International Journal of Public Health Science (IJPHS)

Vol. 14, No. 1, March 2025, pp. 409~415

ISSN: 2252-8806, DOI: 10.11591/ijphs.v14i1.24406  409

Social support as a key factor in the health promotion model:

influencing diabetic wound prevention behavior

Suyanto Suyanto1,2, Tintin Sukartini2, Mohammad Arifin Noor1

1
Department of Medical and Surgical Nursing, Faculty of Nursing, Universitas Islam Sultan Agung, Semarang, Indonesia
2
Department of Medical and Surgical Nursing, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia

Article Info ABSTRACT

Article history: Diabetic foot wounds are a serious problem that threatens the quality of life
of diabetes patients. Individual factors, family, and social support have an
Received Dec 24, 2023 important role in preventing diabetic foot wounds. This research aims to
Revised Apr 5, 2024 determine the aspects of social support in preventing diabetic foot wounds.
Accepted Apr 24, 2024 The research employed a cross-sectional design, involving 120 respondents.
The Modified Diabetic Foot Care Behavior (MD FCB) instrument was used
to assess behavior related to diabetic foot care. Data analysis was conducted
Keywords: using logistic regression. The results indicated a positive correlation between
high levels of social support and the prevention of diabetic foot wounds. In
Diabetic wound prevention assessing patient knowledge about foot care, it was found that 20 people
Family support (16.7%) had poor knowledge. Additionally, low family support was seen in
Health care support 23 people (19.2%), low peer support in 17 people (14.2%), and low support
Health promotion theory from health workers in 15 people (12.5%). Furthermore, 42 people (35%)
Peer group support exhibited poor behavior in preventing foot wounds. The Chi-square test
revealed a significant influence of knowledge on behavior for preventing
diabetic foot wounds (p-value 0.001). Meanwhile, the correlation between
family support, peer support, and support from health workers in relation to
diabetic foot wound prevention behavior was significant, with each showing
a p-value of 0.01. Enhancing social support is identified as an effective
strategy for reducing the risk of diabetic foot wounds and their associated
complications. Therefore, efforts to increase social support levels for diabetes
patients should be considered an integral part of their care regimen.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Suyanto Suyanto
Department of Medical and Surgical Nursing, Faculty of Nursing, Universitas Islam Sultan Agung
Semarang, Indonesia
Email: [email protected]

1. INTRODUCTION
Diabetes mellitus (DM) poses a significant global public health challenge, with long-term elevated
blood glucose levels contributing to serious medical complications [1]. The chronic condition results from a
lack of insulin secretion by the pancreas or the body's inability to utilize produced glucose [2]. In 2012, DM
caused 1.5 million deaths globally and contributed to an additional 2.2 million deaths due to heightened
cardiovascular disease risk [3]. Projections suggest that by 2035, 592 million people worldwide will suffer
from DM, with a concentration in low-income and intermediate countries [4]. Addressing this epidemic
requires comprehensive strategies, including preventive measures, early detection, accessible treatment
options, public awareness campaigns, and global collaboration among governments and healthcare
stakeholders.

Journal homepage: http://ijphs.iaescore.com

410  ISSN: 2252-8806

The International Diabetes Federation indicates that diabetes prevalence among the elderly globally
is currently over 134.6 million, projected to rise to 252.8 million by 2035 and surpass this figure further [2].
The worldwide prevalence of diabetes in adults was 4.7% in 1980 (108 million people), escalating to 8.5% in
2014 (422 million people). Projections for 2040 estimate a staggering 642 million adults affected by diabetes.
This increase is evident across age groups and disease types, with approximately 463 million people,
constituting 9.3% of the global adult population aged 20 to 79, affected by diabetes in 2019 [5]. These statistics
emphasize the urgent need for global efforts to address and manage the escalating prevalence of diabetes.
DM presents various complications, including foot wounds that demand meticulous attention and
coordinated treatment by a healthcare team to minimize amputations [6]. Patient education is crucial in
empowering individuals with diabetes by imparting knowledge, skills, and self-care abilities, fostering self-
efficacy, and motivating lifestyle changes, thereby enhancing therapy compliance and awareness of
complications [5]. Family support plays a pivotal role in diabetes management, as most care occurs within the
household. This support aids in improving the well-being and self-management of diabetes sufferers by
assisting in self-care activities and providing essential social and emotional support [7]. The involvement of
both healthcare professionals and family members is integral in creating a comprehensive and effective support
system for individuals living with diabetes.
Self-management is a critical aspect of diabetes treatment, but the growing diabetic population faces
challenges in receiving adequate health education due to limited resources and time constraints of medical
staff. Recognizing this gap, a peer support educational model for diabetes patients becomes crucial, utilizing
the influence and experiences of peers to deliver effective programs [8]. Peer-administered education, often
referred to as peer counseling or peer education, involves individuals with similar backgrounds and experiences
sharing insights and learning from each other, providing a valuable complement to traditional healthcare [9].
The impact of online communities on peer support, demonstrating that these platforms offer emotional and
technical support while empowering individuals. The altruistic spirit within society contributes to building self-
confidence among diabetes patients, emphasizing the potential of peer-driven approaches in enhancing diabetes
self-management.
Diabetes patients require routine self-care, particularly in foot care, which can reduce the risk of
complications by 49% to 85%. A study in Malaysia highlighted poor knowledge and practices regarding foot care
among diabetes patients, with significant risk factors including work activities, inappropriate footwear, and going
barefoot at home [10]. Addressing this challenge calls for targeted support and interventions to raise awareness
and promote effective foot care practices among individuals with diabetes. This study aimed to determine the
correlation between social support with diabetic wound prevention behavior of diabetic mellitus patients.

2. METHOD
The design of this research is cross-sectional, a descriptive correlation study conducted in Semarang,
Indonesia. In this study, 120 respondents as research samples were diabetes millitus (DM) patients at Semarang
health centers. Determining the sample size in this study uses the Rule of Tumb formula with the maximum
likely hood method. The minimum sample size is 100-150 respondents or 5-10 times the indicator (observed
variable) is 5:1 indicator, meaning the parameter to be estimated [11]. The sampling technique used consecutive
sampling. Inclusion criteria include Age between 40-55 years, duration of suffering from DM 1-5 years, level
of compensatory awareness, living with family (nuclear family/extended), and DM patients with an
International Working Group on the Diabetic Foot (IWGDF) risk score of 0-3. The exclusion criteria for this
study were having diabetic foot wounds, visual and hearing problems, and complications micro vessels (CKD)
and macrovascular complications (stroke). This research uses several instruments, including; The research
instrument used to measure knowledge about foot care modified diabetic foot care knowledge (MDFCK).
Instrument social support consists of an instruments family support questionnaire to measure family support.
Instrument functions of diabetes peer support group scale (F-DPSG) to measure peer support and instrument
support from health workers to measure support from health workers. Meanwhile, to measure behavior to
prevent diabetic foot injuries using instruments. The knowledge instrument measures the level of understanding
of foot care, social care support measure family support, peer support, and health worker support. The
behavioral instrument for preventing diabetic foot wounds is in the form of modified diabetic foot care behavior
(MDFCB) to measure good or bad behavior in preventing diabetic foot wounds. The research instrument used
a questionnaire previously tested for validity and reliability with construct validity with alfa Cronbach 0.7 and
was declared valid and reliable.
This research has received an ethical test with number 309/A.1-KEPK/FIK-SA/VIII/2022. Potential
respondents who fit the research criteria have been explained about; the objectives, and benefits of the research,
and then fill in informed consent as proof of availability following this study. Data is collected anonymously
and is voluntary. Data was analyzed using the software SPSS 24. Before analyzing the data, researchers carry

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out editing to see if there is missing data. The results of descriptive analysis are used to see the frequency and
percentage of categorical data and for numerical data the mean, standard deviation, minimum and maximum
values are used. Chi-square was used to assess the relationship between foot injury prevention behavior.
Multiple logistic regression was used to see the variables that most influence the behavior of preventing diabetic
foot wounds.

3. RESULTS AND DISCUSSION

Table 1 presents average age of the surveyed individuals was 59 years. Respondents reported suffering
from DM for a duration of five years. This demographic information provides a snapshot of the characteristics
of the study population, which can be valuable for understanding the context and potential implications of the
findings related to foot care knowledge, support, and behavior.

Table 1. Characteristics of DM patients included age and length of DM

Variable Mean±SD Median Min-max 95% CI
Age 59.23±7.66 59 39-86 57.84-60.61
Length of DM 5.06±1.81 5 2-10 4.73-5.39

Table 2 shows that respondents' knowledge levels regarding diabetic foot care and the impact of social
support on preventive behavior for foot ulcers. It was found that 20 respondents (16.7%) had low knowledge
about foot care, highlighting the need for improved education. Social support plays a significant role, with
57.5% of respondents receiving high family support, 85.8% receiving good support from peers, and 60%
experiencing significant support from healthcare professionals. Despite low knowledge, 65% of respondents
exhibited good preventive behavior, indicating that social support can enhance preventive actions. These
findings emphasize the need for interventions that integrate both education and social support to reduce the
risk of diabetic foot ulcers

Table 2. Distribution of knowledge, family support, peer group support, health care support and diabetic
wound prevention behavior of DM
Variable Frequency (%)
Knowledge of foot care
low 20 (16.7%)
currently 52 (43.3%)
height 48 (40%)
Family support
low 23 (19.2%)
currently 28 (23.3%)
height 69 (57.5%)
Peer support
less 17 (14.2%)
Good 103 (85.8%)
Health care support
low 15 (12.5%)
currently 33 (27.5%)
height 72 (60%)
diabetic wound prevention behavior
Not good 42 (35%)
Good 78 (65%)

Table 3 conclude a significant portion of DM patients demonstrate moderate to high levels of foot
care knowledge, supported by generally high family and peer group support as well as good healthcare support.
However, there is room for improvement in enhancing family and healthcare support, particularly for those
with low support levels. Targeted interventions are crucial to address the notable portion of patients exhibiting
poor preventive behavior, emphasizing the need for comprehensive strategies to enhance overall foot care in
this patient population. The variable that has the most influence on behavior to prevent diabetic foot injuries is
family support (p value 0.0001). The influence of knowledge, family support, peer support, and health worker
support on behavior to prevent diabetic foot injuries. There is a relationship between family support, peer
support, and health worker support with diabetic foot wound prevention behavior. Predictors of diabetic foot
wound prevention behavior: The logistic regression test was used to determine the variables that most influence
the behavior of preventing diabetic foot wounds.
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Table 3. Multivariate analysis of regression social support factors associated with diabetic
wound prevention behavior
95% CI for odds ratio
Variable B S.E p-value Odds ratio
Lower Upper
Knowledge -.321 0.442 0.468 0.726 0.305 1.727
Family support 2.2.17 0.461 0.0001 9.177 3.721 22.635
Peer group support 3.113 0.526 0.002 22.495 3.026 167.219
Health care support 1.528 1.023 0.004 4.610 1.645 12.922

Diabetic foot ulcers (DFU) was a significant risk of lower extremity amputation and contribute
substantially to mortality and morbidity among diabetes patients [12]. DFUs also lead to frequent hospitalizations,
placing a substantial burden on both individuals and society [13]. Effective prevention and treatment of DFUs
involve multidisciplinary management, addressing various risk factors such as blood glucose levels, blood
pressure, lipid levels, and smoking cessation. Local DFU management, including debridement, bandaging,
revascularization, stem cell decompression, and oxygen therapy, is crucial for successful outcomes [14]. Patients
with diabetes play a vital role in foot care, as proper self-care reduces the risk of foot injuries, and family support
is integral to fostering patient independence in managing this serious complication.
Family support is significantly associated with better self-management activities and is very important
in managing and limiting the prevalence of diabetes [15]. Lack of family support for patient self-management
behavior can hinder efforts to implement necessary behavioral changes. Absence, reduction, or loss of family
support due to differences in gender and culture in different families can hurt the patient's health. Living together
with people in the same house does not guarantee support in diabetes management. It is therefore very important
to let patients narrate their life experiences in connection with the support of their family members [16].
Family support that is willing to provide attention will make DM patients feel cared for, appreciated
and loved, make someone feel cared for, appreciated and loved [17]. Acceptance from a partner who suffers
from DM is very much needed, such as in sexual matters which may be disturbed, this can give rise to anxiety,
guilt, and feelings of failure as well as communication problems, and loss of sexual intimacy which can lead
to a 'limbo state' with emotional emptiness and reduced quality of life [18]. A person with DM cannot be denied
as a disease that can disrupt the sufferer's well-being. Not only do they have to tolerate the physical symptoms
of the disease, its complications, and the side effects of treatment, but they also have to struggle to adapt their
lives to accommodate self-care activities and adhere to recommended management [19].
Health education support from professional health services on the topic of management of diabetic
feet needs to be emphasized, such as training from professional health workers for DM patients. In a survey of
>400 health service providers in large tertiary care facilities, around 67% of doctors reported that DM patients
had poor knowledge or no knowledge at all about diabetic foot ulcers [20]. The support provided by healthcare
professionals, including information, monitoring, and advice, greatly influences the extent to which patients
follow foot care guidelines [21]. Support from the health care system, such as easily accessible health services,
availability of equipment, and assistance by medical personnel, can increase patient awareness and facilitate
preventive actions. Then emotional and practical support from family and peers can motivate patients to carry
out foot care more accurately and regularly [22].
Peer education has proven effective in improving self-care behavior among diabetes patients,
suggesting its applicability in diabetes prevention and management efforts in Iran and surrounding regions [9].
Additionally, a pilot study on lupus patients, the peer approach to lupus self-management (PALS) intervention,
showed positive trends with participants experiencing lower disease activity, higher quality of life, reduced
pain symptoms, and increased social support after participating in the program (effect size>0.3). These findings
highlight the potential of peer-based interventions to positively impact health outcomes and the well-being of
individuals managing chronic conditions like diabetes and lupus. Additionally, both mentees and mentors
scored very high for perceived credibility of treatment and service delivery support from either nurses or other
people with the same illness are experts in the management of their illness and often have valuable self-
management strategies to share with others [23]. Some patients with chronic illnesses may feel isolated if they
do not have others in their social circle who understand the nature of their condition in more depth [24].
The results of research in China show that diabetes management focuses on medication management,
nutrition, physical activity, patient involvement, and social support. However, it is difficult to directly measure
whether educational aspects are effective in knowledge and self-care behavior [25]. Good knowledge with the
support of family, peers, and health workers has a significant impact on foot wound prevention behavior in diabetes
patients. These factors are the focus of education and intervention programs to ensure diabetes patients maintain
good foot health [14]. Patients with good knowledge, family support, peer support, and health care provider
support are more likely to adopt foot injury prevention behaviors, including wearing appropriate footwear,
checking their feet regularly, maintaining cleanliness, and avoiding activities that could harm the feet [26].

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Studies show that patients with good knowledge about foot care, along with support provided by
family, peers, and health professionals, are more likely to adopt foot wound prevention behaviors [21]. Patients
routinely check their feet for signs of damage or injury, maintain good foot hygiene, and avoid activities that
could compromise the integrity of the foot skin [27]. The social support and knowledge provided by the people
around the patient, along with the guidance and education provided by healthcare professionals, play a key role
in encouraging patients to take the necessary preventive measures to protect their foot health [28]. Patients with
good knowledge, family support, peer support, and health care provider support are more likely to adopt foot
injury prevention behaviors, including wearing appropriate footwear, checking their feet regularly, maintaining
cleanliness, and avoiding activities that could harm the feet [29].
The results of the study show that knowledge about foot care, support from family, and peers, and
support from health workers play an important role in improving foot wound prevention behavior in diabetes
patients. Good knowledge of foot care allows patients to take appropriate precautions, while emotional and
practical support from family and peers helps motivate patients to take good care of their feet. Support from
health workers, including education and regular monitoring, also makes a significant contribution to promoting
diabetes foot wound prevention behavior. Overall, knowledge and support from various parties have a positive
influence on foot wound prevention behavior in diabetes patients [30].

4. CONCLUSION
Social support plays an important role in increasing patient knowledge and awareness regarding the
risk of diabetic foot wounds. Support from family, and friends, having sufficient knowledge about how diabetes
can affect their foot health. This knowledge is important to prevent foot injuries and minimize the risk of
complications. The social environment can increase monitoring of the condition of diabetes patients' feet. With
social support, patients can incorporate changes, including minor injuries that may develop into serious
problems if not addressed quickly. This support helps in early detection of diabetic foot wounds, and timely
treatment. Apart from its effect on preventing diabetic foot wounds, social support also has a positive impact
on the patient's quality of life. Emotional support from those closest to you can reduce the levels of stress and
depression that are often associated with diabetes. A stable emotional condition can speed up the wound-
healing process because patients are more likely to feel positive and motivated to take good care of themselves.

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BIOGRAPHIES OF AUTHORS

Suyanto Suyanto is a lecturer and ners that interest in exploring various aspects of
diabetes management, particularly in the context of diabetic foot care, wound healing, and
peripheral nerve protection. Research in diabetic foot care might focus on new technologies and
methods for preventing and managing foot ulcers, which are common complications of diabetes.
Additionally, exploring peripheral nerve care could involve examining strategies to prevent or
manage nerve damage, which is crucial for maintaining overall patient health in diabetes
management. He can be contacted at email: [email protected].

Tintin Sukartini is a Full Professor of medical surgical nursing at Airlangga

University. She interests in oncology nursing, which involves exploring advancements in cancer
treatment and management, including the latest developments in chemotherapy,
immunotherapy, and targeted therapies. Engaging in research and evidence-based practices
within oncology nursing is essential for improving patient outcomes and advancing the field She
can be contacted at email: [email protected].

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Int J Public Health Sci ISSN: 2252-8806  415

Mohammad Arifin Noor is a lecturer focus on musculoskeletal, spiritual,

and wound care. His work also includes exploring spiritual care, emphasizing the importance of
addressing patients' spiritual needs and integrating spiritual support into overall care
plans. Additionally, focus on wound care, examining advanced techniques and best practices
for effective wound management and healing. He can be contacted at email:
[email protected].

Social support as a key factor in the health promotion model: Influencing … (Suyanto Suyanto)