Relationship between Diabetic Patients' Knowledge Regarding Diabetic Foot Ulcer care and their Wound Status

Background: Diabetic foot ulcer represents a major global medical, social and economic problem. It is the commonest major end-point of diabetic complications. Patients with a Diabetic foot ulcer need to be assessed holistically to identify intrinsic and extrinsic factors. Aim: This study aimed to determine the relationship between diabetic patients' knowledge regarding diabetic foot ulcer care and their wound status at Port Said general hospitals. Subjects and Methods: A descriptive correlational design was applied in the current study. The study was conducted in surgical outpatient clinics at hospitals affiliated to the ministry of health in port said city. A convenient sample included 109 patients with diabetic foot ulcer. Two tools were used for data collection; Foot care knowledge questionnaire and Bates-Jensen Wound Assessment. Results of the study showed more half of the studied had satisfactory Knowledge regarding diabetic foot ulcer care. Although the majority of patients had wound regeneration. Conclusion: there no statistically significance relation between patient's knowledge regarding diabetic foot care and their wound status. The current study recommended that, further studied should be carried out to investigate risk factors for the development of diabetic foot ulcer and wound healing rate.


INTRODUCTION
Diabetes mellitus (DM) is a public health problem and the leading cause of morbidity and mortality worldwide.Global diabetes incidence is increasing rapidly this is likely to bring a concomitant increase in its complications among diabetic patients.One important complication of DM is the Foot problems; these complications constitute an increasing public health problem and are a leading cause of hospital admission, amputation and mortality in diabetic patients (Desalu et al., 2011).
The World Health Organization(WHO) criteria define diabetic foot as "the foot of diabetic patients with ulceration, infection and / or destruction of deep tissue associated with neurological abnormalities and various degrees of peripheral vascular disease in lower limb" (Khanna and Tiwary, 2016).Moreover, it is estimated that in 2012 approximately 370 million people have diabetes which accounts for 8.3% of the world's population.Around 80% of these people live in developing countries.By 2030, the global estimate is expected to rise to over 552 million -9.9 % of the adult population (IWGDF, 2013).
In Egypt, the prevalence of diabetic foot ulcers has been found to be high.The reasons commonly stated for this prevalence includes inappropriate footwear and the lack of knowledge regarding diabetic foot problems.The latter is very pertinent to Egypt since more than 90% of the people having diabetes do not receive education on diabetic foot problems (Gawish, 2012).
Despite the high incidence of foot ulceration and lower extremity amputation, a few studies indicated that patients with diabetes lack adequate knowledge related to foot self-care.Up to 40% of patients with diabetes are not aware of risk factor for foot ulceration, do not recognize foot problems, have limited knowledge of self-care strategies to protect the feet and therefore do not engage in foot self-care behaviors such as washing, inspecting feet, selecting and using proper shoes and socks (Fan et al ., 2014).
Care of the diabetic foot requires input before, during and after the development of complications.Prevention of foot ulceration can be optimized by educating patients with diabetes about the use of appropriate footwear and by regular reinforcement of foot -care advice.The annual, thorough inspection of feet is an essential part of a diabetic examination.Standards should be in place to help identify at -risk feet.In particular the feet of patients with diabetes should be carefully examined for the presence of deformities, callus, reduced blood supply and nerve damage (Shaw and Cummings, 2012).
Patients with Diabetic Foot Ulcer (DFU) need to be assessed holistically to identify intrinsic and extrinsic factors.This should encompass a full patient history including medication, comorbidities and diabetes status.It should also take into consideration the history of the wound, previous DFUs or amputations and any symptoms suggestive of neuropathy or peripheral arterial disease.In addition to, a physical examination should determine size, depth, appearance and location of the DFU, status of the wound edge, exudate type and amount, necrosis or gangrene (Wounds International, 2013).
The clinical assessment of diabetic foot is composed of three steps (the whole patient, the affected leg , the ulcer) (Jung, 2016).In addition to, Health care providers should follow a standardized and consistent strategy for evaluating a foot wound, as this will guide further evaluation and therapy (schaper et al., 2016).

Significance of the Study:
A diabetic foot ulcer is a pivotal event in the life of a person with diabetes and a marker of serious disease and comorbidities.Without early and optimal intervention, the wound can rapidly deteriorate, leading to amputation of the affected limb.On the other hand every year, four million people worldwide get a foot ulcer and one in every six people with diabetes develop a foot complication in their life time.People with diabetes are up to 40%times more likely to undergo lower leg amputation.Every 30 seconds a leg is lost due to diabetes in the world and 70% of all leg amputations were done on people with diabetes somewhere in the world (Gholap and Mohiet, 2013).Also inadequate knowledge related to foot self-care lead to foot problems that may contribute to ulceration, amputation of lower extremities and substantial health care costs (Fan et al., 2014).So that, diabetic patient play an important role in caring with his foot and preventing deterioration Therefore, it found that there was an indication to assess patients' knowledge about diabetic foot ulcer care and affecting on their wound status.Operational definitions:  Diabetic foot ulcer care  Wound status

SUBJECTS AND METHOD:
A descriptive correlational research design was used to conduct this study to fulfill the aim of the study and the research objectives.

Setting:
This study was carried out in surgical outpatient clinics at three hospitals affiliated to the ministry of health in Port Said city (Port-Said General Hospital, Port -Fouad General Hospital, and El-Zohoer Centeral Hospital).

Subjects:
The convenient sample was included 109 diabetic patients' that have diabetic foot ulcer that determined using the following equation (Dobson, 1984): Z 2 Sample size (n) = ---P (100 -P)  2 Tools of data collection: Two tools were used in the current study.
TOOL I: Structure Interview questionnaire: This tool was adapted from (Suitor, 2007) to assess patients' knowledge about foot care.It consisted of two parts: Part I: this part included socio-demographic data characteristics of patients under study.It was composed of 19 multiple choice questions.which include personal data such as age, sex, level of education, occupation, marital status, number of kids, working hours, income, history of chronic disease, previous went to specialized doctor, allergies, causes of allergy, previous suffered from foot ulcer, used shoes to decrease pressure, diabetic foot ulcer duration, family history of chronic diseases, first degree relative suffered from diabetes mellitus.Part II: Foot care knowledge questionnaire: It was developed by (Suitor, 2007) and was modified by the researcher to assess patients' knowledge about foot care which included 14 multiple choice questions, each question have 4 to 5 choices, whereas the right response gave score (1)and wrong response gave score (0), and the total score ranged from (zero-14).It was translated from English language to Arabic language then re translated from Arabic language to English language.Scoring System: Foot care knowledge questionnaire consists of 14 questions, the total score ranged from (zero-14).total patient's knowledge more than 60% means patients had satisfied knowledge about diabetic foot ulcer care and total patient's knowledge less than 60% means patients had unsatisfied knowledge about diabetic foot ulcer care.

TOOL II: Bates-Jensen Wound Assessment:
It was developed by Bates-Jensen and Sussman (2012) and was modified by the researcher on anatomic site as (dorsum of foot, plantar of foot and toes).It was used to assess patient's wound status which consisted of 13 items.Thirteen assessment parameters are measured on a scale ranged from 1 to 5; the higher the total score, the more severe the wound status.Once the numbers were recorded and the scale was completed, a total was calculated using all thirteen parameters and then placed on a linear chart.The total score ranged from 1(Tissue Health), 13 (Wound Regeneration) and 65 (Wound Degeneration).It was translated from English language to Arabic language then re translated from Arabic language to English language.

Content validity
Content validity of both tools was tested by nine experts from Faculty of Nursing in the field of Medical-Surgical Nursing (four experts) and physicians from faculty of medicine (five experts).The questionnaire was modified according to the experts' comments and recommendations

Reliability:
The both tools tested for reliability.The internal consistency of tools has been tested using Cronbach's alpha coefficient.Cronbach's alpha for Foot care knowledge questionnaire and wound assessment were (0.851 &0.855).

Pilot study:
A pilot study was done to assess the feasibility and applicability of tools and estimate the proper time required for filled in each tool.It was conducted on 10.0% of patients from previously mentioned setting and it was conducted over a period of two weeks before embarking on field work of the study.After obtaining the result of the pilot study, the necessary modifications were done as (patients' occupation, work hours) and the final form was developed.The patients included in the pilot study were excluded from the main sample.

Field work:
Data were collected over a period of four months from the beginning of November, 2015, to the end of February, 2016.Data collected for three days a week (Wednesday, Thursday and Saturday) at morning shift from 9:00amto12:00pm.Verbal consents were obtained from each participant (patients) to be included in the study after explaining clarification of the nature and purpose of the study.Data were collected using written questionnaire sheet for each patient that was interviewed individually to fill in the questionnaire sheet by the researcher which was read the questionnaire to the patients and as they answered, then the researcher filled in the questionnaire, then the researcher attendance with the patient in dressing room to assess wound status during dressing one time according to Bates-Jensen Wound Assessment tool items.The alltime needed for the application of the study tools was lasted approximately about 25 to 30 minutes.First tool was interviewing questionnaire; it lasts about 15 minutes to fill in it, while the second tool was Bates-Jensen Wound Assessment it lasts about 10-15 minutes to fill in it.

Ethical Consideration:
An approval was taken from directors, physicians, nurses after explaining the aim of the study and from patients at surgical outpatient clinics of the concerned hospitals before asking them to participate in the study, stressing on confidentiality of the collected information.Verbal consents were obtained from each patient to be included in the study after explaining clarification of the nature and purpose of the study.The researcher was emphasized that, the participations were absolutely voluntary and each patients have the right to withdraw from the study at any time without explaining any reasons, as well as confidentiality was assured.

IV-Statistical Analysis:
Statistical analysis was done using statistical package for social science (SPSS) version 19.0.Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations for quantitative variables.Qualitative variables were compared using t-test and ANOVA test as the test of significance and the p-value is the degree of significant and Pearson correlation is used for assessing correlation between patient's knowledge regarding diabetic foot care and wound status.

RESULTS:
Table (1): reveals that, less than half of the studied patients (45%) were at age group >48 to 60 years, more than half of the studied patients (59.6%) were male, more than half of the studied patients (50.5%) were illiterate, more than one third of patients (33.9%) were house wife, more than two thirds of patients (69.7%) were married, less than half of patients (49.5%) had one to three kids, while the minority of them (3.7%) had seven to nine kids.and the majority of the studied patients (93.6%) were not enough.

Table (2):
represents that, more than two thirds of the studied patients (67%) had chronic diseases; 53.2% of them suffered from hypertension, 1.8 % of them had osteoporosis.The majority of the studied patients (94.5%) had recent referral; 66.1% of them had peripheral vascular disease, 3.7% of them had peripheral nerves, 12.8% of them suffered from allergy whereas 6.4% of them had food allergy, and 55% of them had previous foot ulcers.the majority of the studied patients (91.7%) had not used shoes to decrease pressure on foot.

Graph (1):
shows that more than half of studied patients (55%) had satisfactory knowledge regarding to diabetic foot ulcer care Graph (2): represents that, the majority of studied patients (96.3%) had wound regeneration while none of them had wound degeneration.

Table (3):
there was no correlation between patient's knowledge regarding diabetic foot care and their wound status.

DISCUSSION:
As result yielded by the current study, more than half of studied patients had satisfactory knowledge regarding diabetic foot ulcer care.This may be due to good communication between health care providers and patients, most patients are run once or twice per week at outpatient clinics which allow them to meet many diabetic patients to exchange their knowledge about their disease.Moreover, most of studied patients had long duration of diabetes which provides them with more opportunities for exposure information regarding their disease and multiple visits to the health care facility by people with longer duration of diabetes which would have exposed to more education and most of studied patient had previous DFU which is considered clinical experience that could be a method of acquired knowledge about foot care previously.Moreover, this result is in accordance with (Seid and Tsige, 2015) who were studied knowledge, practice and barriers of foot care in North West Ethiopia and were found that more than half of their studied patients had a good knowledge of diabetic foot care.This finding was in disagreement with (Chiwanga and Njelekela, 2015) that were studied diabetic foot knowledge and foot self-care practice among diabetic patient in Tanzania and were stated that knowledge about foot care is low among diabetic patients.
The result of the current study was in accordance with (George et al., 2013) which found that, most of his studied patients walk barefoot inside the house.The majority of current studied patients were wearing open shoes and sandals due to the size of their dressing.Also, it was observed that the patients had a knowledge deficit regarding criteria of appropriate shoes for diabetic foot and they thought that open shoes with larger size or sandals are suitable and prevent foot complications.This is similar to (Bakker, 2006) which mention that in the developing countries there is no formal training in podiatry; suitable shoes and orthotics "an externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system" are rarely found.
The current study revealed that, the majority of studied patients had wound regeneration while the minority of them had wound healing which might explain poor healing of patients wound.From the researcher point of view, this may be because of that studied patients were collected in winter that lead to inadequate blood supply to extremities.Also, most of patients had peripheral vascular disease which imped the blood circulation in legs.Moreover, the majority of patients had insufficient income to cover treatment costs.
Regarding site of wound, the current study revealed that, more than two fifths of the studied patients had toes and plantar of foot wound.This may be due to, most of studied patients wear open shoes or sandals and walking bare-foot indoors that can lead to penetrating and traumatic foot injures.The result in accordance with (Lawrence, 2013) who mentioned that diabetic neuropathic ulcers are found at a site of increased weight bearing (abnormal pressure distribution on foot), such as a plantar surface of foot, the heel, or on the dorsal surface of a toe that is rubbing against a shoe.Regarding shape of wound, the current study revealed that, less than half of patients had a round-shaped wound.This may be refer to that, most of patients' wounds in the current study were located at planter of foot and toes that lead to round-shape of wound.This result confirms the fact that neuropathic ulcers are usually round in shape and almost form at pressure points (Bowker and Pfeifer, 2008).
The current study revealed that, more than two thirds of the studied patients had dry wound or no exudate.From the researcher point of view this might be related to inadequacy wound dressing and most of nurses in the out patients clinics do not know the principles of choosing appropriate wound dressing that can give back fluid to the wound.The result confirms the fact of wounds that are dry or have a very low level of exudate need to be moisturized to stimulate healing (Rajendran, 2009).
The current study elicited that, there was statistically significance relation between patients' occupation and their knowledge regarding diabetic foot ulcer care, this might refer to that more than half of studied patients were housewife and retied and this give them a chance for talking with relatives, neighbors and their sons about their disease and exchange knowledge and experience.This similar to (Kumar, 2012) which found that, there was a relation between patients' occupation and their knowledge about diabetic foot care.
The current study revealed statistical significant relation between patients' kids number and their knowledge regarding diabetic foot ulcer care.This may be due to patients' kids might be educated, read and understand some educational supportive materials and use information technology to obtain more information about parents disease then tell and teach them.
The current study showed that, there was a statistical significant between patients' history of respiratory disease and their knowledge regarding diabetic foot ulcer care.
From the point view of the researcher, studied patients was obtained in winter in which respiratory diseases an activated that might lead patients to go to hospitals and medical centers to follow up their chest which allows them to deal with many health care providers and other patients and exchange knowledge about their disease.
The current study revealed a statistical significant relation between family history of cancer and knowledge regarding diabetic foot ulcer care.from the point view of the researcher, cancer was chronic and serious disease that mostly leading to death and when the patient had a family history of this disease ,he is usually afraid of the progress of his disease and seeks for gaining knowledge about his disease and caring about himself.
The current study was elicited that, there were no statistically significant relationship between socio demographic data and wound status.although most of patients were illiterate and low socio economic status.This result was in disagreement with (Bikramjit et al., 2015) which mentioned that both low education level and poor economic status are constantly related with the more severe forms of diabetic foot ulcer disease.
The current study found a statistical significant relation between patients' recent referral and wound assessment in area of orthopedic.This is interpreted with that, orthopedic problems might have impact on patients walking, standing and sitting normally which could effect on pressure distribution on foot and so on wound status , especially the studied sample obtained in winter and orthopedic problems increase in this season.
The current study found a statistical significant relation between patient's family history of heart diseases and wound status.This result confirms the impact of heart diseases on the process of wound healing which disturbed normal blood circulation in whole body especially extremities.This may be because of the family history of heart disease may effect badly on the patient psychological state due to the patient afraid of having heart disease as his family which in turn has an badly impact on wound status.
The current study elicited that, there was no correlation between patient's knowledge regarding diabetic foot care and their wound status.Although more than half of studied patients had satisfactory level of knowledge regarding diabetic foot care.From the point view of the researcher, this may be due to do not apply that knowledge into practice and this could refer to that, most of patient had low socioeconomic status, they did not attend daily to change dressing on their DFU and used unsterile equipment during wound care at their home.Otherwise, nurses who provided dressing procedure in surgical outpatient clinics might be do not know adequate principles of dressing, wound assessment and how to choose the appropriate dressing depending on wound assessment which might have a bad effect on wound status.

CONCLUSION:
Based on the finding of the current study, More than half of patients had satisfactory knowledge regarding diabetic foot ulcer care, Although the majority of patients had wound regeneration.Also, there was no correlation between patients' knowledge regarding diabetic foot ulcer care and their wound status.

RECOMMENDATION:
Based on the findings of this study, the following recommendations can be suggested: Provide educational programs for diabetic patients about proper foot care, periodic selffoot examination and diabetic foot ulcer prevention as selection of foot wear to reduce foot problems.For the ministry of health : A detailed foot examination should be done by the attending dialectologist at every visit of the diabetic patient to rule out neuropathy or vasculopathy, Provide hospitals with essential supplies to provide optimal DFU dressing according to wound needs.Also, Health care facilities should incorporate foot care among other routine care being provided to diabetic patients in order to identify patients with risk factors and those who already have foot ulcers.

Table ( 3
): Correlation between patient's knowledge regarding diabetic foot care and their wound status: