Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12008 Exploring the correlation of social networks, family support, health worker assistance, and health education using the precede-proceed model: impact on emotional responses in diabetes mellitus patients Umdatus Soleha, Siti Nurjanah, Umi Hanik Faculty of Nursing and Midwifery, Universitas Nahdlatul Ulama Surabaya, Surabaya, Indonesia Abstract Diabetes Mellitus is a chronic disease that has the potential to cause stress due to uncertainty about the course of the disease, treatment, and complications. The aim of this research was to ana- lyze the relationship between the support of health workers, fam- ily support, social networks, and health education through the pre- cede-proceed model approach to emotional responses. The type of research is a cross-sectional study. The research was conducted at the Simo Mulyo Health Center in Surabaya, with data collected from June to July 2023. The independent variables, namely the support of health workers, family support, social networks, and health education, were measured using a questionnaire, while the dependent variable, emotional response, was measured using a questionnaire. The population in this study comprised all people with diabetes Mellitus registered at the Simo Mulyo Health Center in Surabaya. The inclusion criteria for this study were as follows: patients with unstable blood sugar regulation, aged between 26 and 65 years, capable of reading, and willing to be respondents. The sample size in this study was 112 respondents, and the sam- pling technique used was simple random sampling. Data analysis utilized the Spearman rho correlation test with a significance level of α=0.05. The findings indicate that social network support and emotional response, with a p-value of 0.000 (p<0.005) and r=0.879. Health education is correlated with emotional response, with a p-value of 0.000 (p<0.005) and r=0.585. Health worker support is correlated with dealing with emotional responses, with a p-value of 0.000 (p<0.005) and r=0.786. Family support is cor- related with emotional response, with a p-value of 0.000 (p<0.005) and r=0.738. Social network support, health education, family support, and health worker support correlate with the emo- tional response of people with diabetes Mellitus. Therefore, health workers, families, and social networks can enhance support to improve the quality of the patient’s emotional response, promoting patient enthusiasm for adhering to treatment and minimizing com- plications due to diabetes Mellitus. Introduction Diabetes Mellitus (DM) is classified as one of the Non- Communicable Diseases (NCDs).1 It is a chronic condition that has the potential to induce stress, stemming from uncertainty regarding the disease’s progression, treatment, and complications due to insufficient insulin production by the pancreas.2 The ability to respond positively to stressors and manage emotions is crucial in the treatment of this disease. The prolonged duration of treat- ment can lead sufferers to experience feelings of hopelessness, fear, anxiety, and depression.3 In 2021, the International Diabetes Federation (IDF) recorded 537 million people living with diabetes.4 Indonesia ranks seventh globally in the number of people with diabetes Mellitus (DM), totaling 19.47 million people, indicating a prevalence of 10.6%. The 2018 Riskesdas results reveal that the prevalence of DM with a doctor’s diagnosis has increased by 2% from the original 2013 prevalence of 1.5%.5 DM is the primary chronic disease associated with severe psychosocial problems.6 Riskesdas data from 2018 indicates that the prevalence of emotional disorders in individuals aged 15 years and over increased from 6% to 9.8%, with the prevalence of depression sufferers reaching 6.1%.7 Factors influ- encing the psychological adjustment in individuals with DM, according to the precedence-procedure theory, include predispos- Correspondence: Umdatus Soleha, Faculty of Nursing and Midwifery, Universitas Nahdlatul Ulama Surabaya, Surabaya, Indonesia. E-mail: umdatus@unusa.ac.id Key words: diabetes mellitus, emotional response, family support, health education, health worker support, social network. Contributions: US conceptualization, formal analysis, methodology,writ- ing – original draft; SN validation, visualization; UH review and editing; FE data curation, review and editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received eth- ical approval from the Brahmanda Lentera Chakra Institute No. 094/010/VII/EC/KEP/LCBL/2023. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research was supported by a research grant from Universitas Nahdlatul Ulama Surabaya with contact https://lppm. unusa.ac.id/ Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 20 October 2023. Accepted: 21 December 2023. Early access: 8 February 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12008 doi:10.4081/hls.2024.12008 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 product 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 2024;12:12008] [page 249] Non -co mmerc ial us e o nly ing factors such as age, education, employment status, and knowl- edge. Enabling factors encompass the distance of residence and family income, while reinforcing factors involve peer support, health workers, and family.8 Individuals with diabetes are at a high risk of decreased psychological well-being, with over 40% experi- encing emotional aspects.9 This is attributed to changes in treat- ment and health well-being since diagnosis. People with diabetes often report difficulty accepting a diagnosis of a long-term condi- tion that necessitates constant self-management.10 This difficulty leads to various psychological reactions, including rejection and avoidance, resulting in poor glycemic control. Reinforcing factors from the environment, in the form of support from health workers, family, and friends, significantly contribute to enhancing the opti- mism of individuals with chronic diseases, thereby reducing psy- chological burdens.11 Other research indicates that individuals with diabetes generally experience greater anxiety compared to patients with other diseases.12 Increased support serves as reinforcement and is essential to reduce fear, anxiety, and depression, fostering positive emotional responses. The aim of this research was to ana- lyze the relationship between the support of health workers, family support, social networks, and health education using the precede- proceed model approach to understand emotional responses. Materials and Methods This research was meticulously crafted as a cross-sectional study, homing in on individuals grappling with Diabetes Mellitus at Simo Mulyo Health Center in Surabaya. A carefully curated group of 180 respondents actively participated, meeting stringent inclu- sion criteria that encompassed patients contending with unstable blood sugar regulation, individuals aged between 26 and 65 years, those possessing reading capabilities, and a willingness to be respondents. To guarantee the representativeness of the sample, a methodical approach employing simple random sampling was undertaken. The study delved into diverse independent variables, including the examination of health worker support, family dynam- ics, social networks, and health education. The focal point of inves- tigation revolved around the emotional response of the participants, serving as the dependent variable. Methodologically, data collec- tion was executed using a meticulously designed questionnaire, rig- orously validated, and tested for reliability. This meticulous approach aimed to ensure the robustness and accuracy of the results. The subsequent analysis employed the Spearman rho corre- lation test, with a predetermined significance level set at α=0.05. Moreover, ethical considerations played a pivotal role throughout the research process. The study garnered ethical clearance from the Chakra Brahmanda Lentera Institute under the reference number 094/010/VII/EC/KEP/ LCBL/2023, thereby attesting to its unwa- vering commitment to upholding ethical standards and guidelines. Results Table 1 presents the demographic data of the respondents. In this study, most respondents were classified as late elderly (37.5%), with a significant portion employed in the private sector (74.1%). Furthermore, a predominant percentage of respondents had attained primary education as their highest educational level (60.7%). Regarding the duration of suffering from diabetes Mellitus, the majority reported a duration of 6 months to 1 year (78.6%), and a significant proportion had never been treated in a hospital for their condition (61.6%). Table 2 illustrates the social network support among respondents, with the majority reporting Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Demographic characteristics of the respondent. Characteristics Frequency (n) Percentage (%) Age (year) 26-35 12 13.4 36-45 10 8.9 46-55 26 23.2 56-65 42 37.5 >65 19 17 Total 112 100 Work Government employees 12 10.7 Private sector employees 83 74.1 Pension 6 5.4 Trader 8 7.1 Doesn't work 3 2.7 Total 112 100 Education Primary education 68 60.7 Secondary education 31 27.7 High education 13 11.6 Total 112 100 Long suffered 6 month - 1 year 88 78.6 2 year - 5 year 24 21.4 Total 112 100 Hospital experience Been in hospital 43 38.4 Never been in hospital 69 61.6 Total 112 100 Table 2. Variable characteristics. Characteristics Frequency (n) Percentage (%) Social network Good 14 12.5 Enough 57 50.9 Not enough 41 36.6 Total 112 100 Health education Good 83 74.1 Enough 17 15.2 Not enough 12 10.7 Total 112 100 Family support Good 20 74.1 Enough 77 15.2 Not enough 15 10.7 Total 112 100 Health worker support Good 32 28.6 Enough 70 62.5 Not enough 10 8.9 Total 112 100 Emotional response Good 26 23.2 Enough 41 36.6 Not enough 45 40.2 Total 112 100 [page 250] [Healthcare in Low-resource Settings 2024;12:12008] Non -co mmerc ial us e o nly sufficient support (50.9%). The health education received by respondents was predominantly deemed good (74.1%), while fam- ily support was largely considered sufficient (68.8%). Additionally, a substantial proportion of respondents indicated receiving adequate support from health workers (62.5%), and the emotional response of the respondents was largely characterized as sufficient (40.2%). Table 3 show the correlation between social network support and emotional response, with a p-value of 0.000 (p<0.005) and r=0.879. Health education is correlated with emo- tional response, with a p-value of 0.000 (p<0.005) and r=0.585. Health worker support is correlated with dealing with emotional responses, with a p-value of 0.000 (p<0.005) and r=0.786. Family support is correlated with emotional response, with a p-value of 0.000 (p<0.005) and r=0.738. Discussion The results indicate that the social network has an effect on the patient’s emotional response, implying that the better the patient’s social network, the better their emotional response to their illness. This finding aligns with research conducted by Moulaei et al. (2022). Social networking refers to the connection of people with diabetes Mellitus to others, including friends, both individually and organizationally, physically, and through social media. In this study, indicators include social activities, roles and interaction intensity outside the home, friendships, and frequency of interac- tion.13 A strong social network assists sufferers in developing their emotional responses and helps them avoid fear, anxiety, and depression. This is consistent with the findings of the Schram et al. (2021) study, which asserts that robust social networks for people with diabetes Mellitus can enhance emotional relationships. Sufferers receive more attention, affection, and care from those around them, enabling them to manage emotional symptoms aris- ing from diabetes Mellitus, such as increased anxiety, irritability, and frequent discomfort.14 The results indicate that family support has an effect on the emotional response of sufferers, signifying that good support from the family can improve the emotional response of individuals in coping with their illness. This finding aligns with the research con- ducted by Wulandari et al. (2021), which emphasizes the essential role of family support for the elderly in the treatment process. Physical limitations experienced by elderly sufferers necessitate support from the family in various forms, including informational, instrumental, emotional, and appreciation support.15 The family can serve as a potent motivator for individuals with diabetes Mellitus in terms of glycemic control, particularly when they con- sistently offer companionship to the elderly during health facility visits and actively engage in problem-solving with them.16 Another study conducted by Mphasha et al. (2022) stated that family support plays a crucial role in therapy, especially when pro- vided to elderly patients. It is a vital aspect in empowering the elderly for engaging in activities and fostering a desire to explore and adopt new things or novel concepts.17 Various forms of family support encompass emotional, instrumental, informational, and evaluative support in responding to illness.18 According to the researchers’ assumptions, the family can serve as a source of infor- mation, offer emotional support, accompany sufferers to health services, and provide feedback on efforts made to treat their ill- ness. Sufficient family support can assist sufferers in managing emotional responses. For instance, the assumption is that robust family support can alter a person’s perception of an illness, thereby reducing the potential for stress.19 Family support has the potential to bring inner peace and positivity to the elderly, influencing them to think and engage in positive activities, consequently reducing the incidence of depression in this demographic.18 The results indicate that the support of health workers influ- ences the emotional response of sufferers. The attention provided by health workers in the form of information and feedback serves as effective assistance for sufferers in achieving proper care. This finding aligns with the study conducted by Kalra et al. (2018), which highlights that good support from health workers leads to positive emotional responses, improving the coping mechanisms of sufferers. This positive coping, in turn, fosters adherence to both pharmacological and non-pharmacological medication therapy.19 Health workers’ support is considered integral to the success of patients in avoiding depression.20 Various forms of support from health workers, including emotional support, information, instru- ments, and assessments, are consistently required to motivate indi- viduals with diabetes Mellitus to undergo treatment. Health education also plays a role in affecting the emotional response of sufferers, aligning with the responsibilities of health workers as health promoters. Health workers are tasked with pro- viding preventive, promotive, curative, and rehabilitative services. In line with Chawla et al.’s (2019) perspective, effective preven- tion efforts involve health workers, who are respected individuals within the community. When people with diabetes Mellitus receive advice from health workers, they gradually adhere to the guidance provided. Therefore, the substance of advice material and educa- tion is crucial to achieving overall well-being.21 Another perspective asserts that information provided by health workers inspires sufferers to think more constructively, leading to favorable emotional responses.22 Once individuals receive information about the possibility of a disease through var- ious channels, according to problem-solving theory, they become motivated to return to a state of normality free from problems. This process involves giving meaning to the problem.23 Based on the theory of the precede-proceed model, reinforcing factors are cru- cial in shaping the behavior of individuals with DM. The quality of support from social networks, health education, and health workers significantly influences the level of activity in sufferers. This, in turn, helps them avoid feelings of despair during treatment, enabling them to persevere without complaint and fatigue, and maintain good glycemic control. Conclusions Social network support, health education, family support, and health worker support are correlated with the emotional response of individuals with DM. Continuous efforts are required to build and enhance support, aiming to improve the quality of the patient’s emotional response. This is crucial for individuals with DM to be free from fear, anxiety, and depression. A positive emotional Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 3. Correlation test. Variable Coefficient p correlation Social network support and emotional response 0.879 0.000 Health education and emotional response 0.585 0.000 Health worker support and emotional response 0.786 0.000 Family support and Emotional response 0.738 0.000 [Healthcare in Low-resource Settings 2024;12:12008] [page 251] Non -co mmerc ial us e o nly response significantly influences the patient’s coping mechanisms, fostering adherence to the ongoing treatment, thereby minimizing complications associated with DM. References 1. Akoit EE, Efendi F, Dewi YS. Impact of diabetes self-manage- ment education in middle-aged patients with type 2 diabetes mellitus: A systematic review. Gac Med Caracas 2022;130:S1183–95. 2. Zairina E, Nugraheni G, Sulistyarini A, et al. Factors related to barriers and medication adherence in patients with type 2 dia- betes mellitus: a cross-sectional study. J Diabetes Metab Disord 2022;21:219-28. 3. Aldossari KK, Shubair MM, Al-Ghamdi SH, et al. 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