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Relationship Between Social Isolation and Health Behaviors and Ulcer Severity in Diabetic Foot Patients
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摘要:目的 探讨社会隔离与糖尿病足患者健康行为及溃疡严重程度之间的关系。方法 对2020年9月–2021年12月在南方医科大学南方医院内分泌与代谢科就诊的160名2型糖尿病合并糖尿病足患者进行横断面研究，收集其足部溃疡的Wagner分级、Lubben社会网络量表评分，并分析其健康行为（是否接受过糖尿病足教育、延迟就诊、足部检查频率等健康行为）特点，同时收集患者一般资料，包括性别、年龄、文化程度、工作状况。按照Lubben社会网络量表得分将患者分为社会隔离组（n=60）和非社会隔离组（n=100），比较两组患者足溃疡严重程度及健康行为是否存在差异。结果 本研究结果提示，与非社会隔离组相比，社会隔离的糖尿病足患者就诊时Wagner 3～5级的比例更高（P<0.05）。健康行为分析显示，社会隔离组中从不检查足部及延迟就诊的糖尿病足患者比例更高（P<0.05），两组间在是否接受过糖尿病足教育、足部损伤原因、伤口自行处理、吸烟及饮酒上差异无统计学意义。相关性分析显示，Lubben社会网络量表得分与延迟就诊（r=−0.353，P=0.001）呈弱负相关，即社会隔离程度越高，糖尿病足患者延迟就诊时间可能越长。结论 社会隔离与糖尿病足患者健康行为及溃疡严重程度有一定关系。关注糖尿病足患者的社会隔离，增加其社会环境及社会网络成员的接触，可能会对改善糖尿病足患者延迟就诊情况有积极作用，对后续的治疗尤为重要。Abstract:Objective To explore the relationship between social isolation and health behaviors and ulcer severity in patients with diabetic foot.Methods A cross-sectional study was conducted with 160 patients suffering from type 2 diabetes mellitus combined with diabetic foot. The patients received treatment at the Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University between September 2020 and December 2021. Patient information was collected, including the scores for Lubben Social Network Scale and the Wagner classification of foot ulcers. Analysis was conducted to study the characteristics of the patients’ health behaviors, including whether they received information and education on diabetic foot, whether there were delays in their attempt to access medical service, the frequency of foot examinations, etc. In addition, patient demographic data were collected, including sex, age, education, and employment status. According to their scores for Lubben Social Network Scale, the patients were divided into a social isolation group (n=60) and a non-social-isolation group (n=100). The severity of the foot ulcers and the health behaviors of the two groups were compared to identify differences.Results The findings suggest that, compared with the non-social-isolation group, the social isolation group had a higher proportion of diabetic foot patients with Wagner grade 3-5 diabetic foot ulcers (P<0.05). Analysis of the health behaviors showed that the social isolation group had a higher proportion of diabetes foot patients who had never undergone examination of their feet and those who had delayed attempts to access medical service for their condition (P<0.05). There were no significant differences between the two groups in terms of whether the patients had received information and education concerning diabetic foot, causes of foot injury, self-treatment of wounds, smoking, and drinking. Correlational analysis suggested that the scores of Lubben Social Network Scale were negatively correlated with the delayed attempts to access medical service (r=−0.353, P=0.001), that is, the higher the degree of social isolation, the longer the delay in patients’ attempt to access medical service for their diabetic foot.Conclusions Social isolation is correlated to health behaviors and ulcer severity in patients with diabetic foot. Giving more attention to the problem of social isolation of diabetic foot patients and increasing their ties with the social environment and the members of their social network may have a positive effect on improving the delays in diabetic foot patients’ attempt to access medical service, which is particularly important for follow-up treatment.
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Keywords:
- Diabetic foot /
- Social isolation /
- Health behaviors
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随着我国糖尿病发病率的逐年增长，糖尿病足的患病率也随之增加，是我国当前非创伤性截肢的最主要病因[1-2]。如何降低足部溃疡的严重程度、促进伤口愈合始终是至关重要的[3]。目前糖尿病足的治疗主要集中在清创、减压、血管评估、控制感染及血糖控制等方面，忽视了社会隔离在糖尿病足中所起的作用。当前社会隔离是一个严重的公共卫生问题，COVID-19大流行期间有关社会隔离与疾病的关系尤被关注[4]。社会隔离被定义为有限的社会网络和社会支持，主要表现为与家人、朋友或团体社会接触的减少或独自生活[5]。既往研究结果显示，拥有较少和较差的社会网络与不良的健康状况和更高的死亡风险有关[6-8]。同时研究表明，在人类和动物模型中，孤独感和社会隔离会延迟伤口愈合[9]。社会网络受限也被证明对个体的健康行为有不良影响，并可能会限制个体与医疗保健系统的接触，最终导致疾病恶化[10-12]。目前已有研究发现社会隔离与糖尿病足关系密切[13]。但是国内尚无关于糖尿病足患者社会隔离与健康行为及溃疡严重程度的关系的研究报道。
本研究对近两年收治的160名糖尿病足患者进行横断面研究，探索其社会隔离情况与糖尿病足溃疡的严重程度的关系，并分析社会隔离对糖尿病足患者健康行为的影响。
1. 对象与方法
1.1 研究对象
对2020年9月–2021年12月，在南方医科大学南方医院内分泌代谢科就诊的160名符合纳入和排除标准的糖尿病足患者进行连续入组。纳入标准：①年龄≥18岁；②符合2型糖尿病诊断标准；③符合糖尿病足诊断标准；④自愿参与本研究；⑤能够理解所有的研究要求。排除标准：①非糖尿病性溃疡；②存在明显交流障碍（如视听障碍或认知功能障碍）。本研究项目经南方医科大学南方医院医学伦理委员会批准（NFEC-2021-310）并获患者知情同意。
1.2 研究方法
1.2.1 研究工具
1.2.1.1 一般数据收集问卷
采用自行设计的一般数据收集问卷，包括人口特征、健康行为及Wagner分级。其中人口特征包括性别、年龄、受教育程度、居住地及工作状况。健康行为包括吸烟、饮酒、足部损伤原因、自行处理伤口、是否接受过糖尿病足教育、延迟就诊及足部检查频率。延迟就诊被定义为糖尿病足患者出现足部创口后就诊于正规医疗机构的时间>24 h，同时收集患者首次出现伤口后首次就诊于正规医疗机构的具体天数[14]。根据Wagner分级评估糖尿病足溃疡严重程度，其中Wagner 1～2级为轻度，Wagner 3～5级为重度[15]。
1.2.1.2 Lubben社会网络量表
采用LUBBEN在2020年修订的Lubben社会网络量表（Lubben Social Network Scale-Revised, LSNS-R）进行社会隔离评估，该量表包含家庭及朋友两个维度，共12个条目，每个条目采用0～5分评分，总分60分，<24分提示出现社会隔离[16]。同时Lubben社会网络量表得分越低，表明社会网络越有限。梁淑敏等[17]对Lubben社会网络量表在中国人群中进行了信效度检验，其中内容效度为1.0，Cronbach's α=0.77，具有较高的信效度，在国内人群中可有效使用。根据Lubben社会网络量表得分将入组的糖尿病足患者分为社会隔离组与非社会隔离组。
1.2.2 资料收集方法
以上所有问卷均采用面对面访谈的形式进行，由经过培训的工作人员与受访者在安静且无其他人的房间内进行。完成问卷后所有纸质版数据将经过双重核对后录入电子系统进行储存以便后期对资料进行核查。
1.2.3 统计学方法
对缺失值采用多重填补（MI）处理。首先进行描述性分析以检查社会隔离与非社会隔离组糖尿病足患者的人口学特征，计量资料采用
$ \bar x \pm s $ 表示，计数资料采用率或构成比表示。符合正态分布且方差齐的两组间计量资料比较采用两独立样本t检验，不符合正态分布且方差不齐的两组计量资料比较采用非参数检验（Mann-Whitney U检验）。无序计数资料采用卡方检验，有序计数资料采用秩和检验。相关性分析采用Pearson相关性检验。检验水准α=0.05。 2. 结果
2.1 糖尿病足社会隔离组与非社会隔离组基本社会人口学特征比较
本研究共包括160名糖尿病患者，其中社会隔离组60人，非社会隔离组100人；社会隔离组平均年龄为（59.80±12.53）岁，女性19例（31.70%）。非社会隔离组平均年龄为（60.83±11.86）岁，女性44例（44.00%）。两组在性别、年龄、居住地、工作状况及受教育程度上差异无统计学意义。见表1。
表 1 社会隔离组与非社会隔离组一般人口统计学特征比较Table 1. Comparison of general demographic characteristics between the social isolation group and the non-social-isolation groupVariable Social isolation group (n=60) Non-social-isolation group (n=100) Z/t/χ2 P Age/yr., $ \bar x $±s 59.80±12.53 60.83±11.86 0.68 0.603 Sex/case (%) 2.39 0.122 Male 41 (68.30) 56 (56.00) Female 19 (31.70) 44 (44.00) Education level/case (%) 5.77 0.143 Primary education 24 (40.00) 38 (38.00) Secondary education 36 (60.00) 53 (53.00) Junior college 0 (0.00) 4 (4.00) Higher education 0 (0.00) 4 (5.00) Residence/case (%) 0.56 0.508 City 33 (55.00) 61 (61.00) Countryside 27 (45.00) 39 (39.00) Employment status/case (%) 2.12 0.146 Employed or others 20 (32.20) 45 (45.00) Retired or unemployed 40 (67.80) 55 (55.00) 2.2 糖尿病足社会隔离组与非社会隔离组健康行为比较
表2显示了与非社会隔离组患者相比，社会隔离组患者中从不检查足部的占比更高，延迟就诊的比例更高，差异均有统计学意义（P<0.05），而吸烟、饮酒、是否自行处理足部伤口、足部损伤原因及是否接受糖尿病足教育等健康行为在两组间差异无统计学意义。
表 2 社会隔离组与非社会隔离组健康行为特征比较Table 2. Comparison of health behavior characteristics between the social isolation group and the non-social-isolation groupVariable Social isolation group (n=60) Non-social-isolation group (n=100) χ2/t/Z P Smoking/case (%) 1.72 0.423 None 37 (61.70) 70 (70.00) Quit 7 (11.70) 12 (12.00) Current smoking 16 (26.70) 18 (18.00) Drinking/case (%) 2.39 0.302 None 49 (81.70) 78 (78.00) Quit 4 (6.70) 14 (14.00) Still drinking 7 (11.70) 8 (8.00) Causes of foot injury/case (%) 0.61 0.436 Trauma 25 (41.70) 48 (48.00) Others 35 (58.30) 52 (52.00) Self-treatment of the wound/case (%) 0.00 1.000 Yes 39 (65.00) 65 (65.00) No 21 (35.00) 35 (35.00) Information and education on diabetic foot/case (%) 3.84 0.072 Yes 24 (40.00) 56 (56.00) No 36 (60.00) 44 (44.00) Frequency of foot examination/case (%) 3.56 0.000 Never 33 (55.00) 30 (30.00) Occasionally 18 (30.00) 32 (32.00) Often 9 (15.00) 38 (38.00) Delayed attempts to access medical service/case (%) 11.43 0.001 Yes 56 (93.30) 71 (71.00) No 4 (6.70) 29 (29.00) Treatment time/week, $ \bar x $±s 7.17±7.35 3.41±4.58 8.39 0.000 进一步对糖尿病足患者延迟就诊情况进行分析发现，非社会隔离组出现伤口后就诊于正规医疗机构的时间要短于社会隔离组，差异有统计学意义（P<0.05）。
2.3 糖尿病足社会隔离组与非社会隔离组溃疡严重程度比较
表3显示了社会隔离组与非社会隔离组溃疡严重程度的差异。与非社会隔离组患者相比，社会隔离组患者中糖尿病足溃疡重度患者（Wagner 3～5级）的占比更高，差异有统计学意义（χ2=3.95，P<0.05）。
表 3 社会隔离组与非社会隔离组溃疡严重程度比较Table 3. Comparison of ulcer severity between the social isolation group and the non-social-isolation groupSeverity Social isolation group (n=55) Non-social-isolation group (n=86) χ2 P Mild (Wagner 1-2)/case (%) 8 (14.55) 25 (29.07) 3.95 0.047 Severe (Wagner 3-5)/case (%) 47 (85.45) 61 (70.93) 5 patients in the social isolation group and 14 patients in the non social isolation group did not have Wagner data. 2.4 社会隔离与患者就诊时间相关性分析
Pearson相关性检验结果显示，社会网络量表得分与延迟就诊时间呈负相关，即社会网络量表得分越低，延迟就诊时间越长（r=−0.353，P=0.001），呈低度相关。
2.5 足溃疡严重程度与患者就诊时间相关性分析
进一步对糖尿病足患者就诊时间与足溃疡严重程度分析，Sperman相关性检验结果显示，Wagner分级与就诊时间呈正相关，即患者出现伤口后就诊于正规医疗机构的时间越长，Wagner分级越高（r=0.10，P=0.003），但相关度较低。
3. 讨论
本研究通过对就诊于南方医院的160名糖尿病足患者进行横断面研究，对社会隔离与糖尿病足患者健康行为及溃疡严重程度的关系进行探索。
国际糖尿病足工作组（IWGDF）对于加强足部溃疡预防的建议就包括定期检查和评估有溃疡风险的足[18]。本研究结果显示，社会隔离组患者从不检查足部的占比为55.00%，而非社会隔离组从不检查足部的患者占比为30.00%，社会隔离组从不检查足部的比例要显著高于非社会隔离组。社会隔离主要是有限的社会网络及不足的社会支持[5]。其中社会网络主要是指个人与家庭成员、亲戚和朋友之间的互动[19]。社会支持被定义为通过社会网络建立联系，并且获得帮助和支持的过程，包括情感支持、物质支持等[20]。既往研究显示糖尿病患者感知社会支持与良好的自我管理呈正相关，同时也对健康的生活方式有着积极影响[21-23]。LAOPOULOU等[24]通过对140名糖尿病足患者进行横断面调查，发现了社会支持与更好的自我护理呈正相关。较高的社会支持水平的患者能更好地了解健康状况和其他自我护理行为（如坚持服药、坚持推荐的体育活动、与护理人员有良好的关系、检查和护理足部）。积极的社会参与、与周围环境的更多接触对糖尿病患者的自我管理起着一定积极作用。本研究结果与上述研究结果一致。因此，我们推测，社会隔离程度高的患者，由于从社会网络成员中获得的社会支持较少，最终导致自我护理行为缺乏或依从性的下降，无法及时发现早期的伤口，延误就诊时间，最终导致足溃疡的进一步加重。
结果提示，社会隔离的糖尿病足患者就诊时Wagner 3～5级的比例更高，同时社会隔离的糖尿病足患者，延迟就诊比例更高。相关性分析结果显示，延迟就诊时间与Lubben社会网络量表得分之间有相关关系，社会网络量表得分越低，糖尿病足患者的延迟就诊时间可能越长。来自国外的一项针对54名糖尿病足患者的队列研究结果显示，28%的患者延迟就诊时间大于1周，20%的患者延迟就诊时间大于2周[25]。PROMPERS等[26]调查了欧洲14个糖尿病足中心的糖尿病足溃疡患者转诊轨迹的持续时间。17%的延迟就诊时间为<1周，58%的患者为1周至3个月，25%的患者大于3个月。而在本研究中，社会隔离组平均延迟就诊时长为（7.17±7.35）周，非社会隔离组（3.41±4.58）周。隔离组的糖尿病足患者延迟就诊时间显著长于非隔离组。SAKURAI等[12]发现社会隔离可能通过限制个体与医疗系统的接触，最终导致不良的健康后果。
同时本研究进一步分析就诊时长与糖尿病足溃疡严重程度的关系，结果显示出现伤口后就诊于正规医疗机构的时长越长，就诊时Wagner分级可能越高，但相关性较弱。本研究结果与曹强等[14]的一项横断面结果一致，该研究发现就诊延迟与Wagner 分级呈正相关。延误就诊不仅会导致错失最佳治疗时机，甚至可能导致感染及截肢风险的升高。对于严重感染、缺血的糖尿病足溃疡而言，时间就是组织，时间就是生命，对其进行及时正确的治疗至关重要。
由于本研究是横断面研究不允许进行因果推断，因此我们只能推测糖尿病足患者社会社会隔离与健康行为及足溃疡严重程度的可能关系。同时由于本研究仅就是针对单中心的研究，患者来源较单一，后续可行多中心研究并进一步扩大样本量。
社会隔离与糖尿病足患者健康行为及溃疡严重程度相关。关注糖尿病足患者的社会隔离，增加其社会环境及社会网络成员的接触，可能会对改善糖尿病足患者延迟就诊情况有积极作用，对后续的治疗尤为重要。
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利益冲突 所有作者均声明不存在利益冲突
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表 1 社会隔离组与非社会隔离组一般人口统计学特征比较
Table 1 Comparison of general demographic characteristics between the social isolation group and the non-social-isolation group
Variable Social isolation group (n=60) Non-social-isolation group (n=100) Z/t/χ2 P Age/yr., $ \bar x $±s 59.80±12.53 60.83±11.86 0.68 0.603 Sex/case (%) 2.39 0.122 Male 41 (68.30) 56 (56.00) Female 19 (31.70) 44 (44.00) Education level/case (%) 5.77 0.143 Primary education 24 (40.00) 38 (38.00) Secondary education 36 (60.00) 53 (53.00) Junior college 0 (0.00) 4 (4.00) Higher education 0 (0.00) 4 (5.00) Residence/case (%) 0.56 0.508 City 33 (55.00) 61 (61.00) Countryside 27 (45.00) 39 (39.00) Employment status/case (%) 2.12 0.146 Employed or others 20 (32.20) 45 (45.00) Retired or unemployed 40 (67.80) 55 (55.00) 
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表 2 社会隔离组与非社会隔离组健康行为特征比较
Table 2 Comparison of health behavior characteristics between the social isolation group and the non-social-isolation group
Variable Social isolation group (n=60) Non-social-isolation group (n=100) χ2/t/Z P Smoking/case (%) 1.72 0.423 None 37 (61.70) 70 (70.00) Quit 7 (11.70) 12 (12.00) Current smoking 16 (26.70) 18 (18.00) Drinking/case (%) 2.39 0.302 None 49 (81.70) 78 (78.00) Quit 4 (6.70) 14 (14.00) Still drinking 7 (11.70) 8 (8.00) Causes of foot injury/case (%) 0.61 0.436 Trauma 25 (41.70) 48 (48.00) Others 35 (58.30) 52 (52.00) Self-treatment of the wound/case (%) 0.00 1.000 Yes 39 (65.00) 65 (65.00) No 21 (35.00) 35 (35.00) Information and education on diabetic foot/case (%) 3.84 0.072 Yes 24 (40.00) 56 (56.00) No 36 (60.00) 44 (44.00) Frequency of foot examination/case (%) 3.56 0.000 Never 33 (55.00) 30 (30.00) Occasionally 18 (30.00) 32 (32.00) Often 9 (15.00) 38 (38.00) Delayed attempts to access medical service/case (%) 11.43 0.001 Yes 56 (93.30) 71 (71.00) No 4 (6.70) 29 (29.00) Treatment time/week, $ \bar x $±s 7.17±7.35 3.41±4.58 8.39 0.000
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表 3 社会隔离组与非社会隔离组溃疡严重程度比较
Table 3 Comparison of ulcer severity between the social isolation group and the non-social-isolation group
Severity Social isolation group (n=55) Non-social-isolation group (n=86) χ2 P Mild (Wagner 1-2)/case (%) 8 (14.55) 25 (29.07) 3.95 0.047 Severe (Wagner 3-5)/case (%) 47 (85.45) 61 (70.93) 5 patients in the social isolation group and 14 patients in the non social isolation group did not have Wagner data.
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