9th Win n’ Learn Academic Event 2014

Research Category

FOOT ASSESSMENT AND KNOWLEDGE AMONG PATIENTS ATTENDING DIABETIC CLINIC IN SHINYANGA REGIONAL HOSPITAL

Author: LUTFI ABDALLAH [Medical Student]

Supervisor: LARY O AKOKO MD. MMED (Surgery)

OUTLINE• Introduction & background

• Problem Statement and rationale

• Broad and specific objectives

• Results and Discussion

• Conclusion, Recommendations and Reference

1. INTRODUCTIONDM is a metabolic disorder that is characterized by chronic hyperglycemia; it is common and potentially disabling chronic disease.

The prevalence of DM worldwide is 8.3% [1]

More than 371 million people have DM. [1]

4 out of 5 people with diabetes live in low- and middle-income countries. [1]

Half of people who die from diabetes are under the age of 60. [1]

Half of people with diabetes don’t know they have it. [1]

• Every 20 seconds a lower limb or part of a lower limb is lost somewhere in the world as a consequence of diabetes. [3]

Up to 70% of the people who undergo lower extremity amputation due to diabetic foot die within 5 years [2]

2. PROBLEM STATEMENT• Despite the frequency of complications involving diabetic patients’ lower limbs, primary care

practitioners frequently neglect to examine their feet. Surveys of physicians and patient chart evaluations

have determined that fewer than 50% of diabetic patients receive appropriate foot evaluation as part of

their annual medical checkups. [21] Prevention of diabetic foot ulceration is critical in order to reduce the associated

high morbidity and mortality rates, including the risk of amputation. It is essential to identify the foot at risk, through

careful inspection and physical examination of the foot followed by neuropathy and vascular test. [22]

 

• Regular foot examination, patient education, simple hygienic practices, provision of appropriate footwear, and prompt

treatment of minor injuries can decrease ulcer occurrence by 50% and eliminate the need for major amputation in non-

ischemic limbs. [4, 22] According to the American Diabetes Association, there are certain guidelines to be followed by

diabetic persons. [23]

 

• Data in Tanzania and many other sub-Saharan African countries on the diabetic foot assessment,

knowledge of the patients and health care workers on foot care and foot assessment respectively and the

factors hindering foot assessment in the diabetic clinic are sparse. However, as diabetes and foot

complications, especially amputations increase worldwide. There is no reason to believe that Tanzania is

any different, given our health resources. This is particularly evident is the scarcity of co-ordinated foot

care and podiatry.

3. RATIONALEThe study aimed at exploration of health care workers knowledge and practice towards foot

assessment as a tool for better care of diabetic patients.

The findings from this study will raise the need for the development of a tool to standardize

foot assessment among diabetic patients attending diabetic clinics country wide.

The results of the research will also help healthcare professionals to be aware of the gaps in

follow up of the diabetic patients attending the diabetic clinic.

The study has generated an Elective report as a partial fulfillment for an award of MD

Bachelor degree at Muhimbili University of Health and Allied Sciences.

4. OBJECTIVES

1.To determine on exit if foot assessment has been done to

patients who attended the clinic.

2.To assess the knowledge of diabetic patients on foot care.

3.To assess knowledge of health workers on assessment of

the foot of a diabetic patient.

4.To determine factors hindering diabetic foot assessment at

the clinic.

5. METHODOLOGY

– Study design: A cross-sectional study design.– Study area: Shinyanga Regional Hospital Diabetic Clinic– Data collection: A pre-tested, structured, close-ended, self-

administered questionnaire was used. – Sampling technique: Convenient sampling– Study population: All diabetic patients coming for regular

diabetic’s clinic at the regional hospital and the staff dedicated to offer diabetic services from August to October

– Sample size (n): The sample size was 268 pt. by using Keylie-Leslie formula

Inclusion criteria:

a) All the health care providers (nurses, CO, AMO, MD) attached to the diabetic clinic in Shinyanga regional Hospital

b) Diabetic patients who attended the diabetic clinic in Shinyanga regional hospital (No patient refused to participate in the study)

Exclusion Criteria:

c) Those who will be unwilling to be included in the study.d) Patients who don’t wish to complete the questionnairee) Patients with cognitive impairment, visual or hearing loss. f) Those who have no diabetes.

Ethical Clearance– Ethical clearance to conduct this study was received from

Muhimbili University of Heath and Allied Sciences Institution Review Board, through school of medicine.

– A separate permission to conduct the study was sought from Shinyanga Regional Hospital administration.

– All participants signed an informed consent form. No direct patient identifiers were used in data collection.

– This study carried no risk to the participant and was meant to improve diabetic patients management by decreasing morbidity associated with foot complications in the country.

6. RESULTS

Characteristics of the patients in the study (N=268)

Variables Total N (%)

Age group

≤19 25 (9.30%)20 – 29 10 (3.70%)30 – 39 38 (14.2%)40 – 49 55 (20.5%)50 – 59 65 (24.3%) ≥60 75 (28.0%)

GenderFemale 150 (56.0%)Male 118 (44.0%)

Level of EducationNo formal education 25 (9.30%)Primary School level 138 (51.5%)Secondary School level 50 (18.7%)Higher education 55 (20.5%)

Type of DM Type 1 44 (16.4%)Type 2 224 (83.6%)

First Year Diagnosed with DMNot more than 1 year 61 (22.8%)1 – 2 37 (13.8%)3 – 5 61 (22.8%)6 – 10 79 (29.5%)More than 10 years 30 (11.2%)

48.5 ± 15.566

1:1.3

• Female patients were the majority by 150(56.0%), giving a male to female ratio of 1:1.3. The age range was 13 to 78 with a mean of 48.5 ± 15.566 years.

• Most of the study subjects were above 60 years of age at 75(28%) and the least were below 29 years at 35(13%).

• Again majority of the respondents had primary level of education or less by 163(60.8%) and only 55(20.5%) had higher education. Most of the patients had been having the disease for more than six years 109(40.7%), while 61(22.8%) were just diagnosed in the same year.

Parameters assessed during clinic visit (N=268)

• Blood pressure measurement was the most performed examination, 216(80.6%), followed by weighing 225(84.0%), feet evaluation 80(29.9%) and eye examination in 10(3.7%). Most of the patients had Fasting and Random blood sugar checked 265(89.9%).

Patients response on knowledge assessment Foot care Questions

Sn Questions related to knowledge on foot care Knowledge 1 Importance of taking antidiabetic treatment to prevent

complications 179 (66.8%)

2 DM patients shouldn’t smoke because it causes poor circulation affecting the feet.

107 (39.9%)

3 Checking temperature of water before using 146 (54.5%)

4 Drying the feet after washing 134 (50.0%)

5 Talcum powder usage for keeping interdigital spaces dry 50 (18.7%)

6 Keeping skin of the feet soft to prevent dryness 164 (61.2%)

7 Lotion not to be applied in the interdigital spaces 163 (60.8%)

8 Daily change of socks 169 (63.1%)

9 Trimming nails of feet once a day by respondents 126 (47.0%)

10 Inspection of feet once a day by respondents 79 (29.5%)

11 Wearing comfortable coat shoes 86 (32.1%) 12 Checking the shoes from inside before wearing 107 (39.9%)

13 Not walking bare foot 173 (95.0%)

14 If you found redness/bleeding between your toes what is the first thing to do

117 (43.7%)

15 Even if you have never had a corn/hard skin lesion, what would you do if you have one

51 (19.0%)

Variable Knowledge Level on foot care  Poor

Knowledge<50%N (%)

SatisfactoryKnowledge50 – 69%

N (%)

Good Knowledge

>70N (%)

2(P-Value)

Age group (years)<2020 - 2930 - 3940 - 4950 - 59> 60

 4 (16.0)5 (50.0)17 (44.7)23 (41.8)37 (56.9)36 (48.0)

 14 (56.0)2 (20.0)13 (34.2)17 (30.9)17 (26.2)23 (30.7)

 7 (28.0)3 (30.0)8 (21.1)15 (27.3)11 (16.9)16 (21.3)

  

14.837(0.138)

 

GenderMaleFemale

 46(39.0)76(50.7)

 42(35.6)44(29.3)

 30(25.4)30(20.0)

 3.655

(0.161)

Level of Education      5 (20.0)20 (14.5)10 (20.0)25 (45.5)

  

20.987(0.002)

No formal educationPrimary School LevelSec. School LevelHigher education

13 (52.0)70 (50.7)20 (40.0)19 (34.5)

7 (28.0)48 (34.8)20 (40.0)11 (20.0)

History of Foot infectionYesNo

 51(56.7)71(39.9)

 28(31.1)58(32.6)

 11 (12.2)49 (27.5)

 9.992

(0.007)Type of DMType 1Type 2

  10(22.7)112(50.0)

 23(52.3)63(28.1)

 11 (25.0)49 (21.9)

 12.852(0.002)

Year first diagnosedNot more than 1 Year1 – 2 Years3 – 5 Years6 – 10 YearsMore than 10 Years

 41 (67.2)12 (32.4)27 (44.3)27 (34.2)15 (50.0)

 13 (21.3)15 (40.5)23 (37.7)29 (36.7) 6 (20.0)

 7 (11.5)

10 (27.0)11 (18.0)23 (29.1) 9 (30.0)

   

22.097(0.005)

Total 122 (45.5) 86 (32.1) 60 (22.4) 268

TABLE 3: Distribution of the level of knowledge about foot care among the diabetic patients (N = 268)

• Majority of the respondents had poor knowledge on foot care by 122 (45.5%), followed by satisfactory knowledge among 86 (32.1%) and only 60 (22.4%) had good knowledge.

• Most of the female had poor knowledge when compared with male but this was not statistically significant, p value 0.16. Age too had no significant influence on foot inspection with both having poor knowledge.

• Increasing level of education was associated with good knowledge of diabetic foot assessment, p-value of 0.002, so were the diagnosis of type 1 diabetes and no prior history of foot infection.

• The Clinic had 3 HCWs, the Registered nurse who had received a 3 month diabetes

training and 2 registrars.

• Among 3 HCWs, 2 (66.6%) had good knowledge on foot assessment.

• The minimum score was 5 and the maximum was 11.

• The nurse, who had undergone a special training on diabetic care had the highest

score than colleagues who had not received a special diabetic training.

• All HCWs cited work over load as the hindrance to foot assessment and two reported lack of monofilaments for sensation assessment.

7. Discussion

• The results from this study show that nearly half of the patients had poor

knowledge regarding foot care. This is similar to findings by other

researchers on the same topic. [24-27]

• The deficiency in the knowledge may also be due to poor communication

between the doctors and the patients and also lack of counseling by the

doctors and nurses as result of busy clinic schedules, negligence or work

overload. This is supported by a study conducted in UK where there was a

positive correlation between the score and having advised on foot care. [24]

• The relationship between the level of education and foot care among DM patients

has been observed in similar studies in India, Iran, Pakistan and Nigeria where

respondents with lower education level were least knowledgeable. [25-28]

• This can be explained by the fact that higher level of education might be associated

with increased quest for reading about the disease and its complication from

different sources

• Knowledge was also low in those with prior history of foot infection. This

is contrary to expectation that prior foot infection might have led to

education on foot care to prevent future diabetic foot related problems.

• This is supported by the findings of other researchers which explain the

impact of psychological and behavioural issues on diabetic foot thus

patient cognitive changes which influence comprehending abilities and

therefore reduce the effectiveness of foot health education. [6, 13,10,11]

• This also explains why some patients get repeated ulceration despite of

being educated and warned of the risk of ulceration. [2, 9, 10,11]

• Type one diabetic patients seem to have good knowledge when

compared to type two patients.

• This could also be explained by the expected young age of the

cohort with increased quest for information regarding care of

their afflicting disease.

• Women and those above the age of 50 were less knowledgeable

about foot care, although these associations were not

statistically significant but due to socio-cultural beliefs women

are not allowed to attain higher educational status in many third

world countries compared with their male counterpart in the

family, eventually resulting in women having less knowledge

of foot care.

8. Conclusion

The level of knowledge of foot care among DM patients in this study was poor which

may lead to lower extremity complications and recurrent foot infections, if left

untreated might lead to amputation and even death.

Improved providers knowledge and might improve diabetic care including foot

assessment.

On the other hand, overall improvement of education standards, including adding DM

education to current curricular of primary schools should be encouraged.

9. RecommendationI. Develop a schedule for health education to diabetic patients including foot care on

regular basis.

II. Train health care providers on diabetic care, and increase more staff to alleviate the

shortage in the clinic.

III.Develop patient’s treatment charts to show expected care and services during each

visit.

IV. Review the role of the diabetic nurse to include provision of foot care to diabetic

patients.

V. Consider use of DM patients with good knowledge on diabetic care as role model

and peer educator on diabetic care, including foot care.

References1. IDF DIABETES ATLAS 5th edition |2012 Update. Online document http://www.idf.org/sites/default/files/5E_IDFAtlasPoster_2012_EN.pdf (Accessed on 2nd Feb. 2013)2. Andrew Clarke. Avoiding foot complications in diabetes. CME 2010, 28(4):181-285 3. http://www.iwgdf.org (Accessed on 2nd Feb 2013)4. Alexiadou K, Doupis J. Management of Diabetic Foot Ulcers. Diabetes Ther 2012, 3(1): 45. http://www.worlddiabetesfoundation.org/projects/maharashtra-india-wdf03-056 Accessed 2nd Feb 20136. Abbas ZG, Lutale JK, Morbach S, Archibald LK: Clinical outcome of diabetes patients hospitalized with foot ulcers, Dar es Salaam, Tanzania. Diabetic Medicine 2002, 19(7):575-579.7. Abbas ZG, Archibald LK: Challenges for management of the diabetic foot in Africa: doing more with less. Int Wound J 2007, 4(4):305-13.8. Hellar AM, Mbembati NAA: The Pattern and Surgical Management of Diabetic Foot at Muhimbili National Hospital, Dar-es-salaam, Tanzania. East and Central African Journal of surgery 2011:16(1):37–459. Nyamu PN, Otieno CF, Amayo EO, Mcligeyo SO: Risk factors and prevalence of diabetic foot ulcers at Kenyatta National Hospital, Nairobi.10. Foster AVM. Podiatric Assessment and Management of the Diabetic Foot. London:Churchill Livingstone, Elsevier, 2006.11.Vileikyte L. Psy chological and behavioural issues in diabetic foot ulceration. In: Boulton AJM, Cavanagh PR, Rayman G, eds. The Foot in Diabetes, 4th ed. Chichester: John Wiley 2006; 132-142.12. Peters E. Screening for the diabetic foot: How and why. Diabetes Voice 2005; 50: 25-27.13. Edmonds ME, Foster AVM, Sanders LJ. A Practical Manual of Diabetic Foot Care. 2nd Ed.UK:Blackwell;200814. Levin ME, Foster AVM, Edmonds ME. Diabetic Foot: A Clinical Atlas. 1st ed. London: Jaypee;200315. Boulton AJM, Cavanagh PR, Rayman G. The Foot in Diabetes. 4th ed. UK: John Wiley & Sons; 200616. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 13(5): 513-21, 1990.

17. Isakov E, Susak Z, Budoragin N, et al. Self injury resulting in amputation among vascular patients: A retrospective epidemiological study. Disability and Rehabilitation 14:78-80, 1992.

18. Apelqvist J, Larsson J, Agardh CD. The influence of external precipitating factors and peripheral neuropathy on the development and outcome of diabetic foot ulcers. Journal of Diabetes Complications 4(1):21-5, 1990.19. Sanders LJ: Diabetes mellitus- prevention of amputation. Journal of the American Podiatric Medical Association 84(7): 322-28, 1994.

20. Ahroni JH: Teaching foot care creatively and successfully. The Diabetes Educator 19(4):3 20-5, 199321. Bowering CK.Diabetic foot ulcers; Pathophysiology, assessment, and therapy. Can Fam Physician 2001; 47:1007-1016.22. Lavery LA, Wunderlich RP, Tredwell JL. Disease management for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations. Diabetes Res Clin Pract. 2005; 70:31–7.23. http://familydoctor.org/online/famdocen/home/common/diabetes/living/352.html. [Accessed 2nd Feb 2013].24. Pollock RD, Unwin NC, Connolly V. Knowledge and practice of foot care in people with diabetes.Diabetes Res Clin Pract 2004; 64:117–22. 25. Khamseh ME, V atankhah N, Baradaran HR. Knowledge and practice of foot care in Iranian people with type 2 diabetes.Int Wound J. 2007; 4(4):298-302.26. Hasnain S, Sheikh NH. Knowledge and practices regarding foot care in diabetic patients visiting diabetic clinic in Jinnah Hospital, Lahore. J Pak Med Assoc. 2009; 59(10):687-90.27. Viswanathan V, Shobhana R, Snehalatha C, Seena R, Ramachandran A. Need for education on footcare in diabetic patients in India.J Assoc Physicians India. 1999; 47(11):1083-5.28. Desalu OO, Salawu FK, Jimoh AK, Adekoya AO, Busari OA, Olokoba AB. Diabetic Foot Care: Self reported knowledge and Practice among patients attending three tertiary Hospitals in Nigeria. Ghana Medical Journal. 2011; 45(2) 60-6529. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005; 293: 217 – 228.30. De Beradis G, Pellegrini F, Fanciosi M, Belfiglo M, Di Nardo B, Greenfield S, et al. Are Type 2 diabetic patients offered adequate foot care? The role of physician and patient characteristics. J Diabetes Complications 2005; 19: 319-27.

Thank you for Listening