Abstract
About one‐third of admissions to the surgical unit annually are diabetes foot infections in need of amputation In St. Kitts and Nevis. However, the risk factors related to diabetes foot and amputation remain unknown. This study investigated factors associated with diabetic foot and amputation (DFA). Retrospective case control study design, and purposive and quota sampling method was used to recruit the participants. Patients with and without DFA were interviewed at two main hospitals, several primary health centres, and a private doctor's office during July and August 2018. Self‐development questionnaires were applied to assess patients' demographic, physical and behaviour, foot care knowledge, attitudes, and practices related to DFA. Chi‐square, t‐test, and multiple logistic regressions were used to analyse the data. A total of 210 patients were evaluated, 89 had DFA, while 121 did not, with a mean age of 61.10 (SD = 11.85). Participants' responses indicated good knowledge, favourable attitudes, and adequate practices related to foot care. The two items of the questionnaire, ways to maintain blood flow in the lower extremities and wash their feet daily, had significant lower score in DFA group. In multiple logistic regression, knowledge, attitudes, and practices related to foot care were not a significant predictor of DFA. Being male was a predictor of DFA than female (OR = 3.53; 95% CI = 1.65‐7.57; P < .01). Participants who were currently unemployed were less likely to have DFA than those who were employed (OR = 0.38; 95% Cl = 0.17‐0.86; P < .05). Comparing patients with the longest experience of diabetes mellitus (31 years or more) with those who had diabetes for the shortest period of time (between 1 and 10 years) was less likely to have DFA (OR = 0.38; 95% CI = 0.15‐0.97; P = <.05). The combination of these independent variables could explain 29% of the variance in DFA. Based on these findings, strategies to prevent diabetic foot and amputation should focus on male and outdoor heavy worker, and longer duration of diabetes patients which are identified in this study.
Keywords: amputation, attitude, diabetic foot, knowledge, practice
Abbreviations
- CVI
content validation index
- DFA
diabetic foot and amputation
- DM
diabetes mellitus
- KAP
knowledge, attitudes, and practice
- SPSS
statistical package for social sciences
- w/oDFA
without diabetic foot and amputation
- wDFA
with diabetic foot and amputation
1. BACKGROUND
The prevalence of diabetes mellitus (DM) is still increasing year by year, 1 and it is estimated that the number of people with diabetes will increase 1.5 times from 463 million in 2019 to 700 million in 2045. 2 Among diabetic patients, foot problems remain the most frequent cause of hospital admissions. There is a 25% probability that a diabetic patient can develop an ulcer during their lifetime and an 85% probability of all lower limb amputations as a result of foot ulcers in diabetic patients. 3 Complications from diabetic foot compromise patients' health and quality of life and contribute to excess mortality, increasing the physical, psychological, and financial burden of the disease on patients and the community. 4 , 5
Over the last two decades, studies have focused on diabetics' knowledge, attitudes, and practices (KAP) regarding care of their feet with the goals of identifying obstacles to seeking medical care, improving self‐care, and making lifestyle changes. 6 , 7 , 8 , 9 These results establish the correlation and predictive relationship between KAP and diabetic foot. Although some research results are inconsistent, but most of them support a higher level of knowledge and positive attitude toward diabetic foot care, which improve the practice of diabetic foot care. 6 , 9 , 10 The KAP related research could be utilised to change the current situation and develop appropriate designs surrounding interventions of diabetic foot.
Beside the KAP, research also focuses on the correlation between personal features and diabetic foot. The factors such as gender, age, occupation status, and having family history of DM are founded in these studies related to the higher occurrence of diabetic foot. 11 , 12 , 13 , 14 , 15 DM related health maintenance behaviours have been discussed in relation to diabetic foot in previous studies. The behaviour with poor compliance of DM drug, 16 higher frequency of smoking, 17 and drinking alcohol 18 is more likely to develop diabetic foot. The physiological parameters included abnormal body mass index (BMI) 19 , 20 and irregular glycemic level 21 , 22 could make diabetic feet worse.
The increase of DM in the Federation of St. Kitts and Nevis follows same broader trend in the Caribbean and worldwide, affecting an estimated 20% of the population in 2012, 23 about one‐third of admissions to the surgical unit annually are diabetes patients who are receiving treatment or surgical interventions for diabetic foot ulcers such as debridement and amputation. However, it has not yet been determined whether diabetic foot is related to the lower KAP level or related to other factors. Finding out the factors related to diabetes foot is important to improve the quality of diabetes foot care. However, to date, the relationship between KAP and the other risk factors with the diabetes foot remain unknown in St. Kitts and Nevis.
The purpose of the study was to investigate factors associated with and predictive of diabetic foot and amputation, as well as diabetes patients' KAP regarding foot care in St. Kitts and Nevis.
2. METHODS
2.1. Research design
This is a retrospective case control study that compared two groups of diabetes patients: those with diabetic foot and amputation (cases) (wDFA) and those without diabetic foot and amputation (controls) (w/oDFA) to identify factors that indicate risk of diabetic foot and amputation. Purposive and quota sampling was used for this study.
2.2. Study settings and procedures
The interim ethics review committee of the Ministry of health approved the study (IERC‐2018‐07‐016). Data were collected from diabetic patients at multiple health facilities in St Kitts and Nevis, including the two main hospitals, one private doctor's office, and several primary health centres. Once a patient agreed to participate, a one‐on‐one interview using the questionnaire will be given in any private room available in the facility.
2.3. Participants
The target population was diabetic patients who attended diabetes clinics at health centres, who were admitted to the surgical and medical wards of the two hospitals, and patients being followed‐up through the hospitals' outpatient clinics. Participants had to meet the following inclusion criteria: (a) adults over the age of 18 years old; (b) patients diagnosed with DM, with or without diabetic foot and or amputation; and (c) patients who were able to read to answer the questionnaire. Exclusion criteria included: (a) under 18 years of age and (b) patients with foot lesions or amputations unrelated to DM.
2.4. Demographic, physical, and behaviour questionnaire
The demographic questionnaire included gender, age, marital status, educational level, occupational status, family history of DM, and duration since diagnosis. The physical and behaviour questionnaire contains 12 questions, which included information of normal or abnormal of BMI, level and checking time of blood sugar and HbA1c, adherence of DM medication regimens, frequency of smoking and alcohol consumption.
2.5. KAP questionnaire
This study self‐developed a KAP questionnaire with open‐ended and closed questions about diabetic foot. Gopi Chellan and colleages agreed to the adaptation of their instrument. 6 The resulting questionnaire consisted of 10 questions to evaluate participants' foot care knowledge, 5 questions to assess their attitude toward foot care, and 8 questions to assess their foot care practice. The total possible score on the knowledge section was 10 points (≦3 means very poor, 4‐7 means average level, and ≧8 means good). The highest possible score on the attitude section was five points (≦2 means an unfavourable attitude and ≧3 means a favourable attitude). For practice scoring, a result between 0 and 3 revealed poor foot care practice, scores between 4 and 7 indicated average foot care practice, and scores 8 showed good foot care practice. The questionnaire possessed good reliability, with a Kuder–Richardson formula 20 score of 0.70, indicating good internal consistency. The validity of the KAP questionnaire was assessed by two professors of nursing and one medical doctor who specialised in DM. The content validation index (CVI) scores for relevance, importance, and clarity were 100%, 100%, and 100% respectively, which shows the questions were appropriate for the study topic.
2.6. Statistics
The data were analysed using the SPSS version 20. The independent t‐test or chi‐square test were used to compared demographic data and foot care KAP of DM patients wDFA and those w/oDFA. Multiple logistic regression was used to predict diabetic foot and amputation using the independent variables. Using G Power 3.1.2, the required sample size (alpha = 0.05, power = 0.8, effect size = 0.2) was 191. Ten percent of attrition rate was assumed; therefore, the sample size had to be 210.
3. RESULTS
A total of 210 patients was interviewed and two people refused to join the study, therefore, an attrition rate is 0.94%.
Table 1 shows the differences in demographic, physical, and behaviour score between the participants with and without diabetic foot and amputation. There is more of participants (n = 121, 57.6%) who did not have DFA compared to those who did (n = 89, 42.4%). Proportionately, different gender is significant related to with and without diabetic foot and amputation (P = .001). Specifically, men constituted 51.7% (n = 46) of the wDFA group, with women accounting for 48.3% (n = 43). The participants' ages ranged from 26 to 90 years with a mean of 61.10 (SD = 11.85) years. The mean age of the participants with DFA were slightly older than participants without DFA but did not reach the statistics significant difference. Occupational status is the second variable which significantly related to with and without diabetic foot and amputation (P = .004). Nearly three quarters of the participants wDFA and employed (n = 65, 73.0%) which is 46% more than the participants wDFA (n = 24, 27.0%) and unemployed. Duration since diagnosis with DM is the third variable which significantly related to with and without diabetic foot and amputation (P = .045). Compared to the group w/oDFA, patients in wDFA had been diagnosed with DM for longer periods of time: between 11 and 30 years and over 31 years. The other demographic and disease related variables did not differ significantly between the two groups.
TABLE 1.
Comparison of demographic, physical and behaviour of wDFA and w/oDFA
| Group | Total (n = 210), n (%)/M ± SD | wDFA (n = 89), n (%)/M ± SD | w/oDFA (n = 121), n (%)/M ± SD | χ 2 value | P‐value |
|---|---|---|---|---|---|
| Variables | |||||
| Gender | 11.211 | .001** | |||
| Male | 81 (38.6%) | 46 (51.7%) | 35 (28.9%) | ||
| Female | 129 (61.4%) | 43 (48.3%) | 86 (71.1%) | ||
| Age | 0.708 | .400 | |||
| <65 years old | 142 (67.6%) | 63 (70.8%) | 79 (65.3%) | ||
| >65 years old | 68 (32.4%) | 26 (29.2%) | 42 (34.7%) | ||
| Marital Status | 0.159 | .690 | |||
| Single | 126 (60%) | 52 (58.4%) | 74 (61.2%) | ||
| Married | 84 (40.0%) | 37 (41.6%) | 47 (38.8%) | ||
| Education level | 0.034 | .853 | |||
| Up to secondary | 183 (87.1%) | 78 (87.6%) | 105 (86.8%) | ||
| College and above | 27 (12.9%) | 11 (12.4%) | 16 (13.2%) | ||
| Occupational status | 8.112 | .004** | |||
| Employed | 130 (61.9%) | 65 (73%) | 65 (53.7%) | ||
| Unemployed | 80 (38.1%) | 24 (27.0%) | 56 (46.3%) | ||
| Family history of DM | 0.262 | .608 | |||
| No | 19 (9.0%) | 7 (7.9%) | 12 (9.9%) | ||
| Yes | 191 (91.0%) | 82 (92.1%) | 109 (90.1%) | ||
| Duration since diagnosis with DM | 6.199 | .045* | |||
| 1‐10 years | 94 (44.8%) | 31 (34.8%) | 63 (52.1%) | ||
| 11‐30 years | 75 (35.7%) | 38 (42.7%) | 37 (30.6%) | ||
| 31 years and more | 41 (19.5%) | 20 (22.5%) | 21 (17.4%) | ||
| BMI | 0.001 | .981 | |||
| Normal | 45 (21.4%) | 19 (21.3%) | 26 (21.5%) | ||
| Overweight | 165 (78.6%) | 70 (78.7%) | 95 (78.5%) | ||
| Blood sugar checking | 0.296 | .863 | |||
| Daily | 60 (28.6%) | 25 (25.8%) | 35 (28.9%) | ||
| Weekly | 83 (39.5%) | 37 (41.6%) | 46 (38.0%) | ||
| Monthly or more | 67 (31.9%) | 27 (30.3%) | 40 (33.1%) | ||
| Last blood sugar reading | 0.029 | .865 | |||
| 70‐110 mg/dL | 32 (15.2%) | 14 (15.7%) | 18 (14.9%) | ||
| 111 mg/dL and higher | 178 (84.8%) | 75 (84.3%) | 103 (85.1%) | ||
| HbA1c test | 1.270 | .530 | |||
| Every 3 months | 92 (43.8%) | 35 (39.3%) | 57 (47.1%) | ||
| Every 6 months | 77 (36.7%) | 35 (39.3%) | 42 (34.7%) | ||
| Once every year | 41 (19.5%) | 19 (21.3%) | 22 (18.2%) | ||
| HbA1c results | 0.016 | .898 | |||
| <5.7% | 9 (4.3%) | 4 (4.5%) | 5 (4.1%) | ||
| >5.7% | 201 (95.7%) | 85 (95.5%) | 116 (95.9%) | ||
| On DM medication | 2.999 | .083 | |||
| No | 4 (1.9%) | 0 (0.0%) | 4 (3.3%) | ||
| Yes | 206 (98.1%) | 89 (100.0%) | 117 (96.5%) | ||
| Type of medication | 5.542 | .063 | |||
| Tablets | 125 (59.5%) | 47 (52.8%) | 78 (64.5%) | ||
| Insulin | 59 (28.1%) | 33 (37.1%) | 26 (21.5%) | ||
| Both | 22 (10.5%) | 9 (10.1%) | 13 (10.8%) | ||
| Medication regimen | 40.97 | .129 | |||
| Once a day | 60 (28.6%) | 20 (22.5%) | 40 (30.1%) | ||
| Twice a day | 123 (58.5%) | 60 (67.4%) | 63 (52.1%) | ||
| Three times a day | 23 (11.0%) | 9 (10.1%) | 14 (11.6%) | ||
| Missed medication (a week) | 1.869 | .172 | |||
| Nil | 163 (77.6%) | 65 (73.0%) | 98 (81.0%) | ||
| One or more times | 47 (22.4%) | 24 (27.0%) | 23 (19.0%) | ||
| Smokes cigarettes | 1.335 | .248 | |||
| Never smokes | 200 (95.2%) | 83 (93.3%) | 117 (96.7%) | ||
| Used to smoke | 10 (4.8%) | 6 (6.7%) | 4 (3.3%) | ||
| Drinks Alcohol | 0.652 | .420 | |||
| No | 166 (79.0%) | 68 (76.4%) | 98 (81.0%) | ||
| Yes | 44 (21.0%) | 21 (23.6%) | 23 (19.0%) | ||
| Alcohol consumption | 5.151 | .076 | |||
| Daily | 1 (2.3%) | 0 (0%) | 1 (4.3%) | ||
| Weekly | 4 (9.1%) | 0 (0%) | 4 (17.4%) | ||
| Occasionally | 39 (100%) | 21 (53.8%) | 18 (46.2%) |
Note: *P < .05, ** P < .01.
Abbreviations: DM, diabetes mellitus; wDFA, with diabetic foot and or amputation; w/oDFA, without diabetic foot and or amputation.
Table 2 presents the analysis of mean difference of KAP score between two groups. Overall, the mean score of foot care knowledge is 7.31 (SD = 1.85), an average level of knowledge. The total mean score of attitudes is 4.94 (SD = 0.30) and practices is 5.68 (SD = 1.88), which represent a favourable attitude and average level of foot care practice. For those in wDFA, the mean foot care knowledge score was 0.225 lower than the w/oDFA group. The mean score of attitudes in DFA group was 0.021 higher than that in w/o DFA group. The mean score of foot care practice was 0.062 lower in DFA group than w/o DFA group. The mean difference of KAP score are not reaching the statistically significant differences between two groups.
TABLE 2.
Comparison of foot care knowledge, attitudes, and practices between wDFA and w/oDFA
| Group | Total (n = 210), Mean (SD) | wDFA (n = 89), Mean (SD) | w/oDFA (n = 121), Mean (SD) | Mean difference | t‐value | P‐value |
|---|---|---|---|---|---|---|
| Variables | ||||||
| Knowledge | 7.31 (1.852) | 7.18 (1.742) | 7.40 (1.930) | −0.225 | −0.870 | .385 |
| Attitudes | 4.94 (0.304) | 4.96 (0.257) | 4.93 (0.335) | 0.021 | 0.498 | .619 |
| Practices | 5.68 (1.877) | 5.64 (2.018) | 5.70 (1.773) | −0.062 | −0.236 | .814 |
Abbreviations: wDFA, with diabetic foot and or amputation; w/oDFA, without diabetic foot and or amputation.
Further analysis was done to determine if there were statistically significant differences between responses of participants wDFA and w/oDFA to each question on the KAP questionnaire (Table 3). For the first question of knowledge, “True that all patients with DM develop reduced blood flow in their feet?,” 50.6% (n = 45) of the participants in wDFA group answer incorrectly which is significantly higher than 31.4% (n = 38) in the w/o DFA group (P = .005). Comparing specific items on the attitude questionnaire identified no statistically significant difference between the two groups. For foot care practices, only responses to the first question, “Do you wash your feet daily?” showed a significant difference between the two groups. Of participants in wDFA, 91% (n = 81) said they did wash feet daily which is 7.3% significantly less (P = .014) than those in the w/o DFA group (Table 4).
TABLE 3.
Comparison of foot care knowledge items between wDFA and w/oDFA
| Items | Knowledge questions | Total (n = 210), N (%) | wDFA (n = 89), n (%) | w/oDFA (n = 121), n (%) | χ 2 value | P‐value |
|---|---|---|---|---|---|---|
| Q1 | True that all patients with DM develop reduced blood flow in their feet? | 7.873 | .005* | |||
| Yes | 83 (39.5%) | 45 (50.6%) | 38 (31.4%) | |||
| No a | 127 (60.5%) | 44 (49.4%) | 83 (68.6%) | |||
| Q2 | True that all patients with DM develop lack of sensation in their feet? | 1.796 | .180 | |||
| Yes | 81 (38.6%) | 39 (43.8%) | 42 (34.7%) | |||
| No a | 129 (61.4%) | 50 (56.2%) | 79 (65.3%) | |||
| Q3 | True that all DM patients develop foot ulcers? | 2.974 | .085 | |||
| Yes | 32 (15.2%) | 18 (20.2%) | 14 (11.6%) | |||
| No a | 178 (84.8%) | 71 (79.8%) | 107 (88.4%) | |||
| Q4 | True that all DM patients develop gangrene? | 0.011 | .917 | |||
| Yes | 17 (8.1%) | 7 (7.9%) | 10 (8.3%) | |||
| No a | 193 (91.9%) | 82 (92.1%) | 111 (91.7%) | |||
| Q5 | Were you given any information regarding foot care? | 2.645 | .104 | |||
| Yes a | 171 (81.4%) | 77 (86.5%) | 94 (77.7%) | |||
| No | 39 (18.6%) | 12 (13.5%) | 27 (22.3%) | |||
| Q6 | Can smoking reduce blood flow to feet? | 0.275 | .600 | |||
| Yes a | 90 (42.9%) | 40 (44.9%) | 50 (41.3%) | |||
| No | 120 (57.1%) | 49 (55.1%) | 71 (58.7%) | |||
| Q7 | Can loss of sensation to your foot make you more prone to foot ulcers? | 2.303 | .129 | |||
| Yes a | 164 (78.1%) | 74 (83.1%) | 90 (74.4%) | |||
| No | 46 (21.9%) | 15 (16.9%) | 31 (25.6%) | |||
| Q8 | Can reduced blood flow to your foot make you more prone to foot ulcers? | 0.006 | .939 | |||
| Yes a | 161 (76.7%) | 68 (76.4%) | 93 (76.9%) | |||
| No | 49 (23.3%) | 21 (23.6%) | 28 (23.1%) | |||
| Q9 | If you have a foot infection, will you develop a foot wound? | 0.030 | .369 | |||
| Yes a | 185 (88.1%) | 78 (87.6%) | 107 (88.4%) | |||
| No | 25 (11.9%) | 11 (12.4%) | 14 (11.6%) | |||
| Q10 | Which is the appropriate way of trimming toe nails? 1. Cutting along the edge or 2. Cutting straight through | 0.806 | .369 | |||
| 1 | 73 (34.8%) | 34 (38.2%) | 39 (32.2%) | |||
| 2 a | 137 (65.2%) | 55 (61.8%) | 82 (67.8%) |
Abbreviations: DM, diabetes mellitus; wDFA, with diabetic foot and or amputation; w/oDFA, without diabetic foot and or amputation.
Note: *P < .01.
Correct answer.
TABLE 4.
Comparison of foot care practice items between wDFA and w/oDFA
| Items | Practice items | Total (n = 210), N (%) | wDFA (n = 89), n (%) | w/oDFA (n = 121), n (%) | χ 2 value | P‐value |
|---|---|---|---|---|---|---|
| Q1 | Do you wash your feet daily? | 6.085 | .014* | |||
| Yes a | 200 (95.2%) | 81 (91.0%) | 119 (98.3%) | |||
| No | 10 (4.8%) | 8 (9.0%) | 2 (1.7%) | |||
| Q2 | Do you moisturise dry areas of your feet daily? | 1.905 | .168 | |||
| Yes a | 152 (72.4%) | 60 (67.4%) | 92 (76.0%) | |||
| No | 58 (27.6%) | 29 (32.6%) | 29 (24.0%) | |||
| Q3 | Do you check your feet daily for any injury? | 1.997 | .158 | |||
| Yes a | 150 (71.4%) | 59 (66.3%) | 91 (75.2%) | |||
| No | 60 (28.6%) | 30 (33.7%) | 30 (24.8%) | |||
| Q4 | What would you do if you find an abnormality on your feet? | 0.034 | .853 | |||
| Manage it yourself | 18 (8.6%) | 8 (9.0%) | 10 (8.3%) | |||
| Consult doctor/nurse a | 192 (91.4%) | 81 (91.0%) | 111 (91.7%) | |||
| Q5 | Are your toenails cut straight through regularly? | 1.105 | .293 | |||
| Yes a | 155 (73.8%) | 69 (77.5%) | 86 (71.1%) | |||
| No | 55 (26.2%) | 20 (22.5%) | 35 (28.9%) | |||
| Q6 | Do you check if your shoes/socks leave marks on your feet? | 0.052 | .819 | |||
| Yes a | 135 (64.3%) | 58 (65.2%) | 77 (63.6%) | |||
| No | 75 (75.0%) | 31 (34.8%) | 44 (36.4%) | |||
| Q7 | How often do you change your footwear? | 2.733 | .255 | |||
| When slippers are damaged | 116 (44.3%) | 44 (49.4%) | 72 (59.9%) | |||
| Once in a year a | 42 (20.0%) | 22 (24.7%) | 20 (16.5%) | |||
| More than once in a year | 52 (23.1%) | 23 (25.8%) | 29 (24.0%) | |||
| Q8 | How often do you go for foot check ups? | 4.417 | .220 | |||
| Once a month a | 62 (29.5%) | 25 (28.1%) | 37 (30.6%) | |||
| Once in 6 months | 57 (24.2%) | 24 (27.0%) | 33 (27.3%) | |||
| Once in a year | 12 (2.1%) | 2 (2.2%) | 10 (8.3%) | |||
| Only when ill | 79 (38.2%) | 38 (42.7%) | 41 (33.9%) |
Abbreviations: wDFA, with diabetic foot and or amputation; w/oDFA, without diabetic foot and or amputation.
Note: *P < .05.
More appropriate practice.
Table 5 present the analysis results of multiple logistic regression. Thirteen of the major independent predictors and foot care KAP were entered together to determine which factors might significantly predict diabetic foot and amputation. Three variables were statistically significant. The first was gender: being male was a predictor of DFA than female (OR = 3.53; 95% CI = 1.65‐7.57; P = <.01). In occupational status, patients who were currently unemployed were less likely to have DFA than those who were employed (OR = 0.38; 95% Cl = 0.17‐0.86; P = <.05). Being currently employed was the second variable that proved to be a significant predictor of DFA. Compared to patients with the longest experience of DM (31 years or more), those who had diabetes for the shortest period of time (between 1 and 10 years) were less likely to have DFA (OR = 0.38; 95% CI = 0.15‐0.99; P = <.05). However, the incremental chi square statistic is not a significant critical value in foot care KAP as a predictor of DFA participants in this analysis. The combination of these independent variables could explain 29% of the variance in DFA.
TABLE 5.
Multiple logistic regression predicting wDFA and w/oDFA (n = 210)
| Variables | B (SE) | OR | 95% CI | R2 |
|---|---|---|---|---|
| Gender: male vs female | 1.26 (0.39) | 3.53** | 1.65‐7.57 | |
| Age: >65 y/o vs <65 y/o | 0.19 (0.44) | 1.20 | 0.51‐2.85 | |
| Marital status: single vs married | −.04 (0.35) | 0.95 | 0.48‐1.91 | |
| Education: up to high school vs college and over | 0.31 (0.55) | 1.38 | 0.46‐4.03 | |
| Occupational status | ||||
| Not employed vs Employed | −0.96 (0.41) | 0.38* | 0.17‐0.86 | |
| Duration since DM diagnosis | ||||
| 31 years or more | Ref. | |||
| 1‐10 years | −0.97 (0.48) | 0.38* | 0.15‐0.97 | |
| 11‐30 years | −0.21 (0.47) | 0.81 | 0.32‐2.04 | |
| BMI: normal vs overweight | −0.33 (0.45) | 0.72 | 0.30‐1.73 | |
| Blood sugar checking | ||||
| Daily | Ref. | |||
| Weekly | 0.23 (0.43) | 1.26 | 0.54‐2.94 | |
| Monthly or longer | −0.24 (0.48) | 0.78 | 0.31‐2.01 | |
| HbA1c test | ||||
| Every 3 months | Ref. | |||
| Every 6 months | 0.51 (0.38) | 1.67 | 0.79‐3.51 | |
| Once every year | 0.14 (0.49) | 1.15 | 0.44‐3.00 | |
| HbA1c result: > 5.7% vs < 5.7% | 0.02 (0.87) | 1.02 | 0.19‐5.56 | |
| Medication regimen | ||||
| Once a day | ||||
| Twice a day | 0.78 (0.43) | 2.19 | 0.95‐5.07 | |
| Three times a day | 0.51 (0.64) | 1.66 | 0.48‐5.77 | |
| Missed medication | ||||
| Once or more vs Nil | 0.31 (0.43) | 1.36 | 0.59‐3.13 | |
| Drinks alcohol: yes vs no | −0.01 (0.45) | 0.99 | 0.41‐2.40 | |
| Foot care knowledge | ||||
| Good knowledge | Ref. | |||
| Poor knowledge | 0.60 (1.18) | 1.83 | 0.18‐18.39 | |
| Average knowledge | 0.57 (1.54) | 1.77 | 0.09‐36.56 | |
| Foot care practice | ||||
| Good practice | Ref. | |||
| Poor practice | 1.19 (0.82) | 3.29 | 0.66‐16.36 | |
| Average practice | 1.97 (1.35) | 7.16 | 0.51‐101.38 | |
| Foot care attitude | 0.18 (0.60) | 1.20 | 0.37‐3.90 | |
| Nagelkerke R2 | 0.286 |
Note: *P < .05, **P < .01.
Abbreviations: OR = odds ratio; CI = confidence interval.
4. DISCUSSION
The major finding of the study was that gender, occupational status, and duration of DM associated with DFA in St. Kitts and Nevis. Overall, the KAP questionnaire revealed that participants had average level of food care knowledge, favourable attitudes, and average level of foot care practice. In multiple logistic regression, foot care KAP were not a significant predictor of DFA.
In this study, males were more likely to have diabetic foot and amputation than females, echoing previous research findings in Saudi Arabia. 5 The possible reason is that men generally carry more weight, which puts pressure on their feet; they experience decreased joint movement in their feet, and may wear ill‐fitting shoes. The type of workmen including construction worker, carpenter, and electrician do in St. Kitts and Nevis may require standing for long periods at a time which increase pressure on their feet. A study on predictors of diabetic foot and leg ulcers in another developing country, Sri Lanka, likewise found that men had a higher prevalence of DM than women and were at greater risk of injury related to the type of jobs they had compared to females. 24 Women in St. Kitts and Nevis are more likely to have office jobs, which put less stress on their feet and do not require long periods of standing, and take more pride in caring for their feet.
A report showed that patients who were working were more likely to develop DFA than those who were not employed in Iran likewise 17 which is similar with our result that occupational status was a statistically significant predictor of DFA. The possible reason included having busy schedules that allow less time and attention for proper DM self‐care, including foot care. Also, in St. Kitts and Nevis, work hours often conflict with the clinic hours at primary care health centres and private doctors' offices, making it more difficult for working people to receive adequate preventive care, including regular blood sugar testing and information about how self‐care can prevent complications. Moreover, because of the inadequate medical resources and clinics limited to daytime hours, health workers at hospitals in St. Kitts and Nevis have less time for patient counselling.
DM foot requires long‐term monitoring and care. Numerous studies have found that the longer the time since diagnosis with DM, the more likely that patients suffer peripheral damage to the lower extremities; 22 , 25 , 26 same result was founded in our research result.
The study of Al‐Hariri et al has similarly found good knowledge about foot care among diabetes patients. 10 The possible reason why patients with DFA scored average level of foot care knowledge may be related to duration of DM; participants who have had DM longer would have received educational sessions on proper foot care many times. This suggests that patients' knowledge about foot care should be collected at the time that diabetic diagnosis, rather than afterward, when the patients have already received education about proper foot care. Our result in knowledge score suggests, further patient education for preventing DM foot should include ways to maintain blood flow in the lower extremities, for instance, avoiding standing or sitting for a long time, getting proper exercise, and promoting blood circulation through isometric muscle contraction exercises. 27
Both groups in this study showed favourable attitudes about taking care of their feet and there was no significant difference in attitudes between them. Chellan et al obtained similar results in India. 6 In this study, there was a slightly higher mean score for the group with DFA. Participants with DFA could be more attentive to self‐care to prevent further problems. This could be a form of coping, in other words, fear about the possibility of reoccurrence of diabetic foot or amputations that they decide to attend for their feet to minimise the significance of the threat. 28
Overall, the foot care practice of participants in this study was adequate which is congruent with findings of studies in other developing countries. A study done in Southern India 29 likewise found that 67% of all participants had good practice scores on foot care. One likely reason is that, in our study, most of the participants had had DM for over 10 years. A study in china suggested that the longer the patients have the disease, the more they become responsible for self‐care and focus on their feet. 30 However, our result reveal that people with DFA had lower score in washing their feet daily than w/o DFA group. The possible reason could be the constrained movements due to DFA. Moreover, almost four out of five of the diabetics in this study were overweight. It could be a barrier for them to look down and keep the balance to wash their feet. More care aid, such as soft sponge with extended handle, could be applied to wash the foot easily.
The study was conducted on St. Kitts and Nevis, two small islands that form a single nation in the Caribbean. The findings cannot be generalised to other countries due to the small size of the sample size. Participants were recruited from multiple health facilities. Due to the limitation of research funding, only one researcher conducted the data collection. It was difficult to collect data from all 17 health centres which had diabetes clinics at fixed times that often overlapped. Partly because of sampling difficulties, the two groups were unequal in size—diabetic participants without DFA significantly outnumbered those with DFA—a fact which could have biased the findings of the study. Moreover, to meet social expectations, subjects may present positive, acceptable knowledge, attitudes, and behaviours in ways that affect the authenticity of the results.
The research results can be generalised in small developing countries and be applied through the following methods. First, the manpower and diabetic education training of community health care workers should be increased to provide knowledge, attitude assessment, and foot care behaviour observation for patients with newly diagnosed diabetes. Mobile healthcare can be delivered to work environment to provide individualised and continuous diabetic foot prevention education and practice.
Since the primary health caregivers start to pay attention to the diabetic foot issue of male, heavy‐duty worker, and long‐term diagnosed with diabetes in St. Kitts and Nevis, a research question is aroused to guide the next research: whether the prevention and treatment measures for diabetes foot targeting male and outdoor heavy worker can effectively prevent the occurrence or improve the progress of diabetes foot and amputation? To improve the authenticity of risk factor collection of diabetes foot, we suggest direct and cohort observation to determine patients' actual foot care behaviour, as opposed to relying on a questionnaire, since there could be respondent bias—a desire to give expected answers, true or not. Also, to obtain a clearer understanding as to why patients develop diabetic foot problems, their foot care practices should be documented at the time their diabetic foot and amputation occur, rather than afterwards when they have been taught the proper ways to care for their feet.
5. CONCLUSION
This research comparing foot care KAP among diabetes patients with and without diabetic foot and amputation provides information in St. Kitts and Nevis that can be used to improve outcomes and as a foundation for future research. In this study, participants had average level of foot care knowledge and practices, and favourable attitudes. However, there were specific areas of knowledge and practices that could be improved by raising patients' awareness about lower limb circulation and performing better foot cleaning. Moreover, three variables—gender, occupational status, and duration of disease—varied significantly between the patients with and without diabetic foot and amputation. A need remains for future research that applies cohort observation at the onset of diabetes foot to better understand factors that explain why some patients end up having diabetic foot or amputations.
CONFLICT OF INTEREST
The authors declare no conflicts of interest.
ACKNOWLEDGEMENTS
The researchers would like to thank the health care facilities and their staff for their kind cooperation and guidance throughout the 2 months of data collection. We also wish to thank the participants who so willingly participated in the study. Thank Guan‐Ting Liu for helping organise a small part of the introduction section.
Hanley G, Chiou P‐Y, Liu C‐Y, Chen H‐M, Pfeiffer S. Foot care knowledge, attitudes and practices among patients with diabetic foot and amputation in St. Kitts and Nevis. Int Wound J. 2020;17:1142–1152. 10.1111/iwj.13446
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