Ann. N.Y. Acad. Sci.

ISSN 0077-8923

A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S
Issue: The Year in Diabetes and Obesity

Family interventions to improve diabetes outcomes

for adults
Arshiya A. Baig, Amanda Benitez, Michael T. Quinn, and Deborah L. Burnet
Department of Medicine, University of Chicago, Chicago, Illinois

Address for correspondence: Arshiya A. Baig, M.D., M.P.H., Section of General Internal Medicine, University of Chicago,
5841 S. Maryland Ave. MC 2007, Chicago, IL 60637. abaig@uchicago.edu

Diabetes self-care is a critical aspect of disease management for adults with diabetes. Since family members can
play a vital role in a patient’s disease management, involving them in self-care interventions may positively influence
patients’ diabetes outcomes. We systematically reviewed family-based interventions for adults with diabetes published
from 1994 to 2014 and assessed their impact on patients’ diabetes outcomes and the extent of family involvement. We
found 26 studies describing family-based diabetes interventions for adults. Interventions were conducted across a
range of patient populations and settings. The degree of family involvement varied across studies. We found evidence
for improvement in patients’ self-efficacy, perceived social support, diabetes knowledge, and diabetes self-care across
the studies. Owing to the heterogeneity of the study designs, types of interventions, reporting of outcomes, and
family involvement, it is difficult to determine how family participation in diabetes interventions may affect patients’
clinical outcomes. Future studies should clearly describe the role of family in the intervention, assess quality and
extent of family participation, and compare patient outcomes with and without family involvement.

Keywords: family-based; diabetes; self-management

Background with diabetes2 . For adults with type 2 diabetes,

engaging in diabetes self-care activities is associ-
The burden of diabetes
ated with improved glycemic control and can pre-
According to the Centers for Disease Control and
vent diabetes-related complications2–5 . Much of a
Prevention, over 29 million adults in the United
patient’s diabetes management takes place within
States are living with diabetes1 . In 2012 alone,
his/her family and social environment6 . Address-
1.7 million adults were newly diagnosed with
ing the family environment for adults with dia-
diabetes1 . People with diabetes are at risk for numer-
betes is important since this is the context in which
ous complications, including diabetic retinopathy,
the majority of disease management occurs. The
nephropathy, neuropathy, cardiovascular disease,
Institute for Patient- and Family-Centered Care
amputations, and premature death1 . The manage-
defines family members as two or more persons
ment of diabetes can be relatively complex for
who are related in any way—biologically, legally,
patients. They must attend multiple physician visits
or emotionally7 . Thus, family members can include
per year; adhere to several different types of medi-
nuclear, extended, and kinship network members8 .
cations to control their disease; participate in many
Family members can actively support and care for
facets of self-care, including home glucose moni-
patients with diabetes9 . Most individuals live within
toring, healthy eating, and exercise; and negotiate
a household that has a great influence on diabetes-
barriers to management, such as cost of care and
management behaviors10 . A study of more than
balancing work and life commitments2 .
5000 adults with diabetes highlighted the impor-
Importance of family in diabetes self-care tance of family, friends and colleagues in improving
Diabetes self-management education (DSME) is well-being and self-management11 . Family mem-
a critical component of care for all individuals bers are often asked to share in the responsibility

doi: 10.1111/nyas.12844
Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
C 2015 New York Academy of Sciences. 89
Family interventions to improve diabetes outcomes for adults
of disease management. They can provide many
forms of support, such as instrumental support in
driving patients to appointments or helping inject
insulin and social and emotional support in help-
ing patients cope with their disease12,13 . Through
their communications and attitudes, family mem-
bers often have a significant impact on a patient’s
psychological well-being, decision to follow recom-
mendations for medical treatment, and ability to
initiate and maintain changes in diet and exercise14 .
Among middle-aged and older adults with type
2 diabetes, social support has been found to be
associated with improved self-reported health in
long-term follow-up15 . Family cohesion and fam-
ily functioning have also been found to be posi-
tively related to patients’ self-care behaviors and to
improvements in blood glucose control16–19 .
Providing diabetes education to just the individ-
ual with type 2 diabetes could limit its impact on
patients, since family may play such a large role in
disease management. Family-based approaches to
chronic disease management emphasize the context
in which the disease occurs, including the family’s
physical environment, as well as the educational,
relational, and personal needs of patients and family
members12,20 . Including family members in educa-
tional interventions may provide support to patients
with diabetes, help to develop healthy family behav-
iors, and promote diabetes self-management21 .
The negative ways family can affect diabetes
Patients’ family and friends can provide support
in overcoming barriers in executing diabetes self-
management, but behaviors of family members
also have the potential to be harmful22 . How the
family is structured and its beliefs and problem-
solving skills or lack thereof can exacerbate the
stresses associated with disease management12 . The
lifestyle changes required for optimal diabetes self-
management often conflict with established family
routines23 . Self-management tasks may necessitate
changing the types of food prepared and con-
sumed in the home, time away from work for
the family member to attend medical visits with
the patient, and reprioritization of family finances,
all which may affect family routines. Since family
members participate in purchasing groceries, creat-
ing family schedules, and cooking meals, they can
help or hinder necessary lifestyle changes for peo-
ple with diabetes22 . In studies of adults with type
90 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
Baig et al.
2 diabetes, participants have reported that fam-
ily members’ non-supportive behaviors were asso-
ciated with being less adherent to one’s diabetes
medication regimen and with having poorer glu-
cose control24–26 . Family members may sabotage or
undermine patients’ self-care efforts by planning
unhealthy meals, tempting patients to eat unhealthy
foods, or questioning the need for medications25,27 .
Family members may also nag or argue with patients
in an attempt to support adherence25,28 . One study
found that pressure from a spouse regarding a
patient’s diet is associated with higher diabetes-
specific distress among adults with type 2 diabetes29 .
A family’s obstructive behaviors may be more harm-
ful among adults with limited health literacy and
patients who are experiencing other stressors or
major depressive symptoms26,30 . Hence, diabetes
self-management interventions should focus not
only on the individual patient, but also on the fam-
ily members, so that they are better equipped to
positively support their loved one with diabetes25 .
Supporting family
Diabetes self-management interventions may need
to place greater emphasis on targeting family mem-
bers’ communication skills and teaching them pos-
itive ways to influence patient health behaviors31 .
Family members can feel distressed by their loved
one’s diabetes28,32–34 due to limited knowledge
about diabetes or not knowing how to support their
loved one12,27,35–37 . Family may also have miscon-
ceptions, such as believing the patient knows more
about diabetes than the patient actually reports
or not understanding their loved one’s needs in
diabetes management27,38 . Knowledge about the
disease, strategies to alter family routines, and opti-
mal ways to cope with the emotional aspects of
the disease are some of the aspects of diabetes self-
management that family members need39 . Educat-
ing family members about diabetes-care needs can
help ease this strain by explaining why these changes
are necessary, how these changes can best be imple-
mented, and where to find additional information,
such as healthy recipes or exercise routines24 . Effec-
tive family management can also reduce the strain
that family members may experience when cop-
ing with altered lifestyles and disease progression24 .
It is important to provide family members with
information about the illness and possible treat-
ment options, validate their experiences as providers
C 2015 New York Academy of Sciences.
Baig et al.
of support, teach them various stress management
skills, and help them plan for the future31 .
Influencing family member outcomes
Carefully designed studies are needed to evaluate the
benefits of diabetes self-management interventions
for both the patient and the family member40 . How
families manage chronic disease affects not only the
patient’s health, but the health of others in the fam-
ily as well12 . Assessing family members’ knowledge
in diabetes self-care and perceived ability to support
their loved one with diabetes may be important end
points for diabetes self-care interventions. Family
members may also benefit more directly by reduc-
ing their own psychological distress regarding their
loved one’s diabetes and by improving their own
health behaviors through attending health educa-
tion programs32,41,42 . Furthermore, family members
at high risk for diabetes may decrease their own like-
lihood of developing diabetes through improved
lifestyle behaviors and weight loss. In a review
of randomized controlled trials of chronic disease
interventions, benefits for family members were
rarely assessed40 .
Importance of culture
The importance of family involvement in diabetes
self-management has been demonstrated across
patients from various racial and ethnic minority
populations43–45 . A systematic review of DSME
interventions among older adults with diabetes
from ethnic minorities found that characteristics
of successful interventions included involvement
of spouses and adult children44 . In another study
among African American women with diabetes,
many women noted that support primarily came
from family27 . In a study of Korean immigrants
with type 2 diabetes, family support specific to
diet was significantly associated with better glucose
control43 . In American Indian populations, active
family nutritional support was significantly asso-
ciated with control of triglyceride, cholesterol, and
A1c levels46,47 . Furthermore, among many Latinos,
familismo, the importance of family and family-
centeredness, is an important cultural value8 .
Tailoring clinical care and developing novel educa-
tional approaches that include family and commu-
nity are central to improving the health of Latinos
with diabetes8 . Studies of Latinos with diabetes have
found that including family members in educa-
tional interventions may promote patients’ diabetes
Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
C 2015 New York Academy of Sciences.
Family interventions to improve diabetes outcomes for adults
self-management21,48,49 . Understanding a patient’s
cultural and family environment is important in
supporting diabetes self-care and in considering
how to culturally tailor interventions for patients
from racial/ethnic minority populations.
Including family members in diabetes
interventions
Recognition of the important role that family mem-
bers play has led increasingly to incorporating the
index patient’s family members into diabetes self-
management interventions50 . Family members play
an especially significant role in managing diabetes
for children and adolescents; thus, most family-
based interventions to date have targeted children
with diabetes20,51,52 . A review of family-based inter-
ventions for patients with diabetes mellitus con-
ducted in 2005 found that most family interventions
for diabetes in the previous 15 years were among
youth and adolescents with type 1 diabetes, but few
studies had focused on adult patients and their fam-
ily members20 .
Among adults, inclusion of a close family member
in psychosocial interventions for chronic conditions
may also be more efficacious than focusing solely on
the patient40 . For example, including family mem-
bers in educational interventions has been shown to
improve rates of smoking cessation53,54 and weight
loss55,56 . In a review of randomized controlled trials
of chronic diseases, interventions using a family-
oriented approach for adults were more benefi-
cial than solely patient-oriented interventions40 . In
a review of interventions for couples and families
managing chronic health problems, including com-
mon neurological diseases, cardiovascular diseases,
cancer, and diabetes, family interventions showed
promise in helping patients and family members
manage chronic illnesses57 .
Among adults with diabetes, interventions
including family or household members of peo-
ple with diabetes may be more effective than
usual care in improving diabetes-related knowl-
edge and glycemic control20,40,52,58–60 . Family
support has also been associated with improved
medication adherence and blood sugar control in
studies of adults with diabetes18,44,61,62 . Addressing a
diabetes patient’s social–environmental support has
been found to be positively associated with healthy
diet and exercise63 . However, several interventions
seeking to improve self-management behaviors by
91
Family interventions to improve diabetes outcomes for adults
increasing social support from family and friends
have shown varying results64–66 .
Conceptual framework
We found several published conceptual frameworks
that describe the theoretical underpinnings of a
family-based diabetes intervention for adults.
The Institute for Patient- and Family-Centered
Care provides guidance on the major concepts
underlying patient- and family-centered care across
health conditions7 . In family- and patient-centered
care, healthcare providers respect, listen to, and
honor patient and family perspectives and choices7 .
Patient and family knowledge, values, beliefs, and
cultural backgrounds must be incorporated into the
planning and delivery of care. Patients and families
require timely, complete, and accurate information
in order to effectively participate in care and deci-
sion making. Moreover, patients and families are
encouraged and supported in participating in care
and decision making7 . Key strategies in mobiliz-
ing family support for patients with chronic health
conditions may include guiding family members to
set goals for supporting patient self-care behaviors,
training family members in supportive commu-
nication techniques, and giving families the tools
and infrastructure to assist in monitoring clinical
symptoms35,59 .
In terms of interventions for patients with dia-
betes, others have described frameworks for the
inclusion of family in health interventions12,67,68 .
Clinical interventions may be most effective when
characteristics of patients that affect disease out-
comes are integrated with perspectives of the family
context12 . The family provides the arena in which
the patient, family member stress or support, and
healthcare factors intersect, providing an ideal locus
for meaningful intervention12 . Interventions must
address how the family is structured, how the family
solves problems, and how family members manage
emotions. Interventions must also address patients’
and family members’ beliefs and expectations, fam-
ily stresses, and allocation of the responsibilities
of disease management. Other frameworks stress
the importance of biculturalism and integrating
cultural knowledge, skills, practices, and identi-
ties into diabetes self-management interventions for
racial/ethnic minorities69 . Furthermore, couples-
based interventions ought to address the behav-
iors, feelings, and thoughts of both partners68 . This
92 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
Baig et al.
approach recognizes the interdependence of part-
ners, and that their interaction affects them both,
rather than simply the behavior of one affecting the
other70 .
Objective
Considering that adults with diabetes depend on the
support of family for assistance in managing their
diabetes, examining family-based interventions for
adults with diabetes is important in understanding
how to strengthen current diabetes self-care pro-
grams. In the past decade, several studies have tested
family-based interventions among adults with dia-
betes. We systematically reviewed published family-
based interventions for adults with diabetes from
the years 1994–2014, assessed the level of family
participation, and considered how this involvement
affected the patients’ outcomes.
Methods
We searched for family-based diabetes self-
management intervention articles published from
January 1994 to October 2014 using the elec-
tronic databases PubMed, CINAHL, and PsycINFO.
We used prespecified Medical Subject Headings
(MeSH) and keywords to identify evaluation stud-
ies (Evaluation, Effectiveness, Improvement, Con-
trolled clinical trial, Randomized, Randomized con-
trolled trials) that were designed to test diabetes
self-management interventions (Intervention, Edu-
cation, Self-management, Self-care, Problem solv-
ing, Program, Social support), were family-based
(Family, Couple, Significant others, Spouse, Rela-
tionship, Relatives, Caregiver, Partner), and targeted
adults with diabetes (Diabetes mellitus, Diabetes
mellitus, type 2). Appendix S1 describes in fur-
ther detail the search terms used in the database
searches. We supplemented our electronic database
search with a hand search of issues from selected
journals with a high likelihood of publishing dia-
betes self-management intervention studies (Dia-
betes Care and The Diabetes Educator). We also
hand searched related articles and references cited in
previously published systematic reviews of family-
based interventions20,31,40,52,57,60,65,71–73 .
To be included in our review, a study must have
been conducted in the United States, be published
in English or Spanish, and be focused on improv-
ing diabetes treatment processes and patients’ out-
comes. We included all study types in our review
C 2015 New York Academy of Sciences.
Baig et al.
(e.g., randomized controlled trials, prepost, and
pilot) that met our inclusion criteria. We excluded
studies that focused solely on diabetes prevention or
targeted patients under the age of 19 or women with
gestational diabetes. If studies included patients
with other chronic conditions other than diabetes
or included patients at risk for diabetes in addition
to patients with diabetes, we included only those
studies that reported results of subgroup analyses
conducted with the subsample of diabetic patients.
We excluded studies that only reported outcomes
aggregated across patients and family members that
made it difficult to interpret the impact of the pro-
gram on index patients with diabetes.
From the PubMed, CINAHL, and PsycINFO
database searches, we identified 2340 unique arti-
cles. Three co-authors (AAB, AB, and MTQ) inde-
pendently reviewed the titles and abstracts of the
first 10% of articles (234 articles) identified through
the database searches to determine whether arti-
cles met inclusion or exclusion criteria. We subse-
quently met to discuss discrepancies and to reach
consensus. We repeated independent review of the
titles and abstracts of the next 10% of articles two
more times until we reached a ␬ greater than 0.60,
which indicated moderate to substantial agreement
among reviewers. The remaining titles were then
divided among the three co-authors to indepen-
dently review. The title and abstract review yielded
a total of 200 articles in need of full text review to
determine their inclusion or exclusion in the sys-
tematic review.
Once we had established an adequate ␬, one co-
author (AB) completed a title and abstract review
of the 2010–2014 issues of Diabetes Care and 2009–
2014 issues of The Diabetes Educator. Through the
hand search, 76 additional articles were identi-
fied that were in need of full text review. Hand
searches of reference lists of relevant articles identi-
fied through the database and journal hand searches
yielded an additional 28 articles in need of full text
review.
We then divided the 304 articles from the database
and hand searches between three co-authors (AAB,
AB, MTQ) and independently reviewed the full
text of the selected articles. During the full text
review, we noted that many studies mentioned fam-
ily involvement in the interventions but lacked detail
on how the family was involved in the study pro-
cedures. Since our focus was on the family-based
Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
C 2015 New York Academy of Sciences.
Family interventions to improve diabetes outcomes for adults
nature of interventions, we included only studies
that described the role and activities of family mem-
bers in the intervention, provided a qualitative or
quantitative assessment of outcomes related to fam-
ilies, or reported outcomes associated with family
members’ participation. We excluded studies that
did not provide details in their background, meth-
ods, results, or discussion sections regarding the role
and activities of family members in the intervention
or outcomes related to family involvement. Cre-
ated using PRISMA guidelines, our literature-search
flowchart is depicted in Fig. 174 .
Data abstraction
We used a validated instrument to guide our
abstraction75 . We abstracted data from each study
into a table (Appendix S2) that included the objec-
tive of the study, the setting, the study design, the
population sampled, a description of the interven-
tion, and patient outcomes reported. Each study in
the table was given a quality score by two mem-
bers of the research team using an adapted ques-
tionnaire based on the Downs and Black guidelines
(27-point scale: 0 worst, 27 best)76 . The Downs and
Black questionnaire is a valid and reliable checklist
that assesses both randomized and non-randomized
studies, provides an overall score of study quality,
and includes five subscales that measure quality of
reporting, external validity, bias, confounding, and
power76 . We report the average of the two qual-
ity scores. We abstracted data into a separate table
(Table 1) to describe how the study defined family,
how family was involved, the level of family partici-
pation in the intervention, and any outcomes related
to family involvement.
Results
We identified 26 unique studies described in 46 arti-
cles that used family-based interventions to address
diabetes self-management and outcomes among
adults with diabetes. These studies are described in
detail in Appendix S2.
Study design
Of the 26 studies, 13 used a randomized controlled
trial (RCT) study design77–101 and 11 used a prepost
design21,50,102–113 . One study assigned individuals
to one of three arms based on their commu-
nity of residence114 . Another study reported
only postintervention measures115 . Participa-
tion and follow-up rates were high for many
93
Family interventions to improve diabetes outcomes for adults Baig et al.

Figure 1. Literature search flowchart. *Several articles were excluded for more than one reason, so numbers do not add up to 258.

studies, as noted in Appendix S2. Follow-up Intervention details

ranged from immediate postintervention to Of the 26 studies, 21 interventions were diabetes
12 months21,80–82,90,92,95,96,99,100,111,113,114,116 , 24 self-management interventions that offered group-
months77,83 , and 36 months78,79 . based or one-to-one individualized counseling.
One intervention was a cooking class112 . Four inter-
Populations and settings
ventions incorporated home visits77–82,102 . Three
Of the 26 studies, 22 recruited patients from racial/
studies used technology, including mobile com-
ethnic minority populations. Studies included
munication technology, to support serum blood
American Indian106,107,114,117,118 , African American
77–79,88,89,93,95,96,102–104,119 glucose monitoring108 , teletransmission for home
,Latino21,50,80–86,90–92,94,97,98,
101,103,104,112,119,120 glucose monitoring99,100 , and interactive voice
, and Asian, including Bangla-
response (IVR) to provide patient monitoring and
deshi American111,121 and Korean American99,100
self-care support between primary care visits109,110 .
patient populations. Two studies did not collect or
Interventions were led by community
report race/ethnicity data87,115 .
health workers (CHWs) or promo-
Studies also represented different regions across
toras77–79,90–92,94,97,98,103,104,111,119, nurses50,77–79,90–94,
the United States, including the Midwest104–107,109, 99,100,102,106,107,112
110,119 , pharmacists101,115 , certified dia-
, South21,88,89,93,95,96,101,102,108,113,115 , West/
betes educators (CDEs)87–89,93,94,97,98,102,112,113, peer
Southwest83–86,97,98,112,114,117,118,120 , East77–81,87,94,99,
100,111,121 or lay leaders50,80,82,95,96,114,117 , registered dieti-
, and along the Texas–Mexico border50,
90–92 tians (RDs) or nutritionists50,80,82,83,85,86,90–93,95,96,
. Several were conducted in rural settings21,50, 99,100,102,106,107,112,115,120
88–93,102,113 , physicians106,107,115 , mental
or urban settings77–86,94,99,100,103,104, 87,106,107,115
106–108,111,115,119–121 health providers , nurse practitioners21,
. Two studies were conducted in 113 80,82
, health educators , tribal elders/leaders106,107 ,
Native American communities 106,107,114 . 115
and dentists .
Interventions took place in diverse settings, inclu-
ding community health centers21,97,98,111 , other
Outcome measures
community sites47,50,80–82,88,89,91,92,99–101,103,104,106,
107,111–113
, academic medical centers77,94,105,115 , Patient clinical outcomes
95,96
churches , and Veterans Administration (VA) Clinical outcomes for index patients with dia-
hospitals109,110 . betes varied across studies. Of the 19 studies

94 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 

C 2015 New York Academy of Sciences.
Baig et al. Family interventions to improve diabetes outcomes for adults

Table 1. Family participation in the interventions and family outcomes

Quality
Definition Description of family Level of family Family score
Reference of family involvement participation outcomes (out of 27)
Gary (2004)78 Not reported The clinical algorithms used in the Not reported None reported 24.5
Gary (2009)79 intensive intervention addressed
several areas, including
socioeconomic issues, and took
into consideration patients’
caregiver concerns. Also as part
of the intensive intervention, the
community health workers
(CHWs) made home visits to
study participants and reported
interacting with family, for
example, in teaching family
members of a patient with poor
eyesight to perform glucose
monitoring and in reviewing
foods in the kitchen cabinet and
refrigerator.
Gary (2003)77 Not reported The CHW was intended to serve as Not reported None reported 23.5
a liaison between the healthcare
system and the family, in
addition to providing diabetes
education and social services. She
monitored participant and family
behavior, reinforced adherence to
treatment recommendations, and
mobilized social support.
Anderson-Loftin Family members A traditional African American Not reported None reported 23
(2005)93 (AA) meal prepared with low-fat
techniques and ingredients was
served to participants and family
members following most classes.
Meals were framed as social
events, such as a church
homecoming supper or Fourth of
July picnic. Participation of
family members was encouraged
not only to integrate AA cultural
traditions associated with food
but also to capitalize on the value
of family and to provide
transportation, a common
barrier in rural areas. The peer–
professional discussion groups
used an approach that facilitated
emotional support from peers
and family and is the preferred
group structure of southern AAs.
Rosal (2009)82 Significant others SOs were invited to attend the group Not reported None reported 22
Rosal (2010)81 (SOs), defined as sessions to elicit home-based
Rosal (2011)80 family members or support. Group sessions included
friends living in culturally popular activities (e.g.,
the participant’s eating together as a family and, if
household possible, involving the family).
Group meals accompanied by
discussion guides stimulated
discussion around ways of
implementing the recipes at
home, acceptability to family and
friends, and steps to trying new
eating styles at home.

Continued

Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 

C 2015 New York Academy of Sciences. 95
Family interventions to improve diabetes outcomes for adults Baig et al.

Table 1. Continued
Quality
Definition Description of family Level of family Family score
Reference of family involvement participation outcomes (out of 27)
Samuel-Hodge Family members and One intervention focus was on Not reported None reported 21.5
(2006)95 friends organizing education around the
Samuel-Hodge “church family,” which included
(2009)96 congregants, family, and friends.
This focus was viewed as one way to
deliver the intervention in a
culturally appropriate and sensitive
manner. Family members were
included as study participants and
family and friends were invited as
guests to group sessions.
Vincent (2007)97 Support person; Participants were encouraged to bring Not reported In postintervention 21
Vincent (2009)98 family member a support person to the 8 weekly 2-h focus groups,
group sessions since support from participants
friends and family has been shown reported they and
to improve glycemic control. their families
Inclusion of cultural content benefited from the
included addressing family issues. intervention.
Additionally, participants were given “Benefit to
low literacy, Spanish-language families” was one
materials to share with their family of only two major
members. The cultural concept of themes identified
familismo (family support and in the focus group
cohesiveness) and the importance of data. Family
family support to facilitate lifestyle benefited from
changes needed for diabetes healthier eating
self-management was the basis for and became more
including family in the intervention. supportive of
participants’
lifestyle changes.
Toobert (2010)84 Family members The social support group component Not reported Family support had 21
Toobert taught participants how to problem an effect on
(2011a)83 solve and how to mobilize social increases in
Toobert support among family and friends. physical activity
(2011b)85 The intervention also included a (PA) even after
Osuna (2011)120 “Family Night” where family accounting for the
Barrera (2014)86 members could join participants effects of group
during the social support group support. Study
portion of the meeting, hear an authors suggested
overview of ¡Viva Bien! activities, the finding might
celebrate the diabetes participants’ be attributed to
achievements, and exchange the involvement of
questions and answers. Family family in the
nights were viewed as vehicles for intervention and
increasing the families’ support for dedicating sessions
participants’ intervention to the
engagement. Families were also mobilization of
invited to a final celebratory family and friend
meeting. The involvement of family support.
was viewed as being consistent with
the Latino cultural value of
familismo.
Aikens (2014a)109 Family member or Patients received weekly interactive 39% of patients Rates of engagement 21
Aikens close friend living voice response (IVR) calls to assess participated with were higher
(2014b)110 outside the health status and self-care and to an informal among patients
patient’s home provide tailored, prerecorded caregiver; based on enrolling with an
(informal support messages. Patients could opt patients’ feedback informal caregiver
caregiver); to be to designate one family member or at baseline, the (87.7% of
eligible, informal close friend to receive emailed lack of caregiver assessments
caregivers needed summaries of each completed call involvement was completed versus

Continued

96 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 

C 2015 New York Academy of Sciences.
Baig et al. Family interventions to improve diabetes outcomes for adults

Table 1. Continued
Quality
Definition Description of family Level of family Family score
Reference of family involvement participation outcomes (out of 27)
to be ࣙ18 years along with structured suggestions usually due to 81.6% for those
old, have no for supporting the patient’s DSM. personal not participating
history of Participating caregivers preference and not with an informal
cognitive or severe underwent DVD-based training unavailability of a caregiver, P =
psychiatric on communicating effectively with person to play this 0.008). Patients
impairment, and the patient and any in-home role. Caregiver who participated
have access to caregiver that may be involved. participation was with an informal
email. Intervention strategies were based significantly more caregiver were less
upon the assumption that likely among likely to report
patients, informal caregivers, and patients with frequent high
healthcare teams can use frequent lower income and glucose levels
information updates about the lower health (P = 0.021) and
patient’s health and self-care to literacy levels. more likely to
promptly identify emerging regularly check
problems and improve illness their blood
self-management. One of the pressure (BP)
overall goals of the intervention (P = 0.017) than
was to generate guidance on DSM those patients not
support for patients’ informal participating with
caregivers via structured emails. an informal
caregiver.
Kim (2009)99 Family members During the educational program, Not reported None reported 20.5
Song (2010)100 study participants, their family
members, CHWs, and diabetes
educators actively engaged in
group education in a synergistic
manner. The program recognized
the traditional Korean cultural
values of close familial
interdependence and social
relationships. The researchers
encouraged the active involvement
of other family members in the
group education to create a
synergistic group interaction while
building an environment
promoting family and social
support. This strategy was
intended to enhance the deep
cultural tailoring of the
intervention by supporting the
social/environmental forces
influencing health behavior.
Brown (2002)91 A family member, Subjects were required to identify a Not reported None reported 20
Brown (2005)92 preferably a spouse family member or close friend to
Brown (2013)90 or first-degree participate with them in the
relative, who intervention as a support person.
would participate Family/friends were invited to
as a support attend 12 weekly education
person. If a family meetings and 14 biweekly support
member was not group meetings to talk about DSM
available, a close problems and the impact of
friend diabetes on the family. Social
participated. support was fostered through
family members and friends, as
well as other group participants
and intervention leaders. Group
leaders emphasized support from
family members and encouraged
support persons to improve their
health habits.

Continued

Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 

C 2015 New York Academy of Sciences. 97
Family interventions to improve diabetes outcomes for adults Baig et al.

Table 1. Continued
Quality
Definition Description of family Level of family Family score
Reference of family involvement participation outcomes (out of 27)
Two Feathers Family members; Kieffer (2004) reports preliminary Not reported Postintervention, 20
(2005)103 family member or focus group findings that identified patients with
Two Feathers friend the importance of family support for diabetes reported
(2007)107 DSM and led to the inclusion of they were
Kieffer (2004)119 family members in the intervention encouraging their
and family and social support being family members to
a key characteristic of the eat healthier meals
intervention. Participants were and to exercise
encouraged to bring a family with them.
member or friend to group diabetes
self-management education (DSME)
meetings. The Family Health
Advocates worked with patients with
diabetes and their family members,
providing them group DSME
classes, case management and
referral services. Role-playing was
used to improve communication
with family members about DSM.
Utz (2008)88 Supportive family Supportive family and/or friends were 6 family members Several of the 20
Jones (2008)89 and/or friends invited to selected group sessions to and friends (1 participating
obtain information about diabetes mother, 1 adult support persons
and family/peer support. During son, 2 friends, 1 expressed that
one of the sessions, family members adult daughter, they appreciated
and friends were given a “Helpful and 1 wife) came the opportunity to
Hints for Family Members” to the invited attend one session
guideline developed by two of the sessions. with their loved
study’s authors about how to be one to understand
supportive to the person with diabetes better.
diabetes. Along with the guideline,
the family member or friend had an
opportunity to view three videos
about family communication
around diabetes. The facilitator also
guided a discussion during which
time family members could ask
questions and share their
experiences and the participants
could discuss how interactions
between those with diabetes and
their family members/ friends
affected DSM. Family and friends
were also invited to participate in a
cooking demonstration by a dietitian
to show how to cook healthy meals
that are easy and taste good.
Castejón Either a family The support person was asked to come 67% of control and None reported 19.5
(2014)101 member or a with the study participant for every 79% of the
friend clinical screening and educational intervention
Attending partners session, when available. Both the group patients had
were a spouse, participant and support person a partner attend at
friend, sibling, or received a physical assessment at the baseline; 42% of
child clinical screenings, including a controls and 33%
recording of weight, height, waist of the intervention
circumference, body mass index group had
(BMI), and BP. Participants were partners at both
given two copies of their clinical clinical screening
results, one for their primary care visits.
provider and one for their own
records, and were

Continued

98 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 

C 2015 New York Academy of Sciences.
Baig et al. Family interventions to improve diabetes outcomes for adults

Table 1. Continued
Quality
Definition Description of family Level of family Family score
Reference of family involvement participation outcomes (out of 27)
debriefed about their clinical values. Most partners were
During the group educational female and had an
session, the pharmacist led a closing average age of 48
discussion that focused on (20–77) years.
misconceptions brought up by
participants and their partners
during the earlier focused discussion
group that was moderated by a
project coordinator (Master in
Public Health level). Family was
involved in the study because the
patient’s family was viewed as one of
three major social and
environmental factors affecting a
patient’s DSM and should thus be a
target for DSM interventions to
encourage appropriate nutrition,
exercise, self-management, medical
treatment, involvement, and
support.
Gilliland In the family and Gilliland (1998) and Carter (1997) Not reported None reported 19
(2002)114 friend (FF) arm, report on preliminary research that
Gilliland patients with led to the inclusion of family and
(1998)117 diabetes received addressing family support in the
Carter (1997)118 the intervention in intervention. The FF arm included
family and friend activities to encourage social
groups interaction and discussion about
diabetes among members of the
group. The mentor encouraged them
to discuss and share their stories
about living with diabetes. The FF
arm joined in physical activities as a
group and shared a healthy meal.
Corkery (1997)94 Family member Family members could attend Patients were defined None reported 18.5
education sessions. In the CHW as having family
arm, the CHW acted as a liaison participation if a
between the patients, their families, family member
and health care providers. attended most of the
For the non-CHW intervention group, education sessions.
encounters took place only between The family
the nurse and the patient and family participation rate
member. was 31%.
Hu (2014)21 Adult family member There were two family sessions, for 37 family members Significant changes in 17.5
who resides in the which the family unit, including enrolled in the family member BMI
diabetes patient’s multiple members, was invited. The study. (–0.25 kg/m2 ) and
household, is ࣙ18 first family session explained the At baseline, family diabetes knowledge
years of age, and is purpose of the study, the format of members were from baseline to
willing to the intervention, and requirements primarily female postintervention.
participate of participants. Informed consent (70%) with an No significant
was obtained from the participant average age of 40.6 changes in waist
and participating adult family years and an average circumference, BP,
member, and baseline data were BMI of 32.7 kg/m2 ; PA, and fruit and
collected. The last family session 51% had vegetable
included postintervention data hypertension, 87% consumption, but
collection and discussions with had a high school trend noted in SBP,
family members about DSM. Each education or less, PA, and fruit and
participant was also asked to bring at 89% had a vegetable
least one family member to the 8 household income consumption (0.05
weekly group intervention meetings <$10,000, and 78% < P < 0.09).
that took place between the two were from Mexico.

Continued

Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 

C 2015 New York Academy of Sciences. 99
Family interventions to improve diabetes outcomes for adults Baig et al.

Table 1. Continued
Quality
Definition Description of family Level of family Family score
Reference of family involvement participation outcomes (out of 27)
family sessions. A group discussion
with open-ended questions on
family support was facilitated at the
end of the first and last group
meetings. The last group session also
included a celebration of completion
of the program for both participants
and family members with a
certificate and food. Focusing on
family involvement and family
centeredness was viewed as an
important aspect of the intervention
due to the Hispanic cultural value of
familismo. Support from family
members was viewed as an
important social factor affecting
behavior change; thus, the
intervention focused on fostering
behavioral changes through building
family support.
Williams Supportive family One intervention strategy was Not reported None reported 16
(2014)113 member or friend involving a key family/friend as a
to serve as a supporter for achieving patient DSM
support person goals. Some of the group DSME
sessions also involved the
participation of a supportive family
member or friend to encourage
shared learning and to enhance the
ability of the support person to
know how to be helpful.
Anderson-Loftin Family members Families were encouraged to The article reports None reported 15.5
(2002)102 participate in the dietary education many family
group sessions and discussion members actively
groups to capitalize on the value of participated in the
family and to provide cooking class.
transportation. Healthy meals were
served to participants and family
members at the end of the first class.
The second class was a cooking class,
and after the meal preparation,
participants and family dined and
were encouraged to share their own
healthy recipes. The home visit by
the nurse case manager (NCM) was
also meant to solicit family support.
Kluding Family members or Family members or other supportive Not reported None reported 15
(2010)105 other supportive people were invited for all
people educational sessions and were
specifically included for two sessions:
“family support day” in week 5 and
“graduation ceremony” in week 10.
Trief (2011)68 Couples were In the couples’ intervention arm, Not reported None reported 14.5
enrolled; patients patients and partners participated in
with diabetes and exercises to promote collaborative
their partners both problem solving as they worked on
had to be >21 their goals. The intervention
years of age and included two phone calls on
been married or speakerphone that focused on
partnered >1 year couples’ communication,

Continued

100 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 

C 2015 New York Academy of Sciences.
Baig et al. Family interventions to improve diabetes outcomes for adults

Table 1. Continued
Quality
Definition Description of family Level of family Family score
Reference of family involvement participation outcomes (out of 27)
particularly around emotions and
situations that might be
problematic for the patient, so that
the partner could share his/her
feelings and they could discuss ways
to problem solve together.
Homework and discussion tasks
involved both partners in goal
setting, contracting, and skills to
improve communication.
Islam (2013)111 Family members Islam (2012) reports on focus group Not reported CHWs qualitatively 14.5
Islam (2012)121 findings that led to the inclusion of reported having an
family and addressing family impact on family
support in the intervention. Based members and on
on the findings from the facilitating family
preliminary focus group study, it support between
was determined that strategies to participants and
overcome family conflict and their family
promote positive family members.
communication and family
activities to promote social support
would be incorporated into the
intervention. Thus, “Effects of
family support on managing stress”
was one of the session topics. CHWs
also encouraged family support
during the one-on-one visits.
Brown (1995)50 A family member, Each participant was required to On average, family Family members 14
preferably a spouse identify a support person who members/support indicated in
or first-degree would participate in the educational persons attended 6 postsession
relative who would and support sessions. The bilingual of the 9 meetings. interviews that the
participate as a Mexican-American lay community The size of the group, sessions helped
support person. If worker conducted follow-up 6 patients and 6 them to improve
a family member support sessions with family members, their health
was not available, patients/families after the education was deemed practices,
a close friend sessions were done. One of the appropriate by particularly with
participated. emphases during sessions was participants. regard to
support from family, friends, and nutrition.
other subjects. Family/friends were Patients reported in
invited to the support session to talk postsession
about DSM problems and the interviews that
impact of diabetes on the family. having family
Encouraging support from family members/support
members and motivating them to persons at the
improve their health habits was also sessions was very
emphasized. helpful.
Mendenhall Family members, Family members attended all meetings Not reported, except None reported 13.5
(2010)106 including patients’ of the Family Education Diabetes in saying that
Mendenhall spouses, parents, Series program. They were involved generally 35–40
(2012)107 and/or children in data collection by checking and community
recording each other’s blood sugar, members,
weight, and BMI and by conducting including patients
foot checks. Family members were and family
viewed as program participants but members,
not enrolled as study participants attended meetings
for the purposes of the research
study. The program also had a
session topic specifically focusing
on family relationships and social
support.

Continued

Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 

C 2015 New York Academy of Sciences. 101
Family interventions to improve diabetes outcomes for adults Baig et al.

Table 1. Continued
Quality
Definition Description of family Level of family Family score
Reference of family involvement participation outcomes (out of 27)
Roblin (2011)108 A supporter, defined A family member, relative, or close Patient and Qualitative findings 12
as a family friend was asked by the patient to supporter indicated that
member, relative, serve in the support role. During the attended both the support persons
or close friend enrollment session, supporters were enrollment and reported an
whose support instructed in motivational coaching disenrollment improved ability
and opinion were so they could provide effective sessions and confidence to
valued by the feedback to the diabetes patient and provide emotional
diabetes patient, help assess barriers to effective and instrumental
who did not live in self-monitoring of blood glucose support to their
the patient’s same (SMBG). During the intervention, a paired diabetes
household, and summary of SMBG adherence and patient in their
who agreed to results were sent to the patient or SMBG and an
enroll in the study support person to prompt improved social
as a support conversations and facilitate proximity to their
person supportive relationships in order to paired diabetes
reinforce the importance of SMBG patient.
and achieving good glucose control.
Both the patient and supporter were
asked for input about the
intervention at the disenrollment
session.
Archuleta Family members Family members were invited to attend Class participants None reported 12
(2012)112 four 3-h cooking/nutrition classes included family
with their family member with members without
diabetes. Conducting the education diabetes, but only
together with caregivers or spouses data from diabetes
and in a community setting with patients was
food that is socially acceptable was reported.
intentionally incorporated into the
intervention as a strategy to build
social support.
Glueck (2014)115 Loved ones; a spouse The goal of the diabetes management In 2007, 6 of 24 None reported 10
or family member and treatment support groups was to (25%) patients
provide education and support to enrolled brought a
individuals diagnosed with diabetes spouse. In 2008, 3
and their loved ones and to promote of 19 (16%)
DSM. Another critical goal for these enrolled brought a
groups was that individuals spouse. In 2009,
diagnosed with diabetes and their attendance data
family members be active was not available
participants rather than simply for the 14 patients
attend the program passively and to who registered for
make the group about the process the series.
and an experience for enhanced
learning for families. Incorporation
of family members active in the
caregiving process in the groups was
viewed as important because
diabetes affects the family, and
treatments and recommendations
must be changed within the context
of the patient’s social, cultural, and
ecological environment. As such,
when patients registered, they were
encouraged to bring a spouse or
family member to weekly meetings
to also share and receive support
from the group.

102 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 

C 2015 New York Academy of Sciences.
Baig et al.
that reported A1c, 11 found significant improve-
ments50,80,83,85,91,94,96,99,102,103,106,114 . Seven studies
noted improvement in A1c from baseline to post-
intervention50,91,94,96,99,103,106 , while others reported
improvements from baseline to 5 months post-
intervention102 , 30 weeks postbaseline99 , 7.7 months
postbaseline94 , and 12 months postbaseline91 . Four
studies demonstrated short-term improvements in
A1c that were not maintained at 6 months106 , 12
months80,96 , or 24 months85 .
Of the 11 studies that reported blood pressure
outcomes, three demonstrated short-term improve-
ments in blood pressure21,96,106 , two reported
improvements at 12 months113,114 , and one reported
improvements in diastolic blood pressure at
24 months77 . Among the nine studies tracking
weight, four noted significant weight loss over
time93,98,101,106 . Of nine studies reporting body-mass
index (BMI), three found improvements in BMI
in the short-term83,85,101,113 ; however, for one study
these results were not sustained at 12 months113 .
Three of 11 studies assessing cholesterol showed
improvements in lipid profiles77,87,99 .
Patient psychosocial outcomes
Several studies assessed psychosocial outcomes for
patients. All three studies measuring depression
found improvements in patients’ reported depres-
sive symptoms99,109–111 . One study measured dia-
betes distress and found improvements109,110 . Of
the four studies that assessed quality of life, three
demonstrated improvements21,96,99 . Of 10 studies
measuring self-efficacy, seven found improve-
ments21,80,83,85,99,105,108,111 . The ¡Viva Bien! program
also noted improvements in patients’ perceived
supportive resources83,85 . One study reported that
patients felt increased emotional and instrumental
support in blood glucose self-monitoring108 .
Patient diabetes self-management behaviors
Of the 13 studies measuring diabetes knowl-
edge, 12 noted improvements in patients’ dia-
betes knowledge21,50,80,91,94,96,99,103,107,111,113,115 . Of
15 studies assessing diet, 11 demonstrated improve-
ments in dietary habits21,80,83,85,93,94,102,103,107,111,
112,115
. A study utilizing cooking classes showed sig-
nificant improvements in dietary behaviors, includ-
ing caloric intake, saturated fat, cholesterol, and
fat consumed112 . Out of 12 studies assessing exer-
cise, five found improvements in patient physical
activity83,85,107,111,113,115 . However, one study found
Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
C 2015 New York Academy of Sciences.
Family interventions to improve diabetes outcomes for adults
that improvements in physical activity were not sus-
tained at 12-month follow-up113 . Six out of eight
studies measuring patients’ blood glucose monitor-
ing noted improvements21,80,97,108–110,115 , and two
out of six measuring medication adherence noted
improvements109,115 . Some studies found improve-
ments in some self-care behaviors but not in
others21,97,98,103,111,113 .
Healthcare utilization
One study found a significant decrease in emer-
gency room visits by intervention participants but
not in the number of hospitalizations79 . Another
study found improvements in the number of acute
care visits but no change in length of hospital stay102 .
Cost
Only two studies reported the cost of the inter-
vention91–93 .
Patient outcomes by family involvement
Of the 26 studies, 17 studies did not report
patient outcomes by family involvement77,79,80,
88,89,93,96–103,105–107,111–113,115
. Four studies required
patients in all arms to enroll with a family member/
support person, thus precluding them from assess-
ing outcomes by family involvement21,50,90,91,108 .
Three studies reported positive effects of fam-
ily involvement. Barrera reported that family sup-
port had an effect on increases in physical activity
after accounting for the effects of group support86 .
Gilliland demonstrated a decrease in diastolic blood
pressure in the family arm114 . Aikens conducted
subgroup analyses comparing patients with fam-
ily involvement to those without and found that
patients enrolling with an informal caregiver had
higher rates of engagement, were less likely to
report frequent high glucose levels (P = 0.021), and
more likely to regularly check their blood pressure
(P = 0.017)110 .
However, two studies found no impact of
family involvement. One reported results from
subgroup analyses comparing patients with family
involvement to those without and found that
family participation in education sessions was not a
significant factor in program completion94 . In their
telephone-based intervention, Trief et al. compared
outcomes of patients with family involvement to
those without and, contrary to their hypothesis,
found that results in the individual intervention
103
Family interventions to improve diabetes outcomes for adults
group appeared to be better overall than those in
the couples intervention group87 .
Family participation and outcomes
Table 1 describes family participation in the inter-
ventions and family outcomes. Of 26 studies,
most defined family members as spouses, par-
ents, children, or relatives50,80,82,90–92,106,108,115 . One
study involved couples87 . Two studies required
that the family member reside in the patient’s
household21,80,82 . Many studies stated that family
members were included in the intervention with-
out explaining who they defined as a family
member. Some studies included other support-
ive people105 or friends in lieu of a family
member for index participants who chose this
option50,88–91,101,103,104,113,114 . One further specified
that the friend had to be living in the partici-
pant’s household80–82 , while another stated the fam-
ily member or close friend must be someone living
outside the patient’s home109,110 .
Family involvement varied across studies.
Most studies noted that families were invited to
attend the intervention classes or meetings21,50,80,
82,83,85,89,91,93–95,97,98,100–102,106,107,112,113
. In some
studies, authors stated that family members were
enrolled in the study21,87,95,108 . Some interventions
included family-themed topics in the education ses-
sions, such as support of family in managing stress
and traditional cultural values regarding familial
and social relationships21,80,82,88,89,93,97,98,100,103,104,
111,119,121
. In other studies, family participated
in physical activities or shared a healthy meal83,
85,88,89,93,114,120
. Family support was encouraged by
CHWs77–79,100,111,121 . Excluding the interventions
that specifically enrolled dyads21,50,87,90,91,108 , only
some studies noted actual rates of family
participation50,89,94,101,109,110,115 , which ranged
from 16% to 79%.
In Aikens et al., patients received weekly IVR calls
to assess health status and self-care and to receive tai-
lored, prerecorded support messages. Family care-
givers were notified of the results of each call
and were given suggestions for self-management
support109,110 .
In Roblin’s study108 , family supporters were
instructed in motivational coaching so they could
provide effective feedback to the patient and
help assess barriers to effective self-monitoring of
blood glucose (SMBG). During the intervention, a
104 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
Baig et al.
summary of SMBG adherence and results were sent
to the patient and his/her support person to prompt
conversations and facilitate supportive relationships
in order to reinforce the importance of SMBG and
achieving good glucose control. Both the patient
and supporter were asked for feedback about the
intervention at the final session.
In Trief’s study, patients and partners partici-
pated in exercises to promote collaborative problem
solving87 . Two phone calls on speakerphone were
conducted with each couple, focused specifically
on the couples’ communication. Homework and
discussion tasks involved both partners in goal
setting and improving communication skills87 .
While most studies focused on encouraging fam-
ily members’ supportive behaviors, five studies
reported addressing emotions and situations that
might be problematic for the patient50,87,91,101,109 .
Few studies reported on actual outcomes for par-
ticipating family members. Some studies reported
qualitative findings that the intervention improved
family members’ ability to support to their loved
one with diabetes regarding SMBG and also helped
family members to improve their own diets50,98,108 .
One study noted significant improvements in BMI
and diabetes knowledge among family members
but no changes in waist circumference, blood
pressure, physical activity, or fruit and vegetable
consumption21 .
Quality scoring
The quality scores for the studies ranged from 10
to 24.5, with a mean score of 18. Of the 27 cri-
teria composing the quality score, the studies we
reviewed scored the lowest in the following cate-
gories: attempt to blind the study subjects, attempt
to blind those measuring the main outcomes,
reporting of adverse events, using a representative
sample, and reporting of sample-size calculation.
Appendix S3 describes the quality scores in further
detail for each study.
Fifteen studies had above average quality scores
(ࣙ18). Of these 15 studies, seven had sub-
stantial family involvement88–92,97,98,101,103,104,109,110,
114,117–119
. Of these seven studies, only two stud-
ies found improvements in A1c90–92,103,104,119 . Four
of the seven studies showed no improvement
88,89,97,98,101,114
, and one study did not measure
A1c109,110 . There were two more studies that
reported substantial family involvement in the study
C 2015 New York Academy of Sciences.
Baig et al.
intervention; however, they both had lower quality
scores and either did not measure108 or did not find
a significant improvement in A1c87 .
Discussion
Since the majority of disease-management activ-
ities for many adults occurs within the family
environment, involving families in diabetes self-
care interventions may be a key mechanism to
improving diabetes outcomes for patients. We
systematically reviewed the literature from 1994 to
2014 and identified 26 studies that reported find-
ings from family-based diabetes self-management
interventions for adults with diabetes. Studies
were conducted in a range of patient populations
and settings but reported varying levels of family
involvement and impact on patient outcomes.
Many studies used scientifically rigorous study
designs, such as randomized controlled trials; how-
ever, the quality of the studies varied significantly76 .
Some reports included an in-depth description of
methods or referred to previously published study
protocols; however, many other studies did not
report details on their methods, including power
calculations. Quality scores were also lower for stud-
ies that did not report attendance or follow-up rates
or assess fidelity to the intervention. Furthermore,
we had to exclude several studies from our review
because they did not describe in detail the involve-
ment of family in the background or methods sec-
tion. Previous systematic reviews of family-based
interventions have found a similar lack of detailed
descriptions in the methods used73 . The family-
based intervention was often offered as a group
program that was compared to either usual care or
individual educational sessions. Studies may need
to compare similar interventions both with and
without a family component to truly assess the
impact of including family on patient outcomes.
More studies are needed that utilize rigorous study
designs, adhere to reporting guidelines122 , assess
outcomes specific to diabetes patients, and include
relevant comparison groups to fully understand the
impact of family-based interventions on patient
outcomes.
We found that the involvement of the family
members and integration of families into the inter-
ventions varied widely across studies. Some studies
used a strong theoretical framework for the inclu-
Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
C 2015 New York Academy of Sciences.
Family interventions to improve diabetes outcomes for adults
sion of family and described family-based activities
and involvement in great detail21,87,101,108–110,115 .
Many included family-themed topics in the educa-
tion sessions, such as teaching ways to manage stress
and having family members engage in physical
activities and healthy meals together with patients.
Other studies encouraged family support through
home visits and interactions with CHWs. However,
many studies did not describe a theoretical basis
for the involvement of family or report on the
extent of family involvement. Several studies in
our review mentioned that families were invited
to intervention meetings, classes, and home visits
but lacked detail on the content that was designed
for family members, how family members inter-
acted in the class, and what family outcomes the
interventions were targeting. Few studies reported
on family attendance or participation rates in the
intervention. Also, many studies did not define
who qualified as a “family member,” a detail which
should be specified since the definition can be very
broad and may include friends and other support
persons67 , and the level of support these contacts
provide may differ123 . Who is considered a “family
member” may also vary with cultural context in
different populations. Without a clear understand-
ing of the theoretical basis of involving family, who
could serve as a “family member,” and how family
is involved in the intervention and to what extent, it
is challenging to draw conclusions about the impact
of including family in self-care interventions.
Many interventions in our review measured
patients’ clinical outcomes, but their impact varied.
Several studies found improvements in A1c in the
short term; however, studies with follow-up beyond
1 year found that these improvements were not
maintained. Some studies demonstrated improve-
ments in other clinical patient outcomes important
to patients with diabetes, such as blood pressure,
weight loss, and cholesterol; however, many stud-
ies found no significant changes. The impact of
self-care interventions on long-term patient out-
comes can be challenging after the intensive inter-
vention period ends124 , but involving family in these
interventions should help support patients in sus-
taining changes in self-care and in maintaining
improvements12 . In addition to strengthening the
family-based components of self-care interventions,
having more intensive or longer interventions and
105
Family interventions to improve diabetes outcomes for adults
providing linkages with the healthcare system and
the community may be needed to affect patient clin-
ical outcomes124,125 .
Studies that assessed psychosocial outcomes
found improvements in patients’ depressive symp-
toms, diabetes distress, quality of life, self-efficacy,
and perceived social support. Many studies also
found improvements in patients’ diabetes knowl-
edge, self-care behaviors, and dietary habits, but
several studies found no change in these outcomes
or improvements in only some self-care behaviors.
This finding is not surprising, since social support
may be associated with some self-care behaviors
more than others33,66 . Based on our review, it
seems that family-based interventions may affect
psychosocial outcomes, diabetes knowledge, and
some self-care behaviors in the short-term. Further
research is needed to assess the maintenance over
time of improvements in patients’ psychosocial and
behavioral outcomes and how these changes can
be utilized to improve physical health. Involving
families in diabetes education interventions may
enable them to be more supportive of the patient
and improve the patient’s feeling of being supported
in their diabetes self-care126 .
Through their participation in health inter-
ventions, family members may also experience
improvements in their own knowledge about
diabetes, skills in supporting loved ones with
diabetes, and changes in their own health behav-
iors and health outcomes. While the studies in
our review measured a large range of patient out-
comes, few reported on family member outcomes.
Some studies found that family members were
highly satisfied with the interventions and that
their involvement improved their ability and confi-
dence to provide emotional and instrumental sup-
port to their loved ones with diabetes50,108 . A few
studies noted improvements in family members’
BMI, diabetes knowledge, and diet and exercise
behaviors21,50,97,98,103,104 . However, we found many
studies that we excluded from our review because
family members’ results were aggregated with the
patients’ outcomes. Ultimately, failure to separately
assess effects on both the patient and family member
provides an incomplete picture regarding the effec-
tiveness of these health education interventions40 .
Lack of improvement for the patient might be
explained by negative effects of the intervention
on the family member31 . Future studies need to
106 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
Baig et al.
evaluate the benefits of diabetes self-management
interventions for both the patient and the family
member40 .
We found several studies conducted with diverse
patient populations that were culturally tailored to
the target audience. The inclusion of family in dia-
betes self-care interventions is important for many
patients from racial/ethnic minority populations
and is an important aspect of culturally tailoring
educational programs46–48,67,124,127–130 . The litera-
ture notes many benefits of involving families of
patients from racial/ethnic minority groups in dia-
betes interventions, including the chance to provide
family members with knowledge about the disease,
dispelling myths and misconceptions about the dis-
ease, and teaching them ways to support patients
in self-care8,33,37,46–48,131 . Families are also eager to
learn strategies for being supportive of their family
members with diabetes33,127 . While the studies
we reviewed included diverse patient populations
and settings, only two studies targeted Asian
Americans99,100,111 . Further studies using family-
based diabetes interventions need to target Asian
subpopulations, many of which have high rates of
diabetes1 .
Considering more than a quarter of adults aged
65 and older have diabetes1,132 , there is a pressing
need for family members to support older patients
with diabetes. In our review, only a few studies tar-
geted older adults105,109,110,113,114 . Only one study
was conducted in the VA, a setting that provides
healthcare for many older patients with chronic
diseases109,110,133 . Considering many older patients
have greater needs for social support and may
need assistance in diabetes self-care, future studies
should be conducted among older adult and veteran
populations132–134 . One study found that elderly dia-
betic patients whose spouses participated with them
in a diabetes education program showed greater
improvements in knowledge, metabolic control, and
stress level than those who participated alone135 .
Considering the burden of diabetes among older
adult populations, involving family members and
caregivers in interventions for older patient popu-
lations may be crucial for providing older patients
with instrumental and social support related to their
diabetes management.
Future family-based interventions may also need
to consider the role of gender in family-based
interventions and include an assessment of cost
C 2015 New York Academy of Sciences.
Baig et al.
and healthcare utilization. Previous studies have
noted differences in support received by female
patients with diabetes65,126,136 . We found some
studies that assessed the impact of the intervention
by gender90,93 . Future studies should explore how
family support may differ by gender of the patient
and of the support person, and how this may affect
clinical outcomes. Family-based studies should
also include measures beyond clinical, behavioral,
and psychosocial outcomes, such as cost and
healthcare utilization. We found few studies which
measured cost of the intervention or patients’
healthcare utilization79,91–93,102 . Assessing the cost-
effectiveness of family-based interventions will help
to further quantify the benefit of including family in
interventions for diabetes. Furthermore, assessing
healthcare utilization, such as hospitalizations and
emergency room visits, is also important because it
bears a heavy expense on patients and may indicate
worsening of disease or lack of instrumental or
social support.
Limitations
Although we found many studies reporting on
family-based interventions to improve adult dia-
betes outcomes conducted over the past 20 years,
there were many limitations to this literature. Given
the heterogeneous designs and varying patient pop-
ulations and settings, we could not compare effect
sizes across studies. Only a few studies reported
cost data, thus making cost effectiveness difficult to
assess. Although we made an effort to search multi-
ple databases and conduct hand searches, there may
be family-based interventions that we did not iden-
tify or that we excluded because they did not describe
family involvement or did not report outcomes spe-
cific to the patients with diabetes. In addition, some
organizations that have conducted interventions to
improve diabetes care may not have published their
findings in peer-reviewed journals. Our review was
also limited by publication bias, because positive
findings tend to be published more frequently than
null findings.
Conclusions
Developing diabetes interventions that include fam-
ily may be critical in improving the health of adults
with diabetes. We found only two studies that were
of high quality and with substantial family involve-
Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
C 2015 New York Academy of Sciences.
Family interventions to improve diabetes outcomes for adults
ment that reported improvement in A1c91,103,104,119 .
Owing to the heterogeneity of the study designs,
interventions, extent of family involvement, and
reporting of results, it is difficult to determine
whether and how family involvement in diabetes
interventions can affect patient and family mem-
bers’ health outcomes. Future studies should clearly
describe the role of family in the intervention,
provide details on family-based topics in the inter-
vention, assess the quality and extent of family par-
ticipation, and compare patient outcomes with and
without family involvement. While including fam-
ilies in diabetes self-management interventions for
adults has a strong theoretical and cultural basis for
many patient populations6,12,124 , there is much work
to be done to fully understand what roles family
members should play in family-based diabetes self-
management interventions and how their involve-
ment can affect patients’ diabetes outcomes.
Acknowledgments
We would like to thank Haley Johnson for her assis-
tance in conducting and organizing our database
search and Patricia Fernandez for her help in for-
matting. We are also indebted to our medical librar-
ians, Deborah Werner and Ricardo Andrade, for
their assistance in our database search and to Yue
Gao for her help calculating our kappas. This
research was supported by grants from the Univer-
sity of Chicago Clinical and Translational Science
Award (UL1RR024999), the National Institute of
Diabetes and Digestive and Kidney Diseases Dia-
betes Research and Training Center (P60 DK20595)
and the Chicago Center for Diabetes Translation
Research (P30 DK092949). Dr. Baig is supported by
a NIDDK Mentored Patient-Oriented Career Devel-
opment Award (K23 DK087903-01A1).
Conflicts of interest
The author declares no conflicts of interest.
Supporting Information
Additional supporting information may be found
in the online version of this article.
Appendix S1: Search strategy.
Appendix S2: Family-based interventions for adults
with type 1 and type 2 diabetes, 1994 to 2014.
107
Family interventions to improve diabetes outcomes for adults
Appendix S3: Quality scores for family-based inter-
ventions for adults with type 1 and type 2 diabetes,
1994 to 2014.
References
1. Centers for Disease Control and Prevention. 2014. National
Diabetes Statistics Report: Estimates of Diabetes and Its Bur-
den in the United States, 2014. Atlanta, GA: U.S. Department
of Health and Human Services.
2. American Diabetes A. 2014. Standards of medical care in
diabetes–2014. Diabetes Care 37(Suppl 1): S14–S80.
3. Deakin, T.A., C.E. McShane, J.E. Cade & R. Williams. 2005.
Group based training for self-management strategies in
people with type 2 diabetes mellitus. Cochrane Database
DOI: 10.1002/14651858.CD003417.pub2.
4. Gary, T.L., J.M. Genkinger, E. Guallar, et al. 2003. Meta-
analysis of randomized educational and behavioral inter-
ventions in type 2 diabetes. Diabetes Educ. 29: 488–501.
5. Turner, R., R. Holman, C. Cull, et al. 1998. Intensive blood-
glucose control with sulphonylureas or insulin compared
with conventional treatment and risk of complications in
patients with type 2 diabetes (UKPDS 33). Lancet 352: 837–
853.
6. World Health Organization. 2002. Noncommunicable Dis-
ease and Mental Health Cluster. Innovative care for chronic
conditions: building blocks for action: global report. Geneva:
World Health Organization.
7. Institute for Patient- and Family-Centered Care. 2014.
What is meant by the word “family”? Cited December 31,
2014. http://www.ipfcc.org/faq.html.
8. Weiler, D.M. & J.D. Crist. 2009. Diabetes self-management
in a Latino social environment. Diabetes Educ. 35: 285–292.
9. Chesla, C.A., L. Fisher, M.M. Skaff, et al. 2003. Family
predictors of disease management over one year in Latino
and European American patients with type 2 diabetes. Fam.
Process 42: 375–390.
10. Denham, S.A., L.J. Ware, H. Raffle & K. Leach. 2011. Fam-
ily inclusion in diabetes education a nationwide survey of
diabetes educators. Diabetes Educ. 37: 528–535.
11. Kovacs Burns, K., A. Nicolucci, R.I. Holt, et al. 2013. Dia-
betes attitudes, wishes and needs second study (DAWN2):
cross-national benchmarking indicators for family mem-
bers living with people with diabetes. Diabetic Med. 30:
778–788.
12. Fisher, L., C.A. Chesla, R.J. Bartz, et al. 1998. The family
and type 2 diabetes: a framework for intervention. Diabetes
Educ. 24: 599–607.
13. Wagner, E.H., B.T. Austin, C. Davis, et al. 2001. Improving
chronic illness care: translating evidence into action. Health
Aff. (Millwood) 20: 64–78.
14. Burg, M.M. & T.E. Seeman. 1994. Families and health: the
negative side of social ties. Ann. Behav. Med. 46: 1097–1108.
15. Nicklett, E.J., M.E. Heisler, M.S. Spencer & A.M. Rosland.
2013. Direct social support and long-term health among
middle-aged and older adults with type 2 diabetes mellitus.
J. Gerontol. B. Psychol. Sci. Soc. Sci. 68: 933–943.
16. Eaton, W.W., M. Mengel, L. Mengel, et al. 1992. Psychoso-
cial and psychopathologic influences on management and
108 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
Baig et al.
control of insulin-dependent diabetes. Int. J. Psychiatry
Med. 22: 105–117.
17. Griffith, L.S., B.J. Field & P.J. Lustman. 1990. Life stress
and social support in diabetes: association with glycemic
control. Int. J. Psychiatry Med. 20: 365–372.
18. Cardenas, L., C. Vallbona, S. Baker & S. Yusim. 1987. Adult
onset diabetes mellitus: glycemic control and family func-
tion. Am. J. Med. Sci. 293: 28–33.
19. Walker, R.J., M. Gebregziabher, B. Martin-Harris & L.E.
Egede. 2015. Quantifying direct effects of social determi-
nants of health on glycemic control in adults with type 2
diabetes. Diabetes Technol. Ther. 17: 80–87.
20. Armour, T.A., S.L. Norris, L. Jack Jr., et al. 2005. The effec-
tiveness of family interventions in people with diabetes
mellitus: a systematic review. Diabetic Med. 22: 1295–1305.
21. Hu, J., D.C. Wallace, T.P. McCoy & K.A. Amirehsani. 2014.
A family-based diabetes intervention for Hispanic adults
and their family members. Diabetes Educ. 40: 48–59.
22. Denham, S.A., M.M. Manoogian & L. Schuster. 2007. Man-
aging family support and dietary routines: type 2 diabetes
in rural Appalachian families. Fam. Syst. Health 25: 36.
23. Manoogian, M.M., L.M. Harter & S.A. Denham. 2010. The
storied nature of health legacies in the familial experience
of type 2 diabetes. J. Fam. Commun. 10: 40–56.
24. Trief, P.M., P.C. Morin, R. Izquierdo, et al. 2006. Marital
quality and diabetes outcomes: the IDEATel project. Fam.
Syst. Health 24: 318.
25. Mayberry, L.S. & C.Y. Osborn. 2012. Family support, med-
ication adherence, and glycemic control among adults with
type 2 diabetes. Diabetes Care 35: 1239–1245.
26. Mayberry, L.S., R.L. Rothman & C.Y. Osborn. 2014. Family
members’ obstructive behaviors appear to be more harm-
ful among adults with type 2 diabetes and limited health
literacy. J. Health Commun. 19(Suppl 2):132–143.
27. Carter-Edwards, L., A.H. Skelly, C.S. Cagle & S.J. Appel.
2004. “They care but don’t understand”: family support of
African American women with type 2 diabetes. Diabetes
Educ. 30: 493–501.
28. Rosland, A.M., M. Heisler, H.J. Choi, et al. 2010. Family
influences on self-management among functionally inde-
pendent adults with diabetes or heart failure: do family
members hinder as much as they help? Chronic Illn. 6: 22–
33.
29. Stephens, M.A., M.M. Franks, K.S. Rook, et al. 2013.
Spouses’ attempts to regulate day-to-day dietary adherence
among patients with type 2 diabetes. Health Psychol. 32:
1029–1037.
30. Mayberry, L.S., L.E. Egede, J.A. Wagner & C.Y. Osborn.
2015. Stress, depression and medication nonadherence in
diabetes: test of the exacerbating and buffering effects of
family support. J. Behav. Med. 38: 363–371.
31. Martire, L.M., R. Schulz, V.S. Helgeson, et al. 2010. Review
and meta-analysis of couple-oriented interventions for
chronic illness. Ann. Behav. Med. 40: 325–342.
32. Fisher, L., C.A. Chesla, M.M. Skaff, et al. 2002. Depres-
sion and anxiety among partners of European-American
and Latino patients with type 2 diabetes. Diabetes Care 25:
1564–1570.
33. Gleeson-Kreig, J., H. Bernal & S. Woolley. 2002. The role of
social support in the self-management of diabetes mellitus
C 2015 New York Academy of Sciences.
Baig et al.
among a Hispanic population. Publ. Health Nurs. 19: 215–
222.
34. Dowds, B.N. & R. Bibace. 1996. Entry into the health care
system: the family’s decision-making process. Fam. Med.
28: 114–118.
35. Rosland, A.M., M. Heisler & J.D. Piette. 2012. The impact of
family behaviors and communication patterns on chronic
illness outcomes: a systematic review. J. Behav. Med. 35:
221–239.
36. Keogh, K.M., S.M. Smith, P. White, et al. 2011. Psycho-
logical family intervention for poorly controlled type 2
diabetes. Am. J. Manag. Care 17: 105–113.
37. Hu, J., K. Amirehsani, D.C. Wallace & S. Letvak. 2013. Per-
ceptions of barriers in managing diabetes: perspectives of
Hispanic immigrant patients and family members. Diabetes
Educ. 39: 494–503.
38. White, P., S.M. Smith, D. Hevey & T. O’Dowd. 2009. Under-
standing type 2 diabetes: including the family member’s
perspective. Diabetes Educ. 35: 810–817.
39. Orvik, E., L. Ribu & O.E. Johansen. 2010. Spouses’ edu-
cational needs and perceptions of health in partners with
type 2 diabetes. Eur. Diabetes Nurs. 7: 63–69.
40. Martire, L.M. 2005. The “relative” efficacy of involving fam-
ily in psychosocial interventions for chronic illness: are
there added benefits to patients and family members? Fam.
Syst. Health 23: 312.
41. Sorkin, D.H., K.A. Biegler, M. Peyreda, et al. 2013. Unidas
por la vida (United for life): implementing a culturally-
tailored, community-based, family-oriented lifestyle inter-
vention. J. Health Care Poor Underserved 24: 116–138.
42. Trief, P.M., C.L. Himes, R. Orendorff & R.S. Weinstock.
2001. The marital relationship and psychosocial adaptation
and glycemic control of individuals with diabetes. Diabetes
Care 24: 1384–1389.
43. Choi, S.E. 2009. Diet-specific family support and glucose
control among Korean immigrants with type 2 diabetes.
Diabetes Educ. 35: 978–985.
44. Sarkisian, C.A., A.F. Brown, K.C. Norris, et al. 2003. A sys-
tematic review of diabetes self-care interventions for older,
African American, or Latino adults. Diabetes Educ. 29: 467–
479.
45. Glazier, R.H., J. Bajcar, N.R. Kennie & K. Willson. 2006.
A systematic review of interventions to improve diabetes
care in socially disadvantaged populations. Diabetes Care
29: 1675–1688.
46. Epple, C., A.L. Wright, V.N. Joish & M. Bauer. 2003. The
role of active family nutritional support in Navajos’ type 2
diabetes metabolic control. Diabetes Care 26: 2829–2834.
47. Shaw, J., J. Brown, B. Khan, et al. 2013. Resources, road-
blocks and turning points: a qualitative study of American
Indian/Alaska Native adults with type 2 diabetes. J. Com-
mun. Health 38: 86–94.
48. Brown, S.A. & C.L. Hanis. 2014. Lessons learned from 20
years of diabetes self-management research with Mexican
Americans in Starr County, Texas. Diabetes Educ. 40: 476–
487.
49. Wen, L.K., M.D. Shepherd & M.L. Parchman. 2003. Family
support, diet, and exercise among older Mexican Ameri-
cans with type 2 diabetes. Diabetes Educ. 30: 980–993.
Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
C 2015 New York Academy of Sciences.
Family interventions to improve diabetes outcomes for adults
50. Brown, S.A. & C.L. Hanis. 1995. A community-based, cul-
turally sensitive education and group-support intervention
for Mexican Americans with NIDDM: a pilot study of effi-
cacy. Diabetes Educ. 21: 203–210.
51. Hood, K.K., J.M. Rohan, C.M. Peterson & D. Drotar. 2010.
Interventions with adherence-promoting components in
pediatric type 1 diabetes meta-analysis of their impact on
glycemic control. Diabetes Care 33: 1658–1664.
52. Chesla, C.A. 2010. Do family interventions improve health?
J. Fam. Nurs. 16: 355–377.
53. Roski, J., L.A. Schmid & H.A. Lando. 1996. Long-term
associations of helpful and harmful spousal behaviors with
smoking cessation. Addict. Behav. 21: 173–185.
54. Shiffman, S., S.E. Brockwell, J.L. Pillitteri & J.G. Gitchell.
2008. Use of smoking-cessation treatments in the United
States. Am. J. Prev. Med. 34: 102–111.
55. Brownell, K.D. 1999. The central role of lifestyle change in
long-term weight management. Clin. Cornerstone 2: 43–51.
56. Marrero, D.G. 2005. Time to get moving: helping patients
with diabetes adopt exercise as part of a healthy lifestyle.
Clin. Diabetes 23: 154–159.
57. Shields, C.G., M.A. Finley & N. Chawla. 2012. Couple and
family interventions in health problems. J. Marital Fam.
Ther. 38: 265–280.
58. White, P., S.M. Smith & T. O’Dowd. 2005. The role of the
family in adult chronic illness: a review of the literature on
type 2 diabetes. Irish J. Psychol. 26: 9–15.
59. Rosland, A.-M. & J.D. Piette. 2010. Emerging models for
mobilizing family support for chronic disease manage-
ment: a structured review. Chronic Illn. 6: 7–21.
60. Hartmann, M., E. Bäzner, B. Wild, et al. 2010. Effects of
interventions involving the family in the treatment of adult
patients with chronic physical diseases: a meta-analysis.
Psychother. Psychosom. 79: 136–148.
61. Garay-Sevilla, M.E., L.E. Nava, J.M. Malacara, et al. 1995.
Adherence to treatment and social support in patients with
non-insulin dependent diabetes mellitus. J. Diabetes Com-
plicat. 9: 81–86.
62. Primomo, J., B.C. Yates & N.F. Woods. 1990. Social support
for women during chronic illness: the relationship among
sources and types to adjustment. Res. Nurs. Health 13: 153–
161.
63. King, D.K., R.E. Glasgow, D.J. Toobert, et al. 2010. Self-
efficacy, problem solving, and social-environmental sup-
port are associated with diabetes self-management behav-
iors. Diabetes Care 33: 751–753.
64. Hogan, B.E., W. Linden & B. Najarian. 2002. Social support
interventions: do they work? Clin. Psychol. Rev. 22: 381–
440.
65. van Dam, H.A., F.G. van der Horst, L. Knoops, et al. 2005.
Social support in diabetes: a systematic review of controlled
intervention studies. Patient Educ. Couns. 59: 1–12.
66. Rosland, A.M., E. Kieffer, B. Israel, et al. 2008. When is
social support important? The association of family sup-
port and professional support with specific diabetes self-
management behaviors. J. Gen. Intern. Med. 23: 1992–1999.
67. Chesla, C.A., K.M. Chun, C.M. Kwan, et al. 2013. Testing
the efficacy of culturally adapted coping skills training for
Chinese American immigrants with type 2 diabetes using
109
Family interventions to improve diabetes outcomes for adults
community-based participatory research. Res. Nurs. Health
36: 359–372.
68. Trief, P.M., J. Sandberg, L. Fisher, et al. 2011. Challenges and
lessons learned in the development and implementation of
a couples-focused telephone intervention for adults with
type 2 diabetes: the Diabetes Support Project. Behav. Med.
Pract. Policy Res. 1: 461–467.
69. LaFromboise, T., H.L. Coleman & J. Gerton. 1993. Psy-
chological impact of biculturalism: evidence and theory.
Psychol. Bull. 114: 395–412.
70. Rusbult, C.E. & P.A. Van Lange. 2003. Interdependence,
interaction, and relationships. Annu. Rev. Psychol. 54: 351–
375.
71. Ford, M.E., B.C. Tilley & P.E. McDonald. 1998. Social sup-
port among African-American adults with diabetes, Part.
2: a review. J. Natl. Med. Assoc. 90: 425.
72. Thorpe, C.T., L.E. Fahey, H. Johnson, et al. 2012. Facilitat-
ing healthy coping in patients with diabetes: a systematic
review. Diabetes Educ. DOI: 10.1177/0145721712464400.
73. Torenholt, R., N. Schwennesen & I. Willaing. 2014. Lost
in translation—the role of family in interventions among
adults with diabetes: a systematic review. Diabet. Med. 31:
15–23.
74. Moher, D., A. Liberati, J. Tetzlaff & D.G. Altman. 2009.
Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. Ann. Intern. Med. 151:
264–269, w64.
75. Zaza, S., L.K. Wright-De Aguero, P.A. Briss, et al. 2000.
Data collection instrument and procedure for systematic
reviews in the Guide to Community Preventive Services.
Task Force on Community Preventive Services. Am. J. Prev.
Med. 18: 44–74.
76. Downs, S.H. & N. Black. 1998. The feasibility of creating a
checklist for the assessment of the methodological quality
both of randomised and non-randomised studies of health
care interventions. J. Epidemiol. Commun. Health 52: 377–
384.
77. Gary, T.L., L.R. Bone, M.N. Hill, et al. 2003. Random-
ized controlled trial of the effects of nurse case manager
and community health worker interventions on risk fac-
tors for diabetes-related complications in urban African
Americans. Prev. Med. 37: 23–32.
78. Gary, T.L., M. Batts-Turner, L.R. Bone, et al. 2004. A ran-
domized controlled trial of the effects of nurse case manager
and community health worker team interventions in urban
African-Americans with type 2 diabetes. Control. Clin. Tri-
als 25: 53–66.
79. Gary, T.L., M. Batts-Turner, H.-C. Yeh, et al. 2009. The
effects of a nurse case manager and a community health
worker team on diabetic control, emergency department
visits, and hospitalizations among urban African Ameri-
cans with type 2 diabetes mellitus: a randomized controlled
trial. Arch. Intern. Med. 169: 1788–1794.
80. Rosal, M.C., I.S. Ockene, A. Restrepo, et al. 2011. Ran-
domized trial of a literacy-sensitive, culturally tailored dia-
betes self-management intervention for low-income Lati-
nos: Latinos en Control. Diabetes Care 34: 838–844.
81. Rosal, M.C., M.J. White, A. Borg, et al. 2010. Transla-
tional research at community health centers challenges and
110 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
Baig et al.
successes in recruiting and retaining low-income latino
patients with type 2 diabetes into a randomized clinical
trial. Diabetes Educ. 36: 733–749.
82. Rosal, M.C., M.J. White, A. Restrepo, et al. 2009. Design and
methods for a randomized clinical trial of a diabetes self-
management intervention for low-income Latinos: Latinos
en Control. BMC Med. Res. Methodol. 9: 81.
83. Toobert, D.J., L.A. Strycker, M. Barrera Jr., et al. 2011.
Outcomes from a multiple risk factor diabetes self-
management trial for Latinas: ¡Viva Bien! Ann. Behav. Med.
41: 310–323.
84. Toobert, D.J., L.A. Strycker, R.E. Glasgow, et al. 2010.
¡Viva bien!: overcoming recruitment challenges in a
multiple-risk-factor diabetes trial. Am. J. Health Behav. 34:
432– 441.
85. Toobert, D.J., L. Strycker, D. King, et al. 2011. Long-
term outcomes from a multiple-risk-factor diabetes trial
for Latinas: ¡Viva Bien! Behav. Med. Pract. Policy Res. 1:
416–426.
86. Barrera, M., Jr., D. Toobert & L. Strycker. 2014. Relative
contributions of naturalistic and constructed support: two
studies of women with type 2 diabetes. J. Behav. Med. 37:
59–69.
87. Trief, P., J.G. Sandberg, R. Ploutz-Snyder, et al. 2011. Pro-
moting couples collaboration in type 2 diabetes: the dia-
betes support project pilot data. Fam. Syst. Health 29: 253.
88. Utz, S.W., I.C. Williams, R. Jones, et al. 2008. Culturally
tailored intervention for rural African Americans with type
2 diabetes. Diabetes Educ. 34: 854–865.
89. Jones, R.A., S.W. Utz, I.C. Williams, et al. 2008. Family
interactions among African Americans diagnosed with type
2 diabetes. Diabetes Educ. 34: 318–326.
90. Brown, S.A., K. Kouzekanani, A.A. Garcia, et al. 2013. Dia-
betes self-management and leptin in Mexican Americans
with type 2 diabetes: the Starr County border health initia-
tive. Diabetes Educ. 39: 820–827.
91. Brown, S.A., A.A. Garcia, K. Kouzekanani & C.L. Hanis.
2002. Culturally competent diabetes self-management edu-
cation for Mexican Americans the Starr county border
health initiative. Diabetes Care 25: 259–268.
92. Brown, S.A., S.A. Blozis, K. Kouzekanani, et al. 2005.
Dosage effects of diabetes self-management education for
Mexican Americans the Starr county border health initia-
tive. Diabetes Care 28: 527–532.
93. Anderson-Loftin, W., S. Barnett, P. Bunn, et al. 2005. Soul
food light: culturally competent diabetes education. Dia-
betes Educ. 31: 555–563.
94. Corkery, E., C. Palmer, M.E. Foley, et al. 1997. Effect of
a bicultural community health worker on completion of
diabetes education in a Hispanic population. Diabetes Care
20: 254–257.
95. Samuel-Hodge, C.D., T.C. Keyserling, R. France, et al. 2006.
A church-based diabetes self-management education pro-
gram for African Americans with type 2 diabetes. Prevent.
Chronic Dis. 3: A93.
96. Samuel-Hodge, C.D., T.C. Keyserling, S. Park, et al.
2009. A randomized trial of a church-based diabetes self-
management program for African Americans with type 2
diabetes. Diabetes Educ. 35: 439–454.
C 2015 New York Academy of Sciences.
Baig et al.
97. Vincent, D., A. Pasvogel & L. Barrera. 2007. A feasibil-
ity study of a culturally tailored diabetes intervention for
Mexican Americans. Biol. Res. Nurs. 9: 130–141.
98. Vincent, D. 2009. Culturally tailored education to promote
lifestyle change in Mexican Americans with type 2 diabetes.
J. Am. Acad. Nurse Pract. 21: 520–527.
99. Kim, M.T., H.R. Han, H.J. Song, et al. 2009. A community-
based, culturally tailored behavioral intervention for
Korean Americans with type 2 diabetes. Diabetes Educ. 35:
986–994.
100. Song, H.J., H.R. Han, J.E. Lee, et al. 2010. Translating cur-
rent dietary guidelines into a culturally tailored nutrition
education program for Korean American immigrants with
type 2 diabetes. Diabetes Educ. 36: 752–761.
101. Castejón, A.M., J.L. Calderón, A. Perez, et al. 2014. A
community-based pilot study of a diabetes pharmacist
intervention in Latinos: impact on weight and hemoglobin
A1c. J. Health Care Poor Underserved 24: 48–60.
102. Anderson-Loftin, W., S. Barnett, P. Sullivan, et al. 2002.
Culturally competent dietary education for southern rural
African Americans with diabetes. Diabetes Educ. 28: 245–
257.
103. Two Feathers, J., E.C. Kieffer, G. Palmisano, et al. 2005.
Racial and Ethnic Approaches to Community Health
(REACH) Detroit partnership: improving diabetes-related
outcomes among African American and Latino adults. Am.
J. Public Health 95: 1552–1560.
104. Feathers, J.T., E.C. Kieffer, G. Palmisano, et al. 2007. The
development, implementation, and process evaluation of
the REACH Detroit Partnership’s Diabetes Lifestyle Inter-
vention. Diabetes Educ. 33: 509–520.
105. Kluding, P.M., R. Singh, J. Goetz, et al. 2010. Feasibility
and effectiveness of a pilot health promotion program for
adults with type 2 diabetes: lessons learned. Diabetes Educ.
36: 595–602.
106. Mendenhall, T.J., J.M. Berge, P. Harper, et al. 2010. The
Family Education Diabetes Series (FEDS): community-
based participatory research with a midwestern American
Indian community. Nurs. Inq. 17: 359–372.
107. Mendenhall, T.J., K.L. Seal, B.A. Greencrow, et al. 2012.
The Family Education Diabetes Series: improving health
in an urban-dwelling American Indian community. Qual.
Health Res. 22: 1524–1534.
108. Roblin, D.W. 2011. The potential of cellular technology
to mediate social networks for support of chronic disease
self-management. J. Health Commun. 16(Suppl 1):59–76.
109. Aikens, J.E., K. Zivin, R. Trivedi & J.D. Piette. 2014. Diabetes
self-management support using mHealth and enhanced
informal caregiving. J. Diabetes Complicat. 28: 171–176.
110. Aikens, J.E., A.-M. Rosland & J.D. Piette. 2014. Improve-
ments in illness self-management and psychological dis-
tress associated with telemonitoring support for adults with
diabetes. Primary Care Diabetes 9: 127–134.
111. Islam, N.S., L.C. Wyatt, S.D. Patel, et al. 2013. Evaluation of
a community health worker pilot intervention to improve
diabetes management in Bangladeshi immigrants with type
2 diabetes in New York City. Diabetes Educ. 39: 478–493.
112. Archuleta, M., D. Vanleeuwen, K. Halderson, et al. 2012.
Cooking schools improve nutrient intake patterns of people
with type 2 diabetes. J. Nutr. Educ. Behav. 44: 319–325.
Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
C 2015 New York Academy of Sciences.
Family interventions to improve diabetes outcomes for adults
113. Williams, I.C., S.W. Utz, I. Hinton, et al. 2014. Enhancing
diabetes self-care among rural African Americans with dia-
betes: results of a two-year culturally tailored intervention.
Diabetes Educ. 40: 231–239.
114. Gilliland, S.S., S.P. Azen, G.E. Perez & J.S. Carter. 2002.
Strong in body and spirit: lifestyle intervention for native
American adults with diabetes in New Mexico. Diabetes
Care 25: 78–83.
115. Glueck, B.P. & B.H. Foreman. 2014. Lessons learned from
designing and leading multidisciplinary diabetes educa-
tional groups J. Mental Health Counsel. 36: 160–172.
116. Brown, S.A., A.A. Garcia & M. Winchell. 2002. Reaching
underserved populations and cultural competence in dia-
betes education. Curr. Diab. Rep. 2: 166–176.
117. Gilliland, S., J. Carter, G. Perez, et al. 1998. Recommenda-
tions for development and adaptation of culturally compe-
tent community: health interventions in minority popula-
tions with type 2 diabetes mellitus. Diabetes Spectrum 11:
166–174.
118. Carter, J.S., S.S. Gilliland, G.E. Perez, et al. 1997. Native
American Diabetes Project: designing culturally relevant
education materials. Diabetes Educ. 23: 133–134, 9.
119. Kieffer, E.C., S.K. Willis, A.M. Odoms-Young, et al. 2004.
Reducing disparities in diabetes among African-American
and Latino residents of Detroit: the essential role of com-
munity planning focus groups. Ethnicity Dis. 14: S27–S37.
120. Osuna, D., M. Barrera, L.A. Strycker, et al. 2011. Meth-
ods for the cultural adaptation of a diabetes lifestyle inter-
vention for Latinas: an illustrative project. Health Promot.
Pract. 12: 341–348.
121. Islam, N.S., D. Tandon, R. Mukherji, et al. 2012. Under-
standing barriers to and facilitators of diabetes control and
prevention in the New York City Bangladeshi community:
a mixed-methods approach. Am. J. Public. Health 102: 486–
490.
122. Schulz, K.F., D.G. Altman & D. Moher. 2010. CONSORT
2010 Statement: updated guidelines for reporting parallel
group randomised trials. BMJ Med. 340: c332.
123. Ahia, C.L., E.W. Holt & M. Krousel-Wood. 2014. Diabetes
care and its association with glycosylated hemoglobin level.
Am. J. Med. Sci. 347: 245–247.
124. Norris, S.L., P.J. Nichols, C.J. Caspersen, et al. 2002. Increas-
ing diabetes self-management education in community set-
tings. A systematic review. Am. J. Prev. Med. 22: 39–66.
125. Baig, A.A., C.M. Mangione, A.L. Sorrell-Thompson & J.M.
Miranda. 2010. A randomized community-based interven-
tion trial comparing faith community nurse referrals to
telephone-assisted physician appointments for health fair
participants with elevated blood pressure. J. Gen. Intern.
Med. 25: 701–709.
126. Trief, P.M., W. Grant, K. Elbert & R.S. Weinstock. 1998.
Family environment, glycemic control, and the psychoso-
cial adaptation of adults with diabetes. Diabetes Care 21:
241–245.
127. Baig, A.A., C.A. Locklin, A.E. Wilkes, et al. 2014. Integrat-
ing diabetes self-management interventions for Mexican-
Americans into the catholic church setting. J. Relig. Health
53: 105–118.
128. Pollard, S.L., D.A. Zachary, K. Wingert, et al. 2014. Fam-
ily and community influences on diabetes-related dietary
111
Family interventions to improve diabetes outcomes for adults
change in a low-income urban neighborhood. Diabetes
Educ. 40: 462–469.
129. Peek, M.E., A. Cargill & E.S. Huang. 2007. Diabetes health
disparities: a systematic review of health care interventions.
Med. Care Res. Rev. 64: 101S–156S.
130. Fisher, T.L., D.L. Burnet, E.S. Huang, et al. 2007. Cultural
leverage: interventions using culture to narrow racial dis-
parities in health care. Med. Care Res. Rev. 64: 243S–282S.
131. McEwen, M.M., A. Pasvogel, G. Gallegos & L. Barrera. 2010.
Type 2 diabetes self-management social support interven-
tion at the U.S.-Mexico border. Public Health Nurs. 27:
310–319.
132. Kirkman, M.S., V.J. Briscoe, N. Clark, et al. 2012. Diabetes
in older adults. Diabetes Care 35: 2650–2664.
112 Ann. N.Y. Acad. Sci. 1353 (2015) 89–112 
Baig et al.
133. Kessler, C.S., S. Bhandarkar, P. Casey & A. Tenner. 2011. Pre-
dicting patient patterns in veterans administration emer-
gency departments. West. J. Emerg. Med. 12: 204–207.
134. Nelson, K.M., L. McFarland & G. Reiber. 2007. Factors
influencing disease self-management among veterans with
diabetes and poor glycemic control. J. Gen. Intern. Med. 22:
442–447.
135. Gilden, J.L., M. Hendryx, C. Casia & S.P. Singh. 1989.
The effectiveness of diabetes education programs for older
patients and their spouses. J. Am. Geriatr. Soc. 37: 1023–
1030.
136. Kvam, S.H. & J.S. Lyons. 1991. Assessment of coping strate-
gies, social support, and general health status in individuals
with diabetes mellitus. Psychol. Rep. 68: 623–632.
C 2015 New York Academy of Sciences.