Spirituality Level, Family Support, and Spiritual Self Care Behavior among Patient with Diabetic Ulcers

Article history: Received: 10 May 2020 Accepted: 12 July 2020 Introduction: Patients with diabetic ulcers tend to experience problems in implementing spirituality practices. Patients with diabetic ulcers also experience weaknesses and impaired mobilization that have an impact on family dependence and decreased self-efficacy. The purpose of this study was to determine the relationship between spirituality level and family support with spiritual self-care behavior in diabetic ulcer patients. Methods: A descriptive correlation design with a cross-sectional approach. In a total of 92 patients with diabetic ulcers in Sidoarjo General District Hospital in June-July 2019 recruited. Independent variables were the level of spirituality and family support. The dependent variable was spiritual self-care behavior. Data obtained through the Daily Spiritual Experience Scale (DSES) questionnaire, family support questionnaire, and Spiritual Self Care Practice (SSCPS) questionnaire. Data were analyzed using the Chisquare test of categorical variables with a p-value ≤ 0.05 and logistic regression for multivariate analysis. Results: The study showed there was a significant relationship between spirituality level (p = 0,000) and family support (p = 0,001) with spiritual self-care behavior in diabetic ulcer patients. The result of regression analysis showed the respondents with a high level of spirituality would increase 0.138 times of the spiritual self-care behavior probability. Conclusion: The level of spirituality and family support can promote individual coping to be more positive which may accelerate the process of receiving and healing wounds.

times more frequent compared to nondiabetic people. It is estimated that the incidence of diabetic ulcers will continue to increase following the incidence of diabetes [1]. In Indonesia, the prevalence of diabetic ulcer patients is 15% of DM patients. People with a history of diabetic ulcers have the possibility of recurrence. For 5 years the likelihood for re-injury is 66% and amputation is 12% [2]. Based on preliminary studies, it was found that in 2016 the Patients with diabetic ulcers tend to experience problems in the implementation of spirituality practices. One effort to meet the spiritual needs of patients to performing spiritual practices known by term of spiritual self-care behavior [3]. Moreover, patients with diabetic ulcers have another tendency to experience problems such as physical weakness and decreased ability to mobilize which have an impact on decreased ability to perform daily activities, family dependency, lower self-efficacy, and low recovery expectancy [3,4].
Based on the results of preliminary studies, it was found that some patients expressed a sense of dependency on people around them, experienced a decreased ability to perform daily activities, and a tendency to withdraw from social life. Some patients also stated the inability to practice prayer due to their wounds, physical weakness, lack of knowledge about how to purify, and misperception about impure wounds.
Patients with diabetic ulcers tend to rely on the family for the fulfillment of daily needs [5].
One of the major family assistance was in meeting patient's spiritual needs [6].
Diabetes Mellitus is a chronic disease that occurs for a long time. The DM patients with complications have a susceptibility to stress. A body with psychologically depressed will have another susceptibility to experiencing other diseases because stress hormones will inhibit T-cells, macrophage activity, and reduce the number of lymphocytes. This condition, if left unchecked, will be resulting in another body immunity degradation following a disease vulnerability and slower the wound healing process [5].
Psychological factors such as depression not only affect the quality of life but also affect the ability to fight chronic disease progression [3,7]. Psychological pressure on DM patients is influenced by the level of spirituality and religious adherence, the poor quality of the spiritual level will increase the risk for the patient to experience depression and resulting in a decrease in quality of life [8,9].
Spirituality is an individual's belief in the purpose life, the meaning of the environment and fellow human beings, and the meaning of God [3,10]. Spirituality is proven to be one of the effective methods of coping strategies.
When a patient has positive coping control, it will affect the ability to control pain as well increases the illness acceptance and improve the quality of life [5,10,11].
Spiritual self-care is defined as spiritual activities perform by individuals to maintain and improve personal well-being when in health or sickness. Spiritual self-care is based on mind-body-spirit, moral, religious background, and experiences related to beliefs, feelings, and emotional connections. were DM patients with grade 0 diabetic ulcers according to the Meggitt Wagner classification [12].
The data collection process starts with research licensing as a preparation stage. The paper-based questionnaires were used to collect the participant information.. The study was conducted every two weeks to avoid the presence of the same respondents. It was also due to the prediction of the length of stay among each patient was 5-10 days. In the beginning, the researcher came to the concerned room that has been designated by the hospital and the data collection process was accompanied by the nurse on duty.
Respondents who agree to participate in the study will be given an approval letter, have to sign the consent form, and asked to fill out the research questionnaires.
In this study respondents were required to fill out the demographic data questionnaires, Daily Spiritual Experience Family support is measured using a family support questionnaire to assess family efforts to assist the needs of patients during illness [14].

RESULTS
Based on the demographic data of the respondents in Table 1       church. This is influenced by physical limitations that also influence a person in practicing spirituality [18].  [15].
In this study, there were also respondents with high family support but had low self-care spiritual behavior (N = 13, 33.3%). Patients with good family support but low self-care spiritual behavior can be influenced due to many factors such as age and education. In elder patients, the inability to perform activities will get worse [19]. Good family support not accompanied by the patient's ability to carry out activities resulting in non-effectivespiritual practices.
The level of education also influences the ability of families to provide support and the ability of patients to receive support [21].
Diabetic ulcer patients who have a high level of spirituality will have a high level of self-care spiritual behavior, the high level of spirituality support the effectiveness of the treatments. In this study, we also found the respondentwith a high level of spirituality would increase 0.138 times of their spiritual self-care behavior. Engaging in spiritual selfcare is strongly affected by the foundational disposition of spirituality. Spiritual self-care may be done by the person to feel a connection with a higher power. Spiritual selfcare may also be done to help the person feel connected to others, individuals may pursue other spiritual self-care practices that enhance their sense of well-being [17].

CONCLUSION
In this study, it was found that diabetic ulcer patients with an adequate level of spirituality and family support also had sufficient spiritual self-care behavior as well. Therefore, it is important to provide nursing care efforts to increase and optimize the level of spirituality and family support to achieve the optimal patient's spiritual self-care behavior .
A good spiritual self-care behaviour will improve the quality of life and acceptance of the wounds as well as to accelerate the process of healing.