resources, opportunities and authority to do so. It is a part- nership, which respects and values self and others – aiming to develop a positive belief in self and the future”. The em- powerment process involves client-centered collaborative partnership, an active client role, shared decision-making, freedom to make choices, and acceptance of responsibility for one’s actions (Adolfsson et al., 2008; Booker et al., 2008). Several approaches, based on the empowerment concept, have been implemented in diabetes care to facilitate clients’ self-management, with different levels of success. Conven- tional individual counseling, which focuses on goal-setting and problem-solving strategies, can encourage clients to iden- tify realistic diabetes goals and could improve diabetes outcomes (Corser et al., 2007; Utz et al., 2008). Hence, the intervention is restricted by clients’ limited knowledge of diabetes and, thus, inability to make informed choices (Ado- lfsson et al., 2008). Group education intervention underlines shared experiences of managing diabetes, highlighting that empowerment can be facilitated through reassurance from others in a similar situation (Adolfsson et al., 2008; Booker et al., 2008). Moreover, interventions that are based on client expertise, such as lay-led research advisory groups, stress real world connection and client involvement in health research Correspondence address: Agnes Yin Kwan Ho, Solgärdesvägen 13, 436 42 Askim, Sweden. Email: hoykchina@hotmail.com Received 9 June 2009; accepted 14 January 2010. Nursing and Health Sciences (2010), 12, 259–267 © 2010 Blackwell Publishing Asia Pty Ltd. doi: 10.1111/j.1442-2018.2010.00517.x