Effect of Supportive Education System on Knowledge of Diabetic Foot Ulcer Prevention among Type 2 Diabetes Mellitus Patients | ||
| Health Education and Health Promotion | ||
| Article 12, Volume 13, Issue 2, 2025, Pages 281-287 PDF (309.63 K) | ||
| DOI: 10.58209/hehp.13.2.281 | ||
| Authors | ||
| T. Jamini* 1; C.K. Negara2; H. Herawati2 | ||
| 1Department of Nursing Sciences, STIKES Suaka Insan, Banjarmasin, Indonesia | ||
| 2Department of Nursing, Faculty of Medicine and Health Sciences, University of Lambung Mangkurat, Banjarmasin, Indonesia | ||
| Abstract | ||
| Aims: Type 2 diabetes mellitus is a chronic disease that can lead to serious complications, one of which is diabetic foot ulcers. Health education plays a crucial role in enhancing patients’ understanding of the prevention of such complications. This study aimed to analyze the effect of the supportive education system on knowledge of diabetic foot ulcer prevention among patients with Type 2 diabetes. Materials & Methods: This quasi-experimental study with a pre-test-post-test control group was done on 160 patients with type 2 diabetes selected using purposive sampling. They were divided into an intervention group (n=80) and a control group (n=80). The intervention group received the supportive education system over four sessions, while the control group received conventional education. Knowledge levels were measured before and after the intervention using a standardized questionnaire. Findings: There was a significant increase in knowledge levels in the intervention group compared to the control group (p<0.001), as assessed by the Mann-Whitney U test. These findings indicated that a support-based educational approach was more effective than conventional education in improving patients’ knowledge. Conclusion: The supportive education system significantly enhances the level of knowledge regarding diabetic ulcer prevention in patients with type 2 diabetes mellitus. | ||
| Keywords | ||
| Diabetic Foot; Education; Knowledge; Ulcer | ||
| Full Text | ||
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Introduction Diabetes mellitus (DM) is a chronic metabolic disorder characterized by persistent hyperglycemia resulting from defects in insulin secretion, insulin action, or both. It is one of the most prevalent non-communicable diseases worldwide and is associated with considerable morbidity, mortality, and economic burden on healthcare systems and society at large. According to the International Diabetes Federation (IDF) Diabetes Atlas 2023, approximately 537 million people worldwide are currently living with diabetes, and this number is projected to rise dramatically to 643 million by 2030 and to 783 million by 2045 if comprehensive preventive strategies are not implemented [1]. In Southeast Asia, the prevalence of diabetes has increased steadily over the last two decades due to rapid urbanization, changes in lifestyle, and population aging [2]. Indonesia, as one of the largest countries in this region, ranks fifth globally in terms of diabetes burden, with an estimated 19.47 million cases reported in 2023, representing a significant increase from previous years [3]. National health surveys indicate a rising trend in diabetes prevalence, from 6.9% in 2018 to 8.5% in 2023, with the burden being particularly evident in urban and semi-urban provinces such as South Kalimantan [4]. The complications of diabetes are both microvascular and macrovascular in nature, with diabetic foot problems representing one of the most devastating manifestations. A diabetic foot ulcer (DFU) is defined as a full-thickness wound penetrating through the dermis, typically located on the foot, which occurs in people with diabetes as a result of neuropathy, peripheral arterial disease, or trauma [5]. The pathophysiology involves a combination of sensory neuropathy, motor neuropathy leading to foot deformities, autonomic neuropathy causing dry skin and fissures, and impaired wound healing due to microvascular disease and hyperglycemia [6]. When not managed appropriately, these ulcers can become infected, progress to gangrene, and ultimately require lower limb amputation. The World Health Organization (WHO) has reported that more than 15% of people with diabetes will develop a foot ulcer at some point in their lifetime, and approximately 85% of diabetes-related amputations are preceded by a foot ulcer that was either untreated or inadequately treated [7]. The situation in Indonesia mirrors these global patterns but is compounded by unique local challenges. Studies indicate that more than one-quarter of Indonesian patients with diabetes develop foot lesions, with prevalence varying according to region and level of healthcare access [8]. In provinces such as South Kalimantan, limited health literacy, socioeconomic constraints, and geographic barriers often result in delayed presentation and suboptimal management of foot wounds. Diabetic foot ulcers (DFUs) not only threaten limb integrity but also severely compromise quality of life, increase healthcare expenditures, and contribute to significant psychological distress among patients and their families [9]. Despite the gravity of the problem, DFUs are largely preventable through early identification of at-risk feet, regular podiatric assessments, the use of protective footwear, and patient self-care practices such as daily foot inspection, hygiene maintenance, and prompt reporting of abnormalities [10]. Preventive education is therefore considered a cornerstone of diabetic foot care. However, in many low- and middle-income settings, including Indonesia, gaps in patient knowledge and adherence remain significant. Previous educational initiatives, often limited to one-off counseling sessions or leaflet distribution, have shown limited impact because they do not adequately address motivational and behavioral factors that influence sustained foot care practices [11]. Patients frequently report that they lack understanding of the rationale for recommended practices, feel overwhelmed by complex instructions, or face cultural and logistical barriers to implementing advice [12]. To overcome these challenges, researchers and practitioners have increasingly turned to innovative, patient-centered educational models. One such model is the Supportive Education System (SES), which integrates evidence-based knowledge delivery with ongoing social support, peer engagement, and motivational strategies designed to empower patients and reinforce positive behaviors [13]. Unlike conventional education, which often terminates after the initial information provision, SES emphasizes continuity, follow-up, and active problem-solving. For example, patients may receive regular reminders, participate in group sessions to share experiences, or have access to peer educators who provide encouragement and practical tips. This holistic approach acknowledges that knowledge alone is insufficient for behavior change and that psychosocial factors—such as self-efficacy, perceived barriers, and social support—play critical roles in whether patients adopt and maintain recommended foot care practices [14]. In Indonesia, the implementation of SES within diabetes education remains relatively novel, with few studies evaluating its specific impact on knowledge and self-care behaviors related to foot ulcer prevention. Given the increasing prevalence of diabetes and the substantial proportion of patients at risk for foot complications, there is a pressing need for evidence-based interventions that can be adapted to local contexts and delivered within existing healthcare infrastructures. The integration of SES into routine care could potentially bridge the gap between knowledge dissemination and behavioral adherence, leading to better prevention outcomes. The present study was therefore undertaken to evaluate the effectiveness of a Supportive Education System in improving knowledge about diabetic foot ulcer prevention among patients with type 2 diabetes mellitus (T2DM) attending healthcare facilities in South Kalimantan, Indonesia. By providing not only information but also ongoing support and motivation, SES is hypothesized to enhance patients’ understanding of foot care principles, increase their confidence in performing daily preventive measures, and ultimately reduce the incidence of foot ulcers and related complications. The findings of this study are expected to inform the development of more effective and sustainable educational interventions tailored to the needs of Indonesian patients with diabetes, contributing to broader efforts to curb the growing burden of diabetes-related morbidity in the region. Materials and Methods Design This study utilized a quasi-experimental design with a pre-test-post-test control group to evaluate the effect of the SES on improving knowledge of diabetic foot ulcer prevention among patients with T2DM. This design allows for a comparison between an intervention group receiving SES and a control group receiving conventional education, thus enabling an assessment of the effectiveness of the applied educational approach. The study was conducted from August to December 2024 at the Diabetic Foot Clinic of Banjarmasin Regional General Hospital (RSUD Banjarmasin), South Kalimantan, Indonesia. The study period included participant recruitment, implementation of the SES intervention, and post-intervention data collection and analysis. Sample The study population consisted of T2DM patients receiving care at the diabetic foot clinic of Banjarmasin Regional General Hospital (RSUD Banjarmasin). A purposive sampling technique was used, with inclusion criteria, including T2DM patients who had not yet developed diabetic foot ulcers, had good communication abilities, and were willing to participate in the study. Exclusion criteria included patients with cognitive impairments or severe comorbidities that hindered participation in the educational sessions. The sample size was determined using Slovin’s formula, resulting in a total of 160 participants. The sample was divided into two groups: 80 participants in the intervention group and 80 participants in the control group. Data collection Data collection was conducted using a standardized knowledge questionnaire on diabetic foot ulcer prevention. Before implementation in this study, the questionnaire underwent a thorough process of validity and reliability testing. Content validity was evaluated by a panel of five experts consisting of diabetes nurse specialists, an endocrinologist, and lecturers experienced in health education and psychometrics. Each item was assessed for clarity, relevance, and representativeness, yielding an item level content validity index (I-CVI) ranging from 0.84 to 1.00 and a scale level CVI of 0.92, indicating excellent content validity. Reliability testing was performed in a pilot study involving 30 patients with characteristics similar to the study sample but not included in the main analysis. Internal consistency, measured using Cronbach’s alpha, was 0.87 for the overall scale, with subscale coefficients ranging from 0.81 to 0.89, demonstrating high internal consistency. Test–retest reliability over a two-week interval produced a Pearson correlation coefficient of r=0.91 (p<0.001), confirming the instrument’s stability. Based on these assessments, the questionnaire was deemed valid and reliable for measuring knowledge related to diabetic foot ulcer prevention. The final questionnaire was administered as a pre-test prior to the intervention and as a post-test after the educational sessions in both the intervention and control groups. The intervention group received the SES, which consisted of comprehensive education on diabetic foot care, supported by motivational strategies, personal assistance, and interactive Q&A sessions delivered over several sessions during a four-week period. Meanwhile, the control group received only conventional education in the form of a brief counseling session without additional support. Upon completion of the intervention, a post-test was conducted in both groups to evaluate changes in knowledge. Data analysis Data normality was assessed using the Shapiro-Wilk test. The results indicated that the knowledge scores were normally distributed; therefore, parametric tests were used for analysis. The paired t-test was employed to compare pre-test and post-test scores within each group, while the independent t-test was used to compare post-intervention scores between the intervention and control groups. Statistical analysis was performed using SPSS 32, with a significance level set at p<0.05. Findings A total of 160 patients participated in this study, with 80 assigned to the intervention group and 80 to the control group. The majority of participants were aged 45-59 years (45%), female (51.3%), had completed senior high school (33.1%), and were predominantly unemployed (23.7%; Table 1). Table 1. Frequency of age, gender, education, and occupation among participants (n=160)  Before the implementation of the SES, the knowledge levels of participants on diabetic foot ulcer prevention were assessed (Table 2). Table 2. Frequency of knowledge levels on diabetic foot ulcer prevention before intervention (n=160)  Following the implementation of the SES, the proportion of participants with high knowledge levels increased markedly to 62.5% in the intervention group, whereas only 18.7% of the control group achieved high knowledge levels (Table 3). Table 3. Frequency of knowledge levels on diabetic foot ulcer prevention after intervention (n=160)  The mean knowledge score in the intervention group increased significantly from 1.63±0.67 before the intervention to 2.56±0.60 after the intervention (paired t-test; p<0.001). In the control group, the mean score increased slightly from 1.65±0.68 to 1.87±0.72; however, this change was not statistically significant (p=0.081; Table 4). Table 4. Comparison of mean knowledge levels on diabetic foot ulcer prevention before and after intervention in the intervention and control groups  Discussion This study aimed to evaluate the effectiveness of the SES in improving knowledge about diabetic foot ulcer prevention among patients with T2DM. Univariate analysis revealed that the majority of respondents were aged 45-59 years (45%), followed by those aged ≥60 years (28.7%) and those aged <45 years (26.3%). Age significantly influences patients’ knowledge and awareness of diabetes complications, including diabetic foot ulcers. Negara et al. [9] found that patients aged 45-59 years are more proactive in seeking health information compared to older age groups, likely due to their active social and economic engagements. Conversely, elderly patients tend to experience cognitive decline and limited access to health information, which can affect their understanding of diabetic foot ulcer prevention [15]. The gender distribution was relatively balanced, with males comprising 48.7% and females 51.3% of respondents. Studies indicate that females are generally more health-conscious and more frequently seek information on preventing diabetes complications than males [16]. Furthermore, researchers have reported that males have a higher risk of developing diabetic foot ulcers due to lower adherence to foot care practices, particularly regarding footwear choices and self-care habits [17]. Regarding education, most respondents had completed junior high school (32.5%) and senior high school (33.1%), while 11.3% had tertiary education. Educational attainment is closely linked to comprehension of disease prevention. Patients with higher education levels possess better knowledge about diabetic foot care compared to those with lower educational backgrounds [18]. This is attributed to individuals with higher education having broader access to health information sources, including digital media and healthcare professionals. In terms of occupation, respondents exhibited varied distributions: unemployed (23.7%), entrepreneurs (23.1%), farmers/laborers (19.4%), private employees (17.5%), and civil servants/military/police (16.3%). Occupation influences access to healthcare services and the adoption of healthy lifestyles [19]. Unemployed or low-income respondents tend to face limitations in accessing healthcare facilities and encounter greater challenges in implementing optimal diabetic foot care, especially regarding appropriate footwear use and regular health check-ups [20]. Prior to the implementation of the SES intervention, the majority of respondents in both groups exhibited low to moderate levels of knowledge. This finding highlights an existing information gap concerning diabetic ulcer prevention among T2DM patients. Several factors may contribute to this low level of knowledge, including limited access to accurate information, insufficient ongoing education from healthcare professionals, and a lack of patient awareness in independently seeking health information. According to Zaini et al. [21], unstructured education and ineffective learning methods often hinder the enhancement of patient knowledge regarding complication prevention, including diabetic ulcers. Furthermore, this result aligns with the study conducted by Mewo et al. [22], which found that most T2DM patients have a limited understanding of diabetic foot care, thereby increasing the risk of ulceration and amputation. This is corroborated by research from Samuel et al., which states that ineffective education can lead to a higher incidence of diabetic ulcers, especially among patients who do not routinely perform foot examinations [23]. There was a significant increase in the knowledge levels of respondents in the intervention group following the implementation of the SES intervention, compared to the control group. This improvement indicates that a systematic, socially supported educational intervention can effectively enhance patient understanding of diabetic ulcer prevention. This study is consistent with research conducted by Adiewere et al., reporting that structured education using participatory methods can improve patient knowledge and adherence to diabetic foot care practices [24]. Repeated, interactive, and patient-centered education has proven to be more effective than conventional one-way information delivery methods. Additionally, these findings are supported by research from Olowo et al. [25], emphasizing that increased knowledge is a crucial initial step in reducing the incidence of diabetic ulcers and the risk of amputation in T2DM patients. This study highlights that patients with a better understanding of risk factors, early signs, and preventive measures for diabetic ulcers are more capable of performing independent foot care, ultimately reducing complications. Here, the control group, which did not receive the SES intervention, only experienced a non-significant increase in knowledge. This suggests that unstructured conventional educational approaches are less effective in enhancing patient understanding. Education that relies solely on brief counseling without active patient involvement often does not significantly impact changes in knowledge and behavior [26]. The observed improvement in the intervention group also indicated that the SES-based approach is superior to conventional educational methods. This educational model not only provides information but also facilitates interaction, social support, and a more personalized and repetitive approach, making it easier for patients to comprehend and apply the information provided. There was a significant difference between the intervention and control groups after implementing the SES. This suggests that educational methods based on social support are more effective in enhancing patient knowledge compared to conventional education. Negara et al. [27] found that group-based educational interventions with a participatory approach can improve the understanding of diabetes mellitus patients regarding the prevention of diabetic foot complications. This study highlights that active learning methods, such as group discussions and direct demonstrations, have a greater impact than one-way education [28]. These findings support the current study’s results, indicating that the SES can significantly enhance patient knowledge through a more interactive approach involving active patient participation. Furthermore, research by Rohmaniah [28] demonstrated that health education delivered repeatedly and based on multimedia is more effective than conventional methods in increasing patient awareness about diabetic foot care [29]. This study emphasizes that using engaging educational media, such as images, videos, and interactive modules, can help patients better understand the concept of diabetic ulcer prevention [30]. This aligns with the SES intervention in the current study, where a more varied approach to material delivery can optimally enhance patient understanding. Moreover, Satehi et al. [31] found that social support provided by healthcare professionals and fellow patients in diabetes education programs contributes to increased patient understanding and adherence to diabetic ulcer prevention measures. This social support creates a more comfortable learning environment and motivates patients to apply the information they have acquired [32]. These findings reinforce the results of the current study, demonstrating that an educational approach based on social support within SES can enhance the effectiveness of patient learning. On the other hand, the control group, which only received conventional education, did not experience a significant increase in knowledge. This is consistent with studies conducted by Wattimena [33], Ramadhan [34], and Pujilestari et al. [35], reporting that health education based solely on lectures is not sufficiently effective in comprehensively improving patient understanding, especially when conducted in a short time without follow-up education. Consequently, our findings align with existing literature, confirming that an interactive, structured, and socially supported educational intervention can effectively enhance patient knowledge regarding diabetic foot ulcer prevention. The SES thus emerges as a promising strategy that can be integrated into broader preventive programs for individuals with T2DM, with the potential to improve patient self-care practices, quality of life, and mitigate the risk of foot ulceration. Nonetheless, several limitations should be acknowledged. First, this study assessed only the level of knowledge without evaluating actual behavioral changes or long-term adherence to recommended foot care practices; therefore, the sustained impact of the SES intervention remains to be determined. Second, the research was conducted in a single geographic area, which may limit the generalizability of the findings to other populations with differing socio-economic and cultural contexts. Third, extraneous parameters, such as individual motivation, access to supplementary information, and family support, were not comprehensively controlled and may have influenced the outcomes. Finally, the relatively short duration of the pre-test and post-test design did not allow for the assessment of knowledge retention or behavioral maintenance over time. Future studies employing longitudinal designs and incorporating objective behavioral and clinical outcome measures are recommended to validate these findings and establish the long-term efficacy of the SES approach. Conclusion The SES significantly enhances the level of knowledge regarding diabetic ulcer prevention in patients with T2DM. Acknowledgments: Gratitude is extended to STIKES Suaka Insan Banjarmasin and Universitas Lambung Mangkurat Banjarmasin, Indonesia. Ethical Permissions: The procedure was reviewed and granted ethical clearance (Number: 1903-KEPK) by the Institutional Review Board (IRB) at the Banua Institute, Indonesia. Conflicts of Interests: The authors reported no conflicts of interests. Authors' Contribution: Jamini T (First Author), Introduction Writer/Discussion Writer/Main Researcher (50%); Kusuma Negara C (Second Author), Assistant Researcher/Discussion Writer (25%); Herawati (Third Author), Assistant Researcher/Discussion Writer (25%) Funding/Support: This research is supported by STIKES Suaka Insan Banjarmasin and Universitas Lambung Mangkurat Banjarmasin, South Kalimantan, Indonesia. | ||
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