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Journal of Endocrinology & Metabolism

Original Article

Volume 6, Number 6, December 2016, pages 172-177

Diabetic Foot Care: Knowledge and Practice

Diabetes mellitus (DM) is considered as one of the most challenging public health concerns, as globally 422 million adults were living with diabetes in 2014, compared to 108 million in 1980 [1, 2]. The global prevalence of diabetes has nearly doubled since 1980, rising from 4.7% to 8.5% in the adult population [2].

One of the major complications associated with DM is the diabetic foot (DF) disease. This complication almost affects 50% of patients and accounts for nearly 80% of all non-traumatic amputations of the lower limb [3, 4]. The disease represents nearly 35% of all hospital admissions in diabetic specialized clinics [3]. DF complication is the major cause of a significant loss of quality and years of life of diabetic patients [4, 5]. In term of cost, it represents 12-15% of the overall cost associated with diabetes and up to 40% in developing countries [5, 6].

Proper patients’ awareness about foot care is important defense line in preventing DF problems and amputation [7]. Correct practices of foot health care are essential for reducing the incidence of foot ulcers and complication [8].

Gulf Arabian countries are characterized by high and increasing diabetes prevalence. In Saudi Arabia, the prevalence of DM in adults was 25% [9]. Recent research in Saudi Arabia suggested that more than 44% of individuals aged 55 or older had severe to uncontrolled diabetes with long-term complications [10].

Although there are significant studies in Saudi Arabia about DF and its complication [11-15], studies in Jazan region are scanty. The main objective of this study was to measure the knowledge level among diabetic patients about DF and to assess the adherence level among diabetic patients to foot care.

This is an observational cross-sectional study conducted in Jazan town, the provincial capital of Jazan region. Jazan region is located in south-western part of Saudi Arabia. It is bounded to the north by Asir region and to the south by the State of Yemen and from the east Asir region and the State of Yemen, and the Red Sea to the west. Jazan Diabetic Center was established to improve the lives of people with diabetes and its complications through innovative care, education, and research that will lead to prevention and cure of the disease. The center is semi-autonomous institution located within Jazan General Hospital.

Participants were recruited during October 2013 from patients attending Jazan Diabetic Center. Eligibility criteria included: 1) age of 18 years and above; 2) being diagnosed with DM; and 3) having clinical file in the Center. Patients who consented to participate in the study were asked to complete a questionnaire. A random sampling of 250 patients was calculated using prevalence of DF, 95% confidence interval and error not more than 7%. Systematic random sampling was used to select the participants.

A pre-tested structured questionnaire was used as study tool. This tool was developed after consulting relevant studies conducted in Saudi Arabia [13, 14] and elsewhere [16, 17]. The final version of the questionnaire consisted of 47 classified into main five sections. Section one contained socioeconomic background characteristics questions. The second section includes information about DM like duration of the disease and type of DM. The third part asked questions on DF and its pattern, while the fourth and fifth sections include questions on DF knowledge and practice. Medical students collected the information using face to face interview.

Data were reviewed carefully to verify that there are no data mistakes and the errors were corrected immediacy. The Statistical Package for Social Sciences (SPSS) software program was used for data analysis. Frequency distributions were obtained and descriptive statistics were calculated. Knowledge was measured using 10 questions covering good foot care practice in the areas of feet washing techniques, skin and nail care and foot wear care. Each “yes” answer carried one [5] point and zero point for a “no”. The points were then added up to provide total knowledge score. The level of knowledge, whether good or poor, was determined based on the mean score. Those who scored more than the mean were considered as good and scores lower than the mean were considered as poor. Another level of data analysis was conducted using Chi-square test to test some associations. A P value less than 0.05 was considered significant.

Ethical approval for the current study was obtained from the College of Medicine, Jazan University. Participants were told that they have the right to not participate in the study or to withdraw from the study if they wish at any time. The participant’s privacy was respected, and data were kept confidentially and utilized for study purposes only. Participants were asked to read and sign a consent form.

Table 1 presents some background information about the study participants. A total of 250 patients were included in this study (112 males and 138 females). Most patients were more than 48 years old (67.7%). A majority of the patients were married (78.8%) and 26.4% of the patients had received a university education degree. The prevalence of diabetes is higher among patients with lower to middle income (38.0% and 39.2%, respectively) and 42.4% live in traditional houses (Table 1).

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Table 1. Background Characteristic of Study Population (n = 250)

According to Table 2, the prevalence of DF among males and females was 58.0% and 52.9%, respectively, without significant difference between both sexes. Eighteen percent of study population reported history of foot ulcer. Prevalence of tingling sensation was 70.5% among males compared to 74.6% for females, also without significant differences between the two groups. Regarding attitudes towards foot wounds, 75.5% of males said that they go to doctor, compared to only 46.0% of females, with significant difference between both sexes (P value less than 0.001) (Table 2).

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Table 2. Diabetic Foot Features and Attitudes According to Gender

The majority of patients who were attending Jazan Diabetic Center had moderate foot care knowledge, with 53.6% of them scoring more than the mean score. Gender, duration of DM, marital status and age had no significant association with knowledge and none of the variables had a P value of less than 0.05 (Table 3).

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Table 3. Analysis of Factors Associated With the Levels of Knowledge

Table 4 shows the pattern of foot care among diabetic patients. There is no significant difference between males and females in foot inspection, nail care, adherence to medication and shoes check. But we found that males were more adherent to foot drying by 65.2%, while females are applying more attention to softening of skin by 72.3%.

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Table 4. Practice of Foot Care Among Study Population

The aim of this study was to measure the knowledge level among diabetic patients attending Jazan Diabetic Center about DF and to assess the adherence level the patients to foot care.

An important result was that a significant proportion of the Jizani population had poor knowledge of foot care (46.4%). There was no significant difference between males and females for this indicator. This finding was comparable with other related studies, which also reported the same pattern of scoring for knowledge and practice of foot care [16, 17]. Many other studies showed the presence of inadequate knowledge of self-foot-care in diabetic patients [18, 19]. In Saudi Arabia, a group of studies highlighted a lower level of foot care knowledge than the optimum [13, 20]. All researchers indicated the need for foot care education programs and improving the way of delivering it.

Tingling sensation is the first sign of foot problems and its increase with uncontrolled plasma glucose. In our study, there is high prevalence of tingling sensation reaching 72.8%. Although 57.3% of the patients taking vitamins, also taking vitamin B12 could improve foot nerve, but the longer patient has the disease, the more he suspected to have a neuropathy complication. We found that there is an inverse association between tingling sensation and sport practice. The tingling sensation decreases by an increase in exercise time because the exercise increases the circulations of the blood, so nerves have good nutrient.

It is well known that when clinicians are aware of a patient’s very elevated risk for lower-extremity amputation, they were more likely to prescribe preventive foot care behaviors [21]. This fact is slightly against what we found, since 70.8% of our patients have a history of tingling sensation, 36.8% have a history of slow healing wounds, and 24.5% have a history of ulcer.

We found that there is no difference between males and females in foot inspection and nail care, because 90% of Arab populations are Muslims. They pray five times per day where the feet have to be washed before praying. These maneuvers help patients to inspect their feet as well as clean them. Washing feet before praying and the praying itself offer some sort of physical massage to the feet. Trimming the nails is a habit encouraged by Islam [22].

Our results revealed that generally foot care is inadequate since 68.0% inspect their foot regularly, 57.2% dry their fingers and foot properly, and 44.0% wake bare foot. This poor level of foot care practice in this study is in agreement with other previous studies [19, 23, 24]. Some of the inadequacies of foot care practice in our subjects include also non-inspection of inside of their footwear (23.8%) and wearing shoes without socks (29.6%). The poor practice of foot care in this study may be attributed to the lack proper knowledge of foot care among the participants.

Our results suggested a gender difference regarding attitudes towards foot wounds among study participants, as 75.5% of males said that they consult a doctor, compared to only 46.0% of the females. This result seems to be in contrast with the available literature on foot care, where there is either no gender difference between both sexes [16] or males are usually reluctant to acknowledge their health problems and seek professional care [25, 26].

The strength of this study is that it is the first study to discuss this important issue in Jazan region. Despite this strength, the study has some limitations that should be mentioned to facilitate the proper understanding of study outcomes. First, because the work is based on a cross-sectional survey design, the direction of relationships and causal relationships cannot be determined. Second, the result of this study should be interpreted carefully since it is based on a single center. Second, this is a clinic-based study. Hospital-based studies cannot provide true picture of DF care knowledge and practices of the community. Third, we used a questionnaire that is not validated among Arabian population.

In conclusion, the knowledge and practice of foot care among DM patients in our study participants were not adequate. The result of this study has highlighted the gaps in their knowledge and practice and underscores the urgent need for a patient friendly educational intervention. It is important to activate the role of health education to everyone who has direct contact with the patient, to minimize the DF complications.

Acknowledgments

The authors would like to thank the Diabetic Center of Jazan General Hospital for the support of this study. The authors also acknowledge, with much appreciation, the input and participation of all medical staff in the center for their support and encouragement. They also extend their thanks to the patients who sacrificed their valuable time and actively participated in the survey.

Author Contributions

Amal Abduallah Al-Faify, Duaa Thiyabi Hakami, Mymona Abdullah Al Faifi, Abrar Wali Hakami, Abrar Humeed Hakami and Halimah Hamood Sharif conceptualized and designed the study, conducted data collection and wrote the report. Hala M. Kheir supervised the whole work and approved the final manuscript as submitted. Mohamed S. Mahfouz carried out the initial analysis, drafted the manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted. Yahya M. Solan supervised the work, critically reviewed the manuscript, and approved the final version of the manuscript. All of the study team approved the final version of the manuscript as submitted.

Conflicts of Interest

The authors declare no conflicts of interest.

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Journal of Endocrinology and Metabolism is published by Elmer Press Inc.