Hrev_master Healthcare in Low-resource Settings 2023; volume 11(s1):11212 The correlation between family support and health status in patients with diabetes mellitus Setyoadi,1 Ah Yusuf,2 Niko Dima Kristianingrum,3 Yati Sri Hayati,3 Linda Wieke Noviyanti,3 Nurmalia Filda Syafiky3 1Nursing Doctor Student Universitas Airlangga Mulyorejo, Surabaya, Indonesia; 2Lecture Faculty of Nursing Universitas Airlangga Mulyorejo, Surabaya, Indonesia; 3Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya Malang, Indonesia Abstract Introduction: The health status of a patient is strongly influ- enced by the family members because they play an important role during the health care process, and in healthy living. This implies that they must be involved in decision-making and therapeutic actions at every stage of the treatment. Therefore, this study aims to determine the relationship between family support and the health status of diabetes mellitus patients in Malang. Design and Methods: This study used a descriptive correla- tional design with a cross-sectional approach, which was carried out by filling questionnaires to determine the relationship between family support and the health status of diabetes mellitus patients. The sample population consists of 327 diabetes mellitus patients and 327 family caregivers of patients with the disease. Meanwhile, the respondents were selected through a cluster ran- dom sampling technique. Results: The results showed that 62.7% of the caregivers pro- vided a good family support, while 90.8% of the patients have a good health status. This indicates that there is a positive correla- tion between family support and the health status of people with the disease (p-value= 0,000, α<0.05, r= 0,400). Conclusions: Further studies are advised to explore the use of nursing interventions as an effort to maintain and improve the ability of families in providing long-term care for members with diabetes mellitus. Introduction Diabetes Mellitus (DM) is a long-lasting metabolic disorder caused by the inadequate production of insulin by the pancreas or the body’s inability to effectively use it. Insulin is a hormone that regulates blood sugar levels, thereby preventing high glucose lev- els in the body (hyperglycemia).1 Furthermore, the disease is char- acterized by hyperglycemia due to defects in insulin function and/or secretion abnormalities.2 In 2014, the World Health Organization (WHO) discovered that there were 422 million overweight or obese adults with dia- betes mellitus globally. The disease accounted for over 1.5 million deaths among people less than the age of 70. Based on doctors’ diagnosis, the 2018 Riskesdas result showed that its prevalence increased to 2% among people in Indonesia aged> 15 years. Furthermore, in East Java Province, there was a 0.5% increase in its rate between 2013 and 2018, when a prevalence of 2.6% was recorded5. Malang city has the eleventh highest rate of 2.3% among the 38 cities in East Java.6 The health profile data about the city revealed that DM was ranked 4th out of the 10 common dis- eases, and various public health data revealed that its prevalence is expected to continue increasing over the next couple of years.7 Data from the Malang City Health Office in 2017 showed that approximately 22,206 people had diabetes in the 16 Primary Health Centers with an average of 1,850 cases per month.8 Furthermore, lower numbers were obtained in 2018, where 18,817 cases were recorded with an average of 1,568 per month.9 In 2019, a total of 12,509 cases were reported between January and July with an average of 1,787 people per month.10 Diabetes mellitus is a non-communicable disease and is a seri- ous threat to world health. It is caused by abnormal blood sugar levels, and the patients usually express clear physical symptoms. Meanwhile, the condition or state of health of a person is known as health status, and it is influenced by the ability of the patients to understand and optimize their condition. It is also influenced by their ability to reach their physical and mental potentials optimally as well as to prevent risk factors that can occur due to illness.11 The American Diabetes Association stated that there is a need to develop a medical intervention using a multifactorial risk reduction strategy that is beyond glycemic control.12 The manage- ment of DM is guided by the 4 pillars of diabetes management, which consists of knowledge about the condition, a regulated diet, adequate amount of physical activity, and medication adherence.13 Furthermore, the management of the disease can be divided into two category, where the first management is short-term, which involves controlling blood sugar and preventing constant illness in the patients.14 Families are expected to participate in the treatment from the beginning because they play an important role in the recovery program.15 Family support is defined as an act of accep- tance by the families of patients with certain health problems. Furthermore, it can be divided into 4 types, namely informational, reward, instrumental, and emotional support.16 Motivation and Article Significance for public health Family is the main source of support for people with chronic diabetes mellitus. Furthermore, their support is easier to obtain because they are closely related, hence, they can help to improve knowledge, attitudes, and compliance during the treatment process. The health status of the patients is strongly influenced by the form of support provided by the family. Therefore, this paper describes the correlation between family support and the health status of diabetes mellitus patients. [Healthcare in Low-resource Settings 2023; 11(s1):11212] [page 145] No n- co mm er cia l u se on ly support from families are needed in the management of diabetes.17 The health status of patients is strongly influenced by their family members because they play a role during the treatment.16 Therefore, they need to participate in decision-making and thera- peutic action at every stage to achieve successful disease manage- ment.18 A challenge that often occurs during DM treatment is the patient’s disobedience during the process. Support from family is an important element in improving their health because they can promote the patient to live healthily.19 Therefore, this study aims to determine the relationship between family support and the health status of diabetes mellitus patients in Malang City. Design and Methods This study used an analytical correlational design with a cross- sectional approach, which involves the concurrent measurement and observation of data to determine the relationship between fam- ily support and health status of diabetes mellitus patients. A quan- titative data analysis method was used by recording the data obtained in the form of numbers for analysis. The inclusion criteria for the study were DM patients who were members of the Prolanis program at every public health center, had health insurance, and were willing to be respondents. Furthermore, a total of 327 dia- betes patients and 327 family caregivers of patients with the dis- ease were obtained using Slovin’s formula in Malang city. A clus- ter random sampling technique was used to select the respondents from the 16 Public Health Centers in the city. Data collection was carried out by visiting each selected public health center by first calculating the proportion, then we took it randomly based on the attendance list at the time of the Prolanis activity (health program activities for managing chronic diseases). Instrument using family support scale (FSS) and health status using Short Form 12 (SF-12). The results of the validity and reliability test have an r arithmetic value of 0.48 – 0.79 (> 0.44) and a Cronbach Alpha coefficient of 0.932 > 0.600, and have an r arithmetic of 0.466 – 0.721 (> 0.44) and a Cronbach Alpha coefficient of 0.909 > 0.600. Data analysis was then carried out using the Pearson Product Moment SPSS because the data is a numerical scale, test with a 95% confidence level (CI; 5%). Results and Discussions Table 1 shows the characteristic of respondents and the major- ity of the caregivers were <45 years (48.3%), and this finding is consistent with Damayanti where most of the family respondents were in the same age range with this study.20 Furthermore, this range is known as productive age and has sufficient experience to care for members that are suffering from a disease.21 Friedman reported that the level of maturity affected the support received by the respondents, hence, age is an important factor that affects the role of caregivers in family nursing.16 The level of education influences the knowledge on environ- mental factors that affect health requirements as well as the amount of knowledge and information received.22 158 caregivers (48.6%) had the latest high school or equivalent education, and this is in line with Chusmeywati that obtained a total of 29 respondents (55.8%) with the same level of education.23 The insight about car- ing for family members with disease conditions is influenced by education level. Almost all of the caregivers used in this study were Muslims, and this finding is consistent with Chusmeywati where all respondents practiced the religion.23 Friedman’s theory states that God, prayer, and faith are needed to overcome any dis- ease.16 Furthermore, Susanti reported that the spiritual factor, which is a guidance in daily living affects the rate of socialization with the surrounding environment and the ability to achieve life’s desires.24 The majority of the family respondents were male (51.4%), and this is inconsistent with Jessica where 57.6% (19 caregivers) were female.25 Furthermore, 57.5% of the caregivers (188) have a private or self-employed job, and this finding is in line with Alfiaturrohmah.21 Good financial ability to support life can be obtained when the respondent has a job.21 Chusmeywati reported that 40.4% of the caregivers (21 respondents) were children, and a similar result of 47.1% (154 respondents) was obtained in this study.23 The elementary school was the most recent education in 169 patients (51.7%), while cleonara reported that 14 respondents (45.2%) have an elementary school education.26 A low educational level makes it difficult to receive information due to limited knowledge. Furthermore, inappropriate food selection and uncon- trolled diet are factors that can increase the risk of diabetes melli- tus.27 Table 2 reveals that 285 respondents (96%) received good emotional support, while 290 (97.6%) received appraisal support. The diabetic patients in the working area of the Public Health Centre in Malang City received good family support, and this is in line with Damayanti that it influences the implementation of self- management.20 Friedman stated that there are 4 types of family support, namely instrumental, informational, emotional, and appreciation supports.16 The highest type of support received by the patients was reward support, followed by emotional, informa- tional, and instrumental supports. Furthermore, 92% of the patients received reward support, which is the feedback received for their action, and this is incon- sistent with Setyoadi where it was the lowest type of support. This type of support can be given in the form of praise or appreciation, providing motivation, and asking for their opinion while solving problems.26 Emotional support was the second-highest type of sup- port received with a total of 296 respondents (90.5%). This finding is in line with Setyoadi, which reported that approximately 89.47% of the respondents received this type of support.26 Examples of emotional support are attention, affection, and sympathy.16 Furthermore, it can be provided in the form of psychosocial pro- tection by listening to their complaints, keeping their feelings pri- vate, comforting the patients when they are sad as well as express- ing affection with actions and words. 87.5% of the patients received good informational support, which is not in line with Setyoadi where it was the most widely received by 51 respondents (89.47%).26 This type of support can be in the form of providing solutions to problems, advice, and information needed in the heal- ing process. Informational support can easily be received because information about a disease can easily be accessed from various media.27 202 respondents (61.8%) received good instrumental sup- port because the families have good health care and economic function. Providing food, clothing, shelter, and assisting patients in taking medication are health care functions that can be provided. Meanwhile, providing adequate finance for care and medication is an economic function in the family.28 Based on these results, family support is an important aspect that is needed during the treatment process. The health status of diabetic patients tends to deteriorate when the support received is less. Furthermore, several factors affect the level of support, name- ly age, education, occupation, gender, and relationship with the patient. Good family support gives the patient a sense of calmness and comfort.29 It can also decrease mortality rate and increase the recovery rate, consequently, Friedman concluded that family sup- port is very beneficial because it has a major effect on health and Article [page 146] [Healthcare in Low-resource Settings 2023; 11(s1):11212] No n- co mm er cia l u se on ly well-being.16 Most of the respondents have a better health status (Table 3), and this is in line with Amigo that good health status was obtained in 123 respondents (75.5%) out of 163.11 Furthermore, most of the patients are between the age of 45-65 years (63.3%). A similar result was obtained by Trisnawati where 47.5% of the respondents were within the age range of 45-52 years.9 The risk of developing diabetes increases along with age because glucose intolerance begins at the age of 45-65 due to decrease in the activ- ities of the pancreatic β cells. 80.4% of the respondents were females because they have a greater chance of developing a high BMI. Fats are easily accumulated in their body due to hormonal processes, such as premenstrual syndrome and post-menopause, Article Table 1. Distribution of respondents. Demographic aspects Caregivers Patients f % f % Age (years) <45 158 48.3 7 2.1 45-65 123 37. 207 63.3 >65 46 14.1% 113 34.6 Religion Islam 317 96.9 317 96.9 Christian 7 2.1 7 2.1 Catholic 3 0.9 3 0.9 Gender Male 168 51.4 64 19. Female 159 48.6 263 80.4 Last education Uneducated 1 0.3 2 0.6 Elementary School 71 21.7 169 51.7 Middle School 54 16.5 76 23.2 High School 159 48.6 65 19.9 College 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 TNI/POLRI 2 0. 1 0.3 Entrepreneur 188 57.5% 95 29.1 Relationship with patients Husband 102 31.2 - - Wife 51 15.6 - - Child 154 47.1 - - Mother 1 0.3 - - Grandchild 9 2.8 - - Sister 6 1.8 - - Niece 1 0.3 - - Son/Daughter in law 5 0.9 - - Older Suffer (Years) <1 - - 36 1 1-5 - - 159 48.6 >5 - - 132 40.4 The last result of GD (mg/dL) 80-109 - - 9 2.8 110-125 - - 34 10.4 >125 - - 284 86.9 Table 2. Distribution of family support and type of support. Family Support Not good Good Frequency (f) Percentage (%) Frequency (f) Percentage (%) Whole support 122 37. 205 62.7 Emotional Support 31 9.5% 296 90.5 Appraisal Support 26 8 301 92 Instrumental Support 125 38.2 202 61.8 Informational Support 41 12.5% 286 87.5 [Healthcare in Low-resource Settings 2023; 11(s1):11212] [page 147] No n- co mm er cia l u se on ly hence, they have a high risk of developing diabetes mellitus.30 Damayanti reported that 60.3% of the respondent used were female, while 39.7% were males.20 Based on the results, the most recent blood sugar level was 125 mg/dl, which was obtained in 284 respondents (86.9%). This result is consistent with Cleonara where all respondents had sugar levels of 126 mg/dl, which has been pre- viously categorized as an uncontrolled level.31 Uncontrolled eating patterns combined with decreased physical activity make it diffi- cult for diabetic patients to control blood sugar.32 Table 4 shows that 197 patients with good health status (66.3%) received good family support, while 100 patients with good health status (33.7%) were not supported by their families. Furthermore, a total of 195 patients (65.7%) received instrumental support, while 277 (93.7%) received informational support and they all have a good health status. Table 5 shows the analysis results, which revealed that there is a significant relationship between family support and health status (p <0.001; α = 0.05; r = 0.400). The higher the family support, the higher the health status of the patients. Previous study also confirmed the positive correla- tion in type 2 diabetes mellitus patients, where 38.30% of the respondents that received family support were healthier. Therefore, the higher the support from the family, the better the health status.33 Good appreciation support with good health status has the highest percentage in this study, which accounted for 97.6% of the respondents (290). This finding is in line with Yusra that there is a relationship between the dimensions of appreciation and the qual- ity of life of diabetic patients.34 These results are also consistent with Friedman’s theory that reward support is a form of effective family function, which improves the mental health of sick mem- bers.16 Patients receive recognition for their abilities and skills with the support of appraisals, and they help to improve their psychoso- cial status, motivation, enthusiasm, and self-esteem, which also improve their health status. Good emotional support with good health status had the sec- ond-highest percentage of 96% (285 respondents). A similar study reported that the easiest type of support to obtain was emotional support, which can be in the form of acceptance by the family.35 This support makes the patients more alert and able to manage the complications as well as their physical disorders.36 This finding is in line with Nuraisyah that support has a relationship with the qual- ity of life.37 Health can be improved through family support, which helps to reduce the incidence of stress in diabetic patients. Medical and paramedics are expected to always advise families to be closer to the patient. They can assist in arranging a routine blood sugar check schedule, which serves as a motivation to improve their Article Table 4. Cross tabulation results between family support, types of family support and health status. Health Status Not good % Good % Family Support Less 22 73.3 100 33.7 Good 8 26.7 197 66.3 Types of family support Emotional Support Less 19 63.3 12 4 Good 11 36.7 285 96 Appraisal Support Less 19 63.3 7 2.4 Good 11 36.7 290 97.6 Instrumental Support Less 23 76.7 102 34.3 Good 7 23.3 195 65.7 Informational Support Less 21 70 20 6.7 Good 9 30 277 93.7 Table 5. Results of analysis of the relationship between family support and health status using the pearson product moment test. Variable Correlation Coeff. P-value Family Support with Health Status in Diabetes Mellitus Patients 0.400** 0,000 [page 148] [Healthcare in Low-resource Settings 2023; 11(s1):11212] Table 3. Distribution of health status domain. Health Status Domain Not good Good Frequency (f) Percentage (%) Frequency (f) Percentage (%) General health 145 44.3 182 55.7 Physical function 17 5.2 310 94.8 Physical role 48 14.7 279 85.3 Discomfort 31 9.5 296 90.5 The role of emotions 26 8 301 92 Mental health 4 1.2 323 98.8 Vitality 97 29.7 230 70.3 Social function 6 1.8 321 98.2 No n- co mm er cia l u se on ly health status.36 This motivation can also be provided through infor- mational support, and in this study, 277 respondents (93%) that received it had a good health status. Instrumental support has the lowest percentage of 65.7% where 195 respondents that received it had a good health status. This kind of support can be provided through diet monitoring, medication adherence, exercise, as well as a routine control of blood sugar levels. Furthermore, a similar study stated that it can provided by increasing the level of medication adherence and blood sugar stability.37 The health status of patients with the sup- port was better compared to others without it, and this result is con- sistent with Friedman’s theory, which states that the instrumental dimension involves supporting each respondent’s efforts to exer- cise, care efforts, paying for treatment, and providing food based on the required diet.16 Active instrumental support from the family affects the adherence to diabetes mellitus treatment.38 Previous studies showed that health increases along with the level of support provided by the family. They provide motivation to sick members and also work together to provide treatment. This study’s findings are in accordance with Friedman that a good fam- ily support decreases the incidence of death and facilitates the recovery of intellectual function, physical, and emotional health.16 The limitations of the results of the study only looked at one exter- nal factor, namely family support, there was also a health service support factor, and family values. Health status is also largely determined by internal factors such as self-efficacy, demographic characteristics, and level of independence. It is suggested for the next research to involve more other variables that affect the health status of DM patients to get more comprehensive results. Conclusions Based on the results, 62.7% of the family caregivers in the working area of Malang City Public Health Center provided good family support for their member, while 90.8% of the diabetic patients had a good health status. This finding indicates that there is a positive correlation between family support and health status (p <0.001; α = 0.05; r = 0, 400). References 1. Ministry of Health of the Republic of Indonesia. Infodatin, Diabetes Situation and Analysis. Jakarta: Data and Information Center of the Ministry of Health of the Republic of Indonesia; 2014. 2. American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2010;33:S62–9. 3. PERKENI. Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2015. [Consensus on Management and Prevention of Type 2 Diabetes Mellitus in Indonesia 2015.] Jakarta: PERKENI; 2015. 4. WHO. Global report on diabetes. 2016. Accessed 2021 May 2. Available from: https://www.who.int/publications-detail-redi- rect/9789241565257 5. Ministry of Health Republic of Indonesia. Basic Health Research Data 2017. Jakarta: Ministry of Health Republic of Indonesia; 2018. 6. Dini CY, Sabila M, Habibie IY, et al. 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[Correlation between Characteristics and Implementation of Family Health Care Tasks with Health Article Correspondence: Setyoadi, 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: setyoadi@ub.ac.id Key words: Family support, health status, diabetes mellitus. Acknowledgment: The authors are grateful to the Faculty of Health Sciences, Universitas Brawijaya Malang, Indonesia for their kind sup- port and encouragements during this study. Contributions: All authors contributed equally to this article. Conflict of interests: The author declares no conflict of interest. Funding: This study was funded by the Faculty of Medicine, University of Brawijaya, Malang. Clinical trials: This study was approved by the health research ethics committee of the Faculty of Medicine, University of Brawijaya, Malang. 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: 7 December 2021. Accepted for publication: 12 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):11212 doi:10.4081/hls.2023.11212 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):11212] [page 149] No n- co mm er cia l u se on ly Status in Aggregate Elderly with Hypertension in Jetis District, Yogyakarta.] Depok: Universitas Indonesia; 2012. 12. American Diabetes Association. Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers. Clinical Diabetes 2022;40:10–38. 13. Putri NHK, Isfandiari MA. 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[The Relationship between Family Support and Quality of Life for Type 2 Diabetes Mellitus at the Pademawu Health Center.] Jurnal Berkala Epidemiologi 2017;5:240-25 38. Nuraisyah F, Kusnanto H, Rahayujati TB. Dukungan keluarga dan kualitas hidup pasien diabetes mellitus. [Family support and quality of life of diabetes mellitus patients.] BKM J Com Med Public Health 2017;33:25. Article [page 150] [Healthcare in Low-resource Settings 2023; 11(s1):11212] No n- co mm er cia l u se on ly