Impacts of psychological resilience on self-efficacy and quality of life in patients with diabetic foot ulcers: a prospective cross-sectional study

Introduction

Diabetes mellitus (DM) has become the most important metabolic disease nowadays and there are over 400 million people with DM globally according to the report of the International Diabetes Federation in 2015 (1). It is expected that the number of diabetic patients will continue to increase over the coming decades (2). The blood sugar disorder of diabetic patients may induce injury of the blood vessels and peripheral nerves. Furthermore, advanced DM can cause some severe complications including diabetic nephropathy, diabetic retinopathy, and diabetic neuropathy (3). Diabetic foot ulcer (DFU) is another important complication of DM, which has attracted much attention from diabetic scholars.

The causes of DFU are both diabetic neuropathy and angiopathy. On the one hand, injury of blood vessels would lead to vascular stenosis, and then insufficient blood supply of the lower extremity. Lower limb ischemia then leads to limb ulcer and even gangrene (4). On the other hand, diabetic nephropathy inhibits patients from feeling pain or any discomfort, leaving feet vulnerable to being unwittingly squeezed and deformed (4). In a previous study, the incidence of DFU in diabetic patients older than 50 years was 8.1% (5), which was slightly higher than the average worldwide incidence (6). Patients with DFU usually have poor prognosis, and there is a diabetic amputation every 20 seconds (7). The annual mortality of DFU patients is as high as 11%, and the mortality of amputation patients has reached 22% (8). In addition, the recurrence of DFU after healing is relatively high at up to over 50% (9).

Poor quality of life (QoL) is also associated with DFU, especially when it recurs or deteriorates. In attempts to improve the QoL of DFU patients, many studies have been performed to analyze the risk factors of poor QoL and provide guidance for the diagnosis, treatment, and nursing of DFU. Alrub et al. reported that female gender and obesity were related to poorer QoL in Jordanian DFU patients (10). Al Ayed et al. reported that, in addition to gender and obesity, education, occupation, income, and the number of complications were predictors of poor QoL in DFU patients (11). A recent meta-analysis indicated that some other risk factors such as the level of C-reactive protein (CRP), ulcer size, and level of glycated hemoglobin (HbA1c) had significant impacts on the QoL of DFU patients (12). Increasingly, attention has been paid to the role of psychological factors in the QoL of DFU patients. Polikandrioti et al. reported that severe anxiety contributed to poor QoL in DFU patients (1). Psychological resilience refers to how people react psychologically and behaviorally to change in their external environment. It has been reported that improved psychological resilience was related to higher QoL in patients with inflammatory bowel disease, breast cancer, and hypertension (13-15). However, no related study has yet been performed to investigate the impacts of psychological resilience on QoL in DFU patients.

In this study, we prospectively enrolled DFU patients in our hospital to determine the role of psychological resilience in their QoL. Besides, self-efficacy represents the confidence of patients to complete certain activities independently and the ability to inject insulin facilitated an increased QoL among DM patients (16). We also analyzed the role of psychological resilience in regulating the self-efficacy of DFU patients, along with the risk factors of psychological resilience. We present the following article in accordance with the STROBE reporting checklist (available at http://dx.doi.org/10.21037/apm-21-967).

Methods

Study design

This was a prospective cross-sectional study conducted in a single center from January 2018 to February 2020. All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by institutional ethics board of Affiliated Hospital of Jiangnan University (No.: 02017014) and informed consent was taken from all the patients.

Study population

The inclusion criteria of this study were as follows: patients who were diagnosed with DFU, older than 18 years, able to complete the questionnaires, and conscious to cooperate with the treatment. The exclusion criteria were as follows: patients who were diagnosed with other life-threatening diseases, had mental diseases, were participating in other clinical trials, and refused to complete the questionnaires.

Data collection

The following data were collected at the time of participant enrolment: gender, age, body mass index (BMI), marital status, educational status, occupational status, number of children, smoking history, perceived social support, treatment pattern, latest level of HbA1c, classification of foot ulcer, psychological resilience, self-efficacy, and QoL scores.

Measurements

Social support as perceived by participants in this study was assessed by the multidimensional scale of perceived social support (MSPSS) questionnaire. The MSPSS questionnaire had been translated into Chinese and contained 12 items in total. Each item had a score from 1 point, representing ‘very strongly disagree’, to 7 points, representing ‘very strongly agree’. The higher participants scored, the more social support they felt they had access to.

The classification of foot ulcer was based on the Wagner ulcer classification, which was divided into 5 grades including grade 1, superficial diabetic ulcer; grade 2, extended ulcer (to tendon, bone, or joint); grade 3, deep ulcer with abscess or osteomyelitis; grade 4, gangrene in a portion of the forefoot; and grade 5, extensive gangrene of the foot (17).

Psychological resilience of the participants was assessed by Connor-Davidson resilience scale (CD-RISC), which had been translated into Chinese and contained 25 items in total. Each item had a score from 0 point, representing ‘never’, to 4 points, representing ‘always’. The total possible score of CD-RISC was 100 points and a score of more than 85 points defined high psychological resilience.

Self-efficacy was assessed using the diabetes management self-efficacy scale (DMSES). The DMSES had been translated into Chinese and contained a total of 20 items. Each item had a score from 0 points, representing ‘cannot be completed at all’, to 10 points, representing ‘absolutely can be completed’. A higher score indicated higher participant self-efficacy.

The QoL of participants was assessed by the 36-item short-form health survey (SF-36). The SF-36 had been translated into Chinese and it contained 36 items in total covering 8 aspects of QoL. Each item had a different score and proportion. The higher participants scored, the better their QoL was.

Statistical analysis

All statistical analyses in this study were performed using SPSS 20.0 (IBM Corp., Armonk, NY, USA). Categorical variables were expressed as number and percentage and compared between 2 groups using chi-square test. Continuous variables were expressed as mean and standard deviation. Univariable and multivariable linear regression were used to analyze the risk factors of self-efficacy and QoL and determine the role of psychological resilience in regulating self-efficacy and QoL. Then, univariable and multivariable logistic regression were used to analyze the predictors of psychological resilience. A P value less than 0.05 represented statistical significance.

Results

We enrolled 98 DFU patients in this study as shown in Table 1. A total of 68 of these participants were male, the mean age of the cohort was 67.3±13.5 years, and their mean BMI was 24.7±7.9. Marital status was recorded and 80 participants (81.6%) were married. Regarding educational status, 37 participants (37.8%) had received primary school education, 39 (39.8%) had achieved middle school education, and 22 (22.4%) had completed high school or above education. A total of 31 participants (31.6) were employed and 67 (68.4%) were retired or unemployed. Most of these participants had at least 1 child and 44 (44.9%) had at least 2 children. A total of 34 participants (34.7%) had a history of smoking. According to MSPSS, the mean score of perceived social support was 68.9±10.4 points. More than half (57.1%) of the participants were undergoing insulin treatment, 20 (20.4%) were taking oral hypoglycemic agents, and 22 (22.4%) were receiving insulin combined with oral hypoglycemic agents. The mean level of HbA1c was 6.6%±1.2%. Based on CD-RISC, the mean score of psychological resilience in enrolled patients was 77.0±18.9 points. The classification of foot ulcer in DFU patients is summarized in Table 2. A total of 30 participants (30.6%) were diagnosed as grade 1, 51 (52.0%) were diagnosed as grade 2, 11 (11.2%) were diagnosed as grade 3, 5 (5.1%) were diagnosed as grade 4, and 1 (1.0%) was diagnosed as grade 5.

Table 1 Characteristics of enrolled DFU patients
Full table

Table 2 Classification of foot ulcer in DFU patients
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A CD-RISC score of more than 85 points was defined as high psychological resilience. There were 28 participants with high psychological resilience and 70 with low psychological resilience in this study (Table 1). More participants with high psychological resilience were employed compared to those with low psychological resilience (50% vs. 24.3%, P=0.013). Besides, patients with high psychological resilience received much more social support than those with low psychological resilience (75.3±8.9 vs. 66.3±10.7, P<0.001). More participants with high psychological resilience were diagnosed with grade 1 foot ulcer; however, no significant difference was found (Table 2). There was no significant difference in other variables between 2 groups.

The self-efficacy and QoL of DFU participants are summarized via DMSES and SF-36 scores in Table 3. Participants with high psychological resilience had significantly higher levels of self-efficacy, general health, vitality, social functioning, role emotional, and mental health than participants with low psychological resilience (self-efficacy 67.0±7.9 vs. 61.6±7.3, P=0.003; general health 60.0±9.3 vs. 54.1±8.4, P=0.005; vitality 63.9±11.2 vs. 53.1±11.3, P<0.001; social functioning 65.1±6.8 vs. 56.8±5.5, P<0.001; role emotional 41.5±8.3 vs. 34.5±7.6, P<0.001; mental health 61.9±9.1 vs. 51.9±8.3, P<0.001).

Table 3 Self-efficacy and QoL of enrolled DFU patients
Full table

Risk factors of self-efficacy were analyzed using univariable and multivariable linear regression, as shown in Table 4. Low psychological resilience, older age, low education, unemployment, and higher level of HbA1c were identified as potential risk factors according to univariable linear regression. After adjusting by multivariable linear regression, low psychological resilience and older age were identified as risk factors of self-efficacy.

Table 4 Univariable and multivariable linear regression analysis of risk factors of self-efficacy in DFU participants
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Then, risk factors of QoL in DFU participants were analyzed (Table 5). Low psychological resilience, older age, lower perceived social support, and higher level of HbA1c were identified as risk factors of QoL according to multivariable linear regression.

Table 5 Univariable and multivariable linear regression analysis of risk factors of QoL in DFU participants
Full table

Predictors of psychological resilience were analyzed using univariable and multivariable logistic regression (Table 6). The results showed that males had lower psychological resilience than females and participants receiving more social support had higher psychological resilience than those receiving less social support.

Table 6 Univariable and multivariable logistic regression analysis of predictors of psychological resilience in enrolled DFU patients
Full table

Discussion

There were different grades of foot ulcer among the participants in our study, most of whom had grade 1 or grade 2 foot ulcers. Generally, most DFU participants were diagnosed with a grade of less than 4 according to a previous study (1,18). However, conditions graded as such will still incur a significant decrease in the QoL of patients. Based on our results, the mean score of general health in all participants was 55.8±9.0 out of 100 points, which was similar to previous reports (19,20). Moreover, most participants in our study had low self-efficacy with a mean score of 63.2±7.9 out of 200 points. Previous studies have also determined that self-efficacy may be significantly decreased in diabetic patients (16,21). The ascertainment of risk factors of QoL and self-efficacy, therefore, has become an important topic to date.

In their study, Polikandrioti et al. found that living in a capital city and having high levels of anxiety was significantly harmful for patients’ general health (1). Another study also found that female gender, overweight, peripheral vascular disease, and stress in life may be related to lower QoL in DFU patients (10). A study from Saudi Arabia found that many factors may affect the QoL of DFU patients, including age, educational status, occupational status, income, and complications (11). In the present study, low psychological resilience, older age, lower perceived social support, and higher level of HbA1c were identified as risk factors of QoL. The level of HbA1c reflected the adherence characteristics of DFU patients; adherence characteristics were verified in previous study as important factors of QoL in diabetic patients (22). Polikandrioti et al. also found that the decrease of social support was significantly related to the increase of depression in DFU patients and the presence of depression would further affect the QoL of patients (18). Most importantly, low psychological resilience was identified as an important risk factor of QoL in DFU participants in our study, which is similar to how it has been shown to influence patients with other diseases (13,14).

Our study identified low psychological resilience and older age as risk factors of self-efficacy. Only a few studies have previously mentioned the risk factors of self-efficacy and a randomized controlled clinical trial confirmed that resilience training can improve the self-efficacy in diabetic patients (21). Some more well-designed studies are needed to further verify these findings.

Considering the important role of psychological resilience in QoL and self-efficacy in DFU patients, we also analyzed the predictors of psychological resilience in this study. Female gender and higher social support would strengthen psychological resilience of DFU patients according to our results. It is not difficult to understand the important role of social support in psychological resilience. Machisa et al. also concluded that increased social support was related to increased psychological resilience in survivors of intimate partner violence and patients with posttraumatic stress disorder (23,24). However, the role of gender in regulating psychological resilience is not so clear. It may be explained by different socioeconomic status or physiological hormone levels of patients.

Some limitations existed in this study. Firstly, this prospective cross-sectional study enrolled only 98 DFU patients from a single center. The number of enrolled patients was relatively small and there may have been some resulting bias in the results. Secondly, some previous studies have also collected the adherence characteristics of DFU patients. These characteristics may be related to psychological resilience and affect the self-efficacy and QoL of patients. However, we did not collect these characteristics in this study, which may be improved in a future study. Thirdly, perceived social support, psychological resilience, self-efficacy, and QoL were assessed by several scales. In effect, some participants may not have filled out these scales truthfully, leading to the instability of the results.

Our study enrolled 98 DFU patients from a single center and found that most patients were classified as having either grade 1 or grade 2 of foot ulcer. According to linear regression analysis, low psychological resilience and older age were identified as risk factors of self-efficacy while low psychological resilience, older age, lower perceived social support, and higher level of HbA1c were identified as risk factors of QoL. These results may provide some evidence for the improvement of QoL and self-efficacy in DFU patients. Besides, female patients and receiving higher social support may help to improve psychological resilience in DFU patients.

Acknowledgments

Funding: This work was supported by the Scientific Research Foundation of Wuxi Health Commission (Q201929).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at http://dx.doi.org/10.21037/apm-21-967

Data Sharing Statement: Available at http://dx.doi.org/10.21037/apm-21-967

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/apm-21-967). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by institutional ethics board of Affiliated Hospital of Jiangnan University (No.: 02017014) and informed consent was taken from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: J. Jones)