Effect of Self- and Family Management of Diabetic Foot Ulcers Programs on Health Outcomes Among Individuals With Diabetic Foot Ulcers in Indonesia

Study background:

Diabetic foot ulcer (DFU) is described as a full-thickness lesion appearing at the skin of the foot along with infection, destruction of tissues due to neuropathy and/or peripheral artery disease (PAD) in people with diabetes (International Working Group on the Diabetic Foot, 2015). DFU commonly develops in middle-aged diabetic patients due to a long period of type 2 diabetes and poor adherence to control blood glucose level (Madanchi et al., 2013). Prevalence of DFU was four times higher than all combined cases of cancers in the world (Boulton, 2013; McInnes, 2012; Shaw, Sicree, & Zimmet, 2010). Numerous published studies have documented the rate of DFU at around 25% in Western Population (Boulton, 2013). Prevalence of DFU was stated between 7.3 % - 24 % at Indonesia hospitals (Soewondo, Ferrario, & Tahapary, 2013). An Indonesia nursing study recorded 12 % of diabetic foot ulcer cases from 249 individuals with type 2 diabetes in a regional hospital of Eastern Indonesia (Yusuf et al., 2015). Cases of infected DFU occurred in 98 patients in Sardjito Hospital Yogyakarta Indonesia in 2016 (Longdong, 2016).

In long-term conditions, DFU leads to lower extremity amputation (LEA) (Pemayun, Naibaho, Novitasari, Amin, & Minuljo, 2016). Several factors relating to LEA were ischemia, neuropathy, end-stage renal disease, and depth of the wound along with infection (Widatalla, Mahadi, Shawer, Elsayem, & Ahmed, 2009). The incidence of LEA was forecasted to be more than a million per year (Peter-Riesch, 2016; Wu, Driver, Wrobel, & Armstrong, 2007). Two studies exposed that amputation procedures were performed every 20 seconds in the diabetic population in the world (Fejfarová et al., 2014). A recent study found the estimated range of amputations around 15 - 32 % in Indonesia (Soewondo et al., 2017). As a consequence, this condition will directly impact on the patient's health-related quality of life that encompasses physical, social, economic, and psychological aspects (Vileikyte, 2001).

In order to diminish the wide-reaching impact of DFU, a number of efforts have been performed in Indonesia. A study documented that sufficient diabetic patients' knowledge in performing foot care is able to decrease the incidence of DFU as well as LEA (Wulandini, Saputra, & Basri, 2013). Foot ulcers health education program was interrelated with patients' knowledge as well as attitudes concerning responsibility and involvement in DFU care (Arianti, Yetti, & Nasution, 2012; Mahfud, 2012; Sa'adah, Primanda, & Wardaningsih, 2016; Yoyoh, Mutaqqin, & Nurjanah, 2016). In line with their findings, another study confirmed that intensive health promotion increased patients' knowledge and practice in regard to perform routine foot care (Abbas, 2013). Also, health promotion intervention improves Hemoglobin A1c (HbA1c) in type 2 Diabetes (Brown, 1990; Norris, Lau, Smith, Schmid, & Engelgau, 2002; Florkowski, 2013). However, a number of these studies merely focused on the patient, not engaged family members as it may potentially reduce the effectiveness of therapy.

Currently, poor adherence to DFU treatment is taken into consideration on the diabetes population in Indonesia. Many diabetic patients had poor adherence in maintaining diabetes treatment which potentially leads to suboptimal diabetes outcomes involving increased blood glucose level, more hospital admissions, diabetes-related complications, and multiplied medical care costs (Putri, Yudianto, Kurniawan, & Titis, 2013; Waluya, 2008). To overcome this issue, intensive health promotion has been considered as the first-line approach in Indonesia (Windasari, 2014). In addition, strategies addressing poor adherence must be focused on reducing DFU complications in the future. This could be successfully achieved by incorporating family members in a particular intervention. A systematic review also pointed out that family support in a given treatment strengthens patient adherence to diabetes treatment (Rintala, Jaatinen, Paavilainen, & Astedt-Kurki, 2013). Efforts have been performed in Indonesia, even though it has some limitations. For instance, some studies merely addressed the age, gender, duration of diabetes and level of patient' education relating to the adherence, not focused on patients' motivation which is presently being the main problem in Indonesia (Ainni, 2017; Srikartika, Cahya, & Hardiati, 2016). Also, providing care to those suffering diabetes potentially becomes a burden on both physical and emotional aspects. Also, some individuals reported that they felt sadness when their family does not fully support their care. In line with these findings that, negative family support is the robust predictor for the patient's stress and decreased diabetes outcome (Pardamean & Dharmady, 2003; Isworo, Ekowati, Iskandar, & Latifah, 2018). The other study stated that patients receiving non-supportive care from a family member are more likely to have a poor blood glucose level (Isworo & Saryono, 2010). Moreover, the lack of family knowledge, low levels of self-efficacy, and insufficient social support from family members lead to poor diabetes self-management (Pamungkas, Chamroonsawasdi, & Vatanasomboon, 2017).