ABSTRACT

Introduction: As the largest part of elderly (65 years and older) diabetic care is given at home, family support has an important role in their blood sugar level control. This study aimed to assess the relationship between family support and glycemic control in the elderly suffering diabetes type 2.

Materials and Method: It was a descriptive-co relational study, of 150 elderly suffering diabetes type 2 who were referred to the Endocrinology and Metabolism Center of Iran University of Medical Sciences, and who were selected continuously. A self-reporting questionnaire was used for gathering information. The questionnaire consisted of four sections: demographic data, HbA1C, perceived family support and family network size. Data were analyzed by SPSS version 15 by using Chi-square and Logistic regression tests.

Results: Results showed a significant relationship between family support and glycemic control (p<0/0001). Also there were significant relationships between family support gender and marital status (p=0/001). There was also a significant relationship between glycemic control and marital status (p=0/002). (Financial status (p=0/04) and educational level (p=0/002).

Conclusion: Findings of this research added further evidence about the impact of family support on the health of older adults with diabetes. These findings suggest using family centered health career intervention and collaboration of family members in the care of the elderly with type 2 diabetes.

Key words: elderly, family support, diabetes type 2, glycemic control

INTRODUCTION

In the present century, infectious diseases have mostly been controlled, and therefore chronic diseases such as diabetes (type 2 diabetes = NIDDM = non-insulin dependent diabetes mellitus) are considered the most important causes of death in the elderly. [1]

Diabetes is a chronic disease which involves all aspects of life, and its treatment requires fundamental changes in the patient's lifestyle. [2]

The elderly population in all nations of the world is increasing due to various factors such as mortality rate reduction, which in turn is caused by developments in the areas of medical sciences, hygiene, and education. Therefore, the rates of life expectancy and aging are progressively increasing. [3] The world population is increasing 1.7% each year, and the growth rate of individuals 65 years old and older is over 2.5%. This gap drives the age-constitution of the world towards aging, and it is anticipated that in the next 25 years, 1.2 billion people will be 60 years old and older. [4] Pertaining to the last census of Iran's Statistics Center, the population of individuals older than 60 years in 2006 is estimated to be 7.27%. [5]

Although the prevalence of both types of diabetes is increasing worldwide, the prevalence of type 2 diabetes is expected to increase with an accelerated rate due to the increasing prevalence of physical inactivity and obesity. The prevalence of diabetes increases with age; and was estimated to be 0.91%, 8.6%, and 20% among individuals under 20, over 20, and elderly over 65 years of age, respectively. The prevalence rate of diabetes mellitus is similar among most age groups and sex groups, but is slightly higher among men over 60 years old. [6]

The high prevalence rate of diabetes among the elderly, accompanied by the expensive costs of health-care and therapy in these patients, has increased the economic burden of this disease. [7] Diabetes is the seventh leading cause of death and the most important cause of non-traumatic amputation, blindness, and complete renal failure in the United States of America. [8]

Among the factors influencing self-care (i.e. the health care system and its employees, the workplace, society, and the family), the least investigation has been conducted on the family; and most research in this regard has been performed on children and adolescents suffering type 1 diabetes, and little research has been reported on the elderly suffering type 2 diabetes. [9] Regarding the fact that approximately 92% of the elderly are taken care of by their families in Iran, and the family is considered the best support for taking care of the elderly, the researcher performed research in this regard in order to investigate the relationship between family support and glycemic control in the elderly suffering type 2 diabetes.

MATERIALS AND METHODS

In the present correlative and descriptive study, 150 patients suffering type 2 diabetes, who were referred to the Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, constituted the research population. The inclusion criteria were: an age of 60 years or higher; diagnosis of type 2 diabetes being made at least a year prior; and treating the disease with insulin or oral hypoglycemic drugs. The exclusion criteria were: the presence of complications of diabetes such as renal failure, blindness, etc; suffering refractory illnesses such as malignancies; suffering various diseases that alter glycosylated hemoglobin level [HbA1C], such as different anemia's, hemoglobinopaties, uremia, renal failure, etc; and suffering illnesses such as mental disorders or drug abuse that affect the family support received or perceived by the patient. The present study was confirmed in the "Ethics in Research" committee of Iran University of Medical Sciences and Health Services.

The data collecting tool of the research was a self-reported questionnaire completed by the subjects, and consisting of 3 main sections: the first section pertaining to the subjects' demographic characteristics, including age, gender, occupation (housewifery, retirement, employment), educational level (illiterate, high school undergraduate, high school graduate, and graduate), marital status (single, married, widowed, divorced), the number of family members, the family type (centered, secondary centered, expanded, fragmented, isolated), the type of therapy (oral, insulin, both), the duration of disease, and economic status (high, good, average, low).

The second section of the questionnaire related to determining and recording the level of glycosylated hemoglobin. In this regard, after rendering explanations about this laboratory test and the method of performing it to the patients and acquiring their consent, and after requesting the test by a physician, they were referred to the Institute of Endocrinology and Metabolism medical laboratory. 5ml of blood was obtained from the patients. In the Institute of Endocrinology and Metabolism medical laboratory, chromatography was used as the method of measuring glycosylated hemoglobin. The results were given to the patients after a week, and were included in their medical records. In order to evaluate the efficiency of glycemic control, the glycosylated hemoglobin level was divided into two groups: HbA1C < 4.3%, revealing adequate glycemic control, and HbA1C ? 4.4%, revealing inadequate glycemic control.
In the third section of the questionnaire, family support was measured using a standard tool, - the "Social Support Questionnaire of Diabetics - Family Version". [10] This questionnaire was designed in 2002 by Greco in order to evaluate the support received by 13-18 year old adolescents suffering type 1 diabetes. It was also used in the present study for elderly suffering type 2 diabetes after internet-based correspondence and acquiring the designer's permission and revising the questions. Following revision, the number of questions of the questionnaire was reduced from 52 to 51. The questionnaire generally evaluated the feeling of belonging and also the amount of emotional, informational, and instrumental supports received and perceived by the patients regarding 4 areas, namely: drug usage, blood-glucose testing, diet, and exercise.

The questions were graded based on a 5-point Likert Scale ranging from never (1 point) to always (5 points), and another choice titled "no indication" was also added for patients that didn't have any indication to answer the pertaining questions, which had no score, and wasn't considered in the statistical analysis. The range of total score was 51-204 points, and the higher the total score, the higher was the family support received by the diabetic patient.

The scientific validity of the tool was determined using content validity, and its scientific reliability was determined using the test-retest method (r = 0.96).

Sampling was performed continuously; such that the researcher visited the Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, continuously on different days of a week, and after selecting the subjects meeting the inclusion criteria, she introduced herself, explained the aim of the research, and then acquired written consent and reassured them about the confidentiality of data collected by the questionnaire. Consequently, the personal data and family support questionnaire was given to the subjects.

The research data was analyzed using the SPSS software (version 15) and also descriptive and analytic statistical methods (Chi-square and Pearson tests).

RESULTS

The results revealed that most (55.4%) of the subjects were females; the maximum and minimum age of the subjects were 60 and 85 years old, respectively, with a mean age of 66.15 yrs, and most subjects (78.3%) were in the 60-69 years old age group; 76.1% of the subjects were married. The mean duration of diabetes was 14.2 ± 9.2 years; and the mean number of family members was 1.94 ± 0.5. Other characteristics of the subjects are presented in Table 1.

The results of the present research showed that the mean support received was 178.29 ± 0.7; and most subjects (42.4%) received considerable support from their families. The subjects' mean glycosylated hemoglobin level was 5.06 ± 0.89; and the level of HbA1C was higher than 4.3% in 62% of the subjects.

The results of the Pearson test revealed a statistically significant and indirect correlation between family support and the level of HbA1C; such that 61.5% of the subjects receiving more support from their family members, had lower HbA1C levels (r = - 0.56; p < 0.0001). The frequency distribution of family support received by the subjects according to the level of glycemic control is presented in Table 2.

The findings of this research showed that male patients (53.7%) and the married patients (52.9%) had received the most family support (p < 0.0001 ; p < 0.0001, respectively); whereas the divorced patients and the widowed patients had received the least family support. Statistical tests didn't reveal any correlation between family support and variables such as age, occupation, educational level, the number of family members, the family type, the type of therapy, the duration of disease, and economic status.

Other findings of the research showed a statistically significant correlation between glycemic control and variables such as marital status (p = 0.02), educational level (p = 0.05) and economic status (p = 0.04). Statistical tests didn't reveal any correlation between glycemic control and variables such as age, gender, occupation, the number of family members, the family type, the type of therapy, and the duration of disease.

DISCUSSION AND CONCLUSION

The nature of diabetes and the type of its treatment requires that the patient and his/her family take over a considerable proportion of the therapeutic responsibilities. [11] The aim of this cross-sectional research was investigating the relationship between family support and glycemic control in the elderly suffering type 2 diabetes.

The findings of this research showed a statistically significant correlation between family support and glycemic control, such that patients receiving the most support from their families, had achieved a desirable glycemic control. The studies of other researchers such as Schwartz [12] and Dai [1] have also had similar results. Glasgow states that family support is the most prominent factor that determines compliance with diet therapy in patients suffering type 2 diabetes. [13] A similar conclusion was found in a study performed by Dai et al. [4] Graham suggested that women are generally the care providers at home, and in fact, they are an intermediate link between the family and the official health care systems in the society. [14] Kagawa claims that women tend to continue to perform their housewifery duties even in their worst physical conditions, because they believe taking care of family members is their responsibility, and it is difficult for them to quit their basic roles and be taken care of. [15] The findings of a research performed by Wong also showed that in general, women actively supported their diabetic husbands (by buying nutrients and preparing meals appropriate for diabetic patients and also by encouraging them to have healthy diets), and rapidly adapted themselves to their husbands' lifestyle changes, whereas diabetic women were only passively supported by their husbands. [16]

Based on the results of the present research, the married diabetic elderly received the most family support, whereas the divorced and widowed diabetics received the least family support. In their research, Trif et al showed that a successful marriage improves the adaptation to different conditions of diabetes. Support from the patient's spouse, is considered the most important source of support for diabetics in different periods of their disease. [17] Different researchers have revealed that divorced individuals experience more psychosomatic disorders as compared to single and widowed individuals, and that the incidence rate of disorders such as malignancies, cardiovascular disease, pneumonia, and hypertension is higher among them compared to single, married, and even widowed individuals. Some investigators attribute this to losing the most important source of social support (i.e. the family), because the related families either disagree with divorce or experience psychological crises and cannot afford to render appropriate supports. [18]

Although the findings of this research didn't reveal a statistically significant correlation between family support and the duration of disease, the subjects had received the most support 5-9 years after being diagnosed as a diabetic. This may probably have been due to the fact that when a chronic disease such as diabetes is diagnosed in an individual, it causes psychological crisis and stress in his/her family in the first few years; as time passes, the family members become adapted to the new conditions of the patient, and will be able to render the essential support. In addition, during the first years the disease is diagnosed, family members may not have sufficient awareness about the disease, and may not know what kind of support the patient needs. The results of research performed by Schwartz didn't reveal any relation between family support and the duration of the disease either. [12]

Although statistical tests didn't indicate any correlation between family support and family type, diabetics who lived with their spouses after marriage had received the most support from their family. Although expanded families were the cradle of respect and support for the elderly in the past, large families are nowadays, due to the movement of societies towards industrialization and modernization, moving towards spouse-centered families in which the role of family members are profoundly changing, which in turn, influences the relationships among the members. [19] In spite of the change in family structure (from a large and expanded family to a small and centered one), passion and interconnection and friendship and care-giving spirit has not necessarily been disrupted yet among family members. Even if the youngsters migrate and abandon their families, passion and care-giving spirit may still remain among parents and children. [2]

Similar to the results of Schwartz' research, the findings of the present research revealed that individuals who lived alone received the least family support. [12] Ki Kim too believes that living in isolation restricts the availability to different kinds of support. [20]

Although in the present research, individuals with a higher educational level had received more family support, no statistically significant correlation was found between educational level and family support, which may have been due to the low educational level of most subjects.

In addition, no correlation was found between family support and economic status, which may have been due to the strong emotional connections between family members in the Iranian culture, which obliges them to support the other members, apart from the financial condition they have.

Although the findings of this research didn't reveal any correlation between family support and the type of treatment, patients on both oral and parenteral therapies had received the most family support, and patients on insulin had received the least family support. This may have been due to the fact that family members assume that the elderly who receive both types of treatment are critically ill and need more support, whereas the family members of a diabetic elderly that only receives insulin, don't have much awareness about the treatment of diabetic patients, and presume that insulin alone could achieve glycemic control and thus these patients don't need any support regarding their disease.

Although the retired elderly received the most family support, statistical tests didn't reveal a statistically significant correlation between family support and the occupational status of the elderly. Suppapitiorn states that the elderly spend more time with their family after retirement, and this may be the reason for receiving more support from their family members. [11]

The results of the present research revealed that the married elderly had achieved better glycemic control. Research has showed that diabetics experience poorer glycemic control when they have conflicts with their spouses. It is even claimed that excellent glycemic control is related more to the attitude of the patient's spouse regarding proper glycemic control rather than to the patient's own beliefs about it. [17]

The findings of this research showed a statistically significant correlation between economic status and the level of glycemic control, such that individuals with better economic status achieved better glycemic control, and individuals with a low economic status couldn't achieve proper glycemic control. This was also confirmed by the findings of Dai's research.[4] It has been proved that the diabetics' health care costs (such as doctors' fee, the cost of drugs, the cost of diabetic diets, etc) are very high, and the high cost of supplying these nutrients and achieving healthy lifestyles may preclude proper glycemic control in the poor. Having a good economic status ensures selecting and purchasing proper nutrients for diabetics; various sport devices, specialized books and journals regarding diabetes, etc, and therefore directly influences self-care in these patients. [21, 22]

Educational level is also considered an influential factor in glycemic control. In the present research, elderly with academic education achieved better glycemic control. This finding was also confirmed by the results of research performed by Schwartz. [12]

Statistical tests didn't reveal any correlation between glycemic control and variables such as age, gender, occupation, the number of family members, the family type, the type of therapy, and the duration of disease. This finding was also confirmed by the results of research performed by Suppapitiorn.

The cross-sectional nature and the low number of subjects were the most important limitations of the present research. Performing longitudinal research with more subjects may explain the "cause and effect" relationships among the findings of this research.

Suggestions

In spite of the aforementioned limitations, the findings of this research and other research revealed that proper glycemic control is correlated to family support. Regarding these findings and also the important role of family in taking care of the elderly and supporting them, we recommend that health care givers take advantage of participating family members in the treatment of diabetics. For example, the family members of the diabetic elderly should also attend educational sessions, so they would be encouraged to play a more active role in the treatment of diabetic patients.

According to the findings of this research, diabetics living in isolation had received the least family support. Therefore we recommended that the medical team be one of the resources of social support. Regarding economic factors influencing glycemic control it is recommended that the community resources available to support these people, need to be introduced as active centers to which they can be referred.

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