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Abstract

Introduction

Diabetes mellitus (DM) is a global health issue. Diabetic wounds have become a severe health complication. Interdisciplinary education and the use of homecare have led to improvements in the health of patients with chronic disease. The family caregiver's knowledge and self-efficacy positively impact the DM patient's self-care in the physical and psychological dimensions. There is still a need for interdisciplinary education to enhance family caregivers’ knowledge and self-efficacy regarding diabetic wound care.

Objective

To determine the effect of 6 months of interdisciplinary education on family caregivers’ knowledge and self-efficacy regarding diabetic wound care.

Methods

A quantitative longitudinal study with a quasi-experimental, one-group, pretest–posttest design was conducted. Family caregivers received 6 months of interdisciplinary education regarding diabetic wound care. The Foot Care Confidence Scale (FCCS) was used to measure the family caregivers’ knowledge and self-efficacy regarding diabetic wound care. The dependent samples t test and the Wilcoxon signed-rank test were used for statistical analysis.

Results

Sixteen caregivers of patients with diabetic ulcer wounds in the homecare unit participated in this intervention with a 6-month follow-up. Six months of interdisciplinary education significantly increased the family caregivers’ knowledge (p = 0.001) and self-efficacy (p = 0.001). However, there was no significant correlation between self-efficacy and gender, age, education level, or duration of wound care (p = 0.91; 0.93; 0.38; 0.40, respectively). Long-term interdisciplinary education improved caregiver performance across genders, ages, education levels, and wound care experience durations.

Conclusion

Long-term interdisciplinary education of family caregivers is recommended as one method to enhance the family support system with respect to diabetic ulcer care management. In addition, interprofessional collaboration could be performed to enhance the understanding of healthcare, especially diabetic ulcer care.

Keywords

diabetic interdisciplinary homecare caregivers

Introduction

Diabetic ulcers require specific and adequate management to prevent infection and amputation (Sulistyo, 2018). Interdisciplinary care is an effort to provide effective and efficient care to patients with chronic health conditions by including various groups of health care professionals (e.g., doctors, nurses, pharmacists, dietitians, and health educators) in the treatment approach, with the patient and family composing the core team (Codispoti et al., 2004). The interdisciplinary care model provides comprehensive treatment that improves glucose and diabetic ulcer control management (Dutra et al., 2019; Sagha Zadeh et al., 2018; Tan et al., 2019; Tremblay et al., 2017), thereby preventing the need for amputation (Ugwu et al., 2019).

Review of Literature

Diabetes mellitus (DM) is a global health issue (Federation_Global, 2020). Indonesia has the sixth-highest prevalence of citizens diagnosed with DM in the world (6.2% of the total Indonesian citizens) (Mihardja et al., 2014; Region, 2020). According to the American Diabetes Association (ADA), DM is a metabolic disease marked by hyperglycemia (Association, 2014; Rossi, 2010). It has been reported that there is a high prevalence of DM among individuals older than the age of 45 years old; this population also has a high rate of DM complications (20.6%) (Turns, 2011). Various complications can result from uncontrolled DM. Two major complications of hyperglycemia are macrovascular effects, which impact the cardiovascular and cerebrovascular systems, and microvascular complications, which impact nephropathy, retinopathy, and neuropathies. Advanced complications from peripheral neuropathy, peripheral arterial disease and infection could induce diabetic ulcers that are difficult to treat (Zhang et al., 2017).

One of the DM complications that has become a very serious health problem is diabetic ulcer (Siddiqui & Bernstein, 2010). The prevalence of diabetic ulcer was reported to be approximately 15–20% (Zhang et al., 2017). A total of 50% of patients with this complication undergo amputations (Adeleye et al., 2020; Ugwu et al., 2019), and the mortality rate among this subgroup is also 50% (Adeleye et al., 2020). A previous study reported that DM patients with diabetic ulcers have a low quality of life (Jayalakshmi et al., 2020), experience high levels of anxiety and depression (Ahmad et al., 2018), have a high risk of systemic infection, have a 15-fold higher risk of amputation (Ugwu et al., 2019), lack independence, and incur high treatment costs, thereby causing an economic burden on the family (Alsanawi et al., 2018; Woods et al., 2020). Previous research has shown that 80% of diabetic ulcers require hospital treatment or outpatient care for more than 6 months (i.e., long-term care) (Russo et al., 2020) and require comprehensive treatment (i.e., both systemic and local treatment) (Sulistyo, 2018).

Another previous study reported that interdisciplinary treatment could be used to improve a patient's quality of life by providing treatment for all types of needs that are unique to the patients (Sagha Zadeh et al., 2018). Interdisciplinary treatment has been shown to increase the recovery rate in stroke patients (Clarke & Forster, 2015), diabetes mellitus wound patients (Musuuza et al., 2020; Wang et al., 2016), and cancer patients (Janssen et al., 2017). Additionally, homecare is a type of health care provided in the patients’ house via visitation. A previous study reported that homecare could increase the quality of life and increase satisfaction among patients (Kizza & Muliira, 2019; Kuo et al., 2016). Family support is an important factor for treatment adherence among patients with chronic diseases, including DM. Family support is defined as the assistance provided by the family members, which can lead to physical and psychological comfort. Caregiver support is an indicator that has the strongest positive impact on self-care among DM patients. The objective of the current research is to determine the effect of 6-month interdisciplinary accompaniment on family caregivers’ knowledge and self-efficacy regarding diabetic wound care.

Methods

Study Design

This is a quantitative longitudinal study with a quasi-experimental one-group pretest–posttest design.

Research Question

Is 6 months of interdisciplinary therapy associated with improvements in family caregivers’ knowledge and self-efficacy regarding diabetic wound care?

Sample

The participants were recruited using an accidental sample approach between January and June 2022. Sixteen caregivers of diabetic ulcer patients in the homecare unit of an Indonesian hospital were included during the 6-month follow-up of the intervention program.

Inclusion and Exclusion Criteria

The inclusion criterion was being a family caregiver of patients with diabetic wounds. Family caregivers with cognitive impairments were excluded from this study.

Ethical Consideration

The study obtained approval from the ethical committee (reff. 1940//I/2022). All participants provided written informed consent before receiving education on diabetic ulcer wound care.

Intervention

All caregivers received 6 months of interdisciplinary education regarding the wound care process. Individual education was provided via leaflets and the demonstration of diabetic ulcer treatment by researchers. The interdisciplinary approach involved professionals from four fields: nursing, physiotherapy, nutrition, and psychology. All professionals participated in the wound treatment process for 6 months; the education was provided twice a week for each caregiver via face-to-face interactions in the caregiver/patient's house (home-based education).

Data Collection and Instruments

Knowledge and self-efficacy were measured via face-to-face assessment before (the beginning of the first month) and after the 6-month intervention program (the end of the sixth month). The wound care assessment knowledge questionnaire (Cronbach's alpha score is 0.893) consists of 16 questions and was used to measure the caregiver's wound care knowledge. The maximum score on this questionnaire was 16, and higher scores indicated greater knowledge. The modified Foot Care Confidence Scale questionnaire (FCCS) (with a Cronbach's alpha score of 0.869) was used to measure the caregiver's level of self-efficacy. The FCCS used a 5-point Likert scale with the following response options: 1 indicates very not confident, 2 indicates feeling confident enough, 3 indicates confident, 4 indicates feeling confident, and 5 indicates very confident. The scores for each item are summed to obtain a final result; the scores ranged from 11 to 55.

Statistical Analysis

Because the data were normally distributed, dependent samples t tests were used to compare pretest and posttest self-efficacy among caregivers for performing simple wound care (Shapiro‒Wilk p = 0.084; 0.157). Additionally, to analyze the difference between pretest and posttest knowledge, the Wilcoxon signed-rank test was used since the data were not normally distributed (Shapiro‒Wilk p = 0.204; 0.001).

Results

Sample Characteristics

Seven respondents were in the highest age group of 26–45 years old (43.8%). Twelve (75%) respondents were female. The highest education level was senior high school (11 respondents; 68.8%). In addition, six respondents were entrepreneurs (37.5%), and nine respondents (56.3%) had been caretakers for the patients for more than one year (summarized in Table 1).

Table 1.

The Caregivers’ Characteristics of Diabetic Ulcer Homecare Patients (n = 16).

Characteristic	Frequency (f)	Percentage (%)
Age
17–25	2	12.5
26–45	7	43.8
46–65	4	25.0
>65	3	18.8
Gender
Male	4	25.0
Female	12	75.0
Latest education
Senior high school	11	68.8
Diploma/university	5	31.3
The duration of the family suffers from diabetic ulcer
≤1 year	7	43.8
≥1 year	9	56.3
Occupation
Housewife	5	31.3
Civil servant	3	18.8
Entrepreneur	6	37.5
College student	2	12.5

Research Question Results

The dependent-samples t test revealed a significant difference in caregiver self-efficacy between the pretest and posttest (p = 0.001). However, there was no significant correlation between self-efficacy and gender, age, education level, or duration of wound care (p = 0.91; 0.93; 0.38; 0.40, respectively) in this study. The Wilcoxon signed-rank test revealed a significant gap in the average knowledge the caregiver possessed before and after the 6-month interdisciplinary treatment (p = 0.001), as shown in Table 2.

Table 2.

The Result of the Dependent t-Test; Caregiver Self-Efficacy in Performing Diabetic Ulcer Care and Wilcoxon Effectiveness Test of 6-Month Interdisciplinary Accompaniment on Family Caregivers’ Knowledge and Self-Efficacy Regarding Diabetic Wound Care.

Dependent t-Test (self-efficacy caregiver)
Data	Mean	p
Pre-test	27.13	0.001^*
Post-test	49.31	0.001^*
Gender		0.19
Age		0.93
Education		0.38
Duration of wound care		0.40
Wilcoxon (wounds care caregiver knowledge)
Z	3.537b
Asymp. Sig. (2-tailed)	0.001^*

*Significant.

Discussion

This study revealed that 6 months of interdisciplinary care with family caregivers improved the knowledge and self-efficacy regarding diabetic wound care. This finding is supported by previous research showing that home-based oral care education can achieve significant improvements in knowledge and self-efficacy among family caregivers of stroke survivors (Kuo et al., 2016). Another study reported that home-based education intervention significantly and positively influenced family caregivers’ knowledge and self-efficacy for pain management while at home (Kizza & Muliira, 2019). This research provides further evidence that interdisciplinary homecare education for family caregivers is essential to increase the support system of patients with diabetic ulcers.

Family caregivers play an important role in providing long-term care for people with DM (Kristianingrum et al., 2021). Studies have shown that caregivers play diverse and significant roles in improving diabetes-related foot ulcer prevention and/or management outcomes (Suglo et al., 2022). Another study also reported that family-based education intervention creates family empowerment to accelerate wound healing of diabetic foot ulcers (Appil et al., 2022). However, lower extremity amputation for the treatment of chronic diabetic foot ulcers leads to an increase in the caregiver's burden (Çamur et al., 2020).

Self-efficacy is a cognitive variable that affects behavior and belief in one's ability to take action to manage future situations. A previous study reported that increased knowledge and self-efficacy can foster independence and self-confidence, including wound care practice (Wantonoro et al., 2022). Therefore, interdisciplinary caregiver assistance is essential for improving the knowledge, skill and confidence of caregivers in diabetic ulcer wound management.

Interestingly, demographic data such as gender, age, education level, and duration of wound care were not correlated with self-efficacy among caregiver in this study. These results indicate that 6 months of interdisciplinary care with caregivers effectively improved their self-efficacy regarding diabetic wound care. The findings of the current study were consistent with previous findings indicating that caregivers who receive thoughtful education have greater knowledge about promoting wound healing and preventing infection (Kirkland-Kyhn et al., 2018). Another study reported that caregivers with accompaniment in wound care treatment demonstrated a higher healing rate and lower total hospital visits (Jessee, 2021). This study implied that long-term interdisciplinary accompaniment improved caregiver performance across genders, ages, education levels, and wound care experience durations.

This study showed that patients with wounds experience psychosocial problems related to the presence and treatment of the wounds; thus, wound care research should include professionals from more disciplines (Dyeson, 2005; Ousey & Edward, 2014). Interdisciplinary approaches tailored to the self-identified needs of the patients and caregivers could improve adherence (Zamani et al., 2021). Interdisciplinary approaches are associated with significant reductions in the rate of major amputations among patients with diabetic foot ulcers (Musuuza et al., 2020). Interdisciplinary management of diabetic foot disease is associated with a reduction in the rate of major amputation among patients with diabetes (Wang et al., 2016).

Family-based intervention (homecare) programs are effective at improving glycemic control and wound healing (Wuri Kartika et al., 2021). The results of the current study are supported by a previous study, which found interdisciplinary homecare has a positive influence on the knowledge, skill, and self-confidence of the caregiver, prevents infection, and improves the diabetic ulcer wound recovery process. Another study reported that homecare strategies for patients suffering from diabetic ulcers are more cost effective than hospital care (Jafary et al., 2020). However, education from several scientists and healthcare professionals is a good strategy for enhancing caregivers’ self-efficacy regarding diabetic ulcer wound treatment.

Strengths and Limitations

The use of long-term interdisciplinary accompaniment is a strength of this study. This study has several limitations, including the one-group study design and the limited sample size. In addition, most of the caregivers for family members with a diabetic ulcer had been in that role for an extended period, so they had a high level of experience caring for diabetic ulcer wounds, which may affect the research results.

Implications for Practice

Long-term interdisciplinary care accompanied by education among family caregivers is recommended as part of the nursing care plan for patients receiving diabetic wound care.

Conclusions

A long-term interdisciplinary accompaniment for family caregivers is recommended as one way to provide support for families in the context of diabetic ulcer care management. In addition, interdisciplinary collaboration could be performed to maximize the understanding of healthcare, especially diabetic ulcer care.

Footnotes

Acknowledgments

The authors thank the following: (1) the Indonesia Ministry of Education, Culture, Research, and Technology, (2) the Ministry of Finance Indonesia Research Funding, (3) the Homecare Unit of RS PKU Muhammadiyah Yogyakarta, and (4) the caregivers, patients, and students who participated in this study.

Author Contributions

Study conception and design: WW and KK.

Data collection: WW and SH.

Data analysis and interpretation: WW, DRI, KK and TVN.

Drafting the article: WW and KK.

Critical revision of the article: TVN.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Indonesia Ministry of Education, Culture, Research, and Technology and the Ministry of Finance Indonesia Research Funding—eRISPRO 2021.

ORCID iDs

Wantonoro Wantonoro

Tuan Nguyen

References

Adeleye

O. O.

Ugwu

E. T.

Gezawa

I. D.

Okpe

Ezeani

Enamino

(2020). Predictors of intra-hospital mortality in patients with diabetic foot ulcers in Nigeria: Data from the MEDFUN study. BMC Endocrine Disorders, 20(1), 134. https://doi.org/10.1186/s12902-020-00614-4

Ahmad

Abujbara

Jaddou

Younes

N. A.

Ajlouni

(2018). Anxiety and depression among adult patients with diabetic foot: Prevalence and associated factors. Journal of Clinical Medicine Research, 10(5), 411–418.

Alsanawi

Hassan

Mustafa

Hattan

Abdullah

Mamdouh

Junayd

Alamri

Jawahraji

, & Mohammed

(2018). Pathogenesis and management of diabetic foot ulcers. International Journal of Community Medicine and Public Health, 5(11), 4953–4958.

Appil

Sjattar

E. L.

Yusuf

Kadir

(2022). Effect of family empowerment on HbA1c levels and healing of diabetic foot ulcers. The International Journal of Lower Extremity Wounds, 21(2), 154–160.

Association

A. D.

(2014). Diagnosis and classification of diabetes mellitus. Diabetes Care, 37(Suppl. 1), S81–S90.

Çamur

Batıbay

S. G.

Bayram

(2020). Effect of lower extremity amputation on caregiving burden in caregivers of patients with diabetic foot: Prospective cohort study. International Wound Journal, 17(4), 890–896.

Clarke

D. J.

Forster

(2015). Improving post-stroke recovery: The role of the multidisciplinary health care team. Journal of Multidisciplinary Healthcare, 8, 433–442. https://doi.org/10.2147/JMDH.S68764

Codispoti

Douglas

M. R.

McCallister

Zuniga

(2004). The use of a multidisciplinary team care approach to improve glycemic control and quality of life by the prevention of complications among diabetic patients. The Journal of the Oklahoma State Medical Association, 97(5), 201–204.

Dutra

L. M. A.

Melo

M. C.

Moura

M. C.

Leme

L. A. P.

De Carvalho

M. R.

Mascarenhas

A. N.

Novaes

M. R. C. G.

(2019). Prognosis of the outcome of severe diabetic foot ulcers with multidisciplinary care. Journal of Multidisciplinary Healthcare, 12, 349–359.

10.

Dyeson

T. B.

(2005). Home health and wound care: An interdisciplinary research opportunity. Home Health Care Management & Practice, 17(3), 222–224.

11.

Federation_Global, I. D. (2020). IDF Diabetes Atlas [Internet]. Global. International Diabetes Federation 9th edition 2019. https://www.diabetesatlas.org/en/resources/

12.

Janssen

Brunner

Keep

Hines

Nagarajan

S. V.

Kielly-Carroll

, Dennis

McKeough

, & Shaw

(2017). Interdisciplinary eHealth practice in cancer care: A review of the literature. International Journal of Environmental Research and Public Health, 14(11), 1289.

13.

Jayalakshmi

M. S.

Thenmozhi

Vijayaragavan

(2020). Impact of chronic wound on quality of life among diabetic foot ulcer patients in a selected hospital of Guwahati, Assam, India. Ayu, 41(1), 19–23.

14.

Jafary

M. R.

Amini

M. R.

Sanjari

Aalaa

Goudarzi

Najafpour

Mohajeri Tehrani

M. R.

(2020). Comparison home care service versus hospital-based care in patients with diabetic foot ulcer: An economic evaluation study. Journal of Diabetes and Metabolic Disorders, 19(1), 445–452.

15.

Jessee

(2021). Relationship between caregiver attendance at wound clinic visits and wound healing in patients with diabetes: A retrospective multicenter evaluation. Wound Management & Prevention, 67(12), 16–24.

16.

Kirkland-Kyhn

Generao

S. A.

Teleten

Young

H. M.

(2018). Teaching wound care to family caregivers. The American Journal of Nursing, 118(3), 63–67.

17.

Kizza

I. B.

Muliira

J. K.

(2019). The influence of a home-based education intervention on family caregivers’ knowledge and self-efficacy for cancer pain management in adult patients within a resource-limited setting. Journal of Cancer Education, 34(6), 1150–1159.

18.

Kristianingrum

N. D.

Ramadhani

D. A.

Hayati

Y. S.

Setyoadi

(2021). Correlation between the burden of family caregivers and health status of people with diabetes mellitus. Journal of Public Health Research, 10(2). https://journals.sagepub.com/doi/epub/10.4081/jphr.2021.2227

19.

Kuo

Y. W.

Yen

Fetzer

Chiang

L. C.

Shyu

Y. I.

Lee

T. H.

H. I.

(2016). A home-based training programme improves family caregivers’ oral care practices with stroke survivors: A randomized controlled trial. International Journal of Dental Hygiene, 14(2), 82–91.

20.

Mihardja

Soetrisno

Soegondo

(2014). Prevalence and clinical profile of diabetes mellitus in productive aged urban Indonesians. Journal of Diabetes Investigation, 5(5), 507–512.

21.

Musuuza

Sutherland

B. L.

Kurter

Balasubramanian

Bartels

C. M.

Brennan

M. B.

(2020). A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers. Journal of Vascular Surgery, 71(4), 1433–1446.e1433.

22.

Ousey

Edward

K. L.

(2014). Exploring resilience when living with a wound—An integrative literature review. Healthcare (Basel), 2(3), 346–355.

23.

Region, I. D. F. I. (2020). IDF Diabetes Atlas [Internet]_Indonesian Region. International Diabetes. Federation 9th edition 2019 https://idf.org/our-network/regions-members/western-pacific/members/104-indonesia.html

24.

Rossi

(2010). Diagnosis and classification of diabetes mellitus. Recenti Progressi in Medicina, 101(7–8), 274–276.

25.

Russo

Landi

Courric

. (2020). Cost-Effectiveness Analysis for the Treatment of Diabetic Foot Ulcer in France: PRP vs Standard of Care. Department of Management, Università Ca’ Foscari Venezia Working Paper No. 4, Available at SSRN.

26.

Sagha Zadeh

Eshelman

Setla

Sadatsafavi

(2018). Strategies to improve quality of life at the end of life: Interdisciplinary team perspectives. The American Journal of Hospice & Palliative Care, 35(3), 411–416.

27.

Siddiqui

A. R.

Bernstein

J. M.

(2010). Chronic wound infection: Facts and controversies. Clinics in Dermatology, 28(5), 519–526.

28.

Suglo

J. N.

Winkley

Sturt

(2022). Prevention and management of diabetes-related foot ulcers through informal caregiver involvement: A systematic review. Journal of Diabetes Research, 2022, 9007813.

29.

Sulistyo

A. A. H

. (2018). Management of diabetic foot ulcer: A literature review. Jurnal Keperawatan Indonesia, 21(2), 10.

30.

Tan

Khoo

Gani

L. U.

Malakar

R. D.

Tay

T. L.

Tirukonda

P. S.

Tang

T.Y

. (2019). Effect of multidisciplinary intensive targeted care in improving diabetes mellitus outcomes: A randomized controlled pilot study—The integrated diabetes education, awareness and lifestyle modification in Singapore (IDEALS) program. Trials, 20(1), 549.

31.

Tremblay

Roberge

Touati

Maunsell

Berbiche

(2017). Effects of interdisciplinary teamwork on patient-reported experience of cancer care. BMC Health Services Research, 17(1), 218.

32.

Turns

(2011). The diabetic foot: An overview of assessment and complications. British Journal of Nursing, 20(15), S19–S25.

33.

Ugwu

Adeleye

Gezawa

Okpe

Enamino

Ezeani

(2019). Predictors of lower extremity amputation in patients with diabetic foot ulcer: Findings from MEDFUN, a multi-center observational study. Journal of Foot and Ankle Research, 12(1), 34.

34.

Wang

Mai

L.-f

., Yang

Liu

Sun

Song

Luo

Zhang

Ren

Yan

(2016). Reducing major lower extremity amputations after the introduction of a multidisciplinary team in patient with diabetes foot ulcer. BMC Endocrine Disorders, 16, 38.

35.

Wantonoro

Anita

Mamnuah

Nguyen

T. V.

(2022). The effectiveness of the real-case online-based learning on nursing care plan self-efficacy. Open Access Macedonian Journal of Medical Sciences, 10(G), 144–149.

36.

Woods

T.-J.

Tesfay

Speck

Kaambwa

(2020). Economic evaluations considering costs and outcomes of diabetic foot ulcer infections: A systematic review. PLoS One, 15(4): e0232395.

37.

Wuri Kartika

Widyatuti

Rekawati

(2021). The effectiveness of home-based nursing intervention in the elderly with recurrent diabetic foot ulcers: A case report. Journal of Public Health Research, 10(2), 2162.

38.

Zamani

Chung

Evans-Hudnall

Martin

L. A.

Gilani

Poythress

E. L.

Skelton-Dudley

Huggins

J. S.

Trautner

B. W.

Mills

J. L

. (2021). Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers. Journal of Vascular Surgery, 73(4), 1388–1395.e1384.

39.

Zhang

Jing

Tang

Zhu

(2017). Global epidemiology of diabetic foot ulceration: A systematic review and meta-analysis. Annals of Medicine, 49(2), 106–116.

The Influence of 6-Month Interdisciplinary Accompaniment on Family Caregivers’ Knowledge and Self-Efficacy Regarding Diabetic Wound Care

Abstract

Introduction

Objective

Methods

Results

Conclusion

Keywords

Introduction

Review of Literature

Methods

Study Design

Research Question

Sample

Inclusion and Exclusion Criteria

Ethical Consideration

Intervention

Data Collection and Instruments

Statistical Analysis

Results

Sample Characteristics

Research Question Results

Discussion

Strengths and Limitations

Implications for Practice

Conclusions

Footnotes

Acknowledgments

Author Contributions

Declaration of Conflicting Interests

Funding

ORCID iDs

References