- Email: [email protected]
Self-esteem in patients with diabetes mellitus and foot ulcers
Journal of Tissue Viability (2011) 20, 100e106
www.elsevier.com/locate/jtv
Clinical study
Self-esteem in patients with diabetes mellitus and foot ulcers ´*, Donata Maria de Souza Pellegrino, Leila Blanes, Geraldo Magela Salome Lydia Masako Ferreira Division of Plastic Surgery, Universidade Federal de Sa˜o Paulo (UNIFESP), Sa˜o Paulo, Brazil
KEYWORDS Quality of life; Diabetes mellitus; Diabetic foot
Abstract Aim: To evaluate self-esteem in individuals with diabetes mellitus (DM) and foot ulcers. Methods: This was a controlled, cross-sectional, analytical study. We selected 50 individuals with DM and foot ulcers (study group), as well as 50 with DM and without foot ulcers (control group). Self-esteem was evaluated using the Federal University of Sa ˜o Paulo/Paulista School of Medicine Portuguese-language version of the Rosenberg Self-Esteem Scale, on which scores range from 0 to 30, higher scores indicating lower self-esteem. Results: Of the individuals evaluated, 27 (54%) of those in the study group and 31 (62%) of those in the control group were classified as being of low socioeconomic status (monthly income at or above, but less than double, the national minimum wage). In addition, 27 (54%) of the study group patients had type 2 DM, compared with 29 (58%) of those in the control group. Hypertension was observed in 31 (62%) of the study group patients and 29 (58%) of the control group patients. Of the patients in the study group, 33 (66%) had been diagnosed with heart disease, compared with 23 (46%) of those in the control group. High Rosenberg Self-Esteem Scale scores (21e30) were more common in the study group, being observed in 30 (60%) of the patients, whereas 33 (66%) of the control group patients had low scores (0e10). Conclusion: Foot ulcers appear to have a negative impact on the self-esteem of patients with DM. ª 2010 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Disciplina de Cirurgia Pla ´stica, Universidade Federal de Sa ˜o Paulo, Rua Napolea ˜o de Barros 715 - 4o andar, Vila Clementino, 04024-002 Sa ˜o Paulo, Brazil. Tel.: þ55 11 55764118. E-mail address: [email protected] (G.M. Salome ´). 0965-206X/$36 ª 2010 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jtv.2010.12.004
Self-esteem in patients with diabetes mellitus and foot ulcers
Introduction Globalization and changes in the process of demographic transition have increased life expectancy, and the population is therefore susceptible to certain noncommunicable diseases associated with aging, constituting a public health problem [1]. Diabetes mellitus (DM) is a heterogeneous syndrome, with a multifactorial etiology, resulting from a lack of insulin or from the inability of the body to process insulin efficiently [2]. The World Health Organization and the International Diabetes Federation estimated that, in 2002, approximately 160 million individuals worldwide had DM. The projections for 2025 are that 300 million individuals will have DM [3]. The direct cost of DM ranges from 2.5% to 15% of the annual health budget, depending on the prevalence of DM and on the degree of sophistication of the treatment available. The direct cost of DM in Brazil has been estimated at approximately US$ 3,900,000,000, in comparison with US$ 800,000,000 in Argentina and US$ 2,000,000,000 in Mexico [4]. Diabetic foot is among the most common complications of DM. It is characterized by foot ulcers resulting from the vascular or neurological changes (or a combination of the two) that are typically found in patients with DM. Diabetic foot is a chronic complication that occurs, on average, 10 years after the onset of the disease, and it is the principal cause of hospitalization among patients with DM [5]. This type of lesion causes patient suffering (including changes in lifestyle and quality of life) and often prevents patients from performing their regular activities. In addition, the socioeconomic costs of diabetic foot are high due to amputations, which constitute a major cause of disability, incapacitation, early retirement, and avoidable death [6]. The first half of the 21st century brought a high degree of technological sophistication in the monitoring of DM patients, with or without foot ulcers. Therefore, in order to ensure quality of life (which influences self-esteem), it is important to invest in the prevention of complications, avoiding hospitalization and, consequently, public expenditures [7]. Quality of life has been defined as the perception of individuals regarding their health status in relation to social, physical, psychological, economic, and spiritual aspects [8]. The skin has long been extremely important from a psychological standpoint, influencing emotional stability in a quite specific manner. Skin lesions can
101
trigger mental and psychosocial disorders that have an impact on the quality of life, self-esteem, and self-image of patients [9]. It has become increasingly important to evaluate self-esteem in individuals with skin lesions, because such lesions alter the standard of living and lifestyle of those individuals. Desires and values are often unfulfilled and disparaged. Individuals feel rejected and live in isolation because of the smell and appearance of the lesions. The importance of self-esteem for social and individual well-being is internationally recognized. Nevertheless, there have been few studies investigating self-esteem in Brazil, and there is a lack of population-based studies in particular. One of the obstacles to an epidemiological approach to selfesteem is the lack of instruments that have been validated for use in Brazil; this prevents this attribute from being better understood in the context of scientific investigation [10]. The objective of the present study was to evaluate the self-esteem of individuals with DM, with and without foot ulcers, thereby providing relevant information that can have implications for the treatment of such individuals.
Material and methods This was a controlled, cross-sectional, analytical study conducted at a hospital in the state of Sa ˜o Paulo, Brazil. The study group (diabetic foot group) comprised 50 patients (18 years of age) with DM and foot ulcers. In the selection of patients, no restrictions were imposed regarding the number of ulcers or the time elapsed since the onset of the ulcers. The control group comprised 50 individuals (18 years of age) with DM and without foot ulcers. All of the participants were selected from among those followed at the hospital where the data were collected. The data were collected between January 20, 2009 and July 20, 2009. The study design was approved by the Research Ethics Committee of the Federal University of Sa ˜o Paulo. Written informed consent was obtained from all participating patients. The data were collected by the researchers themselves. The participants were interviewed in a quiet, isolated room. We used a standardized questionnaire in order to collect demographic and clinical data. For the evaluation of self-esteem, we used the Federal University of Sa ˜o Paulo/Paulista School of Medicine Portuguese-language version of the Rosenberg Self-
102 Esteem Scale, validated for use in Brazil [11]. The scale is a specific instrument for measuring quality of life. It comprises 10 closed questions, the answer options being “strongly agree”, “agree”, “disagree”, and “strongly disagree”. The score for each item therefore ranges from 0 to 3. The total score ranges from 0 to 30, higher scores translating to lower self-esteem [11]. For the statistical analysis, we used the chisquare test, the Student’s t-test, and the nonparametric ManneWhitney test. For all statistical tests, the level of significance was set at 5% (p < 0.05).
Results As can be seen in Table 1, 22 (44%) of the patients in the diabetic foot group were in the 60e69 year age bracket, compared with only 15 (30%) of the those in the control group. Of the 50 diabetic foot group patients, 28 (44%) were male, as were 19 (38%) of the control group patients. White individuals accounted for 66% of the patients in the diabetic foot group and 72% of those without. Of the 50 patients in the diabetic foot group, 20 (40%) were married, compared with 26 (52%) of those in the control group. In addition, 23 (46%) of the diabetic foot group patients were illiterate, as were 29 (58%) of the control group patients. Furthermore, 18 (36%) of the patients in the diabetic foot group were retired, as were 25 (50%) of those in the control group. Monthly family income was at or above, but less than double, the national minimum wage in 27 (54%) of the diabetic foot group patients and 31 (62%) of the control group patients. There were no significant differences between the groups under study in terms of any of the sociodemographic characteristics evaluated. Table 2 shows the descriptive statistics (mean and standard deviation) related to the age of the patients in the groups under study. Table 3 shows the clinical profile of the two groups in terms of the type of diabetes, as well as the presence of hypertension and heart disease. As can be seen, 27 (54%) of the diabetic foot group patients had type 2 DM, as did 29 (58%) of the control group patients. Of the 50 patients in the diabetic foot group, 31 (62%) had hypertension and 33 (66%) had heart disease, compared with 29 (58%) and 23 (46%), respectively, of those in the control group. In terms of the prevalence of heart disease, the difference between the two groups was significant (p ¼ 0.044). As can be seen in Table 4, the majority of the patients in the diabetic foot group scored above 20
G.M. Salome ´ et al. on Rosenberg Self-Esteem Scale score ranging, whereas the majority of those in the control group had a score of 10 or below. For this parameter, there were significant differences between the two groups (p < 0.001). Table 5 shows the mean and median of the Rosenberg Self-Esteem Scale scores for the groups under study.
Discussion In patients with chronic diseasesdprincipally in those with DM and in those with DM and foot ulcersdthemes such as health, quality of life, and self-esteem have piqued the interest of researchers attempting to understand the multidimensional nature of the living conditions of these individuals. The foot is a structure that provides humans with support and locomotion, as well as being esthetically important; it comprises numerous structures, which must be in harmonious balance in order to perform their functions [12]. Diabetic foot is a chronic complication of DM and is characterized by infection, ulceration, or destruction of deep tissue, associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limbs [8]. In addition to its acute and chronic complications, diabetic foot, which can result in amputation, has major socioeconomic repercussions related to incapacity for work and work absenteeism, as well as to the high costs of control and treatment [12]. According to Franc ¸a and Tavares [13], foot ulcers affect work productivity and result in retirement due to disability, as well as limiting activities of daily living and leisure activities. For many patients, venous disease translates to pain, loss of mobility or functional capacity, and worsening of quality of life. Because DM patients with foot ulcers begin to depend on their families and friends to perform their activitiesdhousehold activities, leisure activities, social activities, or family activitiesdthey lose their autonomy. In the present study, most of the participants (in both groups) were over 60 years of age. According to the latest census conducted in Brazil (in 2000), elderly individuals account for 8.6% of the Brazilian population as a whole, which means that the elderly population of the country has increased by 1.02% since the previous census, conducted in 1991 [14]. Farinasco et al. investigated 86 elderly patients and reported that the
Self-esteem in patients with diabetes mellitus and foot ulcers
Table 1
103
Sociodemographic characteristics of the two groups.
Variable
pa
Group With foot ulcers
Without foot ulcers
N
%
n
Age bracket 28e39 years 40e49 years 50e59 years 60e69 years 70e86 years Total
3 9 13 22 3 50
6.0 18.0 26.0 44.0 6.0 100
3 9 14 15 9 50
6.0 18.0 28.0 30.0 18.0 100.0
0.579
Race White Non-White Total
33 17 50
66.0 34.0 100
36 14 50
72.0 28.0 100
0.517
Gender Male Female Total
22 28 50
44.0 56.0 100
31 19 50
62.0 38.0 100
0.071
Marital status Single Married Separated Widow/Widower Total
7 20 15 8 50
14.0 40.0 30.0 16.0 100
7 26 11 6 50
14.0 52.0 22.0 12.0 100
0.641
Level of education Illiterate <9 years of schooling 9 years of schooling High school (incomplete) High school (complete) College (complete) Total
23 4 7 13 20 15 50
46.0 8.0 14.0 26.0 2.0 4.0 100
29 9 4 5 1 2 50
58.0 18.0 8.0 10.0 2.0 4.0 100
0.221
Occupation Retired Homemaker Unemployed Electrician Painter Other Total
18 15 7 3 5 2 50
36.0 30.0 14.0 6.0 10.0 4.0 100
25 8 0 3 3 11 100
50.0 16.0 0.0 6.0 6.0 22 100
0.233
Family income 1 the national MW 2e3 the national MW >3 the national MW Total
27 16 7 50
54.0 32.0 14.0 100
31 15 4 50
62.0 30.0 8.0 100
0.569
MW: minimum wage. a Chi-square test.
%
104
G.M. Salome ´ et al.
Table 2
Descriptive statistics of the age of the patients, by group.
Group
Age
With foot ulcers Without foot ulcers Total
n
Mean
SD
Minimum
Maximum
50 50 100
56.90 58.16 57.53
10.0757 12.4595 11.2909
34 28 28
71 86 86
Student’s t-test.
self-reported health status ranged from good to excellent in 47.7%, as well as that 77.9% were still independent, despite the fact that 76.7% had two or more diseases [15]. There has been considerable debate regarding the importance of employing teams of health professionals in order to implement preventive measures and measures to promote health among elderly individuals and their families. Although a certain degree of physiological impairment (limitation of the ability to perform activities of daily living) is an expected consequence of aging, this impairment is more severe among elderly individuals with foot ulcers. The intensity and frequency of this impairment vary and depend on the living conditions of individuals in different socioeconomic, historical, and cultural contexts [15]. One study investigating patients with foot ulcers reported that most of the patients were male and illiterate [16]. The level of education certainly plays a role in determining whether elderly individuals, principally those with chronic diseases, will require the
Table 3
Clinical profile of the two groups. pa
Variable Group With foot ulcers Without foot ulcers n
%
Type of 1 2 Total
diabetes 23 46.0 27 54.0 50 100
Arterial Yes No Total
hypertension 31 62.0 19 38.0 50 100
Heart disease Yes 33 66.0 No 17 34.0 Total 50 100 a
Chi-square test.
n
%
21 29 50
42.0 58.0 100
29 21 50
23 27 50
58.0 42.0 100
46.0 54.0 100
0.687
0.683
assistance of a caregiver, since they have to deal with medications, dressing changes, and diets that are often complex. However, the dynamics of living can be completely different when the level of education is higher, since patients with a higher level of education often have more job opportunities and higher salaries [17]. In the present study, arterial hypertension was observed in 58% of the control group patients and 62% of the diabetic foot group patients. Of the control group patients, 66% had heart disease, as did 46% of the diabetic foot group patients, and the difference between the two groups was statistically significant. It is known that the prognosis for patients with DM and heart disease is poorer than is that for DM patients without heart disease, as are short-term survival and treatment response; it is also known that the former group of patients are at a higher risk of recurrence [18]. Shukla et al. evaluated pain in 50 patients with chronic skin lesions and concluded that such pain negatively affected the quality of life of those individuals [19]. In patients with DM, foot ulcers cause suffering, resulting in changes in lifestyle and quality of life [5]. This condition often prevents such individuals from performing social, leisure, and family activities due to limited work capacity and work absenteeism in their economically productive years [20]. In the present study, Rosenberg Self-Esteem Scale scores were in the 21e30 point range for 60%
Table 4 group.
Rosenberg Self-Esteem Scale scores, by
Rosenberg Self-Esteem With foot Scale score ulcers
0.044
0e10 11e20 21e30 Total
Without foot ulcers
n
%
n
%
11 9 30 50
22 18 60 100
33 10 7 50
66 20 14 100
Self-esteem in patients with diabetes mellitus and foot ulcers Table 5 Descriptive statistics of the Rosenberg Self-Esteem Scale scores. Group
Rosenberg Self-Esteem Scale score n
With foot ulcers 50 Without foot 50 ulcers Total 100
Mean
Median
Margin
2.48 0.48
3.0 0.0
3 2
1.48
1.0
3
of the diabetic foot group patients, compared with only 14% of the control group patients, whereas scores were in the 11e20 point range for 18% and 20%, respectively, and in the 0e10 point range for 22% and 66%, respectively. These data indicate that foot ulcers have a negative effect on the selfesteem of patients with DM. The inability to perform all of the instrumental activities of daily living affects the social lives of individuals with DM and foot ulcers and is a potential cause of distress among the individuals themselves and their families; the latter, depending on the professional activity of the individuals, will have to devote more time, energy, and financial resources to meeting those demands [19,20]. Diabetic foot has a major socioeconomic impact related to expenditures related to treatment and hospitalization (prolonged and recurrent), as well as to physical and social impairment, such as job loss and reduced productivity. Diabetic foot has an impact on the social lives of individuals because it negatively affects self-image and self-esteem, as well as the roles these individuals play in their families and in society; in addition, if there is physical limitation, social isolation and depression can occur [7,19e21]. The present study underscores the need to change the focus of health care for DM patients with foot ulcers. Efforts should be made in order to identify, in the daily routine of health care services (at hospitals, at outpatient clinics, via home care, etc.), changes in the emotions, quality of life, and functional capacity of such patients, as well as their principal health care needs. There is also a need to increase the knowledge that caregivers have on how to deal with the disabilities resulting from foot ulcers. Due to the needs that have emerged in recent decades with the increase in the number of chronic diseases and of patients with skin lesions, it is essential to change the focus of the academic development and improve the qualifications of health care workers, giving emphasis not only to theoretical content but also to health care practice.
105
Further studies involving larger patient samples (multicenter studies) are needed in order to understand the magnitude of all aspects of the quality of life of patients with DM.
Conclusions Based on the data presented here, we conclude that foot ulcers have a negative effect on the selfesteem of patients with DM.
Conflict of interest None of the authors have any conflict of interest.
References [1] Otero LM, Teixeira CRS. Caracterı´sticas so ´cio demogra ´ficas e clı´nicas de portadores de diabetes em um servic ¸o de atenc ¸a ˜o a sau ´de. Latino-am-Enfermagem 2007;15:768e73. Nu ´mero especial. [2] Mancini MM. Diabetes mellitus. Brasileira de medicina 2003;60:41e5. [3] Wilds S. Estimates for the year. 2000. And projections for 2030. Diabetes Care 2004;27(5):1047e53. [4] Torquato MTCG, Montenegro JRN, Viana LAL, Souza R, Lanna CMM, Lucas LCB. Prevalence of diabetes mellitus and impaired glucose tolerance in the urban population aged 30e69 years in Ribeira ˜o Preto (Sa ˜o Paulo). Braz Med J 2003;121(6):224e30. [5] Morgan CL, Currie CJ, Stott NC, Smithers M, Butler CC, Peters JR. The prevalence of multiple diabetes related complications. Diabet Med 2000;17(1):146e50. [6] Fiusa SM, Menezes ALF, Prado SLP, Ataide BC. Caracterizac ¸a ˜o dos pacientes diabe ´ticos atendidos em um ambulato ´rio de estomaterapia. Estima 2006;4(3):19e22. [7] Peixoto SV, Giatti L, Afradique ME, Lima-Costa MF. Custo das internac ¸o ˜es hospitalares entre idosos brasileiros no ´ nico de Sau a ˆmbito do Sistema U ´de. Epidemiol Serv Sau ´de 2004;13(4):46e53. [8] Ciconelli RM, Ferraz MB, Santos W, Meina ˜o I, Quaresma MR. Traduc ¸a ˜o para a lı´ngua portuguesa e validac ¸a ¸a ˜o do questiona ´rio gene ´rico de avaliac ˜o de qualidade de vida SF-36 (Brasil SF-36). Rev Bras Reumatol 1999; 39(3):143e50. [9] Holfeld KI, Hogan DJ, Eldemire M, Lane PR. A psychosocial assessment of patients with basal cell carcinoma. J Dermatol Surg Oncol 1990;16(8):750e3. [10] Avanci JQ, Assis SG, Santos NC, Oliveira RVC. Adaptac ¸a ˜o transcultural de Escala de Auto-Estima para adolescentes. Rev Psicologia: reflexa ˜o e critica 2007;20(3):397e405. [11] Dini GM. Validade de construc ¸˜ ao e sensibilidade da Escala de Auto-estima Rosenberg/UNIFESP- EPM em lipoaspirac ¸˜ ao. [Tese] Sa ˜o Paulo. Universidade Federal de Sa ˜o Paulo, 2004. [12] Zanetti AL, Otero LM, Peres DS, Santos MA, Guimara ˜es M, Freitas MCF. Satisfac ¸a ˜o do paciente diabe ´tico em seguimento em um programa de educac ¸a ˜o em diabetes. Rev Latino-am Enfermagem 2007;15(4):583e9. [13] Franc ¸a LHG, Tavares V. Insuficie ˆncia venosa cro ˆnica. Uma atualizac ¸a ˜o. J Vasc Br 2003;2(4):318e28.
106 [14] Porciu ´lise de ´ncula MVP, Rolim LCP, Ferreira SRG. Ana fatores associados a ulcerac ¸˜ ao de extremidades em indivı´duos diabe ´ticos com neuropatia perife ´rica. Arq Bras Endocrinol Metab 2007;51(7):1134e42. [15] Farinasso ALC, Marques S, Rodriques RAP, Haas VJ. Capacidade funcional e morbidades referidas de idosos em uma a ´rea de abrange ˆncia do PSF. Rev Gau ´cha Enferm 2006; 27(1):45e52. [16] Silva E, Ribeiro JP, Cardoso H, Ramos H. Qualidade de vida e complicac ¸o ˜es cro ˆnicas da diabetes. Rev Ana ´lise psicolo ´gica 2003;2:185e94. [17] Siqueira AFA, Pititto BA, Ferreira SRG. Arq Bras Endocrinol Metab 2007;51(2):257e67.
G.M. Salome ´ et al. [18] Araujo AF, Souza MEA, Menezes CA. Qualidade de vida e aspectos socioeconomicos em diabetes tipo 1. Arq Bras Endocrinol Metab 2008;52(7):1124e30. [19] Shukla D, Tripathi AK, Agrawal S, Ansari MA, Rastogi A, Shukla VK. Pain in acute and chronic wounds: a descriptive study. Ostomy Wound Manage 2005;51(11): 47e51. [20] Salome ´ GM, Blanes L, Ferreira LM. Capacidade funcional dos pacientes com diabetes mellitus e pe ´ ulcerado. Rev Acta Paul Enferm 2009;22(4):412e6. [21] Salome ´ GM, Espo ´sito VHC. O impacto da ferida para o idoso com diabetes mellitus: um estudo fenomenolo ´gico. Rev Nursing 2010;13(146):365e72.
www.elsevier.com/locate/jtv
Clinical study
Self-esteem in patients with diabetes mellitus and foot ulcers ´*, Donata Maria de Souza Pellegrino, Leila Blanes, Geraldo Magela Salome Lydia Masako Ferreira Division of Plastic Surgery, Universidade Federal de Sa˜o Paulo (UNIFESP), Sa˜o Paulo, Brazil
KEYWORDS Quality of life; Diabetes mellitus; Diabetic foot
Abstract Aim: To evaluate self-esteem in individuals with diabetes mellitus (DM) and foot ulcers. Methods: This was a controlled, cross-sectional, analytical study. We selected 50 individuals with DM and foot ulcers (study group), as well as 50 with DM and without foot ulcers (control group). Self-esteem was evaluated using the Federal University of Sa ˜o Paulo/Paulista School of Medicine Portuguese-language version of the Rosenberg Self-Esteem Scale, on which scores range from 0 to 30, higher scores indicating lower self-esteem. Results: Of the individuals evaluated, 27 (54%) of those in the study group and 31 (62%) of those in the control group were classified as being of low socioeconomic status (monthly income at or above, but less than double, the national minimum wage). In addition, 27 (54%) of the study group patients had type 2 DM, compared with 29 (58%) of those in the control group. Hypertension was observed in 31 (62%) of the study group patients and 29 (58%) of the control group patients. Of the patients in the study group, 33 (66%) had been diagnosed with heart disease, compared with 23 (46%) of those in the control group. High Rosenberg Self-Esteem Scale scores (21e30) were more common in the study group, being observed in 30 (60%) of the patients, whereas 33 (66%) of the control group patients had low scores (0e10). Conclusion: Foot ulcers appear to have a negative impact on the self-esteem of patients with DM. ª 2010 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Disciplina de Cirurgia Pla ´stica, Universidade Federal de Sa ˜o Paulo, Rua Napolea ˜o de Barros 715 - 4o andar, Vila Clementino, 04024-002 Sa ˜o Paulo, Brazil. Tel.: þ55 11 55764118. E-mail address: [email protected] (G.M. Salome ´). 0965-206X/$36 ª 2010 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jtv.2010.12.004
Self-esteem in patients with diabetes mellitus and foot ulcers
Introduction Globalization and changes in the process of demographic transition have increased life expectancy, and the population is therefore susceptible to certain noncommunicable diseases associated with aging, constituting a public health problem [1]. Diabetes mellitus (DM) is a heterogeneous syndrome, with a multifactorial etiology, resulting from a lack of insulin or from the inability of the body to process insulin efficiently [2]. The World Health Organization and the International Diabetes Federation estimated that, in 2002, approximately 160 million individuals worldwide had DM. The projections for 2025 are that 300 million individuals will have DM [3]. The direct cost of DM ranges from 2.5% to 15% of the annual health budget, depending on the prevalence of DM and on the degree of sophistication of the treatment available. The direct cost of DM in Brazil has been estimated at approximately US$ 3,900,000,000, in comparison with US$ 800,000,000 in Argentina and US$ 2,000,000,000 in Mexico [4]. Diabetic foot is among the most common complications of DM. It is characterized by foot ulcers resulting from the vascular or neurological changes (or a combination of the two) that are typically found in patients with DM. Diabetic foot is a chronic complication that occurs, on average, 10 years after the onset of the disease, and it is the principal cause of hospitalization among patients with DM [5]. This type of lesion causes patient suffering (including changes in lifestyle and quality of life) and often prevents patients from performing their regular activities. In addition, the socioeconomic costs of diabetic foot are high due to amputations, which constitute a major cause of disability, incapacitation, early retirement, and avoidable death [6]. The first half of the 21st century brought a high degree of technological sophistication in the monitoring of DM patients, with or without foot ulcers. Therefore, in order to ensure quality of life (which influences self-esteem), it is important to invest in the prevention of complications, avoiding hospitalization and, consequently, public expenditures [7]. Quality of life has been defined as the perception of individuals regarding their health status in relation to social, physical, psychological, economic, and spiritual aspects [8]. The skin has long been extremely important from a psychological standpoint, influencing emotional stability in a quite specific manner. Skin lesions can
101
trigger mental and psychosocial disorders that have an impact on the quality of life, self-esteem, and self-image of patients [9]. It has become increasingly important to evaluate self-esteem in individuals with skin lesions, because such lesions alter the standard of living and lifestyle of those individuals. Desires and values are often unfulfilled and disparaged. Individuals feel rejected and live in isolation because of the smell and appearance of the lesions. The importance of self-esteem for social and individual well-being is internationally recognized. Nevertheless, there have been few studies investigating self-esteem in Brazil, and there is a lack of population-based studies in particular. One of the obstacles to an epidemiological approach to selfesteem is the lack of instruments that have been validated for use in Brazil; this prevents this attribute from being better understood in the context of scientific investigation [10]. The objective of the present study was to evaluate the self-esteem of individuals with DM, with and without foot ulcers, thereby providing relevant information that can have implications for the treatment of such individuals.
Material and methods This was a controlled, cross-sectional, analytical study conducted at a hospital in the state of Sa ˜o Paulo, Brazil. The study group (diabetic foot group) comprised 50 patients (18 years of age) with DM and foot ulcers. In the selection of patients, no restrictions were imposed regarding the number of ulcers or the time elapsed since the onset of the ulcers. The control group comprised 50 individuals (18 years of age) with DM and without foot ulcers. All of the participants were selected from among those followed at the hospital where the data were collected. The data were collected between January 20, 2009 and July 20, 2009. The study design was approved by the Research Ethics Committee of the Federal University of Sa ˜o Paulo. Written informed consent was obtained from all participating patients. The data were collected by the researchers themselves. The participants were interviewed in a quiet, isolated room. We used a standardized questionnaire in order to collect demographic and clinical data. For the evaluation of self-esteem, we used the Federal University of Sa ˜o Paulo/Paulista School of Medicine Portuguese-language version of the Rosenberg Self-
102 Esteem Scale, validated for use in Brazil [11]. The scale is a specific instrument for measuring quality of life. It comprises 10 closed questions, the answer options being “strongly agree”, “agree”, “disagree”, and “strongly disagree”. The score for each item therefore ranges from 0 to 3. The total score ranges from 0 to 30, higher scores translating to lower self-esteem [11]. For the statistical analysis, we used the chisquare test, the Student’s t-test, and the nonparametric ManneWhitney test. For all statistical tests, the level of significance was set at 5% (p < 0.05).
Results As can be seen in Table 1, 22 (44%) of the patients in the diabetic foot group were in the 60e69 year age bracket, compared with only 15 (30%) of the those in the control group. Of the 50 diabetic foot group patients, 28 (44%) were male, as were 19 (38%) of the control group patients. White individuals accounted for 66% of the patients in the diabetic foot group and 72% of those without. Of the 50 patients in the diabetic foot group, 20 (40%) were married, compared with 26 (52%) of those in the control group. In addition, 23 (46%) of the diabetic foot group patients were illiterate, as were 29 (58%) of the control group patients. Furthermore, 18 (36%) of the patients in the diabetic foot group were retired, as were 25 (50%) of those in the control group. Monthly family income was at or above, but less than double, the national minimum wage in 27 (54%) of the diabetic foot group patients and 31 (62%) of the control group patients. There were no significant differences between the groups under study in terms of any of the sociodemographic characteristics evaluated. Table 2 shows the descriptive statistics (mean and standard deviation) related to the age of the patients in the groups under study. Table 3 shows the clinical profile of the two groups in terms of the type of diabetes, as well as the presence of hypertension and heart disease. As can be seen, 27 (54%) of the diabetic foot group patients had type 2 DM, as did 29 (58%) of the control group patients. Of the 50 patients in the diabetic foot group, 31 (62%) had hypertension and 33 (66%) had heart disease, compared with 29 (58%) and 23 (46%), respectively, of those in the control group. In terms of the prevalence of heart disease, the difference between the two groups was significant (p ¼ 0.044). As can be seen in Table 4, the majority of the patients in the diabetic foot group scored above 20
G.M. Salome ´ et al. on Rosenberg Self-Esteem Scale score ranging, whereas the majority of those in the control group had a score of 10 or below. For this parameter, there were significant differences between the two groups (p < 0.001). Table 5 shows the mean and median of the Rosenberg Self-Esteem Scale scores for the groups under study.
Discussion In patients with chronic diseasesdprincipally in those with DM and in those with DM and foot ulcersdthemes such as health, quality of life, and self-esteem have piqued the interest of researchers attempting to understand the multidimensional nature of the living conditions of these individuals. The foot is a structure that provides humans with support and locomotion, as well as being esthetically important; it comprises numerous structures, which must be in harmonious balance in order to perform their functions [12]. Diabetic foot is a chronic complication of DM and is characterized by infection, ulceration, or destruction of deep tissue, associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limbs [8]. In addition to its acute and chronic complications, diabetic foot, which can result in amputation, has major socioeconomic repercussions related to incapacity for work and work absenteeism, as well as to the high costs of control and treatment [12]. According to Franc ¸a and Tavares [13], foot ulcers affect work productivity and result in retirement due to disability, as well as limiting activities of daily living and leisure activities. For many patients, venous disease translates to pain, loss of mobility or functional capacity, and worsening of quality of life. Because DM patients with foot ulcers begin to depend on their families and friends to perform their activitiesdhousehold activities, leisure activities, social activities, or family activitiesdthey lose their autonomy. In the present study, most of the participants (in both groups) were over 60 years of age. According to the latest census conducted in Brazil (in 2000), elderly individuals account for 8.6% of the Brazilian population as a whole, which means that the elderly population of the country has increased by 1.02% since the previous census, conducted in 1991 [14]. Farinasco et al. investigated 86 elderly patients and reported that the
Self-esteem in patients with diabetes mellitus and foot ulcers
Table 1
103
Sociodemographic characteristics of the two groups.
Variable
pa
Group With foot ulcers
Without foot ulcers
N
%
n
Age bracket 28e39 years 40e49 years 50e59 years 60e69 years 70e86 years Total
3 9 13 22 3 50
6.0 18.0 26.0 44.0 6.0 100
3 9 14 15 9 50
6.0 18.0 28.0 30.0 18.0 100.0
0.579
Race White Non-White Total
33 17 50
66.0 34.0 100
36 14 50
72.0 28.0 100
0.517
Gender Male Female Total
22 28 50
44.0 56.0 100
31 19 50
62.0 38.0 100
0.071
Marital status Single Married Separated Widow/Widower Total
7 20 15 8 50
14.0 40.0 30.0 16.0 100
7 26 11 6 50
14.0 52.0 22.0 12.0 100
0.641
Level of education Illiterate <9 years of schooling 9 years of schooling High school (incomplete) High school (complete) College (complete) Total
23 4 7 13 20 15 50
46.0 8.0 14.0 26.0 2.0 4.0 100
29 9 4 5 1 2 50
58.0 18.0 8.0 10.0 2.0 4.0 100
0.221
Occupation Retired Homemaker Unemployed Electrician Painter Other Total
18 15 7 3 5 2 50
36.0 30.0 14.0 6.0 10.0 4.0 100
25 8 0 3 3 11 100
50.0 16.0 0.0 6.0 6.0 22 100
0.233
Family income 1 the national MW 2e3 the national MW >3 the national MW Total
27 16 7 50
54.0 32.0 14.0 100
31 15 4 50
62.0 30.0 8.0 100
0.569
MW: minimum wage. a Chi-square test.
%
104
G.M. Salome ´ et al.
Table 2
Descriptive statistics of the age of the patients, by group.
Group
Age
With foot ulcers Without foot ulcers Total
n
Mean
SD
Minimum
Maximum
50 50 100
56.90 58.16 57.53
10.0757 12.4595 11.2909
34 28 28
71 86 86
Student’s t-test.
self-reported health status ranged from good to excellent in 47.7%, as well as that 77.9% were still independent, despite the fact that 76.7% had two or more diseases [15]. There has been considerable debate regarding the importance of employing teams of health professionals in order to implement preventive measures and measures to promote health among elderly individuals and their families. Although a certain degree of physiological impairment (limitation of the ability to perform activities of daily living) is an expected consequence of aging, this impairment is more severe among elderly individuals with foot ulcers. The intensity and frequency of this impairment vary and depend on the living conditions of individuals in different socioeconomic, historical, and cultural contexts [15]. One study investigating patients with foot ulcers reported that most of the patients were male and illiterate [16]. The level of education certainly plays a role in determining whether elderly individuals, principally those with chronic diseases, will require the
Table 3
Clinical profile of the two groups. pa
Variable Group With foot ulcers Without foot ulcers n
%
Type of 1 2 Total
diabetes 23 46.0 27 54.0 50 100
Arterial Yes No Total
hypertension 31 62.0 19 38.0 50 100
Heart disease Yes 33 66.0 No 17 34.0 Total 50 100 a
Chi-square test.
n
%
21 29 50
42.0 58.0 100
29 21 50
23 27 50
58.0 42.0 100
46.0 54.0 100
0.687
0.683
assistance of a caregiver, since they have to deal with medications, dressing changes, and diets that are often complex. However, the dynamics of living can be completely different when the level of education is higher, since patients with a higher level of education often have more job opportunities and higher salaries [17]. In the present study, arterial hypertension was observed in 58% of the control group patients and 62% of the diabetic foot group patients. Of the control group patients, 66% had heart disease, as did 46% of the diabetic foot group patients, and the difference between the two groups was statistically significant. It is known that the prognosis for patients with DM and heart disease is poorer than is that for DM patients without heart disease, as are short-term survival and treatment response; it is also known that the former group of patients are at a higher risk of recurrence [18]. Shukla et al. evaluated pain in 50 patients with chronic skin lesions and concluded that such pain negatively affected the quality of life of those individuals [19]. In patients with DM, foot ulcers cause suffering, resulting in changes in lifestyle and quality of life [5]. This condition often prevents such individuals from performing social, leisure, and family activities due to limited work capacity and work absenteeism in their economically productive years [20]. In the present study, Rosenberg Self-Esteem Scale scores were in the 21e30 point range for 60%
Table 4 group.
Rosenberg Self-Esteem Scale scores, by
Rosenberg Self-Esteem With foot Scale score ulcers
0.044
0e10 11e20 21e30 Total
Without foot ulcers
n
%
n
%
11 9 30 50
22 18 60 100
33 10 7 50
66 20 14 100
Self-esteem in patients with diabetes mellitus and foot ulcers Table 5 Descriptive statistics of the Rosenberg Self-Esteem Scale scores. Group
Rosenberg Self-Esteem Scale score n
With foot ulcers 50 Without foot 50 ulcers Total 100
Mean
Median
Margin
2.48 0.48
3.0 0.0
3 2
1.48
1.0
3
of the diabetic foot group patients, compared with only 14% of the control group patients, whereas scores were in the 11e20 point range for 18% and 20%, respectively, and in the 0e10 point range for 22% and 66%, respectively. These data indicate that foot ulcers have a negative effect on the selfesteem of patients with DM. The inability to perform all of the instrumental activities of daily living affects the social lives of individuals with DM and foot ulcers and is a potential cause of distress among the individuals themselves and their families; the latter, depending on the professional activity of the individuals, will have to devote more time, energy, and financial resources to meeting those demands [19,20]. Diabetic foot has a major socioeconomic impact related to expenditures related to treatment and hospitalization (prolonged and recurrent), as well as to physical and social impairment, such as job loss and reduced productivity. Diabetic foot has an impact on the social lives of individuals because it negatively affects self-image and self-esteem, as well as the roles these individuals play in their families and in society; in addition, if there is physical limitation, social isolation and depression can occur [7,19e21]. The present study underscores the need to change the focus of health care for DM patients with foot ulcers. Efforts should be made in order to identify, in the daily routine of health care services (at hospitals, at outpatient clinics, via home care, etc.), changes in the emotions, quality of life, and functional capacity of such patients, as well as their principal health care needs. There is also a need to increase the knowledge that caregivers have on how to deal with the disabilities resulting from foot ulcers. Due to the needs that have emerged in recent decades with the increase in the number of chronic diseases and of patients with skin lesions, it is essential to change the focus of the academic development and improve the qualifications of health care workers, giving emphasis not only to theoretical content but also to health care practice.
105
Further studies involving larger patient samples (multicenter studies) are needed in order to understand the magnitude of all aspects of the quality of life of patients with DM.
Conclusions Based on the data presented here, we conclude that foot ulcers have a negative effect on the selfesteem of patients with DM.
Conflict of interest None of the authors have any conflict of interest.
References [1] Otero LM, Teixeira CRS. Caracterı´sticas so ´cio demogra ´ficas e clı´nicas de portadores de diabetes em um servic ¸o de atenc ¸a ˜o a sau ´de. Latino-am-Enfermagem 2007;15:768e73. Nu ´mero especial. [2] Mancini MM. Diabetes mellitus. Brasileira de medicina 2003;60:41e5. [3] Wilds S. Estimates for the year. 2000. And projections for 2030. Diabetes Care 2004;27(5):1047e53. [4] Torquato MTCG, Montenegro JRN, Viana LAL, Souza R, Lanna CMM, Lucas LCB. Prevalence of diabetes mellitus and impaired glucose tolerance in the urban population aged 30e69 years in Ribeira ˜o Preto (Sa ˜o Paulo). Braz Med J 2003;121(6):224e30. [5] Morgan CL, Currie CJ, Stott NC, Smithers M, Butler CC, Peters JR. The prevalence of multiple diabetes related complications. Diabet Med 2000;17(1):146e50. [6] Fiusa SM, Menezes ALF, Prado SLP, Ataide BC. Caracterizac ¸a ˜o dos pacientes diabe ´ticos atendidos em um ambulato ´rio de estomaterapia. Estima 2006;4(3):19e22. [7] Peixoto SV, Giatti L, Afradique ME, Lima-Costa MF. Custo das internac ¸o ˜es hospitalares entre idosos brasileiros no ´ nico de Sau a ˆmbito do Sistema U ´de. Epidemiol Serv Sau ´de 2004;13(4):46e53. [8] Ciconelli RM, Ferraz MB, Santos W, Meina ˜o I, Quaresma MR. Traduc ¸a ˜o para a lı´ngua portuguesa e validac ¸a ¸a ˜o do questiona ´rio gene ´rico de avaliac ˜o de qualidade de vida SF-36 (Brasil SF-36). Rev Bras Reumatol 1999; 39(3):143e50. [9] Holfeld KI, Hogan DJ, Eldemire M, Lane PR. A psychosocial assessment of patients with basal cell carcinoma. J Dermatol Surg Oncol 1990;16(8):750e3. [10] Avanci JQ, Assis SG, Santos NC, Oliveira RVC. Adaptac ¸a ˜o transcultural de Escala de Auto-Estima para adolescentes. Rev Psicologia: reflexa ˜o e critica 2007;20(3):397e405. [11] Dini GM. Validade de construc ¸˜ ao e sensibilidade da Escala de Auto-estima Rosenberg/UNIFESP- EPM em lipoaspirac ¸˜ ao. [Tese] Sa ˜o Paulo. Universidade Federal de Sa ˜o Paulo, 2004. [12] Zanetti AL, Otero LM, Peres DS, Santos MA, Guimara ˜es M, Freitas MCF. Satisfac ¸a ˜o do paciente diabe ´tico em seguimento em um programa de educac ¸a ˜o em diabetes. Rev Latino-am Enfermagem 2007;15(4):583e9. [13] Franc ¸a LHG, Tavares V. Insuficie ˆncia venosa cro ˆnica. Uma atualizac ¸a ˜o. J Vasc Br 2003;2(4):318e28.
106 [14] Porciu ´lise de ´ncula MVP, Rolim LCP, Ferreira SRG. Ana fatores associados a ulcerac ¸˜ ao de extremidades em indivı´duos diabe ´ticos com neuropatia perife ´rica. Arq Bras Endocrinol Metab 2007;51(7):1134e42. [15] Farinasso ALC, Marques S, Rodriques RAP, Haas VJ. Capacidade funcional e morbidades referidas de idosos em uma a ´rea de abrange ˆncia do PSF. Rev Gau ´cha Enferm 2006; 27(1):45e52. [16] Silva E, Ribeiro JP, Cardoso H, Ramos H. Qualidade de vida e complicac ¸o ˜es cro ˆnicas da diabetes. Rev Ana ´lise psicolo ´gica 2003;2:185e94. [17] Siqueira AFA, Pititto BA, Ferreira SRG. Arq Bras Endocrinol Metab 2007;51(2):257e67.
G.M. Salome ´ et al. [18] Araujo AF, Souza MEA, Menezes CA. Qualidade de vida e aspectos socioeconomicos em diabetes tipo 1. Arq Bras Endocrinol Metab 2008;52(7):1124e30. [19] Shukla D, Tripathi AK, Agrawal S, Ansari MA, Rastogi A, Shukla VK. Pain in acute and chronic wounds: a descriptive study. Ostomy Wound Manage 2005;51(11): 47e51. [20] Salome ´ GM, Blanes L, Ferreira LM. Capacidade funcional dos pacientes com diabetes mellitus e pe ´ ulcerado. Rev Acta Paul Enferm 2009;22(4):412e6. [21] Salome ´ GM, Espo ´sito VHC. O impacto da ferida para o idoso com diabetes mellitus: um estudo fenomenolo ´gico. Rev Nursing 2010;13(146):365e72.