Family Interventions To Improve Diabetes

HHS Public Access
Author manuscript
Ann N Y Acad Sci. Author manuscript; available in PMC 2016 September 01.
Author Manuscript
Published in final edited form as:

Ann N Y Acad Sci. 2015 September ; 1353(1): 89–112. doi:10.1111/nyas.12844.
Family interventions to improve diabetes outcomes for adults

Arshiya A. Baig, Amanda Benitez, Michael T. Quinn, and Deborah L. Burnet
Department of Medicine, University of Chicago, Chicago, Illinois
Abstract
Diabetes self-care is a critical aspect of disease management for adults with diabetes. Since family
Author Manuscript
members can play a vital role in a patient’s disease management, involving them in self-care
interventions may positively influence patients’ diabetes outcomes. We systematically reviewed
family-based interventions for adults with diabetes published from 1994 to 2014 and assessed their
impact on patients’ diabetes outcomes and the extent of family involvement. We found 26 studies
describing family-based diabetes interventions for adults. Interventions were conducted across a
range of patient populations and settings. The degree of family involvement varied across studies.
We found evidence for improvement in patients’ self-efficacy, perceived social support, diabetes
knowledge, and diabetes self-care across the studies. Owing to the heterogeneity of the study
designs, types of interventions, reporting of outcomes, and family involvement, it is difficult to
determine how family participation in diabetes interventions may affect patients’ clinical
outcomes. Future studies should clearly describe the role of family in the intervention, assess
quality and extent of family participation, and compare patient outcomes with and without family
involvement.
Author Manuscript
Keywords
family-based; diabetes; self-management
Background
The burden of diabetes
According to the Centers for Disease Control and Prevention, over 29 million adults in the
United States are living with diabetes.1 In 2012 alone, 1.7 million adults were newly
diagnosed with diabetes.1 People with diabetes are at risk for numerous complications,
including diabetic retinopathy, nephropathy, neuropathy, cardiovascular disease,
Author Manuscript
amputations, and premature death.1 The management of diabetes can be relatively complex
for patients. They must attend multiple physician visits per year; adhere to several different
types of medications to control their disease; participate in many facets of self-care,
including home glucose monitoring, healthy eating, and exercise; and negotiate barriers to
management, such as cost of care and balancing work and life commitments.2
Address for correspondence: Arshiya A. Baig, MD, MPH, Section of General Internal Medicine, University of Chicago, 5841 S.
Maryland Ave. MC 2007, Chicago, IL 60637. abaig@uchicago.edu.
Baig et al. Page 2
Importance of family in diabetes self-care

Author Manuscript
Diabetes self-management education (DSME) is a critical component of care for all

individuals with diabetes.2 For adults with type 2 diabetes, engaging in diabetes self-care
activities is associated with improved glycemic control and can prevent diabetes-related
complications.2–5 Much of a patient’s diabetes management takes place within their family
and social environment.6 Addressing the family environment for adults with diabetes is
important since this is the context in which the majority of disease management occurs. The
Institute for Patient- and Family-Centered Care defines family members as two or more
persons who are related in any way—biologically, legally, or emotionally.7 Thus, family
members can include nuclear, extended, and kinship network members.8
Family members can actively support and care for patients with diabetes.9 Most individuals
live within a household that has a great influence on diabetes-management behaviors.10 A
Author Manuscript
study of more than 5000 adults with diabetes highlighted the importance of family, friends
and colleagues in improving well-being and self-management.11 Family members are often
asked to share in the responsibility of disease management. They can provide many forms of
support, such as instrumental support in driving patients to appointments or helping inject
insulin, and social and emotional support in helping patients cope with their disease.12–13
Through their communications and attitudes, family members often have a significant
impact on a patient’s psychological well-being, decision to follow recommendations for
medical treatment, and ability to initiate and maintain changes in diet and exercise.14
Among middle-aged and older adults with type 2 diabetes, social support has been found to
be associated with improved self-reported health in long-term follow-up.15 Family cohesion
and family functioning have also been found to be positively related to patients’ self-care
behaviors and to improvements in blood glucose control.16–19
Author Manuscript
Providing diabetes education to just the individual with type 2 diabetes could limit its impact
on patients, since family may play such a large role in disease management. Family-based
approaches to chronic disease management emphasize the context in which the disease
occurs, including the family’s physical environment, as well as the educational, relational,
and personal needs of patients and family members.12,20 Including family members in
educational interventions may provide support to patients with diabetes, help to develop
healthy family behaviors, and promote diabetes self-management.21
The negative ways family can affect diabetes

Patients’ family and friends can provide support in overcoming barriers in executing
diabetes self-management, but behaviors of family members also have the potential to be
harmful.22 How the family is structured and its beliefs and problem-solving skills or lack
Author Manuscript
thereof can exacerbate the stresses associated with disease management.12 The lifestyle
changes required for optimal diabetes self-management often conflict with established
family routines.23 Self-management tasks may necessitate changing the types of food
prepared and consumed in the home, time away from work for the family member to attend
medical visits with the patient, and reprioritization of family finances, all which may affect
family routines. Since family members participate in purchasing groceries, creating family
schedules, and cooking meals, they can help or hinder necessary lifestyle changes for people
Baig et al. Page 3
with diabetes.22 In studies of adults with type 2 diabetes, participants have reported that
Author Manuscript
family members’ nonsupportive behaviors were associated with being less adherent to one’s
diabetes medication regimen and with having poorer glucose control.24–26 Family members
may sabotage or undermine patients’ self-care efforts by planning unhealthy meals, tempting
patients to eat unhealthy foods, or questioning the need for medications.25,27 Family
members may also nag or argue with patients in an attempt to support adherence.25,28 One
study found that pressure from a spouse regarding a patient’s diet is associated with higher
diabetes-specific distress among adults with type 2 diabetes.29 A family’s obstructive
behaviors may be more harmful among adults with limited health literacy and patients who
are experiencing other stressors or major depressive symptoms.26,30 Hence, diabetes self-
management interventions should focus not only on the individual patient, but also on the
family, so that they are better equipped to positively support their loved one with diabetes.25
Supporting family
Author Manuscript
Diabetes self-management interventions may need to place greater emphasis on targeting

family members’ communication skills and teaching them positive ways to influence patient
health behaviors.31 Family members can feel distressed by their loved one’s diabetes28,32–34
due to limited knowledge about diabetes or not knowing how to support their loved
one.12,27,35–37 Family may also have misconceptions, such as believing the patient knows
more about diabetes than the patient actually reports or not understanding their loved one’s
needs in diabetes management.27,38 Knowledge about the disease, strategies to alter family
routines, and optimal ways to cope with the emotional aspects of the disease are some of the
aspects of diabetes self-management that family members need.39 Educating family
members about diabetes-care needs can help ease this strain by explaining why these
changes are necessary, how these changes can best be implemented, and where to find
additional information, such as healthy recipes or exercise routines.24 Effective family
Author Manuscript
management can also reduce the strain that family members may experience when coping
with altered lifestyles and disease progression.24 It is important to provide family members
with information about the illness and possible treatment options, validate their experiences
as providers of support, teach them various stress management skills, and help them plan for
the future.31
Influencing family member outcomes

Carefully designed studies are needed to evaluate the benefits of diabetes self-management
interventions for both the patient and the family member.40 How families manage chronic
disease affects not only the patient’s health, but the health of others in the family as well.12
Assessing family members’ knowledge in diabetes self-care and perceived ability to support
Author Manuscript
their loved one with diabetes may be important end points for diabetes self-care
interventions. Family members may also benefit more directly by reducing their own
psychological distress regarding their loved one’s diabetes and by improving their own
health behaviors through attending health education programs.32,41,42 Furthermore, family
members at high risk for diabetes may decrease their own likelihood of developing diabetes
through improved lifestyle behaviors and weight loss. In a review of randomized controlled
trials of chronic disease interventions, benefits for family members were rarely assessed.40
Baig et al. Page 4
Importance of culture
Author Manuscript
The importance of family involvement in diabetes self-management has been demonstrated

across patients from various racial and ethnic minority populations.43–45 A systematic
review of DSME interventions among older adults with diabetes from ethnic minorities
found that characteristics of successful interventions included involvement of spouses and
adult children.44 In another study among African-American women with diabetes, many
women noted that support primarily came from family.27 In a study of Korean immigrants
with type 2 diabetes, family support specific to diet was significantly associated with better
glucose control.43 In American Indian populations, active family nutritional support was
significantly associated with control of triglyceride, cholesterol, and A1c levels.46,47
Furthermore, among many Latinos, familismo, the importance of family and family-
centeredness, is an important cultural value.8 Tailoring clinical care and developing novel
educational approaches that include family and community is central to improving the health
Author Manuscript
of Latinos with diabetes.8 Studies of Latinos with diabetes have found that including family
members in educational interventions may promote patients’ diabetes self-
management.21,48,49 Understanding a patient’s cultural and family environment is important
in supporting diabetes self-care and in considering how to culturally tailor interventions for
patients from racial/ethnic minority populations.
Including family members in diabetes interventions

Recognition of the important role that family members play has led increasingly to
incorporating the index patient’s family members into diabetes self-management
interventions.50 Family members play an especially significant role in managing diabetes for
children and adolescents; thus, most family-based interventions to date have targeted
children with diabetes.20,51,52 A review of family-based interventions for patients with
Author Manuscript
diabetes mellitus conducted in 2005 found that most family interventions for diabetes in the
previous 15 years were among youth and adolescents with type 1 diabetes, but few studies
had focused on adult patients and their family members.20
Among adults, inclusion of a close family member in psychosocial interventions for chronic
conditions may also be more efficacious than focusing solely on the patient.40 For example,
including family members in educational interventions has been shown to improve rates of
smoking cessation53,54 and weight loss.55,56 In a review of randomized controlled trials of
chronic diseases, interventions using a family-oriented approach for adults were more
beneficial than solely patient-oriented interventions.40 In a review of interventions for
couples and families managing chronic health problems, including common neurological
diseases, cardiovascular diseases, cancer, and diabetes, family interventions showed promise
in helping patients and family members manage chronic illnesses.57
Author Manuscript
Among adults with diabetes, interventions including family or household members of people
with diabetes may be more effective than usual care in improving diabetes-related
knowledge and glycemic control.20,40,52,58–60 Family support has also been associated with
improved medication adherence and blood sugar control in studies of adults with
diabetes.18,44,61–62 Addressing a diabetes patient’s social–environmental support has been
found to be positively associated with healthy diet and exercise.63 However, several
Baig et al. Page 5
interventions seeking to improve self-management behaviors by increasing social support

Author Manuscript
from family and friends have shown varying results.64–66
Conceptual framework
We found several published conceptual frameworks that describe the theoretical
underpinnings of a family-based diabetes intervention for adults.
The Institute for Patient- and Family-Centered Care provides guidance on the major
concepts underlying patient- and family-centered care across health conditions.7 In family-
and patient-centered care, healthcare providers respect, listen to, and honor patient and
family perspectives and choices.7 Patient and family knowledge, values, beliefs, and cultural
backgrounds must be incorporated into the planning and delivery of care. Patients and
families require timely, complete, and accurate information in order to effectively participate
Author Manuscript
in care and decision making. Moreover, patients and families are encouraged and supported
in participating in care and decision making7 Key strategies in mobilizing family support for
patients with chronic health conditions may include guiding family members to set goals for
supporting patient self-care behaviors, training family members in supportive
communication techniques, and giving families the tools and infrastructure to assist in
monitoring clinical symptoms.35,59
In terms of interventions for patients with diabetes, others have described frameworks for
the inclusion of family in health interventions.12,67,68 Clinical interventions may be most
effective when characteristics of patients that affect disease outcomes are integrated with
perspectives of the family context.12 The family provides the arena in which patient, family
member stress or support, and healthcare factors intersect, providing an ideal locus for
meaningful intervention.12 Interventions must address how the family is structured, how the
Author Manuscript
family solves problems, and how family members manage emotions. Interventions must also
address patients’ and family members’ beliefs and expectations, family stresses, and
allocation of the responsibilities of disease management. Other frameworks stress the
importance of biculturalism and integrating cultural knowledge, skills, practices, and
identities into diabetes self-management interventions for racial/ethnic minorities.69
Furthermore, couples-based interventions ought to address the behaviors, feelings, and
thoughts of both partners.68 This approach recognizes the interdependence of partners, and
that their interaction affects them both, not simply the behavior of one affecting the other.70
Objective
Considering that adults with diabetes depend on the support of family for assistance in
Author Manuscript
managing their diabetes, examining family-based interventions for adults with diabetes is
important in understanding how to strengthen current diabetes self-care programs. In the
past decade, several studies have tested family-based interventions among adults with
diabetes. We systematically reviewed published family-based interventions for adults with
diabetes from the years 1994–2014, assessed the level of family participation, and
considered how this involvement affected the patients’ outcomes.
Baig et al. Page 6
Methods
Author Manuscript
We searched for family-based diabetes self-management intervention articles published

from January, 1994 to October, 2014 using the electronic databases PubMed, CINAHL, and
PsycINFO. We used prespecified Medical Subject Headings (MeSH) and keywords to
identify evaluation studies (Evaluation, Effectiveness, Improvement, Controlled clinical
trial, Randomized, Randomized controlled trials) that were designed to test diabetes self-
management interventions (Intervention, Education, Self-management, Self-care, Problem
solving, Program, Social support), were family-based (Family, Couple, Significant others,
Spouse, Relationship, Relatives, Caregiver, Partner), and targeted adults with diabetes
(Diabetes mellitus, Diabetes mellitus, Type 2). Appendix 1 describes in further detail the
search terms used in the database searches. We supplemented our electronic database search
with a hand search of issues from selected journals with a high likelihood of publishing
diabetes self-management intervention studies (Diabetes Care and The Diabetes Educator).
Author Manuscript
We also hand searched related articles and references cited in previously published
systematic reviews of family-based interventions.20,31,40,52,57,60,65,71–73
To be included in our review, a study must have been conducted in the United States, be
published in English or Spanish, and be focused on improving diabetes treatment processes
and patients’ outcomes. We included all study types in our review (e.g., randomized
controlled trials, prepost, and pilot) that met our inclusion criteria. We excluded studies that
focused solely on diabetes prevention or targeted patients under the age of 19 or women
with gestational diabetes. If studies included patients with other chronic conditions other
than diabetes or included patients at risk for diabetes in addition to patients with diabetes,
we included only those studies that reported results of subgroup analyses conducted with the
subsample of diabetic patients. We excluded studies that only reported outcomes aggregated
Author Manuscript
across patients and family members that made it difficult to interpret the impact of the
program on index patients with diabetes.
From the PubMed, CINAHL, and PsycINFO database searches, we identified 2340 unique
articles. Three co-authors (AAB, AB, and MTQ) independently reviewed the titles and
abstracts of the first 10% of articles (234 articles) identified through the database searches to
determine whether articles met inclusion or exclusion criteria. We subsequently met to
discuss discrepancies and to reach consensus. We repeated independent review of the titles
and abstracts of the next 10% of articles two more times until we reached a κ greater than
0.60 that indicated moderate to substantial agreement among reviewers. The remaining titles
were then divided among the three co-authors to independently review. The title and abstract
review yielded a total of 200 articles in need of full text review to determine their inclusion
Author Manuscript
or exclusion in the systematic review.
Once we had established an adequate κ, one co-author (AB) completed a title and abstract
review of the 2010–2014 issues of Diabetes Care and 2009–2014 issues of The Diabetes
Educator. Through the hand search, 76 additional articles were identified that were in need
of full text review. Hand searches of reference lists of relevant articles identified through the
database and journal hand searches yielded an additional 28 articles in need of full text
review.
Baig et al. Page 7
We then divided the 304 articles from the database and hand searches between three co-
Author Manuscript
authors (AAB, AB, MTQ) and independently reviewed the full text of the selected articles.
During the full text review, we noted that many studies mentioned family involvement in the
interventions but lacked detail on how the family was involved in the study procedures.
Since our focus was on the family-based nature of interventions, we included only studies
that described the role and activities of family members in the intervention, provided a
qualitative or quantitative assessment of outcomes related to families, or reported outcomes
associated with family members’ participation. We excluded studies that did not provide
details in their background, methods, results, or discussion sections regarding the role and
activities of family members in the intervention or outcomes related to family involvement.
Using PRISMA guidelines, our literature-search flowchart is depicted in Figure 1.74
Data abstraction
Author Manuscript
We used a validated instrument to guide our abstraction.75 We abstracted data from each
study into a table (Appendix 2) that included the objective of the study, the setting, the study
design, the population sampled, a description of the intervention, and patient outcomes
reported. Each study in the table was given a quality score by two members of the research
team using an adapted questionnaire based on the Downs and Black guidelines (27-point
scale: 0 worst, 27 best).76 The Downs and Black questionnaire is a valid and reliable
checklist that assesses both randomized and non-randomized studies, provides an overall
score of study quality, and includes five subscales that measure quality of reporting, external
validity, bias, confounding, and power.76 We report the average of the two quality scores.
We abstracted data into a separate table (Table 1) to describe how the study defined family,
how family was involved, the level of family participation in the intervention, and any
outcomes related to family involvement.
Author Manuscript
Results
We identified 26 unique studies described in 46 articles that used family-based interventions
to address diabetes self-management and outcomes among adults with diabetes. These
studies are described in detail in Appendix 2.
Study design
Of the 26 studies, 13 used a randomized controlled study design (RCTs)77–101 and 11 used a
prepost design.21,50,102–113 One study assigned individuals to one of three arms based on
their community of residence.114 Another study reported only postintervention measures.115
Participation and follow-up rates were high for many studies, as noted in Appendix 2.
Follow-up ranged from immediate postintervention to 12
Author Manuscript
months,21,80–82,90,92,95,96,99,100,111,113,114,116 24 months,77,83 and 36 months.78,79
Populations and settings

Of the 26 studies, 22 recruited patients from racial/ethnic minority populations. Studies
included American Indian,106,107,114,117,118 African-American,77–79, 88,89,93,95,96,102–104,119
Latino,21,50,80–86,90,91,92,94,97,98,101,103.104,112,119,120 and Asian, including Bangladeshi
Baig et al. Page 8
American111,121 and Korean American,99,100 patient populations. Two studies did not
Author Manuscript
collect or report race/ethnicity data.87,115
Studies also represented different regions across the United States, including the
Midwest,104–107,109,110,119 South,21,88,89,93,95,96,101,102,108,113,115 West/
Southwest,83–86,97,98,112,114,117,118,120 East,77–81,87,94,99,100,111,121 and along the Texas–
Mexico border.50,90–92 Several were conducted in rural settings settings21,50,88–93,102,113 or
urban settings.77–86,94,99,100,103,104,106–108,111,115,119–121 Two studies were conducted in
Native American communities.106,107,114
Interventions took place in diverse settings, including community health centers,21,97,98,111

other community sites,47,50,80–82,88,89,91,92,99,100,101,103,104,106,107,111–113 academic medical
centers,77,94,105,115 churches,95,96 and Veterans Administration (VA) hospitals.109,110
Author Manuscript
Intervention details
Of the 26 studies, 21 interventions were diabetes self-management interventions that offered
group-based or one-to-one individualized counseling. One intervention was a cooking
class.112 Four interventions incorporated home visits.77–82,102 Three studies used
technology, including mobile communication technology, to support serum blood glucose
monitoring,108 teletransmission for home glucose monitoring,99,100 and interactive voice
response (IVR) to provide patient monitoring and self-care support between primary care
visits.109,110
Interventions were led by CHWs or promotoras,77–79,90–92,94,97,98,103,104,111,119

nurses,50,77–79,90–94, 99,100,102,106,107,112 pharmacists,101,115 certified diabetes educators
(CDEs),87–89,9394,97,98,102,112,113 peer or lay leaders,50,80,82,95,96,114,117 registered dietitians
Author Manuscript
(RDs) or nutritionists,50,80,82,83,85,86,90–93,95,96,99,100,102,106,107,112,115,120
physicians,106,107,115 mental health providers,87,106,107,115 nurse practitioners,21,113 health
educators,80,82 tribal elders/leaders,106,107 and dentists.115
Outcome measures
Patient clinical outcomes
Clinical outcomes for index patients with diabetes varied across studies. Of the 19 studies
that reported A1c, 11 found significant improvements.50,80,83,85,91,94,96,99,102,103,106,114
Seven studies noted improvement in A1c from baseline to
postintervention,50,91,94,96,99,103,106 while others reported improvements from baseline to 5
months postintervention,102 30 weeks postbaseline,99 7.7 months postbaseline,94 and 12
months postbaseline.91 Four studies demonstrated short-term improvements in A1c that
Author Manuscript
were not maintained at 6 months,106 12 months,80,96 or 24 months.85
Of the 11 studies that reported blood pressure outcomes, three demonstrated short-term
improvements in blood pressure,21,96,106 two reported improvements at 12 months,113,114
and one reported improvements in diastolic blood pressure at 24 months.77 Among the nine
studies tracking weight, four noted significant weight loss over time.93,98,101,106 Of nine
studies reporting body-mass index (BMI), three found improvements in BMI in the short-
Baig et al. Page 9
term;83,85,101,113 however, for one study these results were not sustained at 12 months.113
Author Manuscript
Three of 11 studies assessing cholesterol showed improvements in lipid profiles.77,87,99
Patient psychosocial outcomes

Several studies assessed psychosocial outcomes for patients. All three studies measuring
depression found improvements in patients’ reported depressive symptoms.99,109–111 One
study measured diabetes distress and found improvements.109,110 Of the four studies that
assessed quality of life, three demonstrated improvements.21,96,99 Of 10 studies measuring
self-efficacy, seven found improvements.21,80,83,85,99,105,108,111 The ¡Viva Bien! program
also noted improvements in patients’ perceived supportive resources.83,85 One study
reported that patients felt increased emotional and instrumental support in blood glucose
self-monitoring.108
Author Manuscript
Patient diabetes self-management behaviors

Of the 13 studies measuring diabetes knowledge, 12 noted improvements in patients’
diabetes knowledge.21,50,80,91,94,96,99,103,107,111,113,115 Of 15 studies assessing diet, 11
demonstrated improvements in dietary habits.21,80,83,85,93,94,102,103,107,111,112,115 A study
utilizing cooking classes showed significant improvements in dietary behaviors, including
caloric intake, saturated fat, cholesterol, and fat consumed.112 Out of 12 studies assessing
exercise, five found improvements in patient physical activity.83,85,107,111,113,115 However,
one study found that improvements in physical activity were not sustained at 12-month
follow-up.113 Six out of eight studies measuring patients’ blood glucose monitoring noted
improvements,21,80,97,108–110,115 and two out of six measuring medication adherence noted
improvements.109,115 Some studies found improvements in some self-care behaviors but not
in others.21,98,97,103,111,113
Author Manuscript
Healthcare utilization
One study found a significant decrease in emergency room visits by intervention participants
but not in the number of hospitalizations.79 Another study found improvements in the
number of acute care visits but no change in hospital length of stay.102
Cost
Only two studies reported the cost of the intervention.91–93
Patient outcomes by family involvement

Of the 26 studies, 17 studies did not report patient outcomes by family
involvement.77,79,80,88,89,93,96–103,105–107,111–113,115 Four studies required patients in all
Author Manuscript
arms to enroll with a family member/support person, thus precluding them from assessing
outcomes by family involvement.21,50,90,91,108
Three studies reported positive effects of family involvement. Barrera reported that family
support had an effect on increases in physical activity after accounting for the effects of
group support.86 Gilliland demonstrated a decrease in diastolic blood pressure in the family
arm.114 Aikens conducted subgroup analyses comparing patients with family involvement to
Baig et al. Page 10
those without and found that patients enrolling with an informal caregiver had higher rates
Author Manuscript
of engagement, were less likely to report frequent high glucose levels (P = 0.021), and more
likely to regularly check their blood pressure (P = 0.017).110
However, two studies found no impact of family involvement. One reported results from
subgroup analyses comparing patients with family involvement to those without and found
that family participation in education sessions was not a significant factor in program
completion.94 In their telephone-based intervention, Trief et al. compared outcomes of
patients with family involvement to those without and, contrary to their hypothesis, found
that results in the individual intervention group appeared to be better overall than those in
the couples intervention group.87
Family participation and outcomes

Table 1 describes family participation in the interventions and family outcomes. Of 26
Author Manuscript
studies, most defined family members as spouses, parents, children, or

relatives.50,80,82,90–92,106,108,115 One study involved couples.87 Two studies required that the
family member must reside in the patient’s household.21,80,82 Many studies stated that
family members were included in the intervention without explaining who they defined as
being a family member. Some studies included other supportive people105 or friends in lieu
of a family member for index participants who chose this
option.50,88,89,90,91,101,103,104,113,114 One further specified that the friend had to be living in
the participant’s household,80–82 while another stated the family member or close friend
must be someone living outside the patient’s home.109,110
Family involvement varied across studies. Most studies noted that families were invited to
attend the intervention classes or
Author Manuscript
meetings.21,50,80,82,83,85,89,91,93–95,97,98,100–102,106,107,112,113 In some studies, authors stated

that family members were enrolled in the study.21,87,95,108 Some interventions included
family-themed topics in the education sessions, such as support of family in managing stress
and traditional cultural values regarding familial and social
relationships.21,80,82,88,89,93,97,98,100,103,104,111,119,121 In other studies, family participated in
physical activities or shared a healthy meal.83,85,88,89,93,114,120 Family support was
encouraged by CHWs.77–79,100,111,121 Excluding the interventions that specifically enrolled
dyads,21,50,87,90,91,108 only some studies noted actual rates of family
participation,50,89,94,101,109,110,115 which ranged from 16% to 79%.
In Aikens et al., patients received weekly IVR calls to assess health status and self-care and
to receive tailored, prerecorded support messages. Family caregivers were notified of the
Author Manuscript
results of each call and were given suggestions for self-management support.109,110
In Roblin’s study,108 family supporters were instructed in motivational coaching so they

could provide effective feedback to the patient and help assess barriers to effective self-
monitoring of blood glucose (SMBG). During the intervention, a summary of SMBG
adherence and results were sent to the patient and their support person to prompt
conversations and facilitate supportive relationships in order to reinforce the importance of
Baig et al. Page 11
SMBG and achieving good glucose control. Both the patient and supporter were asked for
Author Manuscript
feedback about the intervention at the final session.
In Trief’s study, patients and partners participated in exercises to promote collaborative

problem solving.87 Two phone calls on speakerphone were conducted with each couple,
focused specifically on the couples’ communication. Homework and discussion tasks
involved both partners in goal setting and improving communication skills.87
While most studies focused on encouraging family members’ supportive behaviors, five
studies reported addressing emotions and situations that might be problematic for the
patient.50,87,91,101,109
Few studies reported on actual outcomes for participating family members. Some studies
reported qualitative findings that the intervention improved family members’ ability to
Author Manuscript
support to their loved one with diabetes regarding SMBG and also helped family members
to improve their own diets.50,98,108 One study noted significant improvements in BMI and
diabetes knowledge among family members but no changes in waist circumference, blood
pressure, physical activity, or fruit and vegetable consumption.21
Quality scoring
The quality scores for the studies ranged from 10 to 24.5 with a mean score of 18. Of the 27
criteria composing the quality score, the studies we reviewed scored the lowest in the
following categories: attempt to blind the study subjects, attempt to blind those measuring
the main outcomes, reporting of adverse events, using a representative sample, and reporting
of sample-size calculation. Appendix 3 describes the quality scores in further detail for each
study.
Author Manuscript
Fifteen studies had above average quality scores (≥ 18). Of these 15 studies, seven had
substantial family involvement.88–92,97,98,101,103,104,109,110,114,117–119 Of these seven
studies, only two studies found improvements in A1c.90–92,103,104,119 Four of the seven
studies showed no improvement,88,89,97,98,101,114 and one study did not measure A1c.109,110
There were two more studies that reported substantial family involvement in the study
intervention; however, they both had lower quality scores and either did not measure108 or
did not find a significant improvement in A1c.87
Discussion
Since the majority of disease-management activities for many adults occurs within the
family environment, involving families in diabetes self-care interventions may be a key
Author Manuscript
mechanism to improving diabetes outcomes for patients. We systematically reviewed the

literature from 1994 to 2014 and identified 26 studies that reported findings from family-
based diabetes self-management interventions for adults with diabetes. Studies were
conducted in a range of patient populations and settings but reported varying levels of
family involvement and impact on patient outcomes.
Many studies used scientifically rigorous study designs, such as randomized controlled
trials; however, the quality of the studies varied significantly.76 Some reports included an in-
Baig et al. Page 12
depth description of methods or referred to previously published study protocols; however,

Author Manuscript
many other studies did not report details on their methods, including power calculations.
Quality scores were also lower for studies that did not report attendance or follow-up rates
or assess fidelity to the intervention. Furthermore, we had to exclude several studies from
our review because they did not describe in detail the involvement of family in the
background or methods section. Previous systematic reviews of family-based interventions
have found a similar lack of detailed descriptions in the methods used.73 The family-based
intervention was often offered as a group program that was compared to either usual care or
individual educational sessions. Studies may need to compare similar interventions both
with and without a family component to truly assess the impact of including family on
patient outcomes. More studies are needed that utilize rigorous study designs, adhere to
reporting guidelines,122 assess outcomes specific to diabetes patients, and include relevant
comparison groups to fully understand the impact of family-based interventions on patient
Author Manuscript
outcomes.
We found that the involvement of the family members and integration of families into the
interventions varied widely across studies. Some studies used a strong theoretical framework
for the inclusion of family and described family-based activities and involvement in great
detail.21,87,101,108–110,115 Many included family-themed topics in the education sessions,
such as teaching ways to manage stress and having family members engage in physical
activities and healthy meals together with patients. Other studies encouraged family support
through home visits and interactions with CHWs. However, many studies did not describe a
theoretical basis for the involvement of family or report on the extent of family involvement.
Several studies in our review mentioned that families were invited to intervention meetings,
classes, and home visits but lacked detail on the content that was designed for family
members, how family members interacted in the class, and what family outcomes the
Author Manuscript
interventions were targeting. Few studies reported on family attendance or participation

rates in the intervention. Also, many studies did not define who qualified as a “family
member,” a detail which should be specified since the definition can be very broad and may
include friends and other support persons,67 and the level of support these contacts provide
may differ.123 Who is considered a “family member” may also vary with cultural context in
different populations. Without a clear understanding of the theoretical basis of involving
family, who could serve as a “family member,” and how family is involved in the
intervention and to what extent, it is challenging to draw conclusions of the impact of
including family in self-care interventions.
Many interventions in our review measured patients’ clinical outcomes, but their impact
varied. Several studies found improvements in A1c in the short term; however, studies with
Author Manuscript
follow-up beyond 1 year found that these improvements were not maintained. Some studies
demonstrated improvements in other clinical patient outcomes important to patients with
diabetes, such as blood pressure, weight loss, and cholesterol; however, many studies found
no significant changes. The impact of self-care interventions on long-term patient outcomes
can be challenging after the intensive intervention period ends,124 but involving family in
these interventions should help support patients in sustaining changes in self-care and in
maintaining improvements.12 In addition to strengthening the family-based components of
self-care interventions, having more intensive or longer interventions and providing linkages
Baig et al. Page 13
with the healthcare system and the community may be needed to affect patient clinical
Author Manuscript
outcomes.124,125
Studies that assessed psychosocial outcomes found improvements in patients’ depressive

symptoms, diabetes distress, quality of life, self-efficacy, and perceived social support.
Many studies also found improvements in patients’ diabetes knowledge, self-care behaviors,
and dietary habits, but several studies found no change in these outcomes or improvements
in only some self-care behaviors. This finding is not surprising, since social support may be
associated with some self-care behaviors more than others.33,66 Based on our review, it
seems that family-based interventions may impact psychosocial outcomes, diabetes
knowledge, and some self-care behaviors in the short-term. Further research is needed to
assess the maintenance over time of improvements in patients’ psychosocial and behavioral
outcomes and how these changes can be utilized to improve physical health. Involving
families in diabetes education interventions may enable them to be more supportive of the
Author Manuscript
patient and improve the patient’s feeling of being supported in their diabetes self-care.126
Through their participation in health interventions, family members may also experience
improvements in their own knowledge about diabetes, skills in supporting loved ones with
diabetes, and changes in their own health behaviors and health outcomes. While the studies
in our review measured a large range of patient outcomes, few reported on family member
outcomes. Some studies found that family members were highly satisfied with the
interventions and that their involvement improved their ability and confidence to provide
emotional and instrumental support to their loved ones with diabetes.50,108 A few studies
noted improvements in family members’ BMI, diabetes knowledge, and diet and exercise
behaviors.21,50,97,98,103,104 However, we found many studies that we excluded from our
review because family members’ results were aggregated with the patients’ outcomes.
Author Manuscript
Ultimately, failure to separately assess effects on both the patient and family member
provides an incomplete picture regarding the effectiveness of these health education
interventions.40 Lack of improvement for the patient might be explained by negative effects
of the intervention on the family member.31 Future studies need to evaluate the benefits of
diabetes self-management interventions for both the patient and the family member.40
We found several studies conducted with diverse patient populations that were culturally
tailored to the target audience. The inclusion of family in diabetes self-care interventions is
important for many patients from racial/ethnic minority populations and is an important
aspect of culturally tailoring educational programs.46–48,67,124,127–130 The literature notes
many benefits of involving families of patients from racial/ethnic minority groups in
diabetes interventions, including the chance to provide family members with knowledge
Author Manuscript
about the disease, dispelling myths and misconceptions about the disease, and teaching them
ways to support patients in self-care.8, 33,37,46–48,131 Families are also eager to learn
strategies for being supportive of their family members with diabetes.33,127 While the
studies we reviewed included diverse patient populations and settings, only two studies
targeted Asian Americans.99,100,111 Further studies using family-based diabetes
interventions need to target Asian subpopulations, many of which have high rates of
diabetes.1
Baig et al. Page 14
Considering more than a quarter of adults aged 65 and older have diabetes,1,132 there is a
Author Manuscript
pressing need for family members to support older patients with diabetes. In our review,
only a few studies targeted older adults.105,109,110,113,114 Only one study was conducted in
the VA, a setting that provides healthcare for many older patients with chronic
diseases.109,110,133 Considering many older patients have greater needs for social support
and may need assistance in diabetes self-care, future studies should be conducted among
older adult and veteran populations.132–134 One study found that elderly diabetic patients
whose spouses participated with them in a diabetes education program showed greater
improvements in knowledge, metabolic control, and stress level than those who participated
alone.135 Considering the burden of diabetes among older adult populations, involving
family members and caregivers in interventions for older patient populations may be crucial
for providing older patients with instrumental and social support related to their diabetes
management.
Author Manuscript
Future family-based interventions may also need to consider the role of gender in family-
based interventions and include an assessment of cost and healthcare utilization. Previous
studies have noted differences in support received by female patients with diabetes.65,126,136
We found some studies that assessed the impact of the intervention by gender.90,93 Future
studies should explore how family support may differ by gender of the patient and of the
support person, and how this may affect clinical outcomes. Family-based studies should also
include measures beyond clinical, behavioral, and psychosocial outcomes, such as cost and
healthcare utilization. We found few studies which measured cost of the intervention or
patients’ healthcare utilization.79,91–93,102 Assessing the cost-effectiveness of family-based
interventions will help to further quantify the benefit of including family in interventions for
diabetes. Furthermore, assessing healthcare utilization, such as hospitalizations and
emergency room visits, is also important because it bears a heavy expense on patients and
Author Manuscript
may indicate worsening of disease or lack of instrumental or social support.
Limitations
Although we found many studies reporting on family-based interventions to improve adult
diabetes outcomes conducted over the past 20 years, there were many limitations to this
literature. Given the heterogeneous designs and varying patient populations and settings, we
could not compare effect sizes across studies. Only a few studies reported cost data, thus
making cost effectiveness difficult to assess. Although we made an effort to search multiple
databases and conduct hand searches, there may be family-based interventions that we did
not identify or that we excluded because they did not describe family involvement or did not
report outcomes specific to the patients with diabetes. In addition, some organizations that
Author Manuscript
have conducted interventions to improve diabetes care may not have published their findings
in peer-reviewed journals. Our review was also limited by publication bias, because positive
findings tend to be published more frequently than null findings.
Conclusions
Developing diabetes interventions that include family may be critical in improving the
health of adults with diabetes. We found only two studies that were of high quality and with
Baig et al. Page 15
substantial family involvement that reported improvement in A1c.91,103,104,119 Owing to the

Author Manuscript
heterogeneity of the study designs, interventions, extent of family involvement, and

reporting of results, it is difficult to determine whether and how family involvement in
diabetes interventions can affect patient and family members’ health outcomes. Future
studies should clearly describe the role of family in the intervention, provide details on
family-based topics in the intervention, assess the quality and extent of family participation,
and compare patient outcomes with and without family involvement. While including
families in diabetes self-management interventions for adults has a strong theoretical and
cultural basis for many patient populations,6,12,124 there is much work to be done to fully
understand what roles family members should play in family-based diabetes self-
management interventions and how their involvement can affect patients’ diabetes
outcomes.
Author Manuscript
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Acknowledgments
We would like to thank Haley Johnson for her assistance in conducting and organizing our database search and
Patricia Fernandez for her help in formatting. We are also indebted to our medical librarians, Deborah Werner and
Ricardo Andrade, for their assistance in our database search and to Yue Gao for her help calculating our kappas.
This research was supported by grants from the University of Chicago Clinical and Translational Science Award
(UL1RR024999), the National Institute of Diabetes and Digestive and Kidney Diseases Diabetes Research and
Training Center (P60 DK20595) and the Chicago Center for Diabetes Translation Research (P30 DK092949). Dr.
Baig is supported by a NIDDK Mentored Patient-Oriented Career Development Award (K23 DK087903-01A1).
References
Author Manuscript
1. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of
Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and
Human Services; 2014.
2. American Diabetes A. Standards of medical care in diabetes--2014. Diabetes Care. 2014; 37 (Suppl
1):S14–80. [PubMed: 24357209]
3. Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self-management
strategies in people with type 2 diabetes mellitus. The Cochrane database of systematic reviews.
2005:Cd003417. [PubMed: 15846663]
4. Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL. Meta-analysis of randomized
educational and behavioral interventions in type 2 diabetes. Diabetes Educ. 2003; 29:488–501.
[PubMed: 12854339]
5. Turner R, Holman R, Cull C, et al. Intensive blood-glucose control with sulphonylureas or insulin
compared with conventional treatment and risk of complications in patients with type 2 diabetes
(UKPDS 33). Lancet. 1998; 352:837–53. [PubMed: 9742976]
Author Manuscript
6. World Health Organization. Innovative care for chronic conditions : building blocks for action :
global report. Geneva: World Health Organization; 2002. Noncommunicable Disease and Mental
Health Cluster.
7. Institute for Patient- and Family-Centered Care. [Accessed Dec 31, 2014] What is meant by the
word “family”?. http://www.ipfcc.org/faq.html
8. Weiler DM, Crist JD. Diabetes self-management in a Latino social environment. Diabetes Educ.
2009; 35:285–92. [PubMed: 19204101]
Baig et al. Page 16
9. Chesla CA, Fisher L, Skaff MM, Mullan JT, Gilliss CL, Kanter R. Family predictors of disease
management over one year in Latino and European American patients with type 2 diabetes. Fam
Author Manuscript
Process. 2003; 42:375–90. [PubMed: 14606201]

10. Denham SA, Ware LJ, Raffle H, Leach K. Family Inclusion in Diabetes Education A Nationwide
Survey of Diabetes Educators. The Diabetes Educator. 2011; 37:528–35. [PubMed: 21690434]
11. Kovacs Burns K, Nicolucci A, Holt RI, et al. Diabetes Attitudes, Wishes and Needs second study
(DAWN2): Cross-national benchmarking indicators for family members living with people with
diabetes. Diabetic medicine : a journal of the British Diabetic Association. 2013; 30:778–88.
[PubMed: 23701236]
12. Fisher L, Chesla CA, Bartz RJ, et al. The family and type 2 diabetes: a framework for intervention.
Diabetes Educ. 1998; 24:599–607. [PubMed: 9830956]
13. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness
care: translating evidence into action. Health affairs (Project Hope). 2001; 20:64–78. [PubMed:
11816692]
14. Burg MM, Seeman TE. Families and health: The negative side of social ties. Annals of Behavioral
Medicine. 1994; 46:1097–1108.
Author Manuscript
15. Nicklett EJ, Heisler ME, Spencer MS, Rosland AM. Direct social support and long-term health
among middle-aged and older adults with type 2 diabetes mellitus. J Gerontol B Psychol Sci Soc
Sci. 2013; 68:933–43. [PubMed: 24150176]
16. Eaton WW, Mengel M, Mengel L, Larson D, Campbell R, Montague RB. Psychosocial and
psychopathologic influences on management and control of insulin-dependent diabetes.
International journal of psychiatry in medicine. 1992; 22:105–17. [PubMed: 1517018]
17. Griffith LS, Field BJ, Lustman PJ. Life stress and social support in diabetes: association with
glycemic control. International journal of psychiatry in medicine. 1990; 20:365–72. [PubMed:
2086523]
18. Cardenas L, Vallbona C, Baker S, Yusim S. Adult onset diabetes mellitus: glycemic control and
family function. Am J Med Sci. 1987; 293:28–33. [PubMed: 3812547]
19. Walker RJ, Gebregziabher M, Martin-Harris B, Egede LE. Quantifying direct effects of social
determinants of health on glycemic control in adults with type 2 diabetes. Diabetes Technol Ther.
2015; 17:80–7. [PubMed: 25361382]
Author Manuscript
20. Armour TA, Norris SL, Jack L Jr, Zhang X, Fisher L. The effectiveness of family interventions in
people with diabetes mellitus: a systematic review. Diabetic medicine : a journal of the British
Diabetic Association. 2005; 22:1295–305. [PubMed: 16176186]
21. Hu J, Wallace DC, McCoy TP, Amirehsani KA. A family-based diabetes intervention for Hispanic
adults and their family members. Diabetes Educ. 2014; 40:48–59. [PubMed: 24248832]
22. Denham SA, Manoogian MM, Schuster L. Managing family support and dietary routines: Type 2
diabetes in rural Appalachian families. Families, Systems, & Health. 2007; 25:36.
23. Manoogian MM, Harter LM, Denham SA. The storied nature of health legacies in the familial
experience of type 2 diabetes. Journal of Family Communication. 2010; 10:40–56.
24. Trief PM, Morin PC, Izquierdo R, et al. Marital quality and diabetes outcomes: The IDEATel
Project. Families, Systems, & Health. 2006; 24:318.
25. Mayberry LS, Osborn CY. Family support, medication adherence, and glycemic control among
adults with type 2 diabetes. Diabetes Care. 2012; 35:1239–45. [PubMed: 22538012]
26. Mayberry LS, Rothman RL, Osborn CY. Family members’ obstructive behaviors appear to be
more harmful among adults with type 2 diabetes and limited health literacy. Journal of health
Author Manuscript
communication. 2014; 19 (Suppl 2):132–43. [PubMed: 25315589]

27. Carter-Edwards L, Skelly AH, Cagle CS, Appel SJ. “They Care But Don’t Understand”: Family
Support of African American Women With Type 2 Diabetes. The Diabetes Educator. 2004;
30:493–501. [PubMed: 15208847]
28. Rosland AM, Heisler M, Choi HJ, Silveira MJ, Piette JD. Family influences on self-management
among functionally independent adults with diabetes or heart failure: do family members hinder as
much as they help? Chronic Illn. 2010; 6:22–33. [PubMed: 20308348]
29. Stephens MA, Franks MM, Rook KS, Iida M, Hemphill RC, Salem JK. Spouses’ attempts to
regulate day-to-day dietary adherence among patients with type 2 diabetes. Health psychology :
Baig et al. Page 17
official journal of the Division of Health Psychology, American Psychological Association. 2013;
32:1029–37.
Author Manuscript
30. Mayberry LS, Egede LE, Wagner JA, Osborn CY. Stress, depression and medication nonadherence
in diabetes: test of the exacerbating and buffering effects of family support. J Behav Med. 2015;
38:363–71. [PubMed: 25420694]
31. Martire LM, Schulz R, Helgeson VS, Small BJ, Saghafi EM. Review and Meta-analysis of Couple-
Oriented Interventions for Chronic Illness. Annals of behavioral medicine : a publication of the
Society of Behavioral Medicine. 2010; 40:325–42. [PubMed: 20697859]
32. Fisher L, Chesla CA, Skaff MM, Mullan JT, Kanter RA. Depression and anxiety among partners of
European-American and Latino patients with type 2 diabetes. Diabetes Care. 2002; 25:1564–70.
[PubMed: 12196428]
33. Gleeson-Kreig J, Bernal H, Woolley S. The role of social support in the self-management of
diabetes mellitus among a Hispanic population. Public Health Nurs. 2002; 19:215–22. [PubMed:
11967108]
34. Dowds BN, Bibace R. Entry into the health care system: the family’s decision-making process.
Fam Med. 1996; 28:114–8. [PubMed: 8932492]
Author Manuscript
35. Rosland AM, Heisler M, Piette JD. The impact of family behaviors and communication patterns on
chronic illness outcomes: a systematic review. J Behav Med. 2012; 35:221–39. [PubMed:
21691845]
36. Keogh KM, Smith SM, White P, et al. Psychological family intervention for poorly controlled type
2 diabetes. The American journal of managed care. 2011; 17:105–13. [PubMed: 21473660]
37. Hu J, Amirehsani K, Wallace DC, Letvak S. Perceptions of barriers in managing diabetes:
perspectives of Hispanic immigrant patients and family members. Diabetes Educ. 2013; 39:494–
503. [PubMed: 23640301]
38. White P, Smith SM, Hevey D, O’Dowd T. Understanding Type 2 Diabetes: Including the Family
Member’s Perspective. The Diabetes Educator. 2009; 35:810–7. [PubMed: 19783768]
39. Orvik E, Ribu L, Johansen OE. Spouses’ educational needs and perceptions of health in partners
with type 2 diabetes. European Diabetes Nursing. 2010; 7:63–9.
40. Martire LM. The “relative” efficacy of involving family in psychosocial interventions for chronic
illness: are there added benefits to patients and family members? Families, Systems, & Health.
Author Manuscript
2005; 23:312.
41. Sorkin DH, Biegler KA, Peyreda M, Kilgore D, Dow E, Ngo-Metzger Q. Unidas por la vida
(United for life): implementing a culturally-tailored, community-based, family-oriented lifestyle
intervention. J Health Care Poor Underserved. 2013; 24:116–38. [PubMed: 23727969]
42. Trief PM, Himes CL, Orendorff R, Weinstock RS. The marital relationship and psychosocial
adaptation and glycemic control of individuals with diabetes. Diabetes Care. 2001; 24:1384–9.
[PubMed: 11473074]
43. Choi SE. Diet-specific family support and glucose control among Korean immigrants with type 2
diabetes. The Diabetes Educator. 2009; 35:978–85. [PubMed: 19934457]
44. Sarkisian CA, Brown AF, Norris KC, Wintz RL, Managione CM. A systematic review of diabetes
self-care interventions for older, African American, or Latino adults. The Diabetes Educator. 2003;
29:467–79. [PubMed: 12861963]
45. Glazier RH, Bajcar J, Kennie NR, Willson K. A systematic review of interventions to improve
diabetes care in socially disadvantaged populations. Diabetes Care. 2006; 29:1675–88. [PubMed:
16801602]
Author Manuscript
46. Epple C, Wright AL, Joish VN, Bauer M. The Role of Active Family Nutritional Support in
Navajos’ Type 2 Diabetes Metabolic Control. Diabetes Care. 2003; 26:2829–34. [PubMed:
14514587]
47. Shaw J, Brown J, Khan B, Mau M, Dillard D. Resources, Roadblocks and Turning Points: A
Qualitative Study of American Indian/Alaska Native Adults with Type 2 Diabetes. J Community
Health. 2013; 38:86–94. [PubMed: 22772841]
48. Brown SA, Hanis CL. Lessons Learned from 20 Years of Diabetes Self-Management Research
With Mexican Americans in Starr County, Texas. The Diabetes Educator. 2014; 40:476–87.
[PubMed: 24737885]
Baig et al. Page 18
49. Wen LK, Shepherd MD, Parchman ML. Family support, diet, and exercise among older Mexican
Americans with type 2 diabetes. The Diabetes Educator. 2003; 30:980–93. [PubMed: 15641619]
Author Manuscript
50. Brown SA, Hanis CL. A community-based, culturally sensitive education and group-support
intervention for Mexican Americans with NIDDM: a pilot study of efficacy. Diabetes Educ. 1995;
21:203–10. [PubMed: 7758387]
51. Hood KK, Rohan JM, Peterson CM, Drotar D. Interventions with adherence-promoting
components in pediatric type 1 diabetes meta-analysis of their impact on glycemic control.
Diabetes Care. 2010; 33:1658–64. [PubMed: 20587726]
52. Chesla CA. Do family interventions improve health? Journal of family nursing. 2010; 16:355–77.
[PubMed: 21051754]
53. Roski J, Schmid LA, Lando HA. Long-term associations of helpful and harmful spousal behaviors
with smoking cessation. Addictive behaviors. 1996; 21:173–85. [PubMed: 8730519]
54. Shiffman S, Brockwell SE, Pillitteri JL, Gitchell JG. Use of smoking-cessation treatments in the
United States. American journal of preventive medicine. 2008; 34:102–11. [PubMed: 18201639]
55. Brownell KD. The central role of lifestyle change in long-term weight management. Clinical
cornerstone. 1999; 2:43–51. [PubMed: 10696284]
Author Manuscript
56. Marrero DG. Time to Get Moving: Helping Patients With Diabetes Adopt Exercise as Part of a
Healthy Lifestyle. Clinical Diabetes. 2005; 23:154–9.
57. Shields CG, Finley MA, Chawla N. Couple and family interventions in health problems. Journal of
marital and family therapy. 2012; 38:265–80. [PubMed: 22283390]
58. White P, Smith SM, O’Dowd T. The role of the family in adult chronic illness: A review of the
literature on type 2 diabetes. The Irish Journal of Psychology. 2005; 26:9–15.
59. Rosland A-M, Piette JD. Emerging models for mobilizing family support for chronic disease
management: a structured review. Chronic Illness. 2010; 6:7–21. [PubMed: 20308347]
60. Hartmann M, Bäzner E, Wild B, Eisler I, Herzog W. Effects of interventions involving the family
in the treatment of adult patients with chronic physical diseases: a meta-analysis. Psychotherapy
and psychosomatics. 2010; 79:136–48. [PubMed: 20185970]
61. Garay-Sevilla ME, Nava LE, Malacara JM, et al. Adherence to treatment and social support in
patients with non-insulin dependent diabetes mellitus. Journal of diabetes and its complications.
1995; 9:81–6. [PubMed: 7599352]
Author Manuscript
62. Primomo J, Yates BC, Woods NF. Social support for women during chronic illness: The
relationship among sources and types to adjustment. Research in Nursing & Health. 1990; 13:153–
61. [PubMed: 2343156]
63. King DK, Glasgow RE, Toobert DJ, et al. Self-efficacy, problem solving, and social-environmental
support are associated with diabetes self-management behaviors. Diabetes care. 2010; 33:751–3.
[PubMed: 20150299]
64. Hogan BE, Linden W, Najarian B. Social support interventions: Do they work? Clinical
Psychology Review. 2002; 22:381–440.
65. van Dam HA, van der Horst FG, Knoops L, Ryckman RM, Crebolder HF, van den Borne BH.
Social support in diabetes: a systematic review of controlled intervention studies. Patient education
and counseling. 2005; 59:1–12. [PubMed: 16198213]
66. Rosland AM, Kieffer E, Israel B, et al. When is social support important? The association of
family support and professional support with specific diabetes self-management behaviors. J Gen
Intern Med. 2008; 23:1992–9. [PubMed: 18855075]
67. Chesla CA, Chun KM, Kwan CM, et al. Testing the efficacy of culturally adapted coping skills
Author Manuscript
training for Chinese American immigrants with type 2 diabetes using community-based
participatory research. Research in nursing & health. 2013; 36:359–72. [PubMed: 23606271]
68. Trief PM, Sandberg J, Fisher L, et al. Challenges and lessons learned in the development and
implementation of a couples-focused telephone intervention for adults with type 2 diabetes: The
Diabetes Support Project. Behav Med Pract Policy Res. 2011; 1:461–7.
69. LaFromboise T, Coleman HL, Gerton J. Psychological impact of biculturalism: evidence and
theory. Psychological bulletin. 1993; 114:395–412. [PubMed: 8272463]
70. Rusbult CE, Van Lange PA. Interdependence, interaction, and relationships. Annual review of
psychology. 2003; 54:351–75.
Baig et al. Page 19
71. Ford ME, Tilley BC, McDonald PE. Social support among African-American adults with diabetes,
Part 2: A review. Journal of the National Medical Association. 1998; 90:425. [PubMed: 9685778]
Author Manuscript
72. Thorpe CT, Fahey LE, Johnson H, Deshpande M, Thorpe JM, Fisher EB. Facilitating Healthy
Coping in Patients With Diabetes A Systematic Review. The Diabetes Educator. 2012
0145721712464400.
73. Torenholt R, Schwennesen N, Willaing I. Lost in translation—the role of family in interventions
among adults with diabetes: a systematic review. Diabetic Medicine. 2014; 31:15–23. [PubMed:
23870045]
74. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and
meta-analyses: the PRISMA statement. Annals of internal medicine. 2009; 151:264–9. w64.
[PubMed: 19622511]
75. Zaza S, Wright-De Aguero LK, Briss PA, et al. Data collection instrument and procedure for
systematic reviews in the Guide to Community Preventive Services. Task Force on Community
Preventive Services. Am J Prev Med. 2000; 18:44–74. [PubMed: 10806979]
76. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the
methodological quality both of randomised and non-randomised studies of health care
Author Manuscript
interventions. J Epidemiol Community Health. 1998; 52:377–84. [PubMed: 9764259]

77. Gary TL, Bone LR, Hill MN, et al. Randomized controlled trial of the effects of nurse case
manager and community health worker interventions on risk factors for diabetes-related
complications in urban African Americans. Preventive medicine. 2003; 37:23–32. [PubMed:
12799126]
78. Gary TL, Batts-Turner M, Bone LR, et al. A randomized controlled trial of the effects of nurse
case manager and community health worker team interventions in urban African-Americans with
type 2 diabetes. Controlled clinical trials. 2004; 25:53–66. [PubMed: 14980748]
79. Gary TL, Batts-Turner M, Yeh H-C, et al. The effects of a nurse case manager and a community
health worker team on diabetic control, emergency department visits, and hospitalizations among
urban African Americans with type 2 diabetes mellitus: a randomized controlled trial. Archives of
internal medicine. 2009; 169:1788–94. [PubMed: 19858437]
80. Rosal MC, Ockene IS, Restrepo A, et al. Randomized trial of a literacy-sensitive, culturally
tailored diabetes self-management intervention for low-income latinos: latinos en control. Diabetes
Care. 2011; 34:838–44. [PubMed: 21378213]
Author Manuscript
81. Rosal MC, White MJ, Borg A, et al. Translational Research at Community Health Centers
Challenges and Successes in Recruiting and Retaining Low-Income Latino Patients With Type 2
Diabetes Into a Randomized Clinical Trial. The Diabetes Educator. 2010; 36:733–49. [PubMed:
20729512]
82. Rosal MC, White MJ, Restrepo A, et al. Design and methods for a randomized clinical trial of a
diabetes self-management intervention for low-income Latinos: Latinos en Control. BMC medical
research methodology. 2009; 9:81. [PubMed: 20003208]
83. Toobert DJ, Strycker LA, Barrera M Jr, Osuna D, King DK, Glasgow RE. Outcomes from a
multiple risk factor diabetes self-management trial for Latinas: ¡Viva Bien! Ann Behav Med.
2011; 41:310–23. [PubMed: 21213091]
84. Toobert DJ, Strycker LA, Glasgow RE, et al. ¡Viva bien!: Overcoming recruitment challenges in a
multiple-risk-factor diabetes trial. American journal of health behavior. 2010; 34:432–41.
[PubMed: 20218755]
85. Toobert DJ, Strycker L, King D, Barrera M Jr, Osuna D, Glasgow R. Long-term outcomes from a
Author Manuscript
multiple-risk-factor diabetes trial for Latinas: ¡Viva Bien! Behav Med Pract Policy Res. 2011;
1:416–26.
86. Barrera M Jr, Toobert D, Strycker L. Relative contributions of naturalistic and constructed support:
two studies of women with type 2 diabetes. J Behav Med. 2014; 37:59–69. [PubMed: 23109138]
87. Trief P, Sandberg JG, Ploutz-Snyder R, et al. Promoting couples collaboration in type 2 diabetes:
The diabetes support project pilot data. Families, Systems, & Health. 2011; 29:253.
88. Utz SW, Williams IC, Jones R, et al. Culturally tailored intervention for rural African Americans
with type 2 diabetes. Diabetes Educ. 2008; 34:854–65. [PubMed: 18832290]
Baig et al. Page 20
89. Jones RA, Utz SW, Williams IC, et al. Family interactions among African Americans diagnosed
with type 2 diabetes. The Diabetes Educator. 2008; 34:318–26. [PubMed: 18375781]
Author Manuscript
90. Brown SA, Kouzekanani K, Garcia AA, Orlander PR, Hanis CL. Diabetes self-management and
leptin in Mexican Americans with type 2 diabetes: the Starr County border health initiative.
91. Brown SA, Garcia AA, Kouzekanani K, Hanis CL. Culturally Competent Diabetes Self-
Management Education for Mexican Americans The Starr County Border Health Initiative.
Diabetes care. 2002; 25:259–68. [PubMed: 11815493]
92. Brown SA, Blozis SA, Kouzekanani K, Garcia AA, Winchell M, Hanis CL. Dosage Effects of
Diabetes Self-Management Education for Mexican Americans The Starr County Border Health
Initiative. Diabetes care. 2005; 28:527–32. [PubMed: 15735182]
93. Anderson-Loftin W, Barnett S, Bunn P, Sullivan P, Hussey J, Tavakoli A. Soul food light:
culturally competent diabetes education. Diabetes Educ. 2005; 31:555–63. [PubMed: 16100331]
94. Corkery E, Palmer C, Foley ME, Schechter CB, Frisher L, Roman SH. Effect of a bicultural
community health worker on completion of diabetes education in a Hispanic population. Diabetes
Care. 1997; 20:254–7. [PubMed: 9051367]
Author Manuscript
95. Samuel-Hodge CD, Keyserling TC, France R, et al. A church-based diabetes self-management
education program for African Americans with type 2 diabetes. Preventing chronic disease. 2006;
3:A93. [PubMed: 16776894]
96. Samuel-Hodge CD, Keyserling TC, Park S, Johnston LF, Gizlice Z, Bangdiwala SI. A randomized
trial of a church-based diabetes self-management program for African Americans with type 2
diabetes. Diabetes Educ. 2009; 35:439–54. [PubMed: 19383882]
97. Vincent D, Pasvogel A, Barrera L. A feasibility study of a culturally tailored diabetes intervention
for Mexican Americans. Biological research for nursing. 2007; 9:130–41. [PubMed: 17909165]
98. Vincent D. Culturally tailored education to promote lifestyle change in Mexican Americans with
type 2 diabetes. Journal of the American Academy of Nurse Practitioners. 2009; 21:520–7.
[PubMed: 19845810]
99. Kim MT, Han HR, Song HJ, et al. A community-based, culturally tailored behavioral intervention
for Korean Americans with type 2 diabetes. Diabetes Educ. 2009; 35:986–94. [PubMed:
19934458]
Author Manuscript
100. Song HJ, Han HR, Lee JE, et al. Translating current dietary guidelines into a culturally tailored
nutrition education program for Korean American immigrants with type 2 diabetes. Diabetes
Educ. 2010; 36:752–61. [PubMed: 20651099]
101. Castejón AM, Calderón JL, Perez A, et al. A community-based pilot study of a diabetes
pharmacist intervention in Latinos: impact on weight and hemoglobin A1c. Journal of health care
for the poor and underserved. 2014; 24:48–60. [PubMed: 24241260]
102. Anderson-Loftin W, Barnett S, Sullivan P, Bunn PS, Tavakoli A. Culturally competent dietary
education for southern rural African Americans with diabetes. The Diabetes Educator. 2002;
28:245–57. [PubMed: 11924302]
103. Two Feathers J, Kieffer EC, Palmisano G, et al. Racial and Ethnic Approaches to Community
Health (REACH) Detroit partnership: improving diabetes-related outcomes among African
American and Latino adults. American journal of public health. 2005; 95:1552–60. [PubMed:
16051927]
104. Feathers JT, Kieffer EC, Palmisano G, et al. The development, implementation, and process
evaluation of the REACH Detroit Partnership’s Diabetes Lifestyle Intervention. Diabetes Educ.
Author Manuscript
2007; 33:509–20. [PubMed: 17570882]

105. Kluding PM, Singh R, Goetz J, Rucker J, Bracciano S, Curry N. Feasibility and effectiveness of a
pilot health promotion program for adults with type 2 diabetes: lessons learned. Diabetes Educ.
2010; 36:595–602. [PubMed: 20530663]
106. Mendenhall TJ, Berge JM, Harper P, et al. The Family Education Diabetes Series (FEDS):
community-based participatory research with a midwestern American Indian community.
Nursing inquiry. 2010; 17:359–72. [PubMed: 21059153]
Baig et al. Page 21
107. Mendenhall TJ, Seal KL, Greencrow BA, Littlewalker KN, Brownowl SA. The Family Education
Diabetes Series: improving health in an urban-dwelling American Indian community. Qualitative
Author Manuscript
health research. 2012; 22:1524–34. [PubMed: 22910585]

108. Roblin DW. The potential of cellular technology to mediate social networks for support of
chronic disease self-management. Journal of health communication. 2011; 16 (Suppl 1):59–76.
[PubMed: 21843096]
109. Aikens JE, Zivin K, Trivedi R, Piette JD. Diabetes self-management support using mHealth and
enhanced informal caregiving. Journal of diabetes and its complications. 2014; 28:171–6.
[PubMed: 24374137]
110. Aikens JE, Rosland A-M, Piette JD. Improvements in illness self-management and psychological
distress associated with telemonitoring support for adults with diabetes. Primary care diabetes.
2014; 9:127–34. [PubMed: 25065270]
111. Islam NS, Wyatt LC, Patel SD, et al. Evaluation of a community health worker pilot intervention
to improve diabetes management in Bangladeshi immigrants with type 2 diabetes in New York
City. Diabetes Educ. 2013; 39:478–93. [PubMed: 23749774]
112. Archuleta M, Vanleeuwen D, Halderson K, et al. Cooking schools improve nutrient intake
Author Manuscript
patterns of people with type 2 diabetes. Journal of nutrition education and behavior. 2012;
44:319–25. [PubMed: 22572403]
113. Williams IC, Utz SW, Hinton I, Yan G, Jones R, Reid K. Enhancing diabetes self-care among
rural African Americans with diabetes: results of a two-year culturally tailored intervention.
114. Gilliland SS, Azen SP, Perez GE, Carter JS. Strong in Body and Spirit: Lifestyle intervention for
Native American adults with diabetes in New Mexico. Diabetes Care. 2002; 25:78–83. [PubMed:
11772905]
115. Glueck BP, Foreman BH. Lessons Learned from Designing and Leading Multidisciplinary
Diabetes Educational Groups. Journal of Mental Health Counseling. 2014; 36:160–72.
116. Brown SA, Garcia AA, Winchell M. Reaching underserved populations and cultural competence
in diabetes education. Current diabetes reports. 2002; 2:166–76. [PubMed: 12643136]
117. Gilliland S, Carter J, Perez G, Two Feathers J, Kenui C, Mau M. Recommendations for
development and adaptation of culturally competent community: health interventions in minority
populations with type 2 diabetes mellitus. Diabetes Spectrum. 1998; 11:166–174.
Author Manuscript
118. Carter JS, Gilliland SS, Perez GE, et al. Native American Diabetes Project: designing culturally
relevant education materials. Diabetes Educ. 1997; 23:133–4. 9. [PubMed: 9155311]
119. Kieffer EC, Willis SK, Odoms-Young AM, et al. Reducing disparities in diabetes among African-
American and Latino residents of Detroit: the essential role of community planning focus groups.
Ethnicity & disease. 2004; 14:S27–37. [PubMed: 15682769]
120. Osuna D, Barrera M, Strycker LA, et al. Methods for the Cultural Adaptation of a Diabetes
Lifestyle Intervention for Latinas: An Illustrative Project. Health promotion practice. 2011;
12:341–8. [PubMed: 19843703]
121. Islam NS, Tandon D, Mukherji R, et al. Understanding barriers to and facilitators of diabetes
control and prevention in the New York City Bangladeshi community: a mixed-methods
approach. American journal of public health. 2012; 102:486–90. [PubMed: 22390512]
122. Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting
parallel group randomised trials. BMC medicine. 2010; 8:18. [PubMed: 20334633]
123. Ahia CL, Holt EW, Krousel-Wood M. Diabetes care and its association with glycosylated
Author Manuscript
hemoglobin level. The American journal of the medical sciences. 2014; 347:245–7. [PubMed:
24326617]
124. Norris SL, Nichols PJ, Caspersen CJ, et al. Increasing diabetes self-management education in
community settings. A systematic review. Am J Prev Med. 2002; 22:39–66. [PubMed:
11985934]
125. Baig AA, Mangione CM, Sorrell-Thompson AL, Miranda JM. A randomized community-based
intervention trial comparing faith community nurse referrals to telephone-assisted physician
appointments for health fair participants with elevated blood pressure. J Gen Intern Med. 2010;
25:701–9. [PubMed: 20349155]
Baig et al. Page 22
126. Trief PM, Grant W, Elbert K, Weinstock RS. Family environment, glycemic control, and the
psychosocial adaptation of adults with diabetes. Diabetes Care. 1998; 21:241–5. [PubMed:
Author Manuscript
9539989]
127. Baig AA, Locklin CA, Wilkes AE, et al. Integrating diabetes self-management interventions for
mexican-americans into the catholic church setting. Journal of religion and health. 2014; 53:105–
18. [PubMed: 22528288]
128. Pollard SL, Zachary DA, Wingert K, Booker SS, Surkan PJ. Family and Community Influences
on Diabetes-Related Dietary Change in a Low-Income Urban Neighborhood. Diabetes Educ.
2014; 40:462–9. [PubMed: 24685841]
129. Peek ME, Cargill A, Huang ES. Diabetes health disparities: a systematic review of health care
interventions. Med Care Res Rev. 2007; 64:101S–56S. [PubMed: 17881626]
130. Fisher TL, Burnet DL, Huang ES, Chin MH, Cagney KA. Cultural leverage: interventions using
culture to narrow racial disparities in health care. Med Care Res Rev. 2007; 64:243S–82S.
[PubMed: 17881628]
131. McEwen MM, Pasvogel A, Gallegos G, Barrera L. Type 2 diabetes self-management social
support intervention at the U.S-Mexico border. Public Health Nurs. 2010; 27:310–9. [PubMed:
Author Manuscript
20626831]
132. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in Older Adults. Diabetes Care. 2012;
35:2650–64. [PubMed: 23100048]
133. Kessler CS, Bhandarkar S, Casey P, Tenner A. Predicting Patient Patterns in Veterans
Administration Emergency Departments. Western Journal of Emergency Medicine. 2011;
12:204–7. [PubMed: 21691527]
134. Nelson KM, McFarland L, Reiber G. Factors influencing disease self-management among
veterans with diabetes and poor glycemic control. Journal of general internal medicine. 2007;
22:442–7. [PubMed: 17372790]
135. Gilden JL, Hendryx M, Casia C, Singh SP. The effectiveness of diabetes education programs for
older patients and their spouses. Journal of the American Geriatrics Society. 1989; 37:1023–30.
[PubMed: 2809048]
136. Kvam SH, Lyons JS. Assessment of coping strategies, social support, and general health status in
individuals with diabetes mellitus. Psychological reports. 1991; 68:623–32. [PubMed: 1862195]
Author Manuscript
Author Manuscript
Baig et al. Page 23
Author Manuscript
Author Manuscript
Figure 1.
Literature search flowchart. *Several articles were excluded for more than one reason, so
numbers do not add up to 258.
Author Manuscript
Author Manuscript
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Table 1
Family participation in the interventions and family outcomes.
Quality
Baig et al.
score
Level of family (out of
Reference Definition of family Description of family involvement participation Family outcomes 27)
Gary (2004)78 Not reported The clinical algorithms used in the intensive intervention addressed Not reported None reported 24.5
Gary (2009)79 several areas, including socioeconomic issues, and took into
consideration patients’ caregiver concerns. Also as part of the
intensive intervention, the CHWs made home visits to study
participants and reported interacting with family, for example, in
teaching family members of a patient with poor eyesight to perform
glucose monitoring and in reviewing foods in the kitchen cabinet and
refrigerator.
Gary (2003)77 Not reported The CHW was intended to serve as a liaison between the healthcare Not reported None reported 23.5
system and the family, in addition to providing diabetes education and
social services. She monitored participant and family behavior,
reinforced adherence to treatment recommendations, and mobilized
social support.
Anderson-Loftin (2005)93 Family members A traditional African American (AA) meal prepared with low-fat Not reported None reported 23
techniques and ingredients was served to participants and family
members following most classes. Meals were framed as social events,
such as a church homecoming supper or Fourth of July picnic.
Participation of family members was encouraged not only to integrate
black cultural traditions associated with food but also to capitalize on
the value of family and to provide transportation, a common barrier in
rural areas. The peer–professional discussion groups used an approach
that facilitated emotional support from peers and family and is the
preferred group structure of southern AAs.
Rosal (2009)82 Significant others (SOs), SOs were invited to attend the group sessions to elicit home-based Not reported None reported 22
Rosal (2010)81 defined as family members support. Group sessions included culturally popular activities (e.g.,
Rosal (2011)80 or friends living in the eating together as a family and, if possible, involving the family).
participant’s household Group meals accompanied by discussion guides stimulated discussion
around ways of implementing the recipes at home, acceptability to
family and friends, and steps to trying new eating styles at home.
Samuel-Hodge (2006)95 Family members and One intervention focus was on organizing education around the Not reported None reported 21.5
Samuel-Hodge (2009)96 friends “church family,” which included congregants, family, and friends.
This focus was viewed as one way to deliver the intervention in a
culturally appropriate and sensitive manner. Family members were
included as study participants and family and friends were invited as
guests to group sessions.
Vincent (2007)97 Support person; family Participants were encouraged to bring a support person to the 8 weekly Not reported In postintervention focus 21
Vincent (2009)98 member 2-h group sessions since support from friends and family has been groups, participants
shown to improve glycemic control. Inclusion of cultural content reported they and their
included addressing family issues. Additionally, participants were families benefited from
given low literacy, Spanish-language materials to share with their the intervention. “Benefit
family members. The cultural concept of familismo (family support to families” was one of
and cohesiveness) and the importance of family support to facilitate only two major themes
Page 24
Quality
score
lifestyle changes needed for DSM was the basis for including family in identified in the focus
Baig et al.
the intervention. group data. Family

benefited from healthier
eating and became more
supportive of participants’
lifestyle changes.
Toobert (2010)84 Family members The social support group component taught participants how to Not reported Family support had an 21
Toobert (2011a)83 problem solve and how to mobilize social support among family and effect on increases in
Toobert (2011b)85 friends. The intervention also included a “Family Night” where family physical activity (PA)
Osuna (2011)120 members could join participants during the social support group even after accounting for
portion of the meeting, hear an overview of ¡Viva Bien! activities, the effects of group
Barrera (2014)86
celebrate the diabetes participants’ achievements, and exchange support. Study authors
questions and answers. Family nights were viewed as vehicles for suggested the finding
increasing the families’ support for participants’ intervention might be attributed to the
engagement. Families were also invited to a final celebratory meeting. involvement of family in
The involvement of family was viewed as being consistent with the the intervention and
Latino cultural value of familismo. dedicating sessions to the
mobilization of family
and friend support.
Aikens (2014a)109 Family member or close Patients received weekly interactive voice response (IVR) calls to 39% of patients Rates of engagement were 21
Aikens (2014b)110 friend living outside the assess health status and self-care and to provide tailored, prerecorded participated with an higher among pts
patient’s home (informal support messages. Patientss could opt to designate one family member informal caregiver; enrolling with an informal
caregiver); to be ≥ eligible, or close friend to receive emailed summaries of each completed call based on patients’ caregiver (87.7% of
informal caregivers needed along with structured suggestions on supporting the patient’s DSM. feedback at baseline, assessments completed
to be ≥18 years old, have Participating caregivers underwent DVD-based training on the lack of caregiver versus 81.6% for those
no history of cognitive or communicating effectively with the patient and any in-home caregiver involvement was not participating with an
severe psychiatric that may be involved. Intervention strategies were based upon the usually due to informal caregiver, P =
impairment, and have assumption that patients, informal caregivers, and healthcare teams can personal preference 0.008). Patients who
access to email. use frequent information updates about the patient’s health and self- and not participated with an
care to promptly identify emerging problems and improve illness self- unavailability of a informal caregiver were
management. One of the overall goals of the intervention was to person to play this less likely to report
generate guidance on DSM support for patients’ informal caregivers role. frequent high glucose
via structured emails. Caregiver levels (P = 0.021) and
participation was more likely to regularly
significantly more check their BP (P =
likely among patients 0.017) than those patients
with lower income not participating with an
and lower health informal caregiver.
literacy levels.
Kim (2009)99 Family members During the educational program, study participants, their family Not reported None reported 20.5
Song (2010)100 members, CHWs, and diabetes educators actively engaged in group
education in a synergistic manner. The program recognized the
traditional Korean cultural values of close familial interdependence
and social relationships. The researchers encouraged the active
involvement of other family members in the group education to create
a synergistic group interaction while building an environment
promoting family and social support. This strategy intended to enhance
the deep cultural tailoring of the intervention by supporting the social/
environmental forces influencing health behavior.
Page 25
Quality
score
Brown (2002)91 A family member, Subjects were required to identify a family member or close friend to Not reported None reported 20
Baig et al.
Brown (2005)92 preferably a spouse or participate with them in the intervention as a support person. Family/
Brown (2013)90 first-degree relative who friends were invited to attend 12 weekly education meetings and 14
would participate as a biweekly support group meetings to talk about DSM problems and the
support person. If a family impact of diabetes on the family. Social support was fostered through
member was not available, family members and friends, as well as other group participants and
a close friend participated. intervention leaders. Group leaders emphasized support from family
members and encouraged support persons to improve their health
habits.
Two Feathers (2005)103 Family members; family Kieffer (2004) reports preliminary focus group findings that identified Not reported Postintervention, patients 20
Two Feathers (2007)107 member or friend the importance of family support for DSM and led to the inclusion of with diabetes reported
Kieffer (2004)119 family members in the intervention and family and social support they were encouraging
being a key characteristic of the intervention. Participants were their family members to
encouraged to bring a family member or friend to group diabetes self- eat healthier meals and to
management education (DSME) meetings. The Family Health exercise with them.
Advocates worked with patients with diabetes and their family
members, providing them group DSME classes, case management and
referral services. Role-playing was used to improve communication
with family members about DSM.
Utz (2008)88 Jones (2008)89 Supportive family and/or Supportive family and/or friends were invited to selected group 6 family and friends Several of the 20
friends sessions to obtain information about diabetes and family/peer support. (1 mother, 1 adult participating support
During one of the sessions, family members and friends were given a son, 2 friends, 1 adult persons expressed that
“Helpful Hints for Family Members” guideline developed by two of daughter, and 1 wife) they appreciated the
the study’s authors about how to be supportive to the person with came to the invited opportunity to attend one
diabetes. Along with the guideline, the family member or friend had an sessions. session with their loved
opportunity to view three videos about family communication around one to understand
diabetes. The facilitator also guided a discussion during which time diabetes better.
family could ask questions and share their experiences and the
participants could discuss how interactions between those with
diabetes and their family members/ friends affected DSM. Family and
friends were also invited to participate in a cooking demonstration by a
dietitian to show how to cook healthy meals that are easy and taste
good.
Castejón (2014)101 Either a family member or The support person was asked to come with the study participant for 67% of control and None reported 19.5
a friend every clinical screening and educational session, when available. Both 79% of the
Attending partners were a the participant and support person received a physical assessment at intervention group
spouse, friend, sibling, or the clinical screenings, including a recording of weight, height, waist patients had a partner
child circumference, BMI, and BP. Participants were given two copies of attend at baseline;
their clinical results, one for their primary care provider and one for 42% of controls and
their own records, and were debriefed about their clinical values. 33% of the
During the group educational session, the pharmacist led a closing intervention group
discussion that focused on misconceptions brought up by participants had partners at both
and their partners during the earlier focused discussion group that was clinical screening
moderated by a project coordinator (Master in Public Health level). visits.
Family was involved in the study because the patient’s family was Most partners were
viewed as one of three major social and environmental factors female and had an
affecting a patient’s DSM and should thus be a target for DSM average age of 48
interventions to encourage appropriate nutrition, exercise, self- (20–77) years.
management, medical treatment, involvement, and support.
Page 26
Quality
score
Gilliland(2002)114 In the family and friend Gilliland (1998) and Carter (1997) report on preliminary research that Not reported None reported 19
Baig et al.
Gilliland (1998)117 (FF) arm, patientss with led to the inclusion of family and addressing family support in the
Carter (1997)118 diabetes received the intervention. The FF arm included activities to encourage social
intervention in family and interaction and discussion about diabetes among members of the
friend groups group. The mentor encouraged them to discuss and share their stories
about living with diabetes. The FF arm joined in physical activities as
a group and shared a healthy meal.
Corkery (1997)94 Family member Family members could attend education sessions. In the CHW arm, the Patients were defined None reported 18.5
CHW acted as a liaison between the patients, their families, and health as having family
care providers. participation if a
For the non-CHW intervention group, encounters took place only family member
between the nurse and the patient and family member. attended most of the
education sessions.
The family
participation rate was
31%.
Hu (2014)21 Adult family member who There were two family sessions, for which the family unit, including 37 family members Significant changes in 17.5
resides in the diabetes multiple members, was invited. The first family session explained the enrolled in the study. family member BMI
patient’s household, is ≥ 18 purpose of the study, the format of the intervention, and requirements At baseline, family (−0.25 kg/m2) and
years of age, and is willing of participants. Informed consent was obtained from the participant members were diabetes knowledge from
to participate and participating adult family member, and baseline data were primarily female baseline to
collected. The last family session included postintervention data (70%) with an postintervention No
collection and discussions with family members about DSM. Each average age of 40.6 significant changes in
participant was also asked to bring at least one family member to the 8 years and an average waist circumference, BP,
weekly group intervention meetings that took place between the two BMI of 32.7 kg/m2; PA, and fruit and
family sessions. A group discussion with open-ended questions on 51% had vegetable consumption,
family support was facilitated at the end of the first and last group hypertension, 87% but trend noted in SBP,
meetings. The last group session also included a celebration of had a high school PA and fruit and
completion of the program for both participants and family members education or less, vegetable consumption
with a certificate and food. Focusing on family involvement and 89% had a household (0.05 < P < 0.09)
family centeredness was viewed as an important aspect of the income <$10,000,
intervention due to the Hispanic cultural value of familismo. Support and 78% were from
from family members was viewed as an important social factor Mexico.
affecting behavior change; thus, the intervention focused on fostering
behavioral changes through building family support.
Williams (2014)113 Supportive family member One intervention strategy was involving a key family/friend as a Not reported None reported 16
or friend to serve as a supporter for achieving patient DSM goals. Some of the group DSME
support person sessions also involved the participation of a supportive family member
or friend to encourage shared learning and to enhance the ability of the
support person to know how to be helpful.
Anderson-Loftin (2002)102 Family members Families were encouraged to participate in the dietary education group The article reports None reported 15.5
sessions and discussion groups to capitalize on the value of family and many family
to provide transportation. Healthy meals were served to participants members actively
and family members at the end of the first class. The second class was participated in the
a cooking class, and after the meal preparation, participants and family cooking class.
dined and were encouraged to share their own healthy recipes. The
home visit by the nurse case manager (NCM) was also meant to solicit
family support.
Page 27
Quality
score
Kluding (2010)105 Family members or other Family members or other supportive people were invited for all Not reported None reported 15
Baig et al.
supportive people educational sessions and were specifically included for two sessions:
“family support day” in week 5 and “graduation ceremony” in week
10.
Trief (2011)68 Couples were enrolled; In the couples’ intervention arm, patients and partners participated in Not reported None reported 14.5
patients with diabetes and exercises to promote collaborative problem-solving as they worked on
their partners both had to their goals. The intervention included two phone calls on
be >21 years of age and speakerphone that focused on couples’ communication, particularly
been married or partnered around emotions and situations that might be problematic for the
>1 year patient, so that the partner could share his/her feelings and they could
discuss ways to problem solve together. Homework and discussion
tasks involved both partners in goal setting, contracting, and skills to
improve communication.
Islam (2013)111 Family members Islam (2012) reports on focus group findings that led to the inclusion Not reported CHWs qualitatively 14.5
Islam (2012)121 of family and addressing family support in the intervention. Based on reported having an impact
the findings from the preliminary focus group study, it was determined on family members and
that strategies to overcome family conflict and promote positive family on facilitating family
communication and family activities to promote social support would support between
be incorporated into the intervention. Thus, “Effects of family support participants and their
on managing stress” was one of the session topics. CHWs also family members.
encouraged family support during the one-on-one visits.
Brown (1995)50 A family member, Each participant was required to identify a support person who would On average, family Family members 14
preferably a spouse or participate in the educational and support sessions. The bilingual members/support indicated in postsession
first-degree relative who Mexican-American lay community worker conducted follow-up persons attended 6 of interviews that the
would participate as a support sessions with patients/families after the education sessions the 9 meetings. sessions helped them to
support person. If a family were done. One of the emphases during sessions was support from The size of the improve their health
member was not available, family, friends, and other subjects. Family/friends were invited to the group, 6 patients and practices, particularly
a close friend participated. support session to talk about diabetes self-management (DSM) 6 family members, with regard to nutrition.
problems and the impact of diabetes on the family. Encouraging was deemed Patients reported in
support from family members and motivating them to improve their appropriate by postsession interviews
health habits was also emphasized. participants. that having family
members/support persons
at the sessions was very
helpful.
Mendenhall (2010)106 Family members, including Family members attended all meetings of the Family Education Not reported, except None reported 13.5
Mendenhall (2012)107 patients’ spouses, parents, Diabetes Series program. They were involved in data collection by in saying that
and/or children checking and recording each other’s blood sugar, weight, and body generally 35–40
mass index (BMI) and by conducting foot checks. Family members community
were viewed as program participants but not enrolled as study members, including
participants for the purposes of the research study. The program also patients and family
had a session topic specifically focusing on family relationships and members, attended
social support. meetings
Roblin (2011)108 A supporter, defined as a A family member, relative, or close friend was asked by the patient to Patient and supporter Qualitative findings 12
family member, relative, or serve in the support role. During the enrollment session, supporters attended both the indicated that support
close friend whose support were instructed in motivational coaching so they could provide enrollment and persons reported an
and opinion were valued effective feedback to the diabetes patient and help assess barriers to disenrollment improved ability and
by the diabetes pt, who did effective self-monitoring of blood glucose (SMBG). During the sessions confidence to provide
Page 28
Quality
score
not live in the patient’s
intervention, a summary of SMBG adherence and results were sent to emotional and
Baig et al.
same household, and who a

the patient or support person to prompt conversations and facilitate instrumental support to
reed to enroll in the stu
supportive relationships in order to reinforce the importance of SMBG their paired diabetes
y as a support person
and achieving good glucose control. patient in their SMBG and
Both the patient and supporter were asked for input about the an improved social
intervention at the disenrollment session. proximity to their paired
diabetes patient.
Archuleta (2012)112 Family members Family members were invited to attend four 3-h cooking/nutrition Class participants None reported 12
classes with their family member with diabetes. Conducting the included family
education together with caregivers or spouses and in a community members without
setting with food that is socially acceptable was intentionally diabetes, but only
incorporated into the intervention as a strategy to build social support. data from diabetes
patients was
reported.
Glueck (2014)115 Loved ones; a spouse or The goal of the diabetes management and treatment support groups In 2007, 6 of 24 None reported 10
family member was to provide education and support to individuals diagnosed with (25%) patients
diabetes and their loved ones and to promote DSM. Another critical enrolled brought a
goal for these groups was that individuals diagnosed with diabetes and spouse. In 2008, 3 of
their family members be active participants rather than simply attend 19 (16%) enrolled
the program passively and to make the group about the process and an brought a spouse. In
experience for enhanced learning for families. Incorporation of family 2009, attendance
members active in the caregiving process in the groups was viewed as data was not
important because diabetes affects the family, and treatments and available for the 14
recommendations must be changed within the context of the patient’s patients who
social, cultural, and ecological environment. As such, when patients registered for the
registered, they were encouraged to bring a spouse or family member series.
to weekly meetings to also share and receive support from the group.
Note: AA, African American; BMI, body mass index; CHW, community health worker; DSM, diabetes self-management; DSME, diabetes self-management education; FF, family and friend; IVR,
interactive voice response; NCM, nurse case manager; PA, physical activity; SMBG, self-monitoring of blood glucose; SO, significant other
Page 29

Family Interventions To Improve Diabetes

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Family Interventions To Improve Diabetes

Uploaded by

Copyright:

Available Formats

HHS Public Access

Published in final edited form as:

Family interventions to improve diabetes outcomes for adults

Importance of family in diabetes self-care

Diabetes self-management education (DSME) is a critical component of care for all

The negative ways family can affect diabetes

Diabetes self-management interventions may need to place greater emphasis on targeting

Influencing family member outcomes

The importance of family involvement in diabetes self-management has been demonstrated

Including family members in diabetes interventions

interventions seeking to improve self-management behaviors by increasing social support

from family and friends have shown varying results.64–66

We searched for family-based diabetes self-management intervention articles published

or exclusion in the systematic review.

months,21,80–82,90,92,95,96,99,100,111,113,114,116 24 months,77,83 and 36 months.78,79

Populations and settings

collect or report race/ethnicity data.87,115

Interventions took place in diverse settings, including community health centers,21,97,98,111

Interventions were led by CHWs or promotoras,77–79,90–92,94,97,98,103,104,111,119

were not maintained at 6 months,106 12 months,80,96 or 24 months.85

Three of 11 studies assessing cholesterol showed improvements in lipid profiles.77,87,99

Patient psychosocial outcomes

Patient diabetes self-management behaviors

Patient outcomes by family involvement

Family participation and outcomes

studies, most defined family members as spouses, parents, children, or

meetings.21,50,80,82,83,85,89,91,93–95,97,98,100–102,106,107,112,113 In some studies, authors stated

In Roblin’s study,108 family supporters were instructed in motivational coaching so they

feedback about the intervention at the final session.

In Trief’s study, patients and partners participated in exercises to promote collaborative

mechanism to improving diabetes outcomes for patients. We systematically reviewed the

depth description of methods or referred to previously published study protocols; however,

interventions were targeting. Few studies reported on family attendance or participation

Studies that assessed psychosocial outcomes found improvements in patients’ depressive

may indicate worsening of disease or lack of instrumental or social support.

substantial family involvement that reported improvement in A1c.91,103,104,119 Owing to the

heterogeneity of the study designs, interventions, extent of family involvement, and

Process. 2003; 42:375–90. [PubMed: 14606201]

communication. 2014; 19 (Suppl 2):132–43. [PubMed: 25315589]

interventions. J Epidemiol Community Health. 1998; 52:377–84. [PubMed: 9764259]

2007; 33:509–20. [PubMed: 17570882]

health research. 2012; 22:1524–34. [PubMed: 22910585]

Family participation in the interventions and family outcomes.

the intervention. group data. Family

same household, and who a

You might also like