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The impact of focused education on diabetic foot care knowledge among adult type 2 diabetic patients: A hospital-based comparative study
*Corresponding author: Chijioke Stanley Anyigor-ogah, Department of Family Medicine, Alex-ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria. ogahstanly90@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: Agunanne CC, Anyigor-ogah CS, Ozioko IA, Oguejiofor NC, Anyigor-ogah O, Agunanne BC, et al. The impact of focused education on diabetic foot care knowledge among adult type 2 diabetic patients: A hospital-based comparative study. Indian J Med Sci. doi: 10.25259/IJMS_236_2024
Abstract
Objectives:
This study assessed the effect of focused education on diabetic foot care knowledge (DFCK) among adult type 2 diabetic patients.
Materials and Methods:
It is a randomized controlled study which involved 142 type 2 diabetic patients who met the inclusion criteria, whose DFCK were assessed using an interviewer-administered questionnaire. Collected data were grouped and analyzed using the Statistical Package for the Social Sciences software version 22. The effect of focused education and general education on the two arms of the study was examined using the mixed analysis of variance, whereas changes in the mean score of the outcome variables were compared using paired t-test.
Results:
Participants who received focused education improved significantly when compared to the control group on foot-care knowledge (t = 3.08, P = 0.003, effect size = 5.16). The pre-intervention mean standard deviation body mass index (kg/m2) showed a statistically significant difference between the experimental and control group (P = 0.005). Participants had statistically significant glucose control post-intervention (P < 0.001), with statistically significant excellent DFCK in the experimental group compared to the control (P < 0.001).
Conclusion:
Primary care physicians are encouraged to take the center-stage and adopt this cost-effective, easy, and efficient practice of ensuring that patients with type 2 diabetes mellitus are adequately educated on foot care as key component of diabetic care and health promotion aimed to prevent complications which most likely reduces their quality of life.
Keywords
Foot care
Diabetes
Education
Self-efficacy
Knowledge
INTRODUCTION
Untreated diabetes mellitus can cause acute or long-term complications. Serious long-term complications of diabetes mellitus include cardiovascular disease, stroke, chronic kidney disease, damage to the eyes, and diabetic foot.[1] The predicted incidence of diabetes in Africa is 1% in rural areas and ranges from 5% to 7% in urban sub-Saharan Africa.[2] For developing countries, factors related to poverty, literacy and environmental barriers, delays in seeking treatment, and less priority given to foot-care by both patients and health providers had been adduced as major contributing factors that can increase the risk of foot complications.[3]
Studies have showed that diabetic foot disease accounted for increased cases of all diabetic admissions.[4,5] Another study concluded that education may encourage routine foot care but those who are dependent on either formal or informal support to perform foot care do so less frequently.[6,7] Higher level of education and age <65 years old is significantly associated with higher score for previous foot care education.[8] Another study opined that poor knowledge of diabetes is related to age, level of education, satisfaction with the education received, employment status, and household wealth.[9] These findings are similar to studies by Desalu et al. and Alatawi et al. both in methodology and results.[10,11] Bosun-Arije et al. and Kassahun et al. found poor foot self-care knowledge and critical gaps in foot care practice.[12,13] A systematic review by Bonner and colleagues revealed that improving type 2 diabetes foot-related complications would require foot care intervention that includes foot care knowledge and foot care practices.[14]
MATERIALS AND METHODS
Study design
This study was a randomized double blind controlled study.
Sample size
The sample size (n) was calculated thus[15]
Where; n = sample size in each group, Zα = 1.96, standard normal deviate at 95% confidence level, Zβ = 0.84, standard normal deviate at desired power of 80%, P1 taken as 78%, P2 = Control group response, inserting the required information in the formula; n = 57 subjects. Adjusting for attrition, n was 71 per group.
Sampling method
An equal number of computer-generated codes FE and HG were used to group the intervention and control groups, respectively. Participants were randomized into two groups daily by the researcher. Inclusion into this study was adults aged between 18 and 60 years who had been diagnosed to have type 2 diabetes for at least 1 year; all adults with diabetes who met the above criteria and voluntarily agreed to participate in the study; access to a mobile phone by the participant (this was necessary due to the weekly reminders sent to the participants in the experimental group). Exclusion from this study was type 2 adult diabetics with severe medical conditions.
Study instruments
These included an interviewer-administered and semi-structured questionnaire: Revised version of the Summary of Diabetes Self-Care Activities measure, and Diabetic Foot Knowledge Subscale for foot care knowledge.[16] Research assistants were trained to assist with the recruitment and data collection and were made to know the aim and objectives of the research work.
Research protocol
Informed written consent was obtained from the participants. Phase 1 activities were done at first contact. After the initial evaluation, foot care education was provided by the researcher to each patient in the experimental group. Phase 2 activity was purely post intervention with questionnaire administered and measurements taken. None of the participants had the power to choose the group they belonged to. Outcome assessors and the data analyst were kept blinded to the allocation. Subjects’ anthropometry and blood pressure were measured using standard procedure and instruments and the values calculated and recorded. After an overnight fast, the point of care instrument was used to assess the fasting plasma glucose of every participant. Care was taken to ensure the insertion of the correct code key and that all strips had the same batch number.
Data analysis
The data were analyzed using the Statistical Package for the Social Sciences software version 22. Quantitative variables were presented as mean ± standard deviations (SDs), while the qualitative or categorical variables were presented in percentages and proportions. t-test statistics were used to assess for the difference between two likely normally distributed quantitative variables while Chi-square was used for categorical variables. Mann–Whitney U-test was used to find the difference of likely non-parametric quantitative variables between two groups. The significance level was set at <0.05, while the confidence level was set at 98%.
RESULTS
Socio-demographic characteristics of the study participants
There was an overall mean age of 52.09 years. In general, the socio-demographic characteristics of the experimental group and the control group were similar but for the mean age (P = 0.01) and educational status (P = 0.003), as shown in Table 1.
| Variables | Experimental (n=71) | Control (n=71) | Test stat | P-value |
|---|---|---|---|---|
| Mean age in years (SD) | 54.77 (13.09) | 49.40 (11.55) | t=2.58 | 0.01* |
| Gender (%) | ||||
| Male | 29 (40.8) | 38 (53.5) | χ2=3.56 | 0.17 |
| Female | 42 (59.2) | 33 (46.5) | ||
| Marital status (%) | ||||
| Single | 4 (5.6) | 10 (14.1) | χ2=2.28 | 0.32 |
| Married | 49 (69.0) | 46 (64.8) | ||
| Separated/divorced/widowed | 18 (25.4) | 15 (21.1) | ||
| Educational status (%) | ||||
| No formal | 8 (11.3) | 5 (7.0) | χ2=14.14 | 0.003* |
| Primary | 12 (16.9) | 19 (26.8) | ||
| Secondary | 16 (22.5) | 31 (43.7) | ||
| Tertiary | 35 (49.3) | 16 (22.5) | ||
| Social class (%) | ||||
| Upper | 0 (0.0) | 0 (0.0) | χ2=4.37 | 0.11 |
| Middle | 32 (45.1) | 22 (31.0) | ||
| Lower | 39 (54.9) | 49 (69.0) |
NB: SD: Standard deviation, *P-value significant, t: T-test, χ2: Chi square test
Pre-intervention/post-intervention clinical characteristics of the study participants
The pre-intervention mean (SD) body mass index (BMI) (kg/m2) for the experimental and control groups had a statistically significant difference between them (P = 0.005). There existed a statistically significant glycemic control of the participants post-intervention (P < 0.001) [Table 2].
| Clinical variables | Pre-intervention (n=142) | Post-intervention (n=142) | ||||||
|---|---|---|---|---|---|---|---|---|
| Experiment | Control | t-stat | P-value | Experiment | Control | t-stat | P-value | |
| FBG (mg/dL) | ||||||||
| Mean (SD) | 166.96 (94.16) | 163.99 (85.33) | U=2424 | 0.80 | 111.34 (30.04) | 142.09 (43.73) | U=2424 | 0.80 |
| 95% CI | 147.51–192.41 | 143.79–184.18 | 104.23–118.45 | 131.58–152.59 | ||||
| Glycemic control (%) | ||||||||
| Good | 19 (26.8) | 17 (23.9) | χ2=0.06 | 0.81 | 55 (77.50) | 28 (40.0) | χ2=20.4 | <0.001* |
| Poor | 52 (73.2) | 54 (76.1) | 16 (22.5) | 42 (60.0) | ||||
| BMI (kg/m2) | ||||||||
| Mean (SD) | 26.65 (5.06) | 24.29 (4.95) | U=1834.50 | 0.005 | 25.79 (4.57) | 24.88 (4.81) | U=2206 | 0.20 |
| 95% CI | 25.44–27.85 | 23.12–25.47 | 24.71–26.87 | 23.73–26.04 | ||||
| MBI category (%) | ||||||||
| <18 kg/m2 | 3 (4.2) | 8 (11.3) | χ2=5.74 | 0.05 | 6 (8.6) | 7 (10) | χ2=0.79 | 0.85 |
| 18–24.9 kg/m2 | 24 (33.8) | 34 (47.9) | 25 (35.7) | 29 (41.4) | ||||
| ≥25 kg/m2 | 44 (62.0) | 29 (40.8) | 39 (55.7) | 34 (48.2) | ||||
| SBP (mmHg) | ||||||||
| Mean (SD) | 136.38 (24.05) | 134.52 (23.86) | U=2394 | 0.61 | 133.38 (24.05) | 135.52 (23.86) | U=2384 | 0.51 |
| 95% CI | 130.69–142.07 | 128.87–140.17 | 131.69–142.07 | 129.87–140.17 | ||||
| DBP (mmHg) | ||||||||
| Mean (SD) | 79.27 (10.13) | 75.87 (12.91) | U=2059 | 0.05 | 69.27 (10.13) | 70.87 (12.91) | U=2049 | 0.07 |
| 95% CI | 76.86–81.69 | 72.82–78.93 | 76.86–81.69 | 72.82–78.93 | ||||
| RR (c/m) | ||||||||
| Mean (SD) | 17.70 (2.32) | 19.21 (13.11) | U=2451 | 0.89 | 17.48 (1.59) | 17.67 (1.64) | U=2358 | 0.59 |
| 95% CI | 17.15–18.25 | 16.11–22.31 | 17.10–17.86 | 17.27–18.06 | ||||
| Duration of DM (years) | ||||||||
| Mean (SD) | 5.90 (5.83) | 4.77 (3.90) | U=2430 | 0.71 | 5.93 (5.83) | 4.80 (3.86) | U=2440 | 0.74 |
| 95% CI | 4.52–7.28 | 3.85–5.70 | 4.55–7.31 | 3.89–5.72 | ||||
| Mean PR/min | 85.30 (11.61) | 81.63 (11.0%) | t=1.93 | 0.05 | 87.00 (8.03) | 83.41 (8.16) | t=2.73 | 0.007* |
NB: DBP: Diastolic blood pressure, SBP: Systolic blood pressure, RR: Respiratory rate, PR: Pulse rate, CI: Confidence interval, SD: Standard deviation, C/M: Cycles per minutes, FBG: Fasting blood glucose, FBG ≤110 g/dL: Good glycemic control, FBG >110 g/dL: Poor glycemic control, U: Mann–Whitney U-test, *:P-value significant, t: t-test, χ2: Chi-square test, BMI: Body mass index
Comparison of the changes in the outcome variables at pre- and post-focused educational intervention among the experimental and control groups
There were significant changes in the mean diabetic foot care knowledge (DFCK) in the baseline and post-intervention values of the experimental group (P < 0.001) and in the control group (P < 0.001). It is as illustrated in Table 3.
| Variables | Mean (SD) | t-test | P-value |
|---|---|---|---|
| Experimental group | |||
| Post-intervention DFKS | 3.83 (0.90) | −5.16 | <0.001 |
| Pre-intervention DFKS | 3.35 (1.32) | ||
| Control group | |||
| Post-intervention DFKS | 3.61 (1.11) | −4.46 | <0.001 |
| Pre-intervention DFKS | 3.07 (1.28) ss |
NB: DFKS: Diabetic foot knowledge scale, SD: Standard deviation
Comparison of the effect of the intervention on the experimental and control groups on DFCK across intervals of follow-up
The mean difference between the experimental and the control groups was significant at baseline/pre-intervention (P = 0.01) and at post-intervention (P = 0.003) [Table 4].
| Variable | Group | Mean Difference | t-test | P-value | Effect size |
|---|---|---|---|---|---|
| DFCK T0 | Experimental Control | 0.55 | 2.54 | 0.01 | 0.48 |
| DFCK T1 | Experimental Control | 0.45 | 3.08 | 0.003 | 5.16 |
T0: Pre-intervention, T1: Post-intervention, DFCK: Diabetic foot care knowledge
DISCUSSION
Only age and education level had observable statistical significant difference. The statistical significance in age is similar to a work done by Shabani Hamedan et al. who, in their study, found a statistical significance in the age of participants.[17] This might have been due to semi-urban and rural setting nature of the study area, respectively, with a great number of the middle-aged and elderly population. Studies in Ado-Ekiti and Ilorin (both in Nigeria) reported lower mean age while a Malaysian study reported higher mean age.[10,18,19] Racial and cultural differences could have played roles in the above variations. The high level of illiteracy and low socioeconomic status found among many rural and suburban dwellers have contributed to the early age of type 2 diabetes there.[10] Beyond the age of 55 years, the urban prevalence is estimated to be more than twice the rural prevalence.[20] The intervention and the control groups had no significant difference observed between them in marital status (P = 0.32). This similarity may be due to early and intracultural marriage prevalent among the study population. This finding is different from a study by Karimy et al. who had more married participants.[21]
There was a statistical significant difference between the experimental and control group in educational status (P = 0.003) but when this difference was controlled for (using analysis of variance), there was no significance noted. The significance in educational status could be that those who presented to the hospital are majorly the literate ones as those with little education could be in denial of their illness and do not present for expert care. They could also be receiving care from sources other than orthodox care.
There was statistically significant difference in the glycemic control findings among the participants of the experimental and the control group at baseline and post-intervention (P < 0.001). This finding may have been due to improvements in the intervention group participants’ attitude to self-care measures and daily blood glucose monitoring. Highly statistically significant difference existed in the BMI of the participants pre-intervention (P = 0.005). However, after the intervention, no statistical significance difference was found. This result may have been due to improved diet and exercise as practiced by the intervention group following the intervention. This result is similar to a study by Steinsbekk et al.,[22] but differs from another study by Gray et al., who found that moderately elevated BMI is associated with increased risk of foot complications.[23] The duration of diabetes recorded among the participants of the experimental and the control group at baseline and at post-intervention had no significant difference. This finding differs from that of Ko et al., who demonstrated that the longer the duration of diabetes, the more inadequate glycemic control and vice versa.[24]
DFCK improved significantly among participants who received focused education when compared with those who received general education post-intervention (P = 0.003). These findings are consistent with previous reports that have demonstrated significant improvement in DFCK following education.[25,26] A study by Al-Wahbi documented that diabetic foot care education program helped increase patients’ knowledge of diabetes mellitus and reduced the rate of lower limb amputations, unlike before the intervention.[27]
CONCLUSION
The implementation of an education program on diabetic foot care in our outpatient clinics will significantly improve the knowledge and feet self-care in diabetic patients. This educational intervention showed the importance of training in patient’s empowerment and their self-care.
Acknowledgment
We thank the management and its Research and Ethics Committee for the prompt approval, as well as the departmental board and members of Family Medicine Department for the direction provided towards the successful conduct of this research. Special thanks to the respondents who gave their consent and participated very actively in this research.
Availability of data and materials
The sets of data generated and analyzed in this study are available from the corresponding author on reasonable request through the E-mail address of ogahstanly90@yahoo. com or ogahstanly90@gmail.com.
Ethical approval
Ethical approval was obtained from the Hospital Ethical Review and Research Committee (FETHA/REC/VOL.1/2017/625), dated 19th December 2017. This research work complied with the Helsinki Declaration 2013 on human research.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship
Nil.
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