The protocol for the preparation of this review is registered on the Open Science Framework (OSF) platform and can be accessed via the following link: https://osf.io/4wvt6.

The guiding question formulated was the following: What nurse-led programs exist to support self-management in people with T2DM through social support, and what are their characteristics?

Furthermore, the PCC (population, concept, and context) mnemonic strategy was used to integrate the studies in this review. Therefore, the population consists of adults with T2DM; the concept of nurseled social support programs; and the context is primary healthcare or the community.

The eligibility criteria adopted were: studies published with the proposed theme in English, Spanish, and Portuguese; complete articles, theses, and dissertations available online; any study, regardless of methodological design (qualitative, quantitative, or mixed), that explores the participant’s experience in programs aimed at supporting the self-management of DM through social support and led by nurses; studies with participants aged 18 or over, diagnosed with T2DM, conducted in the primary health care setting, and with program interventions led by nurses.

The search for studies was performed in the following databases: Web of Science, Medline (PubMed), Cinahl (EBSCO), Capes Catalog of Theses and Dissertations, Scopus, JBI Evidence Synthesis, PsycINFO (APA), and Open Access Scientific Repositories in Portugal between February 23 and March 17, 2022. Afterward, the reference lists of the included studies were manually searched to identify any relevant studies. The search strategies used for each database are shown in Table 1 and were devised with the assistance of two librarians with expertise in the health field and systematized reviews.

Table 1
Search Strategies Used in the Explored Databases. Brazil, 2022

Source: Search data (2022).

After searching the databases, all the studies were exported to a reference manager (EndNote). Duplicate articles were removed both manually and using an automation tool. It should be noted that the descriptors were adapted for each database, by using synonyms to find the greatest number of studies.

Next, the titles and abstracts were screened based on the inclusion criteria with the help of the Rayyan Systematic Reviews web/mobile app, so that two authors could independently and blindly screen the title/abstract and full text. In the event of any doubts, a third author would read the manuscript and decide whether or not to include it. Publications that met the eligibility criteria were retrieved in full.

A form was designed by the author to extract the data. A pretest was then carried out to assess the need for adjustments. The data extracted included author, title, publication year, study country, journal name, document type, language, study objective, study setting, methods, population/sample size, inclusion criteria, exclusion criteria, collection instrument/technique, program results/impacts, conclusions, participants’ social characteristics, participants’ clinical characteristics, program/intervention duration, core theoretical model, resources used, program implementation, and user satisfaction assessment.

A descriptive analysis of the information related to nurse-led programs and their characteristics was carried out. The evidence was synthesized based on the research questions. A table was prepared with data allocated to the studies included in the review and another table with existing programs. Additionally, a figure was prepared with the basic theoretical model of the interventions. The search steps are represented in the flow diagram of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (Prisma-ScR), which is an extension of the scoping review.

Initially, 1,743 publications were identified, as shown in Figure 1. After removing 10 duplicate studies, the titles and abstracts were then screened, resulting in a sample containing 12 documents for full reading. Subsequently, seven publications were excluded for failing to meet the eligibility criteria, which left five publications eligible for analysis. During the review of the references in the included studies, it was found that it was necessary to incorporate seven additional documents. As a result, this review consisted of 12 studies after the inclusion of the relevant documents.

Figure 1
Study identification and inclusion process. Prisma-ScR flowchart
Source: Own elaboration.

Most of the selected studies were frequently carried out more than five years ago (n = 8) in developed countries such as the United States, England, and Iran (n = 6), as shown in Table 2, which presents the main characteristics of the studies included in this review.

Table 2
Studies included in the scoping review by author, type of study, title, country, and year of publication. Brazil, 2022

Source: Research data (2022).

Regarding the study designs, there was a prevalence of randomized clinical trials (n = 8). The others were systematic reviews plus meta-analysis (n = 2), a systematic review (n = 1), and a longitudinal observational study (n = 1). As for document type, eight were articles, three were theses, and one was a dissertation.

Nurse-led programs were implemented in the following locations: general care clinics (n = 6), specialized care services for people with chronic illnesses (n = 3), and university hospitals (n = 3), as shown in Table 3. It is noted that the programs are designed to improve glycemic control and, simultaneously, achieve significant results in terms of lipid profile, blood pressure, regular physical activity, adequate nutrition, emotional stability, social interaction and, consequently, self-management.

Table 3
Nurse-led programs focusing on social support for people with type 2 diabetes by author, intervention site, results achieved, and population assisted.

Source: Research data (2022). Key: ND - not defined.

The participants’ characteristics indicate a mean age of 54.2} 11.8 years (between 22 and 69 years), with a prevalence of women (n = 7), with a low level of education, having studied for a total of nine years (n = 8).

The studies found on emotional support covered programs consisting of individual, face-to-face counseling, followed by a collective approach and dynamics with family/friends. To consolidate learning, phone calls were made (Table 4). Therefore, the programs converged on an educational basis -with instructions in face-to-face appointments and via phone calls- with a strong influence of affective aspects, since the person with diabetes would need to be the protagonist of their decisions, but there was also family interaction. On average, the interventions lasted 12 months, with a maximum of 36 months and a minimum of 1 month.

Table 4
Programs by Author, Type of Intervention, and Duration

Source: Research data (2022).

Regarding the basic theoretical model used by the programs, most followed the social cognitive theory (n = 3), conversation maps (n = 2), the common sense self-regulation theory (n = 2), the self-efficacy theory (n = 1), and motivational interviewing (n = 1). It is worth noting that the studies that were not mentioned correspond to the fact that they did not present their respective basic models and/or clarified the theoretical framework.

The present study found studies conducted in England, the United States, Iran, Australia, and the Netherlands on programs focused on social support for the self-management of people with T2DM, which were led by nurses and centered on care facilities for people with chronic diseases (9, 11-15).

It is worth noting that in these countries, care for people with diabetes is performed in a unique way and with a holistic approach (16). In developing countries such as Brazil, this approach is still in its infancy, despite efforts to improve care for this population, which has increased significantly over the years (17). Factors such as adequate spending of financial resources on healthcare services, continued training processes and engagement of professionals, as well as technological support and priority on conflict management may be associated with the differences mentioned between these regions (18-20).

In addition, strategies for patients’ attendance and commitment to the treatment of chronic diseases are related to family engagement and effective professional intervention, which highlights the importance of social support in achieving these goals. Such support is an essential tool for promoting improvements in health and interpersonal relationships, which leads to improved cognitive performance, and negative emotional reactions management -e.g., anxiety, and offers behavioral analysis (21, 22). The literature highlights the key role played by nursing professionals in primary care in health education activities and self-management through evidence-based practices (23).

In the present study, the findings regarding the theoretical framework that integrates social support into the main strategic interventions were the social cognitive theory (an active pedagogical strategy that determines that individuals influence and are influenced by observational learning [13, 24-26]); conversation maps (a tool subdivided into four stages, delivered to patients via images and metaphors reproduced on a card table with specific topics [27]); the self-efficacy theory (which determines that commitment, depending on personal will and ability, is decisive in preventing or managing the disease [28]); motivational interviewing (evidence-based counseling, in which healthcare professionals help people adopt targeted treatment recommendations [29]); and the common sense self-regulation theory (which provides strategies aimed at finding out how people feel and think about the disease [30]).

These theories can lead to several benefits for patients, such as a reduction in sedentary lifestyles, which has an impact on BMI control and abdominal circumference in women, a better understandingand acceptance of the disease, as well as stress reduction and increased consumption of fruit and vegetables (13, 24, 25). Thus, knowledge of these theoretical models can enable them to be implemented through low-cost programs and favor care processes with a reduction of risks and problems (31, 32).

A study published in the Revista de Medicina da Universidade de São Paulo showed that the perception of social support and family functionality were positive and there was a significant relationship between glycemic levels and information on the adequate management of T2DM in elderly males, which highlights the importance of family support in the therapeutic management of the disease. Nurse-led programs focused on promoting social support and family integration can promote better engagement between patients and their families and, consequently, contribute to improved self-care, healthy eating habits, and physical activity (33- 35). In addition, it is worth highlighting the inclusion of people with T2DM in support groups and educational activities, as this allows for joint interaction, and sharing experiences and feelings (36).

Regarding the multidisciplinary approach, nutritional interventions focused on fruit and vegetable intake and physical exercise programs were noted (15, 25, 37). In the field of nursing, the use of online tools was the main form of intervention and satisfactory results were achieved in terms of glycated hemoglobin values, fasting glycemia, BP levels, and anthropometric data (9, 14, 24, 31, 37-39, 44). It is worth pointing out that, in the field of primary care, nutritional monitoring associated with an adequate diet has led to the best short-term results with a balanced diet specific to each individual (40).

Regarding physical training programs for people with T2DM, these provided greater benefits by improving insulin sensitivity and glycated hemoglobin, which resulted in lower postprandial hyperglycemic peaks. The recommendation to practice physical exercise between 150 and 300 minutes (light to moderate) or 75 to 150 minutes (intense) has an impact on muscle strength and greater endurance capacity in these individuals, which can improve functional capacity and body maintenance (41). In addition, the professional support provided to recently diagnosed patients has benefits, such as reducing stress levels, especially in those who have been diagnosed within less than five years, and who are more resistant to accepting the disease (13, 15, 31, 44).

However, it is worth noting that, although self-management is effective in changing the cognition of people with T2DM, contributing to behavioral change and emotional perception, the maintenance of these behaviors still seems to be insufficient in the long term; therefore, an approach with individuals who have been diagnosed for longer is also essential, as it ensures continuity of care, reduces the possibility of chronic complications such as neuropathy, retinopathy, renal and neurological damage (25, 42).

The present review found that online programs and phone-based approaches under the guidance and leadership of a nurse were more likely to lead to adherence by participants. This can be justified by the fact that technological resources make communication easier, although access to these devices must be considered (9, 12- 15, 24, 25, 31, 39, 43, 44).

Thus, due to the complexity of the treatment, effective adherence by patients becomes a challenge not only for them but also for the healthcare team and family members. Consequently, comprehensive support and reframing of these individuals’ lifestyle habits must have an impact to promote the practice of effective self-care, as well as conscious decision-making with empowerment through cognitive restructuring (25, 44-47).

As such, the social importance of nurse-led programs for individuals with T2DM is materialized as an important alternative in the follow-up of these individuals in terms of risk reduction, adequate self-care management, and satisfactory family support, which contributes to personal satisfaction and lower demand for healthcare services (9, 48-50).

Although the methodological evaluation of studies is not a stage covered by the scoping review methodology, this can influence the results. The study was limited to the English, Portuguese, and Spanish languages, which may represent a selection bias. Thus, programs from other languages/cultures are not represented in this study. In addition, the studies did not clarify the follow-up and monitoring of the participants included in them, which hinders identifying and characterizing them in the medium and long term.

The strengths of the review include the rigorous and transparent approach adopted to select relevant studies, conducted in line with the Prisma-ScR guidelines. The strengths also lie in the collaboration of a multidisciplinary team of reviewers and the collaboration of librarians with expertise in systematic and scoping reviews to devise the search string.