INTRODUCTION:

Anxiety is one of the psychological responses experienced by DFU sufferers because of changes in health, loss of function, and non-intact conditions in the body such as injuries and amputations. Untreated anxiety will affect blood sugar control, worsen disease progression, increase serious complications and affect foot self-care behavior (1). In addition, anxiety on DFU clients can reduce diabetes self-management (eg diet modification, physical activity, insulin injection). This can result in a slow healing process in DFU and a decrease in quality of life (2).

The World Health Organization states that the prevalence of DM worldwide is estimated at 9%. In 2030, it is estimated that DM ranks 7th in the cause of death in the world (3). The International Diabetes Federation (IDF) predicts an increase in the number of people with DM in Indonesia from 9.1 million in 2014 to 14.1 million in 2035. DM patients in Indonesia at the age of ≥15 years of 6.9% are estimated to have an absolute number of 12 million people. Nearly 50% of diabetics experience diabetic foot ulcers with an mortality rate of 8% -35% and 15% -30% of them experience amputation (Riskesdas, 2018). DM patients in East Java amounted to 2.1% or as many as 605,974 people and 35% of them experienced diabetic ulcers (5).

One of the effects of anxiety is the length of the wound healing process. Research conducted by Razjouyan, et al (2017), found an association between anxiety and wound healing. DFU people with anxiety experience delays in healing wounds. Pedras, et al (2016), found a significant relationship to anxiety and quality of life of people with DFU. Anxiety that occurs shows that they experience ineffective psychosocial adaptations (6). People with chronic diseases, such as DFU, who can adapt well will be able to accept the reality of their illness, rearrange and restructure the environment so that there is meaning and purpose in quality of life that exceeds the limitations posed by the disease (7). Dealing with anxiety is the responsibility of the health care provider who, of course, includes nurses. Efforts that have been made in the treatment room to deal with anxiety are health education, pharmacological therapy, non-pharmacology and stress management but have not been optimal in reducing anxiety in clients (8).

Fear, anxiety, and dread may affect a person’s relationship to his or her sense of safety, whether in term of diabetes or in relation to other chronic conditions. These emotions are causal factors that influence whether or not people with symptoms seek treatment in a timely manner. Some of the most informative responses in the research presented here involve avoidance of health care visits because of the fear of being told they have developed DFU. It is important to study related causes of anxiety in patients with diabetic ulcers. factors that can influence are individual patient factors or hospital service systems. individual patient factors including demographics, age, gender, education and others. service system factors are from insurance to the referral system. most of the patients in Indonesia are insurance users provided by the government, namely BPJS (Badan Penyelenggara Jaminan Sosial). All hospitals in Indonesia are required to accept patients with BPJS insurance. Failure in management anxiety is due to a mismatch between the anxiety experienced with the therapy provided, so it is very important to study related anxiety itself. Nurses as one of the health professions are required to be able to facilitate the basic needs of clients, one of which is psychological needs with a nursing process that views humans as a whole and uniquely puts forward a holistic approach that includes bio-psycho-socio-spiritual and cultural (9). This study aims to find factors that influence anxiety that occur in clients with diabetic ulcers.

Methods:

This research used to find out the factors that influence anxiety in clients with diabetic ulcers. This study was a retrospective analysis.

Ethical Clearence:

Ethical clearance was obtained from The Ethics Committee of the Haji General Hospital, Surabaya (ethics approval number 073/13/KOM.ETIK/2019).

Partisipant:

Data were collected by a medical record and diagnostic results of diabetic ulcers at Haji General Hospital, Surabaya. The sample were 951 pepole suffering from diabteic ulcer between January 2014 - Desember 2018. The inclusion criteria determined in this study were patients over 40 years old, had foot ulcers, HbA1c values above 6.5%, underwent treatment at the Surabaya Hajj general hospital and diagnosed with anxiety based on nursing diagnoses. The specified exclusion criteria are having a mental disorder.

Variables:

Data collected as variables in this study were gender, duration of diabetic ulcers, use of health insurance, type of injury, length of stay and complications. Data is collected using a checklist sheet consisting of these items. The collected data is then categorized based on the provisions set by the researcher. gender consists of men and women. duration of suffering consists of more than 7 months and less than 7 months. The wound type consists of infectious and non-infectious. Length of treatment consists of more than 3 days and less than 3 days. Health insurance is divided into BPJS and non BPJS. Complications exist and there are no complications.

Statistical Analysis:

The Statistical Analysis using SPSS 25. The multivariable model of diabetic ulcer client anxiety was generated using stepwise logistic regression. The first step is to classify the entire data obtained by categorical 1 and 2. The next step is to crosstab the data and choose the chi-square that serves to make variable selection. Variables that have a value of p < 0.25 will be included in the multivariate logistic regression analysis with the provisions p < 0.05. The results of logistic regression are then interpreted and presented.

RESULT:

Participant characteristics:

Participant characteristics can be seen in table 1. Based on the table, there are more men than women. BPJS users are more dominant than non BPJS. This is because every hospital in Indonesia is required to accept patients with BPJS. The type of infection wound is the most type and the duration of treatment more than 3 days is also dominant. Duration of diabetic ulcers more than 7 months and complication more than 1 also dominant. Of the 951 particpant there are differences regarding anxiety status. Participants who experience anxiety are more around 824 and are not anxious 127

Risk Factor For Anxiety On Clients With Diabetic Foot Ulcer in bivariate analyses:

Bivariate tests use chi square by displaying crosstab on each variable analyzed.

ased on table 2 there are 4 independent variables that fit significant criteria. The chi-square test found a wound type (p <0.012; OR = 2.4), duration of illness (p <0.038; OR = 1.03), health insurance (p <0.002; OR = 0.82) and gender (p <0.048; OR = 0.99). The type of wound is the most dominant factor in this test. Variables that have p value <0.25 will then be made covariate variables in the next multivariate test.

Risk Factor For Anxiety On Clients With Diabetic Foot Ulcer with Multivariat analize

Multivariate analysis used was logistic regression by entering the chi square test results that met p <0.25. Tests were carried out stepwise to eliminate variables that did not meet the p value <0.05.

Based on figure 2, the multivariate test results obtained using logistic regression and found three significant variables namely wound type (p < 0.015; OR = 0.91), health insurance (p <0.001; OR = 0.77) and gender (p <0.040; OR = 0.98) with the contribution of the four independent variables at 31% and the prediction accuracy of 86.6%. One variable is Duration of diabetic ulcers not significant in the second model of the logistic regression test so it needs to be eliminated.

Table 1. Characteristics of Participant

Variabel	N = 951	N%	Mean	SD
Gender			0.78	0.41
Women	209	22
Men	742	78
Duration of diabetic ulcers			0.62	0.48
Less than 7 months	359	37.7
More than 7 months	592	62.3
Length of stay			0.78	0.42
Less than 3 days	212	22.3
More than 3 days	739	77.7
Health insurance			0.75	0.43
Non BPJS	242	25.4
BPJS	709	74.6
Wound type			0.70	0.45
Non Infectious	281	29.5
Infectious	670	70.5
Complication			0.63	0.48
Only 1	352	37
More than 1	599	63
Category of Anxiety			0.87	0.34
Anxiety	824	86.6
Non Anxiety	127	13.4

SD : Standart Deviation; BPJS : Badan Penyelenggara Jaminan Sosial

Table 2. Bivariat analize Risk Factor For Anxiety On Clients With Diabetic Foot Ulcer

Variabel	Anxiety (N=951)	Non Anxiety (N=951)	OR	CI (95%)	P value
Gender			1.55	1.02 - 2.36	0.048
Women	172	37	1.39	1.03 - 1.88
Men	652	90	0.89	0.79 -1.00
Duration of diabetic ulcers			1.51	1.04 - 2.20	0.038
Less than 7 months	300	59	1.27	1.03 -1.57
More than 7 months	524	68	0.82	0.71- 0.99
Length of stay			0.98	0.62 - 1.54	1.00
Less than 3 days	184	28	0.98	0.69 - 1.40
More than 3 days	640	99	1.00	0.90 - 1.10
Health insurance			1.89	1.27 - 2.81	0.002
Non BPJS	195	47	1.56	1.20 - 2.02
BPJS	629	80	0.82	0.71 - 0.94
Wound type			1.66	1.13 - 2.45	0.012
Non Infectious	231	50	1.40	1.10 - 1.78
Infectious	593	77	0.84	0.72 - 0.97
Complication			1.25	0.86 - 1.83	0.278
Only 1	299	53	1.15	0.91 - 1.44
More than 1	525	74	0.91	0.78 - 1.06

CI : Confidence Interval ; OR: Odds Ratio; BPJS : Badan Penyelenggara Jaminan Sosial

Table 3. Multivariat analize Risk Factor For Anxiety On Clients With Diabetic Foot Ulcer

Variables	OR	CI 95%	p value	Nagelkelke R Square
Gender			0.040	0.31
Women	1
Men	0.64	0.42 – 0.98
Wound type			0.015
Non Infectious	1
Infectious	0.61	0.41 – 0.91
Health insurance			0.001
Non BPJS	1
BPJS	0.52	0.35 – 0.77

CI : Confidence Interval ; OR: Odds Ratio; BPJS : Badan Penyelenggara Jaminan Sosial

DISCUSSION:

In this study 3 variables were found which affected the anxiety of patients with diabetic foot ulcers. These variables are gender, type of injury, and health insurance. Wound type is the second dominant factor triggering anxiety in patients with foot ulcers. This can be seen from a high OR value that is 0.91 with a p value <0.015. Wound conditions that occur in clients with diabetes can increase the incidence of depression and anxiety (10). The bigger the wound will cause psychological stress, causing negative thoughts on the client. the client will feel that the wound cannot heal. The study found a correlation between wounds with depression and anxiety with measurements of HARDS and CES-D scale (11). In this study it was found that infectious contributes 0.61 times greater than non-infectious conditions. Wounds experienced by diabetics often result in gangrene which is an infectious complication. This condition results in patients having difficulty doing activities and work. The study by Charalambous, Vassilopoulos, & Koulouri (2018), found a correlation between the condition of diabetic wounds with the psychological patient. Research conducted by Razjouyan, et al (2017), found an association between anxiety and wound healing. DFU people with anxiety experience delays in healing wounds (13).

Gender is the dominant factor with OR = 0.98, between male and female is one of the factors that influence the occurrence of anxiety in patients with diabetic ulcers with p value < 0.040. In the results of the study found differences in anxiety on the sexes. Men tend to experience anxiety 0.64 times greater than women. Sex difference is one of the determinants of anxiety conditions. Reisner et al (2016) found a difference in anxiety response in men and women. Men tend to experience anxiety because of their role as the main support in the family (14). The condition of the illness results in the inability to fulfill the duties and responsibilities in the family (15). The whole participant is over 40 years old and has worked so that the tendency to be unable to meet the needs in the family results in anxiety. While the high proportion of male respondents in the current study is in line with other studies of diabetic foot disease affected populations, reasons for this asymmetrical gender distribution remain unclear as the prevalence of diabetes in the age group surveyed is almost the same for men and women

Multivariate models found the effect of health insurance on the anxiety of patients with diabetic ulcers (p <0.001; OR = 0.77). Health insurance is one of the guarantees needed to cover all patient medical expenses. In Indonesia there is health insurance provided by the government, namely BPJS. Most hospitals in Indonesia receive services with BPJS but patients using BPJS must fulfill the entire set of administrations. The complicated process makes patients easily experience stress due to feeling that they have not been taken action by health personnel. BPJS users experience a tendency to experience anxiety 0.52 times greater than patients without health insurance.

All of these aspects make the patient feel frustrated, dissatisfied, insecure, fearful, helpless and uncontrolled. Individuals with injuries feel unable to carry out daily activities, and often consider themselves unable to play their role in society (16).

LIMITATION:

The weakness in this study is that there are still 79% of factors that contribute to increasing anxiety in patients with unknown diabetic ulcers, so further research is needed to examine all aspects of patients and other research methods in revealing the results.

CONCLUSION:

The most dominant factor found in this study was the type of woundTypes of wounds that are infection have a risk of 1.65 times experiencing anxiety compared to non-infection, so nursing interventions can be focused on wound care.

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Received on 18.05.2019 Modified on 10.06.2019

Int. J. Nur. Edu. and Research. 2019; 7(4): 471-474.

DOI: 10.5958/2454-2660.2019.00105.4