Relationships among social support, coping style, self-stigma, and quality of life in patients with diabetic foot ulcer: A multicentre, cross-sectional study.

INTRODUCTION

Diabetes mellitus (DM) is a global public health challenge, which has been rising sharply in prevalence in recent years. The global DM prevalence in 2019 is estimated to be 9.3% (463 million), rising to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045. At a country level, China has the highest number of people living with diabetes in 2019, where there are 116 million diabetes patients. In 2030 and 2045, China will remain at the top of the list with 140 and 147 million people with diabetes, respectively. 1 Evidence shows that poorly managed diabetes leads to serious vascular complications. 2

Among the complications, the most deleterious are foot ulcers. Diabetic foot ulcer is a full‐thickness wound that is present at a level distal to the ankle in DM patients. One out of every six patients with diabetes experiences an ulcer during their lifetime in developed countries, and a higher risk in developing nations. 3 Diabetic foot ulcer is the main cause of the highest rates of morbidity, mortality, hospital admissions, and high amputation risk in these patients. 4 These diabetic foot ulcers significantly affect the health and socio‐economic status, as well as the quality of life of the patient. 5 In addition, the care of diabetic foot ulcer is a tremendous financial burden on society and their families, consuming up to 20% of health care resources in developed countries and 40% in developing countries. 6

Quality of life is an important measure to determine the health benefits of treatment and care. Diabetic foot ulcer patients report poor quality of life, which deteriorates if the ulcer recurs or does not heal and is affected by advanced age, weight, educational status, foot self‐care practice, and peripheral neuropathy, which is also positively associated with physical exercise and beneficial social support, but negatively associated with comorbidity and self‐stigma. 7 , 8 , 9 Although we have recognised DM as a major public health problem in China, data concerning quality of life of diabetic foot ulcer patients are very limited. Therefore, this study aimed to estimate the quality of life and its associated risk factors and the effects of self‐stigma, social support, and coping style on quality of life in Chinese diabetic foot ulcer patients.

Quality of life could be connected to other psychological or social processes. Patients with diabetic foot ulcer have a significantly lower quality of life. 10 Likewise, the diabetic foot is associated with a severely impaired quality of life in both physical and mental health aspects. 11 One of the most important is self‐stigma. 12 , 13 , 14 Self‐stigma is a phenomenon in which the patient accepts negative prejudice and stereotypes about psychiatric disorders, which are based on social preconceptions because of the psychiatric disorder. Patients experience self‐stigma after being diagnosed with a diabetic foot ulcer. 15 Previous research showed that the self‐stigma of diabetic patients affected their social support seeking, healthy diet, psychological distress, and quality of life seriously. 16 , 17 The study also found that self‐stigma can reduce the level of self‐management, social relations, and treatment compliance of diabetic patients. 17 Participatory action may reduce the self‐stigma of patients with diabetes. 18

Coping is an individual's characteristic behaviour for responding to stress, including confrontation coping, giving up coping, and avoidance coping. Studies demonstrated that confrontation coping and accommodation coping benefits quality of life, while avoidance coping will experience more negative outcomes. 19 The quality of life was positively correlated with avoidance coping, and negatively correlated with confrontation coping. 20

In addition, some studies have revealed that social support can directly influence the quality of life 21 and coping style 22 among DM patients. Therefore, based on the previous studies, we founded that social support, coping style, and self‐stigma are the three major variables affecting quality of life. However, to the best of our knowledge, previous published studies investigated the relationship between two variables. Few studies have addressed the associations between social support, coping style, self‐stigma, and quality of life among diabetic foot ulcer patients. Such knowledge is crucial for practitioners to develop interventions for improving self‐stigma, social support, and coping style, so as to improving quality of life. Hence, the purpose of this study was to investigate the impact of self‐stigma on quality of life and further clarify the role of social support and coping style as mediators of effects among Chinese diabetic foot ulcer patients.

MATERIALS AND METHODS

Eligible participants were enrolled from three tertiary hospitals in Tianjin, China. All questionnaires were independently completed by patients between September 2019 and March 2020. Patients were enrolled if the following inclusion criteria were met: (a) diabetic foot ulcer diagnosed by the World Health Organization (WHO) definition of diabetic foot ulcer diagnosis criteria; (b) adults patients (18 years or older) who have independent ability of reading, understanding, and writing; and (c) volunteered to join the study. We excluded patients with serious mental disorders, cognitive impairments, absolutely bedridden, and consciousness disorders from this study. We calculated sample size according to the principle of minimum numbers needed to perform structural equation modelling (SEM). Finally, a total of 244 diabetic foot ulcer patients were recruited and 229 questionnaires were considered to meet the criteria of analysis, with an effective response rate of 93.85%. The process of participants' selection is shown in Figure 1.

Flow chart of the recruitment process. CHMHTMU, Chu Hsien‐I Memorial Hospital (Metabolic Diseases Hospital) of Tianjin Medical University; FTHTUTCM, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine; STHTUTCM, Second Teaching Hospital of Tianjin University of Traditional Chinese Medicine

Social‐demographic and clinical information were collected, including age, gender, occupation, marital status, the course of diabetic foot ulcer, amputation, and other complications of diabetes, etc.

The Stigma Scale for Chronic Illness was translated into Chinese version by Deng et al. 23 There are 13 items in the scale, divided into two dimensions: internal stigma (13 items) and external stigma (11 items). Likert 5 was used for each item. The total score of the scale was 24 to 120 points. The higher the score is, the stronger the sense of stigma is. In this study, The Cronbach's α of the total score was .837.

We used the 10‐item social support scale developed by Xiao 24 to measure the level of social support from three aspects, including objective support (three items), subjective support (four items), and utilisation of support (three items). The higher the score of each dimension, the better the social support. The Cronbach's α of the total score was .826 in this study.

We used a 20‐item Chinese version of the Medical Coping Modes Questionnaire, which was rated on a four‐point Likert scale in this study. 25 The coping style questionnaire was divided into three subscales, including confrontation coping, avoidance coping, and giving up coping. The total score is 20 to 80 points. Finally, the score of each subscale was calculated, and the higher score indicated that individual is more likely to adopt the corresponding coping style. Cronbach's α for each of the three subscales was higher than .65, except for avoidance coping (.60). In the current study, Cronbach's α coefficients were .665, .644, and .791 for confrontation coping, avoidance coping, and giving up coping, respectively.

For the assessment of quality of life in diabetic foot ulcer patients, a diabetes quality of life scale designed and compiled by Liao et al 26 was used. It consists of 27 items, which are grouped into four dimensions: physiological function (12 items), psychology/mental (8 items), social relationships (4 items), and treatment effect (3 items). Each item is graded with a Likert 5. The higher the score, the lower the quality of life. Among them, the total score ≥80 indicates a low level of quality of life; 40‐80 indicates a medium level of quality of life; and ≤40 indicates a high level of quality of life. In this study, the Cronbach's α of the quality of life scale was .894.

Paper questionnaire surveys were used for the data collection. With the help of the head nurse, we obtained relevant medical data to determine the qualified participants. After completing the treatment on that day, a questionnaire was sent to the patients. For patients who are unwell or interrupted during the filling of the questionnaire, we find an appropriate time to dictate and explain the subjects one by one, and truly reflect their answers in the questionnaire according to the subjects' responses. After completing the questionnaire, we checked the integrity of the questionnaire in detail, and made records for missing answers, multiple answers, and suspicious answers timely.

This study was approved by the Medical Research Ethics Committee and the three participants' hospitals. All participants were voluntarily and anonymously selected, and their informed consent was obtained by signing the consent form. This study was also in accordance with the Declaration of Helsinki (1989) of the World Medical Association.

Statistical Package for Social Sciences (Chicago, Illinois) version 23.0 for Mac and Analysis of Moment Structures (Chicago, Illinois) were used to analyse the data. Participants' sociodemographic and clinical variables were summarised by descriptive statistics. Continuous variables are presented by median and interquartile range, and categorical variables are presented by frequencies (percentages). The Pearson correlation coefficient was used to test the association between quality of life and social support, coping style, and self‐stigma. SEM was performed to estimate the effect of social support, coping style, and self‐stigma on the patients' quality of life. The level of statistical significance was set to α = .05.

RESULTS

Table 1 shows the characteristics of the participants. For all 229 participants, they had a mean age of 63.00 years (SD = 11.36). One hundred thirty‐three of them were male (58.08%); 151 of them lived in cities (65.94%); 173 of them were married (75.55%); 127 of them retired (55.64%); approximately 32.75% of the participants had been diagnosed with diabetic foot ulcer for 3 to 12 months; most participants did not receive amputation (87.77%).

Social‐demographic and clinical characteristics of diabetic foot ulcer patients (n = 229)

Overall, the average confrontation coping, avoidance coping, and giving up coping was 17.76 (SD = 4.32), 15.24 (SD = 2.79), and 11.72 (SD = 2.89). The mean score of self‐stigma, social support, and quality of life was 61.67 (SD = 12.83), 36.23 (SD = 11.01), and 72.56 (SD = 12.72), respectively (Table 2).

Descriptive statistics of the stigma, social support, coping style, and quality of life

Table 3 documents the results of correlation analyses of self‐stigma, social support, coping style including confrontation coping, avoidance coping, and giving up coping, and quality of life. The results of the Pearson's rank correlation analyses showed that all dimensions of variables showed significant correlations (r = −.542–.624) except social support and confrontation coping. Because the quality of life scale has opposite scoring, the self‐stigma was negatively correlated with quality of life (r = .481), social support (r = −.340), and confrontation coping (r = −.132). Moreover, There were positive correlations between quality of life and social support (r = .542), giving up coping (r = .564), and avoidance coping (r = .278).

Correlation of stigma, social support, coping style, and quality of life in diabetic foot ulcer patients (n = 229)

SEM with maximum likelihood was used to analyse the path correlations, which are presented in Table 4 and Figure 2. The results showed a better fitness between the construct model and the data (χ 2/df = 2.052, GFI = 0.951, AGFI = 0.906, CFI = 0.968, IFI = 0.969, NFI = 0.941, RMSEA = 0.068). The parameters of the model were statistically significant (P < .05).

Decomposition of standardised effects from the path model

The research model with standardised paths coefficients. *P < .05

As illustrated, self‐stigma had significant direct effects on social support (β = −.20, P < .05), giving up coping (β = .64, P < .05), and quality of life (β = −.23, P = .02) among diabetic foot ulcer patients. The direct pathways from self‐stigma to social support (β = −.20, P < .05), giving up coping (β = −.38, P < .05), and quality of life (β = .41, P < .05) were all statistically significant. Meanwhile, the direct pathway from self‐stigma to giving up coping (β = .64, P < .05) and quality of life (β = .30, P < .05) was also statistically significant.

DISCUSSION

This study evaluated the impact of self‐stigma on quality of life among Chinese diabetic foot ulcer patients and determined whether social support and coping style mediate the association between self‐stigma and quality of life. In this study, the overall quality of life of diabetes foot ulcer patients is at a medium low level, which is consistent with a previous study. 27 Among the four dimensions, the psychological/spiritual score is the highest, that is, the psychological level is the most serious damage to the quality of life. The reason is that diabetes foot ulcer is one of the serious and long‐term complications of diabetes, which makes the patients lack support and help from their families and friends, resulting in certain negative emotions, such as anxiety and depression. Diabetic foot ulcer patients often believe that they are treated differently from strangers, and then have a sense of shame, which has a great impact on the psychological dimension. In addition, foot diseases occur repeatedly and cannot be cured. The huge medical expenses brought by treatment also bring heavy psychological pressure on patients. Clinical medical staff should pay attention to the physiological and psychological changes of diabetes foot ulcer patients, take timely interventions to reduce the psychological burden of patients, and help them alleviate the psychological damage so as to improve their quality of life.

Quality of life is negatively correlated with self‐stigma, which is in agreement with previous studies. 13 , 14 It seems that patients who feel more socially excluded because of stigma experience a lower quality of life to a greater extent. Patients with a certain degree of stigma will reduce their seeking for help and their medical behaviour, which will aggravate the symptoms of patients' disease and affect the disease's recovery, thus affecting the quality of life of patients. 28 Li et al 29 , 30 pointed out that patients with a high sense of stigma cannot correctly understand the public's views on themselves and have inferiority complex in the process of interpersonal communication, resulting in behaviours such as escape or retreat, which has a great impact on the quality of life.

Coping style is an important person's characteristic strategy to maintain or achieve healthy psychological status through improving environmental adaptability when patients experience difficulties. 31 Different coping styles, including confrontation coping, giving up coping, and avoidance coping, have an impact on individual's emotional and mental health status. 32 A positive approach to life may cause a promising effect on quality of life in connection with a positive coping style, whereas emotion‐focused coping reduces both psychological and physical quality of life. 33 In this study, there were negative correlations between quality of life and giving up coping and avoidance coping among diabetic foot ulcer patients, and not correlated with confrontation coping, which is consistent with previous studies. 34 , 35 Medical coping style can affect stress events and patients' physical and mental reactions, disease control, and disease treatment process. 36 Relevant research showed that effective positive coping style can help patients relieve stress, promote disease outcome and quality of life. 37 On the contrary, a negative coping style can aggravate patients' terrible emotions and disease. We studied the relationship between coping style and quality of life, because long‐term treatment of diabetic foot ulcer increases patients' pressure, so the patients are more willing to adopt the negative coping style to face life events.

In this study, social support in diabetic foot ulcer patients was positively correlated with quality of life, which is consistent with Hong et al. 38 Social support refers to the various social relations on patients' subjective and objective influence, including material support and spiritual support. Social support can reduce patients' stress response, significantly improve patients' social and psychological conditions, keep patients in good mood, and effectively improve their quality of life. 29 , 30 In addition, social support is one of the most potential resources in the process of disease treatment, which is conducive to ensuring the compliance of patients, and improving their quality of life of patients. In this study, for diabetic foot ulcer patients, the more social support they obtain from family, friends, and other people, the higher their quality of life of the patients. The higher the utilisation of social support, the better the overall living conditions of the patients can be effectively improved. Therefore, professional and non‐professional social supports should be provided for diabetic foot ulcer patients for the purpose of improving the quality of life.

In addition, we also found that social support and giving up coping partially mediated the relationship between self‐stigma and quality of life. Interestingly, a study investigating the relationship between self‐stigma, coping style, and quality of life in the neurotic spectrum demonstrated our hypothesis. 39 Hence, it is critical to emphasise the role of enhancing the level of social support and an active coping style to enhance the protective effects of self‐stigma on quality of life.

CONCLUSION

The quality of life of diabetic foot ulcer patients is at the middle level. Chinese diabetic foot ulcer patients experienced self‐stigma at a clinically significant level. Social support and giving up coping mediated the negative effects of self‐stigma on quality of life.

LIMITATIONS OF THE STUDY

Although several valuable findings were identified in the study, we still have some limitations. First, convenience sampling methods were used to enrol participants, so random sampling method and multicentre research should be designed to be representative in the future. Second, the cross‐sectional survey design could only establish a mechanism between the variables at one point in time; thus, longitudinal design will be necessary to prospectively clear the mechanism of self‐stigma in buffering the adverse results from quality of life over time. Third, self‐stigma, social support, coping style, and perceived stress using self‐reported were assessed by questionnaires in the present study. Hence, the results may be inflated due to subjective bias from participants and investigators—additional studies consider physiological assessment.

AUTHOR CONTRIBUTIONS

Ruzhen Luo designed the study. Hongyu Sun obtained the funding for this study. Yunan Ji and Xuechun Li collected the data. Ruzhen Luo analysed the data. Ruzhen Luo and Xuechun Li searched the literature. Ruzhen Luo wrote the manuscript. Yan‐hui Liu and Siyuan Tang revised the manuscript. All authors read the manuscript.