Sanaa Univ J Med Sci 2012;4(1):39-44

Sanaa University Journal of

Medical Sciences
Foot Self-Care Practices of Diabetics Attending National Diabetes Center in Sana'a City, Yemen

Nabil Ahmed Al-Rabeei1*, Ph.D

1

Departments of Community Health Nursing, Faculty of Medicine and Health Sciences-Sana'a University, Yemen

ABSTRACT Background: Foot complications are one of the major public health problems in diabetic patient, increasing the incidence of amputation and sequent of disabilities. Aim: To determine the level of foot self-care practices of diabetics in Sana'a city. Methods: Descriptive, cross-sectional survey was performed at national diabetes center-Sanaa city-Yemen. 159 participants were admitted to this study in national diabetes center, Sana'a. Data were collected using structure questionnaire as a face to face interview from October 2010 to December 2010. Results: The findings of the study regarding overall level of foot self-care showed that the majority of diabetic patients 79(49.7%) had a poor overall practices level about foot self-care, 47(29.6%) had a satisfactory level and 33 (20.7%) had only a good level of practices. A significant difference was not observed in foot self-care practices of diabetics and their age, sex, marital status, duration of diabetes (p>0.05) while significant difference was observed between educational level and overall practices level (p<0.05). Conclusion: This study showed low rates of foot self-care practices among diabetics. Health education Program about diabetes foot self-care practices is needed. Key words: Foot self-care practices, Diabetes, Yemen INTRODUCTION Diabetes mellitus and chronic diabetes complications place an enormous burden on the health care system and health care resources. 1 Foot problems are a major determinant of the quality of life in patients suffering from diabetes, and have remained one of the most common reasons of hospital admission among diabetic patients, despite efforts to prevent and treat this longterm complication during the last decade.2 If the complications of diabetic foot remain untreated, they could lead to amputation of feet or even death.3 Foot ulcerations often lead to amputation if not detected early and managed properly among persons with diabetes.4 Foot problems in persons with

diabetes are usually the result of three primary factors: neuropathy, poor circulation, and decreased resistance to infection. Also, foot deformities and trauma play major roles in causing ulcerations and infections in the presence of neuropathy or poor circulation. It is estimated that the risk of diabetes-related foot complications can be reduced by 49% to 85% by proper preventive measures, patient education, and foot self-care.10 Treating the diabetic foot, worldwide is estimated to cost about one billion dollars.5 More than 15% of diabetic patients have diabetic foot6 and 14-24% of them to have amputation of limbs.7 Also probability of ulcer

*Corresponding author: Dr. Nabil A. Al-Rabeei, Faculty of Medicine and Health Sciences-Sana'a University -Sanaa,
Yemen; Telefax: +967 1 370189; P.O. Box: 11215-Mobile; +697 736650015, E-mail:nabilalrabeei@hotmail.com

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Nabil Al-Rabeei et al.

and gangrene in diabetic patients compared to non-diabetic participants is up to 15 and even 59 fold respectively.8 According to results of a study done by the Tehran Medical University, 34.7 % of ulcers in diabetic foot patients resulted in amputation, and their duration of hospitalization was 3.8 weeks, higher than rates elsewhere in the world.9 Diabetic foot complications are emerging as a clinical and public health problem in Yemen. Foot self-care practices are an important component of diabetes control programme. Aim of the study The aim of the study was to determine the level of foot self-care practices of diabetics in Sana'a city. METHODS Study setting The national diabetes center is the only outpatient diabetes clinic in Sana'a city. The center is run by three specialist doctors, four GP and ten nurses. Although none of the nurses have received any specialist diabetes training. All registered patients have files. The center provides care for 1000 diabetics' per year, including assessment of metabolic control and sometimes individual counseling by the doctors and nurses is provided for patients. No dietician is available as part of diabetes education. Services include testing of blood glucose level, urine for glucose and ketones, blood urea and creatinine, cholesterol and triglycerides. There are facilities for measuring ECG, HDL, cholesterol, and HbA1c. The center provides oral hypoglycaemic drugs only free of charge. Urine glucose/ketone strips are provided. Study design A descriptive cross-sectional survey was conducted to determine diabetic foot self-care practices among diabetics attending national diabetes center-Sanaa-Yemen.

Study participants and sampling Convenience sample was used to select 159 diabetic patients to this study. The eligibility criteria to include of patients in the survey were those who fulfilled the following criteria: Yemen nationality, adult with type 1 or type 2 diabetes, able to speak Arabic language, aware, alert and registered in national diabetes center. The exclusion criteria were foreign nationality, neurologic and psychosis patient and patient less than 15 years old. All patients were completed all baseline measures and questions related to self-care practices. Convenience sample was used to select patients. The sample size was calculated using Epi Info, version 6.0, taking into consideration the following criteria: population size = 1000; expected frequency = 20% (research team depended on previous study11; Worst acceptable = 15%. A sample size (n) with 95% confidence level was 159 patients. Data collection Data were collected by research team with a simplified, structured questionnaire using face to face interview among participants during their attendance at national diabetes centerSana'a city from October 2010 to December 2010. The questionnaire consisted of demographic characteristics (age, sex, marital status, and educational background) and clinical history (type of diabetes, type of treatment, duration of diabetes, and family history) and their diabetic foot self-care practices. The questionnaire was started with a discussion of study benefits and purposes and was divided into three parts: (1) demographic characteristics and clinical history of the study participants and (2) fifteen questions related to diabetic foot self-care practices was included (Awareness of personal risk factors, importance of at least annual inspection of feet by a health care professional, the daily self-inspection of feet, proper nail and skin care and injury prevention and treatment). The interview took place in diabetes center during working days and the

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Sanaa Univ J Med Sci 2012;4(1):39-44

interview lasted from 15 to 20 minutes. The questionnaire was pilot tested on 20 patients and was refined accordingly. No substantial difficulties were encountered during the testing and only minor (linguistic) corrections were made. The participants of the pilot study were not included in the final analysis. Statistical analysis The data were analyzed using SPSS, version 16.0 as well as descriptive statistics. The independent t-test was used for numerical values, normal distribution and unpaired variables and one way ANOVA for more than two variables. A 0.05 level was taken as the level of significance and 95% CI. The differences among variables regarding foot selfcare practices were scored (one score was given for each correct answer), and were graded as poor, satisfactory or good with a maximum total scores of 15. The level of practices was graded as poor with a score of <8, satisfactory with a score of 8-11 and good with scores of 12-15. Ethical consideration The research team informed the study participants about the aim of the study and asked them to participate in the study. No one of the participants was refused to participate in the study and verbal consent was obtained. RESULTS Distribution of demographic characteristics and Clinical history 159 diabetic patients participated in the study, including (59.7%) males and (40.3%) females. Other demographic characteristics and Clinical history are shown in Table 1.

Table 1. Demographic characteristics and Clinical history of participants

Item Demographic characteristics Age <30 30-40 41-50 > 50 Sex Males Females Marital status Married Un-married Education Educated Un-educated Clinical history Type of diabetes Type 1 Type 2 Duration of diabetes < 1 year 1-4 year 510 year >10 year. Type of treatment Oral tablets only Insulin only Diet only Family history First degree Second degree None n (%)

15 (9.4) 29 (18.2) 53 (33.3) 62 (39.0) 95 (59.7) 64 (40.3) 148 (93.1) 11 (6.9) 90 (56.6) 69 (43.4)

16 (10.1) 143 (89.9) 11 (6.9) 43 (27.0) 50 (31.4) 55 (34.6) 76 (45.9) 72 (45.3) 11 (6.9) 91 (57.2) 44 (27.7) 24 (15.1)

Overall foot self-care practices among study participants The Overall practices among study sample regarding diabetes foot self-care practices showed that the majority of diabetic patients 79(49.7%) had poor overall practices level about the foot self-care practices, 47(29.6%) had a satisfactory level and 33 (20.7%) had good level of practices regarding foot self-care.

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Table 2. Foot self-care practices in relation to demographic characteristics and clinical history among participants
Characteristic Age <30 30-40 41-50 > 50 Sex Female Male Marital status Married Un-married Education Educated Un-educated Duration of diabetes < 1 year 1-4 year 510 year >10 year 30.2 19.5 45.3 4.4 22.6 27.1 2.6 17.6 11.9 17.6 16.4 13.2 27.7 1.9 18.9 10.7 1.9 10.1 11.3 6.3 13.2 7.5 20.1 0.6 15.1 5.6 1.9 2.5 8.8 7.5 >0.05 3.1 9.4 19.5 17.7 3.8 5 9.4 11.4 2.5 3.8 4.4 10 >0.05 Poor % Satisfactory % Good % P-value

>0.05

<0.05

>0.05

The mean SD of overall foot self-care practices among study participants according to age was (74.1) in age <30 years, in age ranged from 30-40 years was (6.74.7), in age ranged from 41-50 years was (7.33.6), and in age >50 years was (8.43.6). Statistically significant differences was not found among age group towards foot self-care practices (p>0.05). The mean SD of overall foot self-care practices among study participants according to sex was (7.37 4.1) among males and (7.893.47) among females. Statistical differences was not observed between male and female toward foot self-care practices (p>0.05).The mean SD of overall foot self-care practices among study participants according to education background was (8.14.1) among educated and (6.93.5) among un-educated. There were statistically significant differences with respect to educational background toward foot self-care practices (p<0.05). The mean SD of overall foot self-care practices among study participants according to marital status was

(7.73.8) among married and (6.23.9) among un-married. There was no statistical differences in marital status toward foot self-care practices (p>0.05). The mean SD of overall foot selfcare practices among study participants according to duration of diabetes was (9.183.5) in duration of <1 years, (6.53.5) in duration ranged from 1-4 year, (8.104.4) in duration ranged from 5-10 years and (7.73.5) in duration of > 10 years. Statistical significant differences was not found according to duration of diabetes toward foot self-care practice (p>0.05). Table 2.
DISCUSSION Health education is a process that bridges the gap between health information and health practices.12 The findings of our study regarding overall practices of self-foot care among study participants showed that the majority of diabetic patients 79(49.7%) had a poor overall practices level about the self-foot care, 47(29.6%) had a satisfactory level and 33

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Sanaa Univ J Med Sci 2012;4(1):39-44

(20.7%) had good overall practices level about the foot care. Good control of diabetes mellitus and detection of early diabetic foot complications will reduce the number of patients undergoing limb amputation. Necessary actions, including health education, good diabetic control and early detection of feet at risk, must be taken in order to reduce the number of amputations among diabetic patients. Our study indicates that the majority of the participants had poor knowledge about foot care. It has been pointed out that informing patients about the guidelines of foot care and complications of diabetic foot might be a way to motivate health behavior.13 Barth et al14 found that the quality of foot care needs much improvement. Khamseh ME et al.15 found that the mean knowledge and practices score was 66 (SD 30) out of a possible 16, Illiterate patients were the least knowledgeable (P = 0008), 60% failed to inspect their feet and 42% did not know to how trim their toe nails and high risk practices including use of irritants of hot water (665%) and walking barefoot (62%). Our study showed that females and male tended to have a poorer level of practice. A study by Etzwiter DD et al 16 showed that females had a slightly poorer level of practicable than males (99.3% compared to 93.6%). Males were more likely to have a satisfactory and very good level (6.4% compared to 0.7%). Our study indicated no statistical difference in level of foot self-care practices according to marital status and duration of diabetes. Significant differences in overall foot self-care practices level of patients and their educational level. Patients holding no educational certificates were more likely to have a poor level of practicable and to a lesser extent those with primary to secondary education, as compared with university graduates. The same trend was observed as regards practices about foot care. Several studies17,18 found that knowledge and practice related to foot care improves with a

corresponding increase in the level of education. However, practices showed not differences with age with respect to foot selfcare. A significant linear association was not observed between the overall knowledge and practices level of diabetics and their age and sex. Also, a significant linear association was observed between educational level and overall knowledge level.19
CONCLUSION Foot care is an important element of medical management. From the present research it was concluded that the level of foot self-care practices among diabetic patients was poor. We recommended that all diabetics should receive the basic foot self-care education. ACKNOWLEDGEMENT We would like to thank principles of national diabetes center and diabetic patients for their kind cooperation and help. REFERENCES
1. 2. 3. World Health Organization. The costs of diabetes. WHO fact sheet No.236. 2006 Parks textbook of preventive and social medicine,18 edition, 2005; 4:59-60. Yusof M I, Sulaiman A R, Muslim DA J. Diabetic foot complications: a two-year review of limb amputation in a Kelantanese population. Singapore Med J 2007; 48(8):729732 Baghianimoghadam MH, Shafiei F, et al. Efficay of BASNEF Model in controlling of Diabetic Patients in city of Yazd. Iran. Indian Journal of community Medicine 2005;30(4):144-5. Calle-Pascual AL, DurnA et al. Reduction in foot ulcer incidence: relation to compliance with a prophylactic foot care program. Diabetes Care 2006; 24:405-7. Brooke D and Fidle J. Diabetic foot care. Drug Topics 2005; 146: 34. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005; 293: 217-28. Roberts SS. Foot care. What you need to know. Diabetes Forecast 2005; 58: 35-7. Larigani B, Bastanehagh MH, Pjouhi M. survey about the prevalence of amputation in diabetic patients with diabetic foot that were confined to bed in the shariaty and emamkhomaini hospitals from

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1979-1984. Iranian Journal of Diabetes and Lipid 2007;1: 83-5. Pecoraro RE, Reiber GE and Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 2008;13:513-21. Nabil A. Al-Rabeei. Effect of health education program among adult diabetic patient in Sana'a Yemen. Ph.D Thesis, Pune University, 2005. Krall LP. Education: a treatment for diabetes. Philadelphia, 2009:465-82. Cartwright D. Some principles of mass persuasion: selected findings from research on the sale of United States War Bonds. Human Relations 2007, 2:253-69. Barth R, Campbell LV. Intensive education improves knowledge, compliance and foot problems in type 2 diabetes. Diabet Med 8:111117, 2005

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15. Khamseh ME, Vatankhah N, Baradaran HR. Knowledge and practice of foot care in Iranian people with type 2 diabetes. Int Wound J 2007;4:298302. 16. Etzwiter DD, Maiman LA. Patient education and compliance in the management of diabetes. Diabetes mellitus and obesity. Williams and Wilkins, 2008:790-8. 17. Kasl SV, Cobb S. Health behaviour; illness behaviour and sick role behaviour. II. Sick role behaviour. Archives of environmental health 2006, 12(4):531-41. 18. Reiber G, Pecoraro RE, Koepsell T. Risk factors for amputation in patients with diabetes mellitus: a casecontrolled study. Ann Intern Med 2006;117:97105. 19. Ronny A. Bell. Diabetes Foot Self-care Practices in a Rural, Triethnic Population. Diabetes Educ 2005; 31(1): 7583.

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