930120

research-article2020
IJLXXX10.1177/1534734620930120The International Journal of Lower Extremity WoundsAppil et al

Original Article
The International Journal of Lower

Effect of Family Empowerment

Extremity Wounds
1­–7
© The Author(s) 2020
on HbA1c Levels and Healing Article reuse guidelines:
sagepub.com/journals-permissions

of Diabetic Foot Ulcers DOI: 10.1177/1534734620930120

https://doi.org/10.1177/1534734620930120
journals.sagepub.com/home/ijl

Rasnah Appil, MN1,2 , Elly Lilianty Sjattar, PhD1,

Saldy Yusuf, PhD1,3 , and Kasmawati Kadir, MN1,4

Abstract
Objective. To evaluate the effectiveness of family empowerment through educational interventions against HbA1c level and
healing progress of diabetic foot ulcers. Method. A quasi-experimental design was employed involving 33 participants from 4
wound care clinics in Makassar, eastern Indonesia. The intervention group consisted of 17 participants and their families; the
control group was composed of 16 participants who received nonstructural education. Family empowerment was measured
by the Indonesian version of the Family Empowerment Scale instrument. Glycemic control was evaluated with HbA1c levels,
and the wound healing process was evaluated on the Diabetic Foot Ulcers Assessment Scale. Result. After 3 months, Family
Empowerment Scale scores improved, particularly in the subdomain of family knowledge (16.59 ± 3.92 vs 13.38 ± 1.26; P
= .005) and attitude (3.65 ± 0.93 vs 2.75 ± 0.45; P = .002). After 3 months of intervention, HbA1c decreased (from 10.47
± 2.44% to 8.81 ± 1.83%), compared with the control group (P = .048). Meanwhile, an independent t test further revealed
that the wound healing process tended to be better with the intervention group (4.71 ± 7.74) compared with the control
group (17.25 ± 17.06), with P = .010 at the third month. Conclusion. Family-based education intervention creates family
empowerment to control HbA1c levels and accelerate wound healing of diabetic foot ulcer.

Keywords
family empowerment, diabetic foot ulcers, HbA1c, Diabetic Foot Ulcer Assessment Scale, wound healing

Diabetes mellitus (DM) has become a worldwide concern. empowerment on glycemic control and the wound healing
The International Diabetes Federation predicts that by process of diabetic foot ulcers (DFUs) is relatively unex-
2045, the number of people with DM will increase to 693 amined. Thus, the goal of the current study is to evaluate
billion.1 In Indonesia, the prevalence of DM increased the effectiveness of family empowerment through educa-
from 6.9% in 2013 to 8.5% in 2018 as per the RISKESDAS tional interventions on HbA1c levels and the healing prog-
survey.2 In Makassar city, South Sulawesi, DM prevalence ress of DFUs.
was 2.89% in 2018, and DM continues to be a serious
health threat because the number of new cases are increas- Materials and Methods
ing.2 Hence, different intervention strategies are needed to
control DM and delay the onset of serious chronic compli- This study employed a pre- and posttest quasi-experimental
cations in the future.3 One of the interventions that can be design involving 33 participants from 4 wound care centers
applied is family empowerment. Empowerment is defined in Makassar, eastern Indonesia. Participants were divided
as positively controlling a person’s mind and body, culti- into 2 groups: intervention and control. The intervention
vating a positive attitude, and proactively trying to under- group consisted of 17 participants and their families who
stand one’s role as a caregiver to promote a family’s underwent educational intervention for 4 weeks. The con-
caregiving abilities. Other aspects of empowerment trol group consisted of 16 participants who received stan-
include focusing on others as well as oneself, providing dard education from the nurse at wound care clinic. The
assistance to the care receiver to enhance his life quality,
and creating constructive relationships with others.4 These 1
Faculty of Nursing, Hasanuddin University, Makassar, Indonesia
2
aspects correlate with increased metabolic control, higher Massenrempulu General Hospital, South Sulawesi, Indonesia
3
Griya Afiat Makassar, Wound Care and Home Care Clinic, Makassar,
medication adherence, increased knowledge about DM,
Indonesia
increased family function, and improvement in the quality 4
General Hospital of West Sulawesi Province, Mamuju, Indonesia
of life.5 Previous studies indicate an association between
Corresponding Author:
diabetes empowerment and family support.6 In addition,
Saldy Yusuf, Faculty of Nursing, Hasanuddin University, Jl Perintis
education-based empowerment reported a positive impact Kemerdekaan KM 10, Makassar 90245, Indonesia.
on the management of DM.7 However, the effect of Email: saldy_yusuf@yahoo.com
2 The International Journal of Lower Extremity Wounds 00(0)

groups were allocated based on different research settings. A were taken from the participants at the first week (pretest)
simple random sampling technique was chosen with the fol- and 12 weeks later (posttest) to evaluate their HbA1c levels.
lowing inclusion criteria: participants with type 2 DM who The samples were examined in a private laboratory
have DFUs, ≥18 years old, and HbA1c levels ≥6%. The (PRODIA) certified by NGSP (National Glycohaemoglobin
inclusion criteria for family members was that they were liv- Standardization Program). Certified wound care nurses eval-
ing with participants. This study obtained an ethical clear- uated the wound healing process 3 times (in the first, second,
ance from the ethical committee, Faculty of Medicine, and third months) using the Diabetic Foot Ulcer Assessment
Hasanuddin University, Makassar-Indonesia (Number 720/ Scale (DFUAS). The DFUAS scale reported validity in eval-
UN4.6.4.5.31/PP36/2019). Participants and family received uating the healing process of DFUs,12 and the reliability was
a brief explanation before signing informed consent forms. confirmed in the Indonesian setting.13

Family Empowerment Procedure Statistical Analysis

Family empowerment consisted of family-based education Numeric data presented in mean and standard deviation,
interventions that were conducted at the clinic and partici- ordinal and categorical data reported in frequency and per-
pants’ homes. The education was given 4 times (one session centage (n, %). Chi-square or Fisher, and the Mann-Whitney
per week for 4 weeks) solely in intervention groups that test identified participants’ characteristics among groups. A
included family participants. Each session was conducted for paired t test was used to evaluate effect within groups, and
45 minutes, with a 7-day interval between the 2 sessions. an independent t test was used for between-group analysis.
In the first week, the education was provided using a pic- Friedman Test was used to evaluate the effect of wound
ture booklet containing “benefits of family empowerment healing at 3 months. Data analysis was performed using the
and basic knowledge about DM.” In the second week, the SPSS application program, Version 25.0, for Windows
education focused on diet/meal planning, medication, blood (IBM Corporation).
sugar control, physical exercise, and stress management.
This was done through a 45-minute lecture and practice
exercises, including question and answer sessions. In the Results
third week, education about the treatment of DFU was pro- Characteristics of Participants
vided. Last, in the fourth week, an evaluation meeting was
conducted. To verify the activities completed during the The demographic characteristics indicate relatively similar
intervention, a logbook was provided to each participant. ages (56.76 ± 9.66 vs 53.25 ± 8.43) years, sex mainly
Health education using booklets tailored to the individual’s female (n = 8, 47.1%, vs n = 11, 68.8%), and about one
needs combined with telephone calls has been shown to third graduated from elementary school (n = 7, 41.2%, vs
improve outcomes and help maintain high levels of physi- n = 6, 37.5%) for the intervention and control groups,
cal, psychological, and social welfare.8 respectively. Regarding glycemic control, the intervention
Educational media using booklets was implemented pre- group mainly used oral therapy (n = 9, 52.9%), and the
viously to promote self-care adherence in individuals living control group used a combination of oral and insulin ther-
with diabetes foot ulcers.9 An educational program using apy (n = 10, 62.5%). All of the characteristics were statisti-
booklets reported an improvement in the management of cally similar (P > .05; Table 1).
the disease.10 Meanwhile, participants in the control group
received nonstructural education provided verbally by
Characteristics of Family Participants
wound care nurses during wound treatment without family
involvement. The mean age of family participants in both the groups was
similar (38.59 ± 10.9 vs 38.0 ± 10.2) years, whereas the
Evaluation of Family Empowerment, Glycemic majority of family participants in both the groups were
females (n = 15, 88.2%, vs n = 13, 81.3%) in the interven-
Control, and Wound Healing tion and control groups, respectively. Similar patterns were
Our dependent variables were family empowerment, glyce- also found in the education level in the 2 groups, which
mic status, and the healing process. Our independent variable mostly graduated from high school (intervention group:
was family-based education, which was evaluated by the n = 6, 35.3%; control group: n = 7, 43.8%). The relationship
Family Empowerment Scale (FES). The FES has an ade- between participants and family in the intervention group
quate correlation coefficient (0.855-0.917), with Cronbach’s was mostly spouse (n = 7, 41.2%), whereas in the control
α of 0.867 to 0.895.11 Our pilot study also confirmed that group, the relationship was mainly parent-child (n = 9,
FES satisfied Cronbach’s α (0.863) in a community setting. 56.3%) and spouse (n = 7, 43.8%). No statistical difference
In this study, we used “family” as a subscale of FES since our (P > .05) was identified between intervention and control
scope was effect of intervention on family. Blood samples groups for all characteristics of family participants (Table 2).
Appil et al 3

Table 1.  Frequency Distribution Based on Demographic Characteristics of DM Participants.

Intervention (N = 17) Control (N = 16)

Characteristics of
participants N % n % P
Age (mean ± SD) 56.76 9.66 53.25 8.43 .275a
Sex
 Male 9 52.9 5 31.3 .208b
 Female 8 47.1 11 68.8  
Education level
  Elementary school 7 41.2 6 37.5  
  Junior high school 1 5.9 3 18.8 .197b
  Senior high school 6 35.3 4 25.0  
  Bachelor’s degree 2 11.8 3 18.8  
  Postgraduate degree 1 5.9 0 0  
Occupation status
 Working 8 47.1 11 68.8 .208b
  Not working 9 52.9 5 31.3  
Duration of DM (years)
  <5 years 7 41.2 5 31.3 .672b
  5-10 years 4 23.5 6 37.5  
  >10 years 6 35.3 5 31.3  
Therapy of DM
 Oral 9 52.9 6 37.5 .373b
 Oral + insulin 8 47.1 10 62.5  

Abbreviation: DM, diabetes mellitus.

a
Mann-Whitney U test.
b
Chi-square test.

Table 2.  Frequency Distribution Based on Demographic Characteristics of Family Participants.

Intervention (N = 17) Control (N = 16)

Characteristics of
participants n % n % P
Age (mean ± SD) 38.59 10.9 38 10.2 .875a
Sex .656b
 Male 2 11.8 3 18.8  
 Female 15 88.2 13 81.3  
Education level
  Elementary school 3 17.6 3 18.8 .870c
  Junior high school 4 23.5 4 25.0  
  Senior high school 6 35.3 7 43.8  
  Bachelor’s degree 4 23.5 2 12.5  
Occupation status
 Working 9 52.9 5 31.3 .208c
  Not working 8 47.1 11 68.8  
Family relationship
 Spouse 7 41.2 7 43.8 .200c
 Children 7 41.2 9 56.3  
 Brother/sister 3 17.6 0 0  
a
Mann-Whitney U test.
b
Fisher exact test.
c
Chi-square test.
4 The International Journal of Lower Extremity Wounds 00(0)

Table 3.  Effect of Family Empowerment Against FES and Glycemic Control Between Groups.

Pre Post

Intervention, Control, mean Intervention, Control,

Variables mean ± SD ± SD P mean ± SD mean ± SD P
FES (family)  
 Knowledge 12.41 ± 0.79 12.81 ± 0.75 .147 16.59 ± 3.92 13.38 ± 1.26 .005
 Attitude 2.65 ± 0.60 2.50 ± 0.63 .500 3.65 ± 0.93 2.75 ± 0.45 .002
 Behavior 8.65 ± 1.27 10.25 ± 0.45 .001 13.59 ± 3.02 11.63 ± 0.80 .019
Glycemic control (HbA1c) (%) 10.47 ± 2.44 10.86 ± 2.53 .655 8.81 ± 1.83 10.40 ± 2.56 .048

Abbreviation: FES, Family Empowerment Scale.

Table 4.  Family Empowerment on Wound Healing Between Intervention and Control Groupsa.

DFUAS 1st month 2nd month 3rd month Pa

Intervention (n = 17) 64.41 ± 15.29 39.29 ± 20.33 4.71 ± 7.74 .000
Control (n = 16) 64.06 ± 15.72 54.25 ± 22.35 17.25 ± 17.06 .002
Pb .949 .053 .010  

Abbreviation: DFUAS, Diabetic Foot Ulcer Assessment Scale.

a
Friedman test.
b
Independent t test.

Family Empowerment Scale process improved significantly (P < .05) after the 3-month
The first set of questions evaluated the effect of intervention intervention. However, the reduction in the DFUAS score
against the improvement of family empowerment that was was clinically significant in the intervention group com-
evaluated using the subdomain family of the FES scale. The pared with the control group (64.41 to 4.71 vs 64.06 to
independent t test confirmed similar knowledge (12.41 ± 17.25). The mean reduction of DFUAS score was higher in
0.79 vs 12.81 ± 0.75; P = .147) and attitude (2.65 ± 0.60 vs the intervention group (59.71) compared with the control
2.50 ± 0.63; P = .500) for intervention and control groups. group (46.81) (data not presented). An independent t test
After 3 months, there was improvement in family knowl- further revealed that the wound healing process tended to be
edge (16.59 ± 3.92 vs 13.38 ± 1.26; P = .005) and attitude better for the intervention group (4.71 ± 7.74) compared
(3.65 ± 0.93 vs 2.75 ± 0.45; P = .002). Regarding behav- with the control group (17.25 ± 17.06) (Table 4). The mean
ior, despite lower scores at baseline, we noted an improve- difference between group was 12.54 (P = .010) at the end
ment of 5 points (8.65 ± 1.27 vs 13.59 ± 3.02; Table 3). of observation (data not presented).

Discussion
HbA1c Levels
HbA1c levels were evaluated as a marker of the effect of
Effect of Family Empowerment on Glycemic
family empowerment against glycemic control after 3 Control
months of intervention. At baseline, no significant differ- HbA1c levels decreased significantly after the family
ence was observed in the HbA1c levels before family empowerment program was employed in the intervention
empowerment between the intervention (10.47 ± 2.44%) group, whereas in the control group, no significant changes
and control groups (10.86 ± 2.53%), respectively (P = were observed. This is consistent with previous reports that
.655). Interestingly, there was a reduction in the percentage assessed HbA1c levels in participants in the intervention
of HbA1c after 3 months of intervention (from 10.47 ± group after family education.8,14 Education through family
2.44% to 8.81 ± 1.83%) compared with the control group empowerment, family assistance, and family intervention in
(P = .048; Table 3). managing individuals living with DM has been shown to
improve health status and glycemic control.3,15,16 Education
through simulation effectively increased glycemic control.17
Wound Healing Effective empowerment encouraged individuals living with
At baseline, both groups had similar DFUAS scores (64.41 DM to proactively maintain their glycemic control and
± 15.29 vs 64.06 ± 15.72). In both groups, the healing showed a significant decrease in HbA1c levels in the
Appil et al 5

Figure 1.  Flow chart allocation of participants.

treatment group.18 These findings from previous studies edge, and tunneling).12 Social support has been reported to
confirm that family empowerment through education ame- be associated with the healing process.21 Thus, this finding
liorated HbA1c levels, which is in line with our results. In indicates the importance of the role of the family as social
this study, family empowerment was conducted on family support in promoting the wound healing process. Another
participants, including couples and the participants’ children possible explanation for the faster healing process in the
living in the same house with participants. As far as family intervention group was the role of glycemic control. A pre-
participants were concerned, the intervention group was vious study on the relationship between HbA1c and dia-
dominated by couples, whereas the control group was domi- betic foot wound healing from 584 participants with the
nated by children. Previous studies have shown that family average value of HbA1c 8.1% showed that 450 participants
interventions prevent the severity of the disease and promote (77.1%) experienced healing as evidenced by the closure of
better health for people with DM,19 and metabolic control.10 the wound base.22 Wound healing has been shown to occur
Support from the spouse and other family members can faster in participants who have low HbA1c levels, with a
increase adherence to lifestyle interventions and therapies so cure rate of 0.35 cm2 per day23 and controlled HbA1c levels
that optimal glycemic control is achieved, which helps avoid of 7.0% to 8.0% during treatment correlate with the healing
more severe complications.20 Thus, along with these previous of DFU.24 This reinforces that education in individuals with
studies, our study showed that the involvement of a partner or DFU improves glycemic control, which enhances the
child in managing individuals with DM through family wound healing process.
empowerment is effective in glycemic control of DM.
Strength and Limitations
Effect of Family Empowerment on the Wound
The strength of the current study is that observation was con-
Healing Process ducted for 3 consecutive months, which accounts for ade-
We also found that family empowerment affected the wound quately reflecting glycemic patterns and the healing process.
healing process. DFUAS scores decreased significantly (60 However, we noted some limitations of the current study. The
points) by the third month of observation. The DFUAS small sample size became the main issue in the ability to gen-
score evaluated 11 subscales of healing properties (depth, eralize from the current study. Group allocation was based on
size, size score, inflammation/infection, proportion of gran- research setting blocking which potentially resulted in selec-
ulation tissue, type of necrotic tissue, proportion of necrotic tion bias (Figure 1). Another issue was that the FES scale was
tissue, proportion of slough, maceration, type of wound evaluated partially in subdomain families.
6 The International Journal of Lower Extremity Wounds 00(0)

Conclusion 8. Yu M, Chair SY, Chan CWH, Choi KC. A health education

booklet and telephone follow-ups can improve medication
Family empowerment through family-based education adherence, health-related quality of life, and psychological
interventions controls HbA1c levels and accelerates wound status of patients with heart failure. Heart Lung. 2015;44:
healing of DFU. 400-407. doi:10.1016/j.hrtlng.2015.05.004
9. Galdino YLS, Moreira TMM, Marques ADB, Silva FAAD.
Acknowledgments Validation of a booklet on self-care with the diabetic foot.
Rev Bras Enferm. 2019;72:780-787. doi:10.1590/0034-7167-
The authors would like to thank the Health Human Resources
2017-0900
Development and Empowerment Agency, Ministry of Health of
10. Odajima Y, Kawaharada M, Wada N. Development and vali-
Indonesia. dation of an educational program to enhance sense of coher-
ence in patients with diabetes mellitus type 2. Nagoya J Med
Declaration of Conflicting Interests Sci. 2017;79:363-374. doi:10.18999/nagjms.79.3.363
The author(s) declared no potential conflicts of interest with respect 11. Kageyama M, Nakamura Y, Kobayashi S, et al. Validity and
to the research, authorship, and/or publication of this article. reliability of the Family Empowerment Scale for caregivers
of adults with mental health issues. J Psychiatr Ment Health
Nurs. 2016;23:521-531. doi:10.1111/jpm.12333
Funding 12. Arisandi D, Oe M, Roselyne Yotsu R, et al. Evaluation of
The author(s) received no financial support for the research, validity of the New Diabetic Foot Ulcer Assessment Scale in
authorship, and/or publication of this article. Indonesia. Wound Repair Regen. 2016;24:876-884. doi:10.1111
/wrr.12464
13. Hasniati, Yusuf S, Patellongi I, Rasid KA, Harkam H, Supardi
ORCID iDs E. Inter-rater reliability assesment of new diabetic foot ulcers
Rasnah Appil https://orcid.org/0000-0002-4054-7268 (The New Diabetic Foot Ulcer Assessment Scale) based on
Saldy Yusuf https://orcid.org/0000-0002-5993-9325 photographs. Enfermería Clínica. 2020;30:433-438. doi:
10.1016/j.enfcli.2019.11.010
14. Gomes LC, Coelho ACM, Gomides DDS, Foss-Freitas MC,
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