Assessing Foot Care Knowledge in a Rural Population with Diabetes

Literature Review People with diabetes are at high risk for foot and leg ulcers. As the disease progresses, peripheral vascular disease and peripheral neuropathy may develop, with loss of Achilles and patellar reflexes and decreased vibratory sensation. Peripheral neuropathy may be the most important precursor to ulcer development. Distal symmetric polyneuropathy, the most common type of neuropathy in individuals with diabetes, involves sensory, motor, and autonomic nerve fibers, leading to reduced thermal and pain sensation, numbness, and painful paresthesias.1 When an insensate foot is subjected to even minor trauma or increased pressure, as with ill-fitting shoes, an ulcer may develop. Neuropathic foot deformities also occur with the unopposed action of the extensor tendons, which leads to clawing of the toes and prominence of the metatarsal heads. Because of maldistribution of pressure, ulcers are more likely to develop on the areas underlying the metatarsal heads. Infection of chronic ulcers is a major cause of gangrene and, in turn, amputation. Amputation of the feet and legs is one of the biggest threats to adults with diabetes - the leading cause of lower extremity amputation among people aged 18 to 65 years. Ulceration, infection, and gangrene are leading causes of hospitalization at an annual cost of $1 billion.2 Patients are more likely to comply with a treatment regimen when they have sufficient knowledge about their medical condition. According to the American Diabetic Association, daily foot care and inspection can prevent the development of foot ulcers in people with diabetes.3 Preventive behaviors focus on not going barefoot, performing/receiving proper foot care, and wearing properly fitting shoes. Because place or residence, region, and socioeconomic status shape health values, behaviors, and status, people with diabetes in rural settings may have unique problems. People living in rural areas are more likely to suffer from chronic conditions and are less likely to receive preventive care than their urban counterparts.4 The average number of people with diabetes in rural areas exceeds that of urban dwellers.5 In addition, about half as many physicians are available in rural areas, with the southern part of the United States having the fewest. Rural-dwelling people often seek help when their role performance is impaired; they tend to rely on social support networks because they often distrust outsiders. Folk medicine is sometimes used, and relatives and friends are the preferred source of medical information. Confidence in home remedies is high; in small towns, lack of privacy may prevent a person from seeking medical attention for "embarrassing" conditions.5 Rural-living people also face transportation and communication problems. In a study by Strickland and Strickland,4 50% of the minority population studied did not have cars, and 25% did not have phones. Both of these factors interfere with entitlement eligibility and access to health services. The project described in this article was the first in a multiphase program of research that will follow a cohort of rural-dwelling people with diabetes through the progression of their disease, their foot care and foot wear practices, and the effects of the development of foot ulcers. All of the people in this study had been given information and guidance on foot care and shoe management at some time in their medical treatment history. This article reports the findings on self-care practices related to foot care of 61 rural people with diabetes mellitus. This pilot project used an instrument that had been previously validated in Thailand by the Siriraj Foot-Care Score. Methods Setting and participants. This descriptive study was conducted at a treatment facility sponsored by an academic medical center that services clients from 26 rural counties of a southeastern state. The convenience sample included 61 adult men and women with either types of diabetes, 24 with existing foot ulcers and 37 without foot ulcers. Nurses and physicians in the clinic who specialized in diabetes identified potential participants. Potential subjects were approached in the waiting areas during routine visits and asked if they would be interested in participating in a study on foot care. The Institutional Review Board at East Carolina University approved the study. All of the participants had "diminished protective sensation" or a score of 4.31 or greater on the Semmes-Weinstein monofilament test. Participants with foot ulcers had a full-thickness disruption of the skin on the foot with a duration of more than 1 month. Instrumentation. After informed consent was obtained, short interviews were conducted and a questionnaire, the Siriraj Foot-Care Score, a previously validated instrument on patient knowledge of foot care, was administered verbally.6 Sriussadaporn, Nitiyanant, Ploybutr, Vannasaeng, and Vichayanrat7 developed an instrument to analyze foot care based on standard foot care management developed by the Joslin clinic. After permission from the authors of the scale was obtained, the questionnaire was modified slightly to include showering as a method of foot cleaning. The questionnaire consisted of 10 multiple-choice questions (see Figure 1) with a total possible score of 0 to 20. Content validity was established by the use of standard foot assessment practices, and further validity was obtained by consultations with two diabetes educators. The modifications reflect some additional foot cleaning practices. The questionnaire is divided into four categories: foot inspection, foot cleaning, nail care, and use of footwear. Results Demographics. Sixty-one participants were assessed at their regular clinic visit (see Table 1). Of the 61 participants, 30 were men, 31 were women, and 24 of the total had foot ulcers. Forty-eight were Caucasian, 14 were African American, and two were Hispanic. Their mean age was 46 years (range 18 to 81 years). Thirteen (21.3%) lived on a farm and 48 (87.7%) lived in other rural settings. Participants had diabetes for an average of 8.5 years with a range of less than 1 year to more than 10 years. Foot care behaviors. The participants were divided into two groups, those with foot ulcers and those without foot ulcers. The foot care behaviors of the participants are displayed in Table 2. Foot inspection. People with diabetes are instructed by clinicians to examine their feet daily for reddened areas, blisters, corns, calluses, or open areas. No statistically significant difference was found between the scores of the two groups on this item - 78.3% of those with foot ulcers checked their feet at least five times a week compared to 81.1% of those without ulcers. Only three participants never checked their feet; they said they could not see their feet due to obesity or severe retinopathy. Foot cleaning. The American Diabetes Association (ADA) recommendation for foot cleaning is once a day with warm water. No statistically significant difference was noted between the scores of the groups, with 79.2% of those with foot ulcers and 80.6% of those without foot ulcers stating that they cleaned their feet once a day. However, 16.7% of both groups said they cleaned their feet twice a day. When asked what they used to clean their feet, 79.2% of the ulcer group and 73% of the nonulcer group said they used soap and water. Participants also had the option to select, "the water from the shower hits them." This answer was chosen by 16.7% of those with foot ulcers and 27% of those without ulcers. Most diabetes educators would not consider this a satisfactory method of cleaning. When asked what they did if their feet got dirty, only 12.5% of the foot ulcer group said they would clean them right away versus 47.2% of the nonulcer group. This was a significant difference between the groups. The majority of both groups, 83% with ulcers and 87% without, said they washed between their toes, and 83% of those with foot ulcers and 81% of those without ulcers reported drying between their toes. Those without foot ulcers had a slightly higher foot cleaning score, averaging 5.32 versus 4.75 (see Table 3) for the nonulcer group out of a best possible score of 8. Nail cutting. Participants were asked what they used and how they cut their toenails. The differences were not statistically significant. Out of the 61 participants, 49 reported that they cut their own nails. The majority of both groups (93.8% of those with foot ulcers and 97% without ulcers) used nail clippers. However, 6.3% of the ulcer group and 3% of the nonulcer group said they cut their nails using dangerous tools such as knives or razor blades. Most of the participants (76.5% with foot ulcers and 77.4% without) cut their toenails straight across. Again, dangerous behaviors were noted among 23.5% of the ulcer group and 22.6% of those without foot ulcers, who said they would cut their toenails "as much as possible." The total scores were very close in this category - the ulcer group averaged 3.54 out of 4 and the nonulcer group averaged 3.48 out of 4. Going barefoot. People with diabetes are advised always to wear foot protection and never to go barefoot. Cotton socks also are recommended at all times. The questionnaire items asked when and where the participants went barefoot. In response to an item asking about wearing shoes outside, 82.6% of the people with foot ulcers and 70.3% of those without ulcers answered "always." The response ?most of the time? was given by 21.6% of the nonulcer group versus 8.7% of the ulcer group. Approximately 8% of both groups admitted never wearing shoes outside. When asked where they would go barefoot inside, 54.2% of the foot ulcer participants and 83.3% of the nonulcer participants said they would go barefoot ?anywhere? inside the house. Only 37.5% of people with ulcers and 11.1% of those without ulcers replied that they never went barefoot. The difference in the scores for this category of the two groups was statistically significant (P = .004). Those without foot ulcers were more likely to go barefoot inside. Overall foot care scores. Out of a possible score of 20, the nonulcer group averaged a score of 13.57 on overall foot care with a range of 6 to 20. The group with foot ulcers had an average score of 13.88, or slightly higher, with a range of 6 to 19 (see Table 3). Discussion The ADA ascribes 50% of amputations to preventable events and has established prevention of inappropriate foot care behavior as a goal.8 This study examined a convenience sample of high-risk people who already had peripheral neuropathy, several of whom had foot ulcers. Although all of the clients had received education on foot care at some point in their illness, they were using improper or no foot care procedures. Improper foot care was evident in those who already had foot ulcers as well as in those who were at high risk for developing ulcers. Unlike the Sriussadaporn et al study,6 the score for the two groups was very similar except in the area of footwear usage. Interestingly, the scores from this group from the United States were lower than the Thai scores for people with similar afflictions. Criterion validity of this scale was performed by Sruissadaporn et al by univariate analysis. They determined that the risk of developing foot ulcers was significantly associated with a foot care score of less than 15. Sriussadaporn et al6 received scores for the foot ulcer group of 14.50 ± 3.35 and the nonulcer group of 15.74 ± 2.31. Because participants in this study, with and without foot ulcers, were already insensate, and their self-care practices were similar, potential for ulcer development in the nonulcer group was high. Some of the questions were straightforward, and often it appeared that the clients knew the correct answer because of previous training. When the investigator asked the questions, it was sometimes evident that participants were not actually doing what they said, often through no fault of their own. Diabetic retinopathy and obesity were common; participants simply could not see their feet. Most of the participants inspected and cleaned their feet properly the prescribed number of times per week. However, 16.7% of the ulcer group and 27% of the nonulcer group relied on shower water running over their feet as a cleaning method. In showering, balance is required to actually wash each foot individually. When educating people with diabetes, this should be noted. The participants were asked what they did if their feet got dirty - would they clean them immediately or wait until the next bath? The groups differed significantly on this item (p = .017). For the group with foot ulcers, an astonishing 87.5% waited until their next bath to wash their feet. The nonulcer group reported that 52.8% waited until the next bath. Going barefoot is always discouraged for people with diabetes. This fact is always stressed in foot care education. Most of the participants in this study said they would not go barefoot outside. However, when questioned about where in the house they would go barefoot, a majority said "everywhere" (54.2% with ulcers and 83% without). In Plummer and Albert study,8 only 31% of the diabetic respondents said they went barefoot; however, upon further questioning, they admitted to wearing socks alone. Perhaps this large difference is due to the location of the study. People in warmer climates often go barefoot. In the rural southeast where this study took place, going barefoot is commonplace, especially during the warmer months. Not wearing shoes could predispose people to foot ulcers by creating situations that lead to ulcer development. Culture and environment may play an important part in adherence to foot care regimen. As Anderson et al9 pointed out, health belief and health behaviors are influenced by cultural and socioeconomic factors. In some areas, the importance of footwear is not valued, especially inside the home or in warm weather. In several studies that have assessed knowledge of foot care in people with diabetes, participants who did not do regular foot self-examinations were asked why they did not perform foot care. They gave as reasons, "family problems,"10 "can't see my feet,"11,12 lack of motivation,10,11 "no time,"12 and the inability to perform foot inspections.11-13 In Umeh, Wallhagen, and Nicoloff's study,14 only 14% of the elderly diabetic sample had the visual acuity to perform foot inspections properly. In this study, the reason most often given for lack of foot care was that people were unable to reach their feet. In fact, foot inspection requires flexion of the spine, internal rotation of the hip, knee flexion, inversion of the foot, and good visual acuity - many diabetics do not have these abilities.12 Conclusion This instrument is useful for assessing behaviors regarding foot care based on standard foot care management guidelines. It is also useful for obtaining current information on foot care practices at points in time and can indicate a need for foot care education or reinforcement, especially in those with insensate feet who are at high risk for developing a foot ulcer. A score of 15 or less indicates a higher probability of developing a foot ulcer.6 In this study, the average scores were 13.77 for people without foot ulcers and 13.88 for those with existing foot ulcers. At the author's facility, this information was used to alert diabetes educators and nurses of a need to increase foot care education. Nonjudgmental assessments of a person?s current knowledge and foot care practices should be obtained at regular intervals. Patients who have lost protective sensation should understand the implications of improper care. The importance of foot monitoring on a daily basis, proper foot cleaning procedures, and nail care should be emphasized. Often, those with other disabilities such as retinopathy or mobility issues need another person to do foot monitoring and cleaning procedures for them. A foot screening algorithm may be useful for healthcare providers to direct patient education with appropriate referrals. Above all, educators must pay attention to cultural factors in their geographic location and urge clients with diabetes to change poor foot care habits. Anderson et al,9 using focus groups, developed culturally sensitive educational material for a group of city-dwelling African Americans. This approach also may be useful for high-risk rural populations. This includes changing life-long patterns, providing sensitivity, and stressing relevance to their lives. - OWM Acknowledgment The author wishes to thank the Beta Nu chapter of Sigma Theta Tau for providing the funds for this project.

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