Introduction
The development of a foot ulcer is one of the most serious complications of diabetes mellitus which affects 2–3% of the diabetic population each year (Reiber et al.
1995). They are often characterized by poor healing, and approximately that 67% of diabetic foot ulcers remain unhealed after 20 weeks of care (Kantor and Margolis
2000). Poor healing rates increase the burden on patients in terms of morbidity, distress and impaired physical functioning (Muha
2009). The economic consequences are also considerable. In the United States, the total annual economic cost of diabetes in 2007 was estimated to be $174 billion (Ramsey et al.
1999). Medical expenditures totaled $116 billion and were comprised of $27 billion for diabetes care, $58 billion for chronic diabetes-related complications, and $31 billion for excess general medical costs (CDC
2007). Similar data from the United Kingdom suggest costs for treating diabetic foot ulcers totaled £3,220 million per year (O’Meara et al.
2000). Current data suggest that average costs per episode of a foot ulcer care are reported at $13,179 (Stockl et al.
2004). Diabetic foot lesions are a significant source of hospitalization, and these costs have been shown to account from 20% of all diabetic admissions and 50% of all non traumatic amputations (Levin
1996). Studies in the United States estimate that 1 in 5 patients who develop diabetic foot ulcers will eventually have to undergo amputation (Todd et al.
1996).
Foot ulcers are associated with impaired physical and mental functioning that impact the individual’s quality of life (Ahroni and Boyko
2000; RagnarsonTennvall and Apelqvist
2000; Vileikyte et al.
2003; Nabuurs-Franssen et al.
2005). Foot ulcers are also an important factor in the excess mortality rates found in the diabetes population (Apelqvist et al.
1993; Boyko et al.
1996). While these and other previous studies have evaluated health-related quality of life, we are unaware of any reports in the literature that have specifically evaluated degree of religious connectedness in this population. Therefore, the purpose of this study was to explore the effect of religious connectedness on the health-related quality of life in patients with and without diabetes and foot ulcers.
Statistics
The data analysis was performed using the statistical package for social sciences software (SPSS, Version 17). Descriptive data were analyzed using means, standard deviation (95% confidence interval) and percentages. Groups were compared using a independent sample t-test and an ANOVA for quantitative normally distributed parameters; and when normality of distribution is not justified, Mann–Whitney U-test and Kruskall–Wallis test were used instead. For qualitative variables, Chi-square test was used to test significance of differences among subgroups. The relationship and correlation between HRQL and religious connectedness were analyzed using Pearson correlation coefficient, a P value < 0.05 was considered to indicate statistical significance.
Discussion
To the best of our knowledge, this is the first study examining the effect and relationship between religious connectedness and HRQL in patients with and without diabetic foot ulcers. The data suggest that HRQL is severely impaired in diabetic patients with foot ulcers, as indicated by lower mean scores in all SF-36 domains compared with those patients with diabetes without foot ulcers and the non-diabetic control group. This impairment was more prominent in the physical functioning domains than the mental functioning domains. The smallest difference between our groups in the SF-36 domains was approximately 6 points, exceeding what is suggested that the difference of 3–5 points should be considered to represent the minimal clinically important difference for SF-36 scores (Samsa et al.
1999). Group I patients (with diabetic foot ulcers) showed a poorer HRQL with increased severity, duration of foot ulcers and with presence of two rather than one foot ulcer. Also, Group I patients showed a higher percentage of smoking habits, increased severity and longer duration of diabetes, higher percentage of Type I Diabetes and patients on Insulin therapy and higher percentage of patients with other diabetic complications as retinopathy, nephropathy and hypertension compared with Group II patients (diabetic patients without diabetic foot ulcers). Also notable is that the difference in HRQL scores between groups remained significant for all SF-36 domains after adjustment of all these clinical confounders.
Similar findings have been reported in the literature as regards quality of life (QOL) and diabetic foot ulcers. RagnarsonTennvall and Apelqvist (
2000) compared QOL between three groups of patients: those with current diabetic foot ulcers, those with healed ulcers and those who have undergone minor and major amputations. The authors reported that QOL was significantly lower in patients with current diabetic foot ulcers than in patients with healed ulcers and those who undergone a minor amputation. Not surprisingly, QOL was also found to be reduced following major amputations.
Nabuurs-Franssen et al. (
2005) using SF-36 to evaluate the effect of a foot ulcer on quality of life in patients and their caregivers reported that patients with persisting foot ulcer were associated with a low physical and mental functioning scores (PCS = 33, MCS = 49), and their scores were as low as those for patients who had recently suffered myocardial infarction (PCS = 41, MCS = 46) (Muller-Nordhorn et al.
2004). and for women being treated for breast cancer (PCS = 46, MCS = 50) (Wilson et al.
2005), and this is consistent with our results. Brod (
1998) evaluated the QOL in 14 patients with diabetic foot ulcers and reported that the condition had adverse impact on all QOL domains, primarily as a result of the reduction in mobility experienced and the consequent need to adapt their lifestyle.
Ribu et al. (
2007) evaluated the QOL in 127 adults with current diabetic foot ulcer using SF-36 and concluded that in all SF-36 subscales, diabetic foot ulcer patients had much worse HRQL compared with the diabetes population and the general population, especially in physical health and this matched with our results. Iversen et al. (
2009) compared diabetic patients with and without a history of foot ulcer and concluded that perceived health was significantly worse among those with a history of foot ulcer. Meijer et al. (
2001) used the SF-36 to compare HRQL of diabetic patients with and without foot ulcers; scores were significantly lower on the physical functioning, social functioning, physical role and general health for those patients with foot ulcers. The possibility of negative psychological effects of diabetic foot ulcers was also highlighted by Carrington et al. (
1996) who concluded that patients with foot ulcers were more depressed and less satisfied with life than patients with diabetes without foot ulcers.
While QOL is clearly impaired in this Saudi population, it does appear as though intervention including disease-specific education and motivational interviewing is very important and that it can have a positive impact on patient’s HRQL (Osborne et al.
2004; Gabbay et al.
2011). This study also demonstrated that there was a strong association between Wagner’s staging and HRQL, with higher Wagner’s stage, there was a poorer HRQL. This finding has an important clinical implication of endorsing the routine use of wound classification for early detection and monitoring of diabetic patients with foot ulcer in order to ensure early foot ulcer care and treatment, to prevent further deterioration of their HRQL. Prevention by identifying individuals at high-risk has been shown to improve health outcomes for patients with diabetes and foot ulcers. Several prevention modalities are currently available that could help maintain the integrity and function for lower limb for patients diabetes and lower extremity complications (Lavery et al.
2005; Singh et al.
2005; Mayfield et al.
1998).
Finally, the data suggest a positive correlation between religious connectedness and HRQL (in both mental and physical functioning, with more correlation with mental functioning) in patients with diabetic foot ulcer. This may be secondary to increased socialization involved in participation with spiritual activities. This stands to reason, as Ribu et al. (
2007) in a study described above, found significantly more foot ulcer patients lived alone compared to people with diabetes without a wound. Religious connectedness can be considered as an important coping mechanism that has a helpful role in improving HRQL of Muslim diabetic patients with foot ulcer. Religious participation has both short-term and long-term importance, particularly for elderly patients (Idler and Kasl
1997; Idler et al.
2001). There is a complex interplay between the religious connectedness with cultural, biological, psychological and interpersonal aspects of life that may have role in prevention of complications from chronic pathologies. Simson et al. (
2008) studied the effect of supportive psychotherapy in a group of diabetic patients with foot ulcer concluded that psychotherapeutic intervention can have a positive influence on anxiety, depressive symptoms and diabetes related problems in patients with foot ulcer.
The authors conducted a cross-sectional study to identify the role of religious connectedness in health-related quality of life in a specific Muslim population from Jeddah, Saudi Arabia. In future, a prospective study with a 12–18 month follow-up period may help elucidate further details on long-term benefits of religious connectedness with health-related quality of life, and amputation prevention in diabetic foot ulcer patients.
Conclusion
Out findings suggest that HRQL is so much poor in diabetic patients with foot ulcers and becomes poorer with increased severity, duration and number of foot ulcers. In addition, the strong positive relationship between religious connectedness and HRQL in diabetic patients with foot ulcers suggests that clinicians consider this when treating, counseling, and motivating patients.
Acknowledgments
The authors would like to thank “Mohammad Hussein Al-Amoudi Chair for Diabetic Foot Research” for funding of this study. Our thanks also extend to Professor David Armstrong and Dr Manish Bharara from Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona, Tucson, Arizona, USA for their valuable comments on the manuscript.