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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 120-124

Knowledge, beliefs, and practices of people with Type 2 diabetes toward self-management and diabetic foot


1 Department of Internal Medicine, Bausher Polyclinic, Al Nahda Hospital, Muscat, Oman
2 Centre of Studies and Research, Directorate General of Planning and Studies, Ministry of Health, Muscat, Oman
3 Department of Podiatry, Bausher Polyclinic, Al Nahda Hospital, Muscat, Oman

Date of Submission12-Jun-2021
Date of Decision07-Jul-2021
Date of Acceptance09-Jul-2021
Date of Web Publication26-Aug-2021

Correspondence Address:
Dr. Hani Naguib
Department of Internal Medicine, Bausher Polyclinic, Al Nahda Hospital, Muscat
Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdep.jdep_26_21

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  Abstract 


Introduction: Diabetic foot syndrome is one of the most common and devastating preventable complications of diabetes mellitus. Knowledge and awareness about the disease can have a positive influence on attitude and practices of patients. Objectives: We aimed to evaluate the knowledge, beliefs, and practices (KBPs) regarding diabetes and diabetic foot syndrome among Omani type 2 diabetic patients. Patients and Methods: We studied 150 participants from the diabetes clinic, Bausher Polyclinic, Muscat. A questionnaire was used to determine KBPs around diabetic foot care. Results: There were 90 females and 60 males, 67.9% were older than 50 years, 42.7% were illiterate, and 72% of them were not working or retired. Only 38% checked their feet regularly; 5.6% had diabetic foot syndrome. Over half of the respondents (55.3%) did not know the causes of diabetic foot syndrome and half of the respondents did not know symptoms of the same. Just over one-third (37.3%) thought that their doctor alone was responsible for foot examination. Only 32.7% thought that they should examine their own feet. The majority believed that walking barefoot and diabetic foot syndrome are “big” problems (84% and 80%, respectively). More than three-quarters (78%) reported checking water temperature before use, 38.7% use warm water for washing feet, and 39.3% reported drying their feet after washing. Only 38% check their feet regularly. Finally, only one-third confirmed checking their blood sugar regularly. Conclusions: The KBP triad must be interconnected in order to achieve successful preventive foot care.

Keywords: Attitude, diabetic foot, knowledge, practices


How to cite this article:
Naguib H, Raman S, Pinto A, Al Mehrezi A, Al Hinaii A. Knowledge, beliefs, and practices of people with Type 2 diabetes toward self-management and diabetic foot. J Diabetes Endocr Pract 2021;4:120-4

How to cite this URL:
Naguib H, Raman S, Pinto A, Al Mehrezi A, Al Hinaii A. Knowledge, beliefs, and practices of people with Type 2 diabetes toward self-management and diabetic foot. J Diabetes Endocr Pract [serial online] 2021 [cited 2021 Dec 1];4:120-4. Available from: https://www.jdeponline.com/text.asp?2021/4/3/120/324792




  Introduction Top


Diabetes mellitus (DM) is a major public health problem with social and financial implications for countries regardless of their economic status.[1],[2] Countries of the Arabian Gulf region have witnessed an unprecedented rise in the prevalence of noncommunicable diseases, including diabetes[3] The prevalence of diabetes in Oman has increased over the past three decades in parallel with rapid economic growth, urbanization, and changes in lifestyle behaviors.[4] Recent estimates show that 14.5% of Omanis aged ≥18 years have diabetes.[5]

Diabetic foot disease (DFD) is one of the common and devastating albeit preventable DM complications. It is associated with increased morbidity and premature mortality. Lower extremity disease including foot ulceration, peripheral neuropathy, peripheral arterial disease, or amputation is twice as common as in people with diabetes than healthy individuals. The annual incidence of foot ulcer in people with DM ranges from 1.0% to 4.1%.[6] There are some data suggesting an annual incidence of diabetic foot ulceration of 6.3%,[7] and the cumulative risk of developing a foot ulcer in people with diabetes is estimated to be 19%–34%.[6],[8] Lower-limb amputation is at least 10–20 times more common in people with diabetes than in those without diabetes.[9] Up to 75% of amputations are performed in people with diabetes.[10] The 5-year mortality rate following diabetes-related lower-limb amputation is as high as 40%–80%.[6] In Oman, 47.3% of all lower-limb amputations are performed on people with diabetes,[11] with the annual rate ranging between 20 and 36/10,000.[11]

The Omani diabetes guidelines recommend comprehensive annual foot screening for all patients, irrespective of their foot risk status. Furthermore, it stipulates that primary care physicians refer all patients with peripheral neuropathy to a podiatrist at secondary health-care services or to the designated National Diabetes and Endocrine Center for assessment and further management.[12] Secondary care diabetes foot services include dedicated high-risk foot clinics, specialist assessment, and management of established and severe cases of DFD. Patients with DFD who require inpatient treatment or surgical intervention should be managed in tertiary care hospitals.[13]

Several studies showed that knowledge and awareness about diabetes have a positive impact on attitude and practices of patients (Serrano and Jacob, 2010). Patients who engage in effective self-management are more likely to achieve treatment goals. However, gaps in knowledge, attitude, and practice (KAP) still exist. A remarkable number of patients are not effectively managing their condition nor implementing lifestyle changes in a way that can reduce the morbidity and mortality associated with diabetes. We have, therefore, conducted to assess the knowledge, beliefs, and practices (KBPs) of 150 adult patients with T2DM attending the Bausher Polyclinic.


  Patients and Methods Top


Design and objectives

This was a cross-sectional study conducted during April 2020–September 2020 at the outpatient clinic of Bausher Polyclinic in Muscat region of the Sultanate of Oman. We used a questionnaire to evaluate the KBPs of Omani patients diagnosed with T2DM.

Population study

We have included 150 T2DM patients who participated in the study. The inclusion criteria were being a person with type 2 diabetes and older than 20 years of age. Patients with any form of antidiabetic therapy were included. We have excluded patients who declined to provided consent to be part of the study and patients who already had established diabetic foot syndrome, amputated foot, or foot ulcers.

Assessment tool

The questionnaire was combined, modified, revised, and validated to better align with the Omani diabetes and Omani diabetic foot guidelines.[12] The revised questionnaire covered six domains: demographic details, patient-reported diabetes-related foot disease, foot self-care, diabetes care education, foot care education, and professional foot care. A questionnaire containing 40 closed-ended and multiple-choice questions on knowledge, practice, and belief of patients was developed to investigate the relationship between KAP of T2DM patients. The questionnaire also contained items to assess social, economic, and clinical profiles, family history of T2DM, years of conviviality with the pathology, and knowledge-related questions of measures to prevent diabetic foot, attitudes to prevent it, and self-care practices of the person with T2DM. One point was awarded for each correct answer. The questionnaire had been tried on five patients to assess the validity, suitability of content, clarity, and flow of questions. Necessary corrections and modifications were made based on the results of the pilot study. The questionnaire was prepared in English but, prior to use in the study, was translated to Arabic. The Arabic version of the questionnaire was reviewed for language, clarity, and structure and was administered in face-to-face interviews to collect data.

Data synthesis

For analysis, a total of nine items were included in the knowledge section which incorporated elementary knowledge of diabetes, benefits of exercise, complications of diabetes, and prevention of diabetic foot. For the nine items and knowledge questions, the maximum attainable score was “9” and the minimum score was “0.” Likewise, in the belief section, a total of eight items were included which consisted of respondents' belief toward diabetes. A three-point Likert scale was used to measure attitude. Each positive response (agree) carried a score of 1, and each negative response carried a score of 0. For the eight belief-related questions, the maximum attainable score was 8 and the minimum score was 0. Similarly, for the 16 items in the practice category, such as glucose monitoring, physician visit, weight management, exercise, and foot care, the maximum attainable score was 16 and the minimum was 0. The combined level of KAP (KBP) was classified according to each respondent's score. Poor knowledge and practice corresponded to a low score of (<mean − 1 SD); average knowledge and practice corresponded to a score between (mean ± 1 SD); good knowledge and practice corresponded to a score of (>mean ± 1 SD).[14]


  Results Top


Profile of the study population

The demographic and clinical characteristics of the study population are shown in [Table 1]. The majority (87.9%) of the patients were aged 40 years and above. There were more females (60%) than males. There was a high rate of illiteracy and low educational attainment levels [Table 1]. Nearly three-quarters of the patients (72%) were unemployed or retired. Over three-quarters (76%) had diabetes for <10 years, 16% had diabetes for 10–20 years, and 8% had diabetes for more than 20 years. The majority (70%) had a positive family history of diabetes.
Table 1: Demographic and socioeconomic characteristics of the study population

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Knowledge

Most of the respondents (84.6%) did not know the causes of diabetes [Table 2]. Three-quarters (74.7%) did not know what “normal” blood sugar levels were. Over half of the respondents (55.3%) did not know the causes of diabetic foot syndrome and half of the respondents did not know symptoms of the same. Just over one-third (37.3%) thought that their doctor alone was responsible for foot examination, 37.3% did not know about diabetes complications, 36.7% did not know how to prevent diabetic foot syndrome, and 36% did not know risk factors that cause the disease. Only 32.7% thought that they should examine their own feet.
Table 2: Percentages of correct responses to the salient questions in the three domains

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Beliefs

The majority believed that walking barefoot and diabetic foot syndrome are “big” problems (84% and 80%, respectively) [Table 2]. Over two-thirds (67.4%) believed that patients with diabetes cannot eat everything even if they are compliant with medications. One-third (30.7%) thought that checking their blood sugar was the responsibility of their doctor only. A small proportion of respondents believed that diabetes cannot be fully treated (18%) and that uncontrolled diabetes is not a serious problem (12%).

Practices

The majority of the respondents (72%) denied walking barefoot, and 60.7% stated that they check with their doctor if they have a foot problem [Table 2]. Moreover, 61.8% stated that they have been physically active for the previous year and 41.2% reported being physical active three to five times a week and 32.4% were physically active for 30 min or less. More than three-quarters of the participants (78%) reported checking water temperature before use, 38.7% use warm water for washing feet, and 39.3% reported drying their feet after washing. Only (38%) check their feet regularly. Finally, only one-third confirmed checking their blood sugar regularly.

The concordance between the percentage of correct affirmative responses to similar questions in the three survey domains is presented in [Table 3].
Table 3: The concordance between the percentage of correct affirmative responses to similar questions in the three survey domains (knowledge, beliefs, and practices)

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  Discussion Top


Globally, it is estimated that 50%–60% of diabetic patients will develop peripheral neuropathy and 15% of patients with diabetes will develop foot ulcers. Of those who develop ulcers, 20% will require amputation at different levels of the foot.[15]

Knowledge is an essential requirement for better compliance with medical therapy. Awareness of complications of diabetes was not enough among the patients in this study. Eighty-four percent of the patients did not know the cause of DM; 37.3% did not know about diabetes complications; 55.3% did not know the cause of diabetic foot syndrome; 50% did not know about symptoms of diabetic foot.

In the present study, the majority of the patients (60%) were illiterate or can simply read and write. This must have serious implications on their ability to learn about diabetes and its management. Even primary education level was significantly associated with low diabetes KAP score. Patients had insufficient knowledge regarding the symptoms, complications, prevention, and control of disease condition. In terms of attitude and beliefs, a considerable disposition to practice self-examination and self-care was evident. This was reflected in the gaps reported in practice. Important practices such as regularly monitoring blood glucose levels and checking feet daily were not being conducted. 74.7% did not know what their normal blood sugar level was. Only 33.3% of patients were regularly checking their blood sugar. The majority of the patients in the study reported that they only checked their blood sugar at their 3-month checkup with their doctor.

32.7% understood that they should examine their own feet on a regular basis and 84% agreed that walking barefoot carries a high risk for development of diabetic foot complications. This finding could be related to a lack of knowledge and lack of organized diabetes education services in the diabetes clinic. Our findings indicate that KBPs must be interconnected in order to achieve successful preventive foot care. Poor knowledge regarding diabetes has been reported in several studies from developing countries.[14],[16],[17] While, another study in the UK reported poor knowledge of diabetes among ethnic groups.[18] Previous studies have highlighted that low levels of literacy and education are associated with lack of knowledge of diabetes foot care.[19],[20],[21] A study from Malaysia reported a good KAP score among diabetic patients.[22] The differences in the results of studies may be due to the differences in educational level of the diabetic patients and accessibility of information and diabetes education.

Awareness of complications of diabetes was low among the patients. This may be due to some factors such as inappropriate ways of providing information. There are some noteworthy limitations of the study; perhaps, the sample size of 150 patients from a single clinic may limit the generalizability of the results. Recruiting a larger sample from different institutions and including clinics would enhance the generalizability of the findings for future studies. The intention was to enroll our sample of 150 patients into educational sessions and reassess their KBPs before and after the intervention.

This is a high-cost treatment for health-care providers and a poor outcome in terms of quality of life for patients. Lack of awareness about the complications of diabetes among patients affects their ability to self-manage and has a negative impact on outcome of diabetes. A joint effort on the part of health-care professionals and patients is required in terms of increasing knowledge, awareness, and changing practice regarding diabetic foot care. This study highlighted low levels of knowledge about diabetes and practices to prevent diabetic foot syndrome among patients with low levels of literacy and educational attainment. It highlights the need for the development of diabetes education programs which take into account factors such as context, literacy, educational level, and health beliefs of patients, so they are effective and easily understood. Key behaviors with regard to foot care need to be emphasized. All patients newly diagnosed with diabetes should be enrolled in education about diabetic foot care. Educational programs should be continuous across primary and secondary care settings. All health-care professionals should be delivering the same key messages regarding diabetic foot care.[23]


  Conclusions Top


The KBP triad must be interconnected in order to achieve successful preventive foot care. We need dialog with the patient utilizing a motivational interviewing approach. Understanding the level of knowledge and practice in patients with diabetes is important in planning for better control of diabetes and its complications.

Acknowledgments

The authors are grateful to Dr. Thamra Al Ghafry (Muscat) and Ms. Mary MacCalum (UK) for inspiring, editing, and proofreading and also for Dr. Hanan Al Mahrooqi (Bausher Polyclinic) for her logistics support. We are also grateful to Dr. Hamad al Harthy and Dr. Mohamed Al Hinaii (Alnahda Hospital) for their support during the study.

Authors' contributions

All authors participated in the conception of study, data collection and analysis, and drafting and revising of the manuscript. They have all approved the final version of the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Compliance with ethical principles

Ethical approval was obtained from the Ethics and Research Review Committee of the Directorate General of Muscat region. Informed written consent was obtained from all respondents.



 
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