Family issues and family functioning of Japanese outpatients with type 2 diabetes: a cross-sectional study

We conducted a cross-sectional questionnaire survey at the diabetic outpatient clinic of a 219-bed community hospital in Aichi prefecture, Japan, between August 2001 and March 2002. First, the doctor-in-charge briefly explained the study and obtained initial oral consent. Then, the examiner-in-charge explained fully the study protocol in a separate room, and written informed consent was obtained. Next, subjects answered the questionnaire in a private area of the hospital. While the patients completed the questionnaires, the patients could ask questions of the research personnel to ensure that they understood and could completely answer all the questions. With the consent of the subjects, the results of blood pressure, BMI, total calorie intake, and glycemic control levels were retrieved afterwards from the chart.

The inclusion criteria of this study were: 1) adult type 2 diabetic outpatient followed at the diabetic outpatient clinic of the hospital, 2) provided informed consent, and 3) had a blood examination scheduled on the day of the survey. Patients were excluded who did not want to participate in the study, were living alone without any immediate relatives, were unable to read, write, or communicate, could not understand the purpose of the study, or were considered to be inappropriate for the study by the physician-in-charge.

In order to evaluate family issues, we asked “Do you have any worries about your family? If you have, please tell us about them. You are free to decline to answer”. To evaluate family functioning, we used the cohesion and adaptability scores of the FACESKG IV-16. The FACESKG IV is based on the Circumplex model (Figure 1), which is a two-dimensional family function model that relies on a balance between the two dimensions and an avoidance of extremes. Its two dimensions are “cohesion” and “adaptability”. Cohesion indicates the family's emotional bonds. It has four levels: "enmeshed" is the most extreme level (too much closeness), "connected" represents moderate to high closeness, “separated” represents low to moderate closeness, and “disengaged” represents a level of too little closeness. The “connected” and “separated” levels of cohesion are considered to be balanced, and the “enmeshed” and “disengaged” levels are considered to be extreme. Adaptability is the ability of family to adapt to various stressors. Adaptability also has four levels: "chaotic" is the most extreme level (too much change), “flexible” represents high to moderate change, “structured” represents moderate to low change, and “rigid” represents too little change. The "flexible" and “structured” levels of adaptability are considered to be balanced, and the "chaotic" and "rigid" levels are considered to be extreme. The FACESKG IV-16 [28] is a 16-item Thurston scale, a shorter version of the FACESKG IV series. It is especially useful and practical in primary care and family practice settings for its succinctness and ease of use. Its results are based on the sum of the values obtained by multiplying the points for each question by an appropriate coefficient suited to the content. Cohesion and adaptability are each given a score of between −8 points and +8 points, and intermediate scores from −2 to +2 are judged as corresponding to high levels of family functioning. Thus, both extremes in which either too much or too little change on the adaptability axis or too much or too little closeness on the cohesion axis are judged to have a low level of family functioning. It was necessary to adopt the squared value of cohesion score (square of cohesion) to evaluate dysfunction of cohesion. In the same way, it was necessary to adopt the squared value of adaptability score (square of adaptability) to evaluate functional disorder of adaptability.

Physical and serological data were obtained on the same day. We used plasma glucose levels and the HbA1c value of JDS (Japan Diabetes Society) as measures of glycemic control. BMI and total calorie intake were retrieved from the patient’s chart. Daily lifestyle (sleeping time, working time, housekeeping time, and exercise time) was measured by questionnaire. Mental status was measured by HAD (Hospital Anxiety and Depression scale) [29]. HAD is a 14-item, 4-point, self-reported scale for evaluating anxiety and depressive states, consisting of 7 anxiety items and 7 depression items. If each total score is between 0 and 7, the patient has neither anxiety nor depression. If each total score is between 8 and 10, it is doubtful that the patient has anxiety or depression. If each total score is between 11 and 21, the patient, by definition, has anxiety or depression according to the scale. For this investigation, we used the anxiety and depression scores of the HAD Japanese version [30, 31].

First, we calculated the percentage of diabetic patients with family issues and categorized the family issues. Next, we analyzed family functioning according to the score of FACESKG IV-16. Then, we attempted to find relationships between family functioning and each parameter by multiple regression analysis (Dependent variables were Plasma Glucose or HbA1c) of the data. Then, we compared each parameter between patients with and without family issues using the Mann–Whitney U-test. We used the SPSS 11.0 for WINDOWS for the analysis in this study.

Written informed consent was obtained from all subjects. The Institutional Review Board of Nagoya University approved the study protocol.

Of the 133 outpatients recruited as subjects, 121 fulfilled the inclusion criteria (response rate was 91.0%). Among the 12 subjects excluded, Five did not have sufficient time to become involved in the survey, Three declined to answer the questionnaire, Two lived alone (i.e., no family members), One was unable to write without glasses, and one was unable to communicate with us. One patient did not answer the questions on family issues. Regarding family issues, the response rate was 90.2%. All values in the text, tables, and figures are expressed as means ± standard deviation (SD). The male: female ratio was 91:30 and the average age was 52.1 ± 9.2 years old. The number of family members living with patients was 2.5 ± 1.4 and their working hours were 8.0 ± 2.9 hr. /day and 5.3 ± 1.2 days/week. Physical and mental parameters are presented in Table 2.

Forty of the 120 patients (33.3%) had family issues. Three had multiple family issues (One had Three issues and two had two issues), giving a total number of family issues of 44. The data on family issues are presented in Additional file 1: Table S1. Almost two-thirds (63.6%) of the 44 family issues were “Health problems of family members” and “Family life cycle issues” such as Aging, Going on to school, Family death, and Child birth.

As a result of Mann–Whitney U test, family issues did not correlate with plasma glucose level (p = 0.245) or HbA1c (p = 0.256). With regard to each issue, “Family life cycle issues” was correlated with patient anxiety (p = 0.004) and depression (p = 0.032). “Divorce” was also correlated patient anxiety (p = 0.039).

The data on family functioning are presented in Figure 2, and the results of the multiple regression analysis with the backward elimination method are presented as Tables 3 and 4. With regard to models containing plasma glucose, the adjusted R² value of the best fit model was 0.494 and the F value was 3.926 (p = 0.020). With regard to models containing HbA1c, the dependent variables of the best fit model were the squared value of the cohesion score and excise time. The adjusted R² value was 0.082, and the F value was 3.859 (p = 0.026). The results of the best fit model identified Plasma Glucose as an independent variable and the squared value of the cohesion score, depression sore of HAD, Total calorie intake, Excise time, Housekeeping time, and BMI as dependent variables.

Because of missing values, we could not utilize the stepwise analysis, so we utilized the backward elimination method.