Nurse Media Journal of Nursing
e-ISSN: 2406-8799, p-ISSN: 2087-7811
https://medianers.undip.ac.id
14(2):267-278, August 2024
https://doi.org/10.14710/nmjn.v14i2.56893
ORIGINAL RESEARCH

The Effect of Family Caregiver Empowerment
Model Intervention on Fear of Hypoglycemia in
People with Type 2 Diabetes Mellitus
Rondhianto Rondhianto 1, Kushariyadi Kushariyadi 1, M. Nauval Rahmatullah1
1Faculty of Nursing, Universitas Jember, Jember, Indonesia

Article Info
Article History:
Received: 30 July 2023
Revised: 27 August 2024
Accepted: 30 August 2024
Online: 31 August 2024
Keywords:
Empowerment; family caregiver;
fear of hypoglycemia; type 2 diabetes
mellitus
Corresponding Author:
Rondhianto Rondhianto
Faculty of Nursing, Universitas
Jember, Jember, Indonesia
Email: rondhianto@unej.ac.id

Abstract
Background: The family plays a vital role in T2DM self-management, but many
families need to understand their role and function as caregivers. This lack of
understanding can increase the burden of disease management, contributing to
the emergence of psychological problems in people with T2DM, such as fear of
hypoglycemia, which in turn worsens blood glucose control. The Family Caregiver
Empowerment Model (FCEM) intervention is one model that can be used to
empower families as caregivers in T2DM self-management.
Purpose: This study aimed to analyze the effect of the FCEM intervention on the
fear of hypoglycemia in people with T2DM.
Methods: The study design was quasi-experimental with a randomized control
pretest-posttest design. The sample size consisted of 85 respondents (a pair of
family caregivers and people with T2DM), who were randomly divided into two
groups: the treatment group (41 respondents) and the control group (44
respondents). The FCEM intervention was conducted once per week for ten weeks
for family caregivers, and fear of hypoglycemia was measured using the
Indonesian version of the Fear of Hypoglycemia Scale questionnaire. The data
were analyzed using the Wilcoxon signed rank test and independent t-test.
Results: The results showed significant differences in fear of hypoglycemia
between the pre-test and post-test in the treatment group (p=0.001) and the
control group (p=0.001). However, there was a significant difference in the
decrease of fear of hypoglycemia between the treatment and control groups (t=7.087; p=0.001). This finding suggests that FCEM intervention can significantly
reduce the fear of hypoglycemia in people with T2DM.
Conclusions: The FCEM intervention can reduce the fear of hypoglycemia in
people with T2DM by increasing the family caregiver’s ability and support in
managing T2DM. Nurses can use the FCEM intervention in T2DM management
to improve diabetes management outcomes.

How to cite: Rondhianto, R., Kushariyadi, K., Rahmatullah, M. N. (2024). The effect of family caregiver
empowerment model intervention on fear of hypoglycemia in people with type 2 diabetes mellitus. Nurse Media
Journal of Nursing, 14(2), 267-278. https://doi.org/10.14710/nmjn.v14i2.56893
Copyright © 2024 by the Authors, Published by Department of Nursing, Faculty of Medicine, Universitas Diponegoro.
This is an open-access article under the CC BY-SA License (http:/creativecommons.org/licenses/by-sa/4.0/).

1.

Introduction
Type 2 diabetes mellitus (T2DM) is a disease that requires ongoing medical care because it is
a complex chronic disease. As much as 10.5% of the world population in the age range of 20-79
years have diabetes. Indonesia is one of the ten countries with the highest number of T2DM cases
globally, with 19.5 million (International Diabetes Federation, 2021). T2DM not only interferes
with a person’s metabolic system but, in some cases, also causes several mental disorders, such as
distress, anxiety, depression, and fear of hypoglycemia. Fear of hypoglycemia is a specific and
extreme fear of the risk or occurrence of hypoglycemia. A previous study showed that fear of
hypoglycemia affects one in seven people with T2DM worldwide (Hendrieckx et al., 2021).
Research in Central and Eastern European countries showed that 5.9% of people with T2DM
experienced severe fear of hypoglycemia (Haluzik et al., 2018). A study in China also showed that
17.4% of people with T2DM experienced a fear of hypoglycemia (Huang et al., 2022). Another
study at Dr. Soebandi Hospital Jember, Indonesia, showed that 21.4% of people with T2DM
experienced fear of hypoglycemia (Roessanti et al., 2022). The fear of hypoglycemia in people with
T2DM is related to their inability to manage their diabetes independently. The failure to manage
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Nurse Media Journal of Nursing, 14(2), 2024, 268
the disease properly, including diet, physical activity, and taking medication, can cause worry and
fear about whether the actions taken are correct (American Diabetes Association, 2023). In
addition, the inability to self-monitor blood glucose also adds to the problem of further fear
because they do not know what their blood glucose level is when needed (Wang et al., 2019). The
fear of hypoglycemia can change patient habits, such as increasing inappropriate compensatory
behavior, such as improving food portions, reducing insulin use, and others. This fear is often
associated with impaired quality of life and emotional well-being, reduced involvement with
diabetes management, and poor diabetes outcomes (Hendrieckx et al., 2021).
Effective management of diabetes mellitus for individuals with T2DM requires consideration
of their characteristics and the support of their families. Therefore, healthcare providers should
give the family and patient education and training in specific skills required for self-management
at home (American Diabetes Association, 2023; International Diabetes Federation, 2021).
Previous studies showed that families play a vital role in the self-management of diabetes
(Pesantes et al., 2018; Rondhianto et al., 2023). However, a previous study showed that 48.18%
of family caregivers only had self-management skills (diet, physical activity, self-monitoring of
blood glucose with medication, and foot care management) in the moderate category, which was
still not optimal, thus having an impact on diabetes self-management (Rondhianto et al., 2019).
Therefore, it is necessary to make a series of efforts to improve their abilities.
The inability of families to self-manage T2DM can result in failure of self-management,
leading to low family support for managing T2DM, which increases the fear of complications such
as hypoglycemia or other issues (American Diabetes Association, 2023). Nurses can use
behavioral strategies to support diabetes self-management and engagement in health behaviors,
such as medication management, physical activity management, and diabetes diet, to promote
optimal diabetes health outcomes (American Diabetes Association, 2023). Studies show that
family empowerment can improve the self-management of people with T2DM and their health
status (International Diabetes Federation, 2021; Luthfa & Ardian, 2019). The application of the
empowerment model commonly intervened at this time is focused on empowering people with
T2DM. The family’s vital role in managing diabetes often receives less attention from healthcare
workers, making families unable to carry out diabetes self-management (Rondhianto et al.,
2020). Effective management of DM needs to be supported by family and consistent education
for families and patients (Luthfa & Ardian, 2019). Education and self-management support for
diabetes patients is also carried out to support ongoing medical care (Andriyanto et al., 2019),
with the goal of preventing both short and long-term complications (American Diabetes
Association, 2022).
The Family Caregiver Empowerment Model (FCEM) is an intervention developed by nurses
for family caregivers to increase positive control of the mind and body, create positive and
proactive behavior in exploring the role of a family caregiver, support the independence of those
receiving care, foster a positive reciprocal relationship, and promote a positive relationship
between family caregivers and others around them. FCEM interventions can also improve the
ability of family caregivers to carry out diabetes self-management, which includes diet, physical
activity, medication, and monitoring blood glucose levels independently, as well as foot care
(Rondhianto et al., 2022). Several previous studies have been conducted in Indonesia on family
empowerment in diabetes management. However, the most widely practiced empowerment is the
empowerment of T2DM patients, not family caregivers of people with T2DM (Andriyanto et al.,
2019; Damhudi et al., 2021; Deswita et al., 2020; Pamungkas & Chamroonsawasdi, 2020;
Rusdiana et al., 2020; Sari et al., 2022). The absence of optimal support from families who
understand the disease and its management can lead to increased non-compliance and decreased
self-care, thereby increasing the risk of complications (International Diabetes Federation, 2021).
In addition, some interventions in other models are carried out unstructured and prioritize the
educational context that only focuses on improving cognitive aspects and skills of family, without
supporting and mentoring process (Al Mahdi et al., 2020; Appil et al., 2022; Subrata, 2021).
FCEM interventions are structured education, focusing on enhancing cognitive aspects through
education, skills aspects through training, and affective aspects through mentoring, monitoring,
and evaluation (Rondhianto et al., 2020). In addition, previous studies did not examine the effect
of family caregiver empowerment on psychological disorders. Therefore, this study aimed to
analyze the effect of the FCEM intervention on the fear of hypoglycemia in people with T2DM.
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Nurse Media Journal of Nursing, 14(2), 2024, 269
2. Methods
2.1. Research design
This study used a quasi-experimental design with a randomized controlled group and a pretest and post-test design. Randomization was performed to assign respondents to either the
treatment or control groups using single-blind randomization.
2.2. Setting and samples
This study was conducted from 26 March to 2 July 2023 at a public health center in Jember,
Indonesia. The study population consisted of 300 people across five villages: Village 1 (39 people),
Village 2 (83 people), Village 3 (75 people), Village 4 (18 people), and Village 5 (85 people). The
samples consisted of pairs, namely family caregivers and people with T2DM. The inclusion
criteria for family caregivers were: 1) age > 20 years; 2) acting as family caregivers for people with
T2DM; 3) having only one person with T2DM in the family; and 4) willingness to participate as a
respondent. The inclusion criteria for people with T2DM were: 1) diagnosed with T2DM; 2) not
currently hospitalized or receiving treatment in other healthcare facilities; and 3) not having
severe complications that require hospitalization. The exclusion criteria were: 1) family caregivers
with physical disabilities such as blindness and deafness; and 2) illiteracy.
People with T2DM in the working area of the selected PHC met all study criteria (n=300)

Sample size calculation with G*power (n=90)
Cluster random sampling
The sample size for each village in the selected PHC using the fraction cluster sampling formula:
Village 1 (n=12), Village 2 (n=24), Village 3 (n=22), Village 4 (n=6), Village 5 (n=26)
Simple random sampling (single blind)

Treatment group (n=45)

Pre-test

Control group (n=45)

The FCEM Intervention:
1. Six education and training sessions
(home visit, ± 120 minutes/session)
2. Four mentoring sessions: one
session home visit (±120 minutes)
and three sessions by telephone
(±60 minutes/session)

Received standard intervention
(Prolanis program) conducted by PHC

Drop-out respondents:
Refused to continue the intervention
(n=3) and hospitalized (n=1)

Drop-out respondents:
One respondent died

Treatment group (n=41)

Post-test

Control group (n=44)

Data analysis

Figure 1. Flowchart of study stages
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Nurse Media Journal of Nursing, 14(2), 2024, 270
The sample size was calculated using G*Power software (α=0.05; β=0.8; f²=0.64), resulting
in a minimum requirement of 80 respondents. To account for potential drop-outs or loss to
follow-up, the researcher added approximately 10%, yielding a total sample size of 90. The sample
consisted of 45 respondents in the treatment group and 45 respondents in the control group,
selected through cluster random sampling. The researcher determined the sample size for each
village with the fraction cluster sampling formula. With a population (N) of 300, the sample size
for each village was as follows: (1) Village 1 = 39/300 x 90 = 12 respondents, (2) Village 2 = 83/300
x 90 = 24 respondents, (3) Village 3 = 75/300 x 90 = 22 respondents, (4) Village = 18/300 x 90 =
6 respondents, and (5) Village 5 = 85/300 x 90 = 26 respondents. Furthermore, the researcher
randomly divided (single-blind) respondents in each village into two groups, namely the
treatment group and the control group proportionally. During the study, five respondents
dropped out for various reasons: four from the treatment group (one was hospitalized, and three
chose to withdraw) and one from the control group (due to death). The final sample size at the
post-test was 85 respondents, which exceeds the minimum required sample size of 80. Therefore,
the sample size remained appropriate for this study. The study stages are detailed in Figure 1.
2.3. Intervention
The researcher conducted the FCEM intervention for the treatment group. In contrast, the
control group only received standard intervention, namely health education, through the Prolanis
(Program Pengelolaan Penyakit Kronis), or Chronic Disease Management Program, provided by
the PHC. The FCEM intervention was based on the results of previous research. In general, the
FCEM intervention consists of two main stages, namely education and training (sessions 1-6) and
mentoring (sessions 7-10), which are aimed at increasing the capacity of family caregivers in selfmanaging T2DM so that they can provide the assistance needed by people with T2DM
(Rondhianto et al., 2020, 2022). The treatment group was given intervention during 10 sessions
within 10 weeks, namely six education and training sessions followed by four mentoring sessions
(Table 1).
To ensure that the families implemented T2DM self-management correctly, the researchers
provided action record sheets for monitoring, which each family caregiver had to fill in when
carrying out self-management actions according to their components (diet management, physical
exercise management, medication management, self-monitoring of blood glucose, and foot care).
Additionally, the researchers clarified directly with the family caregivers during home visits in
week 7 to check whether they had carried out the actions as planned. The researchers also clarified
directly with people with T2DM regarding the actions taken by their family caregivers. Family
caregivers began carrying out T2DM self-management actions for people with T2DM starting in
week 7 (with home visits by the researchers to ensure correct implementation), and continued
from week 8 to week 10, with monitoring and evaluation conducted via telephone. Monitoring,
evaluation, and corrective actions for the implementation of T2DM self-management by family
caregivers were carried out in stages, beginning with home visits in week 7 and continuing with
telephone follow-ups from week 8 to week 10.
2.4. Measurement and data collection
Fear of hypoglycemia, as the dependent variable in this study, was measured using the
Indonesian version of the Fear of Hypoglycemia Scale (FH-15), which assesses fear of
hypoglycemia in people with T2DM in Indonesia (Roessanti et al., 2022). This questionnaire was
initially developed by Ortiz et al. (2011) and consisted of 15 unfavorable question items
categorized under three indicators: fear, avoidance, and interference. The FH-15 uses a Likert
scale ranging from 1 to 5 (1=never, 2=rarely, 3=sometimes, 4=almost always, 5=every day). The
minimum score for the questionnaire is 15, and the maximum score is 75, with a cut-off point of
28. If the score is ≥28, it means people with T2DM experience a fear of hypoglycemia. A score
<28 indicates that people with T2DM do not experience a fear of hypoglycemia (Ortiz et al., 2011).
The questionnaire was translated into Indonesian by Roessanti et al. (2022) and had its sentence
structure reviewed by a professional language institute. The researcher re-tested the validity and
reliability of the questionnaire using 30 respondents with T2DM from a public health center in
another region that shares similar characteristics with the study site. The validity and reliability
test results showed that this questionnaire is valid and reliable with a value of r = 0.479 - 0.898 >
r table = 0.374 and Cronbach alpha = 0.883. Data collection was conducted through direct
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Nurse Media Journal of Nursing, 14(2), 2024, 271
interviews, where respondents answered questions based on the questionnaire. The researchers
recorded each response in the questionnaire. Before collecting data, the researchers provided an
overview of the study, including its objectives, benefits, procedures, and potential risks.
Respondents who agreed to participate signed a consent form. Data were collected to measure
fear of hypoglycemia both before the intervention (pre-test) and two weeks after the intervention
(post-test).
Table 1. Summary of family caregiver empowerment model intervention
Session/ Time
Session 1 (±120
minutes)

Learning Outcomes
Explain basic
concepts of T2DM,
self-management,
illness management
in the family, and
situational factors in
T2DM selfmanagement

Material
The basic concepts and
self-management of T2DM,
management of illness in
the family, and situational
factors within selfmanagement of diabetes

Session 2 (±120
minutes)

Explain the role of
nurses, filial values,
and empowerment in
T2DM selfmanagement
Demonstrate diet
management
Demonstrate physical
activity management

Filial values, the role of
nurses, and empowering
family caregivers in selfmanagement of T2DM

Session 3 (±120
minutes)
Session 4 (±120
minutes)
Session 5 (±120
minutes)

Session 6 (±120
minutes)

Demonstrate
medication, SMBG,
and foot care
management
Design T2DM selfmanagement plan

Session 7 (±120
minutes)

Face challenges in
T2DM

Session 8-10
(±60 minutes)

Demonstrate T2DM
self-management
independently

DM diet management
concept and strategy
Physical activity
management concept and
strategy
T2DM Medication and
Self-monitoring blood
glucose concept and
strategy
Concepts and strategies for
foot care, prevention of
complications, and
preparation of T2DM selfmanagement plans
Follow-up and support for
resource access (This
activity is carried out so
that family caregivers can
carry out diabetes selfmanagement according to
the target)
Monitoring and evaluation
that includes support and
assistance for the
continuity of quality care

Method
Lectures,
discussions, and
counseling

Strategy
Build relationship
Provide complete and
accurate information
Guide the assessment
of support and
resources
Help determine needs
Provide support in
setting goals in the
T2DM selfmanagement

Lectures,
discussions,
demonstrations,
and counseling

Assess ability
Provide information
Strengthen the
capability
Encourage active
participation
Designing a strategy
for implementing
self-management

Mentoring,
discussion, and
counseling

Encourage action
Help solve problems
Strengthen the ability
Provide information
and choice of sources

Evaluate capability
Monitoring and
support
Recognition of the
role and competence

Source: Rondhianto et al. (2022)

2.5. Data analysis
The researchers conducted a descriptive analysis to describe the respondents’ characteristics
and the variable of fear of hypoglycemia. Inferential analysis was performed to determine the
effect of the FCEM intervention. The Wilcoxon signed-rank test was used to analyze the pre-test
and post-test results for each group, as the data for each group were not normally distributed (pvalue < α = 0.05). However, the score change (∆) in each group was normally distributed (p > α
= 0.05). Therefore, the difference between the treatment and control groups was analyzed using
the independent t-test to compare the pre-test and post-test results for each group.

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Nurse Media Journal of Nursing, 14(2), 2024, 272
2.6. Ethical considerations
An ethical review was conducted for this study and approved by the ethics committee of the
Faculty of Nursing, Universitas Jember, with reference number 124/UN25.1.14/KEPK/2023.
Before conducting the research, the researcher provided prospective respondent with information
about the general description of the study. Additionally, the researchers explained the objectives,
benefits, procedures, potential risks, and rewards for participation. There was no coercion for
participation, and respondents were free to withdraw at any time during the study. Prospective
respondents who agreed to participate were asked to sign the consent form prepared by the
researchers.
3. Results
3.1 Characteristics of respondents
The results showed that the number of respondents in this study was 85 (Table 2). Most of
the respondents were early elderly (43.53%), female (80%), elementary school graduates
(55.29%), unemployed or housewives (56.47%), and married (83.53%). They had T2DM for less
than five years (90.59%), never had hypoglycemia (77.65%), and were hospitalized less than equal
to one time (89.41%).
Table 2. Characteristics of respondents (n=85)
Characteristics
Age (years)
< 25 (late adolescent)
26 – 35 (early adulthood)
36 – 45 (late adulthood)
46 – 55 (early elderly)
56 – 65 (late elderly)
> 65 (old)
Gender
Male
Female
Education level
No education
Elementary school
Junior high school
Senior high school
College
Employment status
Unemployed/housewives
Civil servant
Indonesian National Army/ Police
Fisherman
Laborer
Teacher
Farmer
Self-employed
Marital status
Unmarried
Married
Widow/widower
Duration since diagnosis
< 5 years
> 5 years
Hypoglycemia history
No
Yes
Hospitalization history
≤ 1 time
> 1 time

Treatment Group
(n=41)
f
%

Control Group
(n =44)
f
%

Total
(n=85)
f

%

0
1
4
16
13
7

0
2.44
9.76
39.02
31.71
17.07

0
1
6
21
9
7

0
2.27
13.64
47.73
20.45
15.91

0
2
10
37
22
14

0
2.35
11.76
43.53
25.88
16.48

6
35

14.63
85.37

11
33

25
75

17
68

20
80

6
20
7
7
1

14.63
48.78
17.07
17.07
2.44

10
27
3
4
0

22.73
61.36
6.82
9.09
0

16
47
10
11
1

18.82
55.29
11.76
12.94
1.18

24
1
0
0
0
0
4
12

58.54
2.44
0
0
0
0
9.76
29.26

24
1
0
0
1
0
4
14

54.55
2.27
0
0
2.27
0
9.09
31.82

48
2
0
0
1
0
8
26

56.47
2.35
0
0
1.18
0
9.41
30.58

0
31
10

0
75.61
24.39

0
40
4

0
90.91
9.09

0
71
14

0
83.53
16.47

37
4

90.24
9.76

40
4

90.91
9.09

77
8

90.59
9.42

30
11

73.17
26.83

36
8

81.82
18.18

66
19

77.65
22.35

38
3

92.68
7.32

38
6

86.36
13.64

76
9

89.41
10.59

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Nurse Media Journal of Nursing, 14(2), 2024, 273
3.2 The effect of the FCEM intervention on fear of hypoglycemia
The effect of the FCEM intervention on fear of hypoglycemia is illustrated by the results of
the difference tests shown in Table 3, which include tests for within-group differences (Wilcoxon
signed rank test) for both the treatment and control groups, as well as between-group differences
(independent t-test) comparing the treatment and control groups.
Table 3. Differences in fear of hypoglycemia between the treatment and control groups before
and after the FCEM intervention
Group

Test

Treatment

Pre-test
Post-test
Pre-test
Post-test
∆ treatment group
∆ control group

Control
Difference (∆)
of each group

Normality
test (p)

Mean(SD)

0.149
0.027
0.914
0.025
0.143
0.172

35.59(6.892)
20.85(3.712)
51.36(10.041)
66.27(7.711)
-14.73(6.454)
-3.95(7.483)

Wilcoxon signed
rank-test
Z
p
-5.581

0.001

-3.297

0.001

Independent
t-test
t
p

-7.087 0.001

Table 3 shows a significant difference in fear of hypoglycemia among people with T2DM in
the treatment group before and after family empowerment with the FCEM. A significant
difference in fear of hypoglycemia was also found in the control group, which did not receive the
FCEM intervention. Negative Z scores in both the treatment and control groups indicate that the
pre-test scores were higher than the post-test scores. The researchers applied the non-parametric
Wilcoxon signed-rank test because one of the data sets was not normally distributed. However,
the normality test results for the difference data, which showed the change in scores from the pretest to the post-test, indicated normal distribution (p>α=0.05). Therefore, a parametric statistical
test, the independent t-test, was conducted. The independent t-test results showed a significant
difference in fear of hypoglycemia between the treatment and control groups (t=-7.087, p=0.001
<α=0.05). The negative t-value indicates that the decrease in fear of hypoglycemia scores was
greater in the treatment group than in the control group. Based on the results and interpretation
above, it can be concluded that the FCEM intervention has an effect on reducing fear of
hypoglycemia in people with T2DM.
4. Discussion
This study examined the effect of the FCEM intervention on the fear of hypoglycemia in
people with T2DM. The results showed that the FCEM intervention significantly reduced the fear
of hypoglycemia in people with T2DM. The results of this study align with a previous study
showing that family-based interventions significantly affected knowledge about the risk of T2DM,
self-control, blood sugar measurements, and concerns about T2DM (Feng et al., 2023). In this
study, there were differences in intervention between the treatment and the control groups. The
treatment group received the FCEM intervention, while the control group did not receive any
intervention and was only involved in the pre-test and post-test process. The FCEM intervention
consisted of education and training in six sessions, followed by four mentoring sessions
(Rondhianto et al., 2022, 2020). Family caregiver empowerment is an intervention that involves
family empowerment in its implementation (Abedini et al., 2020; Jafari et al., 2020), which can
increase self-efficacy and self-control in people with T2DM (Al Mahdi et al., 2020). The study
results for the control group showed a significant decrease in fear of hypoglycemia, but not as
much as in the intervention group. Respondents in the control group did not receive the FCEM
intervention. They carried out their usual activities according to directions from health workers,
such as visiting hospitals, attending the Prolanis program, and following their daily routines.
This study also showed that some respondents in the control group had a history of
hypoglycemia. Patients who experience hypoglycemia often have good knowledge about it due to
interactions with healthcare providers and information obtained from other sources (Fisher et al.,
2018). Family caregiver empowerment interventions can increase an individual’s self-efficacy,
self-esteem, and self-control, allowing them to manage diabetes more effectively (Jafari et al.,
2020). Self-efficacy is also essential for managing hypoglycemia events (Grammes et al., 2018).
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Nurse Media Journal of Nursing, 14(2), 2024, 274
Understanding the mechanisms underlying the fear of hypoglycemia is crucial. Tailoring diabetes
education to address themes relevant to people with T2DM can help foster self-efficacy and
prevent negative impacts on self-management and quality of life (Grammes et al., 2017). A
previous study showed a positive correlation between self-efficacy and self-care behavior in T2DM
patients, leading to improved self-care behavior and glycemic control (Tharek et al., 2018). If
family self-efficacy increases, families can regain self-confidence and become more independent,
relying less on health workers and engaging more in disease management discussions (Abedini et
al., 2020; Jafari et al., 2020).
According to previous research, family empowerment interventions can improve family
caregivers’ capabilities in managing T2DM, including components like diet management, physical
activity, drug management, independent blood glucose monitoring, and foot care (Rondhianto et
al., 2022). Other studies also state that family-based interventions can increase families’ ability
to detect hypoglycemia. After the intervention, there was an increase in the motivation and
awareness of respondents and their families regarding the importance of managing DM,
especially the ability to detect hypoglycemia events (Damayantie et al., 2021). Additionally, family
empowerment, conducted for four weeks with 120-minute home visits, positively impacted family
support for people with T2DM (Luthfa & Ardian, 2019). Increasing caregiver support and
supervision can assist patients, particularly those who need help preparing food, taking
medication, and managing hypoglycemia before it becomes severe (Silbert et al., 2018). There is
a positive relationship between family coherence and diabetes self-management ability. The
greater the family support received, the better the independence of diabetes management by
family caregivers will be (Rondhianto et al., 2019). Educating about hypoglycemia and fear of
hypoglycemia can help reduce fear, increase medication adherence, and provide optimal glycemic
control (Yuksel & Bektas, 2021). Furthermore, appropriate health education can improve
patients’ understanding of hypoglycemia (Huang et al., 2022).
The fear of hypoglycemia score in the intervention group was lower than in the control group,
likely due to the provision of the FCEM intervention. The FCEM intervention is structured
education that empowers family members as caregivers by increasing knowledge and skills in
managing T2DM through three stages: education, training, and mentoring. Each family caregiver
receives education and training on T2DM self-management skills gradually over six weeks,
followed by mentoring (discussion and consultation) through home visits and telephone calls
during weeks 7 to 10 (Rondhianto et al., 2022). In addition to receiving materials related to selfmanagement, family caregivers also receive materials about filial values (care, respect, and
responsibility), the role of nurses, and empowering family caregivers in self-managing T2DM.
This helps improve their understanding of the family’s roles in managing the disease and
strengthens collaboration with health workers, particularly nurses (Rondhianto et al., 2020). This
finding is in line with previous studies that suggest family empowerment can increase family
support for diabetes management (Luthfa & Ardian, 2019), self-efficacy (Abedini et al., 2020;
Jafari et al., 2020), and self-care capabilities of family caregivers (Pesantes et al., 2018;
Rondhianto et al., 2022). The FCEM involves families in the intervention process to enhance
caregivers’ ability to manage diabetes and improve both family and patient knowledge of
hypoglycemia, with one session dedicated to explaining hypoglycemia and how to manage it.
Family involvement in diabetes management can facilitate health behavior improvements in
people with T2DM (American Diabetes Association, 2022; Onyango et al., 2022). Providing
continuous education and support from nurses to patients and families regarding hypoglycemia
and fear of hypoglycemia can improve self-efficacy, self-care behavior, and glycemic control in
people with T2DM (Hendrieckx et al., 2021; Tharek et al., 2018; Yuksel & Bektas, 2021). Lack of
family support can lead to increased distress (Li et al., 2021), which in turn increases the risk of
fear of hypoglycemia (Huang et al., 2022; Y. Wang et al., 2021). Improving family understanding
and skills in T2DM management can enhance family involvement and support to help people with
T2DM control blood glucose levels within the normal range and reduce fear of hypoglycemia.
5.

Implication and limitations
The Family Caregiver Empowerment Model (FCEM) intervention can be used as a guideline
in nursing management to address the incidence of hypoglycemia and fear of hypoglycemia in
T2DM patients. Healthcare providers, especially nurses, can improve self-care management skills
for people with T2DM by increasing family caregivers’ health literacy and capability in T2DM selfCopyright © 2024, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811

Nurse Media Journal of Nursing, 14(2), 2024, 275
management to reduce patients’ fear of hypoglycemia. Nurses do not only provide education and
help patients make decisions but they also educate and empower family caregivers. Family
caregivers are essential in assisting patients with independent care related to T2DM. One effort
that can be made is to provide family empowerment interventions. Family empowerment is
expected to increase family knowledge about diabetes care, which can help patients manage selfcare, remind patients to control their fears, and assist in recognizing the signs and symptoms of
hypoglycemia, thus reducing the fear of hypoglycemia in patients. The limitations of this study
include the intervention being postponed for one week due to a significant event that required the
researcher to delay the scheduled interventions. Furthermore, while the study included 85
respondents, this may not be large enough to generalize the findings to a broader population of
people with T2DM and their caregivers.
6. Conclusion
This study concludes that the FCEM intervention effectively reduces the fear of hypoglycemia
in people with T2DM. It enhances family caregivers’ ability to manage T2DM, including regulating
eating patterns, physical activity, medication, blood glucose monitoring, and foot care. Family
caregivers with adequate skills in T2DM self-management can be directly involved in the care of
people with T2DM. Family involvement can provide maximum support in diabetes care,
increasing awareness, self-confidence, and self-control among people with T2DM. This, in turn,
can improve the self-management abilities of people with T2DM, which is necessary for
controlling blood sugar and reducing fear of hypoglycemia. Further research can re-examine the
effectiveness of the FCEM intervention in different locations/settings with a diverse and larger
sample size.
Acknowledgment
The researchers are deeply grateful to all respondents who have participated in this study.
They also express their deepest gratitude to the Jember District Health Office, especially the
Public Health Center where the study took place. We express our appreciation to the Institute of
Research and Community Service, Universitas Jember, which has facilitated this study.
Author contribution
RR, the primary author, selected the theme, developed the concept and intervention protocol,
collected and analyzed data, and compiled the manuscript. KK, as a member author, played a role
in preparing references, analyzing data, and refining the discussion. MNR, as a member author,
compiled the manuscript, collected research data, and compiled the results and discussion.
Conflict of interest
The authors declare no conflict of interest.
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