Family functioning integrated with diabetes self-management: a concept analysis

Diabetes mellitus (DM) is a significant public health problem worldwide. The World Health Organization (WHO) predicts that 422 million people are currently living with DM.¹ Several complications are associated with DM, including diabetic retinopathy, nephropathy, neuropathy, cardiovascular disease, amputations, and premature death.²

Diabetes self-management is relatively complex given that individuals have to attend medical appointments regularly, adhere to several different medications, control their symptoms through physical activity, blood glucose monitoring, and foot care, and negotiate barriers to management and psychosocial problems.³

Family members are a potentially useful support system for diabetes self-management. Much diabetes management takes place within a close social environment.⁴ Therefore, addressing family functioning within diabetes self-management is important, as disease management is mostly facilitated within a family context. However, family functioning contexts are currently unclear and difficult to differentiate from family resilience when a chronic illness is present.⁵

The terms "family functioning" and "family resilience" are sometimes confused and used interchangeably; this is because both terms are related to a family's adaptation and dynamic processes when confronted with stress emanating from a chronic illness. A better understanding of family functioning could clarify ways to help the family and patient maintain balance and functioning when providing diabetes care. Conceptualizing family functioning with regard to diabetes care provides an essential foundation for developing effective and sensitive interventions that promote growth among individual family members and the family unit as a whole.

Concept analyses provide precise operational definitions, refine ambiguous concepts within a theory, and provide a more basic and deeper understanding of underlying attributes within a concept. Eight steps, first identified by Walker and Avant, are conducted: (a) select a concept, (b) determine the purpose of the analysis, (c) identify all uses of the concept, (d) determine the defining attributes, (e) construct a model case, (f) identify antecedents, (g) identify consequences, and (h) define empirical referents.⁶

This initial review included articles that shared relevance with a standard literature review. For initial strategies, "family functioning," "self-management," and "type 2 diabetes" (T2DM) were the main search terms, and these terms needed to be observed either in the abstract or in the title of the study.

Family functioning is defined as the process by which the family system completes a series of tasks, including basic tasks (e.g., managing individual needs such as food and clothing living line, and money management), developmental tasks (e.g., adapting and promoting the growth and development of members), and crisis tasks (e.g., dealing with all kinds of family emergencies).⁷

Attributes are defined as characteristics that appear repeatedly with reference to the concept. These defining attributes assist the researcher in differentiating similar concept definitions.⁶ Defined attributes were as follows: (a) problem-solving, (b) communication, (c) roles, (d) affective responsiveness, (d) affective involvement, and (e) behavioral control (Table 1 ).

Walker and Avant described a model case that demonstrates "all defining attributes of the concept." The example case is provided as follows:

A 60-year-old man with a 6-year history of type 2 diabetes mellitus. Although he was diagnosed in 2011, he had symptoms 3 years before diagnosis. The HbA1 c records indicated values of 8%, which was categorized as poor glycemic control. He had poor eating habits and was not exercising. He really loved to eat large pastas and sweet foods. At the time of initial diagnosis, he was advised to lose weight, but no further action was taken. Referred by his family physician, he was required to decrease his weight and control his blood glucose. He has been trying to lose weight and increase his exercise for the past 6 months without success. He started with glyburide, 2.5 mg, every morning but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation. He stopped these supplements when he did not see any positive results. He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. The patient was required to do multiple tasks for self-management, including attending a regular medical appointment each month, adhere to medication regimens, and engage in self-care behaviors (i.e., at-home blood glucose monitoring, control his diet, and increase physical activity). However, it is often difficult for him to consistently engage in these health behaviors that are necessary for good glycemic control. Common barriers include competing daily demands, frustration, other emotional distress, low self-commitment, lack of knowledge, low levels of self-efficacy to successfully complete an activity, and insufficient social support from family members. To change and maintain positive self-management behaviors, family members were tasked with helping the patient with strategic planning and goal setting. Effective feedback concerning negative diabetes perceptions and good communication was also used for exchanging health information, reducing care resistance, and building self-efficacy emphasized by family members. Additionally, during diabetes treatment, family members emphasized cultural beliefs and values to help support dietary change, physical activity, and blood glucose monitoring. This was done in order to help the patient feel appreciated. Regarding emotional supportive behaviors, family members assessed psychosocial problems. A patient can express negative responses to diabetes self-management, a seasonal mood disorder, and/or the presence of depression due to the illness or retirement during treatment. However, family members are on his side in order to provide emotional support, as well as help with problem-solving. This strategy can boost adherence to medication regimens, encourage a healthy diet, and maintain exercise behaviors. The patient-family relationship, cohesion, and patient-family member communication were achieved.

This model case illustrates successful achievement of all family functioning attributes for effective diabetes self-management. This model also provides information regarding family functioning and means for supporting patients with specific self-management tasks, such as healthy eating habits, selecting appropriate physical activity, blood glucose monitoring, foot care, and stress management. Effective feedback and exchanging health information reflect good communication, emphasizing cultural beliefs and values for generating supportive behaviors as part of family functioning. This includes affective involvement, emotional support, and instrumental support for diabetes care. Outcomes include effective responses from family members, and problem-solving was emphasized when the patient showed negative responses to self-management, depression, and retirement during long-term treatment. From this model case, it is understood that effectiveness of family functioning could influence relationship roles, family cohesion, and family communication for managing patients' behavior.

Walker and Avant defined antecedents as events that must occur prior to the emerging concept. The factors considered as antecedents for implementing family functioning for supporting care include family structure, socioeconomic status, family functioning relationships, family stage, and life events that could impact outcomes.⁷ Managing these factors could influence basic family functioning to provide appropriate environmental conditions for members to complete a series of tasks, including basic tasks (e.g., managing the material needs of the individual such as food and clothing living line), developmental tasks (e.g., adapting and promoting the growth and development of each member), and crisis tasks (e.g., dealing with all kinds of family emergencies).⁸

The review also revealed relationships between the highest levels of family functioning styles with family values and resource mobilization for patients with T2DM.²⁸ Other factors influencing family functioning include parental age, socioeconomic level,²⁹ educational attainment, and sibling relationships.³⁰ In addition, higher income was positively correlated with better physical and mental health, greater longevity, fewer stressful life events, and greater successes.^{29, 31}

Walker and Avant defined consequences as events that occur as a result of the emerging concept. Consequences of family functioning have been demonstrated by research related to diabetes management. Family functioning significantly influences a sense of satisfaction and family cohesion.³² In addition, family functioning is positively affected by diabetes management, illustrating the protective nature of a positive family environment in relation to achieving the most favorable health outcomes.³³ At this point, family functioning may be very helpful in moving the family toward a better level of diabetic control. It is generally accepted that a lack of family functioning leads to declines in diabetic control and can even negatively affect a child's functioning in areas

such as personality, physical well-being, and activity participation.³⁴

Empirical referents are defined as classes or categories of actual phenomena that, by their existence or presence, demonstrate the emergence of a concept. Some instruments are identified for measuring family functioning within the area of chronic disease, including the Family Assessment Device (FAD) survey,⁸ Family Functioning Index (FFI),³⁷ Family Adaptability, Partnership, Growth, Affection, and Resolve Index (AFGAR),³⁸ Family Assessment Measure (FAM),¹⁵ and the Chinese version of the Survey of Family Environment (SFE).³⁹

Epstein et al.⁸ used a 60-item instrument that listed family functioning to identify families experiencing problems, highlighting specific domains and assessing change following treatment. This instrument had seven categories, including problem-solving, communication, role function, affective responsiveness, affective involvement, behavioral control, and overall functioning. The FAD is composed of four statement responses^{12, 3, 4} for each subscale, and the individual scale scores range from 1.0 (best functioning) to 4.0 (worst functioning). This instrument is considered with high internal consistency (Cronbach's a = 0.74–0.92).

Satterwhite et al.³⁷ created the FFI to reflect dynamics within family interactions, an important intervening variable in terms of social and medical outcomes when providing care for a chronic physical disorder. The FFI appears to be a reliable and valid instrument with test– retest correlation scores between 0.74 and 0.83. A total of 15 self-reported dyadic and whole family questions (yes/no on a 5-point rating scale) are grouped into five functions: marital satisfaction, frequency of divergence, communication, problem-solving, happiness, and intimacy.³⁷ The scores range from 0.07 to 0.96 for fathers and 2.1 to 0.95 for mothers.

AFGAR is used to assess a family member's perception of family functioning by examining patient's satisfaction with family relationships. The measure consists of five family functioning parameters: adaptability, partnership, growth, affection, and resolve. The scale is measured on a 5–point scale ranging from 0 "never" to 4 "always." The largest possible score is 20; a score of D9 is considered dysfunctional; 10–12 is moderate family dysfunction; 13–16 points are mild family dysfunction; and 17–20 points are good functionality. The AFGAR is a reliable instrument with good internal consistency (Cronbach's a = 0.80–0.85) and item-to-total correlations ranging from 0.50 to 0.65. Initial validity was also established with a correlation of 0.80 (the latter = 0.64).³⁸

Skinner et al.¹⁵ developed the FAM based on the process model of family functioning. This model described seven key dimensions: task accomplishment, role performance, communication, affective expression, involvement, control, and values and norms. Fourteen items are scored on a 4-point Likert scale ranging from "strongly agree" to "strongly disagree." The FAM is measured at three levels, including the whole family system (general scale, 50 items), various dyadic relationships (dyadic scale, 42 items), and individual functioning (self-rated scale, 42 items). The FAM appears to be a reliable and valid instrument with coefficient alphas ranging from 0.60 to 0.80. The overall FAM ratings yield substantial alpha coefficients: adults = 0.93 general scale, 0.95 dyadic relationships, 0.89 self-rating; children = 0.94 general scale, 0.94 dyadic relationships, and 0.86 self-rating (Table 2).

The SFE consists of 30 items that examine family functioning and family support needs which consist of 5 structures including supra-system, macro-system, micro-system, family internal environment system, and chrono-system. All items are scored on a 5-point Likert scale (1 = "dissatisfied/unimportant," 5 = "satisfied/important") with scores ranging from 1 to 25 points. Internal consistency is high (0.92). In a test–retest study of 33 families, the correlation coefficient was 0.93, indicating the high test–retest reliability. The instrument consists of three dimensions: relationships between family members, relationship between the family and subsystem, and relationship between the family and society.³⁹ (Table 3)

AFGAR, Family Concern Index Questionnaire; FAD, Family Assessment Device; FAM, Family Assessment Measure; FFI, Family Functioning Index; FFFS, Feetham Family Functioning Survey.

The differences between the five instruments are the dimensions measured and settings to which each scale is applied. However, different attributes have been identified in this concept analysis, and unique aspects of the reviewed concept lead to some divergence. Thus, specific instruments could be modified based on the specific family functioning definitions.

The main findings suggest a clarification of defining attributes, antecedents, consequences, and empirical referents related to family functioning in diabetes self-management. The concept of family functioning is made up of several dimensions, including problem-solving, communication, family roles, affective responsiveness, affective involvement, and behavioral control. These attributes are associated with factors known to serve as antecedents, including family structure, socioeconomic status, family functioning relationship, family stage, and life events. The goal of better understanding of family functioning is to ultimately improve health outcomes, family satisfaction, family cohesion, and family relationships. Thus, fully elucidating the concept of family functioning in diabetes self-management could improve health outcomes and provide provisions for health care providers to more appropriately engage services among diabetes patients and their family members. Hence, this review recommends that health care providers become aware of, and consider, the antecedents underlying family functioning concepts for promoting positive health outcomes.