INDONESIAN SCHOLARS JOURNAL 2014-ISJ-001-00110

Descriptive Study of Nursing Students Attitude

Toward Maggot Therapy Application in Ulcer
Care for Diabetics
1

Nurul Fajry Maulida, 2Maufiroh, 3Munzilir Rohmah, 4Lavenda Geshica, 2Yustia Istiarni
1

Faculty of Pharmacy, Universitas Indonesia

Faculty of Nursing Science, Universitas Indonesia
3
Faculty of Mathematical and Natural Science, Universitas Indonesia
4
Faculty of Psychology, Universitas Indonesia
2

Abstract. Background: Maggot therapy has been applied by more than 30 countries. A research by Sherman showed that
maggot therapy was more effective and efficient in debriding non healing foot and leg ulcers in male diabetic veterans compared
to conventional care. Before considering using maggot therapy in Indonesia, the attitudes of nursing student as future nurses and
as prospective therapists should be described first. Objective: The purpose of this descriptive study was to describe the attitude
variable for nursing student at Universitas Indonesia toward maggot therapy application in ulcer care for diabetics. Attitude
variable consists of cognitive dimension, affective dimension, and behavior dimension. Based on our hypothesized, we suggest
that nursing student gives positive response toward maggot therapy. Methods: Sixty students were randomly divided into two
groups; educated and non-educated group about maggot therapy, the education was attached in the front sheet of questionnaire
paper. Non-random sampling is used as the technical sampling. Besides that, we interviewed nurses in Rumah Perawat (Rumat)
as informants to support quantitative data. Results: By calculating each dimension from both educated and non-educated group
data, we used Mann-Whitney test and the result was p = 0.001 for cognitive dimension, p = 0.464 for affective dimension, and p
= 0.105 for behavior dimension. That means, there is difference on cognitive dimension, and there is no difference on affective
and behavioral dimension. Conclusion: The result of this study shows that nursing student attitude gives good response toward
Maggot Therapy.
Keywords: Maggot Therapy, nursing student, attitude description, ulcer care, diabetics

A. INTRODUCTION
th

Indonesia was ranked 4 in the world as the highest

number of people with diabetes mellitus [1]. Diabetic foot
ulcer is a major complication of diabetes mellitus, 12-14% of
its patients need amputation [2]. At RSCM, a national central
hospital in Indonesia, 14.3% of all patients with amputation
will die after one year and 37% of all patients with amputation
will die after three years [3]. In Indonesia, the main ulcer care
for diabetics comprises of three point; debridement,
offloading, and infection control [4].
Nowadays, maggot therapy, as an ulcer care for diabetics,
has been applied by more than 30 countries [5]. Maggot
therapy works using live maggots [6]. A research from
Sherman [7] showed that maggot therapy was more effective
and efficient in debriding non healing foot and leg ulcers in
male diabetic veterans than was continued conventional care.
The larvae from Lucilia sericata (green bottle fly) used for
maggot therapy could be found in Indonesia as tropical area
[8].
According to World Health Organization, nurses play an
important role in ulcer care for diabetics because patients care
is the first duty of nurses [9]. In advance of considering using
maggot therapy in Indonesia, the attitudes of nurses as
prospective therapists should be described first. In this
research, we involved nursing student instead of the nurses
because according to Patidar et al. [10] nursing students have

power to be nursing representative in the future. About 83.2%

of nursing students were self motivated to join nursing, 99.1%
of the students perceived nursing profession as an opportunity
to serve humanity, and 93.4% of the students were not
interested to change their profession. Therefore, the purpose of
this study was to describe nursing student attitude toward
maggot therapy application in ulcer care for diabetics.

B. MATERIALS AND METHODS

The purpose of this descriptive study was to describe the
attitude variable which consists of cognitive dimension,
affective dimension, and behavior dimension for nursing
student at Universitas Indonesia about maggot therapy
application in ulcer care for diabetics. The population of this
research was the nursing students at Universitas Indonesia.
Sixty students were randomly divided into two groups; group
with treatment and without treatment. The treatment, an
education about maggot therapy, attached in the front sheet of
questionnaire paper. Non-random sampling is used as the
technical sampling.
There are two kinds of primary data in this research. First,
quantitative data were directly obtained from questionnaires
given to nursing students. The questionnaire consisted of
forty-five questions, divided into three different dimensions;
cognitive, affective, and behavior. Second, qualitative data

INDONESIAN SCHOLARS JOURNAL 2014-ISJ-001-00110

were obtained from deep interview with nurses at Rumah

Perawat (Rumat)1 using opened questions to dig deeper
informations about attitude description of nurses toward
maggot therapy application in ulcer care for diabetics.
Saphiro-Wilk normality test and nonparametric statistical
test approach (Mann-Whitney test) was used to explore the
normality and to discover whether there is an attitude
description difference between educated and non-educated
group [11].
Cognitive dimension were measured using questions and
provided with 3 possible answers; agree, disagree, or didnt
know. Correct answers were given score 1 if positive
questions were answered agree or negative questions were
answered disagree. If positive questions were answered
disagree, negative questions were answered agree, then it
was given score 0. Then, it was given score 0 too, if positive
or negative questions were answered didnt know. The
category of measurement is:
1) Good, if respondents have total scores above or equal
with the median;
2) Poor, if respondents have total scores under the
median.
Affective dimension were measured using questions and
provided with 2 possible answers; agree or disagree. Correct
answers were given score 1 if positive questions were
answered agree or negative questions were answered
disagree. If positive questions were answered disagree,
negative questions were answered agree, then it was given
score 0. The category of measurement is:
1) Supportive, if respondents have total scores above or
equal with the median;
2) Not supportive, if respondents have total scores under
the median.
Behaviour dimension were measured using questions and
provided with 2 possible answers; agree or disagree. Correct
answers were given score 1 if positive questions were
answered agree or negative questions were answered
disagree. If positive questions were answered disagree,
negative questions were answered agree, then it was given
score 0. The category of measurement is:
1) Good, if respondents have total scores above or equal
with the median;
2) Bad, if respondents have total scores under the
median.

C. RESULTS
The results of the attitude description study between
educated and non-educated group have been shown on table 1,
table 2, table 3, and table 4. Based on Saphiro-Wilk normality
test, the data was not normally distributed (p < 0.05).
Therefore, the test will use nonparametric statical test
approach, that is Mann-Whitney Test, we obtained:

A clinic where nurses can give ulcer care for diabetics.

Table 1. Summary of cognitive dimension.

Noneducated
Educated

Median

Minimum
value

Maximum
value

30

2.00

0.00

11.00

0.001

30

9.00

2.00

13.00

Using 0.05 significance level, we conclude that there is

median difference between educated and non-educated group
on cognitive dimension.
Table 2. Summary of affective dimension

Non
educated
Educated

Median

Minimum
value

Maximum
value

30

12.00

2.00

14.00

0.464

30

12.00

6.00

15.00

Using 0.05 significance level, we conclude that there does not

exist difference among educated and non-educated group on
affective dimension.
Table 3. Summary of behavior dimension

Non
educated
Educated

Median

Minimum
value

Maximum
value

30

12.50

3.00

15.00

0.105

30

14.00

1.00

15.00

Using 0.05 significance level, we conclude that there is no

significant median difference between educated and noneducated group on behaviour dimension
Table 4. Summary of category measurements

Cognitive
Affective
Behaviour

Category
Good
Poor
Supportive
Not-supportive
Good
Bad

Educated
56.7%
43.3%
53.3%
47.6%
60%
40%

Non-educated
6.7%
93.3%
43.3%
56.7%
50%
50%

D. DISCUSSION
Maggot therapy is essentially a controlled therapeutic
myasis (maggot infestation on live host. It is controlled by
selecting a safe and effective species and strain, by chemical
disinfection to make the maggots germ-free, by containing
maggots within special dressings that prevent them from
leaving the wound unescorted, and through quality control
measures throughout the breeding and production processes
[12-13]. Maggots are applied to the wound at a dose of 5-10
larvae per square centimeter of wound surface area and are left
within their dressing for 48-72h [5]. At the point they are
satisfied, finished working, and can be removed. Clinical an
laboratory studies have identified four major actions of

INDONESIAN SCHOLARS JOURNAL 2014-ISJ-001-00110

medicinal maggots on wounds; debridement, disinfection,

stimulation of healing, biofilm inhibition and eradication [5].
Maggot therapy was found to be more effective and
efficient in debriding non healing foot and leg ulcers than
conventional medical and surgical care [7]. It was faster and
more thorough than control therapy when measured at 2 weeks
(p= 0.02) and again at the end of the study period (p= 0.001)
[5]. But, maggot therapy associated pain or discomfort is
reported in 5-30% of wounds treated [14-15]. Like in all cases,
these patients also reported wound pain before receiving
maggot therapy [5]. Medicinal maggots are regulated by some
countries as a prescription-only or drug [5]. Maggot therapy is
cost-effective because the cost of it was just over half of
conventional therapy [16]. Technological advances in material
design have allowed manufacturers to create single-piece,
hinged, cage-like dressings that confine the maggots to the
wound [13]. These dressings are much simpler and less timeconsuming to apply than the current method by which
therapists construct individualized cage dressings out of
materials not specifically developed for maggot therapy [12].
Researchers continue to extend the understanding about
wound healing as they explore the mechanisms by which
maggots help the heal wounds.
Besides, in studies of patients with chronic wounds, most
were quite accepting of maggot therapy [5]. A recent survey
discovered that health care professionals and administrators
are much more likely to be disgusted by the thought of maggot
dressings than are patients with chronic wounds [5]. In fact,
Jones and Thomas said that maggots are being applied earlier
in the disease process and are now often the first choice of
treatment with some specialist practitioners [17]. Related to
this research, we found that there is attitude description
difference in cognitive dimension because the therapy is still
unheard-of in Indonesia. While there is no difference in
affective and behaviour dimension between educated and noneducated group because nursing students as prospective health
practitioners will support whatever kind of ulcer care for
diabetics as long as able to improve patients quality of life.
This thought is also supported by nurses while having deep
interview in Rumat.
I support any good ulcer care as long as its effective,
why not? said a nurse in Rumat.2
Another informant from Rumat Cibubur said,
I felt rather disgusted, if I were a patient., I will search
for another alternative therapy. But, If I were a nurse, I
will
support it.3
According to table 4, we discovered that 53,3% educated
nursing students were good in cognitive dimension while
almost of uneducated nursing students were poor in cognitive
dimension. In affective dimension, 53,3% educated nursing
2

This interview was taken by Nurul on Wednesday, May 21 st

2014 at 14:30 at Rumat Bekasi
3
This interview was taken by Lavenda on Tuesday, May 20th
2014 at 15:30 at Rumat Cibubur

students were supportive, while less than them, 43,3% noneducated nursing students were supportive. Similar with
affective dimension, in behaviour dimension, we have found
that educated nursing students have higher percentage than
non-educated nursing students. Eventhough there is no
difference between educated and non-educated nursing
students from analytical results, from table 4, we still able to
discover a slit of difference.

E. CONCLUSION
Nursing student at Universitas Indonesia as prospective
nurses supported and had good behaviour about maggot
therapy application in ulcer care for diabetics.

ACKNOWLEDGEMENT
We acknowledge nursing student at Universitas Indonesia,
Mr Dadang as Rumat Chairman, nurses at Rumat Cibubur and
Bekasi, Mrs Rani as our advisor lecturer, and our friends from
Research Department in Kelompok Studi Mahasiswa Eka
Prasetya UI, without their sacrifes, we would not able to finish
this paper.
REFERENCES
[1] Depkes Website. (2012, September 19) [Online]. Available:
http://www.depkes.go.id/index.php?vw=2&id=2053.
[2] David S. Perdanakusuma, Penanganan Luka Kronik.: Ulkus Diabetik.
Surabaya: Universitas Airlangga/RSUD Dr. Soetomo.
[3] Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata M., and Setiati S, Ilmu
Penyakit Dalam. Jakarta: Universitas Indonesia, 2006.
[4] Kruse I and Edelman S., Evaluation and Treatment of Diabetic Foot
Ulcer, Clinical Diabetes, vol. 24, no. 2, pp. 9193, 2006.
[5] Robet. A. Sherman, Maggot Therapy Takes Us Back to The Future of
Wound Care: New and Improved Maggot Therapy for the 21 st Century,
Journal of Diabetes Science and Technology, vol. 3, no. 2, pp. 336344,
2009.
[6] Chan DCW, Fong DHF, Leung JYY, Patil NG, and Leung GKK,
Maggot Debridement Therapy in Chronic Wound Care, Hong Kong
Medical Journal, vol 13, no. 5, pp 382-386, 2007.
[7] Ronald A. Sherman, Maggot Therapy for Treating Diabetic Foot Ulcers
Unresponsive to Conventional Therapy, Diabetes Care, vol 26, pp.
446-451, 2003.
[8] Australian Museum. (November 2009) [Online]. Available:
http://australianmuseum.net.au/Decomposition-fly-life-cycles.
[9] Aalaa, Tabatabaei Malazy, Sanjari, Peimani, and Mohajeri, Nurses
Role in Diabetic Foot Prevention and Care; A Review, Journal of
Diabetes and Metabolic Disorders, vol 11, no. 24, pp. 11-24, November
2012.
[10] Patidar, Anurag B., Kaur, Jasbir, Sharma, Sursh K., and Naeraj, Future
Nurses Perception Towards Profession and Carrier Plans: A Cross
Sectional Survey in State Punjab, Nursing and Midwifery Research
Journal, vol. 7, no. 4, pp. 175, 2011.
[11] Sutanto P. Hastono and Luknis Sabri, Statistik Kesehatan. Jakarta: Raja
Grafindo Persada, 2008, pp. 98.
[12] Sherman RA, A New Dressing Design for Use with Maggot Therapy,
Plast Reconstr Surg, vol. 100, no. 2, pp. 451, 1997.
[13] Sherman RA, Tran JM, Sullivan R, Maggot Therapy for Treating
Venous Stasis Ulcers, Arch Dermatol, vol. 132, no. 3, pp. 254, 1996.
[14] Sherman RA, Sherman J, Gilead L, Lipo M, Mumcuoglu KY, Maggot
Debridement Therapy in Outpatients, Arch Phys Med Rehabil, vol 82,
no. 9, pp. 1226-9, 2001.
[15] Sherman RA, Maggot Versus Conservative Debridement Therapy for
The Treatment of Pressure Ulcers, Wound Repair Reagen, vol. 10, no.
4, pp. 208-14, 2002.

INDONESIAN SCHOLARS JOURNAL 2014-ISJ-001-00110

[16] Wayman J, Nirojogi V, Walker A, Sowinski A, Walker MA, The Cost

Effectiveness of Larval Therapy in Venous Ulcers, J Tissue Viability,
vol. 10, no. 3, pp. 91-4, 2000.
[17] Jones M, Thomas S, Larval Therapy. Nurs Stand, vol 14, no. 20, pp.
47-51, 2000.