Diabetic Foot Care: Self Reported Knowledge and Practice among Patients Attending Three Tertiary Hospital in Nigeria

SUMMARY Background: Diabetes Mellitus (DM) foot complications are a leading cause of mortality in developing countries and the prevalence of diabetes is expected to increase in the next decades in these countries. The aim of this study was to determine the knowledge and practice of foot care among diabetes patients attending three tertiary hospitals in Nigeria. Methods: This is a cross-sectional study carried out from November 2009 to April 2010. Pre-tested struc-tured 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%. Results: 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. Conclusion: 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.


INTRODUCTION
3][4] About 60% of the poorest countries in the world are in sub-Saharan Africa and this region will experience the greatest rise in the prevalence of diabetes in the next 20 year. 3 This rise in prevalence of DM is likely to bring a concomitant increase in its complications among diabetic patients.One important complication of DM are the foot problems; these complications constitute an increasing public health problem and are a leading cause of admission, amputation and mortality in diabetic patients.The prevalence of diabetic foot ulcer (DFU) ranged between 1.0% and 4.1% in the United States (US), 4.6% in Kenya, and 20.4% in Netherlands. 5,6,7ospital-based studies demonstrated that the prevalence of limb ulceration were between 11.7% and 19.1% among individuals with diabetes in Nigeria. 8,9he prevalence of DFU among hospitalized patients with diabetes in Iran was 20%. 9ot ulcers are chronic complications of diabetes and have been reported to occur after a mean interval of 13 years from the diagnosis of diabetes in a Nigerian population. 10DFU may become more common in clinical practice in the tropics with the increasing prevalence of diabetes in the Nigerian and Ghanaian adult populations. 11n addition to causing pain and morbidity, foot lesions in diabetic patients also have substantial economic consequences, beside the direct costs of foot complications, there are also indirect costs relating to loss of productivity, individual patients' and family costs and loss of health related quality of life.The lifetime risk of a person with diabetes developing a foot ulcer could be as high as 25%, and it is believed that every 30 seconds a lower limb is lost somewhere in the world as a consequence of diabetes. 12obally, DM foot lesion is a result of peripheral vascular disease and neuropathy which is the major contributing factor that is preventable in most cases in developing countries. 1Some environmental factors like increasing urbanization, unhygienic conditions, poverty, frequent co-existing HIV infection, barefoot gait, low income, and cultural practices have also been said to compound the situation. 14People with diabetes are prone to develop foot ulcer, amputation and other lower extremity clinical abnormalities if they do not have good knowledge of foot care practice.
In Nigeria the mean costs for successfully treating a patient with Diabetic Mellitus Foot ulceration is 181581.00Nigerian Naira (NGN), which approximately equivalent to 1200 US dollars , this amount is unaffordable by most hospital patients as about 60% of the population live below the poverty line. 7Therefore increasing the knowledge, awareness and self care of the foot among diabetic patients have found to be cost effective ways of preventing DM foot ulceration 15,16 especially in low income economy characterized by inadequate healthcare facilities and lack of skilled healthcare personnel.There are no study on knowledge and practice of foot care among diabetic patients in Nigeria.We aimed at conducting a multi-centre study in some tertiary hospitals in Nigeria to determine the knowledge and practice of foot care among diabetic patients.

METHODS
This is a multicentre cross-sectional study carried out in three tertiary hospitals in Nigeria from November 2009 to April 2010 .The country of the study is divided into six geopolitical zones.This survey was conducted in three of the six geopolitical zones which can be considered a representative sample of diabetic patients.We selected Federal Medical Centre in Ido-Ekiti, south western Nigeria, Sir Yahaya Memorial Hospital, Birnin-Kebbi in north western Nigeria and Federal Medical Centre Yola, north eastern Nigeria.
The minimum sample size of 384 was arrived at using the Cochran formula N = Z 2 pq d 2 N = Sample Size, p = prevalence of DM in Nigeria is 2.2%. 17The q = (1 -p), Z = standard normal deviation usually set at 1.96 which correspond to the 95% confidence interval.d = degree of accuracy desired usually set at 0.05.The calculated minimum sample size was 33 All the patients that were willing to participate in the study were recruited at the medical outpatient department and wards of the three hospitals.
The inclusion criteria for the cases included consented patients diagnosed of type I and II diabetes for at least six months and who had never developed foot ulcers.DM patients that were unable to answer the questions because of altered mental state were excluded from the study.9] The questionnaire was in English, which is the official language of communication in Nigeria, adapted, and translated to Hausa and Yoruba language for those who could not communicate in English.The questionnaire consisted of 11 questions on knowledge of foot care and current self-care practice respectively and each correct question was assigned one mark.
The questionnaires were administered by medical officers who also examined for predisposing factors to foot ulcer in the patients.The outcome variables of the study were knowledge and practice regarding foot care in diabetic patients.Data obtained were analysed using SPSS statistical software version 15 (SPSS Inc., Chicago, IL, USA).Frequency and descriptive statistics were used to examine the general characteristics of the respondents.The response to questions on knowledge, practice and barriers to foot care were analysed and the knowledge and the current practice score of each respondent was determined.Their knowledge and practices score were classified as good, satisfactory and poor depending upon the score.If score ≥70% (8-11), it was regarded as good, if score was 50-69% (6-7) it was regarded as satisfactory and if score was less than 50% (<6) it was regarded as poor.Student t test was used to compare the means of the scores and Chi square test was used to assess the significance of the responses and a P value of < 0.05 was considered statistically significant.

Ethical approval
The ethics and research committee of the Federal Medical Centre Ido-Ekiti and the Federal Medical Centre Yola Nigeria approved the study.

RESULTS
We enrolled a total of 352 diabetic patients to the study, 216 (61.4%) were males and 136(38.6%)were females.Two hundred and twenty two (63.1%) were below the age of 50 years.Of 352 patients, 196 (55.7%) had no formal or primary education while 156(44.3%)had a secondary or tertiary education.The mean age of the respondents was 44.0 ± 15.8 years.Of the 352 patients interviewed, 192(54.5%)had some risk factors of diabetic foot.The characteristics of the patients are shown in table 1.

Knowledge of foot care
The mean knowledge score was 5.8 ± 3.3.The range of the knowledge score obtained in this study was 0-11 out of maximum possible score of 11.Two hundred and sixty four (75%) of the DM patients were unaware that smoking causes poor circulation of the feet, 242 (68.8%) were unaware of the first thing to do when they found redness/bleeding between their toes and likewise 227 (62.2%) if they found a corn/ hard skin lesion.Majority of the respondent (61.4%) were unaware of the importance of inspecting the inside of the footwear for objects or torn lining.The distributions, of the response to questions related to the knowledge of foot care are shown in Table 2.
Table 2 : Distribution of the responses to questions related to the knowledge of foot care

Current practice of foot care
The mean practice score was 5.7 ± 1.9.The range of the current practice score obtained in this study was 2-10 out of maximum possible score of 11.Less than half of the respondents (40.9%) regularly inspect their feet, (46%) regularly wash their feet with warm water and (47.7%) inspect the inside of their footwear.The distribution of response to questions related to the practice of foot care is shown in Table 3. ).We also determined the effect of knowledge on the practice of foot care, 174 patients with poor practice score were stratified by their knowledge score and the result showed that 136(78.2%)had a poor knowledge score, 32(18.4%)had a satisfactory score while 6(3.4%) had a good score.

Association of demographic factors with the knowledge and practice of foot care
In order to determine the impact of demographic factors on knowledge and practice of foot care the categorical variables were dichotomized and the student t test was used to compare the mean of the scores.Poor education attainment and low socioeconomic status were significantly associated with lower the knowledge and practice score in this study (Table 4).

Self reported barriers to foot care
In this study, lack of knowledge of foot care was reported by116 (33.0%) as the barrier to good foot care practice, 20(5.7%)cited poverty and 9(2.6 %) cited poor communication between patients and their physician.

DISCUSSION
The result of this study showed that a greater proportion of diabetic patients had a poor knowledge of diabetic foot care.These deficiencies arises from lack of awareness about the effect of smoking in causing poor foot circulation; need for specialist consultation when warning signs like redness/bleeding occurs between toes; importance of regular inspection of the footwear for objects or torn lining and regular inspection of the feet.[21][22] We also found that patients having poor education and in low socioeconomic status significantly had lower knowledge of foot care while gender and age differences were not significantly associated with the knowledge of foot care.1][22] The knowledge of appropriate foot care has been suggested to be positively influenced by patient education which in turn reduces the risk of foot ulceration and amputation in high-risk diabetics. 23The association between education and knowledge may be due to the fact that, educated patient were able to read and understand some of educational supportive materials and also use information technology to obtain more information about the disease.
Women and those above the age of 50 were less knowledgeable about foot care, although these associations were not statistically significant.Similarly in some third world countries due to socio-cultural beliefs women are not allowed to attain higher educational status compared with their male counterpart in the family, eventually resulting in women having less knowledge of DM foot care.This study also revealed that a very small proportion of the diabetic patients (10.2%) had good practice of diabetic foot care (score ≥70%) while almost half (49.4%) had a poor practice of diabetic foot care.This level of foot care is very frightening considering the complication and socioeconomic consequences of diabetic foot ulceration.
This poor level of foot care practice in this study is in agreement with other previous studies [19][20][21][22] .Some of the inadequacies of foot care practice in our subjects include non-inspection of inside of their footwear (47.7%), non inspection of their feet (40.9%), and 88.6% failing to get appropriate size footwear.The poor practice of foot care in this study may be attributed to the lack of knowledge among the respondent as 78.4% of those with poor foot care practice also had poor knowledge of foot care.This association was further corroborated as 33% of the respondents reported lack of knowledge as greatest barrier to good foot care practice.
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. 24rthermore, the education of physician is highly imperative to complement and reinforce the behaviours of patient with regards to foot care; they need to learn and imbibe the skills of counseling and risk assessment.
Our study has been able to determine the knowledge and practice of foot care among diabetic patients in Nigeria.

Strengths and limitations
The results of this study are a wake up call on the clinicians and nurses to establish a patients and physician friendly educational programmes that will enhance and sustain the good knowledge and practice of foot care.The limitation of this study was our inability to cover all six geopolitical zones in Nigeria.

CONCLUSION
In conclusion, the knowledge and practice of foot care among DM patients in study were poor; these were associated with illiteracy and low socioeconomic condition.The result of this study has highlighted the gaps in their knowledge and practice and underscores the urgent need for a patient friendly educational intervention coupled with regular physician reinforcement to reduce the risk of diabetic foot ulcer and amputations.

Table 1 :
Characteristics of the patients in the study (n=352)

Table 3 :
Distributions of responses to questions related to the practice of foot care

Table 4 :
Impact of Demographic factors on knowledge and practice of foot care