This randomised controlled trial demonstrated that family support-based intervention delivered through a mobile app had positive effect on glycaemic control for older adults with diabetes. The improvement in family support, diabetes knowledge, self-management behaviour and medication adherence was also in accordance with the family-involved intervention.
Significant improvement in glycaemic control was seen in the family-based intervention group compared with the control group. The results of this study were agreement with those obtained from studies by Shi et al. [8] and Withidpanyawong et al. [10] which indicated that family support was beneficial for diabetes control. The previous studies had family caregivers accompanied with the patients to take part in the intervention courses, whereas the present study had the family members participate in the intervention sessions only via mobile app. Unlike the current study, a trial by Wichit et al. [9] found lack of difference between groups in glycaemic control when using a family-involved method. However, the follow-up period in the prior trial [9] was only 13 weeks, which is shorter than that in this study (9 months follow-up). Wichit et al. [9] study also provided additional education to participants at week 9. Nevertheless, after this education delivery no further data were gathered 3 months later, that is the optimal timing for HbA1c measurement [2]. Accordingly, it may not be possible to measure the small changes in HbA1c. Findings here confirmed the results of an earlier meta-analysis [21] which indicated that family involvement in patient care was a substantial resource for the control of diabetes outcomes. Adequate glycaemic control is a key aspect of prevention of diabetes-related microvascular and macrovascular complications, particularly in the elderly [22, 23].
Apart from diabetes content of the intervention in this study, the education for family caregivers focused on hypertension-related lifestyle modification. Accordingly, the results showed positive impact on systolic and diastolic blood pressure in the intervention group with significant differences from those in the control group. Lee et al. [24] reported that family assistance was a strong factor for self-regulation in the elderly patients with uncontrolled hypertension. The American Diabetes Association [2] recommends blood pressure targets < 140/90 mm Hg for elderly patients with diabetes. Although baseline blood pressure levels in the intervention group (141/77 mm Hg) were slightly higher than the guideline target, family members’ participation presented as the considerable factor for improvement in these outcomes (132/72 mm Hg). Strict blood pressure control leads to diminished risks of mortality and diabetes complications including nephropathy and cardiovascular diseases [2, 22].
The present findings pointed out that significant increases for supportive and obstructive family behaviour were observed in the intervention group compared to baseline, similar to those of Withidpanyawong et al. [10] study. Helpful family involvement was associated with better self-management of diabetes, on the other hand harmful involvement was related to worse self-management adherence. However, the intervention group experienced significantly greater positive care from family members than did the control group. This may make the participants manage their diabetes more effectively and lead to the improved glycaemic control that was seen in our results.
Elderly diabetes patients are at high risk for developing geriatric syndromes including cognitive dysfunction [2]. A low education level was a significant factor for the insufficient knowledge regarding diabetes self-management in the elderly [25]. The majority of study participants here completed their education at primary school or lower (intervention group 81% vs. control group 75%). Furthermore, the usual hospital education for patients with diabetes was similar in both the intervention and control groups. Nevertheless, the intervention group had a larger improvement in knowledge than did the control group that may be attributed to information acquired from family caregivers using mobile app. Higher diabetes knowledge was significantly associated with better self-management practices and lower HbA1c [26].
Effective self-management behaviour is essential to meet glycaemic goals [2]. Results here observed that self-management practices improved significantly more in the family intervention group than in the control group. The results were consistent with findings in the study by Wichit et al. [9]. Previous research by Getie et al. [27] supported our findings that having family members as caregivers positively affected diabetes self-management. Intervention family caregivers here were predominantly spouses or children (88.5%) and in-home partners (71.8%). Caregivers who were spouses or children acted as the key providers for assistance in terms of self-management [28]. Likewise, more frequent contact or being in-home supporters was correlated with better control of diabetes [29]. However, significant increments in self-management activities were also detected in the control group when compared to baseline. There may be contamination bias from the intervention patients and/or Hawthorne effects from intensive follow-up that may change the behaviour of the control patients.
The intervention group had significantly better medication adherence than did the control group. The family intervention was effective for improving adherence as shown in a trial conducted by Withidpanyawong et al. [10]. Mayberry et al. [29] suggested that greater caregiver closeness had an association with adherence to diabetes medications. Accordingly, the intervention patients who received more support from their family members may increasingly adhere to medication taking. In contrast, patients who perceived taking medications to be unimportant were more likely to have non-adherence [30]. The current study informed the intervention patients about the importance of taking prescribed medications through family-based education via mobile app. This matter may enhance patients’ awareness and improve their behavior in taking medications. Medication adherence was an important factor related to glycaemic target (HbA1c < 7%) in patients with diabetes [2, 31].
The utilisation of mobile app incorporating with family support for elderly diabetes care is the strength of this study. The mobile app has capacity to provide diabetes education as well as facilitate interactions between family caregivers and health providers such as pharmacists. This mobile technology saves family members time and expense by decreasing travel to clinics, which is especially helpful for persons who have hectic schedules or distance barriers [32]. However, there are several limitations to the current study. The participants were recruited from a single hospital in Thailand, hence there is a limitation on generalisability of the findings. In addition, differences in demographic characteristics of family caregivers between the intervention and control groups may affect the research findings. Finally, this study investigated only patients who received oral antidiabetic agents; the results may differ for those who used insulin injections, where the administration is more complicated than that of oral medications.