Proportion of foot ulcer, knowledge and practice on foot care among diabetic patients in medical college and hospital, Kolkata

INTRODUCTION

India is popularly known as the “diabetes capital of the world” and if corrective measures are not taken properly, then the number of people with diabetes will be 134 million by 2045.¹ Diabetic foot ulcer is most fatal complication of diabetes and the prevalence of DFU varies between 4% and 10%, and most common cause of morbidity and mortality in (DFU) is infections, which are seen in 40-80% of the cases.² A systematic review and meta-analysis done and the result showed that the prevalence of diabetic foot ulcers was found to be 6.3% (95% CI: 5.4-7.3%) worldwide. This was greater in males than in females.³

Among 310 diabetic outpatients from a medical college in an eastern Indian state, a three-month cross-sectional study was carried out. There were 44 diabetic foot ulcers among the 310 participants. Educating patients, families, and healthcare professionals is essential in raising awareness of these.⁴ Diabetic foot complications increase the physical, psychological, and financial burden of the disease on patients and the community. They also compromise patients’ health and quality of life and contribute to excess mortality.⁵

A prospective observational study was conducted Kumar et al on prevalence of DFU among diabetic patients and its management. 150 patients with diabetes from all departments and inpatients with diabetic foot ulcers (DFU) from the surgical department, ranging in age from 20 to 80 years. Among patients with diabetes, the prevalence of DFU was 16%.⁶

A cross-sectional study was conducted from a tertiary care hospital in southern India on diabetic foot care: knowledge and practice. 30.39 percent or so had a good knowledge score. Poor glycaemic control, poor educational status, rural background, and a history of foot ulcers were all significantly linked to low foot care knowledge. diabetic patients, policymakers should start foot care education programmes across the regional state to raise awareness about good foot care practices and lower the risk of complications.⁷

Varghese et al conducted a study to assess the knowledge and practice on foot care among the diabetic patients at Aswini Hospital, Thrissur among 60 diabetic patients of selected hospital. This study result showed that 53 patients had adequate knowledge regarding the foot care practice among diabetic patients and 50 patients maintain good practice regarding foot care. The study results also showed that an association between knowledge and practice and a perfect positive correlation found between knowledge and practice.⁸ A cross-sectional study on the burden of diabetic foot ulcers and its determinants among type 2 diabetes patients visiting an “integrated diabetes and gestational diabetes clinic” in eastern India. The prevalence of DFU in this study was found to be 9.5%. The occurrence of DFU was significantly favoured by increasing age, low educational status, longer duration of diabetes, insulin treatment, and BMI≥25.00. Comorbidities such as hypertension, ischemic heart disease, hypothyroidism, PAD, and peripheral sensory neuropathy were also significantly associated with DFU in our study population. Mean HbA1c was significantly higher among the study participants who had DFU.⁹

Objectives

Objectives were to find out the proportion of diabetic foot ulcers among diabetic patients, to assess the knowledge regarding the diabetic foot care among diabetic patients, to determine the practice regarding diabetic foot care among diabetic patients, to find out the relationship between the knowledge with practice of diabetic foot care among diabetic patients, to find out the association between the level of knowledge on diabetic foot care among diabetic patients with selected demographic variables and to find out the association between the practice of diabetic foot care among diabetic patients with selected demographic variables.

METHODS

Study design, settings, sample

Descriptive survey research was conducted from 27 February 2024 to 23 March 2024 among 204 diabetic patients of diabetic clinic of medical college and Hospital, Kolkata. Systematic random sampling technique was adopted where selecting every 6th patient as a sample.

Measurement tools and validity

Tools were divided into for section which were validate by seven experts.

Tool-I

A semi structured interview schedule to obtain demographic data of diabetic patients. This section consists of 9 items regarding age, gender, residence, educational status, occupational status, monthly family income, types of diabetes, duration of diabetes and Presence of ulcer.

Tool-II

Structured interview schedule to assess the knowledge of diabetic patients regarding foot care. This tool was used to assess the knowledge and understanding level of patients regarding foot care.

Tool-III

A structured rating scale was used to assess the stated practice of diabetic patients regarding foot care. Participants are instructed to tell their responses by interviewing that corresponds with the answer that best describes how frequently the patient performs the practice with the statements given in the rating scale.

Inclusion criteria

Diabetic patients who were visiting in diabetic clinic during data collection period and able to understand and speak in Bengali or English or Hindi and willing to participate in the study.

Exclusion criteria

Diabetic patients who were extremely sick and gestational diabetes patients and those who dissented from participating in the study.

Ethical approval and informed consent

Approval from the ethical committee of Medical College, Kolkata was taken and informed consent from the diabetic patients who are attending diabetic clinic of Medical College, Kolkata.

Data collection procedure for final study

Two days per week and every day data from 22 -23 samples were collected and total time was taken for each individual 14-15 minutes. At first according to inclusion and exclusion criteria sampling frame was formed and from this frame 1^st sample selection was done with simple random sampling by lottery method and then according to systematic random technique every 6^th patient selected as a sample. Data collected through interview schedule.

Statistical analysis

The data was organized, tabulated, analysed and interpreted by using descriptive and inferential statistics. The data was computed using MS excel and SPSS version 23. Pearson correlation was used to find out the relation between knowledge and practice regarding foot care among diabetic patients. Chi-square test was computed to determine the association between selected demographic variables and knowledge and practice regarding foot care among diabetic patients.

RESULTS

Table 1 shows that among 204 sample 62.25% of diabetic patients were belongs to the 46-64 years age group. It shows that most of (55.88%) diabetic patients were male, and 55.39% of patients belonged to urban residents. It also shows that 49.02% of diabetic patients had secondary education and 48.53% of diabetic patients were self-employed. Most of diabetic patient (45.10%) had total family income 15000 to 26000. Most of diabetic patients (96.08%) were type 2 DM and 40.20% diabetes patient having diabetes more than 10 years.

Data presented in Figure 1 depicted that 92.64% (189) of diabetic patients do not have foot ulcers, and 7.35% (15) have diabetic foot ulcers. So, the proportion of foot ulcers was 7.35%.

Data presented in Table 2 depicts that majority of the diabetic patients (59.31%) had average knowledge, whereas 22.55% had very poor knowledge and 18.14% had good knowledge regarding diabetic foot care. The study depicted that the mean knowledge score was 13.63, median 14 which can be interpreted that data was almost normally distributed with mild negative skewness (-0.25). The SD of knowledge score was 4.38 that means the data were mildly dispersed.

Data presented in Table 3 shows that highest mean percentage score was in the area of follow up care for diabetes patient (86.02%), and score obtain in recommended nutrition for diabetic patient (80.88%), recommended exercise for diabetic patients (67.81%) and lowest in the area of cause and signs and symptoms (41.01%) of diabetic foot and prevention of diabetic foot (53.92%).

Data presented in Table 4 depict that majority of the diabetic patient (71.57%) had average stated practice score, whereas 16.67% had good practice and 11.76% had poor average regarding foot care. This study showed that mean practice score was 15.39, median 16 which can be interpreted that data was almost normally distributed with mild negative skewness (-0.48). The SD of practice score was 3.75 that means the data were mildly dispersed.

Data presented in Table 5 shows the area wise distribution of practice score. It depicts that highest mean percentage score was in the area of diabetic control related practice (85.84%), and relatively lowest score was obtained in foot hygiene related practice (58.05%).

Data presented in Table 6 shows that the item-wise frequency and percentage distribution on practice of foot care performed by diabetic patients. It was reported that 68.14% of them never washing feet with lukewarm water, 40.19% of them never moisturized their feet, 79.90% of them always dried their leg after washing, 57.35% of them walked with cover and well-fitted shoes, 72.05% of them always trimming toenail regularly, 56.37% of them always inspect their shoes before wearing, 78.43% of them always washing their foot wear weekly, 59.31% never inspect their feet regularly, 80.39% of them always consult with doctor monthly, 57.35% of them avoid sugar in the diet, 44.6% of them doing exercise minimum 30 minutes for 5 days in a week, 87.74% of them always taking anti diabetic medicine regularly.

Table 7 depicts that, the mean of knowledge score and practice score of diabetic patients on diabetic foot care were 13.63 and 15.39 respectively.

Co-relation coefficient has calculated to find out the relation between knowledge and practice scores of diabetic patients on diabetic foot care, which was 0.79 and ‘t’ value 18.31. The computed value was greater than the table value of ‘t’ (2.258) at df 202 at 0.05 level of significance. So, it can be interpreted that the obtain strong positive correlation among the variables is true relationship and not by chance.

The hypothesis can be generated from the above finding in Table 7: H₁ there is statistically significant relationship between knowledge and practice regarding foot care among diabetic patients at 0.05 level.

The data present in Table 8, reveals that there was statistically significant relation found between knowledge level and selected demographic variables of diabetic patients in terms of place of residence, educational status, occupation, monthly family income and duration of diabetes after confirmation at 0.05 level of significance. So, it can be concluded that knowledge of foot care was influenced by place of residence, educational status, occupation, monthly family income and duration of diabetes after confirmation of diabetic patients.

So, from the finding of Table 8 a hypothesis can be generated: H₂ there is significant association between knowledge regarding foot care and their residence, education, occupation, monthly family income, duration of diabetes after confirmation of diabetic patients at 0.05 level.

t(202) =2.258, p<0.05 *Significant.

Chi square (1) = 3.841, p value <0.05.

Chi square (1) = 3.841,*p value<0.05

The data present in Table 9, reveals that there was statistically significant relation found between practice level and selected demographic variables of diabetic patients in terms of educational status, occupation and monthly family income at 0.05 level of significance. So. it can be concluded that practice of foot care was influenced by educational status, occupation and monthly family income of diabetic patients.

Thus, hypothesis can be generated from the findings of Table 9: H₃ there is significant association between Practice regarding foot care and education, occupation, monthly family income of diabetic patients at 0.05 level.

DISCUSSION

In this present study proportion of foot ulcer 7.35% among diabetic patients.

The present study result was also partially supported by a study conducted by Gupta et al, Durgapur, West Bengal, India. Quantitative approach and non-experimental descriptive research design is adopted in this study. The frequency of DFU in this study was found to be 9.5%.⁹

Present study finds that majority of the diabetic patients (59.31%) has average knowledge regarding foot care. Some had (22.55%) very poor knowledge and rest had (18.14%) good knowledge regarding diabetic foot care.

The present study findings partially supported by a study conducted by Varghese et al, Aswini Hospital, Thrissur. The study was revealed that 7 (11.66%) had inadequate knowledge and 53 (88.33%) had adequate knowledge. Analysis showed that there was no significant association between demographic variables and knowledge.⁸

Present study finds that majority of the diabetic patients (71.57%) has average practice regarding foot care. Some had (16.67%) good and rest practice had (11.76%) very poor practice regarding diabetic foot care.

The present study findings partially supported by a study conducted by Bharti et al, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar, Jammu. The result of the study showed that, 40% had satisfactory practice (score 51-69) just 12% of study participants had good foot care practices (score ≥70%), while the majority (48%) had poor practices (score 50%).¹⁰

In the present study represents that computed ‘r’ value between knowledge score and practice score was 0.79. So, there was a strong relationship between knowledge and attitude regarding foot care. It also shows that there was statistically significant relationship between knowledge and practice as the calculated ‘t’ value was 18.31 which was greater that table value (2.58) at df (204), 0.05 level of significance.

The present study findings similar with a study conducted Varghese et al, Aswini Hospital, Thrissur. This study reveals the correlation between level of knowledge and practice of foot care among diabetic patients. Karl Pearson’s correlation was used to test the relationship between foot care practice and knowledge level. Karl Pearson’s correlation coefficient was computed, and its value was +1, which was statistically significant at the 0.05 level. Hence there was a perfect positive correlation found between knowledge and practice.⁸

The finding of current study showed that there was significant association between knowledge score with their type of residence, education, occupation, monthly income of family, duration of diabetes after confirmation (p value<0.05).

The findings of current study were partially supported by the study conducted by Bharti et al on knowledge and practice regarding foot care among type 2 diabetic patients, at Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar, Jammu. The study finding shows that there was a significant association of knowledge level with demographic variables like residence (p=0.01), education (p=0.01), occupation (p=0.023), and income (p=0.01) at p≤0.05 level of significance except for demographic/clinical variables like age (p=0.791), gender (p=1.138), and duration of illness (p=0.119).¹⁰

The finding of current study showed that there was significant association between practice score with their educational status, occupation, monthly family income (p value <0.05).

The findings of current study were partially supported by the study conducted by Pourkazemi et al on “diabetic foot care: knowledge and practice” in Guilan province (north of Iran) among 375 patients. The study finding showed that there was a significant correlation between practice score and gender, duration of diabetes, occupation, level of education, and place of residence (p<0.05).¹¹

The study has following limitations: the study cannot be generalized beyond one district of West Bengal as it was conducted in one Medical College and Hospital, Kolkata. The study was only confined to stated practice but was not any scope to measure actual performed practice of diabetic patients regarding foot care.

CONCLUSION

Diabetic foot is most devastating complication of diabetes with high morbidity, mortality and socioeconomic burden. The result of the study confirms that the majority of diabetic patients have average knowledge and practice regarding foot care. The result of study also shows that there is positive correlation between knowledge and practice score of diabetic patients. So educational programs focusing on awareness of diabetic foot care must directly involve the community, and there upon in order to reduce the incidence of diabetic foot complications. Lack of diabetic foot educational and screen programs are major contributing factors leading to diabetic foot complication and amputations. Development of specialised diabetic centres is needed to use multidisciplinary approach to minimise morbidity and mortality in this group of patients.

Recommendations

Keeping in view of the findings of the present study, the following recommendation are made for further study. A similar study can be conducted in different settings. A teaching programmed can be planned to assess its effectiveness on enhancement of knowledge and practice regarding foot care for diabetic patients. A comparative study can be performed to assess the knowledge and practice regarding foot care between diabetic patients with foot ulcer and diabetic patients without foot ulcer. A more intensive study can be done to assess the barrier of diabetic patients for maintaining proper foot hygiene and foot care practice.

ACKNOWLEDGEMENTS

Authors would like to thank to principal and other faculty members of College of Nursing, Medical College and Hospital, Kolkata.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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