The prevalence of diabetes is rising across the world (Chun et al, 2019), and its complications can lead to serious illness and even death. One person dies every seven seconds from diabetes complications (Schaper et al, 2019). The leading causes of death among patients with diabetes include chronic kidney disease (24.6%), cardiovascular events (19.6%), sepsis (15.6%), respiratory failure (10.0%), malignancy (9.5%) and multi-organ failures (5.0%) (Jeyaraman et al, 2019).
A foot ulcer is a severe complication of diabetes. Treating foot ulcers is expensive, partly because patients with them can be hospitalised for a long period (Marzoq et al, 2019). People living with diabetes are afraid of developing a foot infection and needing a lower limb amputation (Bekele et al, 2019). Lower extremity amputation is the most dreaded consequence of this condition and is associated with complications, diabetes duration (more than 10 years), use of insulin and peripheral neuropathy (Wukich et al, 2018).
Several factors are responsible for slow healing. These include noncompliance with recommended diet programmes, inappropriate use of insulin, improper wound care, not taking enough physical exercise and incorrect cultural beliefs. The treatment patients receive is influenced by level of education, socioeconomic status, social support, age, the presence and severity of comorbidities, treatment experience, information reception, psychological barriers, whether there are multidisciplinary facilities for treatment, diabetic sensory neuropathy and disease complexity, as well as the administration required to access services being too complex. Shortfalls in treatment of diabetic ulcers include poor knowledge of foot care, high levels of self-medication and delays in seeking medical help, which result in prolonged hospitalisation and high levels of lower extremity amputation and general mortality (Ugwu et al, 2019).
Patients with diabetic foot ulcers, especially those from certain ethnic groups, are greatly influenced by their cultural background, which likely determines their health behaviours towards the disease. Cultural belief greatly influences choice of treatment, and this tends to affect patients' health and wellbeing because they may delay in seeking medical assistance (Napier et al, 2017; Sayampanathan et al, 2017). Self-management is practised inadequately, because patients' understanding of the condition is limited (Abdulrehman et al, 2016). Cultures can influence self-management, and people's understanding of the condition and the treatment process.
In this study, the authors seek to understand one of the 633 cultural groups in Indonesia—the Batak Karo ethnic group. This group is one of the oldest and largest ethnic groups originating from north Sumatra (Central Statistics Agency, 2011), and comprises Toba, Karo, Pakpak, Simalungun, Angkola and Mandailing people (Koentjaraningrat, 2010). This ethnic group originates from the Karo plateau, and its members have a good knowledge of cultures and customs. Various ceremonies related to religious beliefs are performed that may influence the treatment process of diabetic ulcers. Religious and cultural beliefs are among the factors that influence the level of vigilance concerning patients with diabetic foot problems (Hikmah et al, 2018); diabetic foot problems cause 80% of hospitalisations and 15-30% of amputations, and lead to 30% of deaths in people with diabetes (Sulistyowati, 2015).
Studies examining diabetic ulcers in the Batak Karo group are scarce, which limits our understanding in regards to their treatment. This study aimed to explore their lived experiences in the treatment of diabetic foot ulcers to understand the healing process comprehensively.
Methods
Study design
This study employed hermeneutic interpretive phenomenology as outlined by Van Manen (2016) in exploring the lived experience of the Batak Karo ethnic group regarding the treatment of diabetic foot ulcers. This study design was selected as the research objective of the various beliefs was identifying the core phenomenon and describing its cultural context. To report the results of this study, the consolidated criteria for reporting qualitative research (COREQ) checklist (Tong et al, 2007) was used.
Participants
A total of 10 participants were selected from Batak Karo group using a purposive sampling technique. The inclusion criteria were Batak Karo people who:
To prevent bias, there was no relationship between the researchers and the participants before the study began.
Data collection
Data were collected for 1.5 years from early 2016 to mid 2017 using in-depth interviews and field notes. The interview was done face to face by the researchers and wound care team in each participant's house, and lasted approximately 60–90 minutes. Interviews were audio recorded to ensure all conversations were adequately captured. Each participant was interviewed once.
The interview guideline drawn up by the researchers included:
The interview guidelines were not pilot tested. The questions were, however, flexible and could be changed depending on the responses of each participant. Questions were continued until data were saturated.
The field notes contained the date, time, place where the interview was held and the condition of the diabetic ulcers. Patients' verbal and nonverbal responses that indicated how they felt (eg tense or relaxed) were used to enrich the data.
Data analysis
All interviews were transcribed and analysed, as outlined by Van Manen (2016). Data analysis was carried out in six stages:
All participants' comments were grouped into subthemes, then subthemes were grouped into major themes.
Trustworthiness
A member check was conducted to ensure trustworthiness, with the transcribed interview validated by the participants. An audit trail among the researchers was used to clarify data analysis. Regarding field notes, both non-verbal and verbal responses were analysed to ensure they were in line with what each participant was expressing.
In addition to carrying out interviews, one researcher (TE) spent 18 months with the participants in their native culture and observed their everyday world to gain a better understanding of behaviour, values and social relationships in a social context.
Ethical considerations
This study was approved by the research ethics committee at the Faculty of Nursing, Universitas Sumatera Utara (number 503/VI/SP/2015). Before data collection, the researchers explained the purpose and procedure of the study to each participant, and asked them to sign an informed consent form if they agreed to take part. The researchers also emphasised that taking part in this study was voluntary and that participants could withdraw at any time without any penalties. They also ensured that all information would be published anonymously.
Results
Participant characteristics
The majority of participants were aged 50 years or above, women and Christian. Most had an elementary and junior high school background and worked as housewives. The participants were most likely to have a grade III wound and were being treated traditionally. The time taken for wounds to heal was at least 2–3 months. Most participants had had diabetes for more than 10 years. None of the participants withdrew from this study (Table 1).
| Characteristic | n | % |
|---|---|---|
| Age | ||
| ≤50 years | 2 | 20 |
| ≥50 years | 8 | 80 |
| Religion | ||
| Islam | 2 | 20 |
| Christianity | 8 | 80 |
| Sex | ||
| Female | 6 | 60 |
| Male | 4 | 40 |
| Education | ||
| Elementary school | 3 | 30 |
| Junior high school | 3 | 30 |
| Senior high school | 2 | 20 |
| Bachelor's degree | 2 | 20 |
| Occupation | ||
| Private employee | 2 | 20 |
| Labourer | 1 | 10 |
| Farmer | 2 | 20 |
| Housewife | 5 | 50 |
| Wound grade | ||
| Grade II | 3 | 30 |
| Grade III | 6 | 60 |
| Grade IV | 1 | 10 |
| Type of wound care | ||
| Traditional | 7 | 70 |
| Modern | 3 | 30 |
| Length of wound healing | ||
| 2–3 months | 7 | 70 |
| 3–6 months | 3 | 30 |
| Length of time with diabetes | ||
| ≤10 years | 1 | 10 |
| ≥10 years | 9 | 90 |
Analytical findings
Five themes emerged from the data:
Participants' quotes about each of these themes can be found in Table 2.
| Themes | Subthemes | Participants' quotes |
|---|---|---|
| Beliefs in health disorders | The spirit is gone |
|
| Magic sent by someone |
|
|
| Caused by disturbed begu |
|
|
| Physical, psychological, social and spiritual changes | Physical changes |
|
| Psychological changes |
|
|
| Social changes |
|
|
| Spiritual changes |
|
|
| Traditional treatments | Drinking spices |
|
| Using yellow ointment (param) |
|
|
| Using Karo oil |
|
|
| Using spray (sembur) |
|
|
| Using wound tambar |
|
|
| Beliefs in culture | Conducting a raleng tendi ceremony |
|
| Performing an erpangir ku lau ceremony |
|
|
| Conducting a prayer ceremony with a guru sibaso |
|
|
| Conducting a prayer ceremony together with guru pertawar |
|
|
| Praying with priests, families, church friends and clan group members |
|
|
| Seeking health services | Visiting modern wound care centres |
|
| Going to the hospital |
|
|
| Visiting a general practitioner |
|
Theme 1. Beliefs about health disorders
This theme had of several subthemes:
Theme 2. Physical, psychological, social and spiritual changes
The majority of the participants experienced changes in their lives, which were related to:
Theme 3. Traditional treatments
The majority of the participants received various traditional treatments intended to cure diabetic foot ulcers, such as: drinking spices or a potion made from plants and administered by a shaman; using ‘yellow ointment’ or param made from fresh herbs; applying Karo oil, made from coconut oil, rhizome, eucalyptus, pepper leaves and other ingredients, to the wound; a spray made from spices, leaves and rice (sembur); and wound tambar, or leaves usually chewed and placed on the wound three times daily.
Theme 4. Cultural beliefs
Batak Karo cultural beliefs relating to the treatment of diabetic foot ulcers were strongly expressed by the participants in the following five activities:
Theme 5. Seeking health services
The participants had tried several ways to seek treatment for their foot ulcers, which included attending modern wound care centres, hospitals and general practitioners. This was done after they had given up on traditional treatments.
Discussion
This study aimed to explore the lived experience of the Batak Karo ethnic group regarding diabetic foot ulcer treatment. Five themes emerged from the data.
The theme ‘beliefs about health disorders’ indicated that Batak Karo people believe magic has a strong and significant impact on health-seeking behaviour, which is in line with Archibong et al (2017). They believe that a diabetic foot ulcer can be caused by magic or a begu that can affect human health. In addition, the majority of participants had been told the cause of the disease when visiting the shaman, which strengthened their belief in the existence of sorcery. Batak Karo people usually visit the shaman, guru sibaso or pertawar first to deal with their health problems. However, when a health condition gets worse, they seek modern medical treatment.
The Batak Karo participants did not acquire information from health workers on treating diabetes, so failed to understand the disease and were unable to self-care, which led to complications. There were limits around self-care ability, particularly around controlling blood sugar. This is in line with the results of a previous study, which found that diabetic patients' knowledge of diabetic foot care and its prevention was related to whether those with more knowledge had a better attitude regarding their ability to self-care (Rahaman et al, 2017). Another study found that the patients with little knowledge and poor practice of diabetic foot care have a higher prevalence of ulcers (Saber and Daoud, 2018). Also, a lack of health education for patients with diabetes about foot care affects the incidence of foot ulcers (Lodha and Yadav, 2015). Therefore, patients with diabetes need comprehensive health education provided by practitioners to become more aware of self-care and to change their attitude towards this, as well as to understand the health risks associated with having diabetes.
The second theme captured physical, psychological, social and spiritual changes. Living with a diabetic foot ulcer often disrupts daily life activities, and is likely to be related to obesity, peripheral vascular disease, stress, anxiety and depression (Boulton, 2008). Furthermore, major depressive disorders, limb complications and other comorbidities may occur (Ahmad et al, 2018; Alrub et al, 2019). This is also in line with the results of research by Thongsai et al (2013), which found that 42.9% of their study participants with diabetes were depressed, and 34% had experienced a disruption in their relationships with family members.
The third theme was related to traditional treatments, which covered the Batak Karo people's habit of using traditional medicinal herbs to treat their condition. The herbs used are nderasi and sikucingen gara leaves, pegagan stems and paku-paku roots in specific amounts. The ingredients are chopped or sliced, dried and cooked, and taken in three litres of water twice daily until the patient is cured. Traditional medicine is established and could be considered an important alternative to modern treatment. Fan et al (2018) used tangbi waixi (a mixture of herbs) to treat diabetic peripheral neuropathy, which helped to relieve clinical symptoms and increase the speed of nerve conduction in the lower limbs. This is supported by Gu and Pei (2017) who found that Chinese traditional medicinal herbs had the ability to increase general effectiveness of treatment and the rate of ulcer healing, reduce amputation rates and shorten healing time.
The theme of ‘cultural beliefs’ included the performance of various traditional ceremonies, such as ralleng tendi, erpangir ku lau, prayer with a guru sibaso or pertawar, priest, family, friends, church members and clan group members. This is consistent with the results of research by Sinaga and Sembiring (2019), which reported that the guru has many positions in the life of the Batak Karo people, depending on their expertise and efficacy. For instance, the guru sibaso, as a medium for communication, can relate to and invite supernatural spirits into the human body. This cultural belief affects diabetic ulcer healing. This maintains the misconception that diabetes is caused by spiritual forces or curses, and is related to the use of herbal medicines, intentional non-compliance with modern healthcare advice, difficulty in changing old habits and a lack of motivation to exercise (Mogre et al, 2019). Other barriers, related to subjective norms, are inadequate family support, social stigma and cultural trust (Mogre et al, 2019).
The final theme was related to the ‘seeking health services’ behaviour, which indicated that Batak Karo people would seek medical assistance when there was no sign of healing using traditional medicines, with some people using both types of treatment. This is consistent with research conducted by Abu-Qamar and Wilson (2012), who found Jordanian patients with diabetic foot injuries eventually sought medical assistance after traditional treatment failed. Before carrying out various searches to determine which treatment would be the best, most participants were already undergoing traditional treatments based on their beliefs. The majority became aware of modern wound care information from friends, families and through the internet. This social influence creates beliefs in people with diabetic foot injuries. The barriers patients with diabetes experience in seeking health services include provision being inadequate, as well as poverty and cultural issues (Basity and Iravani, 2014; Mahmoud et al, 2016).
This study shows that people in the Batak Karo ethnic group have certain views and values as well as different ways of responding to changes in health status. Culture plays a central role in the choices and methods used by individuals to treat diseases. Although this study provides a comprehensive understanding of human experiences in the treatment of diabetic foot ulcers, its findings cannot be generalised to other ethnic groups in Indonesia. Future research could involve recruiting more ethnic groups and comparing their diabetic management according to their cultural beliefs.
Beliefs within a cultural context need to be considered when providing services to improve the Batak Karo ethnic group's health behaviours.
There is also the potential to develop a nursing model to increase nurses' cultural competence so they are able to communicate and interact with people from different cultures and develop cultural awareness and positive attitudes towards differences.
Conclusion
The lived experience of the Batak Karo ethnic group in the treatment of diabetic foot ulcers was culturally related to supernatural and magical powers. This is a hereditary belief held by the participants from their ancestors that every health problem should be cured using the group's rules to get rid of disturbed spirits, avoid calamity and heal disease; this is done through traditional ceremonies such as ralleng tendi, erpangir ku lau, prayer with a guru sibaso or pertawar, priest, family, friends, church members and clan group members, as well as using traditional herbs such as spices, param, Karo oil, sembur and tambar. Nurses need to pay attention to these sociocultural aspects and increase their cultural awareness and competency in providing services to these patients undergoing treatments for a diabetic foot ulcer.