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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Supporting Information

Aims

Family interventions are increasingly recognized as important in the care of people with diabetes. The aim of this study was to synthesize the existing literature on family interventions among adults with Type 1 and Type 2 diabetes and to determine the degree to which they were family centred.

Methods

The literature search was carried out in four databases (Scopus, CINAHL, PsycINFO and ERIC). Two reviewers independently screened the search results. Only English-language articles about interventions on education, care and/or support of adult individuals with diabetes involving the participation of both the individual with diabetes and at least one family member were included.

Results

From an initial 1480 citations, 10 reports were included. The intervention studies varied considerably in terms of design and population. The family dimension generally represented a modest part of the interventions: Two interventions applied a family-relevant theoretical framework. Disease knowledge and lifestyle changes were more prevalent intervention themes than family issues. Biological and behavioural outcomes were most prevalent, whereas psychosocial and family outcomes were used in six of the studies.

Conclusions

The number of trials and statistically significant results in family interventions targeting adults with diabetes is limited. Because of inhomogeneity, it is difficult to come to a conclusion on effective approaches in family interventions. The interventions are inconsistent with regard to theoretical framework, intervention themes and measured outcomes. However, psychosocial and familial dimensions seem sensitive to family-based interventions. From development to evaluation, the family dimension needs to be included to prove the specific effect of family interventions.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Supporting Information

The number of people with diabetes continues to rise, posing a serious threat to the health of individuals and increasing demands on healthcare services [1, 2]. To address this challenge, a partnership model has been suggested between healthcare teams, people with chronic conditions and their families, in which the latter are active participants and collaborators in ongoing support and care [3]. Family-based approaches emphasize the context of disease and provide a valuable supplement to traditional treatment models [4]. The literature contains emerging reports of interventions targeting the chronically ill and their family member(s) [2, 5-12] and of how family interventions among people with chronic disease can be more effective than usual care [6, 10]. Similarly, family involvement in psychosocial interventions results in significantly better health, compared with standard treatment [13]. However, research on family interventions for chronic conditions remains in the development phase [14].

The role of family is also receiving increased attention in interventions specifically targeting people with diabetes, for whom self-management takes place in the context of family and social networks [15]. A study of more than 5000 adults with diabetes highlighted the importance of family, friends and colleagues in improving well-being and self-management [16]. Likewise, a recent study concluded that perceiving family members to be non-supportive was associated with a lower adherence to medication in people with diabetes [17]. A 2005 review concluded that interventions including family or household members of people with diabetes may be effective in improving diabetes-related knowledge and glycaemic control [18]. Sixteen of 19 studies targeted children with diabetes.

Research targeting the interface between adults with chronic disease and their families [2, 4] is relatively scarce and family factors have been virtually ignored in relation to adults with diabetes [19]. Shields et al. reviewed chronic health interventions involving couples and families and were unable to identify any studies pertaining to adults with diabetes [14].

Against this background, we systematically reviewed interventions targeting adults with diabetes and their family members. In addition to reviewing study design and results, we assessed the degree to which the dimension of family was represented—across theoretical framework, content of the interventions and measured outcomes. Thus, the objective of this review is to understand how the family dimension is presented throughout existing interventions and discuss the consistency with which the family is actually included in these interventions.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Supporting Information

A systematic literature search was conducted in October 2012 using the computerized databases Scopus (including MEDLINE), CINAHL, PsycINFO and ERIC. No review protocol is accessible. We searched for all articles published up to October 2012, using a combination of three main concepts: (1) diabetes,(2) intervention and (3) family. Broadly defining both intervention and family, we included a variety of search terms. The Supporting Information (Appendix S1) contains the specific search strategy. We also searched the reference lists of all potentially relevant studies.

We included studies of any design and those targeting individuals with Type 1 or Type 2 diabetes or both, as the social environment plays a significant role regardless of the type of diabetes [20]. We included studies that defined family as: nuclear family members; non-blood relatives; friends; neighbours; or others involved in the daily self-care activities of the individual with diabetes. Finally, we included studies that addressed interventions related to the education, care and/or support of adults with diabetes involving the participation of both the individual with diabetes and at least one family member.

We excluded reports that were not in the English language because of lack of translation resources. We excluded studies of interventions among people with diabetes under the age of 18 years, as well as studies addressing illnesses or chronic conditions other than diabetes.

Two reviewers (RT and NS) independently selected papers in two phases. In the first phase, they reviewed titles for relevance to the review questions. When reviewers could not judge relevance by the title, the article was included for further review. In the second phase, reviewers assessed the abstracts and, as needed, the full text of articles identified as relevant. The two reviewers obtained full concordance regarding selected articles.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Supporting Information

The initial search strategy identified 1480 citations. A majority of these were rejected at the title level. This left us with 72 abstracts, which were reviewed. The most frequent reasons for exclusion were: (1) no intervention was described; (2) the intervention did not address family members; (3) the intervention addressed children or adolescents; (4) the article addressed chronic conditions in general, rather than diabetes in particular; and (5) the intervention did not cover education, care or support. We identified 10 studies of family interventions involving an adult with diabetes and at least one family member [21-30] (Fig. 1). The reference search resulted in five further publications [31-35] supplementing four of the intervention studies [23, 26, 27, 29]. These five publications [31-35], describing four of the interventions and the backgrounds of the interventions in more detail, were also taken into consideration.

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Figure 1. Literature search flow diagram.

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Study design and study population

Nine of the intervention studies were designed as controlled trials [21, 23-30], five of these were randomized controlled trials [21, 24-26, 28] and one was a pilot study assessing the feasibility and potential efficacy of a family intervention [29]. All studies except one [22] included at least two arms. The total number of participating adults with diabetes in the interventions ranged from 10 [24] to 83 [21].

The characteristics of the study population varied. Two studies did not target a specific diabetes type [24, 28]. Eight studies targeted individuals with Type 2 diabetes [21-23, 25-27, 29, 30] and four of these were directed at individuals with poor glycaemic control [21, 25, 26, 29]. Three studies specified insulin-dependent status [22, 24, 28] and three studies used duration of diabetes as an eligibility criteria [24, 26, 28].

Theoretical framework

The intervention studies were all based on the hypothesis that the active involvement of a family member would improve social support, which, in turn, would increase self-management behaviour of the individual with diabetes, ultimately improving clinical and psychosocial outcomes. In five interventions, specific theories or theoretical models are mentioned: Social Learning Theory [23, 27, 29], Innovative Care for Chronic Conditions [21], Self-Regulatory Model of Illness Behaviour [26] and Social Action Theory [23]. However, no articles described in detail how these frameworks were used during the development of the interventions.

The four theoretical frameworks represent a social dimension. The Social Learning Theory, presented in three studies, addresses both the psychosocial dynamics influencing health behaviour and methods for promoting behavioural change. Human behaviour is explained in terms of a dynamic model in which behaviour, personal factors and environment interact [36]. The Innovative Care for Chronic Conditions framework, developed by the World Health Organization [3] and based on the Chronic Care Model, posits that optimal outcomes for chronic conditions occur when a healthcare triad is formed: a partnership among patients and families, healthcare teams and community partners [37]. The Self-Regulatory Model states that an individual's understanding of an illness is not necessarily scientifically or medically valid; rather, it is formulated from personal experience (physical symptoms and emotions), social influences and/or interaction with healthcare providers [38]. Social Action Theory addresses the community level and includes the components of empowerment, critical consciousness, community capacity, social capital, issue selection, participation and relevance [39]. However, none of the studies citing these frameworks described how the social dimension was included in the intervention or explicated its relationship to the dimension of family, making it impossible to assess whether the intervention itself followed from the theory and if the interventions varied as a function of the theory.

One report described the inclusion of theory to address family dynamics [29]. The intervention was based on Interdependence Theory and Family Systems Theory. Interdependence Theory recognizes that interaction affects both patients and family [40], whereas Family System Theory posits that change in one family member influences all others; the system is the appropriate target for interventions [41]. Another study addresses family dynamics; the intervention focuses on behavioural skills, derived from social support and the behavioural marital therapy literature, to enhance mutual support [30]. The report does not, however, specify a theoretical model.

Content of the interventions

Intervention durations varied from 3 weeks [26] to 12 months [21] with three [26] to 16 sessions [30]. Three interventions consisted of group sessions [22, 23, 30], four interventions combined group sessions and individual sessions (people with diabetes and family member) [21, 27, 28] and three interventions consisted of individual (people with diabetes and family member) sessions [24, 26, 29]. Four interventions emphasized active participation in physical activity, cooking, active problem solving, goal setting and building self-efficacy [21, 23, 26, 27]. Four interventions did not emphasize active participation for either the individual with diabetes or the family member [22, 24, 25, 28]. Descriptions of intervention specifics and procedures vary across reports and, generally speaking, they lack detail.

Interventions address three broad themes (Table 1). The first is knowledge of diabetes and lifestyle, addressed through education programmes focusing on healthcare issues specific to diabetes, such as diet, blood sugar, monitoring, insulin, hyper- and hypoglycaemia, employment, social and physical activities, eating habits, physical activity and exercise, foot and skin care, urine testing, medication control, cooking strategies and demonstrations, pathophysiology and terminology, symptoms of poorly controlled diabetes, etc. The second theme of interventions is non-familial psychosocial issues, such as anxiety, depression, stress, mood swings, stress management, etc. The third theme of interventions is family issues; for instance, acquiring skills in asking family members for support in making dietary and exercise changes and learning methods for avoiding or counteracting stimuli that elicit negative behaviours. All interventions address disease knowledge and lifestyle management for the individual with diabetes [21-30]. Six interventions address psychological issues [21, 22, 24, 26, 27, 29] and six interventions address family issues [21, 25-27, 29, 30].

Table 1. Study design and interventions
 Study designPopulation characteristicsIntervention themesDefinition of family
Mau et al., 2001 [27] USANon-randomized studyType 2 diabetes, people at high risk for diabetesDisease knowledge and lifestyle skills, psychosocial issues, family issuesBroad, including friends and co-workers
Hicks, 1991 [24] UKRandomized controlled trialInsulin-dependent, newly diagnosedDisease knowledge and lifestyle skills, psychosocial issuesIntimate relationship in same household
Gilden et al., 1989 [22] USAPre/postNon-insulin-dependent older men with Type 2 diabetesDisease knowledge and lifestyle skills, psychosocial issuesIntimate relationship in same household
Tamez & Vacalis, 1989 [28] USACohortInsulin-dependent, hospitalized, diagnosed with diabetes ≥ 5 yearsDisease knowledge and lifestyle skillsSame household
Kang et al., 2010 [25] TaiwanRandomized controlled trialType 2 diabetes, poor glycaemic controlDisease knowledge and lifestyle skills, family issuesSame household
Garcia-Huidobro et al., 2011 [21] ChileRandomized controlled trialType 2 diabetes, poor glycaemic controlDisease knowledge and lifestyle skills, psychosocial issues, family issuesSame household
Keogh et al., 2011 [26] IrelandRandomized controlled trialType 2 diabetes, poor glycaemic control, diagnosed with diabetes for ≥ 1 yearDisease knowledge and lifestyle skills, psychosocial issues, family issuesSame household
Gilliland et al., 2002 [23] USACohortType 2 diabetes, at risk for diabetesDisease knowledge and lifestyle skillsBroad, including friends and co-workers
Trief et al., 2011 [29] USARandomized pilotType 2 diabetes, poor glycaemic controlDisease knowledge and lifestyle skills, psychosocial issues, family issuesIntimate relationship in same household
Wing et al., 1991 [30] USARandomized controlled trialType 2 diabetes, obeseDisease knowledge and lifestyle skills, family issuesIntimate relationship in same household

With two exceptions, interventions in all themes were directed at the individual with diabetes. However, Wing et al. did not distinguish between the individual with diabetes and the family member, targeting both with respect to addressing family issues [30]. Similarly, Gilden and colleagues addressed all participants equally, whether they were individuals with diabetes or family members [22].

Family issues were addressed in various ways. Two interventions addressed family issues through discussions of family support strategies, family action plans [21] and practical instructions on how to ask a family member for help overcoming challenges in making lifestyle behaviour change [27]. Two studies explicitly addressed relational quality and communication between the individual with diabetes and the family member [29, 30]. One of these studies also included shared goal setting, dietary behaviour change and focus on emotions [29]. The family member was actively involved to promote collaborative problem solving. The other intervention directly emphasized the importance of the relational dimension, teaching spouses to provide each other with positive reinforcement and appropriate listening skills [30].

Definition of family and cultural considerations

Family was defined differently across the 10 reports (Table 1), although all but one required the family member to be 18 years or older [28]. In four interventions, the family member was required to have an intimate relationship with the individual with diabetes and to reside in the same household [22, 23, 29, 30]. Four required residence in the same household, but not necessarily an intimate relationship [21, 25, 26, 28]. Two studies addressed family more broadly, allowing friends, neighbours, co-workers or community members, as well as family members, to participate [23, 27].

Four interventions addressed specific cultural groups: Chileans, Native Americans, Native Hawaiians and Mexican Americans [21, 23, 27, 28]. The remaining studies were conducted in the USA, the UK and Taiwan without reference to a specific cultural group [22, 24-26, 29, 30]. Interventions were culturally tailored through addressing language, local beliefs and principles in regard to illness, and traditional food, exercise traditions and learning methods [21, 23, 27, 28]. Gilliland et al. describe local tailoring of educational material; for example, educational videos were culture specific.

None of the culturally tailored interventions involved studies of culturally contingent family mechanisms. However, Mau et al. describe initial data collection exploring the Hawaiian meaning of family, recognizing that the family is an important construct through which Native Hawaiians see themselves and the rest of the world and that a diabetes programme should therefore involve the whole family [27].

Generally, the studies addressing specific cultural groups have a less narrow definition of family: the interventions addressing Native Americans and Native Hawaiians both demonstrate a broad understanding of family [23, 27].

Outcome measures

The studies discussed here used outcomes measures in four categories (Table 2): biological; behavioural/knowledge; psychosocial; and family-specific. All outcome measures were reported for the individual with diabetes. However, two interventions also measured the outcome for the family member [22, 30]; blood sugar levels were checked in both the individual with diabetes and the family member, and both were given calorie and exercise goals, meaning that the target group was the spouse as well as the individual with diabetes [30]. In the study by Gilden et al., individuals with diabetes and family members alike completed a questionnaire. However, most family members were not available for a 6-month follow-up visit and their long-term data were not included in the analysis [22].

Table 2. Findings from family interventions in diabetes
 SampleOutcomesa
 BiologicalBehavioural/ knowledgePsychosocialFamily
  1. a

    Statistically significant findings are in shown in bold type.

Mau et al., 2001 [27] USA

Intervention

n = 72

Control

n = 75

WeightDiet, physical activity  
Hicks, 1991 [24] UK

Intervention

n = 10

Control

n = 20

 Diabetes self-care  
Gilden et al., 1989 [22] USA

Older men

n = 20

Younger men

n = 47

HbA1c, fasting blood sugar, weight Knowledge about diabetes Stress, social activity, quality of life Family involvement
Tamez & Vacalis, 1989 [28] USAn = 48Fasting blood sugar   
Kang et al., 2010 [25] Taiwan

Intervention

n = 28

Control

n = 28

HbA1c, BMI, lipid profileDiabetes self-care, knowledge about diabetes Attitudes toward diabetes Family support
Garcia-Huidobro et al., 2011 [21] Chile

Intervention

n = 83

Control

n = 160

HbA1cDiet, physical activity, medication adherence, knowledge about diabetesDepressive symptomsFamily functioning
Keogh et al., 2011 [26] Ireland

Intervention

n = 60

Control

n = 61

HbA1c, BMI, blood pressureDiabetes self-carePsychological well-being, self-efficacy, illness perception Family support
Gilliland et al., 2002 [23] USAn = 104HbA1c, weight, blood pressureDiet, physical activity  
Trief et al., 2011 [29] USA

Intervention

n = 22

Control

n = 22

HbA1c, blood pressure, lipid profile, waist circumferenceDiabetes self-care  
Wing et al., 1991 [30] USA

Intervention

n = 24

Control

n = 25

HbA1c, fasting blood sugar, weight, BMIDiet, physical activity  

Nine studies include biological outcome measures [21-23, 25-30]; HbA1c is the most frequently used outcome measure (Table 2). Nine studies include behavioural and knowledge outcome measures [21-27, 29, 30]. Four studies include eight different psychosocial outcome measures [21, 22, 25, 26]. These studies also include family-specific outcome measures. Three different family-specific measures are presented, relating to involvement, support and functioning.

A comparison of results across interventions is complicated by the variation in outcome measures. In six studies, the primary outcome measure was HbA1c level [21-23, 25, 26, 29]. With the exception of one intervention [23], a decline in HbA1c levels among the interventions groups was observed. However, only one study demonstrated a significantly greater decline in HbA1c levels in the intervention group compared with the control group [26]. In this study, Keogh et al. showed a difference in HbA1c of 5 mmol/mol (0.4%) between the groups at 6-month follow-up. In the intervention group, HbA1c levels declined from 76 mmol/mol (9.1%) to 68 mmol/mol (8.4%) [26]. Three studies demonstrated declines in HbA1c levels in the interventions group; however, not significantly greater than the declines in the control groups: García-Huidobro et al. found a decline of 12 mmol/mol (1.1%) at 12 months [21], Kang et al. found a decline of 15 mmol/mol (1.4%) at 6 months [25] and Trief et al. found a decline of 4 mmol/mol (0.3%) at 6 months [29]. Gilden et al. did not find a significant improvement for the entire intervention group; however, 20 individuals with participating spouses showed a significant improvement in HbA1c [22]. How much of an improvement was not reported. Gilliland et al. found a non-significant increase in the adjusted mean change in HbA1c in the intervention group at 1 year (0.5%) [23]. Actual HbA1c levels were not reported.

Other primary outcome measures included diabetes self-care, as measured by a five-point scale [24], and lifestyle behaviours, such as weight, diet and exercise [27, 30]. Hicks generally found a larger improvement in diet in the control group compared with the intervention group. Results demonstrated a decline in calorific and daily fat intake among the comparison group (–94.54 kcal/day and –4.70 g/day) and an increase in the intervention group (+0.46 kcal/day and +0.46 g/day). However, the intervention group showed improvements in mean daily fibre intake (+1.69 g/day) compared with the control group (–0.90 g/day) [27]. Wing et al. found that participants in the intervention group lost 8.7 kg (19.1 lb) on average, whereas the participants in the control group lost 9.0 kg (19.9 lb) on average [30]. Between-group differences in these outcomes did not achieve statistical significance. Koegh et al. reported statistically significant improvement in diet, illness perceptions, psychosocial well-being and family support at 6 months compared with the control group [26]. Kang et al. also found significantly better diabetes knowledge, improved attitudes about diabetes and increased perceived family support at 6 months compared with the control group [25], all to a significant degree.

In summary, three studies demonstrated statistically significant improvements of the family interventions [22, 25, 26].

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Supporting Information

The number of trials of family interventions and statistically significant results is limited. This is not surprising given the emerging state of research in this area. Nevertheless, our assessment of the family-centredness across the family interventions, looking at the relationship between target population, theory to intervention, content of intervention and outcomes, provides insight into directions for improving future research.

A general limitation of the reviewed intervention studies is lack of detailed descriptions of, for example, intervention elements and intervention development processes. This prevents a clear understanding of the methodology and the approaches that family interventions have applied and thus also precludes the possibility of study replication. Increased reporting quality would be facilitated by consistent use of the Consolidated Standard of Reporting Trials (CONSORT) statement and checklist [42].

Likewise, the reports do not, generally speaking, transparently describe the theoretical framework or assumptions underlying the inclusion of family members. In the reports that provided a theoretical perspective, individual change theories were more prevalent than theories addressing family dynamics. Family members were included as a component of social support; the value of addressing the family as a whole was generally overlooked. If the true target of the intervention is the family, the behaviour and functioning of the individual with diabetes, family members and their relational dynamics need to take the centre stage. Conceptualizing the family as merely an aspect of social support is overly simplistic and this tendency may explain why couples-based interventions in health promotion have generally not proven to be more effective [29].

An explicit theoretical basis that guides the development or refinement of interventions will be beneficial to future intervention designs. Another review examining family interventions in general health problems found that studies producing the strongest results targeted specific behaviours and were theoretically driven [14]. Recommendations for the development of complex interventions emphasize the importance of a sound theoretical basis to understand the process of change and the mechanisms leading from intervention to effect [43]. Two reports provide examples of incorporating family issues into interventions using sound theoretical approaches to family behaviour change [29, 30]. However, six of the ten reports include family issues as an intervention theme; given the importance of theory to effective interventions, multifaceted interventions would benefit from a sound theoretical framework about the family.

The reports we reviewed illustrate cultural differences with respect to the definition of family. Family patterns vary throughout the world and a culturally adapted definition is often necessary. We often speak of ‘the’ family, but many types of families occur [44]. Furthermore, the family is also defined by the context in which it exists. Increased individualism in Western societies puts greater emphasis on the need to create personal networks and choose the person to whom one will make commitments of support, thereby blurring the distinctions between consanguineous and affective relationships [45]. Inherent in this phenomenon is the idea that emotional closeness is one of the most important determinants of support [45]. Globally, marriage is increasingly a matter of individual choice, and living apart, divorce and remarriage are becoming more common [44]. Such global changes in the nature of family should be taken into consideration in the development of future family interventions, and explicit definitions of the concept would aid in replicating interventions. Finally, narrow, predominantly Western conceptions of family are perhaps most in need of revision according to broader global trends.

Biological outcome measures dominated the reports of family interventions we reviewed. This is not surprising as they make up essential outcomes in diabetes. However, statistical significance was achieved in a greater proportion of psychosocial and family-specific outcomes. This finding illustrates the benefit of including the family dimension in outcome measures. In general, few of the outcome measures used in the family interventions target or measure relationship or family dynamics; instead, tools for measuring individual change are more frequent. This limitation has also been found in interventions targeting general chronic disease management. Rosland and Piette conclude that several trials do not measure change in the targeted family role or behaviour (such as the number of family goals met or declines in the use of critical statements). They consider this a limitation and argue that analysing how such changes in family behaviours and patients' perceived illness-related support are related to change in patient outcomes is essential to determining which intervention models are most promising [5]. When family outcome measures are not included, important dynamics may be overlooked. Supplementing individual outcome measures with measures that include family dynamics and family members will improve the understanding of the mechanisms behind an intervention.

The success of a treatment plan depends on accurate assessment of the nature of the problem and the potential for solution [46]. Family interventions should include a more complex assessment strategy. In choosing a family assessment strategy, it could be determined what aspects of the family functioning are most likely to be relevant to the goals of the intervention. These may include concepts that are frequently assessed in family psychology research and clinical evaluation of families: family composition, family process, relationship patterns, family affect and family diversity [46]. These dimensions could also serve as starting points for the design of family interventions. Fisher and colleagues suggest guidelines for evaluating family factors in the management of Type 2 diabetes, focusing on the type of family relationship, the individual with diabetes and spouse/partner beliefs and agreement, current and foreseen stresses, and allocation of disease management behaviours [47].

In general, future family interventions for diabetes should address the family dimension more systematically and consistently. The family should make up the central unit of the interventions, and this dimension should be clearly reflected throughout the intervention design. A well-chosen theoretical framework appropriate to a family focus would help define intervention themes and outcome measures. Systems theory may be a useful starting point for capturing the value of including the family in the care of adults with diabetes. The system and the behaviour of its elements can only be explained when addressing all the parts in their mutual interaction and influence [48]. This perspective would facilitate an expansion of the focus from the individual with diabetes towards the family system, increasing the likelihood that interventions are family interventions in fact as well as name.

In order to improve future family interventions we therefore recommend addressing the behaviour and functioning of the entire family. We also suggest that interventions are based on a sound theoretical framework and address family dynamics, using not only individualized outcome measures, but also family dynamics and psychosocial outcomes. We further suggest that family interventions address all persons and families with diabetes in the format of stepped care. This gives an opportunity to provide basic training and knowledge for all and then intensify intervention level depending on specific criteria. These would be, for example, glycaemic control, quality of life and well-being of the person with diabetes and the family members, as well as family dynamics and level of conflict. Such studies are needed in order to prove the effects of ‘real’ family interventions.

Strengths of the review include a systematic literature search and independent screening by two reviewers. Limitations include the limited amount of studies. It may be useful to include non-peer-reviewed literature, guidelines and conference presentations.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Supporting Information

Few of the reviewed studies demonstrate a statistically significant benefit to family interventions. A lack of coherent theoretical frameworks, intervention themes and measured outcomes may, in part, account for the limited effects observed, and robustly including the family dimension is suggested for future family interventions. Family-centred research should focus on the family unit through the choice of theoretical underpinnings, intervention themes and outcome measures. Increasing the degree to which future research is family-centred is a first step toward a more accurate understanding of the potential of family interventions to improve outcomes for people with diabetes.

Funding sources

The study was funded by an unrestricted grant from Novo Nordisk.

Competing interests

RT, NS and IW are employed by Steno Diabetes Center A/S, a research hospital working in the Danish National Health Service and owned by Novo Nordisk A/S. Steno Diabetes Center A/S is an independent academic institution owned by Novo Nordisk and financed partly by Novo Nordisk, partly by the Novo Nordisk Foundation and partly by the Capital Region of Denmark.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Supporting Information

We are grateful to Lawrence Fisher, Professor at University of California San Francisco, for providing valuable comments to the manuscript. Soren Skovlund from Novo Nordisk provided ideas for the manuscript. Jennifer Green from Caduceus Strategies provided English text revision and correction.

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  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Supporting Information
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dme12290-sup-0001-AppendixS1.docxWord document68KAppendix S1. Specific search strategy.

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