|Year : 2020 | Volume
| Issue : 1 | Page : 8-12
Foot practices in patients with type 2 diabetes: Where do we stand?
Tehseen Fatima, Zahid Miyan, Nadeem Naeem, Musarrat Riaz, Abdul Basit
Department of Medicine, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan
|Date of Submission||14-Jul-2018|
|Date of Decision||06-Dec-2018|
|Date of Acceptance||01-Feb-2019|
|Date of Web Publication||18-Dec-2019|
Dr. Musarrat Riaz
Department of Medicine, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi.
Source of Support: None, Conflict of Interest: None
Background: Diabetic foot ulcer is a major cause of morbidity, mortality, hospitalisation, poor quality of life and socio-economic burden in diabetic patients. Educating patients about foot care and improving foot care practices can help in the prevention of foot ulcer and thus reduce the rate of lower extremity amputations. Objective: The aim of this study is to evaluate the knowledge and practices regarding foot care in diabetic patients presenting with foot ulcers in a tertiary care hospital of Karachi, Pakistan. Methodology: This cross-sectional study was conducted at a specialised foot clinic of Baqai Institute of Diabetology and Endocrinology, a tertiary care hospital of Karachi, Pakistan. All patients with type 2 diabetes presenting with a history of foot ulcers were included in the study after taking informed consent. Only those patients with either already diagnosed diabetes mellitus or diagnosed in the clinic according to the American Diabetes Association diagnostic criteria were included in the study. Information regarding history, physical examination, Hba1c levels were collected in all patients through hospital HMS software. Ankle-brachial index and vibration perception threshold were done as part of foot examination in every patient. X-ray and tissue culture/sensitivity were done where indicated. The Nottingham assessment of functional foot care revised 2015 questionnaire was used to evaluate patients’ foot care knowledge and practices before presenting to our institute. The interview was conducted by a trained healthcare professional on one-to-one basis. Patients who scored >70% had good knowledge and practices of foot care, those between 50% and 70% had average and those who scored <50% had poor knowledge and practices of foot care. Results: A total of 358 patients were included in the study. Out of which 243 were male and 115 were female. The average age was 54.43 ± 11.4 years, and the mean duration of diabetes was 13.35 ± 8.30 years, and the mean HbA1c was 9.60 ± 2.30. All the patients included were of type 2 diabetes mellitus. Out of the total respondents, 153 (43.2%) respondents had never received any foot care education from any healthcare professional prior to the development of ulcer and presenting to this institute, ten (0.8%) had received some information of foot care from print or electronic media or through family and friends, whereas 191 (54%) received foot care education formally by a health care professional. Only 148 (41.6%) got their feet examined by some healthcare professional before developing foot ulcer, while 196 (55.1%) never got their feet examined before presenting to this institute. Overall, 7% of the study participants had good foot care knowledge and practices, 55.3% had average and 37.7% had poor foot care knowledge and practices. Conclusion: Knowledge and practices of foot care were found to be unsatisfactory in most of the patients. This is of utmost importance to introduce foot care education programs at primary as well as tertiary care level with regular periodic physician reinforcement to reduce the incidence of diabetic foot ulceration and amputations.
Keywords: Diabetes, education, foot care
|How to cite this article:|
Fatima T, Miyan Z, Naeem N, Riaz M, Basit A. Foot practices in patients with type 2 diabetes: Where do we stand?. J Diabetol 2020;11:8-12
| Introduction|| |
Diabetes mellitus is a chronic metabolic disease characterised by insulin deficiency and/or resistance. The International Diabetes Federation Atlas More Details 2017 reports a prevalence of 8.8% around the globe. Four out of five diabetics live in middle- or low-income countries with MENA region leading the prevalence table with almost 11%. The global prevalence has nearly doubled since 1980, showing a scary doubling rate as compared to other noncommunicable diseases worldwide. It is estimated that the prevalence of diabetes will rise to 591.9 million by the year 2035, while Pakistan currently out of the top 10 countries will be on the 8th spot with 12.8 million diabetics in 2035. Consequently, the complications associated with the disease are also expected to increase. These include microvascular complications such as neuropathy, nephropathy and retinopathy and macrovascular complications such as peripheral artery disease, stroke and cardiovascular diseases.
Diabetic foot ulcer is one of the most devastating and disabling complications of diabetes. It is a major cause of morbidity, mortality, hospitalisation, increased socio-economic burden and poor quality of life. It is estimated that 4%–10% of diabetics develop a foot ulcer and frequency of amputation in these cases was found to be >10%. Idiomatically speaking a hard truth, every 30s a lower limb is lost somewhere in the world as a consequence of diabetes. Chronic complications of diabetes such as neuropathy, peripheral vascular disease and foot deformities increase the risk of foot ulceration in the diabetic population; this implies that special focused and meticulous measures need to be taken to prevent ulceration in this high-risk group. The importance of patient education regarding footcare knowledge in this regard cannot be overemphasised. Good education remains the cornerstone of primary and secondary prevention of diabetic foot ulcers. Muhammad-Lutfi et al. showed that the majority of patients who presented for diabetic foot infections had poor knowledge and practice of foot care. Saurabh et al. have shown that foot care education in diabetics improves their foot care practices, though in the short term and is likely to reduce the incidence of diabetic foot ulcer. Not only patients need to be educated about regular foot care, but their compliance with good foot practices also needs to be improved.
In Pakistan, the data regarding diabetic foot ulcer, risk factors and knowledge of foot care among patients is scarce. The objective of this study was to evaluate the knowledge and practices of foot care in patients presenting with foot ulcer in a tertiary care hospital of Karachi Pakistan.
| Methodology|| |
Study design and place
This observational cross-sectional study was conducted at a specialised foot clinic of Baqai Institute of Diabetology and Endocrinology (BIDE), a tertiary care hospital of Karachi, Pakistan.
Participants, recruitment and sampling procedure
Participants were recruited from patients attending diabetic foot clinic from 1 February to 31 July 2017.
Inclusion criteria included as follows – (1) age of 18 years and above; (2) being diagnosed with type 2 diabetes; and (3) having a clinical record in HMS software of the institute. Patients who consented to participate in the study were asked to complete a questionnaire. A random sampling of 358 patients was calculated using prevalence of Diabetic Foot (DF), 95% confidence interval and error not >7%. Systematic random sampling was used to select the participants. Demographical and personal information was collected. Information regarding the duration of diabetes, complete medical history, physical examination, especially focused on foot findings, Hba1c levels were collected in all patients through hospital HMS software. Ankle-brachial index and vibration perception threshold were done as part of foot examination in every patient. X-ray and tissue culture/sensitivity were done where indicated.
| Instrument|| |
The Nottingham Assessment of Functional Foot Care revised 2015 questionnaire was used to evaluate the patient’s foot care knowledge and practices before presenting to our institute. This questionnaire consists of 26 questions evaluating the knowledge and practices of foot care in diabetic patients. These included important areas of foot care such as daily washing of feet, application of moisturizer, changing of socks and daily inspection of feet and footwear. Each question had four options with score ranging from 0 to 3 for each answer. The validated instrument was translated to the local language (Urdu) for the convenience of patients and interviewers and translated back to English for analysis. The interview was conducted by a trained healthcare professional on one-to-one basis.
In addition, all respondents were inquired if they had received foot care education or had their feet examined by any health-care professional before developing a foot ulcer and presenting to this institute.
Data management and analysis
Data were reviewed carefully to verify that there are no data mistakes and the errors were corrected immediacy. The International Business Machines Corporation (IBM) Statistical Package for Social Sciences (SPSS) version 20, New York, USA software program was used for data analysis. Frequency distributions were obtained, and descriptive statistics were calculated. Patients who scored >70% have good knowledge and practices of foot care, those between 50% and 70% have average and those <50% have poor knowledge and practices of foot care.
Ethical approval for the current study was obtained from the Institutional Review Board BIDE. 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 utilised for study purposes only. Participants were asked to read and sign a consent form.
| Results|| |
A total of 358 patients were included in the study. Out of which 243 were male and 115 were females. All the patients were of type 2 diabetes mellitus. The average age was 54.43 ± 11.4 years, and the mean duration of diabetes was 13.35 ± 8.30 years and the mean HbA1c was 9.60 ± 2.30 as shown in [Table 1].
Out of the total respondents, 153 (43.2%) respondents had never received any foot care education from any health-care professional before the development of ulcer and presenting to this institute. Ten (0.8%) had received some information of foot care from print or electronic media or through family and friends whereas 191 (54%) received foot care education formally by a health care professional. Only 148 (41.6%) got their feet examined by some healthcare professional before developing a foot ulcer, whereas 196 (55.1%) never got their feet examined before presenting to this institute. In only 12 (3.4%) of the respondents, self-examination of the foot was found [Figure 1].
The study revealed that only 156 (43.6%) of total participants inspected their feet daily, whereas 202 (56.5%) used to inspect their feet only once a week or even less frequently. Seventy-nine (22.1%) of our patients never checked their shoes before putting them on while 64 (17.9%) never checked their shoes while taking them off.
Regarding washing of feet, 52 (14.5%) washed their feet more than once a day, whereas 131 (36.6%) washed them at least once a day. After washing, only 53 (14.8%) dried their feet often, whereas 44 (12.3%) never dried up their feet after washing. Furthermore, 52 (14.5%) never used to dry the interdigital spaces after washing.
When inquired about the use of moisturiser, it was found out that 98 (29.1%) never used moisturiser on their feet while only 43 (12.8%) put moisturiser on their feet only once a week. In addition, out of the total respondents, 121 (33.8%) were applying moisturiser in the interdigital spaces at least once a week.
The study also revealed that 52 (14.6%) of patients used to wear slippers/sandals most of the time. While, 65 (18.3%) often wore shoes without socks, and 48 (13.6%) changed their socks <4 times a week.
Concerning the practice of walking barefoot, it was found that 77 (21.6%) and 109 (30.5%) of total respondents never walked barefoot in or outside the house, respectively, whereas 49 (13.7%) and 25 (7%) walked barefoot in and outside the house often. Finally, 78 (22.1%) never put any dry dressing on a blister or cut or burn when they got one [Table 2].
|Table 2: Responses of Nottingham assessment of functional foot care questions|
Click here to view
Overall, 7% of the study participants had good foot care practices, 55.3% had average and 37.7% had poor foot care practices.
| Discussion|| |
The present study demonstrates that a significant percentage of patients had neither received any foot care education nor got their feet examined by a health-care professional before developing an ulcer. This poor level of foot care practice in this study is in agreement with other previous studies from south Asian countries such as Iran, Pakistan and India.,,, but not in consensus with a similar type of study from Saudi Arabia which reported moderate foot care knowledge in the majority of the patient. This emphasizes the need for immediate educational interventions by physicians, especially, in developing part of the world. As the role of educational interventions has been proven to improve patient’s knowledge and reported to improve foot care practices in developed countries, same model can be followed in developing countries to decrease the rate of amputations in diabetics, successfully proven by a study in India.
The finding that only 7% of patients had good foot care knowledge and practices, whereas 37.7% had poor foot care knowledge and practices points toward the overwhelming lack of foot care knowledge and its application among diabetic patients of Pakistan. These results were in consensus with the findings of another study in Pakistan which shows that only 6% of diabetic patients were practicing foot care as per international recommendations. but surprisingly worse than a similar study by Hasnain and Sheikh  where 29% of the respondents had good information about foot care whereas 14% had good foot care practices.
In this study, majority of the patients did not inspect their feet daily which is a crucial part of foot care as the presence of neuropathy and lack of pain sensation can cause the patient significant delay in seeking medical attention and thus initiation of the management of foot ulcers. Washing of the feet multiple times a day was largely seen in patients but drying between the fingers after washing was known to very few. However, most of the patients were washing the feet as part of their religious practice and not as particular foot care practice. Most of the patients did not know that drying between the toes after washing and not applying moisturiser between toes were important to prevent fungal infections. Application of moisturizer was not practiced by the majority of patients which can lead to skin cracking and callous formation and hence ulceration. Inappropriate footwear use was found in the majority of patients. This is important because offloading footwear plays a major role in primary and secondary prevention of foot ulcers. A large percentage did not know how to manage a cut or graze. Very few were aware of the importance of inspecting shoes for objects and torn lining to prevent trauma to the foot. Lack of quality Communication between doctors and patients because of heavy consults and an inadequate number of doctors per 100 patients also adds in poor patient education.,
Improved foot care practices are likely to reduce the incidence of diabetic foot ulcer and reduce morbidity and medical expenses. Foot care education must be incorporated as an integral part of diabetes care in the hospitals and outpatient department. Awareness programs should be organised to spread the knowledge to the community. It has been proven through different studies that application of educational message causes a significant improvement in knowledge and attitude of the patients toward all aspects of diabetes, especially diabetic foot., Physicians from the primary to tertiary care facilities should be motivated to provide detailed information of foot care to patients and reinforce it periodically. Health-care providers should always try to up to date their knowledge regarding foot care and apply that to improve patient care. This should be a routine practice for all diabetic patients in both in and outpatient setting. Education of good diabetic foot care practice will not only increase the patient’s confidence but will also help in achieving better outcomes.
Strength and limitations of the study
The strength of this study is that it is the first study to discuss this important issue in Karachi Pakistan. Despite this strength, the study has some limitations that should be mentioned to help readers in properly interpreting the results. First, because it is a cross-sectional study, the direction of relationships and causal relationships cannot be determined. Second, the study is based on one single center so results cannot represent the whole population. Third, this is a hospital-based study and hospital based studies cannot provide a true picture of DF care knowledge and practices of the community.
| Conclusion|| |
Knowledge and practices of foot care were found to be unsatisfactory in most of the patients. This is of utmost importance to introduce foot care education programs at primary as well as tertiary care level with regular periodic physician reinforcement to reduce the incidence of diabetic foot ulceration and amputations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]