Abstract
Background
Diabetes Mellitus (DM) causes micro and macro vascular complications. One of the complications of DM is diabetic foot that results in amputations and decreased quality of life. The aim of this study was to assess the awareness and practice about foot care and associated factors among admitted patients in a teaching hospital of coastal Karnataka, India.
Material and Methods
A cross-sectional study was conducted in a medical college hospital after obtaining institutional ethics approval from 24th December 2016 to 21st January 2017. Adults with diabetes (N=317) admitted in the hospital were interviewed with a validated structured questionnaire for awareness and practice regarding foot care. The scores obtained were further graded into good and poor. Data was analyzed with SPSS version 22 for descriptive statistics. Bivariate logistic and linear regressions were used to determine the association between variables and awareness/practice scores.
Results
Mean age of the participants was 56.98 (±10.54) years with males constituting the majority (63.4%). Good awareness and practice scores were observed among 69.1% and 41.6% participants, respectively. Good awareness scores were associated with male patients (p=0.027), currently not married (p=0.044), below poverty line socioeconomic status (p=0.014) and presence of foot ulcer (p=0.021). Good practice scores was associated with secondary schooling (p=0.003) and receiving insulin (p=0.045). Moderate correlation with coefficient 0.493 (p<0.001) was observed between awareness and practice scores.
Conclusion
Seven and four out of 10 study participants had good awareness and practice scores about foot care, respectively. A tailor-made health education module addressing the lacunae identified in the awareness and practice domains needs to be provided to the patients with diabetes mellitus.
Keywords: Knowledge, Diabetic foot, Diabetes complications, Health education, Tertiary Care Center
Introduction
Diabetes mellitus (DM), a chronic disease of metabolism is estimated to have affected 463 million adults worldwide. Of these, one out of six adults are from India, accounting for around 77 million diabetic patients [1]. Untreated DM may lead to macro and microvascular complications including diabetic nephropathy, retinopathy, and peripheral neuropathy [2]. Ulcer of foot is one of the frequently observed complications among individuals with DM which often remains undetected and its incidence ranges from 8-17% [3]. Diabetic foot ulcers (DFU) are estimated to be responsible for around 85% of diabetes-related amputations. Micro-angiopathy, neuropathy, foot deformities and mechanical stresses are identified as the risk factors for the development of DFU. Furthermore, individuals with DFU are evidenced to experience reduced health-related quality of life [4].
Self-care practices include modifying diet, increasing physical activity, adherence to medication, monitoring of glucose levels in blood and care of the feet [5]. The activities pertaining to self-care performed by the patients are found to be associated with the outcomes of DM and development of complications. Individuals with DM are at constant risk of developing DFU. Appropriate measures including care from multidisciplinary diabetes care team as well as patient education helps in prevention of around 49-85% of diabetic foot related complications, thereby improving quality of life [6].
Tailor-made health education messages in the socio-cultural context of the patients may be useful to address the shortcomings in knowledge [7]. However, this requires assessment of the knowledge practice gaps in patients with DM. Hence, the aim of this study was to assess the awareness and practice regarding foot care and its associated factors among patients admitted with DM in a medical college hospital of coastal Karnataka, India.
Methodology
Study design and the participants
This cross-sectional study was conducted at Yenepoya medical college hospital, Mangaluru situated in coastal Karnataka, India from 24th December 2016 to 21st January 2017. The tertiary care hospital has 900 inpatient beds. Majority of the patients attending the hospital belong to the southern and central parts of Karnataka and northern Kerala.
Inclusion criteria
All the adults aged >18 years with DM admitted for various complications in medical and surgical specialty wards and provided informed consent for voluntary participation in the study were included.
Exclusion criteria
Seriously ill individuals (patients having cardiac complications like coronary artery disease/neurological complications like stroke) and pregnant women were excluded.
Data collection
Data was obtained by interviewing the patients admitted in medical and surgical wards using a structured questionnaire by four trained medical interns under supervision.
Questionnaire design and validation
We have adopted a structured and validated questionnaire which was used in a similar published study from Kerala [8]. The questions were translated to Kannada and a back translation to English was done. Content validity was performed by involving three subject experts proficient in both English and Kannada. Mean Content validity index (CVI) of the questionnaire was 0.927 and Cronbach’s α coefficient for reliability was 0.808. The questionnaire comprised of 4 sections i.e. socio-demographic variables, clinical variables, awareness and practice questions regarding foot care. There were 10 questions on awareness and 8 questions on practice assessment. Favorable response was scored ‘1’ and unfavorable response was scored ‘0’. Two questions under the section of practice assessment were given scores from 0 to 2. The maximum attainable scores for awareness and practice were 10 each. The scores 0-3 indicated poor score whereas ≥4 indicated good score for both awareness and practice. This categorization was based on a prior study from Indian context [8].
Sample size calculation
Based on the finding that 75% of the patients with DM had a good knowledge score about foot care in Vellore, south India, [4] sample size of 317 was arrived with 5% alpha error, precision of 5% and expecting a 10% non-response rate. Non-probability purposive sampling method was employed in the selection of study participants.
Outcome variables
Awareness and practice scores of patients regarding care of feet.
Explanatory variables
Socio-demographic variables and clinical variables.
Ethics approval
Approval of institutional ethics committee was obtained for the study (protocol no: 2016/372). Informed consent of written nature was obtained from the study participants after explaining the aim and nature of the study in their native language (Kannada/Malayalam). The research adhered to the principles of ethics in medical research involving humans as per the Helsinki declaration.
Data management and statistical analysis
Data was entered in Microsoft excel and analysis was performed using Statistical Package for Social Sciences (SPSS Inc, Chicago, USA; Version 22.0). Descriptive statistics (frequencies, means and standard deviations, median and IQR) were used for demographic/clinical variables and to report participants’ awareness/practice scores. Bivariate logistic regression was used to determine the association between categorical demographic/clinical factors and awareness/practice scores. Linear regression was used to determine the association between continuous variables and awareness/practice scores. Pearson correlation was used to examine the correlation between awareness and practice scores. The p-value for significance was fixed as less than 0.05.
Results
Study characteristics
The study participants were aged 56.98 (±10.54) years and males constituted to 63.4%. Majority of the participants (88%) were married and most of them practiced Islam (46.7%) and Hinduism (43.8%). Half of the participants received education up to primary school and homemakers constituted 21.8% followed by semiskilled and unskilled workers (18% each). Majority of the participants belonged to below poverty line category (79.2%; Table 1).
Table 1:
Socio-demographic and clinical characteristics of patients with diabetes mellitus who were assessed for awareness and practice regarding care of feet at Yenepoya medical college hospital, Karnataka, India (n=317)
| Variables | Frequency | Percentage |
|---|---|---|
| Gender | ||
| Male | 201 | 63.4 (62.1-64.7) |
| Female | 116 | 36.6 (35.3 – 37.9) |
| Religion | ||
| Hinduism | 139 | 43.8 (42.42 – 45.18) |
| Islam | 148 | 46.7 (45.51 – 48.09) |
| Christianity | 24 | 7.6 (7.2 – 7.9) |
| Others | 6 | 1.9 (1.7 – 2.0) |
| Marital status | ||
| Not married | 6 | 1.9 (1.7 – 2.0) |
| Married | 279 | 88.0 (87.41 – 88.59) |
| Widow/widower | 24 | 7.6 (7.2 – 7.9) |
| Divorced | 8 | 2.5 (2.37 – 2.63) |
| Educational status | ||
| Not literate | 74 | 23.3 (22.3 – 24.3) |
| Up to primary school | 162 | 51.1 (49.7 – 52.5) |
| Secondary school | 60 | 19.0 (18.14 – 19.86) |
| Pre university/diploma and above | 21 | 6.6 (6.26 – 6.94) |
| Occupational status | ||
| Semi-professional | 16 | 5.0 (4.74 – 5.26) |
| Skilled | 50 | 15.8 (15.06 – 16.54) |
| Semi-skilled | 57 | 18 (17.17 – 18.83) |
| Unskilled | 57 | 18 (17.17 – 18.83) |
| Homemaker | 69 | 21.8 (20.85 – 22.75) |
| Retired | 16 | 5.0 (4.74 – 6.26) |
| Unemployed | 52 | 16.4 (15.63 – 17.17) |
| Socio-economic status | ||
| Above poverty line | 66 | 20.8 (19.87 – 21.72) |
| Below poverty line | 251 | 79.2 (78.27 – 80.12) |
| Current treatment | ||
| Oral hypoglycemic drugs | 201 | 63.4 (62.1 – 64.7) |
| Insulin | 65 | 20.5 (19.59 – 21.41) |
| Both | 51 | 16.1 (15.35 – 16.85) |
| Medication regularity in the last one month | ||
| Regular | 268 | 84.5 (83.77 – 85.23) |
| Irregular | 45 | 14.2 (13.52 – 14.88) |
| Defaulter | 4 | 1.3 (1.23 – 1.37) |
Median duration of DM was 6 (4-10) years. The mean glycosylated hemoglobin level (HbA1C) was 8.09% (±2.07) and the participants were more likely to receive oral hypoglycemic medications (63.4%). Most of the subjects were taking medications regularly (84.5%), irregular medication intake (compliance <90% in the last month) was seen among 14.2% and 1.3% were defaulters (not taken medication in the last month). The most frequent complication was diabetic foot ulcer (34.4%) followed by coronary artery disease (7.9%) and peripheral neuropathy (7.3%).
Awareness and practice regarding care of feet among patients with DM
In this study, 71.3% of the study participants believed that any infection in the feet could develop into a wound and 27.8% knew that patients with diabetes can develop gangrene of the feet. About 85% patients practiced washing their feet daily whereas 23% patients practiced changing their footwear timely. Other awareness and practice parameters assessed are presented in table 2.
Table 2:
Awareness and practice regarding care of feet among the patients with diabetes mellitus at Yenepoya medical college hospital, Karnataka, India (n=317)
| Awareness-related foot care | Number | Percentage |
|---|---|---|
| Patients with DM will have decreased flow of blood in their feet | 127 | 40.1 (38.75 – 41.45) |
| Patients with DM will have lack of sensations in their feet | 161 | 50.8 (49.4 – 52.2) |
| Patients with DM will have ulcers in their feet | 158 | 49.8 (48.4 – 51.2) |
| Patients with DM develop gangrene | 88 | 27.8 (26.68 – 28.92) |
| Receipt of information regarding foot care in the past | 139 | 43.8 (42.42 – 45.18) |
| Smoking can decrease the blood flow to feet | 135 | 42.6 (41.23 – 43.97) |
| Loss of sensation in feet makes them more prone to have ulcers | 195 | 61.5 (60.17 – 62.83) |
| Reduced blood flow makes them more prone to get foot ulcers | 195 | 61.5 (60.17 – 62.83) |
| Any infection in the feet may develop to wounds | 226 | 71.3 (70.16 – 72.44) |
| Appropriate method of trimming toe nail | 157 | 49.5 (48.1 – 50.9) |
| Practice-related foot care | Number | Percentage |
| Washing feet daily | 269 | 84.9 (84.18 – 85.62) |
| Moisturizing dry areas of feet | 87 | 27.4 (26.29 – 28.51) |
| Checking feet daily for any injury | 98 | 30.9 (29.74 – 32.06) |
| Seeking health care if any abnormality on feet is noted | 184 | 58 (56.64 – 59.36) |
| Cutting the toe nails cut straight through | 163 | 51.4 (50 – 52.8) |
| Checking for shoes/socks leave marks on the feet | 75 | 23.7 (22.69 – 24.71) |
| Practice of changing footwear once/more than once in a year | 73 | 23 (22.01-23.99) |
| Practice of going for foot check up | 88 | 27.8 (26.68 – 28.92) |
The awareness and practice scores were computed by adding the scores. The median awareness score was found to be 5 (3-7). The median practice score was 3 (2-5). It was observed that 219/317 (69.1%) of the study participants had good awareness and 132/317 (41.6%) had good practices towards foot care. (Table 3) There were a few participants (8.2%) who had absolutely no awareness with score of zero and exhibited poor foot care practices (4.4%) where the practice score was zero.
Table 3:
Association between socio-demographic/clinical characteristics and awareness and practice regarding care of feet among patients with diabetes mellitus at Yenepoya medical college hospital, Karnataka, India (n=317)
| Categorical variables | Awareness | Practice | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Good | Poor | Crude OR (95% CI) |
p-value | aOR (95% CI) |
p-value | Good | Poor | Crude OR (95% CI) |
p-value | aOR (95% CI) |
p-value | ||||
| Gender | Male | 150 (74.6) |
51 (25.4) |
2.003 (1.230-3.264) |
0.005 | 2.105 (1.089-4.068) |
0.027 | 89 (44.3) |
112 (55.7) |
1.349 (0.844-2.155) |
0.210 | 0.894 (0.482-1.661) |
0.724 | ||
| Female | 69 (59.5) |
47 (40.5) |
1 | 1 | 43 (37.1) |
73 (62.9) |
1 | 1 | |||||||
| Marital status | Married | 189 (67.7) |
90 (32.3) |
0.560 (0.247-1.271) |
0.161 | 0.404 (0.167-0.976) |
0.044 | 116 (41.6) |
163 (58.4) |
0.979 (0.492-1.944) |
0.951 | 0.837 (0.397-1.763) |
0.639 | ||
| Currently not married | 30 (78.9) |
8 (21.1) |
1 | 1 | 16 (42.1) |
22 (57.9) |
1 | 1 | |||||||
| Educational status | Secondary school and above | 62 (76.5) |
19 (23.5) |
1.642 (0.919-2.935) |
0.092 | 1.664 (0.890-3.109) |
0.110 | 46 (56.8) |
35 (43.2) |
2.292 (1.372-3.830) |
0.001 | 2.249 (1.312-3.857) |
0.003 | ||
| Up to primary school | 157 (66.5) |
79 (33.5) |
1 | 1 | 86 (36.4) |
150 (63.6) |
1 | 1 | |||||||
| Occupational status | Currently employed | 128 (71.1) |
52 (28.9) |
1.244 (0.771-2.009) |
0.371 | 1.026 (0.533-1.975) |
0.938 | 80 (44.4) |
100 (55.6) |
1.308 (0.831-2.058) |
0.246 | 1.356 (0.746-2.467) |
0.318 | ||
| Currently not employed | 91 (66.4) |
46 (33.6) |
1 | 1 | 52(38) | 85(62) | 1 | 1 | |||||||
| Socio-economic | Above poverty line | 38 (57.6) |
28 (42.4) |
0.525 (0.3-0.920) |
0.023 | 0.472 (0.259-0.862) |
0.014 | 30 (45.5) |
36 (54.5) |
1.217 (0.705-2.102) |
0.480 | 1.082 (0.608-1.926) |
0.788 | ||
| status | Below poverty line | 181 (72.1) |
70 (27.9) |
1 | 1 | 102 (40.6) |
149 (59.4) |
1 | 1 | ||||||
| Complication | Foot ulcer | 86 (78.9) |
23 (21.1) |
2.109 (1.229-3.619) |
0.006 | 1.966 (1.109-3.595) |
0.021 | 51 (46.8) |
58 (53.2) |
1.379 (0.863-2.202) |
0.178 | 1.343 (0.801-2.250) |
0.263 | ||
| Other than foot ulcer | 133 (63.9) |
75 (36.1) |
1 | 1 | 81 (38.9) |
127 (61.1) |
1 | 1 | |||||||
| Current treatment | Insulin with/without oral hypoglycemic agents | 81 (69.8) |
35 (30.2) |
1.057 (0.643-1.735) |
0.828 | 0.832 (0.486-1.426) |
0.504 | 57 (49.1) |
59 (50.9) |
1.623 (1.022-2.578) |
0.040 | 1.654 (1.010-2.708) |
0.045 | ||
| Only oral hypoglycemic agents | 138 (68.7) |
63 (31.3) |
1 | 1 | 75 (37.3) |
126 (62.7) |
1 | 1 | |||||||
| Medication regularity | Irregular | 35 (71.4) |
14 (28.6) |
1.141 (0.583-2.233) |
0.699 | 1.204 (0.597-2.424) |
0.604 | 15 (30.6) |
34 (69.4) |
0.569 (0.296-1.095) |
0.089 | 0.557 (0.285-1.088) |
0.087 | ||
| Regular | 184 (68.7) |
84 (31.3) |
1 | 1 | 117 (43.7) |
151 (56.3) |
1 | 1 | |||||||
| Continuous variables | Awareness | Practice | |||||||||||||
|
Coefficient (95% CI) |
p-value |
Coefficient (95% CI) |
p-value | ||||||||||||
| Age | -0.082 (-0.063-0.016) |
0.245 | 0.035 (-0.02-0.034) |
0.622 | |||||||||||
| Years lived with diabetes | 0.077 (-0.029-0.1) |
0.278 | 0.0 (-0.044-0.044) |
0.999 | |||||||||||
| Glycosylated hemoglobin levels | -0.136 (-0.408-(-0.008)) |
0.042 | -0.070 (-0.209-0.064) |
0.298 | |||||||||||
OR=Odds Ratio, aOR=Adjusted Odds Ratio, CI=Confidence Interval
Associations between socio-demographic/clinical characteristics and awareness and practice scores
Good awareness scores regarding care of feet among the patients was associated with male gender (p=0.027), currently not married (p=0.044), socioeconomic status of below poverty line (p=0.014) and presence of ulcer of foot as a complication (p=0.021). Good practice scores was associated with secondary schooling and above (p=0.003) and patients currently receiving insulin with/without oral hypoglycemic agents (p=0.045). Among the continuous variables, awareness score decreased by 0.136 times with every one unit rise in HbA1C levels (p=0.042). (Table 3) There was a moderate correlation between awareness and practice scores with Pearson value of 0.493 (p-value < 0.001).
Discussion
This study looked into the awareness and practice components related to care of feet among patients with DM admitted to medical college hospital using a previously validated scale. Foot self management is one of the cornerstones for preventing DFU. Patient education plays an important role in imparting knowledge and skills about foot care and it is predicted to reduce the DFU cases by 50% [6,9]. Even the patient empowerment theory places patients as focal points and make them the primary decision makers about self-care [10]. Assessment of the existing awareness and practices towards foot care among the patients will help physicians devise an appropriate health education intervention and this was one of the outcomes planned from this study.
Awareness about foot care and associations
Seven out of every 10 individuals exhibited good awareness about foot care in our study. Some parameters like awareness regarding infection causing foot ulcers, sensation being lost and decreased blood flow causing ulcers had higher frequencies whereas patients scored less in the awareness of gangrene as a complication of DFU. Similar findings were recorded in studies from other developing countries [11,12]. One of the studies conducted at diabetic clinics in India showed a higher percentage of patients having good awareness scores which was attributed to good community diabetes care programme [4].
Male gender, currently not married, below poverty line status and presence of foot ulcer as a complication were associated with good awareness scores in our study. Poorly controlled DM, as evidenced by HbA1C was associated with poor scores. Female gender was seen as a better predictor of awareness in Bangladesh [11]. Higher educational levels were associated with better knowledge scores in other studies from the developing world [11-13]. Marital status was also observed to be associated in a study from Saudi Arabia [12]. Factors such as male sex, educational status of lower order and shorter duration of DM were associated with poor knowledge in a study from south India [4]. Another study from south India also reported that patients with DFU had poor knowledge scores as compared to those with no DFU [8]. We interpret that patients with DM who are females, married and those above poverty line need a special focus during delivery of health education about care of feet.
Practice of care of feet and associations
Four out of every 10 individuals exhibited good practice of care of feet. This shows that there is a huge scope for improvement in this domain. Washing feet daily was the only practice which was observed to a great extent by the patients with DM. This may be because of the culturally practiced and accepted habit of washing the feet regularly by Indians. Some practices like trimming the nails straight and seeking health care in case of any abnormality over the feet were moderately observed. Other practices assessed were poorly followed. Suboptimal practices were also reported from other studies [13–17]. A study from southern part of India reported two thirds of the patients with a good practice score [4].
It is to be noted here that patients educated with secondary level and above were having good practice scores like many other studies [11,18,19]. Patients who were on insulin exhibited better scores which implies that they do have controlled DM and hence, the overall knowledge they possess has translated to better self-management. Longer duration of DM was a predictor of good practice in few published studies [11,12]. Awareness and practice scores were positively correlated in our study which was also reported from other studies [16,20].
Health education interventions result in improvement of knowledge and thereby attitudes. These changes will culminate in better preventive self-care practices [10]. Findings from a study revealed that one fourth patients with DM seldom paid attention to foot care in spite of having foot complications or major risk factors. Regular checking of the feet amongst these was related to receipt of education and examination of the feet [21]. Physicians, medical interns and nurses have a vital role to play in educating patients with chronic diseases about self-management in the hospitals. But, it is quite often overlooked especially in academic hospitals due to paucity of time and patient overload. In such a scenario, experiences from our institution suggest that group health education may be incorporated by deputing interns and trained para-medical staff. The health education may also be tried in peripheral health centers with medical officers, nurses and other paramedical staff as recommended by the national programme for non-communicable diseases in India [22]. Self learning module is another alternative which has proved effective in improving awareness and practices towards care of the feet [23].
Limitations of the study
The hospital nature of the study makes the findings not generalizable. We also did not look into the attitudes as we felt that measuring this would be difficult especially among hospitalized patients with one or the other complication. Also, we did not study physician related factors with respect to poor foot care practices which has a scope for further research.
Conclusion
Seven and four out of 10 study participants had good awareness and practice scores about foot care respectively. Good awareness scores were associated with male gender, currently not married, below poverty line status and presence of diabetic foot ulcer. Good practice scores were associated with patients with secondary education and above and those receiving insulin. There was a moderate correlation between awareness and practice scores. Patient education needs to consider these factors when it is delivered.
Future scope of the study:
The effectiveness of health education provided to the diabetics using a structured module which is culturally acceptable needs to be evaluated both quantitatively and qualitatively. Regular follow-ups and complication prevention can be facilitated by scheduled reminders to the patients and this is an area of future research.
What is already known on this topic?
Deficiencies in awareness and practice components of care of the feet among patients with DM are established by multiple studies conducted at hospitals and diabetic clinics. Some studies have looked into the factors influencing them in various contexts.
What this study adds?
The lacunae in the awareness and practice domains were elicited by compiling the responses obtained to the questions. Hence, these aspects should be focused upon while developing the health education module. Factors associated with good/poor awareness and practice scores were obtained. There is a positive correlation between awareness of diabetes foot care being translated to good foot care practice.
Acknowledgements
We acknowledge the contribution of medical interns posted in Community Medicine during the study period towards their help in data collection.
References
- 1.International Diabetes Federation. IDF Diabetes Atlas 9th edition south-east Asia. IDF Diabetes Atlas Updat 2012 | Fed Int Diabetes [Internet] 2019;3-4. [Google Scholar]
- 2.American Diabetes Association. Diagnosis and classification of diabetes mellitus. Vol. 37, Diabetes Care. 2014. 81-90 p. 10.2337/dc14-S081 PMid: [DOI] [PubMed] [Google Scholar]
- 3.Crawford F, Inkster M, Kleijnen J, Fahey T. Predicting foot ulcers in patients with diabetes: A systematic review and meta-analysis. QJM. 2007;100(2):65-86. 10.1093/qjmed/hcl140 PMid: [DOI] [PubMed] [Google Scholar]
- 4.George H, Rakesh P, Krishna M, Alex R, Abraham VJ, George K, et al. Foot Care Awareness and Practices and the Prevalence of Peripheral Neuropathy Among People with Diabetes Attending a Secondary Care Rural Hospital in Southern India. 2013;2(1). 10.4103/2249-4863.109938 PMid: PMCid: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Coyle ME, Francis K, Chapman Y. Self-management activities in diabetes care: A systematic review. Aust Heal Rev. 2013;37(4):513-22. 10.1071/AH13060 PMid: [DOI] [PubMed] [Google Scholar]
- 6.Yazdanpanah L. Literature review on the management of diabetic foot ulcer. World J Diabetes. 2015;6(1):37. 10.4239/wjd.v6.i1.37 PMid: PMCid: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Hawthorne K, Robles Y, Cannings-John R, Edwards A. Culturally appropriate health education for Type 2 diabetes in ethnic minority groups: a systematic and narrative review of randomised controlled trials. Diabet Med. 2009;(3). 10.1111/j.1464-5491.2009.02954.x [DOI] [PubMed] [Google Scholar]
- 8.Chellan G, Srikumar S, Varma AK, Mangalanandan TS, Sundaram KR, Jayakumar RV, et al. Foot care practice - The key to prevent diabetic foot ulcers in India. Foot [Internet]. 2012;22(4):298-302. 10.1016/j.foot.2012.08.007 PMid: [DOI] [PubMed] [Google Scholar]
- 9.Adiewere P, Gillis RB, Imran Jiwani S, Meal A, Shaw I, Adams GG. A systematic review and meta-analysis of patient education in preventing and reducing the incidence or recurrence of adult diabetes foot ulcers (DFU). Heliyon. 2018;4(5):e00614. 10.1016/j.heliyon.2018.e00614 PMid: PMCid: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Rav-Marathe K, Wan TTH, Marathe S. A Systematic Review on the KAP-O Framework for Diabetes Education and Research. Med Res Arch. 2016;4(1):1-21. [Google Scholar]
- 11.Rahaman KS, Majdzadeh R, Naieni KH, Raza O. Awareness, Attitude and Practices (KAP) regarding chronic complications of diabetes among patients with type 2 diabetes in Dhaka. Int J Endocrinol Metab. 2017;15(3). 10.5812/ijem.12555 PMid: PMCid: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Alshammari ZJ, Alsadi LA, Parameaswari PJ, Alzahrani AA. Attitude and awareness about foot care among diabetic patients in Riyadh, Saudi Arabia. J Fam Med Prim Care. 2019;8(6):2089-94. 10.4103/jfmpc.jfmpc_248_19 PMid: PMCid: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Habbash F, Saeed A, Abbas F, Ajlan BY, Abdulla F, Al-Sayyad AS. Awareness and Practice Regarding Foot Care in Patients with Diabetes Mellitus Attending Diabetic Clinics in Health Centers in the Kingdom of Bahrain. Int J Med Public Heal. 2019;9(4):148-53. 10.5530/ijmedph.2019.4.32 [DOI] [Google Scholar]
- 14.Kulkarni V, Unnikrishnan B, Kumar N, Holla R, Thapar R, Rajasekharan D. Self-care activities among patients with diabetes attending a tertiary care hospital in Mangalore Karnataka, India. Ann Med Health Sci Res. 2015;5(1):59. 10.4103/2141-9248.149791 PMid: PMCid: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.de Sa Policarpo N, Moura JRA, de Melo EB, Junior, de Almeida PC, de Macedo SF, da Sila ARV. Awareness, attitudes and practices for the prevention of diabetic foot. Rev Gaúcha Enferm. 2014;35(3):36-42. 10.1590/1983-1447.2014.03.45187 PMid: [DOI] [PubMed] [Google Scholar]
- 16.Pourkazemi A, Ghanbari A, Khojamli M, Balo H, Hemmati H, Jafaryparvar Z, et al. Diabetic foot care: Awareness and practice. BMC Endocr Disord. 2020;20(1):1-8. 10.1186/s12902-020-0512-y PMid: PMCid: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Muhammad-Lutfi A, Zaraihah M, Anuar-Ramdhan I. Awareness and Practice of Diabetic Foot Care in an In- Patient Setting at a Tertiary Medical Center. Malaysian Orthop J. 2014;8(3):22-6. 10.5704/MOJ.1411.005 PMid: PMCid: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Hasnain S, Sheikh NH. Awareness and practices regarding foot care in diabetic patients visiting diabetic clinic in Jinnah Hospital, Lahore. J Pak Med Assoc. 2009;59(10):687-90. [PubMed] [Google Scholar]
- 19.Khan S, Srivastava A, Junej K, Rani R. Diabetic foot wound care practices among patients visiting a tertiary care hospital in North India. Indian J Community Heal. 2016;28(3):260-8. [Google Scholar]
- 20.Ghannadi S, Amouzegar A, Amiri P, Karbalaeifar R, Tahmasebinejad Z, Kazempour-Ardebili S. Evaluating the Effect of Awareness, Attitude, and Practice on Self-Management in Type 2 Diabetic Patients on Dialysis. J Diabetes Res. 2016;2016. 10.1155/2016/3730875 PMid: PMCid: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.De Berardis G, Pellegrini F, Franciosi M, Di Nardo B, Greenfield S, Kaplan SH. Physician Attitudes Toward Foot Care Education and Foot Examination and Their Correlation With Patient Practice. Diabetes Care. 2004;27(5):286-7. 10.2337/diacare.27.1.286 PMid: [DOI] [PubMed] [Google Scholar]
- 22.A Manual for Medical Personnel, National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke. New Delhi: Ministry of Health and Family Welfare, Government of India; 2018. 5 p. [Google Scholar]
- 23.Devi R, Kapoor B, Singh M. Effectiveness of self-learning module on the awareness and practices regarding foot care among type II diabetes patients in East Delhi, India. Int J Community Med Public Heal. 2016;3(8):2133-41. 10.18203/2394-6040.ijcmph20162559 [DOI] [Google Scholar]