Hrev_master Healthcare in Low-resource Settings 2023; volume 11(s1):11195 Family health task implementation and the health status of diabetes mellitus patients: a correlational study Niko Dima Kristianingrum,1 Delfira Arizda,2 Setyoadi,1 Yati Sri Hayati,1 Michael Leo Parchman3 1Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Malang, Indonesia; 2Undergraduate Program, Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Malang, Indonesia; 3Kaiser Permanente Washington Health Research Institute, United States Abstract Introduction: Chronic conditions due to diabetes cause changes in patients’ health status and their family has important roles in the health care. Therefore, this study aimed to analyze the relationship between family health task implementation and the health status of diabetics. Design and methods: An observational analytic design with a cross-sectional approach was used, while the respondents consist- ed of 327 family caregivers and 327 diabetes mellitus patients. This study used both family health task implementation and Short Form Health Survey (SF-12) questionnaires. Results: The result of the Pearson Product Moment test showed a correlation coefficient of 0.593 and a 0.000 p-value (α 0.05). Conclusions: It was concluded that there was a fairly strong relationship between family health task implementation and the health status of diabetes mellitus patients. Nursing intervention is needed to improve the implementation of family health tasks. Introduction The International Diabetes Federation (IDF) estimated the global prevalence of diabetes mellitus to be 151 million in 2000, 366 million in 2011, and 415 million in 2015.1-3 The prevalence of this disease in 2017 in adults aged 18-99 years around the world was 451 million and it is predicted to increase to 693 million in 2045.1-3 Moreover, it was 1.5% to 2% based on a doctor’s diagno- sis in the population aged 15 years from 2013 to 2018 in Indonesia. The Basic Health Research 2018 results showed an increasing prevalence of diabetes mellitus from 6.9% to 8.5% based on blood tests performed in the population aged 15 years from 2013 to 2018.4 Diabetes Mellitus (DM) is a serious threat to the world of health today due to being a lifelong chronic disease that cannot be cured. This causes complications such as cardiovascular disease, stroke, peripheral arterial disease, neuropathy, nephropathy, and retinopathy once not controlled.5 DM also has an impact on health status, where old age, unemployment and being single and widow- er had a significant association with lower Health Related Quality Of Life (HRQOL).6 DM patients need to check their health status because it is one of the main goals in treating incurable chronic diseases. Besides, low health status and psychological problems worsen metabolic disorders, either directly through hormonal stress reactions, or indirectly through complications.7 DM patients are dependent on other people for support, particularly their fam- ily because they experience a decrease in mental and physical function. This causes the diabetics to be unable to carry out activ- ities independently, specifically those related to self-processing in keeping blood sugar levels stable, therefore they need support from others, especially family as the closest people they have.8 Family is the primary support system that provides care direct- ly in every healthy and sick condition to its members for improve- ment in the health status of the sick and other persons.9 Additionally, the health care tasks consist of knowing family health problems, making decisions to take appropriate action, pro- viding care to the members who have health problems, modifying the environment to maintain good health, and using health facili- ties.10 The family has a major role in maintaining health and help- ing diabetics in the care and control of diabetes mellitus, giving encouragement and motivation, and convincing patients to improve their health status to a good state by managing their dis- ease properly.11 A study reported the implementation of good fam- ily health care tasks in hypertensive individuals with good health status in 83 respondents (54.6%) and stated that there was a rela- tionship between the implementation process and the patients’ health status.12 But other qualitative study found that the family habits which highly risky to increase blood glucose older people.13 Increasing blood glucose impact on health status with worsen metabolic disorders.7 Particularly, this study aims to analyze the relationship between family health task implementation and the health status of diabetes mellitus patients. Significance for public health A family is regarded as the smallest unit of the society that lives together and depends on each other. Furthermore, the members with diabetes mellitus require long-term care and the assistance of a caregiver at home. Family health task is important for diabetics considering its relation to the patients’ health status and impact on morbidity, mortality, and the degree of public health. This study contains the basic data of policy created for public health services to improve public health status, specifically in diabetic patients and their families. Article [page 100] [Healthcare in Low-resource Settings 2023; 11(s1):11195] No n- co mm er cia l u se on ly Design and Methods A cross-sectional design was used, while the study population was 1,787 diabetes mellitus patients and their family caregivers obtained from Malang City Health Office. Furthermore, a cluster random sampling technique was employed and the inclusion crite- ria for Diabetes Mellitus Patients were people diagnosed with dia- betes mellitus and being able to communicate verbally well. Family inclusion criteria were living with diabetics, minimum age 17 years old, and being able to communicate verbally well. This study was conducted in Malang City in January-February 2020. The number of subjects was 327 diabetes patients and their fami- lies, while the instrument used to measure the diabetics’ health sta- tus was Short Form 12 (SF-12). Family Health Tasks were mea- sured using a questionnaire containing 21 questions that have been tested for validity and reliability before. This instrument consisted of 5 questions about the family’s health problems recognition, another 5 about the ability to decide on the right action, 5 about the ability to provide care, 2 about the ability to modify the family environment to support the healing process, and 4 concerning the ability to use health service facilities. Demographic data were also collected and the Pearson Product Moment Test results showed that the calculated r-value was 0.48 – 0.79 (> 0.44) and the Cronbach Alpha coefficient was 0.932 > 0.600. The data collection was performed at the respondent’s house where questions read from the instrument were answered and filled accordingly. Ethical approval was received from the Health Ethics Committee Faculty of Medicine Universitas Brawijaya with ethical clearance number 06/EC/KEPK/01/2020 and the participants were given informed consent before participating in this study. Results and Discussions Table 1 shows that most caregivers aged less than 45 years old (48.3%), were Moslem (96.9%), male (51.4%), with senior high school education level (48.6%), had private jobs (57.5%), and with children (47.1%). Also, most diabetes mellitus patients aged between 45-65 years old (63.3%), were Moslem (96.9%), female (80.4%), with last education being elementary school (51.7%), did not work (68.8%), suffered for 1-5 years (48.6%) and their last blood sugar level was >125 mg/dL (86.9%). Table 2 shows that caregivers with good family health tasks were 189 people (57.8%), while up to 138 people (42.2%) lack family health care implementation. Based on the components of family health care tasks, the best was that 65.4% family made deci- sions and the lowest with 57.8% modified the environment (Table 3). Based on Table 4, diabetes mellitus patients were in the catego- ry of good health status, up to 196 people (59.9%). Once viewed from the domain of health status, the best domain was social func- tion (91.4%), while the poorest was general health (44.3%) as can be seen in Table 5. According to Table 6, the statistical test results showed a significant relationship between family health task implementation and the health status of diabetics with a 0.000 p- value (alpha 0.05). Family health care tasks consist of knowing the health prob- lems, as well as the ability to make decisions, demonstrate good health care, modify the environment, and access health centers. The caregiver’s ability to provide health care is influenced by sev- eral factors, namely education, occupation, economic status, and distance to health services. The first domain of the family health care tasks is knowing about health problems. Additionally, the Article [Healthcare in Low-resource Settings 2023; 11(s1):11195] [page 101] Table 1. Characteristics of family caregivers and people with diabetes mellitus. Demographic Characteristics Family caregivers People with DM n % n % Age <45 years old 158 48.3% 7 2.1% 45-65 years old 123 37.6% 207 63.3% >65 years old 46 14.1% 113 34.6% Gender Male 168 51.4% 64 19.6% Female 159 48.6% 263 80.4% Last education No school 1 0.3% 2 0.6% Elementary school 71 21.7% 169 51.7% Middle School 54 16.5% 76 23.2% Senior High school 159 48.6% 65 19.9% Undergraduate or postgraduate 42 12.8% 15 4.6% Profession Does not work 120 36.7% 225 68.8% Labor 9 2.8% 3 0.9% Farmers 1 0.3% 0 0% Civil servants 7 2,1% 3 0.9% Army / Police 2 0.6% 1 0.3% Etc 188 57.5% 95 29.1% Relationship with patients Husband and Wife 153 46.8% Child 154 47.1% Son in law 3 0.9% Sister 6 1.8% Niece 1 0.3% Grandchild 9 2.8% Mother 1 0.3% No n- co mm er cia l u se on ly caregiver’s education level is directly proportional to their level of knowledge and information possessed. Educational background affects a person’s mindset and cognitive abilities have a role in rec- ognizing health problems.11 Education is a change in human beings, hence it is one of the factors influencing a person’s percep- tion to easily make decisions and act.14 Decision-making in family health care task implementation is influenced by social and psy- chological factors.15 Behavior is one of the social factors, and good behavior is caused by a person’s experiences as well as physical and non-physical environmental factors.16 Well-educated care- givers tend to provide good care to family members who have health problems.17 Environmental modification is carried out by reducing the physical hazards existing at home to minimize health risks.18 In theory, caregivers’ ability to modify the environment is a form of emotional support that provides comfort and helps the healing process, besides it can be conducted by providing a com- fortable and conducive home atmosphere.12 The family’s ability or behavior in using health facilities is influenced by education level Article [page 102] [Healthcare in Low-resource Settings 2023; 11(s1):11195] Table 2. Family health tasks implementation. Family health tasks implementation n % Good (score ≥75.46) 189 57.8% Poor (score <75.46) 138 42.2% Table 3. Domain of family health task. Domain of family health task Good Poor n % n % Recognizing the problem 181 55.4% 146 44.6% Making decision 214 65.4% 113 34.6% Provide care 207 63.3% 120 36.7% Encironmemtal modification 138 42.2% 189 57.8% Take advantage of the facilities health 201 61.5% 126 38.5% Table 5. Domain of health status of people with diabetes mellitus. Domain Good Not Good n % n % Physical Dimension Physical function 310 94.8% 17 5.2% Physical Role 279 85.3% 48 14.7% Body Pain 296 90.5% 31 9.5% General perception 182 55.7% 145 43.3% Mental Dimension Emotional Role 301 92% 26 8% Vitality 230 70.3% 97 29.7% Mental Wellness 323 98.8% 4 1.2% Social function 321 98.2% 6 1.8 Table 6. Correlation analysis between the burden of family caregivers and the health status of DM patients. Variable Correlation coefficient p-value The family health tasks implementation 0.593** 0.000 Health Status Table 4. Health status category. Health Status n % Good (score ≥61.91) 196 59.9% Poor (score <61.91) 131 40.1% No n- co mm er cia l u se on ly because both parameters have a significant relationship.19 Busyness and economic level also influence the use of health facil- ities. One of the factors that have a significant effect on health facilities usage is distance, hence people with middle economic level are not necessarily disobedient in the treatment and care pro- gram.20 The health status of DM patients is influenced by several fac- tors including age, gender, education, length of suffering, and occupation.21 As age increases, it becomes more difficult to control blood sugar levels which are increasing due to a decrease in the function of body organs, thereby affecting DM patients’ health sta- tus.22 Based on the result, the gender of the subjects used was most- ly female. This is not in line with another study that states women’s health status is lower compared to men, specifically in mental or psychological aspects because they are more prone to anxiety and depression once exposed to chronic diseases. Health status increas- es along with higher levels of education obtained by the patients, and vice versa.23 Education is an important factor in understanding disease, DM management and blood sugar control, self-care, over- coming symptoms that arise with appropriate treatment, and pre- venting complications. Additionally, patients with higher educa- tion tend to develop coping mechanisms and a good understanding of information, hence they respond positively and take self-benefi- cial actions. Health status consists of the Physical Health Component Scale (PCS) and the Mental Health Component Scale (MCS). The PCS has four domains, namely general health, physical function, phys- ical role, and discomfort. The MSC also has four domains, includ- ing the role of emotions, mental health, vitality, and social func- tioning. Changes in physical roles caused by fatigue in diabetics are a cellular compensatory process to maintain cell function due to the impact of cellular starvation.24 Besides, DM patients experi- ence a decrease in the amount of physical activity due to discom- fort in the form of pain or tingling that occurs. Lack of physical activity is initiated by other reasons, such as the fear of getting ulcers or wounds on the feet.25 Mental health is a condition where individuals are free from all forms of symptoms of mental disor- ders.26 Individuals with good mental health function normally in life, but their counterparts experience disturbances in mood, think- ing ability, and self and emotional control. Positive self-control in dealing with various situations affect one’s mental health and a person’s emotions are said to be healthy once they are controllable.27 In this study, a significant relationship was discovered between family health care task implementation and the health status of dia- betes mellitus patients. The relationship is unidirectional, indicat- ing the better the implementation of family health care tasks, the better the diabetic’s health status. A relationship was also found between the implementation of family health care tasks and the health status of hypertensive patients (p-value 0.009).12 Families who have good abilities in carrying out health care tasks have a 12.03 times higher chance to improve health status than their coun- terparts. A study stated that reported family health task implemen- tation before and after being carried out with family nursing care had a significant effect on health status with a p-value of 0.000.28 The family role is needed to improve the health status of its mem- bers according to health care function. These include five nursing tasks, namely the ability to recognize health problems, take appro- priate health action decisions, care for the members, maintain a pleasant home atmosphere and modify the environment to ensure good health, and the ability to reach health service facilities.29 Based on a study, family and nurses provide effective health care interventions to improve health status outcomes in the elderly with memory impairment and cancer.30 It is evident that family involvement in the intervention improves patient outcomes in effi- cacy, specificity, and effectiveness. Families according to several studies in the field of family health have a big influence on the members’ health status. Moreover, they have a role in the form of health promotion and risk reduction.9 Once there are health prob- lems, the majority of individuals receive more care from their fam- ilies. The family is the most important source of care for sick mem- bers, which influences a health-oriented lifestyle. In this case, it prevents, corrects, causes, or ignores health problems in the mem- bers.9 The family has a major role in maintaining all members’ health and in trying to achieve the desired health status. Health problems in the family are interrelated where the family is an effective and efficient intermediary from which to seek good health status for its members. There may be some possible limita- Article Correspondence: Niko Dima Kristianingrum, Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Jl. Puncak Dieng, Kunci, Kalisongo, Kec. Dau, Malang, East Java Indonesia 65151. Tel.: +62 341 5080686, Fax: +62 341 5080686. E-mail: nikodima.fk@ub.ac.id Key words: Family health tasks, health status, diabetes mellitus. Acknowledgment: The author is grateful to the Faculty of Medicine, Universitas Brawijaya for providing support and encouragement during this study. The author is also grateful to the Malang City Health Office and participants. Contributions: All authors contributed equally to this article, and then read and approved the final manuscript such that NDK wrote, managed, and reviewed the final article. DA was responsible for data collection, while YSH & S served as supervisors and also conducted the review. MLP review the article. Conflict of interests: The author declares no conflict of interest. Funding: Faculty of Medicine, Universitas Brawijaya. Clinical trials: This study has been approved by the health research ethics committee of the Faculty of Medicine, Universitas Brawijaya Malang with ethical clearance number 06/EC/KEPK/01/2020. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Informed consent: Written informed consent was obtained from a legal- ly authorized representative(s) for anonymized patient information to be published in this article. Conference presentation: Part of this paper was presented at the 2nd International Nursing and Health Sciences Symposium that took place at the Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia. Received for publication: 13 December 2021. Accepted for publication: 10 May 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11(s1):11195 doi:10.4081/hls.2023.11195 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2023; 11(s1):11195] [page 103] No n- co mm er cia l u se on ly tions in this study. Some respondents may have difficulty in under- standing the question in SF 12 questionnaire. Having observed this problem, the researcher gave more detailed explanation to the respondents so they can understand the questions. The data gener- ated was only from the questionnaire instrument which is based on the perception of respondents’ answers. A qualitative approach is needed to strengthen conclusions because research instruments are vulnerable to respondents’ perceptions that do not describe the actual situation Conclusions Based on the results showed, there is a relationship between family health care task implementation and the health status of dia- betes mellitus patients, hence both parameters are directly propor- tional. Nurses need to carry out family-centered care to improve the health status of DM patients. Further study needs to analyze the factors influencing family health care tasks, as well as develop and carry out interventions to change family health tasks. References 1. Cho NH, Shaw JE, Karuranga S, et al. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projec- tions for 2045. Diabetes Res Clin Pract 2018;138:271-281. 2. International Diabetes Federation. IDF Diabetes Atlas Ninth edition 2019; 2019. [cited 2021 Oct 10]. Available from: https://diabetesatlas.org/atlas/ninth-edition/ 3. International Diabetes Federation. IDF Diabetes Atlas seventh Edition 2017; 2017. [cited 2021 Oct 10]. Available from: https://diabetesatlas.org/atlas/seventh-edition/ 4. Papatheodorou K, Banach M, Bekiari E, et al. Complications of Diabetes 2017. J Diabetes Res 2018;2018:e3086167. 5. Qinglan D, Funk M, Spatz ES, et al. Association of Diabetes Mellitus With Health Status Outcomes in Young Women and Men After Acute Myocardial Infarction: Results From the VIRGO Study. J Am Heart Assoc 2019;8:e010988. 6. Aschalew AY, Yitayal M, Minyihun A. Health-related quality of life and associated factors among patients with diabetes mellitus at the University of Gondar referral hospital. Health Quality Life Outcomes 2020;18:62. 7. Anizar RDS, Pudjiastuti E. Studi Deskriptif Mengenai Resiliensi Istri sebagai Caregiver pada Penderita Diabetes Melitus (DM) Tipe II di RSUD Sejiran Setason. [Descriptive Study of Wife's Resilience as Caregiver in Type II Diabetes Mellitus (DM) Patients at Sejiran Setason Hospital] Prosiding Psikologi 2017;0:1–6. 8. Yeni F, Handayani T. Hubungan Peran Keluarga Dengan Pengendalian Kadar Gula Darah Pada Pasien Diabetes Melitus di Wilayah Kerja Puskesmas Pauh Padang. [Relationship between the Role of the Family and the Control of Blood Sugar Levels in Patients with Diabetes Mellitus in the Work Area of the Pauh Padang Health Center.] NERS Jurnal Keperawatan 2013;9:136–42. 9. Friedman MM, Bowden, VR, Jones EG. Buku Ajar Keperawatan Keluarga: Riset, Teori & Praktik. [Textbook of Family Nursing: Research, Theory & Practice.] (5th ed.). Jakarta: EGC; 2010. 10. Farida L, Purwaningsih P, Rosalina. Peran Informal Keluarga dalam Pengendalian Kadar Glukosa Darah pada Penderita Diabetes Mellitus. [The Informal Role of the Family in Controlling Blood Glucose Levels in Patients with Diabetes Mellitus.] Jurnal Ilmu Keperawatan Komunitas 2018;1(1):5– 17. 11. Potter PA & Perry AG. Buku Ajar Fundamental Keperawatan: Konsep, Proses dan Praktik (4 Volume 1). [Nursing Fundamental Textbook: Concepts, Processes and Practices (4 Volume 1).] Jakarta: EGC; 2005. 12. Amigo TAE. Hubungan Karakteristik dan Pelaksanaan Tugas Perawatan Kesehatan Keluarga dengan Status Kesehatan pada Aggregate Lansia dengan Hipertensi di Kecamatan Jetis Yogyakarta. [Correlation between Characteristics and Implementation of Family Health Care Tasks with Health Status in Aggregate Elderly with Hypertension in Jetis District, Yogyakarta.] Universitas Indonesia; 2012. 13. Badriah S, Sahar J, Gunawijaya J, et al. Pampering older peo- ple with diabetes in Sundanese culture: A qualitative study. Enfermería Clínica 2019;29:733–8. 14. Notoatmodjo S. Promosi Kesehatan dan Ilmu Perilaku. [Health Promotion and Behavioral Sciences.] Jakarta: Rineka Cipta; 2007. 15. Kamaluddin R. Pertimbangan Dan Alasan Pasien Hipertensi Menjalani Terapi Alternatif Komplementer Bekam Di Kabupaten Banyumas. [Considerations and Reasons for Hypertension Patients Undergoing Complementary Alternative Therapy for Cupping in Banyumas Regency.] SJN 2010;5:95–104. 16. Nugroho W. Keperawatan Gerontik. [Gerontic Nursing.] Buku Kedokteran EGC: Jakarta; 2008. 17. Sahar J, Courtney M, Edwarsd H. Improvement of family car- ers’ knowledge, skills and attitudes in caring for older people following the implementation of a Family Carers’ Training Program in the community in Indonesia. International Journal of Nursing Practice 2002;9:246 – 254. 18. Kaakinen JR, Coehlo DP, Steele R, Robinson M. Family Health Care Nursing: Theory, Practice, and Research [Internet]. F.A. Davis Company; 2018. Available from: https://books.google.co.id/books?id=wNFJDwAAQBAJ. 19. Mandias R. Hubungan Tingkat Pendidikan dengan Perilaku Masyarakat Desa Alam dalam Memanfaatkan Fasilitas Kesehatan di Desa Pulisan Kecamatan Likupang Timur Minahasa Utara. [Relationship between Education Level and Community Behavior in Alam Village in Utilizing Health Facilities in Pulisan Village, East Likupang District, North Minahasa.] Minahasa: Universitas Klabar; 2012. 20. Suhadi. Analisis Faktor-Faktor Yang Mempengaruhi Kepatuhan Lansia Dalam Perawatan Hipertensi Di Wilayah Puskesmas Srondol Kota Semarang. [Analysis of Factors Affecting Elderly Compliance in Hypertension Treatment in the Srondol Health Center, Semarang City.] Jakarta: UI; 2011 21. Moons, P. Why call it health-related quality of life when you mean perceived health status. Eur J Cardiovasc Nurs 2004;3(4):275-7. 22. Suardana IK, Rasdini A, Kusmarjathi NK. Hubungan dukun- gan sosial keluarga dengan kualitas hidup pasien diabetes mel- litus tipe II di puskesmas IV denpasar selatan. [The relation- ship between family social support and quality of life of patients with type II diabetes mellitus at Puskesmas IV Denpasar Selatan.] Jurnal Skala Husada 2015;12:96 – 102. 23. Gautam Y, Sharma A, Agarwal A, et al. A Cross-sectional Study of QOL of Diabetic Patients at Tertiary Care Hospitals in Delhi. Indian J Community Med 2009;34:346–50. 24. Riyadi S, Sukarmin. Asuhan Keperawatan pada Pasien dengan Gangguan Eksokrin dan Endokrin pada Pankreas. [Nursing Care of Patients with Exocrine and Endocrine Disorders of the Pancreas.] Yogyakarta: Graha Ilmu; 2008. Article [page 104] [Healthcare in Low-resource Settings 2023; 11(s1):11195] No n- co mm er cia l u se on ly 25. Lemaster JW, Mueller MJ, Reiber GE, et al. Effect of weight- bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: feet first randomized controlled trial. Phys Ther 2008;88:1385–98. 26. Putri AW, Wibhawa B, Gutama AS. Kesehatan Mental Masyarakat Indonesia (Pengetahuan, Dan Keterbukaan Masyarakat Terhadap Gangguan Kesehatan Mental). Prosiding Penelitian dan Pengabdian kepada Masyarakat. [Indonesian People's Mental Health (Knowledge, and Community Openness to Mental Health Disorders). Proceedings of Research and Community Service.] 2015;2:13535. 27. Hamid A. Agama Dan Kesehatan Mental Dalam Perspektif Psikologi Agama. [Religion and Mental Health in the Perspective of the Psychology of Religion.] Healthy Tadulako J 2017;3:1–14. 28. Yuliyanti T, Zakiyah E. Tugas Kesehatan Keluarga Sebagai Upaya Memperbaiki Status Kesehatan Dan Kemandirian Lanjut Usia. [Family Health Tasks as an Effort to Improve the Health Status and Independence of the Elderly.] Profesi (Profesional Islam): Media Publikasi Penelitian. 2016;14(1): 49–55. 29. Andarmoyo S. Keperawatan Keluarga Konsep Teori, Proses dan Praktek Keperawatan. [Family Nursing Concepts Theory, Process and Practice of Nursing.] Yogyakarta: Graha Ilmu; 2012. 30. Griffin JM, Meis LA, MacDonald R, et al. Effectiveness of Family and Caregiver Interventions on Patient Outcomes in Adults with Cancer: A Systematic Review. J Gen Intern Med 2014;29:1274–82. Article [Healthcare in Low-resource Settings 2023; 11(s1):11195] [page 105] No n- co mm er cia l u se on ly