Psychological Well-Being and Coping Strategies Among Patients With Diabetic Foot Ulcer: A Correlative Study

INTRODUCTION

India is slowly progressing towards the top of the most significant number of patients with diabetes. In 2019, estimates indicated that 77 million individuals in India had diabetes, and this figure is projected to cross 134 million by 2045.^[1] In India, 25% of diabetic patients develop foot ulcers, out of which 50% require hospitalisation and 20% need an amputation. Diabetic foot ulcers (DFUs contribute to approximately 80% of all non-traumatic amputations in India annually.^[2] DFUs affect 50% of type 1 and 2 diabetic patients and make them vulnerable to developing these complications that may lead to morbidity. ^[3,4] A history of non-diabetic foot ulceration increases the risk of developing ulceration among diabetic patients in their lifetime. Due to this, one-third of patients suffer from clinical depression, which further leads to disturbance in psychological well-being.^[5] Approximately two-thirds of foot ulcers will heal within 6-12 months until it is an emotional and physical burden for patients.^[6]

DFUs seriously impact individual response and retard wound healing. The perception of disease is different from person to person based on the severity of the disease. Stress and anxiety due to the severity of the disease make the individual feel frustrated, insecure, fearful, and helpless.^[6] To maintain their mental health, the person resorts to coping mechanisms in response to psychological stress. If the person adopts good coping strategies, there are fewer chances of disturbances in psychological well-being.^[7,8]

The emotional, behavioural, and psychological needs of patients with diabetes are negotiated. Personal efforts to meet these challenges fail to succeed as anticipated when the complications of diabetes take their toll on physical and psychological health.^[9] People using effective coping strategies are less likely to withstand the adverse effects of stressors. But if the coping strategies are inadequate, they experience negative effects.^[10] Foot ulcers are agonising and expensive for every patient and the health care system. A positive outcome is vital in preventing amputation and providing a better prognosis in terms of life span.^[10,11] DFUs themselves involve modification in lifestyle, diet, and frequent medical examination, thus affecting psychological well-being. Some people will adopt healthy coping strategies, and some will not use any strategy that negatively affects their health. The primary aim of the present study was to determine the correlation between psychological well-being and coping strategies among patients with DFU.

MATERIAL AND METHODS

A descriptive correlational study was conducted in the diabetic units of a tertiary care hospital in Karnataka, South India. The research protocol was reviewed and approved by the experts of the Scientific Review Board and Institutional Ethics Committee (Approval number: YEC2/1049 dated 27/08/2022). The study participants were informed about the purpose of the study, and informed consent was obtained. A total of 90 patients with DFU were selected purposively based on patient selection criteria. Patients who are diagnosed with type 1 or type 2 diabetes mellitus (DM) living with DFU were included in the study. Patients who were critically ill during hospitalisation were excluded.

Sample size calculation: The sample size was calculated with a 95% confidence interval and a 9% margin of error. The following formula was used to calculate the sample size. $n={\left(\frac{Z_{1-\alpha /2}\sigma }{E}\right)}^2$

Z₁ – α/2=1.96, σ =6.29, E=9% (margin error)

The data collection tools used were demographic proforma, clinical proforma, psychological general well-being scale, and brief Coping Orientation to Problems Experienced (COPE) Inventory.

Demographic variables: It includes nine items: age, gender, education, marital status, occupation, type of family, dietary pattern, place of residence, and monthly income for the family.

Clinical proforma: It includes type of DM, duration of DM, history of amputation, type of treatment for DFU, any other co-morbidities, history of psychiatric illness, hours of sleep, and degree of ulcer. Wagner’s classification of diabetic foot assesses different degrees of ulceration in the foot.

Psychological general well-being scale: This scale is a measure of subjective experience of psychological well-being that determines an individual’s emotional state.^[12] This is a standardised 6-point scale consisting of 22 items that measure the psychological well-being of an individual. The sub-areas of the scale are anxiety, depression, positive well-being, self-control, general health, and vitality. The score of the psychological general well-being scale ranges from 0-110. Higher scores indicate greater psychological well-being of an individual. The tool is interpreted as strong distress (1-60), moderate distress (60-69), state of no-distress (70-89), and ≥ 90 (State of positive well-being). Permission was obtained to utilise this psychological general well-being scale.

Brief-COPE questionnaire: It consists of 28 self-reported items to measure the effective and ineffective ways to cope with troubling events, such as living with a DFU. This tool was developed by Carver and is available in the public domain.^[13] The domains of the tool are problem-focused coping, emotion-focused coping, and avoidant coping. Problem-focused coping is active coping with the use of informational support, proper planning, and positive reframing. A higher score indicates developing coping strategies that are aimed at adjusting to the new challenges in life. Emotion-focused coping comprises venting emotions, using emotional support from family members, and accepting challenges. A high score indicates the developing coping strategies to regulate emotions associated with challenging situations in life. Avoidant coping is the avoidance of the situation and adopting self-distraction, denial, substance use, and behavioural disengagement. A higher score indicates physical or cognitive efforts developed by the individual to disengage from the stressful situation in life.

Validation and reliability of the data collection tools: All the tools were given for validation to the experts in the field of nursing, and suggestions were incorporated accordingly. The reliability (r-value) of the psychological general well-being scale was 0.84, and Brief COPE was 0.89, which indicates that the tools were reliable.

Statistical analysis: Demographic data, clinical proforma, psychological general well-being score, and brief COPE scores were analysed using descriptive statistics such as frequency, percentage, mean, and standard deviation. Karl Pearson correlation coefficient was used to assess the correlation between psychological well-being and coping strategies. The Chi-square test was used to find the association between psychological well-being and coping strategies with selected demographic variables at a significance level <0.05.

RESULTS

DISCUSSION

The present study showed that most of the patients diagnosed with diabetic foot had distress regarding their health status and treatment outcomes. It is important to recognise the psychological status among patients with DFUs and how they cope with stressful situations. Few previously published studies revealed that the co-existence of depression and anxiety among diabetic foot patients is more compared to other diabetic patients ^[14-16], and treatment for diabetic ulcers aids in reducing patients’ stress.^[17-18] Maheshwari et al. reported a significant association between diabetes, DFUs, and psychological distress.^[19]

Coping style is an important strategy to maintain the healthy psychological status of an individual during stressful life situations. It helps in improving adaptability when an individual experiences difficulties and challenges in life. Different coping styles, such as confrontation coping, giving up coping, spiritual coping, and avoidance coping, have an impact on an individual’s emotional and mental health status.^[20] A qualitative study reported that most of the patients with DFU were afraid of losing their feet and found difficulties in coping with the current situation due to multiple factors. To better understand the needs and problems of patients, healthcare workers should work with these patient groups to educate them in self-care management.^[21] However, many patients adopt different kinds of coping strategies to overcome the current situation. Hidayah et al. revealed a patient living with DFU adopting positive spiritual coping.^[22]

The quality of life of patients with DFU was negatively correlated with self-stigma but positively correlated with social support and giving up coping styles. Social support involves various social interactions, including information support and spiritual support given to patients. It can reduce patients’ stress and significantly improve social and psychological well-being, thus improving their quality of life. In addition, social support is one of the most important resources in the management of disease, ensuring patient compliance. Social support could be obtained from family, friends, and other people to help them overcome the challenges in life. The higher the utilisation of social support, the better the overall living status of patients.^[23]

The present study results showed an association between emotional coping strategies and type of family (p=0.006). Perceived family support is the main factor affecting diabetes management and improving self-care behaviours. Problem-focused coping style helps to identify the needs of patients and manage the situation.^[23] The present study revealed that there is a negative correlation between psychological well-being and coping strategies. Psychological well-being is significantly co-related with problem-focused and avoidant-focused coping strategies. People with DFUs need clinical intervention techniques to develop healthy coping mechanisms to maintain their quality of life.^[22] Assuring emotional, social, and psychological support to patients effective actions are necessary to help them cope with the challenges of living with DFUs.^[24] The present study showed a significant association between psychological well-being and age. Evidence suggests that the physical aspects of quality of life decline with advanced age, but mental health remains stable across age categories and may even improve in patients with advanced age.^[25,26] A study conducted in South India also supports the necessity of developing multiple strategies for diabetic patients to prevent complications.^[27] Patients with DM should be screened for psychological and other factors regularly during their visits to diabetic clinics.^[28] The present study helps future researchers to understand and develop strategies for managing distress and adopting effective coping strategies. This study has certain limitations, including data collection from a single setting at a single point in time, and no follow-up was made to understand patients’ coping abilities. Hence, this study recommends replication on a larger sample size, including multiple settings, among caregivers and patients with DFUs. Intervention studies, including counselling sessions for those with moderate to severe distress to improve psychological well-being, can be conducted.

CONCLUSION

This study showed that patients with diabetic feet were in strong distress. A negative correlation existed between psychological well-being and coping strategies such as problem-focused coping and avoidant-focused coping. The study highlights the need for behavioural therapies and counselling in adopting coping strategies to manage their emotions and actions in every stage of life.