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Will People With Type 2 Diabetes Speak toFamily Members About Health Risk?DAVID L. WHITFORD, MD1

HANNAH MCGEE, PHD2

BERNADETTE OSULLIVAN,PHD

2

OBJECTIVE This study aimed to assess the potential for communication of familial risk bypatients with type 2 diabetes.

RESEARCH DESIGN AND METHODS A questionnaire was completed by a randomsample of patients with type 2 diabetes registered with a hospital diabetes clinic.

RESULTS Two-thirds of patients (65%) had spoken to at least one sibling or child aboutdiabetes risk. They were more likely to believe their familywas at risk, to worryabout their familydeveloping diabetes, and to be aware of the seriousness of diabetes. The results revealed greaterawareness of family risk of type 2 diabetes compared with those from previous studies.

CONCLUSIONS Many patients with type 2 diabetes had already taken the initiative,without formal prompting, to talk to family members about their risk of diabetes. Discussion ofrisk and interventions to reduce risk should be encouraged within families.

Diabetes Care 32:251253, 2009

First-degree relatives and spouses ofindividuals with type 2 diabetes areat increased risk of developing type 2

diabetes (1,2). There is also an establishedcorrelation of other cardiovascular riskfactors in family members; these includeobesity (3), hypertension (4), lipids (5),and smoking (5). Increased family risk is

thought to have both an environmentaland a genetic basis (6,7), giving scope fordecreasing cardiovascular risk throughlifestyle modification in individuals with afamily history of diabetes (8). Nonethe-less, systematic screening of family mem-bers is unlikely for logistic and financialreasons. A more modest approach wouldbe to encourage patients with diabetes todiscuss risk with family members. How-ever, health beliefs of individuals withtype 2 diabetes may lessen their percep-tion of the risk of diabetes among familymembers (9) and of the seriousness of di-abetes (10), raising doubts as to whetherthey would communicate risk factors to

their family members. The Health BeliefModel (11) identifies factors likely to in-crease health-related actions such asspeaking with family members. They in-clude perceived susceptibility, perceivedseverity, perceived benefits and barriers,and cues to action. We explored the be-liefs and actions of patients with type 2

diabetes concerning discussion of risk infamilies.

RESEARCH DESIGN AND

METHODS A questionnaire to as-sess patient beliefs and actions regardingdiscussion of type 2 diabetes risk withfamily members was developed, piloted,and refined based on the Health BeliefModel. A sample size of 353 patients wascalculated to give 95% power at 5% prob-ability. Based on previous studies (12,13),a 50% response rate was predicted. A ran-dom sample intended to achieve 700 pa-tients was drawn from the database ofpatients attending a Dublin hospital dia-

betes clinic (n 4,577). Patients withtype 1 diabetes and secondary causes of

diabetes were excluded. A postal surveywas issued to the resulting sample of 703patients. Reminders were sent 3 weekslater. The study received ethics approvalfrom Beaumont Hospital Research EthicsCommittee.

RESULTS The response rate was49% (297 of 607 eligible participants).Respondents had a mean age of 65 years;56% were male. The mean time since di-agnosis of diabetes was 8 years. Half of thepatients (52%) had at least one parent or

sibling with diabetes (18%, mother; 16%,father; and 35%, sibling).Two-thirds of the patients (181 of

280) had spoken to at least one of theirchildren or siblings about diabetes risk(Table1); more patients spoke to children(61%) than to siblings (44%) (2 55.3,2 d.f.; P 0.001). Younger respondents(2 15.64, 2 d.f.; P 0.001) and thosestill employed (2 7.54, 2 d.f.; P 0.023) were more likely to have spoken tofamily members, whereas sex, educa-tional status, marital status, and durationof diabetes had no association. Three vari-

ables emerged from a nominal logistic re-gression analysis accounting for 41% ofthe variation in speaking to family mem-bers about their risk of diabetes: worryabout their children developing diabetes(odds ratio 4.37 [95% CI 1.7510.92]),treatment with insulin (8.97 [1.7845.28]), and the belief that a benefitwould be prevention of diabetes (2.71[1.017.23]).

Over 90% of respondents recognizedthe benefits of speaking to their familymembers about the risk of diabetes in

terms of improving awareness of diet andexercise, encouraging lifestyle changes,and preventing diabetes. However, manypatients (58%) who felt that their ownlifestyle was unhealthy reported chal-lenges in speaking with family members.Further barriers concerned family mem-bers: not being open to advice (54%), notseeing themselves at risk (45%), and notconsidering diabetes serious (52%). A dif-ferent type of challenge was lack of con-t a c t wit h fa mily me mbe rs (44%).

Although most patients identified obesity(75%) and little or no exercise (59%) as

From the 1Department of Family Medicine, Royal College of Surgeons in IrelandMedical University ofBahrain, Busaiteen, Bahrain; and the 2Department of Psychology, Royal College of Surgeons in Ireland,Dublin, Ireland.

Corresponding author: David L. Whitford, dwhitford@rcsi-mub.com.Received 1 July 2008 and accepted 5 November 2008.Published ahead of print at http://care.diabetesjournals.org on 18 November 2008. DOI: 10.2337/dc08-

1200. 2009 by the American Diabetes Association. Readers may use this article as long as the work is properly

cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be herebymarked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

C l i n i c a l C a r e / E d u c a t i o n / N u t r i t i o n / P s y c h o s o c i a l R e s e a r c hB R I E F R E P O R T

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risk factors for type 2 diabetes, only 50%identified a parent with diabetes and 28%a sibling with diabetes as risk factors.

Half of the patients (56%) moderatelyor strongly agreed that they would speakto family members about their risk of de-

veloping diabetes if they were offered helpto do so. More importantly, 87% of thosewho had not spoken to family members in

Table 1Factors from the Health Belief Model and responses to the question Have you talked to any of your children or siblings about the

possibility of them getting diabetes?

Health Belief Model factor n Yes No Statistic

Susceptibility factors

Likelihood that children will get diabetesNot at all/not very likely 95 57 43 2 7.43, 1 d.f.; P 0.006

Quite/very likely 156 74 26Likelihood that siblings will get diabetes

Not at all/not very likely 112 54 46 2 11.0, 1 d.f.; P 0.001Quite/very likely 131 75 25

Diabetes in first-degree relativeYes 134 72 28 2 4.73, 1 d.f.; P 0.03

No 121 59 41Relative seriousness of diabetes

Compared with cancer 258 0.97 (0.931.02) 0.90 (0.791.00) t 1.54, 256 d.f.; P 0.12Compared with arthritis 253 1.25 (1.191.31) 1.10 (1.011.18) t 3.04, 251 d.f.; P 0.004

Seriousness of treatment typeDiet 44 55 45 2 8.35, 2 d.f.; P 0.015

Oral agents 173 64 36Insulin 53 81 19

Cues to actionWorry that children will get diabetes

Not at all/not very often 84 38 62 2 46.53, 1 d.f.; P 0.001Quite/very often 170 81 19

Worry that siblings will get diabetesNot at all/not very often 149 54 46 2 17.87, 1 d.f.; P 0.001

Quite/very often 91 81 19

Benefit analysisTalking: make relatives more aware of

importance of diet and exerciseAgree 245 68 32 2 5.34, 1 d.f.; P 0.02

Disagree 19 42 58Encourage family to make lifestyle changes

Agree 230 70 30 2

7.79, 1 d.f.; P 0.005Disagree 26 42 58

Help prevent diabetesAgree 230 70 30 2 4.47, 1 d.f.; P 0.03

Disagree 26 42 58Barriers

I do not have a healthy lifestyle myselfAgree 150 67 33 2 0.68, 1 d.f.; P 0.4

Disagree 109 62 38I do not have much contact with my relatives

Agree 114 63 37 2 0.74, 1 d.f.; P 0.4Disagree 145 68 32

My relatives are not open to advice from meAgree 119 68 32 2 0.31, 1 d.f.; P 0.5

Disagree 142 63 35They do not see diabetes as a serious illness

Agree 134 70 30 2 1.02, 1 d.f.; P 0.3Disagree 123 64 36

They do not believe they are at risk for diabetesAgree 115 72 28 2 2.02, 1 d.f.; P 0.2

Disagree 138 64 36

Data are percent or mean (95% CI) unless otherwise indicated.

Communicating family risk of diabetes

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the past reported they would do so if theyreceived assistance.

CONCLUSIONS This study showsthat many patients with type 2 diabeteshad already taken the initiative, withoutformal prompting, to talk to family mem-

bers about diabetes risk. Younger pa-tients, patients with an existing familyhistory of diabetes, and patients on moreintensive treatment were more likely tohave discussed risk with family members.Respondents exhibiting several parame-ters of the Health Belief Model were mostlikely to have spoken to family members,including those with greater perception ofsusceptibility of family members, in-creased awareness of the seriousness ofdiabetes, and increased appreciation ofthe benefits of talking to family members.

Greater anxiety about family members de-veloping diabetes appeared to act as a cueto action. This suggests that emphasizingthese parameters when educating patientswith type 2 diabetes concerning familialrisk may lead to increased discussionwithin families.

This study also reveals an encourag-ing improvement in knowledge, atti-tudes, and behaviors of patients withdiabetes toward sharing informationabout risk with family members com-pared with findings from previous studies(9). However, knowledge of risk factorsfor type 2 diabetes was still poor, andthere were significant barriers to interven-ing within families. A real challenge forrespondents was providing informationregarding suggested lifestyle when theydid not adequately adhere to such guide-lines themselves. Supporting materials ondiet and physical activity to use withintheir families may help overcome this bar-rier. More challenging to address was thereported lack of regular contact with fam-

ily members by a substantial minority ofrespondents.

The typically low postal response ratemerits a note of caution in that those par-ticipating may be more enthusiastic aboutengaging with their families. A strengthwas the use of a theoretical framework(the Health Belief Model) to identify pa-

rameters likely to influence preventivehealth behaviors.

This study suggests that patients witha vascular risk factor such as type 2 dia-betes may provide a valuable outreach ed-ucational role to at-risk family members.They may benefit from provision of infor-mation on familial risk, the seriousness ofthe risk to family members, and interven-tions to reduce the risk, along with en-couragement to discuss this informationwith family.

Acknowledgments We thank the HealthResearch Board, Ireland, for funding.

No potential conflicts of interest relevant tothis article were reported.

We also thank Onja van Doorslaer forconducting focus groups (the results ofwhich informed questionnaire develop-ment); Dr. Chris Thompson and the staff ofthe Diabetes Centre, Beaumont Hospital,Dublin, Ireland, for help in identifying thesample; and Peter and Daniel Whitford forsurvey administration.

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