1. 9th Win n’ Learn Academic Event 2014
Research Category
FOOT ASSESSMENT AND KNOWLEDGE AMONG
PATIENTS ATTENDING DIABETIC CLINIC IN
SHINYANGA REGIONAL HOSPITAL
Author: LUTFI ABDALLAH [Medical Student]
Supervisor: LARY O AKOKO MD. MMED (Surgery)

2. OUTLINE
• Introduction & background
• Problem Statement and rationale
• Broad and specific objectives
• Results and Discussion
• Conclusion, Recommendations and Reference

3. 1. INTRODUCTION
DM is a metabolic disorder that is characterized by chronic
hyperglycemia; it is common and potentially disabling chronic
disease.
 The prevalence of DM worldwide is 8.3% [1]
 More than 371 million people have DM. [1]
 4 out of 5 people with diabetes live in low- and middle-
income countries. [1]
 Half of people who die from diabetes are under the age of
60. [1]
 Half of people with diabetes don’t know they have it. [1]

4. • Every 20 seconds a lower limb or part of a lower limb is lost
somewhere in the world as a consequence of diabetes. [3]

5. Up to 70% of the people who undergo lower extremity
amputation due to diabetic foot die within 5 years [2]

7. 2. PROBLEM STATEMENT
• Despite the frequency of complications involving diabetic patients’lower limbs, primary care
practitioners frequently neglect to examine their feet. Surveys of physicians and patient chart
evaluations have determined that fewer than 50% of diabetic patients receive appropriate foot
evaluation as part of their annual medical checkups.[21] Prevention of diabetic foot ulceration is critical in order
to reduce the associated high morbidity and mortality rates, including the risk of amputation. It is essential to identify
the foot at risk, through careful inspection and physical examination of the foot followed by neuropathy and vascular
test. [22]
• Regular foot examination, patient education, simple hygienic practices, provision of appropriate footwear, and prompt
treatment of minor injuries can decrease ulcer occurrence by 50% and eliminate the need for major amputation in non-
ischemic limbs. [4, 22] According to the American Diabetes Association, there are certain guidelines to be followed by
diabetic persons. [23]
• Data in Tanzania and many other sub-Saharan African countries on the diabetic foot assessment,
knowledge of the patients and health care workers on foot care and foot assessment respectively and
the factors hindering foot assessment in the diabetic clinic are sparse. However, as diabetes and foot
complications, especially amputations increase worldwide. There is no reason to believe that Tanzania
is any different, given our health resources. This is particularly evident is the scarcity of co-ordinated
foot care and podiatry.

8. 3. RATIONALE
The study aimed at exploration of health care workers knowledge and practice
towards foot assessment as a tool for better care of diabetic patients.
The findings from this study will raise the need for the development of a tool to
standardize foot assessment among diabetic patients attending diabetic clinics country
wide.
The results of the research will also help healthcare professionals to be aware of the
gaps in follow up of the diabetic patients attending the diabetic clinic.
The study has generated an Elective report as a partial fulfillment for an award of MD
Bachelor degree at Muhimbili University of Health and Allied Sciences.

9. 4. OBJECTIVES
1.To determine on exit if foot assessment has been done to
patients who attended the clinic.
2.To assess the knowledge of diabetic patients on foot care.
3.To assess knowledge of health workers on assessment of
the foot of a diabetic patient.
4.To determine factors hindering diabetic foot assessment at
the clinic.

10. 5. METHODOLOGY
– Study design: A cross-sectional study design.
– Study area: Shinyanga Regional Hospital Diabetic Clinic
– Data collection: A pre-tested, structured, close-ended, self-
administered questionnaire was used.
– Sampling technique: Convenient sampling
– Study population: All diabetic patients coming for regular
diabetic’s clinic at the regional hospital and the staff
dedicated to offer diabetic services from August to
October
– Sample size (n): The sample size was 268 pt. by using
Keylie-Leslie formula

12. Inclusion criteria:
a) All the health care providers (nurses, CO, AMO, MD) attached
to the diabetic clinic in Shinyanga regional Hospital
b) Diabetic patients who attended the diabetic clinic in Shinyanga
regional hospital (No patient refused to participate in the
study)
Exclusion Criteria:
a) Those who will be unwilling to be included in the study.
b) Patients who don’t wish to complete the questionnaire
c) Patients with cognitive impairment, visual or hearing loss.
d) Those who have no diabetes.

13. Ethical Clearance
– Ethical clearance to conduct this study was received
from Muhimbili University of Heath and Allied Sciences
Institution Review Board, through school of medicine.
– A separate permission to conduct the study was sought
from Shinyanga Regional Hospital administration.
– All participants signed an informed consent form. No
direct patient identifiers were used in data collection.
– This study carried no risk to the participant and was
meant to improve diabetic patients management by
decreasing morbidity associated with foot complications
in the country.

14. 6. RESULTS

15. Characteristics of the patients in the study (N=268)
Variables Total N (%)
Age group
≤19 25 (9.30%)
20 – 29 10 (3.70%)
30 – 39 38 (14.2%)
40 – 49 55 (20.5%)
50 – 59 65 (24.3%)
≥60 75 (28.0%)
Gender
Female 150 (56.0%)
Male 118 (44.0%)
Level of Education
No formal education 25 (9.30%)
Primary School level 138 (51.5%)
Secondary School level 50 (18.7%)
Higher education 55 (20.5%)
Type of DM
Type 1 44 (16.4%)
Type 2 224 (83.6%)
First Year Diagnosed with DM
Not more than 1 year 61 (22.8%)
1 – 2 37 (13.8%)
3 – 5 61 (22.8%)
6 – 10 79 (29.5%)
More than 10 years 30 (11.2%)
48.5 ± 15.566
1:1.3

16. • Female patients were the majority by 150(56.0%), giving a
male to female ratio of 1:1.3. The age range was 13 to 78
with a mean of 48.5 ± 15.566 years.
• Most of the study subjects were above 60 years of age at
75(28%) and the least were below 29 years at 35(13%).
• Again majority of the respondents had primary level of
education or less by 163(60.8%) and only 55(20.5%) had
higher education. Most of the patients had been having the
disease for more than six years 109(40.7%), while
61(22.8%) were just diagnosed in the same year.

17. Parameters assessed during clinic visit (N=268)

18. • Blood pressure measurement was the
most performed examination, 216(80.6%),
followed by weighing 225(84.0%), feet
evaluation 80(29.9%) and eye examination in
10(3.7%). Most of the patients had Fasting and
Random blood sugar checked 265(89.9%).

19. Patients response on knowledge assessment Foot care Questions
Sn Questions related to knowledge on foot care Knowledge
1 Importance of taking antidiabetic treatment to prevent
complications
179 (66.8%)
2 DM patients shouldn’t smoke because it causes poor circulation
affecting the feet.
107 (39.9%)
3 Checking temperature of water before using 146 (54.5%)
4 Drying the feet after washing 134 (50.0%)
5 Talcum powder usage for keeping interdigital spaces dry 50 (18.7%)
6 Keeping skin of the feet soft to prevent dryness 164 (61.2%)
7 Lotion not to be applied in the interdigital spaces 163 (60.8%)
8 Daily change of socks 169 (63.1%)
9 Trimming nails of feet once a day by respondents 126 (47.0%)
10 Inspection of feet once a day by respondents 79 (29.5%)
11 Wearing comfortable coat shoes 86 (32.1%)
12 Checking the shoes from inside before wearing 107 (39.9%)
13 Not walking bare foot 173 (95.0%)
14 If you found redness/bleeding between your toes what is the first
thing to do
117 (43.7%)
15 Even if you have never had a corn/hard skin lesion, what would you
do if you have one
51 (19.0%)

20. Variable Knowledge Level on foot care
Poor
Knowledge
<50%
N (%)
Satisfactory
Knowledge
50 – 69%
N (%)
Good
Knowledge
>70
N (%)
2
(P-Value)
Age group (years)
<20
20 - 29
30 - 39
40 - 49
50 - 59
> 60
4 (16.0)
5 (50.0)
17 (44.7)
23 (41.8)
37 (56.9)
36 (48.0)
14 (56.0)
2 (20.0)
13 (34.2)
17 (30.9)
17 (26.2)
23 (30.7)
7 (28.0)
3 (30.0)
8 (21.1)
15 (27.3)
11 (16.9)
16 (21.3)
14.837
(0.138)
Gender
Male
Female
46(39.0)
76(50.7)
42(35.6)
44(29.3)
30(25.4)
30(20.0)
3.655
(0.161)
Level of Education
5 (20.0)
20 (14.5)
10 (20.0)
25 (45.5)
20.987
(0.002)
No formal education
Primary School Level
Sec. School Level
Higher education
13 (52.0)
70 (50.7)
20 (40.0)
19 (34.5)
7 (28.0)
48 (34.8)
20 (40.0)
11 (20.0)
History of Foot infection
Yes
No
51(56.7)
71(39.9)
28(31.1)
58(32.6)
11 (12.2)
49 (27.5)
9.992
(0.007)
Type of DM
Type 1
Type 2
10(22.7)
112(50.0)
23(52.3)
63(28.1)
11 (25.0)
49 (21.9)
12.852
(0.002)
Year first diagnosed
Not more than 1 Year
1 – 2 Years
3 – 5 Years
6 – 10 Years
More than 10 Years
41 (67.2)
12 (32.4)
27 (44.3)
27 (34.2)
15 (50.0)
13 (21.3)
15 (40.5)
23 (37.7)
29 (36.7)
6 (20.0)
7 (11.5)
10 (27.0)
11 (18.0)
23 (29.1)
9 (30.0)
22.097
(0.005)
Total 122 (45.5) 86 (32.1) 60 (22.4) 268
TABLE 3: Distribution of the level of knowledge about foot care among the diabetic
patients (N = 268)

21. • Majority of the respondents had poor knowledge on foot care by
122 (45.5%), followed by satisfactory knowledge among 86 (32.1%)
and only 60 (22.4%) had good knowledge.
• Most of the female had poor knowledge when compared with
male but this was not statistically significant, p value 0.16. Age too
had no significant influence on foot inspection with both having
poor knowledge.
• Increasing level of education was associated with good knowledge
of diabetic foot assessment, p-value of 0.002, so were the diagnosis
of type 1 diabetes and no prior history of foot infection.

22. • The Clinic had 3 HCWs, the Registered nurse who had received a 3 month diabetes
training and 2 registrars.
• Among 3 HCWs, 2 (66.6%) had good knowledge on foot assessment.
• The minimum score was 5 and the maximum was 11.
• The nurse, who had undergone a special training on diabetic care had the highest
score than colleagues who had not received a special diabetic training.

23. • All HCWs cited work over load as the hindrance to
foot assessment and two reported lack of
monofilaments for sensation assessment.

24. 7. Discussion
• The results from this study show that nearly half of the patients had poor
knowledge regarding foot care. This is similar to findings by other
researchers on the same topic.[24-27]
• The deficiency in the knowledge may also be due to poor communication
between the doctors and the patients and also lack of counseling by the
doctors and nurses as result of busy clinic schedules, negligence or work
overload. This is supported by a study conducted in UK where there was a
positive correlation between the score and having advised on foot care. [24]

25. • The relationship between the level of education and foot care among DM patients
has been observed in similar studies in India, Iran, Pakistan and Nigeria where
respondents with lower education level were least knowledgeable. [25-28]
• This can be explained by the fact that higher level of education might be associated
with increased quest for reading about the disease and its complication from
different sources

26. • Knowledge was also low in those with prior history of foot infection.
This is contrary to expectation that prior foot infection might have led to
education on foot care to prevent future diabetic foot related problems.
• This is supported by the findings of other researchers which explain the
impact of psychological and behavioural issues on diabetic foot thus
patient cognitive changes which influence comprehending abilities and
therefore reduce the effectiveness of foot health education. [6, 13,10,11]
• This also explains why some patients get repeated ulceration despite of
being educated and warned of the risk of ulceration. [2, 9, 10,11]

27. • Type one diabetic patients seem to have good knowledge when
compared to type two patients.
• This could also be explained by the expected young age of the
cohort with increased quest for information regarding care of
their afflicting disease.

28. • Women and those above the age of 50 were less
knowledgeable about foot care, although these associations
were not statistically significant but due to socio-cultural beliefs
women are not allowed to attain higher educational status in
many third world countries compared with their male
counterpart in the family, eventually resulting in women having
less knowledge of foot care.

29. 8. Conclusion
The level of knowledge of foot care among DM patients in this study was poor which
may lead to lower extremity complications and recurrent foot infections, if left
untreated might lead to amputation and even death.
Improved providers knowledge and might improve diabetic care including foot
assessment.
On the other hand, overall improvement of education standards, including adding DM
education to current curricular of primary schools should be encouraged.

30. 9. Recommendation
I. Develop a schedule for health education to diabetic patients including foot
care on regular basis.
II. Train health care providers on diabetic care, and increase more staff to
alleviate the shortage in the clinic.
III.Develop patient’s treatment charts to show expected care and services
during each visit.
IV.Review the role of the diabetic nurse to include provision of foot care to
diabetic patients.
V. Consider use of DM patients with good knowledge on diabetic care as role
model and peer educator on diabetic care, including foot care.

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33. Thank you for Listening