Patients’ awareness and extent of self-reported foot care practices in diabetes population

INTRODUCTION

Diabetes mellitus (DM) is a group of chronic metabolic disorders characterized by elevated level of blood glucose that is associated with significant morbidity, mortality and increasing health care cost.¹ The world prevalence of diabetes is 8.5% and it affects 422 million adults, in 2014.² The prevalence of diabetes has been steadily increasing for the past 3 decades and is growing most rapidly in low and middle income countries. According to the International Diabetes Federation (IDF) report, the prevalence of diabetes in Africa among adults aged 20–79 years was 4.2% in 2017.^2,3 In Ethiopia diabetes mellitus is emerging as one of the major chronic health problem, and the prevalence adjusted to the national population was 4.4% in 2013.^4,5

DM can result in blindness, renal failure, lower limb amputation, coronary artery disease, peripheral vascular disease, stroke and other long-term consequences that have significant impact on the patients quality of life.^1,2 Of these complications, diabetes related foot problem affects majority of DM patients.⁶

Foot ulcer in patients with diabetes is a global health burden and one of the most feared and common complications of diabetes.^7,8 It is the most frequently recognized complication of DM that consists of lesions in the deep tissues associated with neurological disorders and peripheral vascular disease in the lower limbs.^9,10 It has an annual incidence rate of 2 to 4% in developed countries and this prevalence may even be higher in developing countries due to socio-economic differences and variations in standards of care.¹¹ The lifetime risk of DM patients developing a foot ulcer could be as high as 19-34%.¹² Rates of foot ulceration in Africa vary between regions and have been estimated to be between 4 to 19%.¹³ In Ethiopia the incidence and prevalence of foot ulcer is still unknown in the general population.⁴ The study conducted in Northwest and South Ethiopia showed that the prevalence of foot ulcer among diabetes patients is 13.6% and 14.8% respectively.^14,15 In Ethiopia, diabetes related foot ulcer is major health problem which results 12% of death associated with sepsis.¹⁶

Foot problem complications are the most common cause of hospitalization in the person with diabetes.¹⁷ It is estimated that approximately 20% of hospital admissions among patients with DM are the result of diabetes foot ulcer (DFU).^18,19 Lower extremity amputation is one of most devastating consequences of DFU and of all amputations in diabetes patients, 85% are preceded by a foot ulceration which subsequently deteriorates to a severe gangrene or infection (9). DFU results not only physical problem but also it affects psychosocial, economic and overall quality of life of DM patients.^8,20 The risk of foot ulceration and limb amputation increases with older age, long duration of diabetes, poor glycemic control, peripheral neuropathy, cigarette smoking, foot deformities, and peripheral arterial disease.^12,22

Early recognition of foot ulcer and treatment of patients at risk for ulcers and amputations can delay or prevent adverse outcomes.²³ DM patients level of awareness and correct foot self-care practices may reduce the risk of diabetes foot complications, ultimately amputation.^24,25 Even though diabetes foot self-care is an evolutionary process of development of knowledge or awareness by learning that patients do in order to reduce further complication, there is a lack of evidences that assess DM patients awareness and practice regarding foot self-care in Ethiopia. Therefore this study was intend to assess DM patients’ level of awareness and practices of foot care.

METHODS

Study area and period

An institutional based cross-sectional study was conducted at University of Gondar Specialized Hospital ambulatory clinic from March to June 2018. The hospital is located 738km northwest Ethiopia from the capital city Addis Ababa. This study include all adult (age 18 years and above) DM patients. Newly diagnosed and DM patients who had less than one month of duration after diagnosis were excluded in this study.

Sample size

The overall sample size was determined using single population proportion formula. Here we used the expected proportion (p) from previously published study that was done in Felege Hiwot Referral Hospital, Bahir Dar City, North West Ethiopia.²⁷ According to this study the actual number of DM patients having good foot care practice was 54.6% with 95% confidence interval (CI) and margin of error (d) of 5%. The total DM patients registered in this hospital are estimated to be about 3000. By the use of correction formula the final sample size including 10% non-response rate estimated to be 372.

Sampling technique

Convenient sampling technique was used in which all consecutive patients were interviewed until the sample size was reached. To avoid double counting of cases, card number of the participants who had undergone the interview were documented each day. Any patient coming to the clinic at specific day was counterchecked with the document prior to conducting the interview.

Data collection techniques and instrument

The data collection tool had three parts; the socio-demographic, awareness of foot care and practice of foot care. The questionnaire was prepared in English initially and translated to Amharic, the translated version was again translated back to English language to maintain the consistency in the meaning of words or concepts of the data collection tool. The awareness measuring questions was adapted from similar study conducted before.^20,26-29 Whereas foot self-care practices questionnaire is adapted from validated instrument of Nottingham Assessment of Functional Foot care (NAFF).^30,31 Data was collected by 5^th year pharmacy students through face to face interview of the structured questionnaires.

Data analysis and interpretation

The collected data was cleaned, arranged, coded, checked for completeness and then analyzed by SPSS version 20. Descriptive analysis was used to summarize socio demographic and other baseline information. Summary statistics including standard deviations used for continuous variables. Bivariate logistic regression analysis was used to determine the association between variables and level of foot care practice. A p value <0.05 was considered as a statistically significant.

The level of awareness or knowledge was considered as adequate (≥70%), and inadequate (<70%) depending on previous studies.^29,32,33 While the overall level of foot care practice ≥50% was considered as good and <50% poor practice based on NAFF score.^30,31 All the NAFF question items had a score of (0-3). In this study DM patients who had a score of 2 or 3 for each questions were considered to have good practice and 0 or 1 score poor practice (Table 4).

RESULTS

Socio-demographic characteristics

Among the total of 372 study participants 197 (53%) of them were male. The mean age was 43.20 (SD±14.96 years) with an age range of 18-90 years. More than half 231 (62.1%) of the study participants were living in urban area. Around 38% of the study participants were can’t read and write and 9.6% of DM patients were student (Table 1).

Clinical characteristics of the study participants

Out of the total study participants 228 (61.3%) of them were DM-type 2. Majority 347 (93.3%) of DM patients had previous information about DFU. Likewise 132 (34.5%) of the patients had previous history of foot ulcer. Around 93 (25%) of DM patients had hypertension as a comorbid condition (Table 2).

Awareness of DM patients regarding foot self-care

Of all the participants, only 273 (73%) of DM patients aware that they should inspect their feet everyday regularly. Majority 287 (77.2%) of DM patients didn’t know that at what temperature of water they have to wash their feet. Around 34 % of DM patients unaware that they should inspect footwear before they put them on (Table 3).

Patients with diabetes foot self-care practices

The finding of this study showed that majority 244 (65.6%) of DM patients had overall good foot self-care practice. However, more than half 200 (53.8%) of DM patients had poor practice towards drying of their feet after they wash. Majority 271 (72.8%) of the study participants also had poor practice in changing the socks/stockings used regularly (Table 4). In this study the mean practice score was 25.1±6.21 with a range of 5-36 out of possible maximum score of 48.

Factors associated with DM patients’ foot self-care practice

The result of study showed that foot self-care practice had a statistically significant association with level of awareness about foot self-care and previous information about DFU. DM patients who had poor level of awareness or knowledge towards foot self-care had 12 times [AOR 12.55, 95% CI (6.49-24.28)] poor practice as compared to who had good awareness. DM patients who had no previous information about DFU had 7 times [AOR 7.03, 95% CI (2.11-23.46)] poor practice as compared to those had previous information about DFU (Table 5).

*For these items ‘yes’ response was DM patients able to respond the correct response.

*Statistically significant at p value <0.05, COR: crude odds-ratio; AOR: adjusted odds-ratio.

DISCUSSION

Foot ulcer in patients with diabetes is a serious complication of diabetes which results continuous hospital admissions and lower extremity amputation.^9,19,33 The purpose of the study was to assess diabetes patient’s awareness and their foot self-care practice. The result of this study revealed that more than half (50.8%) of DM patients had good awareness or knowledge towards foot self-care. This finding was in line with the study done in Bahir Dar Ethiopia which shows 56.2% of DM patients had good knowledge.²⁷ This might be explained by the similarity between the study population in sociocultural and geographical location. The finding of this study was higher than the study conducted in Hawassa, Ethiopia (27.3%) and India (24%) of DM patients had good awareness regarding foot care. This might be due to majority of their study participants were from rural area and housewife.^16,17 However, the result obtained was lower than other study conducted in Lahore which showed that 86.6% of DM patients had good awareness about their foot care.³⁴ This might be due to the fact that, in Lahore their health facilities provide diabetes guide book that may improve DM patients awareness towards foot self-care which isn’t well practiced in Ethiopia.³⁴

In this study even though majority 73.4% of DM patients aware that they should inspect their feet regularly for foot ulcer, around 85% of DM patients didn’t understand that foot wounds and/or infection may not heal quickly. This might directly affect the special attention given by themselves if foot ulcer occurs. The result of this study showed that 26% of DM patients had cigarette smoking and/ or alcohol drinking habit. However, more than half (61%) of the study participants unaware that smoking will affect the healing process of foot ulcer and it causes poor circulation of blood towards the feet. The finding of this study is similar with the study done in India around 77.4% DM patients didn’t know that smoking causes poor circulation of blood towards the feet.³⁵ The result of this study showed that 40% of DM patients didn’t know that what they have to do at the first time if they found redness/bleeding in their feet. Furthermore around 31% of DM patients unaware that they should consult healthcare professionals at any time if there is any foot problem and only 21% of the study participants undertake previous foot check up by healthcare professionals. These implies that continuous counselling and education regarding foot self-care should be given by healthcare professionals and DM patients foot check-up should be considered as other standard investigation done during their follow-up.

In the present study majority (66%) of DM patients had good practice of foot care. This finding is higher than study carried out in Nigeria, Jinnah Lahore and Jordan which shows 10.2%, 29.3% and 18.2% of DM patients had good practice towards foot self-care respectively.^29,32,33 Such differences could be explained by classification system of practice score in which >70% of total score is considered as good practice in these studies which was not considered in this study. Furthermore more than 93% of DM patients in our study had previous information regarding foot ulcer and this might positively affect their level of practice.

The result of this study showed that DM patients who had previous information about foot ulcer had good practice. This result was consistent with study conducted in Chennai, India.²⁸ This could be explained by the fact that foot-care specific patient education is an essential element of a health system program which significantly improves the patients' knowledge and foot self-care practices.^24,36 Healthcare professionals had a vital role in improving DM patients’ knowledge and practices of foot care. In addition the current study indicated that as DM patients who had poor awareness regarding to foot care had 13 times poor practice as compared to who had good awareness. This result has been consistent with study conducted in Jazan town, Saudi Arabia.³⁷ This might be due to the fact that appropriate foot care practice is positively influenced by patient’s awareness and reduced awareness or knowledge could be the greatest barrier to good foot care practices.²⁸

Limitation of the study

The limitation of this study includes; it is a single center study, there will be recall and personal bias during patient interview and patients’ answers might be over optimistic. Therefore, interpretation of the findings obtained should be taking into consideration of these limitations.

CONCLUSION

Overall DM patients at this setup had good awareness and practices of foot care. However majority of DM patients had selectively poor practice regarding drying of their feet after they wash, changing regularly the socks/stockings used, wearing of slippers with no fastening, and using of moisturizing cream on their feet. Foot self-care practices were positively associated with having good awareness about foot care and having previous information about foot ulcer. Therefore, intensive foot care educational program needs to be established and adhered through multidisciplinary approach in a way that it is easy to understand and practice. On the other hand, health care facilities need to incorporate foot care services among other routine services like investigations and medication refill.

ACKNOWLEDGEMENTS

The authors would like to thank study participants and data collectors who sacrificed their valuable time and actively participated in this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

1. 1. Chisholm-Burns MA, Wells BG, Schwinghammer TL. Pharmacotherapy principles and practice: McGraw-Hill; 2016.
2. 2. World Health Organization (WHO). Global report on diabetes: 2016.
3. 3. Cho N, Shaw J, Karuranga S, Huang Y, da Rocha Fernandes J, Ohlrogge A, et al. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Prac. 2018;138:271-81.
4. 4. Amogne W, Reja A, Amare A. Diabetic foot disease in Ethiopian patients: A hospital based study. Ethiopian J Health Develop. 2011;25(1):17-21.
5. 5. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Prac. 2014;103(2):137-49.
6. 6. Al-Rubeaan K, Al Derwish M, Ouizi S, Youssef AM, Subhani SN, Ibrahim HM, et al. Diabetic foot complications and their risk factors from a large retrospective cohort study. PloS One. 2015;10(5):e0124446.
7. 7. Zubair M, Malik M, Ahmad J. Diabetic foot ulcer: a review. Am J Int Med. 2015;3(2):28-49.
8. 8. Snyder RJ, Hanft JR. Diabetic foot ulcers—effects on quality of life, costs, and mortality and the role of standard wound care and advanced-care therapies in healing: a review. Ostomy/wound management. 2009;55(11):28.
9. 9. Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med. 2017;49(2):106-16.
10. 10. Armstrong DG, Cohen K, Courric S, Bharara M, Marston W. Diabetic foot ulcers and vascular insufficiency: our population has changed, but our methods have not. J Diabetes Sci Technol. 2011;5(6):1591-5.
11. 11. Jones NJ, Harding K. 2015 International Working Group on the Diabetic Foot Guidance on the prevention and management of foot problems in diabetes. Int Wound J. 2015;12(4):373-4.
12. 12. Armstrong DG, Boulton AJ, Bus SA. Diabetic foot ulcers and their recurrence. New England J Med. 2017;376(24):2367-75.
13. 13. Abbas Z, Archibald L. Epidemiology of the diabetic foot in Africa. Med Science Monitor. 2005;11(8):262-70.
14. 14. Mariam TG, Alemayehu A, Tesfaye E, Mequannt W, Temesgen K, Yetwale F, et al. Prevalence of Diabetic Foot Ulcer and Associated Factors among Adult Diabetic Patients Who Attend the Diabetic Follow-Up Clinic. J Diabetes Res. 2017;2017.
15. 15. Deribe B, Woldemichael K, Nemera G. Prevalence and factors influencing diabetic foot ulcer among diabetic patients attending Arbaminch Hospital, South Ethiopia. J Diabetes Metab. 2014;5(1):1-7.
16. 16. Bago BJ. Knowledge, Practice and Barriers of Diabetic Foot Ulcer among Diabetic Patients in Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia. J Health Med Nursing. 2018;46.
17. 17. Gholap MC, Mohite VR. To assess the knowledge and practice regarding foot care among diabetes patients at Krishna hospital, Karad. Indian J Scientific Res. 2013;4(2):69.
18. 18. Shahbazian H, Yazdanpanah L, Latifi SM. Risk assessment of patients with diabetes for foot ulcers according to risk classification consensus of International Working Group on Diabetic Foot (IWGDF). Pakistan J Med Sci. 2013;29(3):730.
19. 19. Yazdanpanah L, Nasiri M, Adarvishi S. Literature review on the management of diabetic foot ulcer. World J Diabetes. 2015;6(1):37.
20. 20. Pitchai P, Joshi J. Knowledge and Practice of Foot Care amongst Diabetics in India: Comparison between Urban and Rural Setting-A Reality Check. Int J Health Sci Res. 2015;5(4):181-9.
21. 21. Association AD. 4. Lifestyle Management: Standards of Medical Care in Diabetes. Diabetes Care. 2018;41(1):38-50.
22. 22. Alexiadou K, Doupis J. Management of diabetic foot ulcers. Diabetes Therapy. 2012;3(1):4.
23. 23. Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, et al. Diabetic foot disorders: a clinical practice guideline (2006 revision). J Foot Ankle Surg. 2006;45(5):1-66.
24. 24. Muhammad-Lutfi A, Zaraihah M, Anuar-Ramdhan I. Knowledge and practice of diabetic foot care in an in-patient setting at a tertiary medical center. Malaysian Orthopaed J. 2014;8(3):22.
25. 25. Amin N, Doupis J. Diabetic foot disease: from the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities. World J diabetes. 2016;7(7):153.
26. 26. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disorders. 2013;12(1):14.
27. 27. Seid A, Tsige Y. Knowledge, practice, and barriers of foot care among diabetic patients attending Felege Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia. Adv Nursing. 2015;2015.
28. 28. Geetha EM. A study on Knowledge, Attitude and Practice of Podiatric care among patients with Diabetes Mellitus in Rural Chennai. Stanley Med J. 2017;4(3):29-33.
29. 29. Desalu O, Salawu F, Jimoh A, Adekoya A, Busari O, Olokoba A. Diabetic foot care: self-reported knowledge and practice among patients attending three tertiary hospital in Nigeria. Ghana Med J. 2011;45(2).
30. 30. Lincoln N, Jeffcoate Mrcp WJ, Ince P, Smith Rgn M, Radford K. Validation of a new measure of protective footcare behaviour: The Nottingham Assessment of Functional Footcare 2007;207-11.
31. 31. Senussi M, Lincoln N, Jeffcoate W. Psychometric properties of the Nottingham Assessment of Functional Footcare (NAFF). Int J Therapy Rehab. 2011;18(6):330-4.
32. 32. Hasnain S, Sheikh NH. Knowledge and practices regarding foot care in diabetic patients visiting diabetic clinic in Jinnah Hospital, Lahore. JPMA J Pakistan Med Assoc. 2009;59(10):687.
33. 33. Moh’d Al-Qaddah R, Abdallah Al Eyadeh M, Ma'en Zaid Abu-Qamar D, Younes N, Al-Ryalat D, Haddad F. Knowledge and Practice of Foot Care among Diabetics at King Hussein Medical Center, Jordan. JRMS. 2016;23(3):55-63.
34. 34. Mustafa A, Iqbal M, Parvez MA. Assessment of Knowledge, Attitude and Practices of Diabetics Regarding Their Foot Care. Age. 2017;40(4):4.
35. 35. Selvakumar S, Shah PB. Awareness and practice regarding foot self-care among patients of known type 2 diabetes mellitus in a rural area. Int J Com Med Public Health. 2017;3(4):861-4.
36. 36. Rönnemaa T, Hämäläinen H, Toikka T, Liukkonen I. Evaluation of the impact of podiatrist care in the primary prevention of foot problems in diabetic subjects. Diabetes Care. 1997;20(12):1833-7.
37. 37. Solan YM, Kheir HM, Mahfouz MS, Al-Faify AA, Hakami DT, Al Faifi MA, et al. Diabetic Foot Care: Knowledge and Practice. J Endocrinol Metab. 2017;6(6):172-7.