INTRODUCTION
Diabetic Foot Ulcer (DFU) is the most common complication of diabetes. Approximately one in four diabetic patients will develop a DFU in their lifetime [1]. The prevalence of DFU is expected to increase as the prevalence of diabetes rises. A systematic review found that the prevalence of ulcers in diabetic patients globally ranges from 3% to 13% [2]. A study in eastern Indonesia reported that the prevalence of DFU was 12.0% [3]. On Kalimantan Island, the prevalence of diabetes mellitus (DM) is 1.8%, and the prevalence of DFU is also estimated to be high [4].
Many studies have reported on the physical, psychological, emotional, and social impacts of DFU that contribute to the quality of life. Other stressors experienced by DFU patients include the burden of care, significant loss of mobility, economic pressure due to the cost of care, and loss of work [5]. Mobility problems were identified as the most frequent discomfort, followed by sleep disturbances and pain in DFU patients [6]. These stressors can lead to the emergence of depressive symptoms, which are an independent determinant of poor quality of life [7,8]. The problems faced by DFU patients can lead to thoughts of fatalism, which may result in decreased self-management in dealing with diabetes.
To overcome the various problems caused by DFU, patients are expected to develop adequate coping skills. Coping is the characteristic behavior of individuals to manage stress in various ways, such as confrontation, surrender, or avoidance. Coping can affect the healing process and the overall well-being of the patient. A study revealed that confrontational coping was a significant predictor of healing in DFU [9]. The ability to cope with the wound situation affects the healing process, and the inability to cope can negatively impact the quality of life for patients with chronic wounds. Patients who rely more on active and minimizing coping styles can reduce depressive symptoms [10].
Based on the Resilience Illness Model, this model comprises two risk factors that influence resilience: illness-related distress (uncertainty and symptom distress) and defensive coping (avoidant, fatalistic, and emotive coping). Additionally, it identifies five protective factors for resilience: spiritual perspective (self-determined spiritual beliefs and practices), social integration (perceived support from friends and healthcare providers), family environment (adaptability, cohesion, perceived strengths), meaning derived from hope, and courageous coping (optimistic, confrontational, and supportive coping)[11].
Religious coping is a method that uses a religious approach to overcome problems [12]. Several studies have demonstrated the relationship between religious coping and disease management. Religious coping needs to be studied because it can play both positive and negative roles in the acceptance of an illness [13]. Patients use strategies such as prayer, dependence on God, and fasting to cope with diabetic conditions [14]. A positive relationship was found between HbA1C levels and the average score of positive religious coping in diabetic patients [15].
There are two subscales in the assessment of religious coping: positive religious coping and negative religious coping. Positive religious coping is characterized by having a secure relationship with God, a greater sense of connectedness with others, and better adaptation and outcomes to the illness experienced [16]. There are many reported benefits of using positive religious coping, including a positive association with social justice commitment, paying more attention to social justice for others [17], higher self-esteem and spirituality [18], and better glycemic control activities such as healthy diet planning [19].
It is known that Indonesia is a country where the population is very strong in the use of religious values in daily life. The population in Indonesia also has various religions, beliefs, and diverse spiritual cultures, but research data on the religious coping of diabetes patients in Indonesia and differences in religious coping styles are still limited. Information about religious coping in DFU (Diabetic Foot Ulcer) patients greatly contributes to resilience and quality of life. Exploration of factors influencing religious coping in DFU patients needs to be conducted because DFU is a chronic disease where they face various stressors that lead to prolonged feelings of anxiety, depression, and despair. This research is particularly important in clinical settings with diverse religions and cultures, as it enables healthcare practitioners, especially nurses, to provide holistic care by considering factors that influence patients' religious coping mechanisms. Therefore, this research needs to be done.
METHODS
1. Design and Participation
This cross-sectional study was conducted over four months (November 2022 - February 2023) in two government-owned hospitals in Banjarmasin city, South Kalimantan, Indonesia: Ulin Hospital and Anshari Shaleh Hospital. The samples were recruited using convenience sampling. The sample size calculation used G*power 3.20 [20]. Z test logistic regression; ⍺ err prob was set at .05; effect size at .15, power (1-β err prob) at .80 and Pr (Y=1| X=1) Ho at .3. The total sample size was calculated as at least 134. The inclusion criteria were DFU patients aged 17~65 years who did not have visual or hearing impairments and were capable of reading and writing in Indonesian. The inclusion criteria include patients who have diabetes complications other than DFU (stroke, renal failure). To prevent issues with reading capability and to address any health disturbances during instrument completion, a nurse acted as a research assistant to help patients complete the instrument. Based on the eligibility criteria, 173 patients were finally participated in this study.
2. Ethical Consideration
The study was conducted in accordance with the protocol approved by the Ethics Committee of the Faculty of Nursing, Universitas Airlangga (IEC: 263/KEPK) and the Ethics Committee of Ulin Hospital Banjarmasin (207/XReg Research/RSDU-22). The subjects of this research were conscious adults who could provide informed consent. Before conducting the study, the researchers explained the research to the subjects and requested that they voluntarily sign a consent form without any coercion. A nurse, acting as a research assistant, helped the patients complete the instrument, ensuring comprehension and addressing any literacy issues. If a subject experienced health problems during the study, the research was temporarily halted. Once the subject's condition improved and they were willing to continue, the research was resumed.
3. Instrumentations
This study used six instruments including general questions about demographic and disease characteristics, Wagner scale (for identify sample), Diabetes Distress Scale (DDS), Multidimensional Scale of Perceived Social Support (MSPSS), Daily Spiritual Experience Scale (DSES), and the Brief RCOPE. A demographic characteristics and disease factor questionnaire was developed by the researcher, including items on age, education level, income, and duration of diabetes.
The Wagner scale was used by nurses to assess the grade of DFU when patients arrived for treatment, utilizing real-time data. This scale provides a structure for determining the severity of wounds by examining their depth and extent and is recommended for assessing wound severity, particularly in diabetic patients. The Wagner classification assesses ulcer depth and the presence of osteomyelitis or gangrene: Wagner Grade 0: Skin is intact with no open lesion or a pre-ulcerative lesion; may have a deformity or cellulitis; Wagner Grade 1: Partial- or full-thickness ulcer (superficial ulcer); Wagner Grade 2: Deep ulcer extending to ligament, tendon, joint capsule, bone, or deep fascia without abscess or osteomyelitis (OM); Wagner Grade 3: Deep abscess, OM, or joint sepsis; Wagner Grade 4: Partial-foot gangrene; Wagner Grade 5: Whole-foot gangrene [21]. In this study, the researchers categorized the severity into two groups: Low (grades 0~2) and Moderate-High (grades 3~5). This categorization was chosen because the majority of the subjects' conditions fell within these grades.
The Diabetes Distress Scale (DDS) in the local language version [22] was employed to measure diabetes distress, authorized by the author. Family support was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS) [23], which was adapted for DFU patients. A portion of the questions from the Daily Spiritual Experience Scale (DSES) was adopted to measure spiritual experience. The assessment of positive religious coping utilized the Brief RCOPE, extensively tested in various clinical studies [16]. All instruments were initially piloted with DFU patients in hospitals different from those where the data were collected.
The Indonesian version of DDS has been reported for use in DM patients with various complications in Indonesia. It comprises 4 indicators (emotional burden, interpersonal distress, physician distress, and regimen distress) with a total of 10 questions. Items are rated on a 6-point Likert scale ranging from 1 (not a problem) to 6 (a very serious problem). This scale has demonstrated good reliability and validity in DFU. The validity results for the diabetes distress instrument yielded r values ranging from .54 to .90 (r ≥ .44), and internal consistency using Cronbach’s ⍺ was .93. Data were reported categorically with the following intervals: no distress (mean score < 2) and distress (mean score ≥ 2) [22].
The MSPSS has been adapted by numerous studies across various multicultural and diverse populations, and its psychometric properties have been tested in the Indonesian version. The MSPSS consists of 12 question items with 3 subscales (family, friends, and significant others). The researcher utilized only the family subscale with 4 question items. Each item uses a five-point Likert scale ranging from 1 (never) to 5 (always). Validity and reliability testing were conducted again before use with 20 DFU patients, yielding r values ranging from .90 to .92 (r ≥.44) and Cronbach’s ⍺ internal consistency of .92. Data scores range from 4 to 20 and were categorized into two groups: High (≥ group median score) and low (< group median score). The MMRS scale used comprises 3 indicators, employing closed-ended questions with Likert scale responses ranging from 1 (never/almost never) to 6 (many times). Respondents' scores range from 7 to 42 and were categorized into two groups: High (≥ group median score) and low (< group median score) [23].
The researcher adopted the DSES, which consists of 7 items with 3 indicators (connectedness, strength and comfort, sense of wholeness). It utilizes a Likert scale ranging from 1 (never/almost never) to 6 (many times). Respondents' scores range from 7 to 42. The validity results yielded r values ranging from .54 to .94 (r ≥ .44) and Cronbach’s ⍺ internal consistency of .92. Data were categorized into two groups: high (≥ group median score) and low (< group median score) [16].
The internal consistency of The Brief RCOPE has been extensively tested in various clinical studies. The researcher obtained direct permission from the developer. Seven question items translated by the researcher into Indonesian were used and tested on DFU patients. The validity results yielded r values ranging from .63 to .95 (r ≥ .44) and a Cronbach’s ⍺ of .93. Each item utilizes a five-point Likert scale from 1 (never) to 5 (always). The total score range of responses is 7-35, and data were categorized into two groups: High (≥ group median score) and low (< group median score). Median score categorization was used because the data produced did not follow a normal distribution during initial analysis [16].
4. Statistical Analysis
Statistical analysis was performed using SPSS Version 23 with p values ≤.05 considered statistically significant. All variables were categorical, so they were presented as frequencies, and percentages. Binary logistic regression was also performed to determine factors associated with positive religious coping with OR (Odss Ratio) considered as a statistically significant. The researcher utilized the mode instead of the median because the data for all variables were not normally distributed.
RESULTS
The demographic characteristics of the 173 DFU patients are shown in Table 1. The highest proportion of DFU patients were older adults (78.0%) and female (52.6%). Additionally, 61.8% of the respondents had completed senior high school and belonged to families with lower income (59.0%). Most of the study participants had a DFU duration of less than 1 year (59.0%) and 68.8% had a moderate-high DFU grade (Wagner scale). Regarding patient factors, most were not in distress (70.5%), had a high level of spiritual experience (77.5%), and had low family support (68.8%).
The relationship with positive religious coping and each factor of disease characteristics, patient factors, and religious coping is presented in Table 2. There was no association between religious coping and demographic factors (age, education) or disease characteristics (DFU duration and grade) (p >.05). However, there was a significant association with diabetes distress (p =.037). A higher prevalence and association with positive religious coping were found in patients with high family income (p =.019), high spiritual experience (p =.015), and high social support (p <.001). These three variables met the requirements for the next logistic regresssion analysis (p =.025).
The next step was to conduct multivariate binary logistic regression analysis using stepwised method on the predictive factors associated with positive religious coping. The results of the multivariate analysis showed that high family support (OR=4.09), high spiritual experience (OR=2.74), and family income (OR 1.84) were all significantly associated with positive religious coping (Table 3). However, the income was not statistically significant, thus it was finally deleted from step 2.
The results showed that the variables that associated positive religious coping are family support and spiritual experience. The magnitude of the relationship value can be seen from the odds ratio. The odds ratio (OR) is used to measure how strongly an event is associated with exposure [23]. The greatest strengths of the relationship in influencing positive religious coping are family support (OR=4.09) and spiritual experience (OR=2.74).
DISCUSSION
Based on bivariate analysis, it was found that factors related to positive religious coping were income, spiritual experience, and family support. Of the three factors, the test was then carried out again, and the results showed that the factors that influenced positive religious coping were family support and spiritual experience. The results of the multivariate analysis, it is evident that the highest OR value is found in family support (OR=4.09). This indicates that high family support is 4.09 times more effective in fostering positive religious coping compared to low family support. Meanwhile, for spiritual experience (OR=2.74), it implies that a good spiritual experience enhances positive religious coping in DFU patients by 2.74 times. This suggests that optimizing family support is more crucial than the patient's spiritual experience in enhancing positive religious coping.
Family support is one of the best intervention strategies for providing assistance to families experiencing health problems. Family support has been conceptualized as family coping, both internal and external. Family support has the purpose of sharing the burden and also provides informational support that is very useful for patients. Thus, a family that provides support through positive spiritual activities will conceptualize these spiritual activities as positive religious coping for family members. Social support, including family support, is a protective factor for individuals experiencing stressful life events including diabetic foot patients [16]. Family support plays an important role in fostering a person's religious coping. The presence of family support can strengthen one's faith and belief in a higher power, which can help in coping with stress, anxiety, and other mental health challenges. Family members can encourage each other to engage in religious practices, such as prayer, meditation, dhikr, or attending religious activities. Family support can encourage positive religious coping by providing emotional support, encouraging religious practices, promoting active coping, and reducing avoidance coping. These factors can contribute to better mental health outcomes and help individuals face life's challenges with resilience and confidence [24,25].
Spirituality can provide a sense of trust, support, and hope to individuals, so spirituality is one of the most important things in supporting treatment programs for people with chronic diseases. Spirituality is defined as a relationship with spirit and passion to get the meaning of life. Spirituality has a positive impact on individuals with chronic illnesses by supporting them to always take responsibility for their health, well-being, and managing their illness. Spiritual experiences can be highly personal and subjective. These experiences can be influenced by childhood spiritual awareness and experiences or various life events, including illness. Spiritual experiences are complex [26]. Religiosity and spirituality can be considered as potential psychological factors that underpin DM patients' experiences of dealing with chronic illness. Based on previous research, the experience of spirituality is closely related to self-management behavior in patients with diabetes mellitus. The experience of spirituality provides support, strength, and trust in dealing with an illness so that it will be related to self-management behavior [27]. Thus, a positive spiritual experience when facing an illness can create positive religious coping when dealing with a health problem such as DFU.
The strength of this research are this study explores topics related to the religious coping of diabetes patients in Indonesia, where such research is very limited and the sample size used is adequate and appropriate. The llimitation of this study is that the research subjects are predominantly Muslim, considering Indonesia is the largest Muslim country in the world. Therefore, the results of this study cannot be generalized, and further research is needed on populations with diverse religions.
CONCLUSION
There was a significant relationship with diabetes distress, but there was no relationship between religious coping, and demographic factors (age, education level), and disease characteristic (duration and degree of DFU). Multivariate binary logistic regression results show the greatest strengths of the relationship in influencing positive religious coping are family support and spiritual experience. It is important to build positive religious coping in DFU patients. Health care providers, including nurses, must be able to optimize positive religious coping through increasing family support and spiritual experiences among DFU patients.
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