Effect of Self- and Family Management of Diabetic Foot Ulcers Programs on Health Outcomes
Effect of Self- and Family Management of Diabetic Foot Ulcers Programs on Health Outcomes
Brief description:

 Diabetic foot ulcer (DFU) is described as a full-thickness lesion appearing at the skin of
 the foot along with infection, destruction of tissues due to neuropathy and/or peripheral
 artery disease (PAD) in people with diabetes (International Working Group on the Diabetic
 Foot, 2015). DFU commonly develops in middle-aged diabetic patients due to a long period of
 type 2 diabetes and poor adherence to control blood glucose level (Madanchi et al., 2013).
 Prevalence of DFU was four times higher than all combined cases of cancers in the world
 (Boulton, 2013; McInnes, 2012; Shaw, Sicree, & Zimmet, 2010). Numerous published studies have
 documented the rate of DFU at around 25% in Western Population (Boulton, 2013). Prevalence of
 DFU was stated between 7.3 % - 24 % at Indonesia hospitals (Soewondo, Ferrario, & Tahapary,
 2013). An Indonesia nursing study recorded 12 % of diabetic foot ulcer cases from 249
 individuals with type 2 diabetes in a regional hospital of Eastern Indonesia (Yusuf et al.,
 2015). Cases of infected DFU occurred in 98 patients in Sardjito Hospital Yogyakarta
 Indonesia in 2016 (Longdong, 2016).

 In order to diminish the wide-reaching impact of DFU, a number of efforts have been performed
 in Indonesia. A study documented that sufficient diabetic patients' knowledge in performing
 foot care is able to decrease the incidence of DFU as well as LEA (Wulandini, Saputra, &
 Basri, 2013). Foot ulcers health education program was interrelated with patients' knowledge
 as well as attitudes concerning responsibility and involvement in DFU care (Arianti, Yetti, &
 Nasution, 2012; Mahfud, 2012; Sa'adah, Primanda, & Wardaningsih, 2016; Yoyoh, Mutaqqin, &
 Nurjanah, 2016). In line with their findings, another study confirmed that intensive health
 promotion increased patients' knowledge and practice in regard to perform routine foot care
 (Abbas, 2013). Also, health promotion intervention improves Hemoglobin A1c (HbA1c) in type 2
 Diabetes (Brown, 1990; Norris, Lau, Smith, Schmid, & Engelgau, 2002; Florkowski, 2013).
 However, a number of these studies merely focused on the patient, not engaged family members
 as it may potentially reduce the effectiveness of therapy.

 Accordingly, DFU is currently being a critical problems needs to be solved in Indonesia.
 Ensuring the engagement of both the patients and their families in treatment is an important
 strategy to deal with the chronic conditions (Baig, Benitez, Quinn, & Burnet, 2015; Miller &
 DiMatteo, 2013; Pamungkas, Chamroonsawasdi, & Vatanasomboon, 2017). Therefore, conducting a
 comprehensive intervention of DFU partnering individuals and their families in association
 with self-and family management is a groundbreaking and challenging strategy to overcome
 problems on DFU. We believe the findings of our study will render significant contributions
 to the national guideline of diabetes in Indonesia and prevention of LEA in nursing practice.
 Furthermore, it will be able to give promising results for accelerating DFU healing.

 Purposes of the study:

 The purpose of this study is to investigate the effect of a self- and family management of
 DFU programs on health outcomes as follows: behaviors (adherence to physical activities,
 medications, diet, foot care, and blood glucose control), family supports, biomarkers (HbA1c,
 wound size) in patients suffering DFU in Indonesia.

 Hypothesis:

 The study participants who joined completely the self- and family management of diabetic foot
 ulcer programs during three months would have a better behavior, biomarkers, and family
 supports than those who received the usual care.
Study background:

 Diabetic foot ulcer (DFU) is described as a full-thickness lesion appearing at the skin of
 the foot along with infection, destruction of tissues due to neuropathy and/or peripheral
 artery disease (PAD) in people with diabetes (International Working Group on the Diabetic
 Foot, 2015). DFU commonly develops in middle-aged diabetic patients due to a long period of
 type 2 diabetes and poor adherence to control blood glucose level (Madanchi et al., 2013).
 Prevalence of DFU was four times higher than all combined cases of cancers in the world
 (Boulton, 2013; McInnes, 2012; Shaw, Sicree, & Zimmet, 2010). Numerous published studies have
 documented the rate of DFU at around 25% in Western Population (Boulton, 2013). Prevalence of
 DFU was stated between 7.3 % - 24 % at Indonesia hospitals (Soewondo, Ferrario, & Tahapary,
 2013). An Indonesia nursing study recorded 12 % of diabetic foot ulcer cases from 249
 individuals with type 2 diabetes in a regional hospital of Eastern Indonesia (Yusuf et al.,
 2015). Cases of infected DFU occurred in 98 patients in Sardjito Hospital Yogyakarta
 Indonesia in 2016 (Longdong, 2016).

 In long-term conditions, DFU leads to lower extremity amputation (LEA) (Pemayun, Naibaho,
 Novitasari, Amin, & Minuljo, 2016). Several factors relating to LEA were ischemia,
 neuropathy, end-stage renal disease, and depth of the wound along with infection (Widatalla,
 Mahadi, Shawer, Elsayem, & Ahmed, 2009). The incidence of LEA was forecasted to be more than
 a million per year (Peter-Riesch, 2016; Wu, Driver, Wrobel, & Armstrong, 2007). Two studies
 exposed that amputation procedures were performed every 20 seconds in the diabetic population
 in the world (Fejfarová et al., 2014). A recent study found the estimated range of
 amputations around 15 - 32 % in Indonesia (Soewondo et al., 2017). As a consequence, this
 condition will directly impact on the patient's health-related quality of life that
 encompasses physical, social, economic, and psychological aspects (Vileikyte, 2001).

 In order to diminish the wide-reaching impact of DFU, a number of efforts have been performed
 in Indonesia. A study documented that sufficient diabetic patients' knowledge in performing
 foot care is able to decrease the incidence of DFU as well as LEA (Wulandini, Saputra, &
 Basri, 2013). Foot ulcers health education program was interrelated with patients' knowledge
 as well as attitudes concerning responsibility and involvement in DFU care (Arianti, Yetti, &
 Nasution, 2012; Mahfud, 2012; Sa'adah, Primanda, & Wardaningsih, 2016; Yoyoh, Mutaqqin, &
 Nurjanah, 2016). In line with their findings, another study confirmed that intensive health
 promotion increased patients' knowledge and practice in regard to perform routine foot care
 (Abbas, 2013). Also, health promotion intervention improves Hemoglobin A1c (HbA1c) in type 2
 Diabetes (Brown, 1990; Norris, Lau, Smith, Schmid, & Engelgau, 2002; Florkowski, 2013).
 However, a number of these studies merely focused on the patient, not engaged family members
 as it may potentially reduce the effectiveness of therapy.

 Currently, poor adherence to DFU treatment is taken into consideration on the diabetes
 population in Indonesia. Many diabetic patients had poor adherence in maintaining diabetes
 treatment which potentially leads to suboptimal diabetes outcomes involving increased blood
 glucose level, more hospital admissions, diabetes-related complications, and multiplied
 medical care costs (Putri, Yudianto, Kurniawan, & Titis, 2013; Waluya, 2008). To overcome
 this issue, intensive health promotion has been considered as the first-line approach in
 Indonesia (Windasari, 2014). In addition, strategies addressing poor adherence must be
 focused on reducing DFU complications in the future. This could be successfully achieved by
 incorporating family members in a particular intervention. A systematic review also pointed
 out that family support in a given treatment strengthens patient adherence to diabetes
 treatment (Rintala, Jaatinen, Paavilainen, & Astedt-Kurki, 2013). Efforts have been performed
 in Indonesia, even though it has some limitations. For instance, some studies merely
 addressed the age, gender, duration of diabetes and level of patient' education relating to
 the adherence, not focused on patients' motivation which is presently being the main problem
 in Indonesia (Ainni, 2017; Srikartika, Cahya, & Hardiati, 2016). Also, providing care to
 those suffering diabetes potentially becomes a burden on both physical and emotional aspects.
 Also, some individuals reported that they felt sadness when their family does not fully
 support their care. In line with these findings that, negative family support is the robust
 predictor for the patient's stress and decreased diabetes outcome (Pardamean & Dharmady,
 2003; Isworo, Ekowati, Iskandar, & Latifah, 2018). The other study stated that patients
 receiving non-supportive care from a family member are more likely to have a poor blood
 glucose level (Isworo & Saryono, 2010). Moreover, the lack of family knowledge, low levels of
 self-efficacy, and insufficient social support from family members lead to poor diabetes
 self-management (Pamungkas, Chamroonsawasdi, & Vatanasomboon, 2017).

 Due to the positive influence of family support on diabetes outcomes, the high-impact efforts
 to improve family support are considered to be necessary. Many studies described the family
 involvement in diabetes care consisting of providing emotional support, helping patients how
 to deal with diabetes problems, providing information and partnering in daily care.
 Nevertheless, they lacked information about how family members provide support in regard to
 self-management behaviors (Pamungkas, Chamroonsawasdi, & Vatanasomboon, 2017). As is well
 acknowledged, individuals' adherence along with family engagement to prescribed diabetes
 treatment is crucial to reach metabolic control lowering the complexities of diabetes,
 respectively. Family involvement in diabetes care may prevent patients from further
 complexities of diabetes (Isworo, Ekowati, Iskandar, & Latifah, 2018). Also, family members
 need to be informed in term of screening to prevent future complexities on individuals having
 diabetes, particular to those who have a sedentary lifestyle, a lack of physical activity,
 and an unhealthy diet (Soewondo, Ferrario, & Tahapary, 2013).

 Managing individual with diabetes along with diabetic foot ulcers in the context of family
 management has been done by some researchers in Indonesia (Rahayu et al., 2014; Yusra, 2011;
 Prantika, Susilo, & Bagus, 2014; Putri et al., 2013; Sari, Susanti, & Sukmawati, 2014; Laily,
 2016). As is culturally known in Indonesia, patients suffering diabetes live with their
 family which may either provide practical help in the management of diabetes or they were
 unsure to their abilities to help their family member particular in accidental situations.
 How family members respond will be different based upon their individual personalities, how
 committed they are to the individual with diabetes and their sense of responsibility
 (Budianto, 2015). Moreover, their reactions could indicate insufficient knowledge, fear,
 worried, or even a desire to support some help. For these reasons, addressing family
 engagement for those with diabetes is imperative since this is the context in which the
 majority of diabetes management happens. Family members play an essential role in a patient's
 disease management, incorporating them in self-care interventions may possibly render
 significant changes in patients' outcomes such as self-efficacy, perceived social support,
 diabetes knowledge, and diabetes self-care (Pamungkas, Chamroonsawasdi, & Vatanasomboon,
 2017; Baig, Benitez, Quinn, & Burnet, 2015).

 In Indonesia context, a study described that implementing a family management program (health
 education, motivational program, follow up care) during three months improved patients'
 quality of life and self-care (Rahayu et al., 2014; Yusra, 2011). The family management
 program is linked with the improvement of blood glucose control (Prantika, Susilo, & Bagus,
 2014; Putri et al., 2013). Incorporating family members are helpful in diabetes therapy
 (Sari, Susanti, & Sukmawati, 2014). What's more, family dynamics have been indicated to have
 an impact on diabetes management in adults. Overall evidence above proofs a beneficial effect
 of a family role for people living with diabetes. However, partnership amid patients and
 their families in those study is lacking and the majority of individuals had insufficient
 knowledge in association with diabetic foot care which this condition may potentially
 increase the risk of LEA (Laily, 2016). Accordingly, family involvement in diabetes care is
 required to give the advantages to the individual outcomes such as patients' well-being,
 physical activities, medication adherence, routine blood glucose control, routine foot care
 and ability to maintain the changes to a healthier lifestyle. Also, intensive health
 education with respect to foot care strategies should be emphasized within the individuals
 and their families in Indonesia.

 In 2015, PERKENI (Persatuan Endokrinologi Indonesia) or the Indonesian Society for
 Endocrinology, officially issued a national guideline of diabetes management entitled
 "konsensus pengelolaan dan pencegahan diabetes mellitus tipe 2 di Indonesia 2015" or
 consensus on management and prevention of type 2 diabetes in Indonesia 2015 (Persatuan
 Endokrinologi Indonesia, 2015). In this guideline, several approaches were recommended such
 as assessing illness trajectory, performing a physical examination, doing laboratory test
 (HbA1c only), implementing health education in lifestyle changing (diet and physical
 activities only), and using appropriate medication. Nevertheless, we have identified
 limitation to the guideline as follows: they have not specifically described the role of
 family involvement in the therapy. It stands to reason that family role is fundamental aspect
 due to their responsibility to address individuals' non-adherence to treatment at home. Also,
 several studies support that non-adherence to the diabetes treatment regimen is possibly the
 most common reason for poor health outcomes among individuals with diabetes in Indonesia
 (Putri, Yudianto, Kurniawan, & Titis, 2013; Waluya, 2008; Windasari, 2014). For that reason,
 the need to improve the guideline is essential as it would enhance the role of a family
 member in diabetes therapy along with preventing the further complications of DFU. Moreover,
 family-based interventions for individuals having diabetes have therefore proven to be an
 effective approach in improving treatment outcomes (Sanjari, Peyrovi, & Mehrdad, 2016).
 Another limitation discovered that guideline has not included wound size as a biomarker of
 evaluation in a given treatment. This marker is important to evaluate the progress of the DFU
 treatment (Roth-Albin et al., 2017; Alexiadou & Doupis, 2012).

 Accordingly, DFU is currently being a critical problems needs to be solved in Indonesia.
 Ensuring the engagement of both the patients and their families in treatment is an important
 strategy to deal with the chronic conditions (Baig, Benitez, Quinn, & Burnet, 2015; Miller &
 DiMatteo, 2013; Pamungkas, Chamroonsawasdi, & Vatanasomboon, 2017). Therefore, conducting a
 comprehensive intervention of DFU partnering individuals and their families in association
 with self-and family management is a groundbreaking and challenging strategy to overcome
 problems on DFU. We believe the findings of our study will render significant contributions
 to the national guideline of diabetes in Indonesia and prevention of LEA in nursing practice.
 Furthermore, it will be able to give promising results for accelerating DFU healing.

 Study objective:

 The purpose of this study is to investigate the effect of a self- and family management of
 DFU programs on health outcomes as follows: behaviors (adherence to physical activities,
 medications, diet, foot care, and blood glucose control), family supports, biomarkers (HbA1c,
 wound size) in patients suffering DFU in Indonesia.

 Study hypothesis:

 The study participants who joined completely the self- and family management of diabetic foot
 ulcer programs during three months would have a better behavior, biomarkers, and family
 supports than those who received the usual care.

 Study design:

 A prospective, randomized controlled trial study proposes to investigate the effect of self-
 and family management of diabetic foot ulcers programs on health outcomes among individuals
 with diabetic foot ulcers in Indonesia. The self-and family management of DFU program was
 designed and adapted based upon a review of the literature along with Indonesia guideline of
 diabetes management developed by the Indonesian Society for Endocrinology (PERKENI). This
 study will be conducted during three months and data will be collected four times in the
 study implementation. HbA1c and wound size have been considered as the distal outcomes in
 this study. On the other hand, individual and family behavior known as the proximal outcomes
 will also be evaluated as the mediator of the distal outcomes.

 The study will be put into operation in four phases, as follows: 1) pre-implementation
 program (O1, 05) consist of measuring several variables as baseline data: individual baseline
 data (behavior: adherence to physical activity, diet for diabetic patients, blood glucose
 control, and foot care; biomarkers: HbA1c and wound size); and family baseline data (family
 supports). 2) Implementing the program phase 1 and measuring individual and family behavior,
 wound size (X1). 3) Implementing the program phase 1 and measuring individual and family
 behavior, wound size (X2). 4) Implementing the program phase 1 and measuring individual and
 family behavior, and biomarkers (HbA1c and wound size) (X3). The study process was depicted
 in the chart below.

 Program implementation:

 Researcher preparation: prior to implementing the program, the researcher will prepare
 several elements such as participants characteristics obtained from selected wound care
 clinics. The procedure the usual care will also be assessed in this stage encompassing
 physical activity, medication, diet, foot care (i.e. wound care), and blood glucose control.
 Family management relating to DFU care will be collected from those clinics.

 Program planning:

 The self- and family management program of DFU was developed based upon the revised framework
 of self- and family management (Grey et al., 2015) and Konsensus Tatalaksana Diabetes
 Mellitus PERKENI Indonesia (2015). Additionally, the researcher added a literature review to
 improve the content of the guideline. In this study, the program will have two main outcomes
 consist of proximal outcome (family support and individual behavior) and distal outcomes
 (HbA1c and wound size). In this phase, the researcher will prepare the program-supported
 tools such as guideline from PERKENI and guideline developed by the researcher.

 Self-management of DFU programs:

 The self-management program will be implemented in one session within fifty minutes each
 session per week. However, it could be longer than as planned due to the atmosphere of
 discussion that possibly might change the duration. A total of 12 sessions was planned for
 program implementation. Teaching, group discussing, and counseling is the method that will be
 used during the study. On the following description, the contents of the self-management of
 DFU programs are presented.

 Physical activities are critical for blood glucose management and overall health in
 individuals having diabetes. This includes all movement that increases energy use, whereas
 exercise is planned, structured physical activity. Regular physical activity may improve
 blood glucose control and reduces or prevent further complexities such as lower extremity
 amputations. In this session, participants will receive counseling, discussion,
 demonstration, and materials from the researcher. This material including the importance of
 performing physical activity according to the specific need of each individual with DFU. For
 instance, performing aerobic exercise (walking), weight training. Also, monitoring blood
 glucose before, during and many hours after activities to see how it effects on blood glucose
 levels.

 Medication in diabetes refers to achieving optimal medication-taking behavior which is a
 collaborative process of communication and understanding between participants and the
 researcher. The objective of this phase is to improve medication-taking behavior in
 participants by modifying their approach on an individual such as discussion, assessment of
 the barrier to adhere to medications. Participants will be encouraged to taken multiple
 medications for hyperglycemia, diabetes-associated conditions, and other comorbidities. This
 approach associates with improved outcomes, including reduced complexities of DFU,
 re-admission to hospital, and fatality.

 Diet goals for those suffering diabetes is to promote and support healthful eating patterns
 of diabetes, attain individualized glycemic, blood pressure, and lipid goals, achieve and
 maintain body weight goals, delay or prevent complications of diabetes, address individual
 nutrition needs based on personal and cultural preferences, maintain the pleasure of eating
 by providing positive messages about food choices, and provide the individual with diabetes
 with practical tools for day-to-day meal planning. In these sessions, the participant will be
 provided a discussion and counseling relating strategies to manage diet on diabetes and
 overcome the barrier that may interfere with the wound healing process.

 Foot care (i.e. wound care) refers to regular to protect the foot from nerve damage,
 circulation problems, and infections that lead to serious diabetic foot problems. Preventing
 diabetes complications, possessing the risk factors, and having the ability to manage
 complications is part of a DFU self-management program. In this stage, the study participant
 will be encouraged to pay much attention to checking feet regularly, inspecting inside the
 shoes daily from foreign objects, keeping the feet clean and using moisturizer, cut nails
 regularly, and changing the wound dressing. Discussion and demonstration to perform wound
 care will also be conducted in this study.

 Blood glucose control in this study refers to self-monitoring of blood glucose (SMBG) which
 is a crucial approach of diabetes therapy. SMBG has been recommended to attain a specific
 level of glycemic control and prevent acute hypoglycemia. The main goal of this phase is to
 collect detailed information about blood glucose levels at many time points to enable
 maintenance of a more constant glucose level by more precise regimens. Moreover, it can be
 used to aid in the adjustment of a therapeutic regimen in response to blood glucose values
 and to help individuals adjust their dietary intake, physical activity, and insulin doses to
 improve glycemic control on a day-to-day basis. Regular monitoring also enables tighter blood
 glucose control that diminish the long-term risks of diabetic complications. In Indonesia
 context, SMBG is the main concern of the individuals having diabetes that need to be improved
 by implementing this present study.

 Family management of DFU programs:

 Family management in this study focuses on three elements as follows the problem-solving
 discussion, establishing family roles in DFU care and effective involvement during DFU care.
 Family members come forward with understanding to deal with the condition alleviating the
 treatment burden as much as possible. For illustrative purposes, an individual having DFU
 always finds a family member for regular dressing and helping hand to handle daily
 activities. A family having patients with DFU should redistribute the roles of their members
 and show sensibility by managing inner conflicts, motivating the persons to adhere to
 treatment as per rule, and helping to nullify the worst impact of DFU. Motivational
 interviews, which can help to identify and reinforce the behavior change can be used to
 enhance the patient's motivation for diabetes self-care.
Individual inclusion criteria:

 1. Individual both men and women who were diagnosed stage 2 and more of DFU by certified
 wound care nurses.

 2. Individual having DFU located on the one or two legs.

 3. An individual who either regularly or not regularly visits the selected wound care
 clinics.

 4. Individual not in the fasting period either in Ramadan or another occasion.

 5. An individual who able to read and communicate in Indonesia language.

 Individual exclusion criteria:

 1. Individual who is hospitalized due to the complexities of diabetes.

 2. Individual who at the end of life care.

 3. Individual who is currently having any critical condition which potentially interferes
 data collection processes such as acute diabetic ketoacidosis and impaired
 consciousness.

 4. An individual who has blindness due to diabetes or aging.

 Family inclusion criteria:

 1. The individual is the caregiver or family members of an individual having DFU.

 2. An individual who able to read and communicate in Indonesia language.

 Family exclusion criteria:

 Individuals who attend the program less than 80 percent due to getting sick or other
 reasons.

 Termination criteria:

 This study will be suspended or terminated some or all research activities if events are
 identified representing serious or continuing noncompliance or unanticipated health issues
 involving risk to subjects or others related to DFU complications.