Effectiveness of Family Empowerment towards Diet Compliance and Family Independence in Caring for Family Members with Diabetes Mellitus: A Systematic Review

Diabetes mellitus has now become a major problem in non-communicable diseases whose prevalence continues to increase. Lack of family independence and client non-compliance with the diet program greatly affects blood sugar levels. This study needs to evaluate the effectiveness of family empowerment towards diet compliance and family independence in caring for family members with diabetes mellitus. A systematic review searched five electronic databases (Scopus, sciencedirect, pubmed, research gate, and google scholar) with the last ten years (2011-2021). The quality of the articles used in this study was assessed using the Joanna Briggs Institute Guideline. The prism protocol is also used to review each journal. We found 15 studies out of a total of 5,865 studies that discussed family empowerment in increasing family independence and dietary adherence in family members suffering from diabetes mellitus. Family empowerment is one method that is quite effective in increasing family independence and adherence to diet programs. There are six articles (40%) that state that planned behavior theory is effective in increasing family independence and dietary adherence to family members suffering from diabetes mellitus. From all the articles analyzed, there are several effective theories to empower families to change the behavior of family independence and individual diet compliance, namely the theory of planned behavior. However, this study is not strong enough to provide an assessment that family empowerment based on the theory of planned behavior and empowerment is the best way to increase independence, therefore further research is needed.


INTRODUCTION
Diabetes mellitus has now become a major problem in non-communicable diseases whose prevalence continues to increase 1 . DM is also called the mother of disease because DM is the parent of various other diseases such as heart disease, hypertension, stroke, kidney failure, blindness, and amputation of the feet 2 . DM cannot be cured, but blood sugar levels can be controlled 3 . DM can be well controlled by diet, exercise, and anti-diabetic drug therapy 4 . Diet and exercise arrangements are the main things that support the therapy program for patients with diabetes mellitus. If these two things are done well, primary and secondary treatment programs will be carried out optimally 5 . According to data from the International Diabetes Federation (IDF), DM sufferers have reached around 463 million people, and with a death rate of around 3.2 million people, placing DM as one of the diseases that does not have the sixth rank with the most mortality in the world 6 . Indonesia ranks sixth in the world as a country with the highest number of DM sufferers. DM is the seventh leading cause of death in the world 7 .
The intervention program from the government in efforts to manage DM disease through primary service units, namely Pusat Kesehatan Masyarakat (Puskesmas) or Health Centre Service, includes the Prolanis Program, Older Adult Posyandu for routine health checks for the older adults, and Posbindu Penyakit Tidak Menular (PTM) or Non-Communicable Disease for screening health status and risk behavior of people at productive age 8 . Treatment and management programs for DM disease that focus on the family have not been appropriately applied to date. Lack of family independence and client non-compliance with the diet program significantly affects the instability of blood sugar levels 9 . This is reasons for the increase in the prevalence of chronic diseases, especially DM, every year in several developed countries, especially in developing countries such as Indonesia 10 .
Various efforts to manage noncommunicable DM diseases that have been carried out are deemed ineffective. This is because the increase in DM patients continues, and it is found that more than half of DM patients at Health Center do not comply with the diet program so that other effort are needed to improve dietary adherence to DM patients, namely empowerment models family 11 . Family empowerment has been proven effective in increasing family independence in several other diseases. Even so, family empowerment interventions through a nursing theory approach need to be studied based on relevant studies. Therefore it is necessary to conduct an in-depth systematic study to test family empowerment nursing approaches to improve dietary compliance and family independence with diabetes mellitus..

METHOD Study Design
A systematic review without metaanalysis was carried out for this study. This review followed the steps that elements for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement 12 .

Data Sources and Searches
Five databases were collected by Scopus, Ebsco, PubMed, ProQuest, and Science Direct published between 2016 and 2020. The article's scope was limited to randomized controlled trials (RCTs) and protocol, human studies, and English publications. The researchers develop search terms to collect items related to selfmanagement intervention 13 . The databases search used the following terms (diabetes mellitus OR diabetes mellitus type 2) AND (compliance or adherence dietary) AND (family empowerment or empowerment) AND (diet compliance or family independence) 14 . A comprehensive search strategy has been shown in figure 1.

Eligibility Criteria
Patients who had been diagnosed with diabetes mellitus were eligible for this review. This study only targeted patients categorized by age group> 16 years, and data for patients with T2DM will be extracted. T2 diabetes is hyperglycemia which is initially insulin resistance 15 . This type is managed effectively and supported by education and a healthy lifestyle, combined with medication as a requirement 16 . All subjects in the intervention group used family empowerment interventions, but the approach in nursing theory varied. Meanwhile, the exclusion criteria, namely the experimental group, did not meet the basic scientific requirements, and the study results did not include a target value 17 . The outcome measure of this review is dietary adherence or family independence 18 . Secondary outcomes are changes in clinical outcomes and healthrelated quality of life 19 .

Type of Intervention
The intervention that researchers identified as research data was family empowerment which was defined in multidefinitions, and there was no standard system for classifying it 20 . The World Health Organization (WHO) states that empowering families can provide health services that are more effective in overcoming chronic diseases 21 . This study focuses on using family empowerment interventions to improve dietary adherence or family independence based on the nursing theory approach.

Data Extraction
The researcher inferentially extracted the data from each article. Data were extracted using narrative analysis to reveal data synthesis, including the characteristics of the study, participants, interventions, and results 22 . The following characteristics report individual studies, such as publication details and methods. The intervention describes the content and characteristics of family empowerment, nursing theory approaches, family roles, and family responses 23 .

Data Synthesis
Qualitative and quantitative analyses were used for this review. The results presented narratively based on each outcome.

RESULTS
In the initial searching the databases, there were 5,865 articles. After removing duplicates and screen the report, 15 articles were finally enrolled in the study (Table 1). Table 1 also showed that the papers were published between 2015 and 2020, with most articles published in 2020 (30.8 %).
Of the 15 articles that have been analyzed, various research designs include randomized controlled trials, quasiexperiments, prospective randomized studies, and case studies. The articles obtained were randomized controlled trials (RCT design), namely four articles. A total of nine articles used a cross-sectional design, and the rest used quasi-experiment design. Participants used in articles vary with a maximum sample size of 991 respondents with an average sample rate in research articles of more than 200 respondents. There are various nursing approaches used in this articles, with most of them use the theory of planned behavior (TPB) with a percentage of 40%. Table 2 showed that there were several studies ranged from moderate and high quality. JBI tool indicated the most of the studies have good quality (11 studies), and only three studies have a moderate bias.  Based on the statistical test, it was found that the P value was <0.001, thus indicating a significant decrease in the hemoglobin glycation score. In the self-care and empowerment statistical test, the P value in the treatment group was <0.001, so that there was an increase in the self-care and empowerment compliance score. So that in this study, it was concluded that there was an increase in client participation in disease management, increased empowerment, increased self-care compliance such as a healthy and regular diet, physical activity and exercise as well as regular monitoring of blood sugar levels.. In this study, it was divided into a control group and an intervention group. The intervention group was provided with online consultation services, with doctors, nurses, and nutrition workers. In addition, if something is unclear, clients can come directly to consult offline. Meanwhile, the control group was given services as usual. Independent: Empowerment, motivation, and medical adherence Instruments: Questionnaire to assess the characteristics of health care climate (HCCQ), Questionnaire to identify self-regulation on medication (TSRQ), Percaived Competence in diabetes (PCD), self-care activity questionnaire (SDSCA), WHO Well Being Index, description of barriers found when suffering from diabetes mellitus (PAID-5), HBa1c, BP, and BMI Analysis: interquartile range, standard deviations, Kruskal Wallis test The results of this study found that there was an increase in the goal setting of clients with diabetes mellitus in regulating diet and physical activity patterns, and there was an increase in autonomy support in the intervention group. This is different when compared to the control group which was relatively unchanged. Despite this increased autonomy support, and goal setting in diet and exercise, the intervention group was no better than the control group in terms of reducing blood sugar levels. 8 The effect of giving the intervention "implementation intention" to increase This study proves that improving self-management in increasing adherence to diet, exercise and activity patterns has a significant effect on improving the quality of life for people with type 2 diabetes mellitus in Australia.

14
The role of perceptions of disease: Self-efficacy, depression rates, and self-care activities in Jordanians with type 2 diabetes Source : 31 Design: Crosssectional survey Sample: 220 respondents Dm type II Variables: Self-care behavior, perceptions of diabetes, feelings of depression, support from social groups, factors of religiosity, individual spiritual coping and self-efficacy Instruments: The research instruments included a diabetes management self-efficacy scale, a short diabetes perception questionnaire, a 9-item patient health questionnaire, a social support instrument, a religious and spiritual coping subscale questionnaire. Analysis: The statistical test in this study uses the structure equation modeling to determine the relationship between the two variables.
The results of this study indicate that the empowerment program has a significant effect on improving self-skills. Psychosocial factors such as perception of disease, depressive symptoms, self-efficacy, social support, religiosity, spiritual coping have a correlation in improving self-care for clients with type 2 diabetes mellitus. Based on the results of statistical tests between social support and the level of information, the level of family information, and behavior in examining diabetes wounds, the p value was <0.05. Social support has a significant influence on several of these factors.

DISCUSSION
From all articles obtained and analyzed, most of the articles discussed family adherence to a diet program based on family support 23 . Through the empowerment approach, it provides allows the exchange of new information by sharing experiences 20 as well as active participation through activities in the learning process which are carried out with a focus on finding new meanings for the event that is being felt 32 . Family empowerment has the influence and effectiveness to increase family independence and client adherence to therapy and diet programs. The family empowerment referred to in this article is family empowerment based on the theory of planned behavior 28 , and family empowerment is based on analysis of client and family background factors 18 , personal factors 14 , social factors, and information factors from the family of patients suffering from DM 33 . The use of behavior change based on a protocol will encourage others to understand and understand important aspects and a sense of responsibility for what has been done in self-care efforts 15 . Dietary control management carried out by diabetic clients has a very important role in controlling blood sugar 9 ; however, it is still found that most Total  Quality  1  2  3  4  5  6  7  8  9  10  11 12 13

JBI critical appraisal/ Number of item
The scores : high = > 75%, moderate = 50-74%, low = 50%; N= 0; UN = 0; Y = 1; NA=0 N = no; UN = Unclear; Y = Yes; NA = Not Aplicable clients are not aware of this diet problem 34 . One of the ways to increase patient knowledge about diet management is to use a family empowerment approach 30 . Through the family empowerment approach, the facilitator can provide materials to increase patient understanding and provide awareness to diabetics about the importance of maintaining diet and diet 35 . Family empowerment is an effective family approach to increase independence and dietary compliance in patients with diabetes mellitus 36 . Through the planned behavior theory approach, it is found that intention has a significant influence on perceived behavioral control 9 between the two there is a direct relationship that mutually affects each other 7 . Based on previous research, it is proven that family empowerment influences and effectiveness in increasing family independence and client compliance in therapy and diet programs 24 . Family empowerment in this discussion is focused on the theory of planned behavior and empowerment focuses on analyzing background factors, personal factors, social factors, and information factors from the families of patients suffering from DM 37 .
One of the strong predictors of a behavior based on the theory of planned behavior is the existence of perceived behavioral control 38 . With the finding of a significant correlation between PBC and behavior, PBC is an important element that needs to be considered in improving diabetes mellitus management so that it becomes better. 39 , this is in line with the previous theory and explanation 40 . Facilitators or health workers must facilitate and pay more attention to the perception of control that is felt by the main patient in dietary behavior and activity patterns, this is because each patient has a different relationship so that it cannot be generalized 30 . Other writings include the policies carried out for routine blood glucose, routine medication, dietary management, physical activity and self-care 41 . Family empowerment carried out by health workers must also pay attention to the multiculture in a patient and family such as social, cultural, demographic, financial and other supporting factors 42 . The use of family empowerment will optimally improve treatment if family independence is carried out with a more holistic approach to managing diabetes mellitus adherence behaviors, taking into account the socio-cultural dynamics that occur in many medical conditions 28 .

CONCLUSION
In conclusion, this systematic review found that family empowerment can effectively increase the role of the family in providing care for patients with diabetes mellitus. Several nursing approaches, one of which uses the theory of planned behavior, states that it effectively increases self-reliance, family roles, and dietary compliance. Based on the results of the literature study that the researchers conducted, it proved that family independence and treatment program adherence could be achieved better by using family empowerment methods based on theory of planned behavior and empowerment. However, this study is not strong enough to provide an assessment that family empowerment based on the theory of planned behavior and empowerment is the best way to increase independence and based, therefore further research is needed to prove the effectiveness of using this approach.