Leukemia is a condition in which there is abnormal and uncontrolled growth of white blood cells. It is characterized by an increase in the number of leukocytes in the blood or bone marrow that disrupts the normal functioning of the body (Zainuddin & Maru, 2019). Leukemia patients often face side effects from the treatment they undergo. To overcome these side effects, patients need to adjust their activities, diet, get enough rest, and take good care of themselves [18].

Research by Ilmiyah (2017) shows that foods suitable for leukemia patients are high energy foods such as potatoes, bread, and bananas, as well as high protein foods such as meat, fish, and beans. This helps maintain the stamina and body condition of leukemia patients during the treatment and healing process [16]. One of the important principles in the treatment of cancer patients is self-care management or the patient's ability to cope with the symptoms experienced and recognize the side effects of treatment. This includes the patient's belief in themselves to be free from symptoms, able to undergo treatment, and evaluate the actions taken [1].

Self-care management involves food management, exercise, and mind management such as meditation [14]. In addition, good self-care behavior is also needed, especially in controlling oral chemotherapy treatment for leukemia patients [18]. Patients with more severe treatment side effects tend to have decreased ability to care for themselves (Docherti, Sandelowski in Treenai, 2016). Some blood cancer patients experience fatigue, weakness, lack of energy, lethargy, nausea, and even difficulty in performing activities, so they need the help of others in self-care. Cancer patients' fatigue can lead to weakness, lack of concentration, feeling unwell, depression, and lack of motivation (Winningham et al., 1994, in Maful, 2016). However, the relationship between motivation and self-care management in leukemia patients remains unexplained.

Leukemia is one of the most diagnosed types of cancer and a cause of death worldwide. Data from GLOBOCAN in 2018 shows that leukemia is the 15th most commonly diagnosed cancer and the 11th cancer that causes death, with a total incidence of 437,033 cases and 309,006 deaths. In Indonesia alone, cancer, including leukemia, is the leading cause of death with a percentage of 6.6%. The mortality rate due to leukemia in men is higher than other types of cancer, reaching 50-60% (Eka Aulia & Rahmasari, 2019). At Soetomo Hospital, the prevalence of leukemia patients treated has increased every year (Warsiki & Larasat, 2018).

In a preliminary survey at Yayasan Kanker Indonesia East Java Surabaya, there were 83 leukemia patients who were members of the East Java Chronic Granulostic Leukemia community. The problem faced by leukemia patients is the side effects of treatment, such as fatigue, memory loss, red eyes, nausea, and vomiting. As a result, not all patients regularly undergo treatment, only about 20 people do so on time. To overcome these side effects, it is important for leukemia patients to know about self-care management, including dietary strategies, physical activity, stress management, and adherence to treatment [6].

A commonly used therapy for the treatment of leukemia patients is the drug imatinib, which belongs to the Tyrosine Kinase Inhibitor (TKI) class. This drug is used in the treatment of Chronic Myeloid Leukemia (CML) by inhibiting tyrosine kinase activity targeted at BCR-ABL1 [13]. Cancer treatment can cause physical and mental side effects in patients. These side effects can affect patients' self-concept and behavior. To overcome these side effects, cancer patients use self-care management such as diet management, meditation, and physical activity.

The cause of leukemia is not known with certainty, but several factors such as family history, radiation exposure, and nutrition during pregnancy, parental smoking behavior, and Down syndrome in parents can increase the risk of leukemia. Leukemia treatment takes a long time and causes fatigue in patients, which can interfere with their self-care. Many leukemia patients also experience psychosocial problems such as depression and anxiety (Pratiwi, 2020).

Motivation plays an important role in the self-care of leukemia patients. Factors such as knowledge, individual awareness, and individual characteristics can affect patients' motivation to perform self-care. Age also affects motivation, with older people tending to have high motivation to maintain health. Although there is a relationship between motivation and self-care in patients with other conditions, specific research on self-care management in leukemia patients has not been conducted. Therefore, further research is needed to explore the relationship between motivation and self-care management in leukemia patients, taking into account factors such as health literacy, self-efficacy, and social support (Suud, 2020).

Leukemia patients experience decreased physical abilities due to disease symptoms or treatment side effects. In their self-care, motivation plays an important role. According to Dorothea Orem's self-care nursing theory, patients have the ability to care for themselves called self-care agency. This ability is implemented in self-care management. Factors such as age, gender, developmental status, health status, willpower, motivation, and knowledge influence self-care management. Motivation is one of the factors that influence a person in implementing self-care management. This study aims to examine the relationship between motivation and self-care management in leukemia patients based on Orem's theory [16].

This study used an analytic descriptive research design with a cross sectional approach. The population in this study were leukemia patients who are members of the Chronic Granulostic Leukemia or Elgeka community at the Surabaya Cancer Foundation, East Java. The sample in this study were leukemia patients who were members of the Chronic Granulostic Leukemia or Elgeka community at the Surabaya Cancer Foundation, East Java with an adult age ≥ 18 with inclusion criteria and exclusion criteria. The inclusion criteria in this study in this study are 1) Patients who have a smartphone and / or can access the questionnaire 2) Patients with leukemia ≥ 1 year. Exclusion criteria in this study are leukemia patients with cognitive impairment (dementia, delirium etc.). This study uses non-probability sampling, namely purposive sampling, where the sample determination technique uses how to select samples among the population according to the research objectives. Determination of the sample using the slovin formula amounted to 69 respondents.

Demographic questionnaires were used to analyze the characteristics of respondents including gender, educational history, age, length of leukemia and marital status. SCHFI (self-care of heart failure index)

6.2 questionnaire. The modified SCHFI was used to measure the self-care management of leukemia patients. This questionnaire consists of 21 questions with a Likert scale with the highest score being 84 while the lowest score is 21. The Motivation Questionnaire adopted from Wahyuni (2014) was used to measure motivation. This questionnaire consists of 20 questions with a Likert scale with the highest score being 80 while the lowest score is 20.

The data that has been collected will be analyzed with Sprearman's Rho correlation statistical test with a degree of significance or significance level α, 0.05. This study has received a certificate of ethical approval from the Health Research Ethics Commission of the Faculty of Dentistry, Universitas Airlangga on May 15, 2023 with number 488/HRECC.FODM/V2023.

Table 1: Distribution of respondents based on age, gender, marital status, duration of leukemia, education level in Elgeka East Java.

Table 1: shows that the majority of respondents in this study were male, with 40 respondents or around 57.97%. Most respondents had a diploma/graduate education, with a total of 34 respondents or around 49.28%. The age range of respondents was mainly between 46-65 years, with a total of 34 respondents or around 49.2%. The majority of leukemia patients in this study were married, with a total of 43 respondents or around 62.31%. Most respondents have suffered from leukemia for 6-10 years, with a total of 29 respondents or around 42.03%.

Table 2: Distribution of the relationship between motivation and self-care management in leukemia patients.

Table 2. Shows that most respondents have high motivation, with a total of 63 people or 91.3%, while the remaining 6 people have low motivation or 8.7%. In the dependent variable, it shows that most respondents have good self-care management, with a total of 61 people or 88.4%. There are only 8 respondents or 11.6% who are not good at self-care management. Based on the table above, it shows that there is a significant relationship between motivation and self-care management in leukemia patients. The p value obtained is 0.000, which means the hypothesis is accepted because the p value <0.05. The results of the analysis also show the Spearman Rho correlation coefficient of 0.531, indicating a positive correlation (unidirectional) between motivation and self-care management. The higher the motivation, the higher the level of self-care management, and vice versa.

This study found that there is a significant relationship between motivation and self-care management in leukemia patients. The relationship is expressed significantly with a p value <0.05 and a Spearman Rho correlation coefficient of 0.531, which is included in the moderate category. Based on Orem's theory, the relationship between motivation and self-care management in leukemia patients has a positive value, meaning that the higher the motivation, the better the self-care management, and vice versa.

Most of the leukemia respondents in this study showed a high level of motivation and good self-care management, which amounted to 93.7%. The majority of respondents agreed on the importance of information and support from close people, the community, and health workers as external motivation. In addition, the majority of respondents also had good self-care management in terms of keeping appointments with health workers when seeking treatment.

 The findings of this study are consistent with previous research on hypertensive patients conducted by Naufal (2020), which also showed a significant relationship between motivation and self-care management. In addition, a cross-sectional study conducted by Handriana and Hijriani (2020) on diabetes mellitus patients found a significant relationship between motivation and self-care management in the Majalengka Health Center working area. Another study conducted by Lukitasari et al. (2021) also revealed that high motivation contributes to improving self-care management in patients with diabetes mellitus.

However, this study also found that a small proportion of respondents had high motivation but poor self-care management (6.3%). On the other hand, there were respondents with low motivation, where only 33.3% of them had good self-care management, while 66.7% had poor self-care management. The distribution of respondents' answers showed that the majority disagreed, especially on the parameters of instrinsic motivation, such as feeling embarrassed if they did not do self-care management. The majority of respondents also did not exercise regularly.

In this study, self-care management can be influenced by several factors such as age, gender, education level, family support, and length of diagnosis. These factors can be taken into consideration in developing more effective interventions and care planning for leukemia patients.

In general, motivation is an important factor in the self-care management of leukemia patients. Individual motivation relates to needs, beliefs, commitment, and confidence to change behavior and achieve goals. In addition, factors such as age, gender, education level, family support, and length of diagnosis can also affect patients' self-care management.

The majority of respondents in this study were aged 46-65 years (49.2%). Older age provides a greater impetus to improve self-care management due to the fear of health vulnerabilities that increase with age.

Education also affects self-care management, with the majority of respondents having a history of Diploma / Bachelor's education (49.28%). A higher level of education tends to provide a higher acceptance of health information and awareness of self-care management.

Length of suffering also affects self-care management, with the majority of respondents (42.03%) having a length of suffering for 6-10 years. Patients who have been undergoing treatment for a long time tend to have a lower level of compliance, but if balanced with a healthy lifestyle according to doctor's recommendations, it can affect self-care management to be good.

Marital status is also a factor that affects self-care management. The majority of respondents (62.31%) were married. Individuals who are not married and live alone tend to have low self-confidence, which can affect poor self-care management.

Gender also plays a role, with the majority of respondents being male (57.97%). Women tend to be more compliant in performing self-care management activities such as exercise, health screening, and self-care management. However, in leukemia patients, the risk of Chronic Granular Lymphocytosis is slightly higher in males although the cause is unknown. The risk of LGM also increases with age, whereas it is rare in children and adolescents.

 Overall, demographic factors such as age, education, length of suffering, marital status, and gender influence self-care management in leukemia patients.

Human motivation in taking action is influenced by cognitive factors and thought processes that are influenced by individual knowledge. A person will be motivated if the action is in accordance with the goals, plans, and expected results. Motivation awakens the desire and drive of individuals to achieve the desired results. Motivation also plays a role in influencing individual behavior through emotional aspects, so that individuals act in accordance with the goals set to achieve satisfaction.

For leukemia patients, good motivation is very important in self-care management so that the treatment process can run well. Motivation is related to the needs and beliefs of individuals in undergoing the steps necessary to achieve certain goals. Each individual has different needs. The level of motivation towards self-care management is influenced by individual beliefs. Motivation is also a strong predictor of behaviors related to self-care management, physical activity, diet, and weight control. Self-care management is a positive activity, and it is expected that with the right motivation, leukemia patients can achieve good self-care management, so as to prevent complications and cope well with side effects.

Motivation has a relationship with self-care management of leukemia patients. Leukemia patients with high motivation have good self-care management. Leukemia patients need to increase motivation by increasing knowledge through structured health education about leukemia, management, and treatment side effects. Nurses have an important role in identifying and increasing patient motivation to carry out self-care management and changing their attitudes to improve health and disease care. The recommendation for future researchers is to develop research with interventions to improve self-care managem ent. In addition, it can examine other factors that influence self-care management in leukemia patients, such as family support and self-efficacy. Future researchers can also sharpen the self-care management research instrument in managing self-care.

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