Diabetes mellitus is a worldwide public health problem representing a great burden on the economy and society in general. According to the World Health Organization (WHO) global report on diabetes, the number of adults living with diabetes has almost quadrupled, from 108 million in 1980 to 422 million in 2014, and diabetes caused 1.2 million deaths in 2012.1 The WHO is calling for action on diabetes to remind people of the need to strengthen prevention and treatment of the disease.1
Self-management of chronic diseases refers to the ability of individuals to work with families, communities and health care professionals to manage symptoms, treat, change lifestyles and improve physical and mental health conditions.2 It is estimated that self-management can reduce the incidence, burden and risk factors associated with arthritis, asthma, cancer, diabetes, heart disease and stroke to improve health.3 For patients with diabetes particularly, self-management skills are essential for enabling them to control their condition.4-6 However, a survey of self-management behavior among 452 diabetic patients in a community in China found that only 20.6% of the patients had a high level of self-management ability.7 Hansen et al.8 conducted an investigation on self-management in 502 Danish diabetic patients, and found that their self-management was lower than the global average.
Quality of life is another concept often used in diabetes research. Studies show that the existence of diabetes significantly weakens the link between the patients and the society they live in, which also increases the risk of psychological distress and reduces the quality of life of patients.9 More and more studies have reported a decline in the quality of life of patients with diabetes. Studies on type 2 diabetes from Poland and the US have shown that these individuals have a lower quality of life possibly due to symptoms of the disease (such as hypoglycemia) or other complications.10 For teenagers with type 1 diabetes, their quality of life is also compromised. They often worry not only about their disease but also social activities in which they are involved, leading to a negative impact on their quality of life.11
Researchers are constantly investigating approaches to improving self-management and quality of life of adults with diabetes. Social network is a hot topic in this field in recent years. A social network is defined as “a collection of relationships maintained by people of all ages”.12(p.5616) A social network consists of two elements: individuals (nodes) and their relationships with their relatives and friends (social relations). Whether a person is happy or not depends not only on themselves but also society comprising their friends and loved ones.13 One's social networks assert positive or negative effects on health as well. Due to the spread of information and behavior norms within groups, members in the same social networks often exhibit similar health or risk behaviors.14
Since it is almost impossible to influence an individual's social networks, current intervention studies on social networks of patients with diabetes focus on interventions involving social networks. In this review, we define interventions involving social networks as interventions that involved individual social network members (those in constant contact or interactions with an individual, e.g. family members, friends, peers), mainly through social support and social participation.15-17 There is growing evidence that interventions involving social networks have a positive impact on people with diabetes through social support and social participation. For example, through support and participation from peer groups, they will share experiences and support each other to maintain a healthy lifestyle, and learn skills to cope with social pressure.18 Social support refers to resource support (such as providing some daily necessities, money and so on), emotional support, information support and assessment support for disease management to assist in self-assessment and health awareness.19 Social support can be provided either by members in social networks (e.g. family members, friends, peers), or parties not from those social networks (e.g. government departments, supporting organizations). Studies have shown that the effect of interventions involving social networks on the self-management of individuals with diabetes is mainly through social support from the social network members,7,20 which will be the focus of this review. Through support from individual social network members, such as shared information, emotional support and material support, individuals can improve their self-management and quality of life.21 Furthermore, diabetes support satisfaction from social network members has been shown to be associated with improved quality of life. Active support predicts a healthy diet and regular physical activity that lead to a better quality of life; negative support predicts poor glycemic control due to missed medication, leading to poorer quality of life.22 Social networks may also influence self-management and quality of life of adults with diabetes through social participation. Social participation refers to the participation of social network members in the patient's health management activities.23 A study in China showed that after receiving 12 months of diabetes health education, adults with family members’ participation in health education achieved a higher quality of life than adults without family members’ participation.23 In Ireland, Keogh et al.24 conducted a psychological intervention involving the participation of family members in adults with type 2 diabetes. Participants in the intervention group participate, with their family members, in three intervention sessions, and participants in the control group receive their usual care. The results of the follow-up at six months showed that glycosylated hemoglobin A1c (HbA1c) levels were significantly lower in the intervention group than in the control group, and significant improvements in diabetes management, mental health, diet, exercise and family support were reported in the intervention group. Hence social participation can improve a patient's disease management level and quality of life by providing them with emotional and information support.
However, there are varying conclusions about the effectiveness of interventions involving social networks on quality of life for patients with diabetes. A systematic review indicated that interventions involving social networks improved social support and glycated hemoglobin of patients with type 2 diabetes, but it did not improve their quality of life.16 Koetsenruijter et al.21 developed a protocol to explore the correlation between social support from social network members, self-management and quality of life of people with diabetes. However, they only considered a European population and it is an investigative research project conducted with questionnaires which cannot demonstrate causation. The existing literature or protocols pertain to only one type of diabetes, a certain population, or one type of intervention involving social networks. Therefore, effectiveness of interventions involving social networks on the self-management and quality of life of diabetic patients needs to be comprehensively evaluated.
According to the WHO, diabetes is divided into four types: type 1 diabetes, type 2 diabetes, gestational diabetes and other special types of diabetes.25 Specific types of diabetes include eight subtypes, each of which includes multiple diseases, such as mitochondrial gene mutation in diabetes (MIDD), maturity onset diabetes in young (MODY), type A insulin resistance syndrome and Genie syndrome. These are the most common specific types of diabetes which have very low incidence.26 Different types of diabetes have similar manifestations and inconveniences in daily life, so therefore there is a need to explore the effectiveness of interventions involving social networks on self-management and quality of life of adults with all types of diabetes. We searched the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library and other major databases such as Web of Science, PubMed, Embase and CINAHL, but did not locate any systematic review exploring this topic.
What is the effectiveness of interventions involving social networks for self-management and quality of life in adults with diabetes?
This review will consider studies that include adults with diabetes 18 years or older diagnosed by the diagnostic criteria for diabetes recommended by WHO or American Diabetes Association (ADA), which include type 1 diabetes, type 2 diabetes, gestational diabetes and other special types of diabetes. Participants in these studies must be recruited from the hospital setting, community hospitals or clinic.
This review will consider studies that evaluate the effect of interventions involving social networks (e.g. support and participation from an individual's social network members) which involve existing members in social networks (such as families, friends and peers) of the adults with all types of diabetes. There is no limitation of the form, frequency and time of the intervention, for example, family, friends or peers of participants being asked to participate in their monthly diabetes education activities, or the patient's family members or companions being given guidance on diet, exercise and other disease management at the time of discharge. In summary, interventions received in the intervention group must involve members of the social network. Besides interventions involving social networks, the intervention group must receive usual treatment and care consistent with the control group.
This review will consider studies that compare the intervention involving social networks with those that do not (such as recruiting patients only to participate in their diabetes education activities), or that compare the intervention involving social networks with a control group without any intervention other than usual treatment and care.
This review will consider studies that include the following outcomes: results of self-management scores and quality of life scores reported together or individually before and after the intervention in an intervention group and a comparison group. Self-management will be measured by validated scales such as the Scale of the Diabetes Self-care Activities (SDSCA) and Self-management Knowledge, Attitude and Behavior Assessment Scale (DSKAB). Quality of life will be measured by WHO Quality of Life scale (WHOQOL) or the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS SF-36 Health Survey).
Types of studies
This review will consider experimental designs and quasi-experimental study designs, which include both randomized controlled trials (RCTs) and non-randomized controlled trials. As most observational studies are correlation studies, and they cannot demonstrate the effect of interventions, they will be excluded.
Studies published in English from database inception to the present will be included in order to comprehensively collect relevant literature.
We will exclude RCTs involving social relationships created during the trial; for example, RCTs testing interventions enrolling and training patients with diabetes to provide peer support to other participants using online communities. We will also exclude studies in which the data are incomplete and the authors cannot be contacted.
The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of effectiveness.27
The aim of the search strategy is to locate published and unpublished studies. A preliminary limited search was conducted on PubMed and Web of Science to identify articles on the topic. The text words contained in the titles and abstracts, and the index terms used to describe these articles were analyzed. This contributed to the development of a search strategy that includes certain keywords and index terms that will be tailored to each source of information. We used PubMed as an example for retrieval, and the specific search strategy is shown in Appendix I.
The databases to be searched include PubMed, Embase, Web of Science and CINAHL Complete.
The trial register to be searched is the Cochrane Central Register of Controlled Trials.
The search for unpublished studies will include: ProQuest Dissertations and Theses, and Google Scholar.
After the search, all identified records will be retrieved and uploaded into EndNote (Clarivate Analytics, PA, USA) and duplicated documents will be deleted. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia). Full-text articles that do not meet inclusion criteria will be excluded, and reasons for exclusion will be provided in an appendix on the final systematic review report. Included studies will undergo a process of critical appraisal. Search results will be fully reported in the final report and presented in the PRISMA flow chart.28 Any disagreement between the reviewers will be resolved through discussion or review with a third reviewer.
Assessment of methodological quality
Two independent reviewers will evaluate the selected literature critically at the study level for methodological quality by using standardized critical appraisal instruments from JBI including 13-item Randomized Controlled Trial Appraisal Tool, nine-item Quasi-Experimental Appraisal Tool.27 Other tools may be used depending on the type of studies to be assessed. Any disagreements will be resolved through discussion, or review with a third reviewer. After critical appraisal, studies that do not meet certain quality thresholds will be excluded. The relevant JBI critical appraisal tools will be used according to study type and reviewers will discuss and agree quality thresholds for each tool. For example, if a study meets more than 60 percent of the specific item, it meets the quality threshold. This decision will be based on agreement of the two independent reviewers. If there is disagreement, a third reviewer will be asked to resolve the disagreement through discussion. The results of the critical appraisal will be reported in narrative form and in a table.
Data will be extracted from articles by two independent reviewers with standardized data extraction tools provided by JBI SUMARI.29 The data extracted will include specific details on the interventions, population, research methods, social network members involved, and evaluation index results (self-management scores and/or quality of life scores). Any disagreements between the reviewers will be resolved through discussion or review with a third reviewer. The author of the paper will be contacted and requested to provide missing or additional data when needed.
Where possible, results will be pooled in statistical meta-analysis using JBI SUMARI.29 The size of the effect will be expressed as the weighted (or standardized) mean difference (for continuous data), and their 95% confidence interval will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-square and I2 tests. If sufficient data are available, subgroup analyses will be performed for interventions involving different social network members such as family members, friends and peers of patients, or for different types of study such as randomized controlled trials and non-randomized controlled trials. Sensitivity analysis will be conducted to test the effectiveness of interventions involving social networks on the self-management and quality of life of the patients with diabetes. If meta-analysis is not possible, the results of the study will be presented in narrative form.
Assessing certainty in the findings
The GRADE30 method for assessing confidence in the quality of the evidence will be used for this review and the results will be displayed in the Summary of Findings created using GRADEpro (McMaster University, ON, Canada). The Summary of Findings will present the following information, where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision and risk of publication bias of the review results. The following outcomes will be included in the Summary of Findings: self-management and quality of life.
This systematic review is funded by Beijing Social Science Fund Project (2018).
Appendix I: Search strategy for PubMed
Date of search: 11/04/2019.
Platform: OVID via Beijing University of Chinese Medicine.
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