Stikes Jenderal Achmad Yani Cimahi
Effect of Community-Based Education to Foot Care Behavior among Type 2 Diabetes Mellitus Patients in
Bandung, West Java Province, Indonesia
1
Citra Windani Mambang Sari*,
2Ahmad Yamin Faculty of Nursing, Universitas Padjadjaran,
*Email: [email protected]
Abstract
Foot care behavior is a very important component in preventing diabetic foot. Patients with diabetes mellitus lack of knowledge and self-efficacy about foot care behavior so that the behavior of foot care less can be realized. The implementation of community-based foot care program for patients with diabetes mellitus directed to improve the behavior of the patient's foot care. Integrated community involvement in the program, so that patients have a social support system to perform foot care behavior. The purpose of this study was to determine the effect of a community- based foot care programs to foot care of patients with diabetes mellitus. The research method using a quasi- experimental design used is a pre-test and post-test with control group design. A total of 37 patients as the intervention group and 42 patients as a control group purposively selected from the patient population highest Type 2 Diabetes Mellitus in 10 Primary Health Care in Bandung. The intervention group received care educational program of cadres had been trained. Kader conduct health education and counseling in the intervention group in the first week and focus group discussion on the second and third weeks. Foot care measured by the modified NAFF (Nothingham Assessment of Functional Foot Care) that comprised six dimensions: foot inspection, foot hygiene, toenails care, footwear, and foot injuries and management of foot injury. Furthermore, the data were analyzed using paired and independent t-test.There are differences in the average foot care before and after community-based education program. The post-test foot care behavior in intervention group (M= 75.73, SD =11.46) was significantly higher compared to the pre- test score (M=44.19, SD 10.82). Meanwhile, in control group, there was a decreased of behavior scores at the pot test (pre test M=44.67, SD =12.56; post test M=46.19, SD=13.71). Foot Care educational-based program is expected to improve the behavior of foot care in patients with diabetes mellitus and lower the risk of diabetic foot. Nurses can integrate educational programs foot care based perkesmas program to the community in an effort to prevent the recurrence of diabetic foot.
Key words : community-based, diabetes mellitus, education, foot care.
Introduction
Diabetes mellitus is one of the increasing of chronic diseases in the world. International Diabetes Federation notes that by 2015 there are 415 million adults in the world who suffer from diabetes mellitus. Data for the year is expected to increase to 642 million people who will have diabetes mellitus by 2040 (IDF, 2015). Approximately 90-95% of the population of diabetes experienced the incidence of diabetes mellitus with type 2 (NIDDM), the type of diabetes mellitus caused by the disturbance of secretion and insulin hormone resistance (Centers for Disease Control and Prevention, 2014).
Indonesia is ranked seventh in the world for the highest prevalence of diabetes after China, India, the United States, Brazil, Russia and Mexico (IDF, 2015). In 2013 there are about 12 million people who have diabetes mellitus and only 3 million people are diagnosed (Pusdatin Kemenkes RI, 2014).
Based on Riskesdas (2013), the prevalence of diabetes mellitus in Indonesia increased from 1.1% to 2.1% compared to 2007.
Similarly, in West Java province also experienced an increase in prevalence from 1.4% in 2007 to 2% in 2013 and has the highest number of people who actually feel the symptoms of diabetes mellitus, but not yet examined that is about 225 thousand people (Riskesdas, 2013). The city of Bandung as the capital of the province is one of the big cities that have the potential to increase diabetes mellitus disease, where the disease is included in the top 10 disease patterns of patients most hospitalized in the Hospital (Profil Kesehatan Kota Bandung, 2015).
One of the complications of diabetes mellitus is diabetic foot. Diabetic foot is an infection or tissue damage associated with neurological disorders and impaired blood flow to the legs (Boulton, Armstrong & Albert, 2008). Disorders of the nervous system and the peripheral blood flow interruption is this which is the onset of diabetic foot (diabetic foot).
Factors that lead to diabetic foot include peripheral neuropathy, vascular abnormalities, poor glycemic control, repetitive trauma, and abnormal anatomical structure of the foot (Adhiarta, 2011).
Peripheral neuropathy and peripheral angiopathy, and minor trauma can cause ulcers in patients with diabetes mellitus. Lack of knowledge of the client and the public become ulcers get worse and may become gangrenous (Waspadji, 2007). Therefore there is need for ulcer prevention and treatment of diabetes mellitus is by foot care.
Research on foot care education programs have been conducted with a lot of measurement results with the aim of increasing self-efficacy in patients. All the research done on the individual patient with a hospital setting (Vatankhah et al, 2009 and Kurniawan et al, 2011), at home (Lincoln et al, 2008 and Sari et al, 2012). Of the four studies only Sari et al (2012) that involve the family in doing foot care education. It's just that no one has studied how the behavior of foot care in patients with Diabetes Mellitus involving the community. According to Friedman (2010), the community can be involved as a target of foot care education for the community can be a driving force as other community members to perform a behavior.
Community involvement in the foot care education are expected to appear confident in doing foot care, as members of the community can be a reminder and support to patients. Foot care education is also very important to involve the community to the other members of the community, given Diabetes mellitus is a hereditary disease that pose a risk to other members of the community. In addition, diabetes mellitus is a chronic disease that decreases the ability of the patient, so that if the community is involved in this educational program, communities can help conduct foot treatment in patients when the patient's condition began to deteriorate.
The purpose of this research is to identify the effect of community-based education program to foot care behavior in patients with diabetes mellitus in Bandung.
Method
The study design is a quasi experimental study design using two groups of intervention and control groups were performed pre-test and post-test in each group. The study population was patients with diabetes mellitus in Bandung. The criteria for inclusion in this study were (1) the client with age> 20-70 years and live with the community, (2) has been diagnosed with type 2 diabetes by a physician, (3) be able to write, read and speak Indonesian. The sampling technique in this research is by using purposive sampling in accordance with the inclusion criteria. The samples in this study are patients with diabetes mellitus, which are grouped into a control group and intervention group based health centers Bandung, West Java, Indonesia. Working areas Public Health Center are Pasir Kaliki, Pasundan, Ramdan, Garuda, Sarijadi , Arcamanik, Ujung Berung Indah, Ibrahim adjie, Babakan Sari and Babakan Surabaya. The research was done by conducted focus group discussion. Research tool was researcher-made by modified in two parts. The first part was used to assess demographic data such as age, sex, marital status, job, education, history of smoking, duration of diabetes, foot symptom, comorbid disease, BMI. The second part, Instrument for measuring foot care behavior using modification questionnaire Kurniawan et al (2011) which has been translated into Bahasa Indonesia and modified in Sari, et al (2012). There are 3 questions that are added about the prevention of foot injuries include foot exercises, smoking and folding feet. The number of questions as many as 31 with 4 choices of answers that is every day, often, rarely and never. Component questions on the instrument include checking the foot, keeping foot clean, foot nail care, footwear selection, injury prevention and management of foot injuries. The results of validity of foot care behavior with the lowest score of 0.39 and the highest score 0.86.
The reliability test result is 0.74.
Higher score indicate the better about foot care behavior. Data were analyzed by descriptive statistics, paired t-test and independent t-test.
The data collection is divided into two phases: training of cadres or community representatives who want to become volunteers. The second stage is the process of collecting data in patients with diabetes mellitus. The study used primary data source is data taken directly from the respondents.
Implementation of community-based foot care education program was held on 8-10 respondents belonging to the intervention group in the study. The intervention group consisted of 6 groups. The program consists of 4 weeks. Before community-based education foot care program starts, pre-test done. As baseline, the respondents were gathered in one place. Cadres leads a discussion on the behavior of foot care done before. Then cadres provide community- based education about foot care behaviors including risk factors and how to clean feet, and nail care, prevention of injuries.
Stikes Jenderal Achmad Yani Cimahi
In the first week of meeting, the cadres teaches how to perform foot care and asks if there are obstacles in performing foot care and also reviews what the respondent has done for a week about foot care. At the second and third meeting, the cadres conducted a home visit and asked the respondent whether the obstacles in performing foot care. Fourth week was conduct Focus Group Discussion and then post-test.
Result
Table 1 Frequency Distribution Analysis and Homogeneity Test Characteristics of Respondents on intervention group and control group in Bandung the study period
from September to November, 2016 (N = 79)
Variables Control Intervention X2 P value
(n=42) (n=37)
f % F %
Age
40 – 59 years 18 45 18 50 0.190a 0.818
60 – 69 years 22 55 18 50
Gender
Male 13 31 6 16 2.339a 0.187
Female 29 69 31 84
Marital Status
Single 2 5 1 3 0.127c 1.000
Married 33 79 24 65
Widow 7 17 12 32
Ethnic
Sundanese 34 81 31 74 0.699a 0.712
Javanese 8 19 6 16
Employement
Does no work 28 67 29 78 0.519b 0.950
Labor 6 14 2 5
Civil 2 5 2 5
Private employee 2 5 2 5
Self employee 1 2 2 5
Other 3 7 0 0
Education
Illiterate 1 2 0 0 0.639b 0.808
Elementary 17 41 18 49
Junior 10 24 12 32
Senior 11 26 7 19
University 3 7 0 0
Notes : a = Chi-Square, b = Kolmogorov-Smirnov
Based on Table 1, the majority of subjects in the intervention group (50%) and the control group (55%) age range of 60-69 years, with the female gender in the intervention group (84%) and the control group (69%) and married status in the intervention group and the control group are married. Almost all respondents in the intervention group (81%) and the control group (74%) are Sundanese. Most respondents in the intervention group (74%) and the control group (61%) did not work. The education level of the majority of respondents in the intervention group (49%) and the control group (41%) were elementary school. This implies that all variables in the intervention and control groups are homogeneous.
Table 2 Frequency Distribution Analysis and Homogeneity Test Clinical characteristics of respondents in intervention group and control group in Bandung
the study period from September to November, 2016 (N = 79)
Variables Intervention Control X2 P Value
(n = 42) (n = 37)
F % F %
Physical Activity
Never 9 21 7 19 1.016b 0.253
Walking 31 74 25 68
Gym 1 2 0 0
Bicycle 1 2 5 13
Smoking history
Never 25 60 31 84 1.067b 0.197
Ever smoked but had 8 19 2 5
stopped
Still smoking 9 21 4 11
Numbness
Yes 34 81 31 84 1.108a 0.777
No 8 19 6 16
Co-morbid disease
Yes 30 71 24 65 0.392a 0.630
No 12 29 13 25
Diabetes history
< 3 years 21 50 21 57 0.240a 0.656
> 3 years 20 50 16 43
Notes: a = Chi-Square, b = Kolmogorov-Smirnov Z
Table 2 illustrates the clinical characteristics of the respondents. The majority of respondents control group (50%) and the intervention group (57%) had diabetes ≥ 3 years old. Sports are run by most of the intervention group (74%) and the control group (68%) is walking distance.
Most of the intervention group (84%) and the control group (60%) had never smoked.
Based on table 2, all respondents had never received any education program Diabetes Mellitus. Most of the intervention group (84%) and the control group (81%) have a complaint neuropathy such as numbness. Most of the intervention group (65%) and the control group (71%) had concomitant diseases other than diabetes mellitus disease. Almost entirely from both groups had high blood sugar at the time of inspection. Based on table 2, we can see the results of the homogeneity test at 6 variables showed a value of p> 0.05. This implies that 8 of these variables in the intervention and control groups are homogeneous.
Stikes Jenderal Achmad Yani Cimahi
Table 3. Test of Mean Differences Foot care of respondents about Diabetes Mellitus before and after intervention in Control group
Variabel Control Group T P value
Before Mean (SD)
After Mean (SD) Foot Care
Behavior
44.67 (12.56) 46.19 (13.71) -0.998 0.324
Note : t = paired t-test, df=41
Mean value of foot care behavior before intervention in the control group was 44.67 (12.56) and after intervention 46.19 (13.71). The mean value of respondents' care behavior in the control group did not change significantly (p = 0.324).
Table 4. Test of Mean Differences Foot care of respondents about Diabetes Mellitus before and after intervention in Intervention group
Variabel Intervention Group T P value
Before Mean (SD)
After Mean (SD) Foot care
behavior
44.19 (10.82) 75.73 (11.46) -15.614 0.000
note : t = paired t-test, df=36
The mean value of foot care behavior before intervention in the intervention group was 44.19 (10.82) and after intervention 75.73 (11.46). The mean value of respondents' foot care behavior in the intervention group showed significant change (p = 0.000).
Table 5 Tests Differences Average behavior of foot care in Respondents about foot care behavior before and after intervention in the control group and intervention
Variabel Control Group Intervention T P value
Group
Mean (SD) Mean (SD)
Before 44.67 (12.56) 44.19 (10.82) 0.180 0.858 After 46.19 (13.71) 75.73 (11.46) -10.31 0.000
Note : t = independent t-test, df=78
Mean of foot care behavior in the control group was before intervention 44.67 (12.56) and after 44.19 (10.82). While in the intervention group before intervention 46.19 (13.71) and after intervention was 75.73 (11.46). The mean of foot care behavior before intervention in both groups was not significantly different (p = 0.858). The mean value of foot care after intervention was significant (p = 0.000).
Discussion
This research is the application of a model application of health education in community- based education program has been conducted by researchers in accordance with the underlying theory, which the researchers involved in the process of educating the cadres role given to patients assisted by investigators. The role of the nurse as a diabetes educator is one area of community nursing specialties that have a role as an instructor of health education in managing diabetes independently one of them to prevent the occurrence of diabetic foot. Task nurse diabetes educator is (1) to provide health education on self-management and periodic basis, (2) a behavioral intervention, (3) counseling and coaching the management of diabetes independently (Mensing et al, 2007).
This study was strengthened by the results of research Jack et al (2004) found that interventions Diabetes Self-Management Education (DSME) using methods, guidance, counseling and behavioral interventions can improve knowledge of diabetes mellitus and improve the skills of individuals and families in managing Diabetes mellitus. The involvement of volunteers in the control of self-care respondents also have an important role in alerting and improve the knowledge, self- efficacy and self-care respondents. In addition, the modules have been given to the respondent, so the respondent can reread again with family. This makes the process of discussion among families, volunteers and responders. The discussion process is that adding and updating knowledge and information from respondents about foot care. The information is part of the power to change the attitudes of individuals who will open one's mind through reasoning, thinking and deeper understanding (Sarafino, 1998).
Foot care behavior in Diabetes Mellitus patient is very important in preventing the occurrence of diabetic foot. There are several things that can improve the behavior of foot care in Diabetes Mellitus patients after family-based foot care education program is done. Some of these are 1) the basis of family-based foot care education programs, 2) educational methods, 3) motivation of cadres, 4) active involvement of the respondents, 5) follow-up of the program. First, the foundation of a family-based foot care education program is sustained by the Interaction Model of Client Health Behavior adapted from Corbett (2003). In addition, the basis of this study is in accordance with previous research that the foot care education program can improve the behavior of foot care patients Diabetes Mellitus (Corbett, 2003; Lincoln et al, 2008; Vatankhah et al., 2009; Kurniawan et al., 2011). Previous studies have reported improvements in foot care behavior at 5 weeks (Kurniawan et al, 2011), 6 and 12 weeks (Corbett), 6 months (Vatankhah et al), 12 months (Lincoln et al) after the intervention. The results of this study can improve the self- care behavior of Diabetes Mellitus patients only 4 weeks after the intervention of community- based foot care education program performed (Sari et al, 2013).
Second, the community-based foot care education program is conducted on Diabetes Mellitus patients using educational materials that are modules that contain about the behavior of foot care with images. According to Sudiharto (2007), the provision of informative and interesting educational materials, as a very strong supporter in providing education. An attractive foot care education material will enhance and stimulate patients and to ask questions and the time required to provide health education is also shortened. Several studies have previously reported that the use of modules during an effective health education session improves knowledge and behavior at 5 weeks (Kurniawan et al, 2011) and at 6 months (Vatankhah et al, 2009). Respondents are given modules that can be read at any time either by the respondent himself and the family at home. In addition, after being given foot care education by cadres, respondents were directed to take decisions to plan foot care behaviors in accordance with the abilities of the respondents.
In addition, in the module there is a self-report about foot care that is filled by respondents or family of respondents if they have undergone foot care. Self-report was made by the researcher so that the respondent can raise awareness to do the foot care although not directly supervised every day by the researcher. The filling of self-report is facilitated by the researcher, so the respondent only gives tick mark on the appropriate foot care behavior column.
Third, the motivation of cadres and respondents increases the behavior of foot care to the respondents. The support system of Diabetes Mellitus patients has an important role in improving foot care behavior. One of the basic supporting factors that can enhance individual capability is family support (Orem, 2001). The results of previous studies that make evidence that there is influence of cadre support toward behavioral independence level of Diabetes Mellitus patient (Sari et al, 2013).
Stikes Jenderal Achmad Yani Cimahi
Fourth, the active involvement of Diabetes Mellitus patients and families at each intervention contributes to improved foot care behavior. Patients have the opportunity to ask, exchange ideasbetween family members, patients and researchers at each phase of the intervention.
This can build a patient's commitment and confidence in performing foot care behaviors. In addition, this family-based foot care education program allows patients to freely express things that are an obstacle in foot care behavior. Previous research results reported that the active involvement of respondents resulted in better foot care behavior (Kurniawan et al, 2011).
Conclusion
Foot Care educational-based program is expected to improve the behavior of foot care in patients with diabetes mellitus and lower the risk of diabetic foot. Nurses can integrate educational programs foot care based perkesmas program to the community in an effort to prevent the recurrence of diabetic foot.
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Stikes Jenderal Achmad Yani Cimahi
