Indonesian Journal of Global Health Research
Volume 3 Number 3, August 2021, pp. 407 - 414
e-ISSN 2715-1972; p-ISSN 2714-9749
http://jurnal.globalhealthsciencegroup.com/index.php/IJGHR
THE ANALYSIS OF THE RELATIONSHIP BETWEEN COMPLIANCE
ACTIVITIES OF DIABETES MELLITUS PATIENTS AND THE EVENT OF
DIABETIC ULCUS
Maria Putri Sari Utami*, Amanda Marselin, Fajar Agung Dwi Hartanto
STIKES Notokusumo Yogyakarta, Jalan Bener No 26, Tegalrejo, Yogyakarta 55243, Indonesia
*
[email protected] ABSTRACT
Diabetes Mellitus is a chronic disease that causes various complications, one of which is diabetic ulcers. This
requires maximum management and compliance of DM patients. Activity compliance is one of the factors
that influence the incidence of diabetic ulcers. This study is a correlation study that aims to determine the
relationship between the activity compliance of diabetes mellitus patients with the incidence of diabetic
ulcers. The research method used is a cross sectional study. The sampling method used consecutive sampling
technique with a total sample of 22 samples. The research site was conducted in five wound care clinics
spread across the district of Yogyakarta Province. Based on the results of the study, it is known that the
highest age is 56-65 years (50%), the highest level of education is at the junior high and high school levels
(27.3%), the most type of work is self-employed (40.9%), the most type of DM is DM type 2 (68.2%), the
duration of suffering 10-15 years (50%), the highest degree of ulcer was grade 1 (45.5%), and as many as
77.3% patients were not obedient in carrying out physical activities. Based on the results of the correlation
test, it is known that activity compliance is not associated with the incidence of diabetic ulcers (p value>0.05).
Activity compliance is not associated with diabetic ulcers.
Keywords: diabetes mellitus; diabetic ulcer; physical activity compliance
First Received Revised Accepted
14 July 2021 20 July 2021 08 August 2021
Final Proof Received Published
27 August 2021 28 August 2021
How to cite (in APA style)
Utami, M., Marselin, A., & Hartanto, F. (2021). The Analysis of the Relationship Between Compliance
Activities of Diabetes Mellitus Patients and the Event of Diabetic Ulcus. Indonesian Journal of Global Health
Research, 3(3), 407-414. https://doi.org/10.37287/ijghr.v3i3.571
INTRODUCTION
Diabetes Mellitus (DM) is a metabolic disorder in which the human body cannot produce or
use insulin properly. Diabetes Mellitus (DM) is a metabolic endocrine disorder disease
characterized by a lack of the insulin hormone in the body. It is the most common disorder
affecting more than 100 million people worldwide. Diabetes, which is caused by a lack of the
insulin hormone, can damage many systems in the body, especially blood vessels, eyes,
kidneys, heart and nerves (Nagesh et al., 2020). Insulin is a hormone that the body needs to
convert sugar into energy. In the absence or reduced amount of insulin in the body will cause
an abnormal process in which blood sugar levels become high beyond tolerance limits. DM is
the oldest type of disease and causes many deaths from the 14th century(Chaudhary & Tyagi,
2018). It is estimated that 300 million people worldwide will suffer from diabetes by 2025
(Jupiter et al., 2015).
Globally, there are 463 million people with diabetes worldwide, an increase of 51%. In North
America and the Caribbean, it has reached 48 million sufferers. Parts of Central and South
America reached 32 million sufferers. Africa has 19 million and Europe has 9 million
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sufferers. Parts of North and East Africa, it has reached 55 million sufferers. The West Pacific
region has 163 million sufferers and Southeast Asia alone 88 million sufferers. Indonesia
ranks 7th with a prevalence of 10.7 million people with DM, of which 73.7% are adults to the
elderly (International Diabetes Federation, 2013). In the Province of the Special Region of
Yogyakarta (DIY), the prevalence of DM is on average 2.44% in residents of all ages in five
districts and cities. The highest prevalence is in the city of Yogyakarta, which is 3.86%
(Kemenkes, 2019).
In DM patients, the most serious complication is foot problems. Foot problems are a serious
problem and require large costs for patients, and extra care (Schaper et al., 2016). Diabetic
foot ulcer is one of the complications of diabetes that is directly related to major morbidity,
mortality, and decreased quality of life and is the most serious complication of diabetes
mellitus (Jupiter et al., 2015). The prevalence of the incidence of diabetic foot incidents is still
increasing. Diabetic foot disease has several pathologies, especially diabetic peripheral
neuropathy and peripheral arterial disease resulting in foot ulceration. Diabetic foot ulceration
can lead to amputation, especially when wound infection occurs (Amin & Doupis, 2016).
According to the 2013 International Diabetes Federation (IDF), it is estimated that there is at
least one limb lost due to diabetic foot in the world every 30 seconds (International Diabetes
Federation, 2013). The results show that the prevalence of diabetic foot among diabetic
patients ranges from 3% to 13% globally (Zhang et al., 2019). Diabetic foot is the most
common cause of hospitalized diabetic patients and has a major socio-economic impact (Khan
et al., 2017). Patients with diabetic foot have a more than two-fold increased risk of death
compared to diabetic patients without diabetic foot (Chammas et al., 2016).
In the management of diabetic patients, an appropriate and optimal treatment is needed. DM
treatment is something that is not easy, requires a long form of treatment and support from all
parties. Several studies, including those conducted in 2013 (Klein et al., 2013) and 2014
(Brunisholz et al., 2014) showed the same results that the management of diabetic patients
with health knowledge is very important because the information provided helps them to
manage their own health conditions, maintain blood glucose levels and prevent damage. Some
forms of management of DM patients include; utilization of health services, blood glucose
management, diet control, and physical activity (Schmitt et al., 2013).
The existence of a form of physical activity carried out by DM sufferers can have a significant
influence on the occurrence of diabetes mellitus (Ponzo et al., 2021). This is also reinforced
by research which states that there is a significant relationship between lifestyle such as diet
and physical activity on the incidence of diabetes mellitus (Hariawan et al., 2019). The
secretory system in the body will run more slowly if the patient does not do physical activity.
As a result, there will be a buildup of fat content in the body which causes weight gain. Lack
of physical activity causes a decrease in muscle contraction so that membrane permeability
decreases as a result of high glucose levels in the blood. Physical activity is very beneficial in
DM patients, but it will be very risky for DM patients with diabetic foot. Research (Tran &
Haley, 2021) shows that physical activity such as exercising does not have a relationship or
correlation with the incidence of diabetic foot. Based on this, further research is needed to
determine the relationship between physical activity and the incidence of diabetic foot in
patients with diabetes mellitus.
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METHODS
This study is a correlation study that aims to determine the relationship between the activity
compliance of diabetes mellitus patients with the incidence of diabetic ulcers. The research
method used is a cross sectional study. The sample in this study were DM patients who had
diabetic ulcers who performed wound care in five wound care clinics spread across various
districts in the Province of D.I. Yogyakarta. The number of samples in this study were 22
samples.
Sampling method using consecutive sampling technique, namely sampling by selecting
samples that match the inclusion criteria until a certain time limit is met. The instrument used
in this study was an activity or exercise compliance instrument consisting of 6 question items.
Respondents are said to be obedient if they do sports or work with light or moderate physical
activity regularly for 3-4 times / week and the total duration of activity is 90 minutes per
week. It is said to be non-compliant if it is done irregularly or the total amount of activity is
less than 90 minutes per week. This research has been declared ethically feasible by the
Health Research Ethics Committee of Surya Global Yogyakarta STIKES with a letter of
ethics number 1.31//KEPK/SG/III/2020.
RESULTS
Table 1.
Characteristics of Respondents (n= 22)
Respondent characteristics f %
Age
36-45 1 4.5
46-55 7 31.8
56-65 11 50.0
66-75 3 13.6
Education level
Not school 5 22.7
Elementary school 2 9.1
Junior high school 6 27.3
Senior high school 6 27.3
Diploma 2 9.1
Bachelor 1 4.5
Job
Civil servant 1 4.5
Enterpreuner 9 40.9
Farmer 8 36.4
Police/Soldier 2 9.1
Not employment 1 4.5
Retirement 1 4.5
Type of DM
Type 1 7 31.8
Type 2 15 68.2
Duration
<10 years 5 22.7
10-15 years 11 50.0
15-20 years 2 9.1
>20 years 4 18.2
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Respondent characteristics f %
Grade of diabetic ulcus
1 10 45.5
2 6 27.3
3 4 18.2
4 2 9.1
Physical activity compliance
Compliance 17 77.3
Not compliance 5 22.7
Table 2.
The relationship between physical activity compliance with the incidence of diabetic ulcers
(n=22)
Correlation coefficient p value
Physical activity compliance 0.158 0.481
with the incidence of diabetic
ulcers
The characteristics of the respondents in this study were based on age, education level,
occupation, type of DM, length of suffering, ulcer degree and activity compliance level. From
the results of the analysis, it is known that the highest age is 56-65 years (50%), the highest
level of education is at the junior and senior high school levels (27.3%), the most type of
work is self-employed (40.9%), the type of DM is type 2 DM ( 68.2%), length of suffering
10-15 years (50%), the most ulcer degree is grade 1 (45.5%), and as many as 77.3% patients
are not obedient in carrying out physical activities. diabetic ulcer (p value>0.05).
DISCUSSION
Respondents in this study are 22 patients with the highest number in the age group 56-65
years by 50%. The highest level of education is at the junior high and senior high school
levels with the same number of 27.3% each. The type of occupation of most respondents is
self-employed with a total of 40.9%. The most common type of DM suffered is type 2 which
amounted to 68.2%. The longest patient suffering from DM is 10-15 years (50%). The results
of previous studies conducted in Rio de Janeiro related to adherence in DM patients also
obtained data that the highest age is in the 65 year age group and the longest duration of
suffering from DM is 8 years (Marinho et al., 2018). Another study of DM patients with
diabetic ulcers conducted in America found that the average age of DM patients is 66.3 years
and in general the average age of DM patients is 65.8 years (Ramsey et al., 1999). The results
of research conducted on type 2 DM patients in Iran found the characteristics of the highest
level of patient education at the high school level, namely 38.6% with an age range of 45.8%
between 50-64 years (Mirahmadizadeh et al., 2020).
The most common ulcer degree experienced by patients in this study was grade 1 as much as
45.5%. Data about the degree of ulcer is important to know to determine the treatment of the
wound experienced by the patient. The most frequently used ulcer grade classification is the
Meggitt Wagner classification which is divided into five degrees, namely only pain in the legs
(grade 0), skin surface ulcers (grade 1), deeper ulcers (grade 2), ulcers involving the bones of
the feet (grade 2). 3), gangrene of part of the leg (grade 4) and gangrene of the whole leg
(grade 5). The research conducted at RSUD dr. Zainal Abidin and RSUD Meuraxa Banda
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Aceh also found that the most common ulcers experienced by patients were grade 1 in the
form of ulcers with minimal exudate, edged like cliffs, pink with minimal inflammation and
occasional pain (Fitria et al., 2017).
A total of 77.3% of patients in this study did not adhere to physical activity in order to
maintain health and control blood sugar levels. The category of physical activity in this study
was light physical activity with a monitored pulse, involving the cardiovascular muscles and
carried out for 20-30 minutes regularly 3 times a week. The recommended physical activities
for DM patients are jogging/walking, cycling and gymnastics. Strenuous sports such as
badminton, tennis and aerobics are not recommended.
Based on these criteria, the results of research conducted in the working area of the Rowosari
Health Center Semarang City also showed that 59% of DM patients were not compliant with
physical activity (Zakiyyah et al., 2019). The results of this study are supported by previous
studies on type 2 DM patients in Rio de Janeiro that only 22.5% of patients had good
adherence to sports or physical activity. Non-adherence to this activity is associated with high
blood sugar levels of the patient. In addition, pain and neuropathy suffered by patients are also
the cause of non-adherence to these physical activities (Marinho et al., 2018).
Most of the patients in this study belonged to the elderly group, the age factor was also the
cause of non-adherence to physical activity. This is reinforced by previous studies, where
elderly patients and women were equally uninterested in physical activity. Elderly patients
have physical limitations related to age as well as several complications of the disease so that
they feel unable to carry out physical activities (Cartagena & Tort-nasarre, 2021). Non-
adherence to physical activity can be caused by internal and external factors of the patient.
Self-decision not wanting to do physical activity is an internal factor, while pain, fatigue and
depression are external factors (Qiu et al., 2012).
Compliance with physical activity is not related to the degree of ulcer suffered by the patient.
An important factor related to knowledge and health literacy is the level of education. Patients
with a high level of education will have good knowledge and health literacy so that they will
adhere to medication, diet and physical activity. Increasing adherence to physical activity in
DM patients will help achieve therapeutic goals and prevent disease complications (Soares et
al., 2020).
The results of another study stated that there was no significant relationship between dietary
compliance, physical activity and age with the incidence of diabetic ulcers in DM patients.
Variables that have a significant relationship with the incidence of diabetic ulcers are duration
of diabetes mellitus, exercise habits, medication adherence, exposure to cigarette smoke, use
of footwear, foot care and history of ulcers (Mitasari et al., 2014). Other studies have found
that factors related to physical activity compliance are age, gender, occupation, perceived
obstacles, self-efficacy, family support and support from health workers (Zakiyyah et al.,
2019).
CONCLUSIONS
There were 77.3% of DM patients with diabetic ulcers who did not adhere to physical activity
in this study. Compliance with physical activity has no relationship with the degree of
diabetic ulcers in patients.
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