ReviewSocial support in diabetes: a systematic review of controlled intervention studies
Introduction
The dramatic increase of type 2 diabetes makes studying the factors influencing outcomes and effectiveness of diabetes care more and more relevant [1], [2]. The epidemic of type 2 diabetes, projected to reach 333 million persons worldwide by 2025, is causing alarm in both medical and political circles. Since increasing obesity and decreasing physical activity are responsible besides the ageing of populations, modification of lifestyle, focusing on diet and exercise, is the logical way of stemming the tide [3]. Patient lifestyle and health behaviour changes, and patient self-management in concordance with professional treatment advices, are cornerstones of diabetes care — but also the most difficult tasks people with type 2 diabetes have to face [4], [5]. Regardless of the diabetes care system applied, about a third to half of the patient group with type 2 diabetes shows inadequate control of blood glucose levels and cardiovascular risk factors [6], [7]. As a consequence, many suffer from macro- and microvascular diabetes complications, e.g. coronary heart disease, stroke, blindness, amputations, nephropathy, and peripheral neuropathy, as well as low levels of quality of life and functional status, emotional distress, and elevated death risk [8].
Until recently, research and guidelines on the patient perspective, on patient-provider interaction, and on patient empowerment in diabetes care and education, did not receive enough consideration [5], [9], [10]. Even less attention was given to the role played by familial and other forms of social support in diabetes care [11], [12], [13]. Better knowledge of the ways in which social support operates seems of vital interest for enhancing diabetes patient self-care, insuring adherence to professional advice, encouraging lifestyle adaptations, and helping to improve outcomes of diabetes care and increase personal freedom. For a number of other medical conditions, and for health care in general, the role of social support has been studied [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28].
In this paper, the results of a systematic review of studies of the effects of social support focused interventions on outcomes of care for type 2 diabetes are presented. A focus on type 2 diabetes seems particularly relevant, as coping with this health problem requires special emphasis on patient self-management in daily life.
Social support has received attention as a mediator or moderator of health outcomes [14], [21]. It has been a target of interventions in other conditions than diabetes [14], [15], [16], [17], [18], [19], [20]. Social support is related to coping [18], [19], [20], [22], [23], [24], [25].
The global notion of social support includes several related concepts. Social support must be distinguished from social network (size) [12], [26], [27], [28], [29]. The social network refers to a web of social relationships and social linkages. This is best measured through enumeration, or quantitative scoring of its size, the number or density of social support sources, and persons around a person. Social support can be defined by its observed or reported content, by the satisfaction about it, or by the perceived support given to a person. These concepts are best measured by observations and reports, by indices of satisfaction, or by scores of perceived support.
Not all social support is equally helpful. There is evidence that social support can have negative as well as positive effects [28], [29], [30], [31]. When the term ‘social support’ is used, a positive influence supporting a certain, wanted behaviour is implicated. The lack of social support during times of need itself can be stressful. ‘Social pressure’ is used for positive (wanted), but more often negative (unwanted) influences, enhancing or rather inhibiting a certain, wanted behaviour [32].
In social support not only familial relations have their part. Peers, friends, neighbours, colleagues, fellow patients, or even pen friends and Internet contacts may play their role. Peer expectations are important, and may vary between men and women [28], [29], [33], [34], [35]. Social support must be separated from any group-based activity, e.g. education group.
Definitions:
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‘Social support is an exchange of resources between at least two persons, aimed at increasing the well-being of the receiver’ — Shumaker and Brownell [36].
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‘Social support (is) information from others that one is loved and cared for, esteemed and valued, and part of a network of communication and mutual obligations from parents, a spouse or lover, other relatives, friends, social and community contacts such as churches or clubs, or even a devoted pet’ — Siegel and coworkers [33], [37].
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‘Social support is the degree to which a person's basic social needs (affection, esteem or approval, belonging, identity, and security) are gratified through interaction with others by the provision of socioemotional (…) or (…) instrumental aid’ — Thoits [38].
Three or four categories of social support can be distinguished: emotional support (warmth and nurturance expressing commitment, reassuring the person that he or she is a valuable individual who is cared for, including approval or appreciation for the patient's behaviour), appraisal support (helping a person understand a stressful event better and what resources and coping strategies may be mastered to deal with it) or informational support (giving advice and information), and tangible assistance or practical-instrumental support (material or other practical help such as services, financial assistance, or goods) [39].
The possible association of social support with (better) glucose level control in type 2 diabetes may have more than one explanation. Some state that the social network provides a substantial part of the information that a patient receives on the diagnosis, treatment, expectations and complications of diabetes [13]. Besides these appraising and informative effects, the social network when offering emotional support, alters the perceived stress and physical reactions which the patient endures. A third effect of social support is that it might offer coping strategies and structure in daily routines, enabling the patient to cope with stressful events, follow-up the treatment regimen in times of stress, and reduce the likelihood that stress will lead to poor health [40].
The hypothesis of ‘direct effect’ adds to the hypothesis of general, ‘indirect’ or ‘buffering effects’ [39], [41]. Social support may have direct effects on patients’ health. They may receive support to cope with the health problems, show better adherence to the prescribed treatment, and make better use of health resources — especially if the social network has a positive attitude regarding this [39]. The ‘buffer hypothesis’ states that social support may have indirect effects on health as well, both in times of stress and non-stress [41], [42]. A person may have experienced social support in times of stress, and the bare knowledge of this possibility has indirect, buffering, reassuring, and protecting effects. People with strong social support perceive their health as being better [41]. For both hypotheses supportive evidence was reported [39].
A ‘social dimension’ is implicated in most theories explaining health behaviour (change) and self-care [43], [44], [45], [46], [47], [48], [49]. Usually the direct influence of the social network is implicated as one of the determinants of health behaviour.
Intervention studies are direly needed. Such studies with a controlled, prospective, intervention design, like randomised controlled trials, cross-over intervention studies, or quasi-experimental pre-/post-test studies, carry powerful evidence of effects of social support focused interventions on specific outcomes, e.g. measures of patient health outcomes or behaviour changes. Evidence from observational and explorative studies will never be equally strong [32], [50].
Can we find methodologically sound studies with prospective intervention design, carrying evidence for effects of social support focused interventions on self-care and health outcomes in type 2 diabetes, especially in primary and hospital outpatient diabetes care? What interventions were studied, and what outcome effects were reported?
Section snippets
Literature search
A literature search was conducted to retrieve publications on specific social support interventions and their effects on outcomes of care for people with diabetes (a, first selection). From these studies, we selected those with good methodological characteristics: randomised controlled intervention trials or quasi-experimental trials with pre-/post-test design (b, second selection), and focused on type 2 diabetes in primary care or hospital outpatient care (c, third selection). Studies on
Findings
From the 1426 retrieved publications by the first selection (a), we selected 69 on trials with sufficiently good methodological design: RCT or quasi-experimental design (b). From these, 63 studies were on hospital in-patients, on patients with type 1 diabetes, or on mixed groups of patients. These 63 were excluded, while six studies on persons with type 2 diabetes in primary care or outpatient hospital care were included for the review (c) [54], [55], [56], [57], [58], [59], [60]. The flow
Discussion
This review shows that the effects of social support interventions in type 2 diabetes in general practice or outpatient settings have been studied in a surprisingly small number of controlled intervention trials. Most of the six reviewed studies carry evidence in support of the idea that social support is influential on self-care and outcomes of diabetes care. The social support interventions show great heterogeneity, and are hardly comparable. One could classify them into two clusters: (a)
Conclusion
This review cannot clarify which aspects of social support, and which active mechanisms behind it, are most effective for enhancing self-management and outcomes of care for people with type 2 diabetes. Future research should address this problem.
For weight reduction, involving the spouse may be useful in obese women with type 2 diabetes. With regard to diabetes control, group consultations with the diabetes care provider (physician, nurse) are promising. ‘Live’, telephone, and Internet-based
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