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Review

Importance of family/social support and impact on adherence to diabetic therapy

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Pages 421-426 | Published online: 06 Nov 2013

Abstract

Diabetes mellitus affects 24 million individuals in the US. In order to manage their diabetes successfully, patients must adhere to treatment regimens that include dietary restrictions, physical activity goals, and self-monitoring of glucose levels. Numerous factors affect patients’ ability to adhere properly, eg, self-efficacy, treatment expectations, health beliefs, and lack of social support. Consequently, diabetes management can be quite complex, requiring lifelong commitment and drastic changes to the patient’s lifestyle. Empirical studies have shown positive and significant relationships between social support and treatment adherence among patients with diabetes. Social support from family provides patients with practical help and can buffer the stresses of living with illness. However, the exact mechanism by which social support affects patient adherence is not yet completely understood. Further research is needed to address how the differences in types of support, such as functional or emotional support, are linked to outcomes for patients. The purpose of this review is to summarize what is known of the impact of social and family support on treatment adherence in patients with diabetes and to explore the current methods and interventions used to facilitate family support for diabetic patients.

Introduction

Diabetes mellitus affects nearly 24 million Americans, making diabetes one of the most common chronic conditions in the US.Citation1 Current empirical research suggests that the number of individuals diagnosed with diabetes (per year) is expected to double by the year 2034.Citation1 Diabetes is considered to be the leading cause of heart disease, stroke, kidney failure, lower limb amputation, and blindness among US adults.Citation2,Citation3 According to the American Diabetes Association, the management of diabetes can be costly, generating both large direct ($116 billion) and indirect ($68 billion) medical costs.Citation4 Diabetic patients spend an average of $10,000 per year compared with $2,700 for nondiabetic patients; most of these costs are associated with hospitalizations due to chronic diabetes-related complications.Citation4

The primary goals in the treatment of diabetes are for patients to maintain proper metabolic control and to reduce the risks of health complications.Citation5 In recent correlational studies, strong associations between patient nonadherence (or noncompliance) and progression or development of diabetes-related complications have been found.Citation6 Research by Gherman et al suggests that increases in adherence can result in patients who are more confident in self-care behaviors, and thus have better overall outcomes.Citation6

The most common forms of diabetes mellitus are type 1 and type 2. Type 1 diabetes mellitus is described as autoimmune destruction of insulin, whereas type 2 diabetes mellitus results from reduced insulin sensitivity and secretion, and is associated with obesity and hypertension.Citation7 Adherence to treatment for type 1 and 2 diabetes mellitus includes tasks such as medication-taking, daily insulin injections, self-monitoring of glucose levels (daily or several times per day), complex dietary restrictions, frequent eye examinations, and daily exercise routines.Citation1,Citation6 Additionally, patients’ ability to self-manage their health behavior plays a crucial role in diabetes management, given that most diabetics provide more than 90% of their own daily care.Citation5

Patients’ efforts to maintain and adhere properly to diabetes management directives often take place in social settings and can alter family and social dynamics.Citation5,Citation8,Citation9 According to research by DiMatteo, support from friends and family promotes adherence by encouraging optimism and self-esteem, which can buffer the stress of being ill and reduce patient depression.Citation10 While social support can influence the ability to adjust and live with illness, some empirical studies have reported opposite findings, such that social support can be a significant barrier to patients’ self-management.Citation6,Citation9 The extent to which social support affects health outcomes and adherence to diabetes treatment has important implications for both policy and practice. The purposes of this review are to summarize what is known of the impact of social support on adherence to diabetes treatment and to explore the types of adherence interventions and methods used to promote social support for patients with diabetes.

Scope of adherence problem

The term nonadherence (or noncompliance) describes the extent to which patients do not follow treatment recommendations given by their health care providers.Citation11 Nonadherence can be intentional or unintentional, where treatment advice is misunderstood, carried out incorrectly, or ignored.Citation11 Rates of nonadherence vary widely across different disease conditions, treatment regimens, and patient populations.Citation10 On average, 25% of patients are nonadherent to treatment. For patients with chronic disease (eg, diabetes), rates of nonadherence are 50% or more.Citation11,Citation12 Additionally, among children and adolescents, 50%–70% are nonadherent to medication directives. Citation13 The economic burden of nonadherence due to preventable complications, hospitalizations, and poor disease outcomes is significant. However, patients and health care professionals fail to recognize that the cause of poor health outcomes may be due to patient nonadherence.Citation12,Citation14

Nonadherence can occur for myriad reasons, including the financial constraints associated with treatment, medication side effects, difficulty in managing complex treatment regimens, inadequate patient health literacy, and lack of social support.Citation10,Citation11,Citation15Citation17 Significant health risks in the care of many chronic diseases are also associated with nonadherence. For example, in diabetic patients, nonadherence is associated with poor glycemic control and long-term health complications, such as retinopathy, neuropathy, and renal disease.Citation5,Citation8 For patients with human immunodeficiency virus, the consequence of nonadherence is viral replication and significant disease progression.Citation11 Additionally, for patients suffering from coronary heart disease, nonadherence to medication directives can drastically jeopardize health and in some cases lead to death.Citation14 Thus, nonadherence can compromise patient outcomes in many ways. Some research suggests that adherence to even a placebo can be beneficial to patients’ health.Citation14

Several decades of research have focused on understanding the inherent factors leading to change in adherence behaviors. One such factor is the effect of social support on patient adherence to diabetes management.Citation18 Previous research by Glasgow and Toobert found that family support was the strongest and most consistent predictor of adherence to treatment in patients with type 2 diabetes.Citation19 In another study of women with gestational diabetes, adherence to dietary recommendations was strongly associated with familial social support.Citation18 More recently, among children with type 1 diabetes, family conflict, perceptions of nonsupportive parents, and lack of responsibility for diabetes management were associated with poor patient adherence.Citation5,Citation18 In contrast, positive dimensions of family functioning, including family guidance and control over the management of diabetes, were related to increases in adherence behaviors.Citation5,Citation18 Furthermore, among elderly patients, social support from family and friends helps patients to remain active in their care when faced with physical, social, and economic vulnerabilities.Citation10,Citation20

Research by DiMatteo suggests that the relationship between social support and health outcomes may be mediated by patient adherence.Citation10 Further investigation is needed to identify the specific types of social support (ie, structural, functional, practical, and emotional) that are most effective in enhancing various diabetes management activities. The unique ways in which family members can provide support for patients with diabetes also deserve investigation. In the following section, aspects of the family and social support-adherence relationship will be discussed.

Impact of family support on adherence

The association between disease management and social support has been researched extensively in the social and behavioral sciences. The precise mechanism by which social support contributes to health outcomes is not yet completely understood. Research does suggest, however, that social support can benefit patients’ health by buffering stress, changing affective states, increasing self-efficacy, and influencing change in negative health behaviors.Citation10 Rosland et al found that practical and emotional support received by both family and friends had a positive influence on global measures of disease management in patients with diabetes.Citation9 In fact, a meta-analytic review of 122 empirical studies found that adherence was 27% higher when patients had practical support available to them.Citation10 Additionally, research by Pereira et al indicates strong associations between positive family dimensions (eg, cohesion and familial guidance) and better glycemic control among diabetic patients.Citation21,Citation22 In regards to family cohesion, in which families are described as warm, accepting, and close, the odds of adherence were three times higher when compared with noncohesive families.Citation10 Furthermore, family structural support (ie, patient’s marital status and living arrangement) is also positively associated with treatment adherence. In research by DiMatteo, the odds of adherence for married patients were 1.27 times higher than for unmarried patients.Citation10 Additionally, “living with others” had positive effects on adherence for adults (r=0.08, P<0.05).Citation10 More specifically, the effect of patient adherence and “living with others” was stronger for behavioral regimens compared with medication regimens.Citation10 Moreover, in the same study, functional social support (eg, practical and emotional support) had stronger effects on adherence than did structural social support, suggesting that the quality of family-patient relationships matters more than just the mere presence of individuals within a patient’s network of support.Citation10

Social support has also been linked to negative health outcomes.Citation9 Some studies suggest that patients often feel criticized or nagged, and sometimes even guilt, when receiving support from family.Citation23 Other studies have shown competing demands between patient and family members as barriers to self-management.Citation24 For example, family members may not want to eat the same foods as a diabetic patient who is trying to maintain a healthier diet. Such competing demands limit patients’ time and energy and introduce stress that can negatively affect patients who are trying to juggle multiple family roles while living with illness (ie, parents or spouse).Citation24

Among adolescents, increases in responsibility for disease management have been linked to higher levels of parent-adolescent conflict and nonadherence to treatment. In a study of patients with cystic fibrosis, adolescents were responsible for almost 90% of their own daily treatment, resulting in significantly lower rates of adherence than if parents were involved.Citation25 Parent-adolescent conflicts stem from differences in perceptions and expectations of autonomy; these discrepancies in decision-making autonomy are referred to as DDMA.Citation26 Studies involving adolescents with type 1 diabetes have found significant and positive associations between adolescent-reported family support, improved treatment adherence, and decreases in DDMA.Citation8 In order to manage diabetes effectively, adolescents, parents, and health professionals must mutually agree upon a family-based treatment plan that accurately refects the abilities of the adolescent.Citation27 Thus, the ways in which social support directly and indirectly affects outcomes in adult and adolescent patients can be quite complicated. Current research points to the importance of designing interventions to improve adherence that include practical help, emotional support, and cohesive networks in the context of diabetes care.Citation10

Methods to build positive family support

Most theories of health and behavior change suggest a need for social support as a crucial component; family members are the most significant source of that support.Citation28,Citation29 Even with correlational evidence suggesting the importance of social support, few intervention studies have targeted familial support as a means of diabetes management in adults.Citation29 In the studies that have included family support, results are promising although somewhat inconsistent.Citation29 For example, in a study conducted by Robinson, a diabetes education and family social support training program was used to assist elderly diabetic patients who had difficulty adhering to dietary restrictions.Citation30 The training program had five goals: to educate patients about the development of diabetes and how to manage living with illness; to allow patients to discuss thoughts and feelings and accompanying lifestyle changes associated with diabetes; to facilitate self-esteem and help patients cope and take control of their illness; to develop solutions and techniques to maintain proper diet; and to help patients develop supportive relationships among family members to maintain dietary adherence over time.Citation30 The results of this study revealed that patients who participated in the training program had reduced blood glucose levels and increases in adherence for up to 24 weeks after completion of the training program.Citation30 In another study, Wing et al compared an individual weight loss intervention with a weight loss intervention that encompassed the support of a spouse and found no significant difference in weight loss, calorie intake, and glycemic control between groups.Citation31 In Gilliland et al, researchers looked at differences across psychoeducational groups among adults and their families, psychoeducational groups without patients’ families, and a control group.Citation32 Results from this study revealed only small increases in glycemic control between the intervention groups and the control group.Citation32 Mayberry et al conducted focus groups to explore the relationship between family support and adherence to medication regimens for adults with diabetes.Citation29 Their results revealed that instrumental support (or observable actions that help patients manage their illness) was the most common type of social support.Citation29 Patient-reported examples of instrumental support included tasks such as spouses maintaining medical appointments and doing the grocery shopping.Citation29 Additionally, some patients in the focus group expressed frustration with family members “sabotaging” or offering “miscarried helping” behaviors.Citation29 These findings suggest that increases in family involvement can create conflict and potentially even undermine patients’ success at performing diabetes self-care tasks.Citation29

Furthermore, the empirical literature on social support and the management of diabetes among adolescents and their families has revealed significant and positive effects on patient adherence to treatment. In a randomized controlled trial, adolescents with type 1 diabetes and their families participated in ten sessions of behavioral family systems therapy. Behavioral family systems therapy is a family-focused multifaceted intervention that targets communication between family members, problem-solving skills, family beliefs that affect communication, and potential barriers to problem-solving tasks.Citation33 The results of this study yielded significant improvements in parent-adolescent relationships and family communication as reported by parents and adolescents.Citation33 However, behavioral family systems therapy had no impact on glycemic control or adherence to treatment.

Interestingly, Wysocki et al sought to determine whether a revised version of behavioral family systems therapy specific to diabetes (BFST-D) would significantly improve adherence.Citation34 In this revision, BFST-D consisted of problem-solving training, communication training, cognitive restructuring, and functional-structural family therapy.Citation34,Citation35 As predicted, BFST-D significantly improved family conflict, metabolic control, and adherence to treatment among families of adolescents with poor metabolic control at baseline.Citation34,Citation35

Additionally, peer support and problem-solving group interventions have been shown to improve health outcomes for adolescents with type 1 diabetes. In a study by Løding et al, adolescents and their parents participated in peer discussions where they were given the opportunity to focus on education and problem-solving strategies to encourage adolescents to take more responsibility in diabetes management.Citation36 In doing so, adolescents showed increases in satisfaction and the ability to communicate more calmly with their parents.Citation36 Adolescents also reported fewer objections to measuring their glucose values and injecting insulin in public after the intervention.Citation36

Future research and practice

Research concerning the effects of social support on patient adherence to diabetes management suggests important implications for future research and clinical practice. First, with the exceedingly large proportion of patients who are nonadherent, intervention studies should focus on different types of social support that may lead to significant increases in adherence behaviors. For example, in Van der Wulp et al, researchers examined the effectiveness of a peer-led self-management intervention in patients recently diagnosed with type 2 diabetes.Citation37 Patients in the intervention group received visits from an experienced peer (someone with diabetes who is adherent to treatment and lifestyle guidelines), and together patients and peers set goals and formulated plans to maintain self-care behaviors over time.Citation37 Patients who participated in the intervention experienced improvements in self-efficacy, coping, and saturated fat intake.Citation37 More recently, integrative health coaching support for patients with type 2 diabetes has been associated with increases in positive health outcomes. Integrative health coaching is a personalized style of intervention that allows patients to identify their own values and expectations for their health.Citation38 Wolever et al found that patient activation and perceived social support increased as a result of integrative health coaching.Citation38

Efforts to improve adherence and social support in patients with diabetes have also been explored through technology-based interventions.Citation39 In Arora et al, researchers developed a mobile health text message-based intervention (ie, mHealth) targeted at improving adherence and self-efficacy in low-income diabetic patients.Citation39 Patients who enrolled in the TExT-MED program received three daily text messages over the course of 3 weeks.Citation39 Each message delivered was based on the following domains: education/motivation, medication reminders, healthy living challenges, diabetes trivia, and links to diabetes management resources and tools.Citation39 Results from this study indicated significant increases in patient adherence behaviors regarding diet and exercise regimens and improved self-efficacy up to 3 weeks after the intervention.Citation39

Moreover, in McKay et al, an Internet-based intervention known as The Diabetes Network (D-Net) was used to assess the effects of peer support on self-management behaviors.Citation40 The purpose of D-Net was to provide peer support and personalized self-management and dietary feedback via the Internet. Each patient was provided with a D-Net computer with which they could access diabetes education, interact with a dietary management coach, and participate in a peer-directed forum in which patients could discuss difficulties in coping with other diabetic patients.Citation40 As a result of the intervention, improvements in adherence to dietary recommendations were found.Citation40 Furthermore, in the clinical setting, research suggests that the quality and types of patients’ relationships are instrumental in assisting patients to receive the most benefit from their treatments.Citation10 Thus, the conducting of more evidence-based interventions examining the quality and type of relationships that affect patient adherence should be a clinical priority.Citation10

Conclusion

Family and social support are important aspects of adherence to diabetes management. Numerous correlational studies have shown a positive and significant relationship between social support and adherence to diabetes treatment. Future research should identify the many types of social support interventions that promote adherence; in doing so, diabetic patients are given the ability to seek social support that is most conducive and appropriate for their lifestyle. Lastly, further empirical evidence is needed to address the mechanisms by which social support works to directly influence health outcomes, health care utilization, and behavior change.

Acknowledgments

The authors would like to thank the following research assistants for helping with this review: Allen Roughton, Shiromi Ratnayake, and Amberly Navalta.

Disclosure

The authors report no conflict of interest in this work.

References

  • Bailey G Barner J Weems J Assessing barriers to medication adherence in underserved patients with diabetes in Texas Diabetes Educ 2012 38 271 279 22316643
  • Centers for Disease Control and Prevention Diabetes public health resource Available from: http://www.cdc.gov/diabetes/ Accessed September 18, 2013
  • Egede L Gebregziabher M Dismuke C Medication nonadherence in diabetes longitudinal effects on costs and potential cost savings from improvement Diabetes Care 2012 35 2533 2539 22912429
  • American Diabetes Association Economic costs of diabetes in the US in 2007 Diabetes Care 2008 31 596 615 18308683
  • Rintala TM Jaatinen P Paavilainen E Astedt-Kurki P Interrelation between adult persons with diabetes and their family: a systematic review of the literature J Fam Nurs 2013 19 3 21 23288886
  • Gherman A Schnur J Montgomery G Sassu R Veresiu I David D How are adherent people more likely to think? A meta-analysis of health beliefs and diabetes self-care Diabetes Educ 2011 37 392 408 21478378
  • American Diabetes Association Standards of medical care in diabetes – 2013 Diabetes Care 2013 36 S11 S66 23264422
  • Lewandowski A Drotar D The relationship between parent-reported social support and adherence to medical treatment in families of adolescents with type 1 diabetes J Pediatr Psychol 2007 32 427 436 17056638
  • Rosland AM Kieffer E Israel B 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 1999 18855075
  • DiMatteo MR Social support and patient adherence to medical treatment: a meta-analysis Health Psychol 2004 23 207 218 15008666
  • DiMatteo MR Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research Med Care 2004 42 200 209 15076819
  • DiMatteo MR Miller TA Treatment adherence in adolescence O’Donohue WT Benuto LT Tolle LW Handbook of Adolescent Health Psychology New York, NY Springer 2013
  • Chappuy H Treluyer JM Faesch S Giraud C Cheron CG Length of the treatment and number of doses per day as major determinants of child adherence to acute treatment Acta Paediatr 2009 99 433 437 19912146
  • DiMatteo MR Haskard-Zolnierek KB Martin LR Improving patient adherence: a three-factor model to guide practice Health Psychol Rev 2012 6 74 91
  • Aljasem LI Peyrot M Wissow L Rubin RR The impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes Diabetes Educ 2001 27 393 404 11912800
  • Fortmann AL Gallo LC Philis-Tsimikas A Glycemic control among Latinos with type 2 diabetes: the role of social-environmental support resources Health Psychol 2011 30 251 258 21553968
  • Cohen J Christensen K Feldmen L Disease management and medication compliance Popul Health Manag 2012 15 20 28 22092187
  • Nicklett E Liang J Diabetes-related support, regimen adherence, and health decline among older adults J Gerontol B Psychol Sci Soc Sci 2009 65B 390 399 19541672
  • Glasgow RE Toobert DJ Social environment and regimen adherence among type II diabetes patients Diabetes Care 1988 11 377 386 3391088
  • Zhang X Norris S Gregg EW Beckles G Social support and mortality among older persons with diabetes Diabetes Educ 2007 33 273 281 17426302
  • Pereira M Berg-Cross L Almeida P Machado J Impact of family environment and support on adherence, metabolic control, and quality of life in adolescents with diabetes Int J Behav Med 2008 15 187 193 18696312
  • Cox DJ Gonder-Frederick L Major developments in behavioral diabetes research J Consult Clin Psychol 1992 60 628 638 1506511
  • 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 Diabetes Educ 2004 30 493 501 15208847
  • Gallant M Help or hindrance? How family and friends influence chronic illness self-management among older adults (report) Res Aging 2007 29 375
  • Modi AC Marciel KK Slater SK Drotar D Quittner AL The influence of parental supervision on medical adherence in adolescents with cystic fibrosis: developmental shifts from early to late adolescents Child Health Care 2008 37 78 92
  • Holmbeck GN A model of family relational transformations during the transition to adolescence: parent adolescent conflict and adaptation Graber JA Brooks-Gunn J Peterson A Transitions Through Adolescence: Interpersonal Domains and Context Hillsdale, NJ Lawrence Erlbaum Associates Inc 1996
  • Miller VA Drotar D Decision-making competence and adherence to treatment in adolescents with diabetes J Pediatr Psychol 2007 32 178 188 16717139
  • Kang CM Chang SC Chen PL Comparison of family partnership intervention care vs conventional care in adults with poorly controlled type 2 diabetes in a community hospital: a randomized controlled trial Int J Nurs Stud 2010 47 1363 1373 20371056
  • Mayberry LS Osborn CY Family support, medication adherence and glycemic control among adults with type 2 diabetes Diabetes Care 2012 35 1239 1245 22538012
  • Robison F A training and support group for elderly diabetics: description and evaluation JSGW 1993 18 127 136
  • Wing RR Marcus MD Epstein LH Jawad AA A “family-based” approach to the treatment of obese type II diabetic patients J Consult Clin Psychol 1991 59 156 162 2002132
  • Gillard SS Azen SP Perez GE Carter JS Strong in the body and spirit: lifestyle intervention for native American adults with diabetes in New Mexico Diabetes Care 2002 25 78 83 11772905
  • Wysocki T Harris MA Greco P Randomized controlled trial of behavioral therapy for families of adolescents with insulin dependent diabetes mellitus J Pediatr Psychol 2000 25 23 33 10826241
  • Wysocki T Harris MA Buckloh LM Effects of behavioral family systems therapy for diabetes on adolescents’ family relationships, treatment adherence and metabolic control J Pediatr Psychol 2006 31 928 938 16401678
  • Wysocki T Harris M Buckloh L Randomized, controlled trial of behavioral family systems therapy for diabetes: maintenance and generalization of effects on parent-adolescent communication Behav Ther 2008 39 33 46 18328868
  • Løding RN Wold JE Skavhaug A Graue M Evaluation of peer-group support and problem-solving training in the treatment of adolescents with type 1 diabetes European Diabetes Nursing 2007 4 28 33
  • Van der Wulp I de Leeuw J Gorter K Rutten G Effectiveness of peer-led self-management coaching for patients recently diagnosed with type 2 diabetes mellitus in primary care: a randomized controlled trial Diabet Med 2012 29 e390 e397 22414198
  • Wolever R Dreusicke M Fikkan J Integrative health coaching for patients with type 2 diabetes: a randomized clinical trial Diabetes Educ 2010 36 629 639 20534872
  • Arora S Peters A Agy C Menchine M A mobile health intervention for inner city patients with poorly controlled diabetes: proof-of-concept of the TExT-MED program Diabetes Technol Ther 2012 14 492 496 22524591
  • McKay GH Glasgow RE Feil EG Boles SM Barrera M Internet-based diabetes self-management and support: initial outcomes from the diabetes network project Rehabil Psychol 2002 47 31 48