INTRODUCTION:

“Health is Wealth”, according to this saying if wealth is lost nothing is lost but if health is lost everything is lost. Therefore, when an individual is in diseased condition he should try to get out of it without endangering his/ her health.

It is estimated that 30,000 people are diagnosed with type 1 diabetes and 798,000 people are newly diagnosed with type 2 diabetes each year.Various risk factors include age, family history, ethnicity, dietary habits, lack of exercise, females with polycystic ovarian disease, gestational diabetes and babies weighing more than 9 lb at birth.¹²Treatment typically includes diet control, exercise, home blood glucose testing, and in some cases, oral medication and/or insulin injections. Approximately 40% of people with type 2 diabetes require insulin injections.

People with diabetes are at risk of nerve damage (neuropathy) and problems with the blood supply to their feet (Ischaemia). Complications affecting the lower limbs are among the most common manifestations of diabetes. Peripheral vascular diseases often result in diabetic foot. Both neuropathy and ischaemia can lead to foot ulcers and slow-healing wounds which, if they get infected, may result in amputation. It was reported that 15% of diabetic patients will eventually suffer from foot ulceration during their lifetime. These complications are a frequent cause of hospitalization and disability; with 1 in 5 hospitalizations among diabetics directly related to foot ulcers.

Extensive epidemiological surveys have indicated that between 40% and 70% of all lower extremity amputations are related to diabetes. This means that every 30 seconds a lower limb is lost to diabetes. Amputation rates vary considerably: incidence ranges from 1 per thousand in the Madrid area in Japan and up to 20 per thousand in some Indian tribes in North America as described by Cavanagh et al (2005). The vast majority (85%) of all diabetes-related amputations are preceded by foot ulcers. For most people who have lost a leg, life will never return to normal. Amputation may involve life-long dependence upon the help of others, inability to work and much misery. Ulcer recurrence rates are high, but appropriate education for patients, the provision of post healing footwear, and regular foot care can reduce rates of re-ulceration. It is estimated that 85% of low amputations of the diabetic foot could be prevented with the development of health education programs.

Aggressive management of the diabetic foot can prevent amputations in most cases. All individuals with diabetes should receive an annual foot examination to identify high-risk foot conditions. Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. This examination should include assessment of protective sensation, vascular status, and skin integrity. Early detection and appropriate treatment of these ulcers may reduce the rate of amputations. Even when amputation takes place, the remaining leg and the person’s life can be saved by good follow-up care from a multidisciplinary foot team.

It appears mandatory to take appropriate action to ensure that people with diabetes thorough out the world receive the quality care that they deserve. It is hoped that if regular and organized planned health education is undertaken, it would not only contribute to create awareness among diabetics related to its complications but also motivate them to observe positive foot care practices. Education of diabetics would improve their treatment compliance that will lead to favourable or uneventful treatment outcomes. Hence, it is obligatory that nurses who are rendering nursing care to the diabetics must be competent, highly skilled and with positive attitude in order to achieve the desired results. It would not only contribute towards improving quality of the patients care but would ensure them a quality life to lead.

The adult population of India alone accounts for 86% of the region’s total population of 856 million in 2011 credited with the Diabetes Capital of the world. Current estimates indicate that 8.3% of the adult population, or 71.4 million people, have diabetes in 2011, 61.3 million of whom are in India. The number of people with diabetes in the region will increase to 120.9 million by 2030, or 10.2% of the adult population. The estimated increase in regional diabetes prevalence to 10.2% in 2030 is a consequence of increasing life expectancy in India.¹⁸ This would mean that every fifth diabetic in the world would be an Indian.

According to IDF (International Diabetes Federation) Diabetes Atlas (2011) estimate, majority of diabetics are between the age of 40-59 years. The most important demographic change to diabetes prevalence across the world appears to be the increase in the proportion of people >65 years of age.

More than half (55%) of these deaths occur in people under the age of 60 and almost a third (27%) under the age of 50. India is the largest contributor to regional mortality with 983,000 deaths attributable to diabetes. It is affecting middle and low income countries thus impacting productive years of life. According to one estimate, diabetes kills 1 person every 8 seconds somewhere in the world. Economic drift and its consequent changes in life style in India have led to an alarming increase in prevalence of diabetes which has now become the greatest health threat. Although knowledge is the greatest weapon against diabetes mellitus to motivate the diabetics to seek proper treatment and to inspire them to take charge of their disease, massive efforts taken to prevent the comorbid complications of diabetes mellitus are still insufficient.

Diabetes Education and Prevention is the World Diabetes Day (November 14) theme for the period 2009-2013. According to IDF, the campaign calls on all those responsible for diabetes care to understand diabetes and take control. For health care professionals, it is a call to improve knowledge so that evidence-based recommendations are put into practice. For the general public, it is a call to understand the serious impact of diabetes and know, where possible, how to avoid or delay diabetes and its complications.

Diabetes mellitus affects almost every aspect of life among diabetics. Managing complicated diabetes mellitus is an expensive affair that not financially exhausts the diabetics but also affects the national economy. There is strong need to conduct research studies to assess knowledge deficit among diabetics and their health-seeking behaviour in the developing countries like India. It is anticipated that diabetics’ education with consequent improvements in their knowledge, attitudes and skills, will lead to better control of the disease, and is widely accepted to be an integral part of comprehensive diabetes care.

NEED OF THE STUDY:

Applied research, especially in community-based demonstration projects and in evaluating different policies and interventions, should be promoted. Such research studies including the reasons for physical inactivity and poor diet, and on key determinants of effective intervention programmes, combined with the increased involvement of behavioural scientists, will lead to better informed policies and ensure that a cadre of expertise is created at national and local levels. Equally important is the need to put in place effective mechanisms for evaluating the efficacy and cost-effectiveness of national disease-prevention programmes, and the health impact of policies in other sectors. More information is needed, especially on the situation in developing countries, where programmes to promote healthy diets and physical activity need to be evaluated and integrated into broader development and poverty-alleviation programmes.²⁵

The need of the current study is justified by the following:

1. Incidence of diabetes mellitus is quiet high in India because the people do not possess sufficient knowledge and positive health practices to control this disease and thus prevention of its complications. Illiteracy and ignorance are considered to be the most leading factors among diabetics and casual attitude towards its treatment. Although many research studies have been carried on different aspects of diabetes but the subject under current study has not been so much explored. Hence, the literature related to the current study was found to be scanty.

2. Majority of diabetics have knowledge deficit related to the required healthy foot care practices and risks of diabetic foot. It has been observed that about 70% of all the lower limb amputations are related to the diabetes proceeded by foot ulcers.

3. Myths and misconceptions among diabetics related to foot care contribute to high prevalence of the peripheral neuropathic complications, which once develop then the treatment is not only lifelong but also financially exhausting.

4. Development of diabetic foot forces the diabetics for their hospitalizations and making them crippled following amputation of lower limbs. Moreover, it has been personally experienced by the investigator while working in the clinical area that most of the diabetics approach to the medical services when there is strong need to amputate the limb in order to save their lives.

5. Poverty ridden persons cannot afford good quality foot wears, so these diabetics are more prone to develop diabetic foot by having even mild foot injury. In Indian culture, people visit the religious places barefoot and in some families, people avoid to wear shoes in their kitchens also. These barefoot walking habits play a key role in the development of foot ulcers.

6. Punjab being the agrarian state of the country, about 80% of its population lives in villages. Farmers usually walk barefoot in the fields and if they are diabetics then they are at high risk to receive foot injuries.

Hence, based on the exhaustive review of the relevant literature, consultation with the experts in the field of nursing, medicine and clinical psychology; and all the above mentioned reasons, the current research project has been chosen by the investigator to assess the knowledge and attitude of diabetics related to diabetic foot and its prevention.

Balagopal et al (2008) evaluated a 7-month community-based nonpharmacological lifestyle intervention in a resource-poor village in Tamilnadu to prevent/reduce the risk of developing diabetes and its complications. In this study total of 703 village inhabitants, comprising adults and youth aged 10–92 years, were provided educational intervention using “trained trainers.” Culturally and linguistically appropriate health education messages addressed diet, physical activity, and knowledge improvement. Results showed that the crude prevalence of diabetes and pre-diabetes among adults were 5.1 and 13.5%, respectively, while the prevalence of pre-diabetes in youth aged 10–17 years was 5.1%. Intervention reduced fasting blood glucose levels of pre-diabetic adults by 11%, pre-diabetic youth by 17%, and type 2 diabetic adults by 25%. The study had charted the increasing prevalence of diabetes and pre-diabetes in rural India. Educational intervention was successful in reducing some of the obesity parameters and improving dietary patterns of individuals with pre-diabetes and diabetes.

Ekore et al(2010) undertook a descriptive, cross sectional, clinic based study which was carried out in Nigeria. Findings indicated that awareness of foot care measures was very poor among known diabetic patients and that was largely due to a lack of education of the patients by their health care providers. Findings also yielded that one hundred and twenty-six (92%) patients out of total 137 subjects had never received any education on foot care from their healthcare providers, while 11 (8%) had received some form of foot care education. Among those who had never received any foot care education, 92 (73%) had been diabetic for 1-5 years, while the remaining 34 (27%) had been diabetic for 6 - 20 years. Of the foot care measures that were known, 35 (25.5%) patients knew to wash their feet daily and dry in between the toes thoroughly, 31 (22.6%) knew not to go outdoors barefooted, 27 (19.7%) checked their feet daily, 27 (19.7%) checked inside their shoes daily, 8 (5.8%) consciously made an effort to avoid injuries to their feet and 4 (2.9%) clipped their toenails with care. From these findings, it is very clear that in this area, there were no educational programmes organised related to self care among diabetes.

MATERIAL AND METHODS:

Descriptive research approach was employed for this study. The target population included all the diabetics who had visited the hospitals named Adesh Hospital and Research Centre, Aashirwad Hospital and Civil Hospital of Sri Muktsar Sahib in the month of January 2012. The sample size of the present study comprised of 100 diabetics. Purposive sampling technique was adopted in the selection of the study sample. The tool was divided into 3 sections:

· Section – A dealt with socio demographic profile of the sample subjects. It consisted of 10 items stating age (in years), gender, marital status, habitat, educational status, occupational status, monthly family income (in Rs.), dietary preference, religion and duration of onset of diabetes (in years).

· Section – B comprised of 30 structured questions to assess the knowledge among diabetics related to diabetic foot and its prevention.

· Section – C included the 5 point Likert’s Scale having 35 statements to assess the attitude among study subjects related to diabetic foot and its prevention.

The structured interview schedule was categorised as follows:

For multiple choice questions:

w General knowledge about Diabetes: 12 Items

w Awareness about favorable conditions in the development of diabetic foot ulcer: 7 Items

w Regarding the use of shoes and socks: 3 Items

w Feet and nail hygiene: 8 Items

The statements of the attitude scale were divided as:

w Diabetes mellitus in general: 18 Statements

w Factors important in prevention of diabetic foot: 04 Statements

w Related to shoes, socks and their inspection: 06 Statements

w Feet and nail hygiene: 07 Statements

PLAN FOR DATA ANALYSIS:

The data collected was analyzed using descriptive and inferential statistical measures. Descriptive statistical tests were used, e.g. mean and percentage to assess the knowledge and attitude of diabetics.

Inferential statistical measures, e.g. chi square test was used to find out the association between knowledge and their attitude on diabetic foot and its prevention with selected socio demographic variables.

Out of 100 subjects, majority 54 (54%) of them were between the age of 40-50 years followed by 33 (33%) who were above 50 years in age and the 13 (13%) subjects were in age group of 30-40 years. Of the 100 study subjects, majority 67 (67%) were males and 33 (33%) were females. Of the 100 study subjects majority 69 (69%) were married and 31 (31%) were widows/ widowers. None of the subjects was unmarried and divorced/ separated. Habitat wise distribution of subjects revealed that the 62 (62%) diabetics hailed from the rural area and 29 (29%) belonged to the urban area and rest of the 9 (9%) subjects were from sub urban area. From educational status point of view, the highest 24 (24%) subjects were illiterate followed by 22 (22%), 16 (16%), 15 each (15% each) and 7 (7%)who were literate up to secondary level, senior secondary level, primary and middle levels and graduate level respectively. Only 1 (1%) of the subjects was found to be postgraduate.

The occupational status wise distribution of subjects showed that out of the 100 subjects, mostly of i.e. 32, (32%) were in the category of student/ house wife/ unemployed followed by 28 (28%) and 27 (27%) who were skilled and professional respectively. 8 (8%) subjects were in semi skilled occupation and the remaining 5 (5%) were involved in business.

Of the 100 subjects, majority, 34 (34%) were having monthly family income between Rs. 10001-15000 followed by 32 (32%) diabetics who were earning above Rs.15001, 23 (23%) diabetics had monthly income Rs.5000-10000 and 11 (11%) subjects had income of below Rs.5000. Out of 100, more than half i.e. 54, (54%) were non vegetarian while 31 (31%) were strictly vegetarian. In addition to it, 15 (15%) were egg vegetarian. Majority i.e. 84 (84%) were Sikhs and the remaining 16 (16%) were Hindus. The 44 (44%) subjects were suffering from the diabetes mellitus for the last 3-5 years followed by 30 (30%) diabetics who had the disease for more than 5 years. 25 (25%) had diabetes mellitus for the last 1-3 years and only 1(1%) subject suffered from the disease since less than 1 year.

Of the 100 subjects, 64 (64%) responded that noncompliance is not an important factor in the management of diabetes mellitus whereas 63 (63%) subjects were aware that hypoglycaemia occurs when the blood glucose level ranges between 40-60 mg/dl.

48 (48%) respondents were familiar with the fact that doing daily brisk walk for 30-40 minutes helps to improve the peripheral blood circulation. Only 30 (30%) subjects responded correctly to use the syringe only once for giving the insulin injection.

Only 7 (7%) subjects were aware that the normal level of fasting blood sugar ranges between 90-120 mg/dl among diabetics.

It is concluded from this table that most of the subjects had adequate knowledge about diabetes mellitus.

In the development of diabetic foot, majority of the subjects had some awareness of the predisposing factors excluding the technique to examine the soles of feet and avoid to sit crossed legs in which they showed knowledge deficit. the study subjects had good knowledge regarding the proper use of shoes and socks.

In attitude scale findings, Diabetics showed knowledge deficit in the area of importance of feet and nail hygiene. Majority of the study subjects demonstrated satisfactory attitude towards the diabetes mellitus. The study subjects had positive attitude towards the healthy foot care practices that are important in the prevention of diabetic foot ulcer except to avoid the posture of crossed legs. most of the diabetics had favourable attitude towards the proper use of shoes and socks. That majority of the study subjects showed healthy attitude towards most of the aspects of feet and nail hygiene except the use of moisturizer in between the toes.

The association between the knowledge scores among the study subjects and their marital status was found to be statistically significant (p<0.05) and the association between the rest of the socio demographic variables and the knowledge scores among the study subjects did not reach the level of statistical significance (p>0.05).

The association between the attitude of the study subjects and their age, educational status of the study subjects and duration of the onset of diabetes was found to be statistically significant (p<0.05) whereas the association of attitude with the remaining socio demographic variables did not reach the level of statistical significance (p>0.05).

TABLE: 1 DISTRIBUTION OF SUBJECTS ACCORDING TO THE LEVEL OF KNOWLEDGE SCORES RELATED TO DIABETIC FOOT AND ITS PREVENTION N=100

Level of knowledge	Scores	N	%
Good	(21 – 30)	20	20
Average	(11 – 20)	80	80
Poor	( up to 10)	0	0

It is evident from table 1 that majority i.e. 80% of the study subjects possessed average level of knowledge scores whereas the remaining 20% were having good level of knowledge scores. Hence, it is concluded that all of the study subjects had prior knowledge related to diabetic foot and its prevention as none of them had scored in the category of poor level of knowledge scores.

TABLE: 2 DISTRIBUTION OF SUBJECSTS ACCORDING TO THE LEVEL OF ATTITUDE SCORES RELATED TO DIABETIC FOOT AND ITS PREVENTION N=100

Level of attitude	Scores	n	%
Excellent	(148-175)	09	09
Good	(120-147)	87	87
Average	(92-119)	04	04
Poor	( < 92)	0	0

Table 2 illustrates that out of 100 study subjects, 87 (87%) showed good level of attitude scores, 9 (9%) diabetics depicted excellent level of attitude scores, while only 4 (4%) scored average level of attitude scores related to diabetic foot and its prevention. It means that majority of the subjects i.e. 96 (87%+9% = 96%) possessed good and excellent levels of attitude scores respectively. However, none of the study subjects scored poor level of attitude scores.

DISCUSSION:

Educational status vise 24 (24%) respondents were illiterate. Similar findings were supported by a study on low awareness of diabetes affecting the clinical outcome of patient in rural area carried out by Khapre et al (2011). The illiteracy is the main contributing factor in the increased incidence of diabetes mellitus and poor knowledge among diabetics.

In the occupational status, findings showed that skilled and professionals were almost same in number i.e. 28 (28%) and 27 (27%) respectively. Similar findings were supported by a study to find out the association between socio demographic factors and diabetes mellitus undertaken by Veghari et al (2010).

With regard to the duration of the onset of diabetes, 44 (44%) had been diagnosed for 4-5 years. This finding was supported by a study to evaluate the knowledge and self care practices in diabetic patients and their role in disease management conducted by Padma et al (2012).

The reason behind the knowledge deficit and poor attitude could be ignorance, illiteracy and compulsive life style habits as noticed by the investigator. Moreover, the diabetics should avoid going to the quacks who generally misguide them for the treatment. They should approach the qualified and specialists physicians in order to improve their knowledge and attitude in a healthy manner.

CONCLUSION:

It was concluded that the study subjects had deficit knowledge related to diabetic foot and its prevention as compared to the corresponding attitude that was found to be favourable. If this knowledge deficit among the diabetics is reduced, it may assist them to develop a more positive attitude towards healthy feet care practices; which will ultimately result in the prevention of diabetic foot.

REFERENCES:

1. Type1 Diabetes Statistics. Available from: http://www. organisedwisdom.com.

2. Health Topic: WHO Diabetes. Available from: http://www .who.int/diabetes/en/index.html.

3. International Diabetes Federation .The Diabetic Foot: Amputations are preventa ble.May 2005 . Available from: http://www.idf.org/position-statement-diabetic-foot reviewed on 22/12/2011.

4. Maskari FAL, Sadiq MEI. Prevalence of risk factors for diabetic foot complications. BMC Family Practice. Oct 2007;8(59). Available from: http Diabetes atlas: South East Asia. Available from: http://www.idf.org/diabetes_atlas/5e/South_east_asia.

5. American Diabetes Association. National Diabetes Fact Sheet released on Jan 26, 2011. Available from: http://www.diabetes.org/ADA/M/S.

6. IDF Diabetes Atlas: The global burden. 5^th ed. Available from: http://www.idf.org/diabetesatlas/5e/the_global_burden.

7. Wild S, Roglic g, Green A, Sicree R, King H.Global prevalence of Diabetes: Estimate for the year 2000 and projections for 2030. Diabetes Care. 2004May; 27(5): 1047-53. Available from: http://www.res easearchgate.net/publication/8592748.

8. Nightingale Nursing Times Journal. Nov 2011;2(4).

9. Chandrakala S. Diabetes Education A key to understand Diabetes and Take control. Indian Journal of Holistic Nursing June 2011;7(1) 18- 20.

10. The compaign Diabetes Education and Prevention. Mar 2011; Available from: http://www.idf.org/worlddiabetesday/.

11. http://www.ldl.gov/Education/ELSI/researchmain.html

12. Balagopal P, Kamalamma N, Patel TG, Misra R. A community based diabetes prevention and management education programme in a rural village in India. Diabetes Care. 2008Jun ;31(6):1097-1104. Available from: http://wwwcare.diabetes. journals.org/content/31/6/1097.abstract.

13. Ekore RI, Ajayi IO, Arije A, Ekore JO. Knowledge of and attitude to foot care amongst Type 2 diabetes patients attending a university-based primary care clinic in Nigeria. Afr J Prm Health Care Fam Med. 2010;2(1):175-77. Available from: http://www.phcfm.org/index.php/phcfm/article/view/175/33.

14. Veghari G, Sedaghat M, Joshaghani H, Hoseini SA, Niknezad F, Angizeh A et al.Association between socio-demographicfactors anddiabetesmellitus in the north of Iran: A population-based study. International Journal of Diabetes Mellitus 2010 Dec; 2(3):154–57. Available from:http://www.sciencedirect.com/sci ence/article/pii/S1877593410000706.

15. Khapre MP, Mudey A, Goyal RC, Wagh V. Low awareness of diabetes affecting the clinical outcome of patient A cross-sectional study conducted in rural tertiary care hospital. International Journal of Biological & Medical Research. 2011;2(3):627-30. Availablefrom:http://www.biomedscidirect.com/journalfiles/IJBMRF2011195/low_awareness_of_diabetes_affecting_the_clinical_outcome_of_patient_a_cross_sectional_study_conducted_in_rural_tertiary_care_hospital.pdf.

16. Padma K, Bele SD, Bodhare TN, Valsangkar S. Evaluation of knowledge and self care practices in diabetic patients and their role in disease management. National journal of community medicine.2012 Mar;3(1):1-4. Available from: http://www.njcmindia.org/home/download/198.

Received on 22.09.2013 Modified on 15.10.2013

Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 50-55