THE LEVEL OF AWARENESS OF DIABETIC FOOT AMONG PATIENTS WITH TYPE 2 DIABETES MELLITUS (T2DM) IN ALAHSA, SAUDI ARABIA

Mohamed Riched Nabouli Asst Prof, Ali Hussain Al Rasasi MBBS, Mohammed Saleh Al Saeed MBBS and Mohammed Fahd Al Momen MBBS and Asma Saleh Alsaeed MBBS. King Faisal University, college of Medicine. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


Introduction and Background:-
Diabetes mellitus is common chronic disease, affecting nearly all the population in the developing and developed countries .Worldwide, more 120 million people affected by diabetes mellitus. It is expected that this number will reach to 250 million by the year 2050 (1). In Saudi Arabia, more than 25 percent of adult population over 30 years of age is suffering from diabetes mellitus and by the year 2030 this number will be more than double. (2) Diabetes mellitus complications especially diabetic foot problems are a major cause of morbidity and premature mortality. Annually around 3.2 million deaths in the world occurs as result of Diabetes mellitus complications. (3)(4) 20 percent of diabetic hospitalizations are attributed to diabetic foot problems. The risk of lower limb amputation is found to be 10 to 15 times higher among diabetic patients compared with non-diabetics. (5) Diabetic foot disease considered as a major challenge for the healthcare system, with enormous economic consequences for people living with diabetes, their families, and society, affecting both quality of life and quality of care. (2) The burden of diabetes and its foot complications is increasing in Saudi Arabia which demanding for effective prevention strategies.
The studies have revealed that there is marked correlation between the level of awareness of diabetic foot lesions and reduction of its occurrence rate. proper education of patients regarding the foot care and awareness of diabetic foot disease have shown to achieve a marked reduction in the limb amputation rate. it reduced the amputation rate by half in addition to minimizing the rate diabetic foot hospitalization and its burden. (5)(6)(7)(8) since education of patient about diabetic foot care is considered as a mainstay of prevention for the diabetic foot complications by many Literatures. This study aimed to assess the level of awareness of diabetic foot among patients with type 2 diabetes mellitus (T2DM). In addition to finding the effectiveness of health education in improving foot care practice among diabetes patients in Alhasa city.

Methodology:-
Study design and setting:-A cross-sectional study was conducted among diabetic patients. The study involved 360 diabetic patients who attended diabetic clinics in Alhasa city, Saudi Arabia between January 2016 to November 2016. The sample size calculated by using Rosoft website, with a margin of error of 5%, and confidence interval of 95%.
Data collection:-Structured questionnaire was used to assess their knowledge and practices regarding foot care. The questioners containing 9 parts, (a) personal data ( age, gender, educational background, socioeconomic status and Province ), (b) duration of DM, (c) current complications ( retinopathy, nephropathy, Diabetic neuropathy, stroke, coronary artery disease (CAD) and peripheral artery disease (PAD)), (d) prior foot or leg problem, (e) surgical intervention for the foot, (f) current treatment for DM ,(g) Hb A1c level , (h) Self-assessment of the Feet, (i) duration of foot washing, (j) Walking barefoot, (k) foot care practices (using nail clipper, warming feet in the winter ,checking water temperature before feet washing , using herbal medication ,wearing comfortable footwear), (l) patients knowledge about diabetic foot disease and its risk factors ( the patient should indicate the source of information), (m) number of feet examination by doctor. After obtaining a written consent, the patients were asked to check the appropriate boxes for the questions. the questionnaire translated to Arabic to ensure full understanding of questions by the patients.

Statistical analysis:-
The data analyzed using Statistical Package for Social Sciences version 22 Descriptive analysis was carried out to analyze the date. In addition to chi-square test and t-test which done tounderstand the variables associated with awareness of Diabetic foot problems. The data checked at 95% confidence interval (CI) and significant level of pvalue of <0.05.

Result:-
A total of 360 diabetic patients were involved in the study. The mean age of the respondents was 57,2 years .out of 360 respondents, 221(61,4%) were male and 139 (38,6%) were female. \Around one third (33.3%) of the sample was having elementary education and one quarter (24,4 %) of the sample was illiterate. Only 16,1 % completed university. The majority (76,45%) of them were living in city and 23,6 % was living in village. regarding the household income around 70 % were having middle income. ( Table 1) The mean duration of diabetes was 11,6 years. More than half (57,8%) of responders were using oral hypoglycemic agent only, 21,7 % were using oral hypoglycemic agent in combination with insulin, 15,0 % were using insulin alone and only few (5,6 %)of them were following diabetic diet only. (table 1) Regarding the diabetic complications, large number of patients were suffering from retinopathy 145(40,3%) and Peripheral Neuropathy 84(23,3%) . Other complications were reported with lower frequencies 52 (14,4%) Diabetic Peripheral Artery Disease of feet , 46 (12,8%) Nephropathy , 29 (8,1%)Brain stroke , 26 (7,2%) Coronary artery disease .141(39,2 %) were not suffering from any complications . (table 2) The greatest number of respondents 300 (83,3%) had no any previous foot injury due to diabetes were 60 (16,7%) only had previews foot injury due to diabetes. Around half of the participants who suffered from diabetic feet injury undergo feet surgery . ( table 2 ) Regarding foot care, some practices were taken into consideration such as using nail clipper, monitoring water temperatures, drying the feet after each exposure to water, warming the feet during winter, using herbs to treat the feet, wearing cotton socks, wearing comfortable closed shoes , self-examination of the foot , duration of foot washing with water and walking barefooted . Of the total sample , Almost all the respondents 352 (98,1%) used nail clippers to cut their nails, 302 (48,1%) monitored water temperature before washing foot or shower ,167 (46,5%) dried their feet after water exposure , 314 (87,5%) kept their feet warm during winter, 258 (71,9%) of the respondents wore comfortable cotton socks , 242 (67,4%) wore closed comfortable shoes and 338 (94,2%) did not use herbs to treat their feet . Regarding self-examination of the foot, 81 (22,5%) of the participants perform it regularly, were 196 (54,4%) perform it in case of pain and 83 (23,1%) don not perform self-examination at all. (table 3).Considering duration of foot washing with water, three quarters of the participants 275 (67,4%) washed for less than 5 minutes. 67 (18,6%) of the participants wash from 5 to 10 minutes. The least number of participants 18 (5%) wash for longer than 10 minutes. The majority of the respondents 253 (70,3%) do not walk barefooted, were 106 (29,4%) of the do walk barefooted . (table 3) 738   Most of the participants 236 (65,6%) indicated that they received foot examination by a doctor only if they have a complaint, were 63 (17,5%) will get their feet examined at each visit to the doctor, and 61 (17%) will not examine even in case of a complaint. (Table 6) Gender (p=0.07) and province (p=0.9) of the participants did not show a significant impact on patients' knowledge about diabetic foot injuries .While the educational level of the participants (p=0,001) and household income (p=0,001) had shown a significant impact on patients' knowledge about diabetic foot injury(.  Previous feet injury (p=0,131), previous feet surgery (p=0,560) due to diabetes were not significantly associated with better knowledge or foot care practices (table 8) . diet. Among these participants, the mean Hb A1C level was (7,8) which indicates that their serum glucose level is not well controlled. This could be a result of medication adherence failure due to lacking of knowledge about the importance of taking medication on regular pattern .
Foot care practices did not show any correlation with patients' knowledge about diabetic foot injury. The patients performed these practices despite their poor background knowledge.. A study have found similar result and attributed this result to basis of Islamic rituals .patients were performing some of these practice religiously without knowing their benefits to their own health . (6) Worldwide, there are more than 1 million lower extremities amputation (LEA) surgery per year, at the rate of one every 30 seconds . (9) up to 50% of the diabetic patients require another lower LEA within 3-5 years from the first LEA . Furthermore, the 5-year mortality rate after LEA on diabetic patients is ~50% (10). despite these facts , only 63 (17,5%) of patients received foot examination at each visit to the doctors and similar percents 61 (17%) of patients had not received any examination even if they had a complaint. additionally , our study reveled that there is a paucity of knowledge among participants with previous foot injuries and surgeries due to diabetes. Previous feet injury (p=0,131) and previous feet surgery (p=0,560) due to diabetes were not significantly associated with better knowledge or foot care practices .This result is similar to the result of study done in India. (11) .Taking in consideration that up to up to 85% of the LEA are completely preventable by simple foot care practices , (12) diabetic patients are in need for effective awareness strategies taken by medical facilities .
More than half of the respondents 214 (59,6%) reported having knowledge about diabetic foot injuries .But when they further asked about the risk factors diabetic foot injuries ,Most of them (64,9%) were found to be lacking of knowledge about the risk factors. The rest of them were found to have poor knowledge about the risk factors.
Duration of having diabetic mellitus was believed to be as a risk factor by (63,2%), were walking bare foot (49,6%) and wearing inappropriate shoes (31,2 ) was the lest to be known as risk factors. Which approves the result of a study carried out in Africa. (13) 212 (59,1%) of the respondents reported obtaining proper awareness about diabetic foot injuries . The majority of them obtained their awareness from doctors 83 (56,5%) and relatives 32 (21,8%) , while the least number of them obtained it either from social media 27 (18,4%) or health education campaign 19 (12,9%) .on the other hand , 147 (40,9%) of the participants did not obtain any awareness . Indicated that the Saudi population need to be aware on the problem size and its impact on the quality of life . There should be awareness campaigns in the hospitals , public area and on social media coupled with educational programmers at the schools and universities ,to highlight the risk factors of diabetic foot injuries and put more emphasis on the urgent need for serious preventive strategies. Furthermore , The provided information through the educational programs should correspond with educational background of patients without affecting the amount or the quality of the provided information .

Conclusion:-
The results from our study revealed that patients are unaware of diabetes foot risk factors and the importance of foot care practices to their health . Awareness programs should be implemented in all hospitals to help to overcome the paucity of knowledge among the participants coupled with regular assessment of the patients foot at each visit to lower the rate of diabetic foot injuries . in addition to enhancing the role of educational campaigns and social media in improving the level of awareness among Saudi population . furthermore , serious preventive steps should be taking by the Saudi population and ministry of health to lower the risk of diabetic foot injuries as well as the complication of T2DM.