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Original Research (Original Article) 


Tariq Chundrigar et al, 2019;3(10):017–022.

International Journal of Medicine in Developing Countries

Diabetic foot care knowledge among Taif University students in Saudi Arabia

Tariq Chundrigar1, Eman Mohy Ibrahim Youssef2, Hadeel Sameer Ashour2*, Marwah Hassan Turkistani, Shams Abdullah Aldosari2, Tahani Mathna Altaifi2, Atheer Musaad S. Altalhi

Correspondence to: Hadeel Sameer Ashour

*Taif University, Taif, Saudi Arabia.

Email: hadeel un [at] hotmail.com

Full list of author information is available at the end of the article.

Received: 17 May 2019 | Accepted: 01 June 2019


ABSTRACT

Background:

Diabetic foot (DF) complications are one of the major global public health problems of concern. Although, amputation rates vary around the world are always observed to be increased in people with diabetes compared to those without diabetes. The global health-care systems, both public and private, have been unsuccessful in managing the overwhelming problems of patients suffering from DF complications. Correct practices of foot health care are essential for reducing the incidence of foot ulcers and complication. The aim of this study was to assess the knowledge of DF care to determine the need to educate the community about DF care.


Methodology:

A cross-sectional study was conducted among Taif university students, Saudi Arabia using a multi-point questionnaire about DF care knowledge.


Results:

A total of 473 Taif university students had participated in this study; 60 were from medical college. Among the total, 194 had poor knowledge. We determined the influence of demographic factors on the knowledge score; it was significant with the students who had a diabetic parent/s (mean =9.78 ± 3.89, p-value =0.000), female gender and among medical college students (mean = 9.45 ± 3.70, 10.62 ± 4.15, p-value =0.002).


Conclusion:

The result of this study showed the gap in knowledge of DF care, more importantly among medical students who would be the providers of knowledge in the near future. We recommend implementing educational programs and community awareness campaigns on DF care inside and outside the university campus.


Keywords:

Knowledge, diabetic foot care, university students, ulcer, amputation.


Introduction

Globally, diabetic foot (DF) complications remain major medical, a social and economic crisis that is majorly experienced by diabetic patients. Diabetes remains a major cause of non-traumatic amputation across the world with rates being as much as 15 times higher than in the non-diabetic population. The incidence of DF has increased due to the worldwide prevalence of diabetes mellitus and the prolonged life expectancy of diabetic patients [1]. A DF is a foot that exhibits any pathology that results directly from diabetes mellitus or any longterm complication of diabetes mellitus [2]. Presence of several characteristic DF pathologies, such as infection, DF ulcer, and neuropathic osteoarthropathy is called DF syndrome. Due to the peripheral nerve dysfunction associated with diabetes (diabetic neuropathy), patients have a reduced ability to feel pain. This means that minor injuries may remain undiscovered for a long while. People with diabetes are at risk of developing a DF ulcer [3]. Ulceration does not occur spontaneously; rather, it is the combination of causative factors that result in the development of a lesion. There are many warning signs that can identify those at risk before the occurrence of an ulcer. The breakdown of the DF traditionally has been considered to result from an interaction of peripheral vascular disease, peripheral neuropathy, and some form of trauma. It is the combination of two or more risk factors that ultimately result in DF ulceration [4]. The most common causes are neuropathy, deformity, and trauma. Edema and ischemia were also studied as common component causes. In addition, ulceration could be also caused due to loss of sensation and mechanical trauma, such as standing on a nail, wearing shoes that are too small, or neuropathy and thermal trauma (e.g., walking on hot surfaces or burning feet in the bath); finally, neuropathy and chemical trauma may result in ulceration from the inappropriate use. For a successful change in reducing the high incidence of foot ulcers and ultimately amputation, a thorough understanding of the pathways that result in the development of an ulcer is increasingly important [5]. Evaluating diabetic patients for foot complication is usually done in a primary care setting with a brief history, the Semmes–Weinstein monofilament examination, measuring foot pressure, assessing vascularity with Doppler ultrasound, and anklebrachial blood pressure index [6]. Patients with high risk for developing a foot ulcer and other DF complication lack the knowledge and skills to provide an appropriate foot self-care [712.]. Patients need to be informed of the risk of having insensate feet, the need for regular self-inspection, foot hygiene, and chiropody/podiatry treatment as required [12], and they must be told what action to take in the event of an injury or the discovery of a foot ulcer. Patients also, often have distorted beliefs about neuropathy, thinking that this is a circulatory problem and link neuropathy directly to amputation. Thus, an education program that focuses on reducing foot ulcers will be doomed to failure if patients do not believe that foot ulcers precede amputations [13]. It is clear that much work is required in this area if appropriate education is to succeed in reducing foot ulcers and subsequently amputations. In summary, foot care education is believed to be crucial in the prevention of ulceration and other DF complications [14] although there is little support for this from randomized controlled trials. Further studies in this area are, therefore, urgently required [15].


Subjects and Methods

A cross-sectional study was conducted among 473 Taif university students, Saudi Arabia for a duration of 7 months from 20 September-2018 to 20 April-2019. Responses were obtained by using a questionnaire that was prepared and distributed in Arabic via Google form to all the study participants. The study employed socialmedia for questionnaire distribution. It consisted of two parts; the first one was about the demographic data of the participants, the second part involved 16 questions on knowledge of foot care, each answer with yes was assigned one point, no and I don't know was assigned zero points. The knowledge score was calculated for each participant by summation of all the points. The knowledge score was classified as good if the score was more than 12, acceptable if the score was between 8 and 12 and poor if the score was less than 8. Ethical approval for the current study was obtained from the Research Ethics Committee at Taif University, Taif, Saudi Arabia and was performed after obtaining informed consent from all participating in the study. Data were collected, revised, coded, and entered to the statistical package for social science (SPSS) version 21. Descriptive analysis was performed on all data. The significant associations between demographic data and knowledge score were analyzed by Kruskal–Wallis Test and Mann–Whitney Test. The p-value was considered insignificant at the level of >0.05, significant at the level of <0.05, and highly significant at the level of <0.01.


Results

Table 1 represents information about the study participants. A total of 473 subjects were included in this study [143 males (30.2%) and 330 females (69.8%)]. Among the total, 374 (77%) were between the age of 18–21. A total of 218 (46.1%) were from scientific colleges. The rest of the students' characteristics are shown in Table 1.

The mean knowledge score was 9.03 ± 3.99. The minimum score was 0, and the maximum was 16. A total of 407 subjects (86%) were aware of the importance of consulting a doctor when a diabetic patient has redness, blisters, cuts, or wound on their feet, 391 (82.7%) students think diabetic patients should wear comfortable shoes even though 382 (80.8%) of them had never read any handouts on proper footwear for diabetic patient, while 377 (79%) had never read any handouts on DF care. The distribution of the responses to questions related to DF care knowledge shown in Table 2.

Table 1. Demographic data of the students (n = 473).

Characteristics Frequency (%)
Age group
18–21 364 (77)
22–25 80 (16.9)
More than 25 29 (6.1)
Gender
Male 143 (30.2)
Female 330 (69.8)
College
Scientific college 218 (46.1)
Literature college 195 (41.2)
Medical college 60 (12.7)
Living area
City 429 (90.7)
Village 44 (9.3)
Diabetic patient
Yes 14 (3)
No 459 (97)
Diabetic parent/s
Yes 209 (44.2)
No 264 (55.8)
Diabetic sibling/s
Yes 27 (5.7)
No 446 (94.3)
Participate in the community's awareness of DF care
Yes 70 (14.8)
No 403 (85.2)

Knowledge score classification of this study showed that 90 (19%) of the students had good knowledge about the DF care, 189 (40%) had an acceptable knowledge, and 194 (41%) had poor knowledge. The Knowledge score classification is shown in Figure 1.

To determine the influence of demographic factors on the knowledge score of DF care, the categorical variables were tested with the Kruskal–Wallis and Mann–Whitney Test, to compare the mean of the score. An acceptable knowledge score was highly significant with the students who had participated in community's awareness of DF care (mean = 11.11 ±3.91, p-value = 0.000), and students who had diabetic parent's (mean = 9.78 ± 3.89, p-value = 0.000). While less significant influence was seen in the age group of 22–25 years (mean = 10.31 ±4.21, p-value = 0.002), the female gender (mean = 9.45 ± 3.70, p-value = 0.002), and medical college students (mean = 10.62 ± 4.15, p-value = 0.002). The rest of the results are shown in Table 3.


Discussion

The mortality rate of diabetic patients with DF complications was higher when compared with diabetic patients without foot complications [16]. Patient’s lack of knowledge about DF risk factors and their poor practice of foot care both reflected the need for proper educational programs, which should be mandatory for those patients [17]. In this study, the mean knowledge score was 9.03 ± 3.99 out of 16. About 194 (41%) which is almost half of the students had poor knowledge. This was consistent with the results from several other studies which used [7,9,11,18,19], a similar study design. However, these studies mainly assessed the knowledge among patients themselves. The poor knowledge scores could be attributed to the lack of students' interest and awareness regarding the importance and prevalence of such complications. The other half of the students in our study had acceptable knowledge, and only 19% had good knowledge. While viewing other studies which were done, we noticed converse results. These studies were also done on diabetic patients [20,21]. Some showed good knowledge with only poor knowledge in certain aspects. Still, the overall knowledge was high. This can be explained by looking at the educational level of the participants and the strength of the educational healthcare program, self-reading, and media were also one of the sources for information regarding that topic. The participants in this study were university students (n = 473). The non-diabetic patients were 459. The majorities of the participants have never contributed to the community's awareness of DF care and have never read any handouts or brochures talking about foot care and proper footwear; these were 403 and 382, respectively. This explains how poor the knowledge they have regarding DF complications and care is. Out of 473 types of research subject, the majority were females and belonged to the age group of 18–21 years. Comparing with other studies, we had younger participants. These studies assessed the knowledge of patients themselves [7,9,11,18,19], this explains the huge difference of the age in our research when compared to others. Regarding the knowledge score, there is a statistically significant acceptable knowledge score among the age group of 22– 25 years (mean =10.31 ± 4.21, p-value =0.002). While in other studies, the knowledge score of the same age group was insignificant [7,9]. Again, this is because other studies were done on diabetic patients. About 330 (69.8%) of our participants were females. Our study showed that we had significant acceptable knowledge score among female students (mean = 9.45 ± 3.70, p-value =0.002), while other studies showed insignificant results [7,9,11,18,19]. The number of our female participants and the level of their education explain our study findings. The mean knowledge scores among medical students were higher when compared to the students from other colleges, with a significant association (p-value = 0.002). This could be because, they received lectures regarding the study topic and most of them have also participated in community awareness campaigns. There was no significant association between the knowledge score and the living area (p-value = 0.944). On the other hand, a crosssectional study which was conducted among diabetic patients attending a rural secondary care hospital, showed significant poor knowledge scores with male participants, lower level of education, and lesser duration of diabetes [21]. In this study, most of the participants live in the city 429 (90.7%), while 44 (9.3%) live in nearby villages; the huge difference could be the cause of the inaccurate result. There are no literature reviews that compare the knowledge score according to the living area. Since this research was conducted on University students, in the questionnaire, we asked about whether the student had diabetes or not. We wanted to assess the difference in knowledge comparing them together. The result showed that 459 of the precipitants were non-diabetic patients with mean knowledge score of (8.99 ± 3.96), the remaining 14 were diabetic patients with the mean knowledge score of (10.21 ± 4.8), there is no significant association (p-value = 0.263). The other studies did not compare the knowledge of DF care in the diabetic and non-diabetic among their study subjects. So, there are no literature reviews to support this result. The result showed a significant high knowledge score (9.78 ± 3.89) with the students who had a diabetic parent/s (p-value = 0.000). In the age group 22–25 years, students spent time at their parents' homes, helping them with the care of their diabetes. This would explain their heightened level of knowledge about DF issues. The mean knowledge score of the students who had a diabetic sibling/s was (10.59 ± 3.1), while it was (8.93 ± 4.02) for those who didn't. There was no significant association (p-value = 0.065); there was no literature review to compare the result. The result was highly significant with the students who had previously participated in the community's awareness of DF care; their mean knowledge score was (11.11 ± 3.1, p-value = 0.000). They had better knowledge when compared to those who did not. In a study of 80 diabetic patients with a mean average age of (53.53 ± 10.19), there was a significant increase in foot self-care through education, the baseline knowledge score was (27.06 ± 8.77), and post-education was (43.12 ± 8.77, p = 0.0001). After education, the result showed that foot and nail lesions improved in 84% and 62.8%, respectively [22]. While an intervention study conducted in Jordan showed that using mobile phone text messaging was an effective method of improving DF knowledge and self-care [23]. The study team found difficulties in comparing the results as there is no similar study conducted on non-diabetic populations.

Table 2. Distribution of the responses to questions related to DF care knowledge.

Questions related to DF care knowledge Correct (%) Wrong (%)
Do you think a diabetic patient should inspect Sole of feet daily? 200 (42.3) 273 (57.7)
Do you think the diabetic patient should wash their feet daily? 308 (65.1) 165 (34.9)
Do you think the diabetic patient should use Lukewarm water to wash feet? 178 (37.6) 295 (62.4)
Do you think the diabetic patient should dry the feet and between toes completely after washing? 263 (55.6) 210 (44.4)
Do you think the diabetic patient should apply Lotions or moisturizing cream on the feet to prevent dryness of the skin? 318 (67.2) 155 (32.8)
Do you think the diabetic patient should apply Lotions between the toes? 218 (46.1) 255 (53.9)
Do you think the diabetic patient should change their Socks daily? 302 (63.8) 171 (36.2)
Do you think the diabetic patient should trim Toenail carefully and straight across? 347 (73.4) 126 (26.6)
Do you think the diabetic patient should wear comfortable shoes? 391 (82.7) 82 (17.3)
Do you think the diabetic patient should inspect the inside of the shoes before wearing them? 305 (64.5) 168 (35.5)
Do you think the diabetic patient should not walk barefoot? 327 (69.1) 146 (30.9)
In cold weather, do you think the diabetic patient should not put their feet on a radiator or use hot compressors? 162 (34.2) 311 (65.8)
Do you think the diabetic patient should consult a doctor if their feet have redness, blisters, cuts or wound? 407 (86.0) 66 (14.0)
Do you think the diabetic patient should follow up at DF clinic regularly? 356 (75.3) 117 (24.7)
Have you ever read any handouts on foot care? 96 (20.3) 377 (79.7)
Have you ever read any handouts on proper footwear? 91 (19.2) 382 (80.8)

%Wrong: false and don't know.

Figure 1. Knowledge score classification.

Table 3. Influence of demographic factors on the knowledge score.

Demographic factor Knowledge score Mean ± SD p–value
Age group
18–21 8.71 ± 3.82
22–25 10.31 ± 4.21 0.002
More than 25 9.45 ± 8.81
Gender
Male 8.13 ± 4.48 0.002
Female 9.42 ± 3.70
College
Scientific college 8.75 ± 3.86 0.002
Literature college 8.84 ± 3.99
Medical college 10.62 ± 4.15
Living area
City 9.05 ± 3.97 0.944
Village 8.82 ± 4.21
Diabetic patient
Yes 10.21 ± 4.8 0.263
No 8.99 ± 3.96
Diabetic parent/s
Yes 9.78 ± 3.89 0.000
No 8.42 ± 3.97
Diabetic sibling/s
Yes 10.59 ± 3.1 0.065
No 8.93 ± 4.02
Participate in the community's awareness of DF care
Yes 11.11 ± 3.91 0.000
No 8.66 ± 3.9

Conclusion

In conclusion, the result of this study showed the gap in knowledge of DF care, more importantly among medical students who would be the providers of knowledge shortly. We recommend universities to implement an educational program and community awareness on DF care inside as well as outside campus. This will help in raising community awareness, which will eventually lead to a lesser disease burden.


Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

This research was done by the approval of al Taif University approval no. 40-36-0156 approval date 30-42019.


Author details

Tariq Chundrigar1, Eman Mohy Ibrahim Youssef2, Hadeel Sameer Ashour2, Marwah Hassan TurkIstani2, Shams Abdullah Aldosari2, Tahani Mathna Altaifi2, Atheer Musaed Altalhi2

  1. Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
  2. Taif University, Taif, Saudi Arabia

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How to Cite this Article
Pubmed Style

Chundrigar T, Youssef EMI, Ashour HS, Turkistani MH, Aldosari SA, Altaifi TM, Altalhi AMS. Diabetic foot care knowledge among Taif University students in Saudi Arabia. IJMDC. 2019; 3(10): 17-22. doi:10.24911/IJMDC.51-1558051722


Web Style

Chundrigar T, Youssef EMI, Ashour HS, Turkistani MH, Aldosari SA, Altaifi TM, Altalhi AMS. Diabetic foot care knowledge among Taif University students in Saudi Arabia. http://www.ijmdc.com/?mno=49311 [Access: October 18, 2019]. doi:10.24911/IJMDC.51-1558051722


AMA (American Medical Association) Style

Chundrigar T, Youssef EMI, Ashour HS, Turkistani MH, Aldosari SA, Altaifi TM, Altalhi AMS. Diabetic foot care knowledge among Taif University students in Saudi Arabia. IJMDC. 2019; 3(10): 17-22. doi:10.24911/IJMDC.51-1558051722



Vancouver/ICMJE Style

Chundrigar T, Youssef EMI, Ashour HS, Turkistani MH, Aldosari SA, Altaifi TM, Altalhi AMS. Diabetic foot care knowledge among Taif University students in Saudi Arabia. IJMDC. (2019), [cited October 18, 2019]; 3(10): 17-22. doi:10.24911/IJMDC.51-1558051722



Harvard Style

Chundrigar, T., Youssef, . E. M. I., Ashour, . H. S., Turkistani, . M. H., Aldosari, . S. A., Altaifi, . T. M. & Altalhi, . A. M. S. (2019) Diabetic foot care knowledge among Taif University students in Saudi Arabia. IJMDC, 3 (10), 17-22. doi:10.24911/IJMDC.51-1558051722



Turabian Style

Chundrigar, Tariq, Eman Mohy Ibrahim Youssef, Hadeel Sameer Ashour, Marwah Hassan Turkistani, Shams Abdullah Aldosari, Tahani Mathna Altaifi, and Atheer Musaad S. Altalhi. 2019. Diabetic foot care knowledge among Taif University students in Saudi Arabia. International Journal of Medicine in Developing Countries, 3 (10), 17-22. doi:10.24911/IJMDC.51-1558051722



Chicago Style

Chundrigar, Tariq, Eman Mohy Ibrahim Youssef, Hadeel Sameer Ashour, Marwah Hassan Turkistani, Shams Abdullah Aldosari, Tahani Mathna Altaifi, and Atheer Musaad S. Altalhi. "Diabetic foot care knowledge among Taif University students in Saudi Arabia." International Journal of Medicine in Developing Countries 3 (2019), 17-22. doi:10.24911/IJMDC.51-1558051722



MLA (The Modern Language Association) Style

Chundrigar, Tariq, Eman Mohy Ibrahim Youssef, Hadeel Sameer Ashour, Marwah Hassan Turkistani, Shams Abdullah Aldosari, Tahani Mathna Altaifi, and Atheer Musaad S. Altalhi. "Diabetic foot care knowledge among Taif University students in Saudi Arabia." International Journal of Medicine in Developing Countries 3.10 (2019), 17-22. Print. doi:10.24911/IJMDC.51-1558051722



APA (American Psychological Association) Style

Chundrigar, T., Youssef, . E. M. I., Ashour, . H. S., Turkistani, . M. H., Aldosari, . S. A., Altaifi, . T. M. & Altalhi, . A. M. S. (2019) Diabetic foot care knowledge among Taif University students in Saudi Arabia. International Journal of Medicine in Developing Countries, 3 (10), 17-22. doi:10.24911/IJMDC.51-1558051722