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.
The International Diabetes Federation predicts that by
2045, the number of people with DM will increase to 693
billion.1 In Indonesia, the prevalence of DM increased
from 6.9% in 2013 to 8.5% in 2018 as per the RISKESDAS
survey.2 In Makassar city, South Sulawesi, DM prevalence
was 2.89% in 2018, and DM continues to be a serious
health threat because the number of new cases are increas-
ing.2 Hence, different intervention strategies are needed to
control DM and delay the onset of serious chronic compli-
cations in the future.3 One of the interventions that can be
applied is family empowerment. Empowerment is defined
as positively controlling a person’s mind and body, culti-
vating a positive attitude, and proactively trying to under-
stand one’s role as a caregiver to promote a family’s
caregiving abilities. Other aspects of empowerment
include focusing on others as well as oneself, providing
assistance to the care receiver to enhance his life quality,
and creating constructive relationships with others.4 These
aspects correlate with increased metabolic control, higher
medication adherence, increased knowledge about DM,
increased family function, and improvement in the quality
of life.5 Previous studies indicate an association between
diabetes empowerment and family support.6 In addition,
education-based empowerment reported a positive impact
on the management of DM.7 However, the effect of
empowerment on glycemic control and the wound healing
process of diabetic foot ulcers (DFUs) is relatively unex-
amined. Thus, the goal of the current study is to evaluate
the effectiveness of family empowerment through educa-
tional interventions on HbA1c levels and the healing prog-
ress of DFUs.
Materials and Methods
This study employed a pre- and posttest quasi-experimental
design involving 33 participants from 4 wound care centers
in Makassar, eastern Indonesia. Participants were divided
into 2 groups: intervention and control. The intervention
group consisted of 17 participants and their families who
underwent educational intervention for 4 weeks. The con-
trol group consisted of 16 participants who received stan-
dard education from the nurse at wound care clinic. The
1
Faculty of Nursing, Hasanuddin University, Makassar, Indonesia
2
Massenrempulu General Hospital, South Sulawesi, Indonesia
3
Griya Afiat Makassar, Wound Care and Home Care Clinic, Makassar,
Indonesia
4
General Hospital of West Sulawesi Province, Mamuju, Indonesia
Corresponding Author:
Saldy Yusuf, Faculty of Nursing, Hasanuddin University, Jl Perintis
Kemerdekaan KM 10, Makassar 90245, Indonesia.
Email: saldy_yusuf@yahoo.com
2 The International Journal of Lower Extremity Wounds 00(0)
groups were allocated based on different research settings. A
simple random sampling technique was chosen with the fol-
lowing inclusion criteria: participants with type 2 DM who
have DFUs, ≥18 years old, and HbA1c levels ≥6%. The
inclusion criteria for family members was that they were liv-
ing with participants. This study obtained an ethical clear-
ance from the ethical committee, Faculty of Medicine,
Hasanuddin University, Makassar-Indonesia (Number 720/
UN4.6.4.5.31/PP36/2019). Participants and family received
a brief explanation before signing informed consent forms.
Family Empowerment Procedure
Family empowerment consisted of family-based education
interventions that were conducted at the clinic and partici-
pants’ homes. The education was given 4 times (one session
per week for 4 weeks) solely in intervention groups that
included family participants. Each session was conducted for
45 minutes, with a 7-day interval between the 2 sessions.
In the first week, the education was provided using a pic-
ture booklet containing “benefits of family empowerment
and basic knowledge about DM.” In the second week, the
education focused on diet/meal planning, medication, blood
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
third week, education about the treatment of DFU was pro-
vided. Last, in the fourth week, an evaluation meeting was
conducted. To verify the activities completed during the
intervention, a logbook was provided to each participant.
Health education using booklets tailored to the individual’s
needs combined with telephone calls has been shown to
improve outcomes and help maintain high levels of physi-
cal, psychological, and social welfare.8
Educational media using booklets was implemented pre-
viously to promote self-care adherence in individuals living
with diabetes foot ulcers.9 An educational program using
booklets reported an improvement in the management of
the disease.10 Meanwhile, participants in the control group
received nonstructural education provided verbally by
wound care nurses during wound treatment without family
involvement.
Evaluation of Family Empowerment, Glycemic
Control, and Wound Healing
Our dependent variables were family empowerment, glyce-
mic status, and the healing process. Our independent variable
was family-based education, which was evaluated by the
Family Empowerment Scale (FES). The FES has an ade-
quate correlation coefficient (0.855-0.917), with Cronbach’s
α of 0.867 to 0.895.11 Our pilot study also confirmed that
FES satisfied Cronbach’s α (0.863) in a community setting.
In this study, we used “family” as a subscale of FES since our
scope was effect of intervention on family. Blood samples
were taken from the participants at the first week (pretest)
and 12 weeks later (posttest) to evaluate their HbA1c levels.
The samples were examined in a private laboratory
(PRODIA) certified by NGSP (National Glycohaemoglobin
Standardization Program). Certified wound care nurses eval-
uated the wound healing process 3 times (in the first, second,
and third months) using the Diabetic Foot Ulcer Assessment
Scale (DFUAS). The DFUAS scale reported validity in eval-
uating the healing process of DFUs,12 and the reliability was
confirmed in the Indonesian setting.13
Statistical Analysis
Numeric data presented in mean and standard deviation,
ordinal and categorical data reported in frequency and per-
centage (n, %). Chi-square or Fisher, and the Mann-Whitney
test identified participants’ characteristics among groups. A
paired t test was used to evaluate effect within groups, and
an independent t test was used for between-group analysis.
Friedman Test was used to evaluate the effect of wound
healing at 3 months. Data analysis was performed using the
SPSS application program, Version 25.0, for Windows
(IBM Corporation).
Results
Characteristics of Participants
The demographic characteristics indicate relatively similar
ages (56.76 ± 9.66 vs 53.25 ± 8.43) years, sex mainly
female (n = 8, 47.1%, vs n = 11, 68.8%), and about one
third graduated from elementary school (n = 7, 41.2%, vs
n = 6, 37.5%) for the intervention and control groups,
respectively. Regarding glycemic control, the intervention
group mainly used oral therapy (n = 9, 52.9%), and the
control group used a combination of oral and insulin ther-
apy (n = 10, 62.5%). All of the characteristics were statisti-
cally similar (P > .05; Table 1).
Characteristics of Family Participants
The mean age of family participants in both the groups was
similar (38.59 ± 10.9 vs 38.0 ± 10.2) years, whereas the
majority of family participants in both the groups were
females (n = 15, 88.2%, vs n = 13, 81.3%) in the interven-
tion and control groups, respectively. Similar patterns were
also found in the education level in the 2 groups, which
mostly graduated from high school (intervention group:
n = 6, 35.3%; control group: n = 7, 43.8%). The relationship
between participants and family in the intervention group
was mostly spouse (n = 7, 41.2%), whereas in the control
group, the relationship was mainly parent-child (n = 9,
56.3%) and spouse (n = 7, 43.8%). No statistical difference
(P > .05) was identified between intervention and control
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
The first set of questions evaluated the effect of intervention
against the improvement of family empowerment that was
evaluated using the subdomain family of the FES scale. The
independent t test confirmed similar knowledge (12.41 ±
0.79 vs 12.81 ± 0.75; P = .147) and attitude (2.65 ± 0.60 vs
2.50 ± 0.63; P = .500) for intervention and control groups.
After 3 months, there was improvement in family knowl-
edge (16.59 ± 3.92 vs 13.38 ± 1.26; P = .005) and attitude
(3.65 ± 0.93 vs 2.75 ± 0.45; P = .002). Regarding behav-
ior, despite lower scores at baseline, we noted an improve-
ment of 5 points (8.65 ± 1.27 vs 13.59 ± 3.02; Table 3).
process improved significantly (P < .05) after the 3-month
intervention. However, the reduction in the DFUAS score
was clinically significant in the intervention group com-
pared with the control group (64.41 to 4.71 vs 64.06 to
17.25). The mean reduction of DFUAS score was higher in
the intervention group (59.71) compared with the control
group (46.81) (data not presented). An independent t test
further revealed that the wound healing process tended to be
better for the intervention group (4.71 ± 7.74) compared
with the control group (17.25 ± 17.06) (Table 4). The mean
difference between group was 12.54 (P = .010) at the end
of observation (data not presented).

HbA1c Levels
HbA1c levels were evaluated as a marker of the effect of
family empowerment against glycemic control after 3
months of intervention. At baseline, no significant differ-
ence was observed in the HbA1c levels before family
empowerment between the intervention (10.47 ± 2.44%)
and control groups (10.86 ± 2.53%), respectively (P =
.655). Interestingly, there was a reduction in the percentage
of HbA1c after 3 months of intervention (from 10.47 ±
2.44% to 8.81 ± 1.83%) compared with the control group
(P = .048; Table 3).
Wound Healing
At baseline, both groups had similar DFUAS scores (64.41
± 15.29 vs 64.06 ± 15.72). In both groups, the healing
Discussion
Effect of Family Empowerment on Glycemic
Control
HbA1c levels decreased significantly after the family
empowerment program was employed in the intervention
group, whereas in the control group, no significant changes
were observed. This is consistent with previous reports that
assessed HbA1c levels in participants in the intervention
group after family education.8,14 Education through family
empowerment, family assistance, and family intervention in
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
Effective empowerment encouraged individuals living with
DM to proactively maintain their glycemic control and
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
confirm that family empowerment through education ame-
liorated HbA1c levels, which is in line with our results. In
this study, family empowerment was conducted on family
participants, including couples and the participants’ children
living in the same house with participants. As far as family
participants were concerned, the intervention group was
dominated by couples, whereas the control group was domi-
nated by children. Previous studies have shown that family
interventions prevent the severity of the disease and promote
better health for people with DM,19 and metabolic control.10
Support from the spouse and other family members can
increase adherence to lifestyle interventions and therapies so
that optimal glycemic control is achieved, which helps avoid
more severe complications.20 Thus, along with these previous
studies, our study showed that the involvement of a partner or
child in managing individuals with DM through family
empowerment is effective in glycemic control of DM.
Effect of Family Empowerment on the Wound
Healing Process
We also found that family empowerment affected the wound
healing process. DFUAS scores decreased significantly (60
points) by the third month of observation. The DFUAS
score evaluated 11 subscales of healing properties (depth,
size, size score, inflammation/infection, proportion of gran-
ulation tissue, type of necrotic tissue, proportion of necrotic
tissue, proportion of slough, maceration, type of wound
edge, and tunneling).12 Social support has been reported to
be associated with the healing process.21 Thus, this finding
indicates the importance of the role of the family as social
support in promoting the wound healing process. Another
possible explanation for the faster healing process in the
intervention group was the role of glycemic control. A pre-
vious study on the relationship between HbA1c and dia-
betic foot wound healing from 584 participants with the
average value of HbA1c 8.1% showed that 450 participants
(77.1%) experienced healing as evidenced by the closure of
the wound base.22 Wound healing has been shown to occur
faster in participants who have low HbA1c levels, with a
cure rate of 0.35 cm2 per day23 and controlled HbA1c levels
of 7.0% to 8.0% during treatment correlate with the healing
of DFU.24 This reinforces that education in individuals with
DFU improves glycemic control, which enhances the
wound healing process.
Strength and Limitations
The strength of the current study is that observation was con-
ducted for 3 consecutive months, which accounts for ade-
quately reflecting glycemic patterns and the healing process.
However, we noted some limitations of the current study. The
small sample size became the main issue in the ability to gen-
eralize from the current study. Group allocation was based on
research setting blocking which potentially resulted in selec-
tion bias (Figure 1). Another issue was that the FES scale was
evaluated partially in subdomain families.
6 The International Journal of Lower Extremity Wounds 00(0)
Conclusion
Family empowerment through family-based education
interventions controls HbA1c levels and accelerates wound
healing of DFU.
Acknowledgments
The authors would like to thank the Health Human Resources
Development and Empowerment Agency, Ministry of Health of
10. Odajima Y, Kawaharada M, Wada N. Development and vali-
Indonesia.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Rasnah Appil https://orcid.org/0000-0002-4054-7268
Saldy Yusuf https://orcid.org/0000-0002-5993-9325
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