ASSESSMENT OF KNOWLEDGE AND PRACTICE OF DIABETIC

PATIENTS REGARDING FOOT CARE IN MIRPUR AZAD KASHMIR.

CHAPTER 01: INTRODUCTION

INTRODUCTION
Diabetes mellitus (DM):
According to WHO, Diabetes mellitus is a chronic disease caused by inherited or acquired
deficiency in production of insulin by pancreas, or by ineffectiveness of the insulin produced.
Such a deficiency results in increased concentrations of glucose in the blood, which in turn
damage many of the body’s systems, in particular the blood vessels and nerves.
There are two types of Diabetes, type 1 and type 2. (1, 2)

Type 1 Diabetes Mellitus:

Type 1 Diabetes (Insulin-Dependent Diabetes Mellitus) in which pancreas fail to produce the
insulin. This form develops most frequent in children and adolescents. (2)

Type 2 Diabetes Mellitus:

Type 2 Diabetes (non-insulin dependent Diabetes Mellitus), which results from the body’s
inability to respond properly to the action of insulin produced by pancreas. It occurs
most frequently in adults. (2)

COMPLICATIONS OF DIABETES:
Diabetes is associated with many complications such as retinopathy, neuropathy. These
conditions are the result from the duration and the severity of hyperglycemia. Other serious
consequences include; the development of cardiovascular disease for example: peripheral arterial
disease, ischemic feet, and coronary heart disease.
Similarly, one of the most common consequences of diabetes in diabetic patient in the lower
extremity is the diabetic foot ulcer.
World Health Organization defines diabetic foot as, “The foot of a diabetic patient that has the
potential risk of pathologic consequences, including infection, ulceration, and/or destruction of
deep tissues associated with neurologic abnormalities, various degrees of peripheral vascular
disease, and/or metabolic complications of diabetes in the lower limb.” (3, 4)
It is prevalent in both types of diabetes (Type I and Type II). Foot ulcers do not erupt
spontaneously and are usually the result of some kind of trauma coupled with neuropathy and
accompanying infection.

PATHOGENESIS OF DIABETIC FOOT ULCERS

Basically, there are two most underlying causes of foot ulceration; Neuropathy and Peripheral
vascular disease (PVD). These are the main contributors to foot disease, are found in more than
10% of people when they are diagnosed with diabetes. Some other risk factors for diabetic foot
ulcerations includes; cigarette smoking, foot deformity, poor glycemic control, previous history
of ulcerations, infection, previous amputations, visual impairment, high blood pressure, living
alone or lack of social support. (3, 4)

Neuropathy:
Neuropathy is defined as nerve damage. It is mostly asymptomatic. 50% of diabetic patients are
affected and diagnosed with neuropathy and risk foot. It is the common and serious
complications of diabetes. It is usually characterized by damage to the peripheral nerves causing
loss of sensation, autonomic dysfunction, foot deformity and impaired mobility.
People with diabetes have a 30-50% risk of developing chronic peripheral neuropathy, with 10-
20% of those diagnosed with neuropathy going on to develop severe neuropathic symptoms. Due
to loss of pain and sensation, patient often fails to seek medical care at right time when the
damage is already significant.

For example, in a study of patients who underwent amputations at a US Veterans Administration

Medical Centre, 41% were found unaware of their sensory deficit. The effects of diabetic
peripheral neuropathy are progressive, permanent and varied depending on the type and extent of
nerve damage.

Although pain is not recognized as the risk factor for ulceration, it can cause range of unpleasant
symptoms such as burning and tingling sensations, shooting pains and parenthesis. Symptoms
are usually worse at night leading to sleep disturbance and reduced quality of life. Chronic
persistent pain can be extremely distressing for the individual, and can contribute to feelings of
anxiety and depression.
Diabetic peripheral neuropathy is related to the dysfunction of sensory, motor and autonomic
neuropathy. These are the three dominant types of peripheral neuropathy causing inevitable
ulcerations. (3, 4)

Motor Neuropathy:
Motor nerves control the muscles. It is mostly prevalent in elderly with type II diabetes.
It occurs when there is damage to the nerves supplying the muscles of body. The symptoms like
loss of muscle strength, getting fatigue easily, muscle starts getting smaller. In advanced case,
patient may experience difficulty in breathing and swallowing.

The nerves’ supplying the muscles fails to maintain the person’s healthy foot shape causing
deformity. This deformity leads to an alteration in the biomechanics of walking, and foot
pressure points during standing and walking. Calluses form in abundance on the new, alien
pressure points and sub-metatarsal head fat pads become thin. This increases the force plantar
pressure that ultimately results in the formation of a foot ulcer, which has a high risk of
becoming infected. (3, 4)

Sensory Neuropathy:
Sensory nerve carries sensation to different parts of the body in the periphery. It is the most
common form of diabetes peripheral neuropathy and is closely associated with the development
of ulcers.

Damage to sensory nerve results in changes in sensation or loss of protective sensation, burning
sensations, nerve pain, tingling or numbness or inability to determine joint position, which
causes balance problems and risk of falling.

The normal sensations experienced by a person are declined. It is the most common form of
diabetes neuropathy, which affiliates ulcer development. Individuals are often unaware of their
condition especially, if it develops at the sole of the foot causing delay or failure in discovering it
on time until they develop an injury as a result of a relatively innocuous trauma, for example
pressure from an ill-fitting shoe or from standing on a sharp object or when it is detected by a
healthcare professional during routine diabetic foot screening. (4)
Autonomic Neuropathy:
Autonomic neuropathy is a serious problem. It occurs when the nerve that helps to control
involuntary functions, including digestion, vascular tone and sweating become damaged. In the
foot, this can cause interruption of the sweat glands, leading to dry, non-sweating skin, which is
prone to cracks and fissuring. Then, the foot becomes portal for infection. (4, 5)

Peripheral vascular disease:

Patients with diabetes are more likely to get peripheral arterial disease. This is a condition when
the fatty deposits or the plaque hinders the blood flow in the legs and feet. This causes stiffening
of the elastic layer of the arterial wall, thereby making it less able to constrict and dilate
normally. The combination of hardening and stiffening and narrowing of the artery leads to
reduced tissue perfusion and peripheral ischemia, with reduced nutritive blood flow and
consequently, reduced tissue viability. The devitalized tissue is therefore unable to withstand
pressure on walking and weight bearing or repeated minor trauma, placing the foot at increased
risk of tissue breakdown, ulceration and possible amputation. (5)

The modifiable risk factors for peripheral arterial disease include dyslipidemia, hypertension
and smoking. The risk of peripheral arterial disease being present is increased if the patient
smokes and has history of stroke or myocardial infarction. (3-5)

Role of C-reactive protein in diabetic foot ulcer:

Diabetic patients have higher concentrations of C-reactive protein than nondiabetic patients,
suggesting an increased role of inflammation in the accelerated atherosclerosis seen in these
patients. The risk of CVD is two- to four times higher in type 2 diabetics and >50% of all
diabetic patients die of CVD. C-reactive thus proliferate the conditions of narrowing of
microvasculature and increase risk of diabetic foot ulcer in diabetic patients. (6)

Foot Deformities:
It is important to recognize deformity in the diabetic foot; it often leads to bony prominences that
are associated with high mechanical pressures on the overlying skin. This results in ulceration,
particularly in the absence of protective pain sensation and when shoes are unsuitable. The most
common deformities include Claw toes, Hammertoes, Charcot foot.(1, 7)
DIABETIC FOOT ASSESSMENT
Diabetic foot ulcers are the single greatest cause of non-traumatic limb amputation in people
with diabetes: amputations are 15 times more common in those with diabetes than those without
the disease. Amputation carries a higher mortality rate than colon, breast or prostate cancer, and
up to 80% of people with diabetes will die within five years of having an amputation. More
significantly, reported that only 50% of all diabetes-related amputees would survive for two
years following surgery. (3)

However, timely and early assessment of the foot at risk can significantly prevent foot ulceration
and limb amputation. Guidelines published by the National Institute for Clinical Excellence
require that all people with diabetes should have an annual foot examination.

There are mainly eight things that can be done for the assessment, which are listed below:

 Neuropathy
 Ischemia
 Deformity
 Callus
 Swelling
 Skin breakdown
 Infection
 Necrosis

The foot at risk can be detected by three-examination procedure:

Simple inspection, Palpation and Sensory inspection:

Neurothesiometer, a device which when applied to the foot delivers a vibratory stimulus, which
increases as the voltage is raised. The Semmes Weinstein Monofilament test is a screening tool
used in patients with diabetes that helps in determining the presence of protective sensation. This
procedure enables early intervention and management to reduce the future risk of ulceration and
lower extremity amputation. (3)
This test is carried out mostly in the three distinctive sites, the plantar aspects of the great toe, the
third metatarsal and the fifth metatarsal. The monofilaments are applied to the test site until it is
bent perpendicularly. Accordingly, the patients are instructed to say ‘Yes’ if they feel the
monofilament on their foot and on contrary if the patient does not feel the sensation, the test is
considered to be insensate.

This procedure is convenient and rapid which is often used in clinical testing and routine self-
assessment. Another common instrument used for the detection of pain sensation is
Neurothesiometer. This device produces a vibrating stimulus once applied to the foot and
increases when the voltage is raised.

If the patient fails to feel 25 volts from the vibratory stimulus, then the patient has high risk of
ulceration. Ischemia is often detected by the palpation of the peripheral pulses.

Risk categorization system for Diabetic Foot

Category Risk profile Checkup frequency
0 No sensory neuropathy Once a year
1 Sensory neuropathy Once every 6 months
Sensory neuropathy and
signs of peripheral vascular
2 Once every 3 months
disease and/or foot
deformities
3 Previous ulcer Once every 1-3 months

STAGES OF THE DIABETIC FOOT

The diabetic foot can be classified into six stages.

Stage 1: -
No risk factors are present. The patient does not have signs of peripheral vascular disease,
neuropathy, deformity, callus, numbness and swelling making him vulnerable to foot ulcers.
Patient is considered as normal.
Stage 2: -
Presence of one or more of the risk factors, which may be neuropathic or ischemic. Patient is at
high risk while having these conditions.

Stage 3: -
The sign of skin breaks down is prominent on the plantar surface or on the margin of foot
causing an ulcer formation. Patient is considered ulcerated in presence of these signs &
symptoms.

Stage 4: -
The ulcer has developed infection, which is progressive. It also affects the skin and soft tissues
underneath. Patient is infected.

Stage 5: -
Presence of necrosis and gangrene worsens the infection causing tissue destruction. Patient is
necrotic in light of these sign & symptoms.

Stage 6: -
The foot cannot be saved and will need a major amputation.
CHAPTER 02: METHODOLOGY
METHODOLOGY:

Objective:
This study aimed to evaluate knowledge and practice of diabetic patients regarding the foot care
in Mirpur Azad Kashmir. (8-10)

Study design:
Cross-sectional study design is executed. (8-10)

Study settings:
This study is conducted among the patients attending outpatient department of District head
quarter hospital of Mirpur Azad Kashmir, Mohhi-ud-din teaching hospital new city & Jhelum
poly clinic Mirpur.

Sample size:
The sample size of 110 is selected.

Inclusion criteria:
(1) The diabetic patients which have diabetes from more than 1 year.
(2) The diabetic patients of age above 18 years are included.
(3) Diabetic Patients which has not developed any foot ulcer.

Exclusion criteria:
(1) We excluded the patients who were below 18 years age.
(2) Patients with poor conscious level were excluded.
(3) Patients having diabetes less than 1 year.
(4) Patients already having diabetic foot ulcer.

Study tool:
A pre-designed questionnaire is used as a tool. It is classified into four main sections
(1) Demographic section
(2) Knowledge related questions regarding foot care
(3) Practice related questions regarding practice of foot care
(4) Physical activity

Procedure:
The questionnaire designed is presented to the patients participating in the study to get
information about their knowledge practice, demographic and physical activity regarding foot
care. The patients were asked to answer the given questions in” Yes” or “No”. (9-11)
Demographic data:

Nationality
Gender
Age
Educational level
Type of job

Assessment of knowledge of diabetes Foot

S.no Questions Yes No

1 Do you know smoking causes poor circulation affecting the feet?
2 DM patient should take their medication because they liable to get
DM complications?
3 Do you know foot ulcer is common complication in DM?
4 Do you have any idea dry and scaly skin is a common symptom of
foot ulcer?
5 Do you know wounds may not heal quickly in DM patients?

6 Do you know infections may not recover quickly in DM?

7 Do you know walking bare foot may cause foot ulcer?

8 Do you think you should inspect the inside of footwear for objects
or torn lining?
9 Stand on one point may cause foot complications?

There are aggregate of 9 questions concerning knowledge of foot care. The scoring criteria for
knowledge of foot care are ordered into low and high state of knowledge. The respondent was
sorted into low state of knowledge with respect to foot care if the right number of questions was
addressed is 1-4 out of 9 questions, while for high state of knowledge of foot care the score was
5-9 out 9. The underneath table demonstrated the aftereffects of the scoring for knowledge state
of foot care. (10-12) (11-13)

Scoring for Knowledge Level of Foot care

Knowledge level of foot care Frequency (n) Percentage (%)

Low (1-4)
High (5-9)
Total

Assessment of practice of the diabetic foot care

S.no Questions Yes No

1 Do you inspect your feet daily?
2 Do you wash your feet two times a day?
3 Do you wash your feet with warm water?
4 Do you trim toe nails straight across?
5 Do you measure your feet size when last you bought footwear?

6 Do you use talcum powder for keeping interdigital space dry?

7 Did you ever inspect inside of your footwear?

8 Do you walk regularly bare foot?
9 Do you add irritants to water before feet cleaning?
10 Do you add antiseptic to water before feet cleaning?
11 Do you wear elasticated hosiery (to prevent edema and
thrombosis)?
12 Do you feel heel ache?

There are 12 questions regarding routine with regards to foot care. The scoring of the act of foot
care is classified into poor, satisfactory and great routine with regards to foot care. The
respondent will be ordered into poor practice with regards to foot care if the right number of
questions addressed is between 0-5 out of 12 question, satisfactory if 6-8 out of 12 questions and
good if 9-12 out of 12 questions. The underneath table demonstrated the consequences of the
scoring for routine with regards to foot care. (10, 12)

Scoring for Practice of Foot Care

Practice of foot care Frequency (n) Percentage (%)

Poor (0-5)
Satisfactory (6-8)
Good (9-12)
Total

Assessment of physical activity of patients

Do you practice physical activity?

Yes _________ No________

How much do you practice physical activity?

Zero_______ Less than 5 days a week_______ Daily/ 5 days a week_______

How much time you give to physical activity?

Zero_______ <30 minutes_______ >30 minutes_______

CHAPTER 03: LITERATURE
REVIEW
Reda Goweda,2017: Conducted a study to assess the knowledge and practice of diabetic patients
regarding foot care in Makkah Saudi Arabia. He stated in his study that about 20.5% of the
Saudis between 20 and 79 years were diabetic. The incidence of non-traumatic lower extremity
amputations was at least 15 times greater in those with diabetes than non-diabetics.it was a cross
sectional study design. The sample size was 350 patients who met the inclusion criteria.
Interviewing questionnaire and patients’ charts review were used to collect the data. The results
concluded that Mean age of patients was 53.0083±13.1 years, and mean duration
of diabetes was 11.24±8.7 years. 35.1% had history of foot ulcer while 25.7% had ulcer on the
time of interview. 11.7 % had history of amputation and 83.1% had numbness. 77.1 % examine
their feet while 49.1% received foot care education and 34% read handouts on foot care.34% of
diabetic patients walk around bare feet. The p-value was <0.05.(14)

AR Muhammad-Lutfi,2014: Performed a cross sectional study to assess patient’s knowledge

and compliance of diabetic foot care. The study was performed on the patients who were
admitted to Hospital Sultanah Nur Zahirah from the 1st September 2013 to 30th April
2014 for diabetic foot infections. The patients were interviewed with a questionnaire 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
median score of each category. Total 157 patients were included in the study with mean age of
56.33 (31-77). There were 72 male (45.9%) and 85 female (54.1%) patients with the majority of
them were Malaysian (154 patients, 98.1%). The results showed that 58% of the patients had
poor foot care knowledge and 61.8% patients had poor diabetic foot care practice. So, they
concluded that majority of patients admitted for diabetic foot infection had poor knowledge and
practice of diabetic foot care. (15)

Hasan A. Al Zahrani,2011: Conducted a cross sectional study related to foot care knowledge
and practice among diabetic patients attended primary health care centers in Jeddah city. A
questionnaire was designed to assess foot care knowledge and practices.747 patients were
included in the study. The lower level of foot care knowledge and practice was noticed than the
optimum level. It was observed that the practice was scored significantly lower in patients with
lower educational level. About 66.5% of the patients reported having one or more diabetic
complications and 45.4% patients reported peripheral neuropathy. Hence it was concluded that
the patients with diabetic mellitus had poor knowledge and practices regarding foot care. (16)

Basu,2004 conducted study on knowledge and practice of foot care in United Kingdom. The
setting selected for study named as Vascular Surgery Research Unit, Southampton University
Hospital, Southampton, United Kingdom. The study was taken in time period of July 2003 to
August 2003. Patients with diabetes were recruited equally from general practitioners’ surgeries,
hospital outpatient clinics, and wards. The inclusion criterion was patients with diagnosis of
diabetes mellitus more than 1 year ago. They excluded those who had been diagnosed with
diabetes within the last 12 months and those who were younger than 18 years old. They
interviewed 110 patients from aforementioned hospitals & clinics. A questionnaire was used to
obtain data from patients about footcare knowledge and practice. They recorded response rate of
100%. Among these 110 patients 40 patients were from general practitioners’ surgeries, 44 were
from this hospital’s outpatient diabetic clinic and 26 were from inpatient department. The mean
age was 43 years. Thirty-seven patients could not recall any information about care of feet, 73
who remembered receiving information, 39 had received verbal information,32in the form of
leaflets and 2 as a part of group session. Thirteen of this group had received information after
they had developed some foot complication. Forty-five patients had received information at the
time of diagnosis of diabetes or within a few weeks of diagnosis. Forty-two patients had last
received advice more than 5 years ago, and in 25 of these, the advice was more than 10 years
ago. (8)

O.O. Desalu, June 2011carried a cross-sectional study from November 2009 to April 2010. Pre-
tested structured questionnaires were presented by medical officers to the willing diabetes
patients. The questionnaire was to test knowledge and practice regarding foot care in diabetic
patients. The knowledge and practice scores were classified as good if score is ≥70%, score was
considered satisfactory if score ranges between 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 Diabetes Mellitus
(DM) foot care. Majority (78.4%) of patients with poor practice had poor knowledge regarding
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. (17)

R.D. Pollock, 23 October 2003 carried a study regarding foot care in diabetic patients of
Middlesbrough, South Tees, UK. Aim of the study was to determine knowledge and practice of
foot care in people with diabetes. A questionnaire was presented to the willing patients to
determine knowledge and practice of participating patients. Results were recorded as: The
maximum possible knowledge score was 11 and ranged from 1 to 11. The mean was 6.5 (S.D.
2.1) and modal score 7. Females had a significantly higher knowledge score (6.8 versus 6.3). In
general, response of high-risk patients was better than those at low risk but there was no
significant difference in the score for those at high risk (6.8) and low risk patients (6.5). There
was no significant association between knowledge score and years since diagnosis of diabetes.
Patients who had previously received advice on foot care had higher knowledge score of 6.9
compared to those with no advice 5.4. In general, foot care practice in the high- risk group was
better than the low risk. Foot self-examination was practiced by 83.7% of high- risk patients.
Eighty-three percent of all patients did not have their feet measured when they last purchased
footwear and only 16.2% received advice on their purchase from the retailer although both these
figures were slightly better for those with high risk feet. 15.2% (9.6–20.8) of high-risk patients
never inspected the inside of their footwear for objects and torn linings. 12.8% of the high-risk
group never visited a chiropodist and 9.6% only went when they had a foot problem. Advice or
information on foot care had been received by 71.3%. (18)

Sofia Hellenberg, 2013 conducted study on “Knowledge and practices regarding foot care
among patients with Type 2 diabetes in Ho Chi Minh City, Vietnam”. Aim: The aim of this study
was to investigate the knowledge and practices regarding footcare among patients with type 2
diabetes in Ho Chi Minh City, Vietnam, and also investigate if there was any difference between
genders in knowledge and practicing of foot care. Method: This study was a cross-sectional
design with quantitative method. The data was collected at the out-patient clinic of the
University Medical Center in Ho Chi Minh City, Vietnam and 100 patients participated
voluntarily to answer questionnaire. Data were analyzed by using statistics. Result: Of the
participants 74 (74%) had good knowledge about foot care. There was no significant difference
between men and women about knowledge of foot care, majority of the patients (>90%) reported
that it is important to take anti-diabetes medication, to wash their feet every day, and to consult
when warning signs had occurred. About 71 (71%) reported warm water should use when
washing the feet. Majority (>80%) also reported that it is important to dry the feet, to keep the
skin soft to prevent dryness, and inspection of feet´s every day. (14.7%) women used it on their
feet and no men reported that they did it. 90 (90%) reported that they examine their feet and 72
(72.0 %) of them thought that they take care of their feet in a correct way. (15.6%) of men who
thought that they did not take care of their feet in correct way. Conclusion: The knowledge of
foot care was good, but the practice of foot care was low. There was not found any significant
difference between the genders in knowledge, but some differences in the foot care practices.
More information about foot care is needed to prevent complications with type 2 diabetes. (19)

Khaled Ibraheem AlQurashe02-03-2018 conducted the study on diabetic patients regarding foot
care in Aladil Primary Health Care Center in Makkah, Saudi Arabia. Objective: To assess the
self-foot care knowledge and practice among Saudi type 2 diabetic patients attending Aladil
primary healthcare canter, Makkah as well as to determine factors associated with them. Method:
A cross-sectional study was adopted. The data were collected through filling an interview
questionnaire. It includes demographic data, clinical data, general knowledge data, knowledge of
foot care practice data and source of information. Regarding practice, a check list was used by
the investigator after examination of the patient and observing his/her feet. Results: Out of 170
eligible type 2 diabetic patients invited to participate in the study, 160 responded, giving a
response rate of 94.1%. Almost two-thirds of them (69.4% aged between 45 and 64 years. 56.3%
were male. (85%) were married participants. (53.8%) had diabetes from 5-10 years. (88.8%) of
them were treated by oral hypoglycemic drugs. The overall knowledge score mean was 14.7±2.9
out of 29. The overall knowledge score mean was 14.7±2.9 out of 29. The mean knowledge
percentage score was 50.5±7.5%. The mean score of practice was 23.5±3.2 out of 28. The mean
practice percentage score was 83.9±11.4%. Older patients (≥65 years) were at almost significant
double risk for having insufficient knowledge compared to younger patients (30-44 years).
Compared to illiterate patients with secondary school or university education were at significant
decreased risk for insufficient self-foot care knowledge.
Seema Hasnain, October 2009 conducted a study on diabetic patients regarding foot care
visiting diabetic clinic in Jinnah Hospital, Lahore. Objective: To assess the knowledge and
practices in the diabetic patients regarding foot care. Methods: In this cross-sectional study. 150
diabetics were included in the study. A pre-tested questionnaire was used and knowledge and
practice were classified as good, satisfactory and poor depending upon the score. Fifteen
questions each were asked regarding knowledge and practices of foot care. Each question was
assigned one mark. Score of 70% (11-15) was regarded as good, score of 50-70% (8-10) was
regarded as satisfactory and score of 50% (<8) was regarded as poor both for knowledge and
practice for foot care. Results: The mean age of the respondents was 48 ± 10.8years. About
29.3% respondents had good knowledge, 40% had satisfactory knowledge and 30.7% had poor
knowledge about foot care. Whereas only 14% respondents had good practices for foot care,
54% had satisfactory practices and 32% had poor practices. Sex and income per capita had
shown no significant statistical association with knowledge and practices regarding foot care.
Conclusion: About one third of diabetic patients had poor knowledge about foot care and only
very few patients had good practices for foot care. Literacy has significant association with the
knowledge and practices related to foot care in diabetic patients. (20)

Mohammad Ebrahim Khamseh, 2007 carried a study on Iranian people with type 2 diabetic
patients regarding foot care visiting diabetic clinic in Firoozgar Teaching Hospital. The aim of
this study was to determine the knowledge and practice of foot care in people with type 2
diabetes. They carried out a cross-sectional study. A questionnaire was completed by 148
patients with type 2 diabetes in Tehran, Iran. Out of the 148 participants, 97 (65.5%) were
women and 51 (34.5%) were men. Their mean age was 56 years (range 18–81 years). Thirty-two
(21.6%) participants were employed, eighty-six (58.1%) were household and twenty-eight
(18.9%) were retired. One hundred and forty-five (98%) participants were married. Thirty-one
(20.9%) were illiterate and eighty (54.1%) had 1–12 grade education. The maximum possible
knowledge score was 16. The mean was 6.6 and ranging from 0 to 13. Patients who had higher
level of education (above 12 grade) had a significant higher knowledge score than other groups.
Patients who had diabetes more than 10 years were more knowledgeable than those who had
diabetes less than 10 years. The maximum possible practice score was 16 and ranged from 1 to
13. (21)
Kamaru Zaman NH,2018: Conducted a study to determine the knowledge and practice of foot
care and also the relationship between socio demographic data with knowledge of foot care
among diabetic elderly in UKM Medical center. It was a quantitative cross- sectional descriptive
study. Total 81 patients participated in the study out of them, more than half of the participants
were females and majority of them were 60-74 years old. The results showed significant
relationship with gender and marital status with the knowledge of foot care among elderly
diabetic patients admitted in the hospital. While the study showed that there was no significantly
relationship between age, occupation, monthly income, duration of diabetes, body image and
level of education with the knowledge and the level of foot care. (22)

Abdulaziz Alhomaidi Al Odhayani,2015: Conducted cross-sectional study in King Khalid

University Hospital, King Abdulaziz University Hospital (KAUH), King Fahad Medical City,
National Guard Hospital, Military Hospital, and Prince Salman Hospital capital city of Saudi
Arabia. Included the patients who had diabetic foot disease and signed the consent form and
completed the questionnaire. Total 350 patients were selected. The mean age of patients was
50.87 ± 15.9 years with a range of 20–90 years. The majority of patients were male (64.3%) and
had family history of hypertension (55.4%), high total cholesterol (58.6%), and diabetes (58.9%).
A family history of smoking, a major risk factor for diabetic foot, was found in 20.3% of cases.
Sixty percent of the patients were using oral medications, 27.1% were using insulin therapy, 10%
were using both oral and insulin therapies, and 10% were on diet. In the study,19.4% of
participants were illiterate while 80.6% had a high school or university level education. The
findings also revealed that some patients had lack of knowledge concerning diabetic foot disease
and future complications. Patients are unaware of the risk factors for diabetes foot and practice
poor foot care. (23)

Rashed Fahad Alhabshan, 12 /9 /2017: carried study on diabetic patients regarding knowledge
of diabetic foot complications (diabetic foot) in KSA. The study was carried in random settings
like coffee shops, shopping malls & pharmacies. Study was aimed to asses knowledge of the
diabetic patients regarding the complications of diabetic foot ulcer. Methods: This was a cross
sectional study conducted from March 2017 to July 2017. 920 diabetic patients were
interviewed. A pre-tested questionnaire about the knowledge of complications was used to obtain
data. The mean age of respondents was 51 years. 55.5% subjects were females, while 44.5%
were males. 46% had a bachelor degree, 29.3% had attended secondary school and 24.7% were
at primary school. The age of participants ranged from 16-35 years old in 50.9%, 36-50 years in
32.9% and 16.2% aged more than 50 years old. 60.2% had a college degree, 26.9% had a
secondary school degree and 12.9% had primary school degree. About 61% of subjects were
employed and 39% were jobless. The respondent’s awareness about complications of septic
diabetic foot showed that 60% didn’t know the causes of diabetic foot disease. The knowledge
regarding the complications of diabetic foot were including decreased blood flow in the feet
(66.5%), loss of sensation in the foot (69.9%), ulcers in the feet (77.1%), foot gangrene. (83.3%),
foot infections impact on ulcers (65.3%) and the importance of routine feet investigations
(58.8%). On the other hand, 35% and 45% had inadequate knowledge regarding the effects of
loss of sensation and reduced blood flow to the foot on increasing the risks of ulcers. 74.3%
don’t read handouts for proper management of feet. (24)

Deepa L. N,2017: Performed cross-sectional descriptive study which was done to determine the
level of awareness and practice of foot care among type 2 diabetes patients attending a tertiary
care center. About 106 diabetic patients were selected who attended a teaching hospital in Kolar.
A questionnaire was designed to assess the level of awareness and practice of foot care. Results
showed that the mean (SD) of awareness and practice of foot care were 5.33 (3.09) and 6.54
(2.94) respectively. Low mean scores were significantly associated (p<0.05) with lack of formal
education and not receiving advice on foot care by doctors. Only 51.9% of them were educated
regarding foot care while 77% of the subjects were advised to do physical activity. Only 8.5% of
them had good knowledge, 35.8% had satisfactory level and more than 50% of them had poor or
very poor knowledge regarding foot care. On the other hand, about 15.1% of the study
participants’ foot care practice was good, 36.8% were satisfactory and 48.1% were poor or very
poor in foot care practice. A strong positive correlation (r=0.85) was observed between level of
awareness and practice of foot care which was statistically significant (p<0.001). (12)

Maira K. Mehmood, 12 December 2018: conducted a study on diabetic patients in primary

healthcare centers Dubai authority. Authors proposed that Diabetic foot disease is the most
common complication of diabetes mellitus. With appropriate management, approximately 49-
85% of diabetic foot complications can be prevented. The aim of this study was to assess the
awareness and practice of foot self-care in patients with type 2 diabetes and study the factors
affecting foot self-care. Methods: A cross-sectional study was used for the purpose of study. 488
participants were interviewed on a pre-tested structured questionnaire. The collective score of
awareness and practice was classified into poor (<50 percentile), average (50- 75 percentile) and
good (>75 percentile). Results: In this study, 52.5% of the participants were females and 47.5%
were males. UAE nationals were 61.3%. 60.9% received previous information on foot self-care,
of which 90.6% received from PHC and 2% received it from Dubai Diabetes Centre (DDC). The
overall awareness of foot self-care was 47%, average in 26% and good in only 27% of the
participants. The overall practice of foot self-care was found to be poor in 46%, average in 26%
and good in only 28% of the participants. 83.0% were aware of the importance of compliance of
medications to avoid complications and 91.0% practiced it. (40.0%) were aware of moisturizing
between toes and only 37.9% practiced it. (25)

CHAPTER 04: KEY FOR

ASSESSMENT OF KNOWLEDGE
AND PRACTICE OF DIABETIC
PATIENTS
KEY FOR ASSESSMENT OF KNOWLEDGE OF DIABETIC PATIENTS
REGARDING FOOT CARE.
Q.1. Do you know smoking causes poor circulation affecting the feet?

Correct Answer: Yes, I know smoking can cause poor circulation.

Reason: Quit smoking, because it accelerates damage to blood vessels, especially the small
blood vessels. This can lead to poor circulation, which is a major risk factor for foot infections
and, ultimately, amputations.

Q.2. DM patient should take their medication because they liable to get DM complications?

Correct Answer: Yes, DM patients should adhere to their medication to avoid complications.

Reason: Adherence to your prescribed medication schedule and monitor blood glucose
routinely to ensure glycemic control.

Q.3. Do you know foot ulcer is common complication in DM?

Correct Answer: Yes, I know foot ulcer is a common complication in DM patients.

Reason: Neuropathy and narrow vasculature due to which blood supply is reduced to
extremities and become a common cause of foot ulcer.

Q.4. Do you have any idea dry and scaly skin is a common symptom of foot ulcer?

Correct Answer: Yes, I know dry & scaly skin is a symptom of foot ulcer.

Reason: Dry and scaly skin is a symptom of poor blood circulation in the foot which may cause
ulcers.

Q.5. Do you know wounds may not heal quickly in DM patients?

Correct Answer: Yes, I know wounds can take a longer time to heal in DM patients.

Reason: Neuropathy and narrow vasculature lead to poor blood circulation to the extremities
and due to which less oxygen supply and less drug distribution occurs which lead to slow healing
of wounds in diabetic foot.
Q.6. Do you know walking bare foot may cause foot ulcer?

Correct Answer: Yes, I know walking bare foot is a liability to feet to get an injury which can
lead to ulcer.

Reason: Foot ulcers can be caused by walking barefoot, and the foot can be at an increased risk
of a foot ulcer due to chance of injury, DM patients already has poor circulation in extremities &
this reduced nerve supply will delay in healing process so the wound or injury can be turned into
an ulcer.

Q.7. Do you think you should inspect the inside of footwear for objects or torn lining?

Correct Answer: Yes, it is important to inspect the footwear for DM patients prior to wearing
the footwear.

Reason: Before wearing footwear, the diabetic patient must check it for any sharp object torn
lining or solid object, because it may cause the foot injured.

Q.8.Standing on one point may cause foot complications?

Correct Answer: Yes, DM patients should not stand on one point to avoid complications.

Reason: Standing on one point may put pressure on foot and cause the slow blood circulation
and worsen the foot ulcer.

Q.9. Do you know infections may not recover quickly in DM?

Correct Answers: Yes, I know infections can take a longer while to recover in DM patients.

Reason: As we know DM patients have poor circulation of blood if any kind of infection occurs
it will not heal quickly because the drugs reaches the site of action through blood & if blood
supply is reduced then a longer time is required to recover the infection.

There are aggregate of 9 questions concerning knowledge of foot care. The scoring criteria for
knowledge of foot care are ordered into low and high state of knowledge. The respondent was
sorted into low state of knowledge with respect to foot care if the right number of questions was
addressed is 1-4 out of 9 questions, while for high state of knowledge of foot care the score was
5-9 out 9. The underneath table demonstrated the aftereffects of the scoring for knowledge state
of foot care.

Scoring for Knowledge Level of Foot care

Knowledge level of foot care Frequency (n) Percentage (%)

Low (1-4)
High (5-9)
Total
KEY FOR ASSESSMENT OF PRACTICE OF DIABETIC PATIENTS

Q.1 Do you inspect your feet daily?

Correct Answer: Yes, I inspect my feet daily.

Reason: Inspect feet daily, including the tops, sides, heels, and between the toes. When
inspecting, look for cuts, cracks, splinters, blisters, and calluses on the feet. Always contact your
primary health care provider if wounds show no signs of healing.

Q.2 Do you wash your feet two times a day?

Correct Answer: Yes, I wash my feet twice a day.

Reason: Wash feet in warm (not hot) water daily to prevent infections. Make sure the feet are
thoroughly dried, especially between the toes.

Q.3 Do you wash your feet with warm water?

Correct Answer: Yes, I wash my feet with warm water.

Reason: Wash feet in warm (not hot) water daily to prevent infections.

Q.4 Do you trim toe nails straight across?

Correct Answer: Yes, I trim toe nails straight across.

Reason: When trimming toenails, cut them straight across, and round the edges slightly with an
emery board.

Q.5 Do you measure your feet size when last you bought footwear?

Correct Answer: Yes, I always measure the feet size before purchasing the footwear.

Reason: Wear supportive, enclosed shoes that fit well and protect your feet. Choose shoes that
are made of leather, canvas, or suede, and are easily adjustable. Do not wear shoes made of
plastic or another material that does not breathe.
Q.6 Do you use talcum powder for keeping interdigital space dry?

Correct Answer: Yes, I use talcum powder to keep dry my interdigital space.

Reason: Talcum powder is hygroscopic in nature, which absorb the moisture from interdigital
space keep them dry, which inhibit the bacterial growth.

Q.7 Did you ever inspect inside of your footwear?

Correct Answer: Yes, I inspect my footwear from inside.

Reason: Inspection the inside of footwear is compulsory to check for any sharp object which can
cause foot injury.

Q.8 Do you walk regularly bare foot?

Correct Answer: No, I don’t walk bare foot.

Reason: To prevent foot injuries, do not walk barefoot, especially outdoors.

Q.9 Do you add antiseptic to water before feet cleaning?

Correct Answer: No, I don’t add any antiseptics to water used for feet cleaning.

Reason: Without the assistance of physician/surgeon Do not use antiseptic solutions on your
feet, because these may burn or injure skin.

Q.10 Do you wear elasticized hosiery (to prevent edema and thrombosis)?

Correct Answer: Yes, I use elasticized hosiery.

Reason: Elasticized hosiery is compulsory to prevent DVT and increase the blood flow to the
extremities.

Q.11 Do you feel heal ache? (the answer cannot be categorized as correct/ incorrect because
only patient know that he/she is feeling heel pain or not)

Positive Answer: Yes, I feel heal ache.

Negative Answer: No, I don’t feel heal ache.

Reason: Due to neuropathy there is numbness in feet so most of the diabetic patient don’t feel
heal ache.

Q.12 Do you add irritants to water before feet cleaning?

Correct Answer: No, I don’t add any kind of irritant to water used to clean my feet.

Reason: Avoid adding irritant to water for feet cleansing. Irritant may cause injury to contact
tissues of the feet.

There are 12 questions regarding routine with regards to foot care. The scoring of the act of foot
care is classified into poor, acceptable and great routine with regards to foot care. The respondent
will be ordered into poor practice with regards to foot care if the right number of questions
addressed is between 0-5 out of 12 question, satisfactory if 6-8 out of 12 questions and good if 9-
12 out of 12 questions. The underneath table demonstrated the consequences of the scoring for
routine with regards to foot care.

scoring for practice of foot care

Practice of foot care Frequency (n) Percentage (%)

Poor (0-5)
Satisfactory (6-8)
Good (9-12)
Total
CHAPTER 05: RESULTS AND
Discussions
Demographic Data Results

Characteristics Frequency (n) Percentage %

Nationality

Kashmiri
Non-Kashmiri
Gender

Male
Female
Age group

<30 years
30-<40 years
40-<50 years
50-<60 years
60 +
Educational level

Primary
Secondary
Graduate
Types of the job

Has a job
Job
Retired
Housewife
Physical Activity Data Results

Particulars Frequency Percentage

(%)
Practice physical activity
Yes
No
Frequency of physical activity

Zero
Less than 5 days a week
Daily/ 5 days a week
Duration of activity
Zero
<30 minutes
>30 minutes
Advised regular physical
activity
No
Yes
Advised by whom
Doctor
Health worker or
Counsellor
Others
1. Atlas D. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels,
Belgium: International Diabetes Federation, 2015.
2. Guariguata L, Nolan T, Beagley J. International diabetes federation. IDF diabetes atlas.
Brussels: International Diabetes Federation; 2014.
3. Annersten Gershater M. Prevention of foot ulcers in patients with diabetes mellitus. 2011.
4. Holt PJNS. Assessment and management of patients with diabetic foot ulcers.
2013;27(27):49.
5. Haycocks S, Chadwick P, Guttormsen KJWU. Use of a DACC-coated antimicrobial
dressing in people with diabetes and a history of foot ulceration. 2011;7(1):104-18.
6. Rodrı́guez-Morán M, Guerrero-Romero FJJod, complications i. Increased levels of C-
reactive protein in noncontrolled type II diabetic subjects. 1999;13(4):211-5.
7. Singh N, Armstrong DG, Lipsky BAJJ. Preventing foot ulcers in patients with diabetes.
2005;293(2):217-28.
8. Basu S, Hadley J, Tan RM, Williams J, Shearman CP. Is there enough information about
foot care among patients with diabetes? The international journal of lower extremity wounds.
2004;3(2):64-8.
9. Bohorquez Robles R, Compean Ortiz LG, Gonzalez Quirarte NH, Berry DC, Aguilera
Perez P, Pinones Martinez S. Knowledge and Practices of Diabetes Foot Care and Risk of
Developing Foot Ulcers in Mexico May Have Implications for Patients of Mexican Heritage
Living in the US. The Diabetes educator. 2017;43(3):297-303.
10. Bonner T, Foster M, Spears-Lanoix E. Type 2 diabetes-related foot care knowledge and
foot self-care practice interventions in the United States: a systematic review of the literature.
Diabetic foot & ankle. 2016;7:29758.
11. Chiwanga FS, Njelekela MA. Diabetic foot: prevalence, knowledge, and foot self-care
practices among diabetic patients in Dar es Salaam, Tanzania - a cross-sectional study. Journal of
foot and ankle research. 2015;8:20.
12. L. N D, Murty P, Reddy M, C M, Shetty S. Assessment of awareness and practice of foot
care and physical activity among people with type 2 diabetes attending a tertiary care teaching
hospital. International Journal Of Community Medicine And Public Health. 2017;4(9):3218.
13. Dixit S, Maiya A, Khetrapal H, Agrawal B, Vidyasagar S, Umakanth S. A questionnaire
based survey on awareness of diabetic foot care in Indian population with diabetes: a cross-
sectional multicentre study. Indian journal of medical sciences. 2011;65(10):411-23.
14. Goweda R. Assessment of Knowledge and Practices of Diabetic Patients Regarding
Diabetic Foot Care, in Makkah, Saudi Arabia. Journal of Family Medicine and Health Care.
2017;3(1):17.
15. Muhammad-Lutfi AR, Zaraihah MR, Anuar-Ramdhan IM. Knowledge and Practice of
Diabetic Foot Care in an In- Patient Setting at a Tertiary Medical Center. Malaysian orthopaedic
journal. 2014;8(3):22-6.
16. Al Zahrani HA, Qadi MAJJoKAUMS. Foot Care Knowledge and Practice among
Diabetic Patients Attending Primary Health Care Centers in Jeddah City. 2011;98(282):1-34.
17. Desalu O, Salawu F, Jimoh A, Adekoya A, Busari O, Olokoba AJGmj. Diabetic foot
care: self reported knowledge and practice among patients attending three tertiary hospital in
Nigeria. 2011;45(2).
18. Pollock RD, Unwin NC, Connolly V. Knowledge and practice of foot care in people with
diabetes. Diabetes research and clinical practice. 2004;64(2):117-22.
19. Thunberg S, Hellenberg S. Knowledge and practices regarding foot care among patients
with Type 2 diabetes in Ho Chi Minh City, Vietnam: A quantitative study. 2013.
20. Hasnain S, Sheikh NHJJTjotPMA. Knowledge and practices regarding foot care in
diabetic patients visiting diabetic clinic in Jinnah Hospital, Lahore. 2009;59(10):687.
21. Khamseh ME, Vatankhah N, Baradaran HRJIwj. Knowledge and practice of foot care in
Iranian people with type 2 diabetes. 2007;4(4):298-302.
22. Hussein S, KamarulZaman NJIjoND. Foot Care Practices And Knowledge Among The
Hospitalized Diabetic Older Adult In The Teaching Hospital, Kuala Lumpur. 2018;8(05):01-6.
23. Al Odhayani AA, Al Sayed Tayel S, Al-Madi F. Foot care practices of diabetic patients
in Saudi Arabia. Saudi journal of biological sciences. 2017;24(7):1667-71.
24. Alhabshan RF, Huwaymil B, Sulaiman M, Alsaqabi OA, Alzaid AN, Almasoud
AIJEJoHM. Assessment of Knowledge toward Complications of Diabetic Septic Foot among
Diabetics Patients in Saudi Arabia. 2017;69(6).
25. Mehmood MK, Parkar AZ, Mustafa NT, Mustafa SS, Makin MA, Alawadi F, et al.
Diabetic foot self-care: awareness and practice among type 2 diabetic patients in primary
healthcare centers, Dubai Health Authority. International Journal Of Community Medicine And
Public Health. 2018;6(1):1.