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. 

In This Article

Social Support Overview: Family & Friends

Perceptions about family inclusion and support in diabetes self-management among 205 certified diabetes educators (CDEs) were investigated by Denham et al.[5] The exposure of the CDE to family theory influenced the perception about family support networks as well as CDE perceptions of meeting patient needs. Overall, CDE formal exposure to family theory impacted the likelihood of educators inviting family members to participate in diabetes education. Understanding the CDE of family inclusion also impacted the perceived knowledge about family support, communication and dynamics. This study found that CDEs may be overestimating their involvement of family support, and there needs to be more formal education and exposure to family theory to organize appropriated diabetes education for patient and families.

Spousal Social Support

Literature involving spousal social support has primarily been among individuals who have been united in long-standing relationships. Iida et al. studied spousal support influence with regard to dietary health behaviors among 126 couples with a mean age of approximately 66 years who had been married on average for approximately 38 years.[6] The study interviewed only couples in whom one of the individuals had diabetes and they had to be older than 55 years of age. Interviews were conducted with and without the presence of spouse, and diaries were kept for 24 days. The determinants of spousal emotional support were evaluated and demonstrated that symptom severity correlates with support given and that negative affect correlates with spousal support. Relationship tension did not correlate with the level of support; however, on evenings when patients experienced more negative affect, there was more emotional support provided by spouses on the following day while the opposite occurred for spouse providers (when spouses experienced negative affect, there was a decrease in the support they provided). In summary, day-to-day deterioration in the amount of spousal support resulted from patient distress.

Another cross-sectional spousal support study (n = 30 couples) was conducted by Beverly et al. to evaluate emotional support of partners related to food-related behaviors.[7] The mean age of the group was 65 years, and each had been married on average for approximately 38 years. Focus groups were conducted and yielded many perspectives including feelings of restriction of food; spousal control over food preparation for men, in particular, was cited. Extreme views included that certain foods had to be given up altogether. Couples in whom both individuals had diabetes had more understanding regarding dietary management.

General Family Social Support

Mayberry et al. explored the role of family support in adults through 11 focus groups among 45 participants (69% women).[8] Family knowledge included perceptions of diabetes self-care knowledge. Advancing age was significantly associated with family members performing fewer nonsupportive behaviors. Overall, support from family members was associated with more diabetes-related control behaviors. Individuals with higher incomes (>US$40,000 annually) reported more supportive behaviors from family members than those with <US$40,000 annually. More education was associated with family members knowing less about the patient's diabetes. Perceiving family members as nonsupportive was associated with worse medication adherence and higher hemoglobin A1c (A1C) levels.

A study by White et al. evaluated family member perspectives among patients with diabetes. Both psychological and social factors were evaluated.[9] Family members were defined as any relative in regular contact with the participant. Social support measured included the number of people available for support and the respondent's satisfaction, along with diabetes support. Overall, families viewed diabetes as coming and going in cycles with a perception that there were more serious consequences for those who had diabetes. There were significantly more female respondents (65.4%) with a large portion among those uncontrolled (A1C >8.5%), but no differences were found between family members with good or poor glycemic control. Overall, the perceptions of family members were in contrary with the patient view for emotional and knowledge questions.

Diabetes Outcomes & Social Support

Social networks and behavior changes that can result in improved diabetes outcomes are important to measure. Pearce et al. conducted a study of 15 primary-care practices where 199 patients were followed-up for approximately 1 year.[10] Outcomes included A1C, systolic blood pressure (BP), low-density lipoprotein (LDL) cholesterol along with rating of physician and overall health. No significant effects were found after 9–12 months. Involvement of a nonhealthcare support person such as a friend or relative did not change outcomes in this Kentucky-based intervention study. The baseline cardiovascular risks showed overall moderate-to-good control for the subjects, and this may have impacted the ability to detect changes as the target sample size was also not achieved.

Social support and ethnicity were evaluated in the National Health and Nutrition Examination Survey data from 2005 to 2006 among white, black and Latino respondents (n = 450).[11] Both clinical care outcomes along with diabetes self-care behaviors were assessed (Table 1). While social support score did not differ significantly by ethnicity, lower education, depression, functional disability status and poorer self-reported health status were associated. No significant association was found between diabetes self-care behavior and social support in unadjusted regression models; however, there was an association with a 5.65 mg/dl decrease in LDL cholesterol (no changes in A1C or diastolic BP). In adjusted analyses that included social support and ethnicity as interactions, social support was found to be associated with controlling weight, exercise and controlling fat and calorie intake, and lowering diastolic BP for African–Americans (AAs). Only LDL cholesterol was significant for Caucasians, and there were no significant effects found in Latinos. Overall, social support had a stronger influence in AA with diabetes.

Social Support & Diabetes Self-management

Social support, self-efficacy and outcome expectations to diabetes self-care behaviors and glycemic control were evaluated by Chlebowy et al. using prospective survey (n = 91) in AAs and Caucasians in the southeastern USA.[12] Outpatient visits were used for study recruitment, and four questionnaires were completed at the site or mailed to participants. There were no significant relationships found between social support and self-efficacy in relation to diabetes self-care support. The authors note that AAs were less satisfied with their social support systems than Caucasians.

Arcury et al. evaluated social integration and diabetes management among rural older adults.[13] Data from 563 interviews of AA, white and American Indian participants >60 years of age were evaluated to assess diabetes management behaviors ( Table 1 ). Children seen in the past month, number of relatives seen in the past month and the number of phone contacts in the past week were analyzed with regard to social integration. Participants who had high levels of social integration (social network, relatives, telephone contact) were associated with provider A1C monitoring and examining feet. Social integration had a small but significant association with diabetes management behaviors (participant self-monitoring of blood glucose [SMBG] and checking feet).

Mani et al. evaluated the influence of social networks on patients' attitudes toward diabetes through a survey of 154 patients (64% response rate out of 240 mailed at two primary-care practices).[14] Patients documented the number of family and friends who had diabetes, and the primary outcome variable was the level of concern about diabetes on a scale of 0 (not at all concerned) to 100% (extremely concerned). For each additional family member with diabetes, there was a greater level of concern expressed by patients regarding potential complications. Likewise, an increased number of friends with diabetes also resulted in patient surveys indicating a greater concern about diabetes.

A study among AA females in the Midwest evaluated how family and friends' social support impacted exercise self-efficacy, physical environment, sense of community, social issues and roles, socioeconomic status and body image.[15] Table 1 provides further details on this. Overall, a positive correlation was reported between family social support for exercise and physical activity frequency. Self-efficacy was also positively correlated to physical activity frequency, while a negative relationship between physical environmental barriers and physical activity frequency was found.

Other studies for diabetes management included a survey evaluation of AA and Latino adults (n = 164) conducted by Rosland et al.[16] The principal independent variables included family and friends support, professional support, self-efficacy and depressive symptoms that were evaluated in multivariable logistic regression modeling. Family and friend's support was found to be primarily associated with glucose monitoring, while nonphysician health professional support was associated with glucose monitoring, following a diabetes meal plan and checking feet. Table 1 provides details of the major findings and limitations of this study.

Social Support & Cognitive Impairment

Okura et al. studied cognitive impairment among adults with diabetes, whether this was associated with worse glucose management and whether social support alters the relationship.[17] Approximately 80% survey, which included a 35-point cognitive scale, was completed (n = 1097). Specific questions were also asked regarding diabetes-related social support. Those with lower cognitive function had higher levels of social support and better A1C. Non-Caucasian race, longer diabetes duration, high depression scores and insulin use were associated with higher A1C levels.

Social Support Summary: Family & Friends

In summary, support from family and friends has been shown to have some effects on patient behaviors and/or health outcomes. Effects do not appear to be dependent on race or ethnicity, although they do depend on good family relationships, possibly including age and income. The variety of methods used in the described studies may account for the variance in effects, but are intriguing enough to warrant further study about how to successfully harness family social support to aid patients in diabetes management.