Knowledge and practice of foot care in people with diabetes
Introduction
Foot ulcers are a major cause of morbidity in people with diabetes [1]. Amputation rates are increased 15–30-fold in diabetes [2], [3] and are associated with considerable mortality.
The main pathway to diabetic limb amputation arises from a breakdown in the skin often resulting from minor trauma or repetitive injury leading to ulceration [4]. Several reports in the literature describe how the pathway to amputation can be interrupted by correct foot care practice by the patient [5], [6], [7], [8]. Patients are at high risk of developing ulcers if they have one or more of neuropathy, PVD, deformity, callus, previous ulcer and amputation.
Current guidelines [9], [10] recommend annual screening for the high risk foot and those so identified should receive enhanced foot care and education additional to that given to all people with diabetes. Low risk patients should be instructed about foot hygiene, nail care, footwear, avoidance of trauma, smoking cessation and actions to take if problems develop. In addition high risk patients should seek professional nail care and be educated about the role that loss of protective sensation plays in foot injury.
Although there is a large amount of literature on the diabetic foot and the importance of foot care, there is a lack of population based studies on foot care knowledge and practice. Therefore, we carried out a cross-sectional study with the aim of determining knowledge about foot care and its practice in people with diabetes.
Section snippets
Sampling frame and sample
All patients were eligible for sampling on the population based diabetes register in Middlesbrough, UK consisting of patients managed in primary or secondary care. The register is based on the enumeration of all people with known diabetes resident in the South Tees Health Authority. Both electronic and manual searching is used to identify patients from the patient lists of every general practitioner in the area, in addition to identifying all patients attending for hospital diabetes care. It is
Experimental design
The study was conducted using a self-administered postal questionnaire. The content of the questionnaire was based on the most recent guidelines for care of the feet in people with diabetes [10], [11], [12], [13], [14]. The study was approved by South Tees Ethical Committee. The questionnaire was piloted on 12 patients with diabetes. Subsequently the questionnaire, covering letter and stamped addressed envelope were posted to the sample. The covering letter clearly stated that patients were
Statistical methods
Data were analysed using the Minitab for Windows statistical program version 11.11 (Minitab Inc., 3081 Enterprise Drive, State College, PA, 16801–3008, USA). A knowledge score was calculated by totalling all correct responses to those questions that were considered to have a well defined correct answer according to current guidelines.
Before applying parametric methods the data were tested for normality using the Ryan-Joiner test. If there was significant deviation from normality or if the data
Results
A total of 365 usable questionnaires were returned. Among the 550 patients selected, 67 had either died or were not at the address on the register. Excluding these gave a response rate of 75.6%. The mean age of responders was 62.3 years (range 13–94 years). 20.4% (95% CI 16.2–24.6) were current smokers. 29.5% (24.7–34.3) were on insulin therapy. The lifetime prevalence of foot ulcers (those who have currently or previously suffered from an ulcer) was 9.04% (31 patients, 6.0–12.1). The point
Knowledge of foot care
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) (0.5 (0.03–0.89); P=0.038).
In general, responses to the knowledge questions for those at high risk were better than those with low risk feet (Table 1) but there was no significant difference in the score for those at high risk (6.8) and those low risk (6.5) (0.3 (−0.86 to 0.19); P=0.21).
There was no significant
Current practice in foot care
Table 2 summarises foot care practice for the high and low risk. In general, foot care practice in the high risk group was better than the low risk.
Foot self-examination was practised by 83.7% (77.7–89.7) of high risk patients. Eighty-three percent (79.1–86.9) of all patients did not have their feet measured when they last purchased footwear and only 16.2% (12.3–20.1) received advice on their purchase from the retailer although both these figures were slightly better for those with high risk
Discussion
There was data on 69.1% of respondents to classify their risk status and of these almost 64% had high risk feet. This indicates the scale of the problem of podopathy in people with diabetes. The remaining third most likely either have their annual diabetes foot care review in primary care or not at all.
The point prevalence of foot ulcers at 1.46% (0.2–2.7) was less than that from another population based study which was 2.75% (2.10–3.40) [15]. The lifetime prevalence of foot ulcers at 9.04%
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