Predicting Factors of Diabetic Foot Care Behaviors Among Type 2 Diabetes Mellitus Patients

Transcription

1 Predicting Factors of Diabetic Foot Care Behaviors Among Type 2 Diabetes Mellitus Patients Estriana Murni Setiawati Master of Nursing Science estriana@rocketmail.com Wipa Sae-Sia Assistant Professor of Surgical Nursing Departement wipa.sa@psu.ac.th Luppana Kitrungrote Assistant Professor of Surgical Nursing Departement luppana.k@psu.ac.th Abstract The objective of this study was to examine the predictive factors of diabetic foot care behaviors among Muslim patients with type 2 diabetes mellitus. The predictive variables were diabetic foot care knowledge and perceived facilitators. One hundred and sixty one of Muslim patients with type 2 diabetes mellitus in Internal Medicine Clinic of Dr. Moewardi Hospital participated. Data were collected using a set of questionnaires consisted of the Personal Characteristic Questionnaire, the Modified Foot Care Knowledge Questionnaire, the Modified Foot Care Confident Scale Questionnaire, the Perceived Facilitators Questionnaire, and the Modified Diabetic Foot Care Behaviors Questionnaire. The content was validated by three experts. The Scale-Content Validity Index was between 0.94 and The reliability of the questionnaires was evaluated and acceptable values of Cronbach s alpha coefficients were obtained. Hierarchical multiple regressions were employed to assess the predictors of diabetic foot care behaviors. The results revealed that both of diabetic foot care knowledge and perceived facilitators accounted for 11% of total variance of diabetic foot care behaviors (R 2 change = 0.09). The result would help the nurses provide health education to improve patients knowledge related to diabetic foot care behaviors. Keywords-diabetic foot care knowledge; perceived facilitators; diabetic foot care behaviors; type 2 diabetes mellitus behaviors [9-11]. SCT consists of a set of determinants that covers knowledge, perceived self-efficacy, perceived facilitators and impediments, outcome expectations and goals [8]. Based on this theory, individuals cannot easily change their behaviors without those determinants. In addition, the literature review showed that diabetic foot care knowledge [12-14] and perceived facilitators [15, 16] were related to diabetic foot care behaviors. In Indonesia, where the majority of the population are Muslim, it was reported that more than half of DM patients did not perform foot care properly [17]. Furthermore, improper diabetic foot care behaviors was shown by not checking the feet every day, walking barefoot outside the home, and not using lotion for drying the feet [17]. To see the problems behind improper diabetic foot care behaviors, finding the factors that could affect diabetic foot care behaviors among Muslim patients with DM was needed. Therefore, the aim of this study was to investigate the predictive factors of diabetic foot care behaviors among Muslim patients with type 2 DM. A. Design II. METHODOLOGY I. INTRODUCTION Diabetes mellitus (DM) population was predicted increase in worldwide up to 415 million people in 2015 and 642 million people in 2040 [1]. Indonesia had a high number of DM patient with 12 thousand million people [2]. Diabetic foot ulcer (DFU) is one of most common complications of DM patients. The incidence of DFU among DM patients in Indonesia was between 7.3 and 24% [3]. The risk of occurrence of DFU increased proportionally with the diabetic peripheral neuropathy (DPN), foot deformity and trauma, and peripheral vascular disease (PVD) [4]. Untreated DFU would cause a serious consequence, namely amputation [5]. In Indonesia, incidence of amputation was found 30% among patients with DM [6]. Early detection and effective interventions are important to prevent the complications of DFU. Diabetic foot care behaviors was proposed to be one of the effective managements to prevent the occurrence of DFU [7]. Diabetic foot care behaviors can help individuals with DM aware their feet conditions. Social Cognitive Theory (SCT) had been reported as one of the theories that had been successfully used to examine the interaction between human behavior and behavior change [8]. Previous studies reported that SCT was used as a study framework to guide the study related to diabetic foot care DOI: / X_ This study was a cross sectional predictive design with three independent variables: diabetic foot care knowledge, perceived self-efficacy, and perceived facilitators. B. Participants The convenience sampling of Muslim patients with type 2 DM at Internal Medicine Clinic of Dr. Moewardi Hospital were recruited. One hundred and sixty one type 2 DM patients between 18 and 65 years old, being able to communicate with Indonesian language and without hearing and vision problem were recruited. Sample size was calculated with power analysis formula [18]. The total of 161 Muslim patients with type 2 DM participated in this study. C. Measuresment The diabetic foot care knowledge was measured by a self-report questionnaire of the Indonesian version of the Modified Diabetic Foot Care Knowledge Questionnaire that modified from Diabetic Foot Care Knowledge Questionnaire [19]. Each question was scored based on true and false categorical responses with a correct response as 1 and a wrong response as 0. The possible score was between 0 and 12. The scale content validity index was 0.94 and the The Author(s) This article is published with open access by the GSTF 1

2 test-retest correlation coefficient for this questionnaire was The perceived self-efficacy was measured by the Indonesian version of the Modified Foot Care Confidence Scale Questionnaire that modified from Foot Care Confidence Scale Questionnaire [20]. Each question was scored based on a five-point response scale between 0 and 4 in which 0 as a strongly not confidence level to 4 as a strongly confidence level. The possible score was between 0 and 64. The scale content validity index of this questionnaire was 1.0 and the Cronbach s alpha coefficient of this questionnaire was The perceived facilitators were measured by the Indonesian version of the Perceived Facilitators Questionnaire. It was developed by the researcher. A fivepoint response scale of 0 and 4 was applied. The possible score was between 0 and 96. The scale content validity index of this questionnaire was 1.0 and the Cronbach s alpha coefficient of this questionnaire was The diabetic foot care behaviors were measured by the Indonesian version of the Modified Diabetic Foot Care Behaviors Questionnaire. That was modified from Kurniawan [19]. Each question was scored based on a fourpoint response scale between 0 and 3. The possible score was between 0 and 93. The scale content validity index was 0.98 and the Cronbach s alpha coefficient of this questionnaire was D. Procedure This study was approved by the ethics committee of the, Thailand, and Dr. Moewardi Hospital, Indonesia. Through the head nurse of Internal Medicine Clinic of Dr. Moewardi Hospital, the researcher obtained the potential patients who met the criteria and were willing to participate in this study. After the patients signed the informed consent, they fulfilled the questionnaires. E. Analysis of Data Descriptive statistics was used to analyze the demographic data. The predictive factors of diabetic foot care behaviors were applied by hierarchical multiple regressions after the assumption of normality, linearity, homoscedasticity, multicollinearity, and autocorrelation were met. The significance alpha level was set as less than III. RESULTS A. Demographic Data of the Participants The age of 161 participants with type 2 DM was between 33 and 65 years with a mean age of years old (SD = 6.77). About half (50.9%) of them were female. The majority of the participants (95%) were married. Seventy one (44.1%) of them had completed senior high school. In term of income, 53.4% of participants had income of more than 2.1 million rupiah per month ( USD). Forty four (27.3%) of the participants were retired and 13 (8.1%) participants were farmer. Most of the participants (80.1%) did not attend foot care education. For the duration of DM, the range was from 1 to 35 years with a mean duration of 8.05 years (SD = 6.73) (Table 1). TABLE 1. THE PERSONAL CHARACTERISTIC DATA (N = 161) Characteristics n % Age (yrs), Min-Max = 33 65, M = 57.09, SD = Gender Male Female Marital status Single Married Widower Widowed Divorced Level of education Elementary school High school Diploma degree Bachelor degree Master degree Income (per month)* 500 thousand 1 million rupiah ( USD) million rupiah ( USD) million rupiah ( USD) 2.1 million rupiah ( USD) Occupation Government employee Private employee Farmer / other Housewife Retired Foot care education attendance Yes No Duration of diabetes Min-Max = 1-35, M = 8.05, SD = 6.73 Less than 10 years More than 10 years Note. * 1 USD = 13,241 IDR (10 November 2017), n = frequency, % = percentage, M = mean, SD = standard deviation, min = minimum, max = maximum B. Predictors of Diabetic Foot Care Behaviors Table 2 and 3 showed the summarized result of the general linier model and hierarchical multiple regressions analyses after deleting the perceived self-efficacy variable due to the fact that the perceived self-efficacy was not significantly related to diabetic foot care behaviors. Therefore, diabetic foot care knowledge and perceived The Author(s) This article is published with open access by the GSTF 2

3 facilitators were remained in the model. It was reported that diabetic foot care knowledge accounted for 2% of the variance in diabetic foot care behaviors. The addition of the perceived facilitators to the model increased the variance explained in diabetic foot care behaviors to 9% (R 2 Change = 0.09). The combination of diabetic foot care knowledge and perceived facilitators accounted for 11% of the variance in diabetic foot care behaviors. Furthermore, it was found that diabetic foot care knowledge (β = 0.84, p = 0.03) and perceived facilitators (β = 0.29, p < 0.001) were significant predictors of diabetic foot care behaviors. TABLE 2. PREDICTOR OF DIABETIC FOOT CARE BEHAVIORS (N= 161) R 2 Model Variables R R 2 Adjusted R 2 Change 1. Diabetic foot care knowledge 2. Diabetic foot care knowledge and perceived facilitators F TABLE 3. EACH PREDICTORS OF DIABETIC FOOT CARE BEHAVIORS (N= 161) Predictors b β t P Diabetic foot care knowledge Perceived facilitators P 0.03 < < health risk and the benefit creates the precondition to change. If the patients lack of knowledge about their life style habit that affect their health, they have less reason to change the detrimental habits [8]. Perceived facilitator was a significant predictor in this study. It means the facilitation related to the diabetic foot care to the patients was directly proportional to the diabetic foot care behaviors. Vaccaro, Exebio, Zarini and Huffman [23] showed that health care support by giving the encouragement and help to the patients would affect to patients performance and maintenance of the health behaviors. In Asian culture, particularly Indonesia, encouragement to perform health behaviors such as diabetic foot care by health care provider would be followed by the patients because they give high respect to the health care provider [19]. This shows that individuals will perform diabetic foot care if the health care provider suggests them to do it. It was confirmed by Social Cognitive Theory [8] that personal change would be easy by the presence of perceived facilitators [8]. Both diabetic foot care knowledge and perceived facilitators accounted for 11% of the variance of diabetic foot care behaviors. The possible explanation is that there should be other factors that not covered yet by this study that can explain higher variance of diabetic foot care behaviors. However, to the best of our knowledge, the research of the predictor factors of diabetic foot care behaviors with more than 2 predictor factors had not been reported. Furthermore, the decreasing of the power from 0.80 become 0.70 could be another reason that could explained the lower value of prediction of diabetic foot care behaviors. Convenience sampling technique might also contribute to the result of this study due to selection bias. IV. DISCUSSION V. IMPLICATION This study shows that diabetic foot care knowledge and perceived facilitators were significant predictors of diabetic foot care behaviors among Muslim type 2 DM patients in Internal Medicine Clinic of Dr. Moewardi Hospital, Indonesia. Both variables accounted for 11% of the variance of diabetic foot care behaviors. Diabetic foot care knowledge was a significant predictor of diabetic foot care behaviors [21]. It means that the more knowledgeable individuals on diabetic foot care, the better of diabetic foot care behaviors will be. The role of diabetic nurses to provide care in the clinical setting by providing information and knowledge about the DM complication and how to manage their DM to minimize the complication, especially on the foot, would affect the increasing patients knowledge related to the diabetic foot care [22]. By increasing their diabetic foot care knowledge, DM patients could learn to maintain diabetic foot care behaviors, which can prevent diabetic foot complication. This shows that patients will perform diabetic foot care if they know the advantage of performing this behaviors. It was confirmed by Social Cognitive Theory [8] that having knowledge of The results support the idea that the diabetic foot care knowledge and perceived facilitators are significant predictor of diabetic foot care behaviors among Muslim patients with type 2 DM in the Internal Medicine Clinic of Dr. Moewardi Hospital, Indonesia. It is important for nurses to provide information to the patients to enhance patients knowledge related to diabetic foot care behaviors. In addition, nurses are recommended to design intervention to offer the diabetic foot care behaviors to reduce the incidence of DFU among type 2 DM patients by providing the facilitation and information related to diabetic foot care behaviors. VI. CONCLUSION Diabetic foot care knowledge and perceived facilitators were significantly accounted for 11% of the variance of the diabetic foot care behaviors. Both, diabetic foot care knowledge (p < 0.05) and perceived facilitators (p < 0.01) was positively predictor of diabetic foot care behaviors. Therefore, nurses are highly recommended to provide The Author(s) This article is published with open access by the GSTF 3

4 information and facilitation related to diabetic foot care behaviors to enhance patients knowledge and performance on diabetic foot care behaviors. ACKNOWLEDGMENT The author would like to thank to the Graduate School, Prince of Songkla University, Thailand and the Research Center for Caring and Healing System for People with Trauma, Emergency, and Disaster, Faculty of Nursing, Prince of Songkla University, Thailand for the funding support. The authors would like to thank to the director of Dr. Moewardi Hospital for permission to conduct this study and also to all the participants in this study for their valuable time and the precious information they shared. REFERENCES [1] International Diabetes Federation [IDF], "IDF Diabetes atlas (7th Ed)," [2] The National Basic Health Research, "Situation and analysis of diabetes," n/infodatin/infodati-diabetes.pdf, [3] P. Soewondo, A. Ferrario, and D. L. Tahapary, Challenges in diabetes management in Indonesia: a literature review, Globalization and Health, vol. 9, no. 63, 2013, pp [4] J. J. Mendes, A. Marques-Costa, C. Vilela, J. Neves, N. Candeias, P. Cavaco-Silva, et al., Clinical and bacteriological survey of diabetic foot infections in Lisbon, Diabetes Research and Clinical Practice, vol. 95, no. 1, 2012, pp [5] R. J. Snyder, and J. R. Hanft, Diabetic foot ulcer effect on quality of life, costs, and mortality and the role of standard wound care and advanced care therapies in healing: A review, Ostomy Wound Management, vol. 55, no. 11, 2009, pp [6] R. T. Hastuti, Risk factors of diabetic foot ulcer among diabetes mellitus patients, thesis, Diponegoro University, Indonesia, [7] American Diabetes Association [ADA], Microvascular complications and foot care, The Journal of Clinical and Applied Research and Education, vol. 38, 2015, pp. S58-S66. [8] A. Bandura, Health promotion by social cognitive means, Health Education and Behavior, vol. 31, no. 2, 2004, pp [9] B. M. Perrin, H. Swerissen, and C. Payne, The association between foot-care self efficacy beliefs and actual foot-care behaviour in people with peripheral neuropathy: a cross-sectional study, Journal of Foot and Ankle Research, vol. 2, no. 1, 2009, pp [10] S. Wendling, and V. Beadle, The relationship between self-efficacy and diabetic foot self-care, Journal of Clinical & Translational Endocrinology, vol. 2, no. 1, 2015, pp [11] E. K. Biçer, and N. Enç, Evaluation of foot care and self-efficacy in patients with diabetes in Turkey: An interventional study, International Journal of Diabetes in Developing Countries, vol. 36, no. 3, 2016, pp [12] M. C. Gholap, and V. R. Mohite, To assess the knowledge and practice regarding foot care among diabetes patients at Krishna Hospital, Karad, Indian Journal of Scientific Research, vol. 4, no. 2, 2013, pp [13] R. Li, L. Yuan, X.-H. Guo, Q.-Q. Lou, F. Zhao, L. Shen, et al., The current status of foot self-care knowledge, behaviours, and analysis of influencing factors in patients with type 2 diabetes mellitus in China, International Journal of Nursing Sciences, vol. 1, no. 3, 2014, pp [14] M. A. Qadi, and H. A. Al Zahrani, Foot Care Knowledge and Practice among Diabetic Patients Attending Primary Health Care Centers in Jeddah City, Journal of King Abdulaziz University: Medical Science, vol. 18, no. 2, 2011, pp [15] R. Bundesmann, and S. A. Kaplowitz, Provider communication and patient participation in diabetes self-care, Patient Education and Counseling, vol. 85, no. 2, 2011, pp [16] Y. F. Chin, T. T. Huang, and B. R. S. Hsu, Impact of action cues, self efficacy and perceived barriers on daily foot exam practice in type 2 diabetes mellitus patients with peripheral neuropathy, Journal of Clinical Nursing, vol. 22, no. 1-2, 2013, pp [17] L. Makmurini, C. Kosasih, and U. Rahayu, Diabetic feet primary prevention efforts in patients with diabetes mellitus at Poli DM Sumedang Hospital Thesis, Padjadjaran University, Bandung, [18] J. Cohen, Statistical power analysis for the behavioral sciences, New York: Psychological Press, [19] T. Kurniawan, Effect of self-management support program on diabetic foot carebehavior Thesis, Prince of Songkla University, Thailand, [20] H. L. Sloan, Developing and testing the foot care confidence scale to measure self-efficacy in foot care, dissertation, Louisiana State University Medical Center School of Nursing, New Orleans, Louisiana, [21] H. George, P. S. Rakesh, M. Krishna, R. Alex, V. J. Abraham, K. George, et al., Foot care knowledge and practices and the prevalence of peripheral neuropathy among people with diabetes attending a secondary care rural hospital in southern India, Journal of Family Medicine and Primary Care, vol. 2, no. 1, 2013, pp The Author(s) This article is published with open access by the GSTF 4

5 [22] H. A. Mohamed, H. E. Elsaher, M. S. Aref, and N. Fouad, The effect of diabetic foot care training program on elderly adults' outcome, IOSR Journal of Nursing and Health Science, vol. 4, no. 4, 2015, pp [23] J. A. Vaccaro, J. C. Exebio, G. G. Zarini, and F. G. Huffman, The role of family/friend social support in diabetes self-management for minorities with type 2 diabetes, World Journal of Nutrition and Health, vol. 2, no. 1, 2014, pp The Author(s) This article is published with open access by the GSTF 5