Effectiveness of Therapeutic Educational Program on knowledge regarding Foot Care among patients at Risk of Developing Diabetic Foot

 

Ramanpreet Kaur, Davinder Kaur1, Rajinder Singh Gupta

1M. Sc Student, Gian Sagar College of Nursing, Ram Nagar, Rajpura, Patiala

2Principal, Gian Sagar College of Nursing, Ram Nagar, Rajpura, Patiala

3Prof. and Ex-Head of Department (Medicine), Gian Sagar Medical College and Hospital,

Ram Nagar, Rajpura, Patiala.

*Corresponding Author E-mail: dav6aug@gmail.com

 

ABSTRACT:

Foot problems are common complication in people with diabetes mellitus. Frequent foot assessments and education by health professional can help the patient to prevent foot problems. This study was done to evaluate the effectiveness of therapeutic educational program on knowledge regarding foot care among patients at risk of developing diabetic foot. After approval from the ethical committee, randomized controlled trial conducted in medicine O.P.D of Gian Sagar Medical College and Hospital, Ram Nagar, Rajpura, District Patiala, Punjab on 60 patients at risk of developing diabetic foot assessed by Nova Scotia form. Patients were randomly allocated in experimental and control group. Knowledge questionnaire and brochure developed. Content validity index was (98%) and reliability was (0.9). After evaluating baseline knowledge in both groups, brochure provided to experimental group and post test was conducted after 2 weeks. Collected data analyzed by descriptive and inferential statistics. The study findings revealed that brochure showed significant increase (p<0.05) in mean knowledge scores of patients at risk of developing diabetic foot in experimental group regarding foot care as compared to control group. This study concluded that therapeutic educational program (brochure) was effective in increasing knowledge about foot care in patients at risk of developing diabetic foot.

 

KEYWORDS: Effectiveness, Therapeutic educational program, Diabetic foot.

 

 

INTRODUCTION:

Diabetes mellitus is a silent and multifaceted disease and is now recognized as one of the fastest growing threat to public health in almost all countries of the world. It is a group of metabolic diseases characterized by hyperglycemias resulting from defect in insulin secretion, insulin action, or both.[1] Whereas, in India there are 6.13 million people with diabetes, which will cross 100 million by the year 2030. It is estimated that globally 366 million people are affected with diabetes mellitus. As there is rising prevalence of diabetes, it is expected that there will be increase in its complications that can result in increased morbidity and mortality and health care expenditure due to the requirement of specialized care.[2]

 

One of the most common complications of diabetes mellitus is foot ulceration. The major risk factor for foot problems among people is poor foot care knowledge and practices. The incidence of foot ulcers among people with diabetes ranges from 8% to 17%. An amputation due to diabetic foot ulcer cause loss of productivity and even adds to the economic burden. Apart from all that, it causes severe disability and hospitalization of the patients. About 85% of amputations occur as a result of foot ulcers.[3,4]

 

Every diabetic patient should be assessed for presence of discolored, ingrown toenails, calluses, blisters, hammer or claw toes, foot care and type of foot wear patient is wearing. Diabetic foot risk assessment enables to rule out patient at risk of developing diabetic foot. Foot specific patient education can change the behavior and increase understanding of patient about self care of feet. Many studies evidenced that increase in Patients knowledge about foot care has resulted in decreased risk of diabetic foot.[2] [5-6]

 

Different diabetic foot risk assessment tools were used by health professionals to rule out the patients who are at risk of developing diabetic foot; early detection is essential step for prevention of diabetic foot. Diabetes care program of Nova Scotia also developed risk assessment form which was brief (5-7 minutes) and comprehensive. This form outlines sign and symptoms alerting about real or potential risk of diabetic foot. Assessment focus on five components of foot inspection i.e. skin/ nails, structure of foot, vascularity, sensation and mobility. It categorizes patient at low, moderate or high risk of developing diabetic foot. Timely detection of diabetic foot decreases the burden of development of diabetic foot; improve quality of life of patient.[5]

 

Different researchers used different interventions to prevent diabetic foot. But, as a nurse; researcher felt that patient need to be well equipped with knowledge about care of feet because patient is the most important member of the health care team. Health care professional can provide care to patients in the hospital setting but if we provide knowledge to patient regarding care of feet that will make them more self reliant and he or she will be able to perform foot care in home care settings itself and will reduce the chances of getting diabetic foot. Therapeutic educational program (Brochure) will be helpful to patients as they can get knowledge at their own pace and convenience. This kind of information will be able to increase their knowledge and improve practice of foot care.

 

RESEARCH PROBLEM:

A randomized controlled trial to evaluate the effectiveness of therapeutic educational program on knowledge regarding foot care among patients at risk of developing diabetic foot visiting medicine O.P.D of Gian Sagar Medical College and Hospital, Ram Nagar, Rajpura, District Patiala, Punjab.

AIM OF STUDY:

To evaluate the effectiveness of therapeutic educational program on knowledge regarding foot care among patients at risk of developing diabetic foot.

 

OBJECTIVES:

1.     To assess the patients at risk of developing diabetic foot.

2.     To assess the baseline knowledge regarding foot care among patients at risk of developing diabetic foot.

3.     To evaluate the effectiveness of therapeutic educational program on knowledge regarding foot care among patients at risk of developing diabetic foot.

4.     To determine the association between knowledge regarding care of foot and the demographic variables of patients.

 

MATERIAL AND METHODS:

A randomized control group design was used to evaluate the effectiveness of therapeutic educational program on knowledge regarding foot care among patients at risk of developing diabetic foot visiting medicine O.P.D of Gian Sagar Medical College and Hospital, Ram Nagar, Rajpura, District Patiala, Punjab. Population comprised patient with type 2 diabetes mellitus who are at risk of developing diabetic foot (assessed by Nova Scotia diabetic foot risk assessment form). Patients who were having type 2 diabetes mellitus were assessed for presence of risk of diabetic foot by using Nova Scotia diabetic foot risk assessment form, patients those were found to be at risk of developing diabetic foot were randomly assigned into experimental and control group by using closed envelope method. Patients who were already have diabetic foot and having peripheral vascular disease and foot gangrene was excluded from the study. Socio demographic profile was developed containing 7 questions and clinical performa sheet was developed containing 2 questions. Nova Scotia foot risk assessment tool used which consists of the five foot assessment components that were skin assessment, structural and vascular assessment, sensation and mobility. Each component has been assigned risk rating that whether the person was at low risk (denoted with green circle), moderate risk (denoted with yellow triangle) or high risk (denoted with red hexagon) of developing diabetic foot. Brochure was developed that contained all information regarding care of foot i.e. daily monitoring of blood glucose, inspection of feet, washing and moisturizing of feet, smoothing of corns and calluses, trimming of toe nails, socks, shoes, protection of feet from hot and cold, promotion of blood circulation to feet and follow ups along with their pictorial representation. To obtain the baseline knowledge scores, self reporting questionnaire was developed containing 24 questions related to the diabetic foot care. Knowledge scores were categorized into poor knowledge (0-8), average knowledge (9-16) and good knowledge (16-24). validity and reliability (r=0.9) of tool established. Pre test was conducted to assess baseline knowledge about foot care among at risk diabetic foot patient using structured questionnaire in both experimental and control group. Brochure was provided to the patients in experimental group. Post test was taken after 2 weeks to reassess the knowledge level regarding care of foot in both experimental and control group. Data analysis was done by using descriptive and inferential statistics with SPSS version 16. Descriptive statistics used were frequency, percentage, mean, standard deviation. Inferential statistics used were paired t test and unpaired t test and chi square test.

 

RESULTS:

In this study it was found that 60 patients were at risk of developing diabetic foot i.e. (low- 39 %, Moderate- 16 %, and High- 5%) and 40 patients were not at risk of developing diabetic foot. (Table 1) So for further study 60 patients who were at risk of developing diabetic foot (meeting inclusion and exclusion criteria) were taken.

 

Table 1: Distribution of patients at risk of developing diabetic foot

                                                                                        N= 100

Risk categories

Patients at risk of developing diabetic foot

f (%)

Low

39 (39)

Moderate

16 (16)

High

5 (5)

Not at risk

40 (40)

 

Patients in experimental group who were at risk of diabetic foot were lying in above 60 age group (46.7%) and whereas, in control group (30.0%) patients were from 30 to 40 age group. In experimental group majority of subjects who were at risk of diabetic foot were males (53.3%) on other hand in control group equal number of males i.e. (50%) and (50%) females were at risk of diabetic foot. Majority of subjects in experimental group and control group were married i.e. 73.3% and 76.7% respectively. People in experimental group were mostly from rural area (50.0%) whereas; people in control group were from urban areas (43.3%). Subjects in experimental group were either illiterate or matric passed that is 26.7% whereas in control group subjects were matric passed (23.3%). Majority of subjects in experimental and control group didn’t have family history of diabetes that is 66.7% and 53.3%. Subjects were homemaker/ unemployed in both groups i.e. 40.0% and 43.3% respectively. The samples were found to be homogenous in all aspects in experimental and control group. (Table 2).

 

Table 2: Distribution of sample according to demographic variables                                                                                        N = 30+30

S. No.

Sample characteristics

Experimental group f (%)

Control group f (%)

χ2 / fisher’sexact

df (p)

1.

Age (in years)

 

 

 

5.352NS

 

 

 

3(.155)

 

1.1

30-40

3(10.0)

9(30.0)

1.2

41-50

5(16.7)

6(20.0)

1.3

51-60

8(26.7)

8(26.7)

1.4

Above 60

14(46.7)

7(23.3)

 

Mean + SD

59.5+13.9127

52.2+16.1452

 

 

.067NS

 

 

1(.796)

2.

Gender

 

 

2.1

Male

16(53.3)

15(50.0)

2.2

Female

14(46.7)

15(50.0)

3.

Marital status

 

 

 

 

 

2.191NS

 

 

 

3(.656)

3.1

Unmarried

0(0)

1(3.3)

3.2

Married

22(73.3)

23(76.7)

3.3

Divorced

2(6.7)

3(10.0)

3.4

Widow/widower

6(20.0)

3(10.0)

4.

Habitat

 

 

 

.899NS

 

2(.686)

4.1

Rural

15(50.0)

12(40.05)

4.2

Urban

12(40.0)

13(43.3)

4.3

Semi urban

3(10.0)

5(16.7)

5.

Education

 

 

5.1

Illiterate

8(26.7)

6(20.0)

3.242NS

6(.703)

5.2

Primary

5(16.7)

4(13.3)

5.3

Middle/elementary

1(3.3)

3(10.0)

5.4

Matric

8(26.7)

7(23.3)

5.5

+2

7(23.3)

6(20.0)

5.6

Graduate and above

1(3.3)

4(13.3)

6.

Family history

 

 

 

 

6.1

Yes

10(33.3)

14(46.7)

1.111NS

1(.292)

6.2

No

20(66.7)

16(53.3)

7.

Occupation

 

 

 

 

7.1

Government

5(16.7)

4(13.3)

1.222NS

4(1.00)

7.2

Semi government

1(3.3)

0 (0)

7.3

Private

6(20.0)

7(23.3)

7.4

Own business

6(20.0)

6(20.0)

7.5

Unemployed/homemaker

12(40.0)

13(43.3)

NS= Not Significant at               p>0.05 level of significance

 

 

Majority of subjects in both experimental and control group had history of diabetes from around 1-5 year i.e. 56.7% and 73.3% moreover; majority of subjects even had co morbidity (Hypertension) in both experimental as well as control group i.e. 63.3% and 83.3%. Both groups are homogeneous in aspect of clinical characteristics. (Table 3)

 

Table 3: Distribution of sample according to clinical characteristics                                                                                          N=30=30

S. No.

Sample charaterstics

Experimental group f (%)

Control group f (%)

χ2 / fisher’s

df (p)

1.

Duration of diabetes

 

 

 

 

1.1

< 1 year

2(6.75)

2(6.7)

2.387NS

3(.522)

1.2

1- 5 years

17(56.7)

22(73.3)

1.3

5-10 years

6(20.0)

4(13.3)

1.4

> 10 years

5(16.7)

2(6.7)

2.

Comorbidity

 

 

 

 

2.1

Yes

19(63.3)

25(83.3)

3.068NS

1(.07)

2.2

No

11(36.6)

5(16.6)

NS= Not Significant     p> 0.05 level of significance

 

Table 4: Comparison of pre test and post test scores among experimental group and control group          N=30+30

Group

Pre test Mean + SD, SE

Post test Mean + SD, SE

Mean difference

t value, df, p (paired t)

Experimental

9.27 + 3.491,

0.63

22.03 +1.712,

0.31

 

 

12.86 + 1.749

 

 

16.7175*, 29, (<0.05)

Control

8.3 + 3.473,

0.63

8.4 + 3.577,

0.65

t value, df, p (unpaired t)

 

18.8964*, 58,

(<0.05)

‘t29’ = 2.04 ‘t58’ = 2.00 * = significant p< 0.05

 

Paired t test (t=16.7175) revealed that there was significant (p < 0.05) mean difference between post test knowledge scores and the pre test knowledge scores in experimental group. Unpaired t test (t = 18.8964) revealed that there was significant mean difference between post test knowledge scores of experimental group and control group at 0.05 level of significance. (Table 4). It was found that education by brochure is effective to improve knowledge of patients regarding foot care.

 

DISCUSSION:

Foot ulcers are the most devastating complication of diabetes. People with diabetes are up to 40% times more likely to undergo lower leg amputation. Every 30 seconds a leg is lost due to diabetes in the world. It has been reported that foot examinations by healthcare professionals, together with appropriate educational initiatives, play a vital role in decreasing diabetic foot complications. Diabetic foot and their consequences are not only a major tragedy for the person suffering from an ulcer but also for his/her family, health care system, society. Diabetic foot can be prevented through careful foot care.

 

The analysis of the data from the present study revealed that 60 patients were at risk of developing diabetic foot i.e. (low risk - 39%, Moderate risk -16%, and High risk -5%) and 40% were not at risk of developing diabetic foot. Correspondingly the study by Wu et al (2015)[6] which also found prevalence of risk factors for diabetic foot complications among 296 patients. According to IWGDF (international working group on the diabetic foot) classification system 35.1% patients were found to be at low risk whereas, 49% of the patients were found at high risk for developing diabetic foot. Study conducted by Nemcova and Hlinkova (2014)[7] contradicts the findings as the patient on the low risk 1 were (27.2%) and low risk 2 (28.4%), moderate risk 3 were (22.6%) and “high risk 4” are (21.4%) of developing foot ulcers; and those with an “active foot disease” (0.4%). In this study, Investigator found that in experimental group mean post- test knowledge scores (22.03+1.712) were higher than the mean pre- test knowledge scores (9.27+ 3.491) with the mean difference of 12.86+1.749. Also the mean post test knowledge scores of experimental group (22.03+1.712) were more than the mean post test knowledge scores of control group (8.3+3.473) with the mean difference of 13.63+1.761. This significant difference (p<0.05) in the pre test and post test revealed the effectiveness of brochure in improving knowledge regarding foot care.

 

The findings were similar to the study conducted by Kafaie et al[8] that also reported that educational program was effective in improving the knowledge level of patients at risk of developing diabetic foot as the post education scores (43.12±8.77) were more than pre test education scores (27.06±8.77) at P=0.0001. Therapeutic educational program was effective in increasing knowledge scores of at risk diabetic patients for prevention of diabetic foot. Many researchers reported that structured teaching programs were effective to increase the knowledge of patients.[9-12]

In present study, it was found that there was no significant association of demographic variables with the knowledge regarding foot care. Findings are in agreement with a study done by Roshan and       Tukaram[13,14] in which there was no significant association of demographic variables with knowledge scores regarding foot care.

 

CONCLUSION:

Based upon above findings it was concluded that Therapeutic educational program was effective in increasing knowledge scores of at risk diabetic patients for prevention of diabetic foot therapeutic educational program. Hence, Brochure was written information that could be ready reference with the patient to take care of their feet on day to day basis to prevent diabetic foot complications and it will also improve their quality of life.

 

REFERENCE:

1.      Manisha C, vaishali R. To assess the knowledge and practice regarding foot care among diabetic foot patient. Indian J.Sci.Res [Internet]. 2013 [cited 2016 October 17]; 4(2): 69-75. Available from : URL www.ijsr.in/upload/ 993669231

2.      Saurabh S, Sarkar S, Selvaraj K, Sekhar S, Ganesh S, Roy G. Effectiveness of foot care education among people with type 2 diabetes in rural pudhucherry. Indian J Endocrinol Metab[Internet]. 2014 Feb [cited2016March20]; 18(1):106-10. Available from: URL: www.nlm.nih.gov/pmc/articles/ PMC3968714

3.      George H, Rakesh P, Krishna M, Alex R, Abraham VJ, George K, et al. Foot care knowledge and practice and the prevalence of peripheral neuropathy among people with diabetes attending a secondary care rural hospital in south India. J Family Med Prim Care [Internet]. 2013 [cited 2016 October 17]; 2(1):27-32. Available from URL: www. nlm.nih.gov/pmc/articles/ PMC3894008

4.      Kaur H. Effectiveness of structured teaching programme regarding self care management in relation to prevention of complications among diabetics. Asian J. Nur. Edu. and Research 4(3): July- Sept., 2014; Page 279-283.

5.      Diabetes care program of Nova Scotia. [Internet]. Nova Scotia: Diabetes care program of Nova Scotia; 2009 Sept [Cited 2016 March 21]. Available from: URL http://diabetescare.nshealth.ca/ sites/ default/files/files/Foot Risk Assessment Form Guide.pdf

6.      Wu L, Hou Q, Zhou Q, Peng F. Prevalence of risk factor for diabetic foot complication in a Chinese tertiary hospital. Int J Clin Exp Med. [Internet]. 2015 March [Cited 2016 Nov];8(3):3785-92 Available from: URL: www. ncbi.nlm.nih.gov/pubmed/26064275.

7.      Nemcova J. and Hlinkova E. The efficacy of diabetic foot care education. JCN [internet]. 2013[cited 2017 May 12];23(5-6):877–82. Available from: http://onlinelibrary.wiley.com/doi/10.1111/ jocn.12290/abstract

8.      Kafiaie p, Noorbala MT, Soheilikhah S, Rashidi M. Evaluation of patients education on foot self care status in diabetic patients. Iran Red Crescent Med J [Internet]. 2012 Dec [cited 2016 October 17];14(12):829-32. Available from: URL: www. ncbi.nlm.nih.gov/ pubmed/23482390

9.      Kumar P, Mangalathil TX, Choudhary V. An experimental study to assess the effectiveness of structured teaching programme on knowledge regarding the management of diabetes mellitus among G.N.M. students in selected nursing school at Sikar, Rajasthan. Asian J. Management 5(3): July-September, 2014 page 329-331.

10.   Girija M, Kokilavani N. Effectiveness of Structured Teaching Programme on Knowledge, Attitude and Practice among Patients with Hypertension. Asian J. Nur. Edu. and Research 4(1): Jan.-March 2014; Page 136-139.

11.   Ravindra HN, Kevin S. Christian, Pooja. G, Prem. R, Priyal. J, Rajat. A, Riya. R. Knowledge and Attitude on Self Monitoring of Blood Glucose (SMBG) Among Diabetic Patients belongs to Waghodia Taluka. Int. J. Adv. Nur. Management. 2016; 4(4): 398-403.

12.   Puhan M, Panda A, Devi S. A Study to assess the Effectiveness of Planned Teaching Programme on Knowledge Regarding Developmental Milestones of Children between 0-2 Years among Mothers at Chirvaltola Basti, BBSR, Odisha. Int. J. Nur. Edu. and Research. 2017; 5(1): 87-90.

13.   Roshan, Tukaram. A study to assess the effectiveness of planned teaching program on knowledge regarding foot care among diabetic client. Ijsr. 2013; (4):1652 .Available from :URL www. ijsr. net/archive/ v4i9/SUB158500. Pdf

14.   Vasudevan NJ, Sara B. A Study to Assess the Effectiveness of Structured Teaching Programme on Knowledge regarding Management of Type 2 Diabetes Mellitus among Patients with Type 2 Diabetes Mellitus attending Diabetic OPD, RMMCH, Annamalai University. Int. J. Nur. Edu. and Research 2(2): April- June 2014; Page 113-116.

 

 

 

Received on 30.3.2020            Modified on 25.04.2020

Accepted on 11.05.2020    © AandV Publications all right reserved

Int. J. Nur. Edu. and Research. 2020; 8(4):445-449.

DOI: 10.5958/2454-2660.2020.00099.X