Keywords
Attitude - diabetic foot - knowledge - practices
Introduction
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
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
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
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
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)
Discussion
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
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.
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.
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.
