A Systematic Review : Family Support Integrated To Diabetes Self-Management among Glycemic Uncontrolled Type II DM Patients *

Background: Diabetes mellitus is dramatically increasing in the wide world. The managing of diabetes care emphasized the self-management education and support into patients’ care


Introduction
family member is the fundamental part since the family has contributed to successfully of diabetes management.
Family members are always required to share the role of diabetes care.
Family can also provide some forms of support such as instrumental support for making an appointment with health care provider or helping for insulin injection and emotional support when patients faced the psychological problem during long-term self-care (9,10) .Guidelines on diabetes care emphasized the selfmanagement education with support in patients' care and families care in which significantly enhance the diabetes self-management.Therefore, an individual education program for patients with diabetes mellitus could limit its impact on the patient since the family has roles in diabetes management.
Diabetes self-management education with family approaches to diabetes management can emphasize the context of the family's roles, as well as education, patients and family needs on diabetes care and promote of diabetes self-management.However, not many review studies explore how family support integration enhances the diabetes self-management among type 2 DM.
Thereby, this review will review the appropriate intervention and explore how the family support integration approach can influence the diabetes selfmanagement education (DSME) among patients with type 2 DM.

Objective
The study aimed to review and synthesizes the effectiveness of DSME strategies involving the family member as a key person to offer social support for diabetes mellitus self-management of glycemic uncontrolled patients.

Methods
This review described the effectiveness of family involvement in diabetes selfmanagement among glycemic uncontrolled patients.We used the PRISMA statement of all stages of the review

Eligibility Criteria
The PICO (Participant-Intervention-Comparison-Outcomes) formats based on Joanna Briggs Institute (JBI), (2014) (11) to create the criteria inclusion for reviewing the articles.In originally studies among uncontrolled type 2 DM with any treatment strategies such as by using the didactic method, participatory learning, Internet-based method for intervention and usual care were included in this review.Specific reasons for excluding the article are an inappropriate subject (diabetes medication or treatment), research design (a single design, descriptive design, qualitative research) or no control group, not an academic journal, and intervention journal without family involvement.Studies focused on diabetes prevention or target population gestational is also excluded.
HbA1c was a primary outcome that reflected the glycemic controlled the last 3 months.Secondary outcomes were self-care behaviors (Diet, physical activity, blood glucose monitoring, foot infection, and medication adherence), physiological outcomes, self-efficacy and social support and clinical outcomes (HbA1c/Blood glucose level, Blood pressure, BMI status, and lipid profile).

Search strategy
The search strategy used to find the relevant articles, including "type 2 diabetes," "self-management," "family support," and "Glycemic uncontrolled."Available title and abstract of articles were reviewed by systematically searching to gain the relevant of DSME with family support program term.

Study selection
Databases accessed through PubMed, CINAHL, and Scopus in this study.We searched and identified the relevant articles published from 2008 through 2016.After removing the articles duplication, the proper articles of relevant abstracts were also retrieved.

Synthesis of Results
The results of this review described narratively.The describing of the results explained about 1) diabetes self-management education (DSME) program, 2) how to integrate the family support into DSME program, and the effectiveness of the program on health outcomes.studies are randomized controlled trials (RCT)  and three studies were conducted by the quasi-experimental study (13,33,34) . From tose fourteen studies, thirteen studies were conducted in Western countries (12-14, 16-19, 22-27, 29-34) , whereas only one study was undertaken in Asian countries (21)

Diabetes Mellitus Self-Management Education (DSME)
We found that DSME based individual program was conducted into 40.9% of the studies (12,13,16,20,23,25,29,30,32) and 59.1% of the studies offered the DSME in a combination of individual and group education (12,14,15,17,20,21,27,31,32,34) .In general, The individual or group-based program provided the intervention of several strategies, including personalized counseling, feedback regarding goal-setting and problem-solving, support for self-care practice from family members, and the follow-up session.

Strategy of Diabetes Self-Management Education
In general, self-management education is divided into three approaches including didactic (offering the learning material throughout educational sessions and following by discussion), participatory learning (encouraging active patients' involvement in the learning process, a discussion session, goal setting, negotiation, and problem solving), and mix (combination of didactic and participatory learning).
Of the 22 existing studies, 16 studies presented group based education or individualized counseling on several strategies such as set the, action planning, problem solving and follow-up strategies (14- 16, 18, 19, 21-24, 27, 29, 31-34) .To improve the knowledge and communication skill, one study the offered a DVD-based training program (17) .In addition, other study used a Bluetooth technology to access the health condition and to communicate with family practice teams (12) .
Aikens' study expanded DVD-based training program to influence the communication skill (35) .Another study presented the cooking class to demonstrate the health food (20) .A study offered diabetes telemonitoring calls by using the mHealth + CarePartner (CP) to improve diabetes self-management and supporting their blood glucose monitoring (26) .

Education Materials
The material of this review varied across from the studies.A bluetooth technology was incorporated to deliver the diabetes information (12) .Four studies used food model, picture, illustration, foot picture (14,18,20,24) .Diabetes handout/booklet (diet, exercise, medication, eye, and foot self-care) been used to spread the knowledge (15,16,19,21,30,32,36) .In addition, four studies (13,14,20,34) used video and DVD to show the successfully of self-care behaviors practice among diabetes patients.Another study used a mobile health (mHealth) to monitor the behaviors and update the diabetes information (26)

Follow-up Strategies
Follow-up strategies are essential components in diabetes care to sustain the self-care management behaviors.This review verified that five studies follow-up the program by using a face-to-face follow-up (12,15,17,(22)(23)(24)33) . Threestudies were noticed to follow-up the program by using the telephone method (13,14,25,26,32) .Mix of telephone and face-to-face follow-up strategies (18)(19)(20)29) and two studies did not mention about the follow-up process for evaluating the program (16,21)

Integration of family support in the DSME program
In recently, DSME program is incorporated into primary care unit or community.Regardless of this setting, the effectiveness of communication and supporting skill on diabetes care is required to influence the self-management behaviors and promote the effectiveness of a coping with day to day care (37) .In this review, family involvement in the program across studies.From 22 existing studies, 13 studies involved patient and family members as a unit intervention and required family member to attend the education class or meeting (14, 15, 19-22, 24, 26, 27, 29, 31-34) , 8 studies focused on patients (12, 13, 16-18, 23, 30, 32) .However, sometimes they asked the family members as a part of support system in the education session, such as support in solving stress when feelings of denial, the presence of discordant conditions, and retirement.
In Karen's study (19) , family members were needed to assist and support patients in the self-management by facilitating them to influence skills including strategies planning, goal setting, and problem-solving.
Effective feedback on the negative perception of diabetes by exchanging the health information, reducing the care resistance and building selfefficacy is emphasized by family members.
In other studies, the author stated that patients received an interactive voice response (IVR) calls to monitor the barriers of selfmanagement, medical check-up seeking and connecting with family members as a caregiver.The role of the family in this session to record patient's improvement, as well as problem during implemented the program and support for self-management behaviors (13,35) .
A study was conducted by using a social cognitive theory focused on the social environment change especially family member to influence the self-efficacy, diabetes self-management and to solve barriers.Family members demonstrated against exercise and shared the healthy meal.
Families emphasized the cultural belief and values in terms of dietary change, physical activity and monitoring blood glucose in order to meet with needs.Family supportive and relationship are associated with diabetes self-management (14) While a study offered the communication skill using the speakerphone among couples to support and solve the problem of behavior changed (38) .This program focused on couples communication skill such as homework and discussion tasks, goal setting and problemsolving.The effectiveness of collaborative chronic care approaches is a fundamental method to achieve goals and tailor intervention in glycemic uncontrolled type 2 DM.
In Ananda's study (26) stated that participants received mHealth +CarePartner (CP) program to monitor the self-management behavior among diabetes patients.On another side, family members also received the email updates on the patient's diabetes and guidance of supporting their self-management.This program is effective to improve the glycemic control and patient-family relationship.
Regarding the emotionally supportive behaviors, seven studies address the psychosocial problem such as feelings of denial, the presence of discordant conditions, and retirement that might occur among diabetes patients (14,19,22,23,35,39) .
The effectiveness of family support integration in DSME program has been shown in cost-effective related to reduce the risk of complication (13) .DSME is also reported to improve HbA1c level by as much as 1% among glycemic uncontrolled patients. (12,15,18,19,21,22,24,32,33) . In adIn addition, several outcomes have a positive effect on psychosocial (35) , self-efficacy (14,24) , dietary and physical behavior aspects (19) , perceived support (15) , knowledge (32) , medication adherence and quality of life (32) .The improvement in several outcomes has clearly confirmed the importance of family involvement in diabetes self-management education.

Effectiveness of family support integration on diabetes Outcomes
DSME with family support has a significant effect on varieties outcomes of existing studies in this review.The outcome will be classified into five outcomes, including self-care behaviors (Diet, physical activity, blood glucose monitoring, foot infection, and medication adherence), physiological outcomes, self-efficacy and social support and clinical outcomes (HbA1c/Blood glucose level, Blood pressure, BMI status, and lipid profile), as follows

Self-care behavior outcomes
Based on the inclusion criteria of the database search, 14 intervention articles examined the impact of DSME with family support on self-care behaviors.There is strong evidence reported that following good self-care behaviors, including diet, physical activity, blood glucose monitoring, foot inspections, and medication adherence have a significantly improve the clinical outcomes and prevent long-term complications (40) .Two studies have a positive impact on healthy dietary intake (27,31) after receiving the DSME with family support involvement.Other study showed an appropriate in selecting healthy food and food exchange (20) , while five studies focused on exercise behavior outcomes of diabetes (13,21,27,31,34) .Both of those studies showed the high level of family support integration on DSM program.
In addition, when the correlation between support perceived with blood glucose monitoring was examined, four studies have been found.Those studies confirmed that higher level of support is significantly influencing the blood glucose monitoring at home (13,14,17,20,24,34) .For medication taking behavior, seven studies demonstrated that regularly medication adherence was conducted under the family support (14,15,(18)(19)(20)(21) .Furthermore, this review confirmed that the increasing of self-awareness on foot inspections is correlated to foot ulcer prevention (13,34) .
In opposite of the previous study, four studies showed not significantly on medication adherence under the family support (12,20,22,23) .It could be correlated with low family participation (20) , understanding of patient and family member roles, and patients' adoption on medication adherence in the long-term period (22) .
Those opposing results indicate that study limitation had minimized the resulting effect.

Psychological outcomes
As an approach to explore the psychological problem in managing self-care behaviors, barriers related to psychosocial were reviewed in this review.Emotional distress associated with poor diabetes self-care and glycemic control which impacted to emotional responses, including feeling discouraged of diabetes treatment, worrying of long-term complications, and incorrectly defining the concrete of goals for diabetes cared (41) .From those existing studies, twelve studies addressed the psychological status as the intermediate outcomes, which reported that higher level of family support has a positive impact on reducing depressive symptoms (13,15,22,26) and positive emotional control (16) , psychosocial well-being (19,31,34) , quality of life (26,32) and diabetes related to distress and reducing barriers (17) .As the results, less depression has positive impacts on self-care behavior and certain clinical outcomes

Self-Efficacy
A concept of self-efficacy was generated in the context of cognitive behavior modification among patients with chronic conditions.Five review studies explained that patients who have higher perceived support are significantly better self-efficacy (12,14,16,20,24) .One study received the one-on-one tailored education session and bi-weekly follow-up to influence the self-efficacy on performing self-management (32) .Consequently, this self-efficacy will improve on self-management practice.

Social Support Perceived
Support is a fundamental approach to sustaining self-care behaviors among diabetes patients.Six experimental studies described the impact on family support integration on social support perceived. (12,13,15,22,23,36) . WhWhile one study explained the positive impact of on the quality of the relationship between patients and family member in managing the diabetes self-management behaviors (26) .For this reason, social support was effective for improving the diabetes self-care behavior.

Clinical Outcomes
Twenty-two articles were reviewed that examined the effect of DSME with family support on clinical outcomes.Ten review studies showed the improvement on HbA1c (12, 15, 18, 20-22, 24, 30-32) after succeeding the diabetes self-management.Five studies focused on the dietary modification support to improve blood pressure level (12,20,21,26,29) .In addition, the relationship between perceives support and lifestyle modification also improved body mass index (12,33) and lipid profile (21,29,32) .These studies showed the high level of family support in sustaining self-care behaviors.Another study also reported that patients in the experimental group that received the one-on-one peer support with DSME program had positive impact on improving blood pressure, LDL level and BMI index than comparison group (32) In opposing to the previous study, two studies confirmed that no significantly change in systolic blood pressure, triglycerides and BMI (25) .It could be linked to the low level of peer support group in the long term period.Other studies also showed no significant on HbA1c level (29,32,34)

Discussion
We conducted the systematic review of 22 existing studies related to diabetes self-management education (DSME) with family support from 2008 to 2016.The results confirmed that impact upon family integration on several health outcomes of type 2 DM.Many studies are strong of study design such as randomized controlled trials The diabetes self-management education based family intervention is often generated by individual and group education.This strategy offered in a combination of didactic teaching and interactive or participatory learning approach.Some studies conducted the diabetes self-management education with mix teaching methods by involving the family members into a collaborative approach (12,14,15,17,20,21) .The combination of didactic with other methods such as goal setting, action plan and problem solving has a positive impact on health outcomes and improve health behaviors (13,(17)(18)(19)(20)(21)23) .
This literature review also found that the integration and involvement of family members into collaborative approach was verifying widely across studies.
Many studies incorporated the details of family members into program activities such as providing the emotional support regarding problem-solving and helping patients to solve the emotional distress or provide informational and roles to facilitate, accommodate, remind motivate and partner with behavior change and do tasks.Some studies in this literature review found that family members were included in an intervention program.However, lack of information about how family members provide the support in diabetes self-management behaviors, interaction in the program and what family outcomes should be addressed from intervention.Only a few study described the role of the family member in the participatory learning.In addition, some studies unconsidered about the key person in that family that has a responsibility to provide caring for the diabetic patients.In order to effectively to engage family members in the intervention, the clearer understanding of the theoretical basis of involving family members is needed to serve the patients during performing the self-care behaviors.
The duration of the intervention and follow-up is measured by using the length of the intervening period from the pre-test until completing the program.
The length of the program is divided in the short-term (less than six months), medium (six months to 12 months), and long-term (more than 12 months).
Studies conducted in the short term duration of several strategies, including weekly telephone follow-up, face to face follow-up, negotiating, and discussing to design the goals and action plan, and modify the goals and action plan were more effective to improve the health outcomes (12, 13, 15, 17-20, 23).On other hands, long-term studies were increasingly emotional discouraged.Higher of perceived self-efficacy associated with the feeling of empowerment (42) Follow-up is an essential component in diabetes self-management among patients with chronic conditions.Generally, follow-ups are categorized into four strategies, including assisting computer-based, phone call, short message service (mail), and home visits.In this literature review, follow-up strategies are used to assess the patient's experience of the program, identify the barrier and use a problem-solving approach to address barriers revise the action plan to meet the goals, and reinforce any successful performance dietary and exercise selfmanagement.Combination of telephone and face to face follow-up is very effective to monitor the patients' achievement and significantly improves the health outcomes by increasing knowledge and self-efficacy to carry out selfmanagement behaviors (14,18) A study that assessed the outcomes found there is a significantly on clinical outcomes such as HbA1c, blood pressure, lipid profile and BMI status have been improved after implementing the program.Three studies mentioned that no significant change of HbA1c level in the short intervening period (17,20,23) .
Other issues in the self-care that is often faced with diabetes patients are to maintain the behavior after the end of the intervention period.However, the engaging of a family member could help the patients strengthen self-care interventions in the longer intervention period (43,44) .

Strength & Limitation
Although in this review, we reviewed many studies involving the family member in diabetes self-management with randomized control trial (RCT) design.However, some limitations are still found in this review.Heterogeneous methods, strategies, populations settings, and outcomes make it difficult to compare the effect size of each study.Even though we created this systematic review by hand tracking, there may be some studies related to family support for diabetes self-management unidentified.

Conclusion
Developing diabetes intervention in family support is an integral part of sustaining the self-care behavior and improve the health outcomes.Various studies showed the heterogeneity of the teaching strategies, follow-up, material, -Questions and feedback messages -Support Tang (2015) (32) Randomized control trial (RCT) (2010) (27) Tobert-Deborah (2011) (28) control  (24) Randomized control trial (RCT)

Figure 1 .
Figure 1.Summary of evidence search and selection recently experimental studies were conducted to explain a diabetes self-management education (DSME) with family support program on diabetes self-management among glycemic uncontrolled patients.Most of these

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instruments, and outcomes.Further study needs to provide details of diabetes self-management education in the intervention and compare the health outcomes of and without family involvement.In addition, the role of family participation should be assessed in diabetes self-management interventions and how the family involvement can affect outcomes.Providing the Bluetooth technology for transmitting readings for patients and family -Advice on lifestyle modification, on lag time for effects of lifestyle and medication change on glucose and blood pressure -Providing information when and how to contact family practice team via research nurses.The participants received the DSME including, diabetes overview, eating with diabetes, physical activity, managing emotions etc. -Participants received glucose meter to test the blood glucose 3 times per day for six months -Participants were assisted to access the resources needs -Assisting in setting goals and problemsolving -Families were encouraged to attend the education session at home -The program consisted of eight one-on-one tailored education session such as selfmanagement behaviors -Families were assisted to access the resources needs such as accessible clinic -Monitor patients barriers of selfmanagement -Provided the diabetes self-management by using messages -Helping the medical seeking -Generate the guidance of self-management -Training of DVD-based training in communicating effectively

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month diabetes self-management education program consisted of 12 weekly 90-minute group sessions, a personalized diabetes complications risk profile, one on one support activities, face to face meeting, self-management goal, develop an action plan and follow-up -Ongoing diabetes self-management support (DSMS) consisted 12 months ongoing DSMS such as emotional and behavioral support in weekly group session, follow-up telephone contact -During follow-up, the researcher addressed self-management challenges, evaluate the action plan, problem-solving and develop the future action plan and set the goals Peer Providing information related to diabetes exercises and diet -Helped to create eating health, monitoring blood glucose and medication taking -Facilitated to problem-solving, action plan and discussion with family member about DSM -Family member was invited to the program and focused on family centeredness -Roles of family on decision-making, problem-solving and emotional support Significant of blood pressure, diabetes self-efficacy diabetes knowledge, and physical and mental components of healthrelated quality of life -Significant of intake of healthy foods and performance of blood sugar tests and foot inspections and lower BMI -No significant changes in levels This program is mHealth +CarePartner (CP) programs -Participants received the weekly automated diabetes telemonitoring calls to include selfmanagement guidance -The care partners such as family member received the email updates on the patient's diabetes and guidance on supporting their selfmanagement Assessing the education needs and divided the family member to small groups based on their education needs -45-60 minutes of educational session about the importance of medication adherence and family support behavior -Teaching about 30-45 minutes and 15 minutes for answering the questions and exchanging of views between family members -Support -Involving family in Education session and exchanging of view between family member -Family as key person has roles on home blood glucose testingInviting the participants to identify the their own needs -Enhanced the participants' engaging by showing the videotaped stories of typical problems -Providing the information by using the culturally appropriate material -Helping participants to set the goals and supporting them for self-care -Families were invited to encourage shared learning and enhance the ability to support and to know how to be helpful -Families also have as key person to affirm the successful behaviors Reflection of personal threat to diabetes care -Providing mastery perception of diabetes -Briefly consultation related to positive-Discrete strategies and skill drawn on interview practice -Role played interactions modeled on routine consultations -Education by using didactic and interactive strategies Practice intervention strategies and skills -Consultations online and to receive feedback Family No significant on HbA1c -More capable of training staff -No significant skill of practitioner -Reduced problem with treatment barriers -Improve treatment adherence -Greater excitement about clinic visits -Providing education related to diabetes complication -Encouraged to self-management practice -Building on culturally relevant knowledge and skill related to self-care behaviors -Providing the communication skill -Action plan on controlling on controlling blood glucose and A1c -Discussing of challenges on diabetes selfmanagement Group training by peer educator and facilitator Storytelling of effectiveness self-Significant on A1c -Significant on knowledge -Significant on selfmanagement behaviors Toobert Randomized -The Viva Bien program including weekly -Families were involved -This study -Not mention

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Addressing of literacy needs and modeling and experiential teaching methods -Cultural tailoring by using an educational soap opera to introduce self-management information and model attitudinal change -Reinforce information taught, emphasis on making traditional food healthier -Increasing the walking steps by using a step counter Brief personalized counseling, goal setting and problem-solving -Families were invited to attend the home-based support, group meals -Family were also invited to discuss the way how to implement the recipes at home and acceptability of family at home -Significant change in HbA1c at 4 months follow-up but not change at 12 months followups -Significant of self-efficacy, 16 hours of training in motivational interviewing -15-minute follow-up telephone call -Individually tailored to participants' needs and attempted (clarify negative perception, personalized action plan, mobilized family -Significant on A1C levels -Improve beliefs about diabetes, psychological well-being, diet, exercise, and family support.support) Building self-efficacy, problem-solving, Three brief individual education session at 1, 3 and 5 months related to diabetes, eating habits, physical activity, and foot care -2-day long group education session at 2 and 4 months related to demonstrating of cooking, exercise, and foot care -Diabetes sharing groups -A monthly 25-30 minutes telephone discussion Meeting of the family education diabetes series program.The meeting is begun by checking the blood sugar, weight and foot inspections -Discussion on meal's ingredients, portion size, and healthy weight maintained -Planning and design a priority of activities based on participants' interest -Informal sharing information and support -The data show significant in weight, blood pressure, and HbA1c level.

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to 4 days per week exercise session included stretching exercise to warm up and cool down with a 20-second hold and deep breathing -Weekly nutrition session included decreasing fat intake, increasing consumption of fruits, vegetables, and-Significant on A1c and pain -Significant on self efficacy whole grain Education session related to setting goals, monitoring ABCs of diabetes, healthy feet, family support day, stress management, preventing depression and building healthy relationship Interdisciplinary family meetings or home visits -Received a recipe book for diabetes and during family meetings, they received a framed family picture.Individual counseling session and one counseling session (Learn about strategy of caring) Multifamily group sessions (trained in motivational interviewing and family counseling and clinicians that guided multifamily groups) The intervention was consisted of two intervention groups such as minimal intervention, a telephone-based intervention and an intensive intervention consisting of education and follow-up service -Minimal intervention included the 6 months remaining of preventive health screening (HbA1c, primary care, and specialty visit) Intensive intervention was conducted 6 weeks such as guidelines and practical information, self-management education, home-based assessment and education, field experience, skill reinforcement and -hour group sessions, didactic: cooking demonstrations, and group support sessions.Culturally tailored: low-fat modifications, discussing of home remedies, and appropriate exercise strategies: walking and dance -To bring a family member as a support person Significant on weight and BMI -Improve frequency of selfglucose monitoring and physical activity -No significant on diet, foot care, or medications, knowledge, self-efficacy, blood glucose, Culturally relevant group DSME intervention was consisted of eight 2-hours education session over 8 weeks period, incorporated the activities and problem solving in each group session -DSME was delivered by emphasizing the supportive atmosphere, storytelling related to diabetes care, diabetes education material, lesson, an approach emphasizing respect and empowerment -Individual DSME session: week 1 is setting goal; week 4 is reviewing the progress, problem solving, offering additional information; and week 8; final review, discussion about the self-management achievement and plan for future self-care -Families were invited to selected group session to gain the diabetes information and peer support DSME improved the self-care activities, A1c level, and goal attainment -Preprints (www.preprints.org)| NOT PEER-REVIEWED | Posted: 12 May 2017 doi:10.20944/preprints201705.0104.v1