Social Support Strategies in Adult Patients With Diabetes

A Review of Strategies in the USA and Europe

Julienne K Kirk; Christine N Ebert; Ginger P Gamble; C Edward Ebert

Expert Rev Endocrinol Metab. 2013;8(4):379-389.

Abstract and Introduction

Abstract

Improvement of adherence in patients with a chronic disease state such as diabetes can be facilitated through well-crafted social support strategies. Family and friends are support options for many individuals living with diabetes. A systematic search of three databases was conducted to evaluate literature published from 2006 to April 2013 regarding social support in adults with diabetes conducted in the USA and Europe. While various studies had different findings, the overall trend shows that social support can result in a positive influence on both the ability of the patient to initiate and sustain diabetes management that can potentially result in positive health outcomes. This appears true even when the patient has low psychosocial skills and a small social support network. Healthcare professional involvement also correlates with patient improvement in specific outcomes not overlapped by the patient's social network. Support facilitated by peers can be a viable option along with the multitude of electronic options to help with social support.

Introduction

A major challenge for patients with diabetes is adherence to self-care management regimens. The growing incidence of diabetes is becoming a worldwide epidemic and a recent systematic analysis indicates prevalence estimates have risen to 347 million people in 2008 and the disease has doubled over nearly the past three decades.^[1] Diabetes is a chronic disease requiring individuals to self-manage multiple components of care. Many patients fail to consistently engage in self-care behaviors such as lifestyle modification, coping strategies, medication management, healthy nutrition, glucose monitoring, regular activity and reducing risks that are necessary for positive health outcomes.^[2] Support systems that include the involvement of family and friends can often play a positive role in the encouragement of individuals to adhere to often complex regimens.

A systematic review of controlled, intervention studies was conducted and published in 2005 by van Dam et al. evaluating social support in diabetes. The the authors recognized that social support can include emotional, appraisal, informational and tangible assistance.^[3] There are various aspects of care that can encompass social support but usually the term involves the concept of coping. A basic definition of social support is as follows: 'an exchange of resources between at least two persons aimed at increasing the wellbeing of the receiver'.^[4] This review examines current aspects of patient social support with an ultimate goal toward evaluating the role of family and friends as support mechanisms for adult patients with diabetes in the developing world. Since social support can also include other forms of contact with peers and the use of a wide array of technology, the utility of these resources will also be addressed. Peer support and technology options (phone, internet and other devices) are gaining increased use, so these areas of social support are included as a brief overview for comprehensiveness.

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Abstract and Introduction
Method & Data Sources
Social Support Overview: Family & Friends
Social Support & Peer Influence
Five-year View
Expert Commentary
References
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Table 1. Social support of family and friends.
Study (year)	Purpose	Study sample, design and setting	Methods, measures and statistical analysis	Major findings	Strengths (S) and limitations (L)	Implications for practitioners	Ref.
Arcury et al. (2012)	To describe DM management behaviors and social integration of older adults	n = 593, cross-sectional60+ year-old adults (95% retention) in rural southeast North Carolina	Diabetes management behaviors (SMBG, checking feet, diet, exercise) Provider A1C and checking feetDescriptive statistics, ANOVA, bivariate and multivariate analysis, χ²	More non-child relatives seen per month yields positive correlation for DM management behaviorsSmaller correlation with number of relatives by telephone and size of social network	S: Large sample size; tri-ethnic population; rural population and good retentionL: Nonrandom selection; limited population/region; self-reporting of DM management behaviors	Increasing social integration likely to lead to more positive management behaviors	[13]
Beverly et al. (2008)	To determine spousal influence on DM patients' health behavior changes and adherence to healthy diet	n = 60 (30 couples), mean age: 65.4 years, mean length of marriage: 37.8 years, mean education: college, mean BMI: 32.2Cross-sectional, focus groupsConvenience sample	Twelve 90-min focus groups of 5–10 participants using a structured guide of questionsQualitative data using intensity sampling with a subset of purposive sampling	There were five core themes related to dietary adherence: control over food, dietary competence, commitment to support, spousal communication and copingReinforcement and self-efficacy were part of the themes	S: Method to maximize interaction with couples to assist them in coping with day-to-day management of DML: Convenience sample; causality by using cross-sectional data; need to have more cultural and social variation regarding marital roles and DM belief	Spouses can play a key role in optimizing DM managementCouple's relationship in adhering to and maintaining a healthful diet useful to study	[7]
Chlebowy et al. (2006)	To evaluate relationships of psychosocial variables (social support, self-efficacy and outcome expectations) in DM self-care behaviors and glycemic control	n = 91 adults AA and Caucasian, mean age: 55 yearsProspective surveys: two-group, comparative descriptive design in southeastern USA after educational sessions	Self-report measures were utilized at outpatient visits in southeastern USA after participating in either 2-day multidisciplinary sessions outpatient clinic visits or outpatient educational sessionsPearson product–moment correlations used	No significant relationships were found between social support or self-efficacy and self-care behavioursAAs reported less social support satisfaction than CaucasiansA significant relationship existed between outcome expectations and self-care behaviors (r = 0.27, p = 0.01)	S: MultidisciplinaryL: Low sample size; confined to southeastern USA; conclusion contradicts previous studies, suggesting that social support is a predictor of glycemic control in individuals with DM	Social support was not significantly related to self-care behaviorsThe greater participants' beliefs that overall DM management will lead to certain outcomes, the greater participants' adherence to their DM regimen	[12]
Denham et al. (2011)	To investigate perceptions about family inclusion and support in DM self-management education	n = 205 CDEs, 95.6% women, 90.6% Caucasian, 49% bachelors degrees, 42.4% advanced degrees (n = 75 for masters, n = 9 for doctorate), 8.6% associates degreesDescriptive survey of 56 questions mailed to CDEs	Descriptive and inferential statistics (t-test, ANOVA, correlation, χ²)Fisher least significant difference	Exposure of CDE to family theory influences perceptions about family support networksCDE perceptions of meeting needs improved self-management activities, no effect in patient skillNo significant differences found in perceptions of knowledge across degrees or duration of certification	S: Used nationwide sample (and analyzed for regional differences)L: Strong possibility of bias; lack of specific questions about exposure to family theory	Practitioners should be exposed to family theory to better provide a foundation to develop a support network for patients, as opposed to a potentially inflated view of how well they themselves	[5]
Iida et al. (2010)	To examine the multiple factors associated with spouses' provision of emotional support to partners with DM	n = 126 couples, mean age: 66.1 years (partner 66 years), mean education: 13.8 yearsCross-sectionalMultilevel model	Diary software used to collect data over 24 days Dependent variable –emotional support, independent variables –symptom severity, diabetes specific anxiety, affect, relationship qualityDescriptive statistic, correlations	Symptom severity correlates with support given and negative affect correlates with spouse supportRelationship tension does not correlate with level of supportMen and women provide support differently	S: Study participants interview with and without spouseL: Diary study can be subjective; need to measure/define the level of relationship/intimacy	Male patients often receive support with increasing symptoms while there does not seem to be a change in support of men for their wives	[6]
Komar-Samardzija et al. (2012)	Examine how family/friend, environment, sense of community, social issues, socioeconomic status and body image influence physical activity	n = 50, AA females, age range: 25–93 years, mean age: 56 yearsCross-sectional Convenience sample recruited for a diabetes center in midsized hospital in northwest Indiana	Descriptive correlational, power analysis, self-efficacy for Exercise Scale, Cronbach's alpha coefficientSocial support and exercise surveyBody image, women and physical activity surveySPSS 11.5 software used for descriptive and correlation analysis	Positive correlation between family social support for exercise and physical activity frequencySelf-efficacy also had positive correlation as aboveNegative relationship between physical environmental barriers and activity	S: Evaluation of the role of family/friend social support with exercise and environmental factorsL: Participants all from one center; correlational study design lacks control group; measurements were self-reported	Incorporate of family social support, exercise self-efficacy and physical environmental barriers can be beneficial to patients	[15]
Mani et al. (2011)	Determine whether patients' social networks influences views of DM and its complications	n = 154 (64% response)Prospective surveysUrban primary care outpatient practices in upstate New York	Used adaptation of the Health Concerns Survey, assessing the number of family and friends with DM and concern about diseaseLogistic regression models	For each additional family or friend member with DM, patients expressed a greater level of concern about their own DMFemales reported more concern	S: Two inner city community primary care officesL: Data were focused to 'extremely concerned'; altered previously verified survey to make study instrument	Increased prevalence of DM within patients' social networks is associated with increased concern about disease	[14]
Mayberry et al. (2012)	Explore the relationship between family members' DM self-care knowledge, supportive/nonsupportive behaviors and participants' med adherence and glycemic control	n = 61 females (AA 28%, Caucasian 67%)Focus-group study (n = 11) 60-min discussion and 20- to 30-min surveyCross-sectional	Diabetes family behavior checklistAdherence to Refills and Medication ScaleSTATA version 11 Mixed methods approachSpearman correlation coefficients	Support from family members associated with more DM control behaviorsNonsupportive/sabotaging behaviors of family members associated with fewer control behaviors and poorer glycemic control	S: Used both quantitative and qualitative methodsL: Patients from single site and self-selected to attend focus group, and/or complete survey; saturation of data collection; participants' perceptions of family behaviors might not reflect actual family behaviors	Practitioners should discuss with family members influence of support and nonsupportive behaviors on patient's self-care and health outcomes and help patient develop strategies to address nonsupportive family member behaviors	[8]
Okura et al. (2009)	To determine whether cognitive impairment is associated with glycemic control and to assess if level of social support for DM care modifies this relationship	n = 1901 patients (>50 years)Cross-sectional2350 mailed surveys, 1901 (80.9%) completed and 1233 valid A1C samples obtained	HRSMailed survey on diabetes and HRS with questions regarding treatment and self-management of diabetesLogistic regression analysis	Older age and lower HRS cognitive subscale scores had higher A1CNonwhite race, longer duration of DM, higher depression scores and insulin use associated with higher A1CAmong those with lower cognitive function, those who had a high level of social support had better A1C	S: Large nationally representative sample; disease-specific surveyL: The possible responses to the questions in the survey related to care were 'understand completely' to 'I don't understand at all' based on responders' self-report, which could introduce bias; there were several waves of study data included	Cognitive impairment is associated with poorer glycemic controlIncreased levels of social support for DM care off set this negative relationship	[17]
Pearce et al. (2008)	To test a practice-based intervention to foster involvement of a friend/relative for reduction of cardiovascular risk	n = 199 patients (>21 years), 108 support persons from 18 primary care practices, hypertension ± dyslipidemiaDesignated support personRandomized, controlled trialIntervention and control groups	A1C, BP, LDL clinical outcomes CVD risk assessed Intraclass correlation coefficient, statistical analysis system procedure PROC MIXEDCronbach's alpha coefficient	Involvement of a friend or relative support person had no significant effect on CVD risksSelf-efficacy and medication adherence at baseline were not found to moderate intervention effectsMean baseline A1C 7.6% may have impacted physician motivation to improve CVD risk	S: Evaluates cardiovascular outcomes; multiple primary care sites of 18 clinicsL: Smaller sample size than projected may have contributed to insufficient power to detect small differences; nonrandom selection may have led to unreliable result	The existence of friend support network should not overshadow what a patient needs to do individually Friends should be chosen wisely and make sure health professionals are involved in the care process	[10]
Rees et al. (2010)	To evaluate how social support and race/ethnicity were associated with diabetes self-care behaviors and outcomes	n = 450 (171 Caucasian, 150 AA, 112 Latino)Cross-sectionalNHANES data 2005–2006	Social Support Index used A1C, BP, LDL clinical outcomesDM self-care measures – weight, calorie intake, checking feet, SMBG, diet/exerciseLogistic regression, race/ethnicity and social support were independent predictorsAdjusted models	No differences in social support across race/ethnicityLower education, depression, functional disability status and poorer self-reported health significantly associated with lower social supportSocial support was associated weight, exercise, fat/calories and DBP for AAs, LDL for Caucasians and nothing for Latinos	S:Considers different ethnic groups may rely on social support in varying ways to manage illness; validated measureL: Measure may only capture subtle differences in social support across ethnicities; tangible support for getting doctor's appointment was not included	Healthcare practitioners could engage patients in discussion not only about social support in their lives but also the impact of this support on their self-management behaviorsIn this study, social support had the strongest influence among AA	[11]
Rosland et al. (2008)	To examine whether family and friend support differentially affects specific self-management behavior and compare the influence of support from health professionals	n = 164 AA and Latino adults living in inner city Detroit, mean age: 52.6 years, cross-sectionalRetrospective evaluation of surveys	Behavioral Risk Factor Surveillance Survey, Survey of Diabetes Self-Care Activities, Patient Health QuestionnaireStudent's t-test, Pearson χ², Multivariable logistic regression models, STATA 9.2Used data from a survey of AA and Latino adults with DM (the REACH Detroit Partnership)	Family/friend support associated with SMBG, but not medication, meals, exercise or feet checking behaviorsHealth professional support improved feet checking and mealsSelf-efficacy associated with glucose testingEach single unit increase in family and friend support increased adjusted odds ratio for testing sugar by 1.77, for exercising by 1.31	S: Evaluated social support in under-represented groups (females, minority populations)L: Underpowered to detect statistically significant support associations; predominantly female; may be over-self-reporting adherence; no distinction between support from family or friend cross-sectional data is unlikely to assess causality	Involving friends and family can result in increased adherence for a few self-management behaviorsProfessionals and self-reliance are associated with more self-management behaviorsSocial support increased diabetes-related behaviors (testing glucose, meal plan, taking meds appropriately but not insulin)	[16]
White et al. (2009)	To examine the relationship between psychological and social factors and diabetes outcomes in people with type 2 diabetes and their family members	n = 153 (only 75 had a family member participate)Questionnaires assessed from outpatient clinic (large urban teaching hospital) and mailed to family membersCross-sectional	Study groups: good control (A1C < 7%) vs poor control (A1C >8.5%)Family members were given standardized questionnaires	Families viewed DM as controlled but with serious consequencesNo difference in DM knowledge between patients and family members except for signs of hypo- and hyper-glycemia, patients knew moreFamilies reported patients were more emotionally distressed	S: Used verified and tested questionnairesL: Subjective; small sample size; family members of patients with good A1C control more likely to respond (therefore probably more supportive); family questionnaires were completed by a person chosen by study participant	Family members reported those with DM were more emotionally distressed and knew more about DM than the patient actually reported themselvesFamily members feel less supported than patients doNeeds include education and encouragement	[9]

A1C: Hemoglobin A1c; AA: African–American; ANOVA: Analysis of variance; BP: Blood pressure; CDE: Certified diabetes educator; CVD: Cardivascular disease; DBP: Diastolic blood pressure; DM: Diabetes mellitus; HRS: Health and Retirement study; LDL: Low-density lipoprotein; NHANES: National Health and Nutrition Examination Survey; REACH: Racial and Ethnic Approaches to Community Health; SMBG: Self-monitoring of blood glucose

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Social Support Strategies in Adult Patients With Diabetes

A Review of Strategies in the USA and Europe

Abstract and Introduction

Abstract

Introduction

Tables

References

Authors and Disclosures

Authors and Disclosures

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