AND PRACTICE OF DIABETIC FOOT CARE IN PATIENTS WITH DIABETIC FOOT ULCER
A Dissertation submitted to
THE TAMIL NADU Dr. M.G.R. MEDICAL UNIVERSITY, CHENNAI- 600 032
In partial fulfillment of the award of the degree of
MASTER OF PHARMACY IN
Branch-VII –PHARMACY PRACTICE
Submitted by Name: JANAANI V REG. No: 261740206
Under the Guidance of
Dr. N. VENKATESWARAMURTHY, M.Pharm, PhD., DEPARTMENT OF PHARMACY PRACTICE
J.K.K.NATTRAJA COLLEGE OF PHARMACY KUMARAPALAYAM – 638183
TAMILNADU.
NOVEMBER – 2019
EVALUATION CERTIFICATE
This is to certify that the dissertation work entitled “A Study On Assessment Of Knowledge, Attitude, And Practice Of Diabetic Foot Care In Patients With Diabetic Foot Ulcer” submitted by the student bearing Reg. No: 261740206 to “The Tamil Nadu Dr. M.G.R. Medical University”, Chennai, in partial fulfillment for the award of Degree of Master of Pharmacy in Pharmacy Practice was evaluated by us during the examination held on………..……….
Internal Examiner External Examiner
CERTIFICATE
This is to certify that the dissertation “A Study On Assessment Of Knowledge, Attitude, And Practice Of Diabetic Foot Care In Patients With Diabetic Foot Ulcer” is a bonafide work done by Reg.No.261740206, J.K.K.Nattraja College of Pharmacy, in partial fulfillment of the University rules and regulations for award of Master of Pharmacy in Pharmacy Practice under my guidance and supervision during the academic year 2018-2019.
Dr. R. Sambath Kumar, M.Pharm, Ph.D., Principal
Dr. N. Venkateswaramurthy,M.Pharm, Ph.D., Guide & HOD
This is to certify that the work embodied in this dissertation en titled “A Study On Assessment Of Knowledge, Attitude, And Practice Of Diabetic Foot Care In Patients With Diabetic Foot Ulcer”
submitted to “The Tamil Nadu Dr. M.G.R. Medical University”, Chennai, in partial fulfillment to the requirement for the award of Degree of Master of Pharmacy in Pharmacy Practice, is a bonafide work carried out by Ms. JANAANI.V, [Reg.No.261740206] during the academic year 2018-2019, under the guidance and supervision of Dr. N.
Venkateswaramurthy M.Pharm, Ph.D., Professor and Head, Department of Pharmacy Practice, J.K.K.Nattraja College of Pharmacy, Kumarapalayam.
Place: Kumarapalayam Date:
Dr. R. SAMBATH KUMAR, M.Pharm, Ph.D., Professor&Principal, J.K.K.Nattraja College of Pharmacy.
Kumarapalayam-638 183.
Tamil Nadu.
This is to certify that the work embodied in this dissertation en titled titled “A Study On Assessment Of Knowledge, Attitude, And Practice Of Diabetic Foot Care In Patients With Diabetic Foot Ulcer”
submitted to “The Tamil Nadu Dr. M.G.R. Medical University”, Chennai, in partial fulfillment to the requirement for the award of Degree of Master of Pharmacy in Pharmacy Practice, is a bonafide work carried out by Ms. JANAANI.V, [Reg.No.261740206] during the academic year 2018-2019, under my guidance and direct supervision in the Department of Pharmacy Practice, J.K.K.Nattraja College of Pharmacy, Kumarapalayam.
Place:Kumarapalayam Date:
Dr. N. VENKATESWARAMURTHY, M.Pharm, Ph.D., Professor & Head, Department of Pharmacy Practice, J.K.K.Nattraja College of Pharmacy,
Kumarapalayam-638 183, Tamil Nadu.
DECLARATION
I do hereby declared that the dissertation titled “A Study On Assessment Of Knowledge, Attitude, And Practice Of Diabetic Foot Care In Patients With Diabetic Foot Ulcer” submitted to
“The Tamil Nadu Dr. M.G.R. Medical University”, Chennai, in partial fulfillment to the requirement for the award of Degree of Master of Pharmacy in Pharmacy Practice, is a bonafide work carried out by Ms. JANAANI.V, [Reg.No.261740206] during the academic year 2018-2019, under the guidance and supervision of Dr. N. VENKATESWARAMURTHY, M.Pharm, Ph.D., Professor &
Head, Department of Pharmacy Practice, J.K.K.Nattraja College of Pharmacy, Kumarapalayam.
I further declare that this work is original and this dissertation has not been submitted previously for the award of any other degree, diploma, associate ship and fellowship or any other similar title. The information furnished in this dissertation is genuine to the best of my knowledge.
Place: Kumarapalayam JANAANI.V Date: Reg.no.261740206
ACKNOWLEDGEMENT
Any success would not be completed unless and otherwise, it is acknowledged. We express our sincere thanks to our guide Dr.N.Venkateswaramurthy, M.Pharm., Ph D., Professor and Head, Department of Pharmacy Practice, J.K.K.Nattraja College of Pharmacy, Kumarapalayam for providing us indispensable guidance, tremendous encouragement at each and every step of this dissertation work. Without his critical advice and deep-rooted knowledge, this work would not have been a reality.
Our sincere thanks to Dr.N. Venkateswaramurthy, M.Pharm., PhD., Professor and Head, Department of Pharmacy Practice, Dr. P.Balakumar, M.Pharm., Ph.D., Professor, Dr. K.
Krishnaveni, M.Pharm., Ph D., Assistant Professor, Dr. R.
Kameswaran, M.Pharm.,Ph D., Assistant Professor, Dr.Mebin Alias, Pharm.D., Assistant Professor, Dr.Sumitha SK, Pharm.D., Lecturer, Dr. Cindy Jose, Pharm.D., Lecturer, Dr.Krishna Ravi, Pharm.D., Lecturer, Mrs. K. Kavitha, M Pharm., Lecturer, Mr.
Mohammed Thoufiq llahi, M Pharm., Lecturer, Department of Pharmacy Practice, for their help during our project.
Our sincere thanks to Dr.R.Sambathkumar, M. Pharm, Ph.D., Professor, & Principal, Dr.S. Bhama, M. Pharm., Ph.D., Associate Professor, & Head, Department of Pharmaceutics, Mr. R.
Kanagasabai, B.Pharm, M.Tech., Assistant Professor, Dr. V.
Kamalakannan M.Pharm., Ph.D., Associate Professor, Mr. K.
Jaganathan, M.Pharm., Assistant Professor, Mr. C. Kannan, M.Pharm., Assistant Professor, Ms. S. Manodhini Elakkiya, M.Pharm., Lecturer, Mr. M. Subramani, M.Pharm., Lecturer and Dr.Rosmi Jose, Pharm.D., Lecturer, Department of pharmaceutics for the valuable help during our project.
It is our privilege to express deepest sense of gratitude towards Dr.M. Vijayabaskaran, M.Pharm, Ph.D., Professor& Head, Department of Pharmaceutical chemistry,Dr.P.Senthil Kumar, M Pharm., Ph D., Assistant Professor,Mrs. B. Vasuki, M.Pharm.,Lecturer, Mrs B. Jayalekshmi M Pharm., Lecturer and Ms. P. Lekha, Lecturer, for their valuable suggestions and inspiration.
Our sincere thanks to Dr. V. Sekar, M.Pharm., Ph.D., Professor & Head, Department of Analysis, Dr.AnandhaThangadurai, M Pharm., Ph D., Professor, Dr.I.
CarolinNimila, M.Pharm., Ph.D., Assistant Professor, and Ms. V.
Devi, M.Pharm., Lecturer, Mr. D. Kamalakannan, M.Pharm., Assistant Professor, Department of Pharmaceutical Analysis for their valuable suggestions.
Our sincere thanks to Dr.Senthilraja, M.Pharm., Ph.D., Associate Professor and Head, Department of Pharmacognosy, Dr.
V. Kishore, M Pharm., Ph D., Assistant Professor, Mrs.MeenaPrabha M.Pharm., Assistant professor, Mr. P. Nikhil., M Pharm., Lecturer, Department of Pharmacognosy for their valuable suggestions during our project work.
Our sincere thanks to Dr. R. Shanmuga Sundaram, M.Pharm., Ph.D., Vice Principal & HOD, Department of Pharmacology, Dr.Kalaiyarasi, M Pharm., Ph D., Professor, Mr. V. Venkateswaran, M.Pharm., Assistant Professor, Mrs.M.Sudha M.Pharm., Assistant Professor, Mrs. P.J. Sujitha, M.Pharm., Lecturer, Mrs. R. Elavarasi, M.Pharm., Lecturer, Mrs.Babykala, M Pharm., Lecturer, Department of Pharmacology for their valuable suggestions during our project work.
Our sincere thanks and respectful regards to our reverent Chairperson Smt. N. Sendamaraai, B.Com., and Director Mr. S.
OmmSharravana, B.Com., LLB., J.K.K. Nattraja Educational Institutions, Kumarapalayam for their blessings, encouragement and support at all times.
We greatly acknowledge the help rendered by Mrs.K. Rani, Office Superintendent, Ms.Sudhalekshmi M.C.A., Office typist,Ms. M. Venkateswari, M.C.A., typist, Mrs. V.
Gandhimathi, M.A., M.L.I.S., Librarian, Mrs.S. Jayakala, B.A., B.L.I.S., and Asst. Librarian for their co-operation. We owe our thanks to all the technical and non-technical staff members of the institute for their precious assistance and help.
Last, but nevertheless, we are thankful to our lovable parents and all my friends for their co-operation, encouragement and help extended to us throughout our project work.
INDEX
Sl.
NO.
CONTENTS PAGE
NO
1
INTRODUCTION
12 LITERATURE REVIEW
113 NEED OF THE STUDY
184 AIM AND OBJECTIVES
195 PLAN OF THE WORK
206 METHODOLOGY
217 RESULTS
238 DISCUSSION
399 CONCLUSION
4410 REFERENCES
4511 ANNEXURES
50INTRODUCTION
Diabetes Mellitus(DM) is metabolic disorder characterized by chronic hyperglycemia and trouble in metabolism of carbohydrates, protein and fat as a result of defect in insulin secretion, insulin action or both.1 DM is highly prevalent worldwide, in 1980; 108 million adults (4.7%) were suffering from DM, this number increased to 422 million (8.5%) in 2014.2 The estimate of 41 million people with diabetes in India affecting 10-16 % of urban population and 5.33-6.36 % of rural population is expected to rise to 66 million by 2025.3
The incidence of DM has increased dramatically in recent decades, predominantly because of changes in life style, an increase in the prevalence of obesity and longevity. Current projections estimate that the number of people with DM will increase by 50.0% by 2010, and will nearly double by 2020.4,5 This metabolic disease is one of the most common endocrine disorders affecting almost 6% of the world’s population.6 DM is fast gaining the status of a potential epidemic in India with more than 62 million diabetic individuals currently diagnosed with the disease.7,8 In 2000, India (31.7 million) topped the world with the highest number of people with diabetes mellitus followed by China (20.8 million) with the United States (17.7 million) in second and third place respectively.
The prevalence of DM is predicted to double globally from 171 million in 2000 to 366 million in 2030 with a maximum increase in India. It is predicted that by 2030 diabetes mellitus may afflict up to 79.4 million individuals in India, while China (42.3 million) and the United States (30.3 million) will also see significant increases in those affected by the disease.9,
10 India currently faces an uncertain future in relation to the potential burden that diabetes may impose upon the country. Plausible reasons for the steady increase in the prevalence of DM in Asian countries may include poor lifestyle, rapid westernization, lack of knowledge, and unsatisfactory attitude and practices toward DM among the general population and diabetic patients.11,12
Types of DM13
DM is currently classified on the basis of the pathogenic process that leads to hyperglycemia. Under this classification
Type 1 DM (Insulin-dependent diabetes mellitus (IDDM) - Type 1 DM is sis characterized by beta cell destruction caused by an autoimmune process, usually leading to absolute insulin deficiency.
Type 2 DM (Non-insulin dependent diabetes mellitus (NIDDM) -Type 2 DM is a heterogeneous group of disorders characterized by variable degrees of insulin resistance, impaired insulin secretion, and excessive hepatic glucose production.
Other Types
Genetic defects [maturity-onset diabetes of the young (MODY)]
Diseases of the exocrine pancreas (chronic pancreatitis, cystic fibrosis, hemochromatosis)
Drugs (nicotinic acid, glucocorticoids, thiazides, protease inhibitors)
Pregnancy [gestational diabetes mellitus (GDM)].
Etiological Classification14 Type 1 DM
Immune destruction of the beta cells of the pancreas (antibodies to islet cells and insulin are present at diagnosis).
Contributing factors:
Genetic predisposition and environmental triggers (infection or other stress)
Type 2 DM
Obesity
Age (onset of puberty is associated with increased insulin resistance)
Lack of physical activity
Genetic predisposition
Racial/ethnic background (African American, Native American, Hispanic and Asian/Pacific Islander)
Conditions associated with insulin resistance (PCOS)
PATHOGENESIS OF TYPE I DM15, 16
The process of destruction of β cells is chronic in nature, often beginning during infancy and continuing over the many months or years that follow. At the time of clinical diagnosis of TIDM, about +80% of the β cells have been destroyed, the islets are infiltrated with chronic inflammatory mononuclear cells (insulitis), including CD8+ cytotoxic T cells. Once islet cell autoimmunity has begun, progression to islet cell destruction is quite variable, with some patients rapidly progressing to clinical diabetes, while others remain in a neuroprogressive state.
Islet cell proteins are presented by antigen presenting cells (APCs) to naïve Th0 type CD4+ T cells in association with MHC class II molecules. Interleukin (IL)-12 is thus secreted by APCs that promotes the differentiation of Th0 cells to Th1 type cells. Th1 cells secrete IL-2 and IFN-γ that further stimulate CD8+ cytotoxic T cells or macrophages to release free radicals (superoxides) or perforin/granzymes, leading to ß cell apoptosis or death. CD8+ cytotoxic T cells further mediate ß cell death by Fas mediated mechanisms. Interleukin (IL)-4, on the other hand, secreted mainly by natural killer T (NKT) cells drives Th0 cell to Th2 pathway leading to benign insulitis.
Diabetes risk and time to diabetes in relatives of patients directly correlates with the number of different autoantibodies present as already discussed. The pathogenesis of T1DM has been extensively studied, but the exact mechanism involved in the initiation and progression of β-cell destruction is still unclear. The presentation of beta cell-specific autoantigens by antigen-presenting cells (APC) [macrophages or dendritic cells (DC)] to CD4+ helper T cells in association with MHC class II molecules is considered to be the first step in the initiation of the disease process. Macrophages secrete interleukin (IL)-12, stimulating CD4 + T cells to secrete interferon (IFN)-γ and IL-2. IFN-γ stimulates other resting macrophages to release in turn, other cytokines such as IL-1β, tumor necrosis factor (TNF-α) and free radicals, which are toxic to pancreatic β-
cells. During this process, cytokines induce the migration of β-cell autoantigen specific CD8+ cytotoxic T cells. On recognizing specific autoantigen on ß cells in association with class I molecules, these CD8+
cytotoxic T cells cause ß cell damage by releasing perforin and granzyme and by Fas-mediated apoptosis of the beta cells. Continued destruction of beta cells eventually results in the clinical onset of diabetes.
PATHOGENESIS OF TYPE II DM14
COMPLICATIONS OF DM
Pathogenesis of Diabetic Complications17
There is growing evidence that the underlying mechanisms in the pathogenesis of diabetic complications include certain genetic and epigenetic modifications, nutritional factors, and sedentary lifestyle.It was found that DNA-methylation, in or near genes belonging to the DNA replication/DNA metabolism process group, might play a key role in this process. Conversely, smoking, hypertension, and duration of DM over 10 years proved to be predictive factors for microvascular complications.
Microvascular Complications18, 19
Diabetic nephropathy, neuropathy, and retinopathy are the main microvascular complications induced by chronic hyperglycemia via several mechanisms such as the production of advanced glycation end products (AGEs), the creation of a proinflammatory microenvironment, and the induction of oxidative stress.
It was concluded that oxidative stress leads to the production of chronic inflammation and the glomerular and tubular hypertrophy, which characterize the early stages of DN. The novel biomarkers indicates renal injury such as transferrin, ceruloplasmin, podocalyxin, and VEGF. These markers can detect renal injury even before the presence of microalbuminuria, which still remains the most valid biomarker for DN in clinical practice. It may be hoped that these mechanisms can help towards defining new therapeutic approaches for this microvascular complication of DM.
To estimate the severity of autonomic neuropathy, found that diabetic retinopathy is the most significant predictive factor for CAN. To identify risk factors for the development of diabetic retinopathy (DR) in patients with type 1 DM.
MacrovascularComplications20
Atherosclerosis is more common in people with DM than in those without. For example, DM increases the risk for stroke in people aged 20 to 65 years more than 5 times .It was reported that patients with DM are more prone to have significant stenosis with calcified plaques and such findings are accompanied by higher hs-CRP levels. In this process, many intracellular signaling pathways contribute to increased oxidative stress, which in turn leads to deposition of hydroxyapatite minerals into the extracellular matrix and vascular calcification.
Miscellaneous Complications21
Diabetic cardiomyopathy is a specific complication that develops independently of coronary artery disease or hypertension and it is possible to lead to increased morbidity and mortality. Low dose ethanol consumption was associated with lower mean arterial pressure, lower heart rate, high hydroxyproline content, and collagen volume fraction in myocardial tissue, together with decreased expression of ALDH2 and downregulation of the JNK pathway.
DIABETIC FOOT ULCER (DFU)
Diabetic foot is one of the most significant and devastating complication of diabetes. World Health Organization (WHO 1985), defines diabetic foot ulcer as an infection, ulceration and/or destruction of deep tissues associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limb. Most of the diabetic foot ulcer patients delay in approaching health care facilities with advanced foot ulcers because of financial worries, poor awareness & inadequate diabetes healthcare which may lead to a non-healing ulcer that causes severe damage to tissues and bone, requiring surgical removal (amputation) of a toe, foot or part of a leg. Foot ulcers significantly contribute to morbidity and mortality of patients with diabetes mellitus.22
DFU is found to be the most common complications of diabetes among retinopathy, nephropathy, heart attack, and stroke. It results ultimately in amputations and also associates greatly with significant mortality and morbidity,23 around 10% of lower limb amputation patients die during the preoperative period. And almost 30% of patients die within 1 year of amputations, in the third year, the probability rises to 50% and the mortality is 70% over 5 years.24 A series of multiple mechanisms, including decreased cell and growth factor response, leads to diminished peripheral blood flow and decreased local angiogenesis, all of which can contribute to lack of healing in persons with DFU. The foot ulcer is a leading cause of hospital admissions for people with diabetes in the world and is a major morbidity associated with diabetes, often leading to pain, suffering and a poor quality of life for patients.25
Diabetic Foot Infection (DFI) is known to be a major cause of disability and mortality among diabetic patients, and it has been estimated that 25%
of all people with diabetes have a foot ulcer at some stage of their life.26 Diabetic peripheral neuropathy is known to be a major risk factor for foot ulceration, and it leads to a loss of protective sensation, resulting in continuous unconscious trauma.27 Therefore, based on the noble quote in the health care profession “prevention is better than the cure”. DFI could be preventable with proper foot care. In recent years, the number of the incidents and complications related to DFI drastically increased due to incidence of multi drug resistant organisms.28
WAGNER CLASSIFICATION OF DIABETIC FOOT ULCER29
GRADE LESION
0 No open lesions; may have deformity or cellulitis 1 Superficial diabetic ulcer (partial or full thickness)
2 Ulcer extension to ligament, tendon, joint capsule, or deep fascia without abscess or osteomyelitis
ETIOLOGY OF DIABETIC FOOT ULCERS30 Peripheral Neuropathy
Peripheral neuropathy may predispose the foot to ulceration through its effects on the sensory, motor and automatic nerves. The loss of protective sensation experienced by patients with sensory neuropathy renders them vulnerable to physical, chemical and thermal trauma. Motor neuropathy can cause foot deformities such as hammer toes and claw foot, which may result in abnormal pressures over bony prominences. Autonomic neuropathy is typically associated with dry skin, which can result in fissures, cracking and callus. Another feature is bounding pulses, which is often misinterpreted as indicating a good circulation.
Loss of protective sensation
It is major component of nearly all DFUs. It is associated with a seven- fold increase in risk of ulceration. Patients with a loss of sensation will have decreased awareness of pain and other symptoms of ulceration and infection.
Peripheral arterial disease
People with diabetes are twice as likely to have peripheral arterial disease as those without diabetes. It is also a key risk factor for lower extremity amputation.
3 Deep ulcer with abscess, osteomyelitis, or joint sepsis 4 Gangrene localized to portion of forefoot or heel 5 Extensive gangrenous involvement of the entire foot
PATHOGENESIS OF DIABETIC FOOT ULCER
In DM patients there is an increased occurrence of the main risk of the occurrence and development of diabetic foot ulcers, namely peripheral neuropathy, peripheral vascular disease and disruption of response to infection. In addition, in DM there is a wound healing disorder that increases the risk of infection. Neuropathy in DM manifests against motor, sensory and autonomic. Damage to the leg muscles causes an imbalance between flexion and leg extension, resulting in deformity and change of pressure points. Gradually, it will cause skin damage that develops into ulcers. Autonomic neuropathy lowers the activity of oil glands and sweat so that the foot moisture is reduced and susceptible to injury. Sensory neuropathy lowers the pain threshold so that it is often unaware of the existence of the wound until the wound worsens.31 In peripheral arteries, hyperglycemia causes endothelial dysfunction and blood vessel muscle, as well as decreased vasodilator production by the endothelium resulting in constriction. 32
Knowledge -Attitude- Practice (KAP)
KAP study measures the Knowledge, Attitude and Practices of a community. The knowledge gained by a community people refers to their understanding of any given topics like HTN and DM. Attitude refers to their feelings towards subject as well as any preconceived ideas that they may have towards it. Practice refers to the ways in which they demonstrate their knowledge and attitude through their action.33
It serves as an educational diagnosis of the community. The main purpose of KAP study is to explore changes in Knowledge, Attitude and Practice of the community towards diseases like hypertension and diabetes.34 It helps for disease management as well as changes in practice that are followed regarding management of disease.There are seven essential self-care behaviors in the people with diabetes which predicts good outcomes namely healthy eating, being physically active, monitoring of blood sugar, compliant with medications, good problem-solving skills, healthy
coping skills and risk-reduction behaviors.35 All these seven behaviors have been found to be positively correlated with good glycemic control, reduction of complications and improvement in the health quality of life .36
Education and awareness of diabetic foot ulcer pathway and the existing foot care measures that are intended to control them are paramount in foot ulcer prevention strategies. Nonetheless, having knowledge of the foot care alone will not be beneficial unless practiced with good compliance. Efforts have been made to increase public awareness of diabetic foot in the forms of health campaigns, public service advertisements and education by primary healthcare workers. However there are no studies in the literature that assess the current level of awareness of diabetic foot care in our diabetic patients. It has been estimated that up to 50% of the major amputations in diabetic patients can be prevented with effective education.
LITERATURE REVIEW
Akbar et.al.,37 states that good knowledge and practice regarding diabetic foot care will reduce the risk of diabetic foot complications and ultimately amputation. To assess patients’ knowledge and compliance of diabetic foot care a cross sectional study was conducted at public diabetic clinic in Bahawalpur Victoria Hospital. A sample of 150 patients were chosen using non probability convenient sampling in the duration of one month. A questionnaire which included demographic details, knowledge and practice of functional foot care was administered. Data was compiled in SPSS V20 software and later analyzed in Community Medicine department, Bahawalpur Victoria Hospital. Out of total of 300 diabetic patients studied, 182 patients (60.66%) had good knowledge regarding prevention of diabetic foot while total of only 110 patients (36.66%) were found to have a good level of practice. Poor educational status and long duration of diabetes was significantly associated with poor knowledge and poor practice of functional foot care. 250 (83.33%) diabetics knew the importance of taking anti diabetic drugs to prevent complications. 68 (22%) knew the warning signs regarding diabetic foot to consult the doctor. 182 patients (60.66%) knew the Importance of keeping feet dry to avoid foot complications. Regarding practices, 156 (52%) patients inspected their feet and toes regularly. 202 (67.3%) washed their feet regularly. 108 (36%) trimmed their nails in time properly. 136 (45%) had a habit of walking bare foot. 128 (42.66%) inspected the inside of the shoes they wore. 104 (34.66%) wore shoes with socks.
Result demonstrates satisfactory data on diabetic foot care however practices of preventive techniques are extremely unsatisfying. The majority of the patients collaborating in the study didn't have higher education and were of low socioeconomic standing. Only a few individuals knew the warning signs concerning diabetic foot to consult the doctor. Practices of correct timely trimming of nails, regular review of feet, carrying socks were found to be terribly poor. But regular feet washing and knowledge of the importance of taking anti diabetic medicine as safety measure was satisfactory.
Sutariya et.al.,38 conducted a hospital based cross- sectional study, at a tertiary care centre of Ahmedabad. Total 103 patients of diabetic foot, who had attended were selected by purposive non probability sampling method. Twenty questions for knowledge of foot care and 14 questions for current foot care practice were included in the questionnaire and each positive answer was assigned one mark and their knowledge and practice scores were classified as good, satisfactory and poor depending upon the score. For the knowledge and practice, if score was ≥70%, it was regarded as good, 50-69%was regarded as satisfactory and less than 50% score was regarded as poor. Only 24(23%) patients had good knowledge, 51 (50%) patients had satisfactory knowledge and 28(27%) had poor knowledge about diabetic foot care. Majority of the patients, 53 (51%) had poor practice, 34 (33%) had satisfactory practice and 16 (15%) had good practice. Duration of the diabetes and frequency of diabetic foot had significant statistical association with knowledge and practices of foot care. Average Knowledge and poor practice were observed among the diabetic foot patients, and it indicates need of giving proper knowledge to diabetes patients by education.
Khan.S et.al.,39 aimed to assess knowledge, attitude and practices of Diabetic Foot Wound Care among the patients suffering from Diabetic Foot and to correlate them with the socio-demographic parameters. It was a Hospital based cross-sectional study involving clinically diagnosed adult (>18 years) patients of Diabetic Foot visiting the Surgery and Medicine departments at Teerthankar Mahaveer Medical College & Research Centre, Moradabad, India. Significant association of KAP (Knowledge, Attitude and Practices) score was seen with age of the patient, education, addiction, family history of Diabetes Mellitus, prior receipt of information regarding Diabetic foot-care practices, compliance towards the treatment and the type of foot wear used. The results highlight areas especially Health education, use of safe footwear and life style adjustments, where efforts to improve knowledge and practice may contribute to the prevention of development of Foot ulcers and amputation.
Chiwanga et.al.,40 conducted a study to determine knowledge of foot care and practice of foot self-care among diabetic patients with the aim of identifying and addressing barriers to preventing amputations among diabetic patients. Patients were randomly selected from all public diabetic clinics in Dar es Salaam. A questionnaire containing knowledge and foot care practice questions was administered to study participants. A detailed foot examination was performed on all patients, with the results categorized according to the International Diabetes Federation foot risk categories.
Statistics were performed using SPSS version 14. 404 patients included in this study, 15 % had foot ulcers, 44 % had peripheral neuropathy, and 15 % had peripheral vascular disease. In multivariate analysis, peripheral neuropathy and insulin treatment were significantly associated with presence of foot ulcer. The mean knowledge score was 11.2 ± 6.4 out of a total possible score of 23. Low mean scores were associated with lack of formal education (8.3 ± 6.1), diabetes duration of < 5 years (10.2 ± 6.7) and not receiving advice on foot care (8.0 ± 6.1). Among the 404 patients, 48 % had received advice on foot care, and 27.5 % had their feet examined by a doctor at least once since their initial diagnosis. Foot self-care was significantly higher in patients who had received advice on foot care and in those whose feet had been examined by a doctor at least once. The prevalence of diabetic foot is high among patients attending public clinics in Dar es Salaam. There is an urgent need to establish coordinated foot care services within the diabetic clinic to identify feet at risk, institute early management, and provide continuous foot care education to patients and health care providers.
Thomas et.al.,41 assess the knowledge with a diabetic foot ulcer patient and to evaluate the severity and grade of diabetic foot ulcer and then to study the self-care behaviour and medication adherence in a patient with diabetic foot ulcer and to counsel the patients. The KAP, self-care foot behaviour and MMAS-8 questionnaire were given during interview; severity using Wagner’s scale was assessed. Knowledge, attitude, self-care foot practice and adherence was measured based on various parameters such as
demographic factors, clinical characteristics, and medication taking characteristics. It was measured before and after the patient counselling to see improvement in the quality of life. In the study period of 6 months 111 cases were gathered. There were 74 (66%) patients who were illiterates; the patients with low economic status were 63 (56%). Patients who are illiterates have poor knowledge and poor self-care behaviour, in our study 74 (66%) are illiterate which improved after counselling and 59 patients with high knowledge. Medication adherence is also associated with the education of the patient. After counselling and providing knowledge most of the patients are having high KAP scores. Wagner’s scale for the study of the severity shows that most of the patients 30 out of 111 are having Grade 4 of the score which shows the need of counselling and education towards foot care.
Improvement in the self-care practice and on safety and prevention was seen after counselling. Knowledge, attitude, self-care practice and adherence of the patient can be improved by establishing a good patient-provider relationship and giving proper patient counselling to the patient or their relatives.
Jinadasa et.al.,42 aimed to determine the level of knowledge and practice of foot care among patients with chronic diabetic foot ulcers.
Individuals having diagnosed diabetic foot ulcers (n=110) were selected from National Hospital of Sri Lanka (NHSL) for this descriptive cross sectional study. They were given an interviewer administered, pre tested questionnaire following informed consent. Patient perceptions of foot care were inquired. A scoring system ranging from 0-10 was employed to analyze the responses given for level of knowledge and practice of diabetic foot care.
Mean age was 58.4 years (SD ±8.6) and 57.3% were males. Non healing ulcers were present among 82.7% and amputations amounted to 38.2%. The control of diabetes was poor in 60%. Regarding foot care knowledge, the mean score was 8.37, 75.5% had scored above mean and 52.7% were aware of all principles of foot care. Regarding foot care practices, the mean score was 4.55, 47.3% participants had scored below mean and 22.7% did not practice any foot care principle and hence scored 0. A Statistically
significant difference exists between the foot care knowledge and practice scores (p<0.001, z= -8.151). In the study sample 51% were not educated prior to occurrence of complications. Results demonstrate a satisfactory knowledge on diabetic foot disease; however their practices of preventive techniques were unsatisfactory. Implementation of a national policy on diabetic foot management and good patient follow-up to increase compliance would help to improve this situation.
Sunny et.al.,43 conducted a study to enhance knowledge, attitude and clinical practice among diabetic foot ulcer patients through pharmacist counseling, and to assist physician in the selection of cost effective antibiotics. Data on the disease condition such as duration of illness, type of diabetes, category of infections, classification of foot ulcer, risk factors, co morbidities and antibiotics used were collected and analyzed.
Additionally, the details of culture sensitivity report for sensitive and resistant microorganisms with respect to antibiotics were recorded.
Appropriate patient education on diabetic foot ulcer helps to improve their knowledge, attitude, and practice significantly. The commonest microbial isolates identified in diabetic foot ulcer patients were Klebsiella pneumonia, Pseudomonas aeruginosa and Staphylococcus aureus.
Muhammad-Lutfi, et.al.,44 conducted a study to assess patients’
knowledge and compliance of diabetic foot care. A cross sectional study performed on patients who were admitted for diabetic foot infections. They were interviewed with a questionnaire of 15 ‘yes’ or ‘no’ questions on foot care knowledge and practice. Score of 1 was given for each ‘yes’ answer. The level of knowledge and practice, whether good or poor, was determined based on the median score of each category. The result was tested using a chi-square test in SPSS version 17. A total of 157 patients were included in this study with a mean age of 56.33 years (31-77). There were 72 male (45.9%) and 85 female (54.1%) patients with the majority of them being Malays (154 patients, 98.1%). Majority of the patients (58%) had poor foot care knowledge while 97 patients (61.8%) had poor diabetic foot care practice as compared to the median score. Based on the chi square test of
relatedness, there was no significant association between knowledge and practice with any of the variables. Majority of patients admitted for diabetic foot infections had poor knowledge and practice of diabetic foot care.
Education regarding foot care strategies should be emphasized and empowered within the diabetic population.
Taksande et.al.,45 aimed to analyze the knowledge, attitude, and practice of foot care in patients with DM in central rural India. The study was conducted at a rural educational hospital in central part of India over 200 patients who have Type 1 and Type 2 diabetes. They were evaluated for their knowledge about foot care and footwear practices. A structured and validated questionnaire was administered to cases. Around 82.9% of the patients were aware of the disease and 23.2% were aware of the complications of the DM. In 63% of the patients, foot care examination and education regarding foot complications were not suggested by their treating physicians. Annual examination of feet by the physician and self-examination were not known facts to the diabetic population. It is necessary to firstly develop awareness of diabetes mellitus and the related complications, one amongst which is foot care. Certain educational strategies should be established for both the consultant physician and also the common man to create awareness for effective foot care.
Desalu et.al.,46 aimed to determine the knowledge and practice of foot care among diabetes patients attending three tertiary hospitals in Nigeria. This is a cross-sectional study. Pre-tested structured questionnaires were administered by medical officers to diabetes patients. The outcome variables were knowledge and practice regarding foot care. The knowledge and practice scores were classified as good if score ≥70%, satisfactory if score was 50-69% and poor if score was < 50%. Out of 352 diabetes patients, 30.1% had good knowledge and 10.2 % had good practice of DM foot care. Majority (78.4%) of patients with poor practice had poor knowledge of foot care. With regard to knowledge, 68.8% were unaware of the first thing to do when they found redness/bleeding between their toes and 61.4% were unaware of the importance of inspecting the inside of the footwear for
objects. Poor foot practices include; 89.2% not receiving advice when they bought footwear and 88.6% failing to get appropriate size footwear. Illiteracy and low socioeconomic status were significantly associated with poor knowledge and practice of foot care. This study has highlighted the gaps in the knowledge and practice of foot care in DM patients and underscores the need for an educational programme to reduce of diabetic foot complication.
NEED OF THE STUDY
Diabetes prevalence has been rising more rapidly in middle- and low- income countries. Diabetic foot is a chronic complication as a result of poor diabetic control measures. Foot complications in diabetes are one of the main reasons for leg or toe amputation. This is one of the main reasons for hospital admission of diabetic patients. Socio-cultural practices like barefoot walking indoors and in religious places, lack of adequate knowledge on foot care practices and use of improper or ill-fitting footwear have been identified as significant contributors of diabetic foot problems. Habits such as smoking further escalate the problem by causing peripheral vascular disease and increasing the risk of neuropathy. Poor knowledge of foot care and poor foot care practices were identified as important risk factors for foot problems in diabetes. The recurrence of foot ulceration, despite careful patient education, is frustrating for management. Education is essential at every visit, for evaluation of feet. Therefore this study was designed to assess the knowledge, attitude and practice of diabetic foot.
AIM AND OBJECTIVES
Aim
The aim of the study is to assess the Knowledge, Attitude, and Practice (KAP) of Diabetic foot care in patients with Diabetic foot ulcer.
Objectives
1. To study the demographic details of patients with Diabetic foot ulcer 2. To study the grading of ulcer in patients with Diabetic foot ulcer
3. Determine the KAP of Diabetic foot care in patients with Diabetic foot ulcer.
PLAN OF THE WORK
The entire study was planned for a period of six months. The study design is given below.
PHASE 1
Approval of the work was obtained from Institutional Ethical Committee.
Literature review.
Designing the data entry form.
Consent was obtained from the hospital.
PHASE 2
Conducted a study in the target population.
Collected the socio-demographic and disease related factors
Assess patient knowledge, attitude, and practice about disease by using KAP – questionnaire.
PHASE 3
Evaluated the results.
Submission of results.
METHODOLOGY
Study design : Prospective observational study Study site : Tertiary care hospital
Study period : 6 months
Study population : Expected sample size - 200.
Actual sample size - 259 Inclusion criteria
Patients of age group between 20-90 years.
Patients who diagnosed as diabetes with diabetic foot infection.
Both male and female patients.
Exclusion criteria
Participants who are not willing to participate.
Patients with gestational diabetes.
Obtained consent from the ethical committee:
The study received clearance from J.K.K.Nattraja College of Pharmacy’s Ethical committee after submitting the proposal with study title, duration, inclusion and exclusion criteria, objectives and a brief methodology about the work. The same had been included in the ANNEXURE for the reference.
Designed data entry form:
A separate questionnaire was prepared to record patient details. The same had been included in the ANNEXURE for the reference.
Designed questionnaire form:
A separate questionnaire form for evaluating KAP of Diabetic foot was designed. The same had been included in the ANNEXURE for the reference.
We used a diabetic foot care questionnaire which is a set of 23 ‘yes’, or
‘no’ questions on knowledge, attitude and practice. The questionnaire was translated into local language. The patients interviewed during the completion of the questionnaire. It covered good foot care practice in the areas of feet washing techniques, skin and nail care and foot wear care.
Each ‘yes’ answer carried one (1) point and zero point for a ‘no’. The points were then added up for each of the knowledge, attitude and practice categories. The level of knowledge and practice, whether good or poor, was determined based on the median score of each category. Those who scored more than the median were considered as good and scores lower than the median were considered as poor.
RESULTS
Table 1: Gender wise distribution
Gender Number of Participants (n=259) Percentage (%)
Male 112 43.24
Female 147 56.75
Figure 1: Gender wise distribution
147 112
Male Female
Table 2: Age wise distribution
Age groups (years) Number of Participants (n=259) Percentage (%)
less than 20 years - -
21-30 5 1.93
31-40 17 6.56
41-50 33 12.74
51-60 73 28.18
61-70 69 26.64
More than 70 years 62 23.93
Figure 2: Age wise distribution
2
9
17
30
27 27
0 5 10 15 20 25 30 35
21-30 31-40 41-50 51-60 61-70 More than
70 years
No of Participants
Age group
Table 3: Distribution of Educational Status
Educational Status Number of Participants (n=259) Percentage (%)
Illiterates 130 50.19
Primary 58 22.39
Secondary 35 13.51
Graduates 32 12.35
Post graduates 4 1.54
Figure 3: Distribution of Educational Status
130
58 35
32
4
Illiterates Primary Secondary Graduates Post graduates
Table 4: Distribution of Occupational Status
Occupational Status Number of Participants (n=259) Percentage (%)
Employee
141 54.44
Un employee
118 45.55
Figure 4: Distribution of Occupational Status
141
118
105 110 115 120 125 130 135 140 145
Employee Un employee
No of Participants (%)
Occupational Status
Table 5: Distribution of Monthly Income
Monthly Income Number of Participants (n=259) Percentage (%)
<5000 73
28.18
5000-`15000 162
62.54
>15000 24
9.26
Figure 5: Distribution of Monthly Income
73
162
24
0 20 40 60 80 100 120 140 160 180
<5000 5000-15000 >15000
No.of Participants
Monthly Income
Table 6: Distribution of Type of DM
Type of DM Number of Participants (n=259) Percentage (%)
Type I 7 2.7
Type II 252 97.29
Figure 6: Distribution of Type of DM
7
252
Type I Type II
Table 7: Distribution of duration of Diabetes
Duration of Diabetes
(in years)
Number of Participants (n=259) Percentage (%)
Less than 10 years 70 27.02
10-20 Years 144 55.59
21-30 Years 22 8.549
31-40 Years 12 4.63
More than 40 Years 4 1.54
Figure 7: Distribution of duration of Diabetes
70
144
22 12
4 0
20 40 60 80 100 120 140 160
Less than
10 years 11-20
Years 21-30
Years 31-40
Years More than 40
Years
No of Patients
Duration of Diabetes in years
Table 8: Distribution of Family History of DM
Family History of DM Number of Participants
(n=259) Percentage (%)
Yes 182 70.27
No 77 29.72
Figure 8: Distribution of Family History of DM
182
77
0 20 40 60 80 100 120 140 160 180 200
Yes No
No of Participants (%)
Family History
Table 9: Distribution of Co morbid diseases
Co morbid diseases Number of Participants (n=259) Percentage (%)
Hypertension 112 43.24
CVD 84 32.43
Kidney Problems 27 10.42
Eye Problems 59 22.77
Stroke 18 6.94
Others 31 11.96
Figure 9: Distribution of Co morbid diseases
43.24
32.43
10.42
22.77
6.94
11.96
0 5 10 15 20 2530 35 40 45 50
No of Partcipants (%)
Comorbid diseases
Table 10: Distribution of Presence of Ulcer
Presence of Ulcer Number of Participants
(n=259) Percentage (%)
With Ulcer 178 68.72
Without Ulcer 81 31.27
Figure 10: Distribution of Presence of Ulcer
178 81
With Ulcer Without Ulcer
Table 11: Distribution of Site of Ulcer
Site of Ulcer Number of Participants (n=178) Percentage (%)
Sole 16 8.98
Toe 44 24.71
Inter-digital 29 16.29
Ankle 27 15.16
Heel 28 15.73
Dorsum 30 16.85
Multiple sites 4 2.24
Figure 11: Distribution of Site of Ulcer
16
44
29 27 28 30
4 0
5 10 15 20 25 30 35 40 45 50
No.of Participants
Site of Ulcer
Table 12: Ulcer Grading by Wagner Classification
Figure 12: Ulcer Grading by Wagner Classification
54
48 36
28
12
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grades Number of Participants (n=178) Percentage (%)
Grade 0 - -
Grade 1 54 30.33
Grade 2 48 26.96
Grade 3 36 20.22
Grade 4 28 15.73
Grade 5 12 6.74
Table 13: Knowledge towards Diabetic foot among study Participants
Sl.no Knowledge towards Diabetic foot
Total no of
participants n=259(%)
Yes No
1 Is it true that all patients with diabetes
develop reduced blood flow in their feet? 42(16.21) 217(83.78) 2 Is it true that all patients with diabetes
develop lack of sensations in their feet? 35(13.51) 224(86.48) 3 Is it true that all patients with diabetes
develop foot ulcers? 87(33.59) 172(66.40)
4 Is it true that all patients with diabetes
develop gangrene? 53(20.46) 206(79.53)
5 Were you given any information regarding
foot care? If yes, when….? 91(35.1) 168(64.86) 6 Are you aware that smoking can reduce
blood flow in your feet? 62(23.93) 197(76.06)
7
Do you know that if you have loss of sensation on your foot, you are more prone to have foot ulcers?
71(27.41) 188(72.58)
8
Do you know that if you have reduced blood flow on your foot, you are more prone to get foot ulcers?
67(25.86) 192(74.13)
9 Do you know that if you have foot infection,
you will develop foot wounds? 172(66.40) 87(33.59)
10
Which do you think is appropriate way of trimming your nail? Cutting along the edges/cutting straight through?
84(32.43) 175(67.56)
Table 14: Attitude towards Diabetic foot among study Participants
Sl.no Attitude towards Diabetic foot
Total no of
participants n=259(%)
Yes No
1
Are you willing to change your food habits and do regular exercise to prevent further complications due to diabetes?
102(39.38) 157(60.61)
2
Do you think people with diabetes should take the responsibility of self foot examinations like checking sole of foot daily/wearing podiatrist prescribed footwear/consulting podiatrist regularly?
143(55.21) 116(44.78)
3 Are you willing to use special footwear prescribed your podiatrist?
85(32.81) 174(67.18)
4 Will you wear footwear indoors as advised by your podiatrist?
68(26.25) 191(73.74)
5
Do you think you can lead a normal life if you take appropriate measures for
diabetes?
154(59.45) 105(40.54)
Table 15: Practice towards Diabetic foot among study Participants
Sl.no Practice towards Diabetic foot
Total no of
participants n=259(%)
Yes No
1 Do you wash your feet daily? 121(46.71) 138(53.28) 2 Do you moisturize dry areas of your feet
daily? 43(16.60) 216(83.39)
3 Do you check your feet daily for any injury? 34(13.12) 225(86.87)
4
What would you do if you find any abnormality on your feet? You manage yourself/consult a podiatrist?
54(20.84) 205(79.15)
5 Are your toe nails cut straight through
regularly? 72(27.79) 187(72.20)
6 Do you check whether your shoes/socks
leave marks on your feet? 32(12.35) 227(87.64)
7
How often do you change your footwear?
When slippers are damaged/once in a year/more than once in a year?
101(38.99) 158(61.00)
8
How often do you go for foot check up?
Once in a month/once in 6 months/once in ayear/only during illness?
142(54.82) 117(45.17)
DISCUSSION
Table no. 1, shows the Gender wise distribution of study population.
Out of 259 patients 56.75% were female and 43.24% were male. Females are greater in number when compared to males.
Table no. 2, shows the age wise distribution. In this most of the patients were in the age group of 51-60 years (28.18%) followed by 61-70 years (26.64%),>70 years (23.93%), 41-50 years (12.74%),31-40 years (6.56%) and 21-30 years (1.93%). Similar study explained that highest proportion of DM were in the age group 50-59 years (26.1%), and it shows that people who are prone to develop complications of DM at an early age (20-40 years) compared with Caucasians (>50 years) and indicate that DM must be carefully screened and monitored regardless of patient age within India.47
Table no. 3, shows the educational level of study population. 50.19%
of the patients were Illiterates. 22.39% and 13.51% of the patients had primary and secondary education up to school level. Only 12.35% and 1.54% of the study population completed Graduate and Post graduate degree level.
Table no. 4, shows the Occupational status of study population. Out of 259 participants, 141(54.44%) were employed and 118(45.55%) were unemployed.
Table no. 5, shows the individual monthly income.62.54% of the patients getting an income of 5000-15000 per month followed by <5000 (28.18%) and >15000 only 9.26%.
Table no. 6, shows the Type of DM of the study population. Out of 259 participants, 252(97.29%) and 7(2.7%) patients have type 1 and type 2 DM respectively. The study conducted by Teksande et.al.,45 showed that 92% of the study participants had type 2 DM.
Table no. 7, shows the duration of DM of the study population. Out of 259 participants, 144 patients (55.59%) had diabetes for 11-20 years, 70
patients (27.02%) had diabetes for less than 10 years, 22 patients (8.54%) for 21-30 years, and 4 patients (1.54%) had diabetes for more than 40 years.
These findings are similar to other study, which showed that diabetic foot problem is a major concern among the elderly people which increases the morbidity in them due to diabetes. It is well understood that diabetic foot disease occurs in long standing diabetic foot disease because the pathological process takes about 10 years to develop. Majority of the patients were admitted with moderate conditions of the disease. The increasing duration of diabetes may increase the risk of diabetes related complications.43
Table no. 8, shows the family history of DM of the study population.
70.27% of the study population had the family history of DM. Only 29.72%
of the patients not have the history of DM.
Table no. 9, shows the co-morbidities of the study population.
Hypertension, Cardiovascular Diseases, Kidney diseases, Eye Problems, and stroke are the co-morbid diseases commonly found with the DM patients. In this study most of the patients have hypertension 112(43.24%), followed by Cardiovascular Diseases 84(32.43%), Eye Problems 59(22.77%), Kidney diseases 27(10.42%), stroke 18(6.94%) and others 31(11.96%). Similar findings were observed in the study conducted by Sunny et.al.43
Table no.10, shows the Presence of Ulcer in study participants.
178(68.72%) study participants have the presence of ulcer and only 81(31.27%) study participants not have the presence of ulcer.
Table no. 11, shows the distribution of site of ulcer of the study population. Out of 259 study participants, 178 had the presence of ulcer. In that the distribution of site of ulcer is more common in toe 44(24.71%), followed by dorsum 30(16.85%), inter-digital 29(16.29%) heel 28(15.73%), ankle 27(15.16%), sole 16(8.98%), and multiple sites 4(2.24%).
Table no. 12, shows the distribution of site of ulcer of the study population. According to Wagner Grading of foot ulcer majority of the
patients were presented with Wagner’s grade I and above, 30.33% in Grade I, followed 26.96% in Grade II, 20.22% Grade III, 15.73% Grade IV and 6.74% Grade V respectively.
Knowledge towards foot care:
Out of 259 study participants, only 42(16.21) of the study participants were aware that the diabetes develop reduced blood flow in their feet and 83.78% were not aware. 87(33.59) and 53(20.46) were aware that all patients with diabetes develop foot ulcers and gangrene and 172(66.40) and 206(79.53) not aware. 62(23.93) were aware that smoking can reduce blood flow in your feet. 188(72.58) of study participants were not aware that loss of sensation on your foot, you are more prone to have foot ulcers. Only 67(25.86) were aware that reduced blood flow on your foot, you are more prone to get foot ulcers. 172(66.40) study participants were aware and 87(33.59) were not awrae that foot infection, will develop foot wounds.
From this study, we know that only 30-40% were had knowledge about diabetic foot ulcer and aware about the disease. 60-70% of the people has no knowledge and not aware about diabetic foot ulcer.
The lack of knowledge about foot care in our study is consistent with findings by other investigators worldwide.48-51
Attitude towards foot care:
Out of 259 study participants, 102(39.38) were have good attitude to change food habits and do regular exercise to prevent further complications due to diabetes. Only 143(55.21) think that people with diabetes should take the responsibility of self foot examinations like checking sole of foot daily, wearing podiatrist prescribed footwear, consulting podiatrist regularly and 116(44.78) were not aware about the disease. 85(32.81) and 68(26.25) were willing to use special footwear and wear footwear indoors as advised by podiatrist. 59.45% of the study participants think that we can lead a normal life if you take appropriate measures for diabetes.
Practice towards foot care:
Out of 259 study participants, only 121(46.71) of the study participants had the pratice of washing feet daily and 138(53.28) were not pratice. 216(83.39) of the participants not moisturize dry areas of feet daily and only 43(16.60) of the participants moisturize dry areas of feet daily. Only 34(13.12) check their feet daily for any injury and 225(86.87) were not checking their feet daily. 205(79.15) of the study participants says if they found any abnormality on feet consult a podiatrist and 54(20.84) says that if they found any abnormality on feet they manage themselves.72(27.79) of the partcipants cut toe nails straight through regularly. 227(87.64) of the study participants not have the practice to check whether shoes and socks leave marks on your feet and 32(12.35) had the practice of check any marks.
158(61.00) of the study participants changed footwear when slippers were damaged or once in a year and 101(38.99) of the study participants changed footwear more than once in a year. 117(45.17) of the study participants go for foot check up once in a month or once in 6 months and 142(54.82) study participants go for foot check up once in a year or only during illness.
The poor level of foot care practice in this study is in agreement with other previous studies.48-51
The role of physicians in passing the knowledge to patients is very important in improving the awareness and good practices of foot care. Poor communication between healthcare workers and patients and little amount of time allocated to educate patients due to a busy clinic schedule are usually the reasons for inadequate patient education.46,52,53 The deficiency in the knowledge may be due to poor communication between the doctors and the patients and also lack of counselling by the doctors and nurses as result of busy clinic schedule. Thus, patient education on the prevention of foot ulceration is imperative and should be incorporated into the routine care of patients with diabetes both in the hospital and in the community. Time must be allotted to communication, information and education during clinic sessions.54
