Diabetic foot: prevalence, risk factors, knowledge and practices of foot care among diabetic patients attending public diabetic clinics in Dar-es-salaam, Tanzania

Abstract

Background: Diabetic foot is one of the devastating complications of Diabetes Mellitus. Diabetic foot ulcers are the leading cause of non-traumatic lower limb amputation resulting in considerable economic loss. It is estimated that, at the time of diagnosis of type 2 DM, about 10% of patients have one or two risk factors for developing foot ulcers and the lifetime risk for developing foot ulcer is estimated to be 15%. However, among the chronic complications of Diabetes Mellitus, foot ulcers are considered the most preventable especially through education on foot self care. Objectives: The main objective of the study was to determine the prevalence and risk factors for foot ulceration among diabetic patients attending public diabetic clinics in Dar-es-Salaam Tanzania, and to assess their knowledge and practices of foot care. Materials and Methods: Patients who were booked and attended the clinic on a particular day were recruited by systematic sampling technique. Questionnaire was administered to all study subjects and all underwent foot examination particular attention given for neuropathy, peripheral vascular disease, foot deformity and presence of foot ulcer or amputation. Knowledge questionnaire involved open ended questions and the total score was 23. Foot self care practice was adopted from the Summary for Diabetes Self Care Activities to assess how many days in the past week they have practiced foot self care. Results: A total of 404 patients were included in the study, 15% had foot ulcers, 44% had peripheral neuropathy, and peripheral vascular disease was present in 15% of patients. In univariate analysis, factors that were significantly associated with presence of foot ulcer were Peripheral neuropathy (odds ratio [95% confidence interval] 8.14 (3.29 - 20.15) for moderate neuropathy, 24.19(10.40 - 56.30) for severe neuropathy, age > 55 years 1.19(1.10 - 3.30), non-alcohol drinking 8.29 (1.10 - 62.17), insulin treatment 2.04 (1.16- 3.59) and history of previous ulcer 3.23 (1.85 - 5.64). In multivariate analysis, only peripheral neuropathy and insulin treatment were significantly associated with presence of foot ulcer. The mean score of knowledge of foot care was 11 (standard deviation ± 6) out of possible 23 total scores. Low mean scores were significantly associated with lack of formal education (8 ± 6.1), diabetes duration of < 5 years (l0.2 ± 6.7) and not receiving advice on foot care (8.0 ± 6.1). Among the 404 patients, 48% had received advice on foot care and 27.5% reported to have had their feet examined by the doctor at least once. Foot self care practices did not differ significantly across risk categories of patients. Self care behaviour practiced more was washing feet (93%), and least practiced was inspecting shoes (37%). Foot self care behaviour improved significantly in patients who had been given advice on foot care and in those whose feet had been examined by the doctor at least once. Conclusions: 1. The prevalence of diabetic foot ulcers is high among patients attending public diabetic clinics in Dar-es-salaam. 2. PN is the major risk factor for foot ulcer in this population. Avoidance of injuries of an anaesthetic limb and appropriate foot care practice by both patients, and health care providers may reduce foot ulcers. 3. Level of knowledge regarding foot care is low among patients and can still be improved. 4. Proper foot care is not practised adequately by patients and health care providers

Recommendations: 1. To improve health education among doctors so as to increase knowledge on identifying risk factors for foot ulcers. 2. To put in place foot care programmes that will be able to identify patients with risk factors and those already having foot ulcers. 3. To improve patients' knowledge on risks of developing foot ulcers and on foot self-care. 4. To encourage patients on foot self care behaviour.