Diabetes mellitus in which the ability of the body to produce or respond to the insulin hormone is impaired leading to impaired metabolism of carbohydrates with elevated blood glucose level

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Diabetes mellitus in which the ability of the body to produce or respond to the insulin hormone is impaired leading to impaired metabolism of carbohydrates with elevated blood glucose level. More than 350 million people worldwide were known to have diabetes mellitus in 2013, and an estimated 592 million are expected to have it by 2035. Most of these people are between 40 and 59 years of age and found at middle and low income countries. The World Health Organization (WHO) estimates that diabetes mellitus will be the seventh leading cause of death in the next 15 years.(Goie, 2016)

The incidence rates of diabetes across the world remain high despite the remarkable advancements that occur in the medical sector both nationally and internationally. Patients undergone amputation surgery are approximated to be 5% to10%, which is more than 50% of all amputations which are not due to injury. The right foot care, good blood glucose control and the diabetes education can prevent up to 85% of the diabetic foot amputations. Other studies shown reduction in the foot amputation rate from 0.8% to 0.5% when appropriate diabetic foot care and education are implemented(Li, Yuan, Guo, Lou, & Zhao, 2014).

In sub-Saharan Africa, countries identified to have the highest rate of type 2 diabetes mellitus are Nigeria, South Africa, Ethiopia, the Congo and Tanzania. The prevalence rate of diabetes mellitus has increased amongst the indigenous people of Africa due to several factors including westernization of the local societies. In South Africa, the prevalence of diabetes mellitus amongst the black population is the second, the first being that of South Africans of Indian origin(Goie, 2016).

Lower limb amputation is one among the complications of diabetes mellitus that can potentially be prevented when the patient is equiped with enough knowledge. Several risk factors may lead to the formation of foot ulcer which in turn may complicate into an adverse form whose only alternative of treatment is lower limb amputation. Major risk factors are peripheral vascular disease and peripheral neuropathy(Chiwanga & Njelekela, 2015).
In addition to these, others are bare foot walking, inappropriate footwear, and delay in seeking medical care as well as poor foot hygiene. In recent years, the level of interest and knowledge about diabetic foot ulcer has grown considerably, as witnessed by the development of an international consensus, clinical guidelines to be used in both prevention and treatment of diabetic foot, and improvements in evidence-based clinical practice in various parts of the world(Chiwanga & Njelekela, 2015).

In a study conducted at the Muhimbili National Hospital (MNH) diabetic clinic, 87 % of patients reported never inspecting their feet, and 66 % reported they were not interested in further knowledge of diabetes foot care (Chiwanga & Njelekela, 2015)

PROBLEM STATEMENT
Among the complications of diabetes mellitus, diabetic foot ulcer is the leading cause for hospitalization and is the most distressing one. Neuropathy, peripheral vascular disease and infections are the other common conditions associated with diabetic foot disease (Fomboh, 2017).It is estimated that 20% of diabetic patients have 15% of developing foot infection in a year and 5% among those with diabetic foot disease will eventually undergo amputation.(Goie, 2016)
Due to the fact that the patient himself is the primary care taker of his feet, raising awareness to these patients will greatly help to reduce the incidence of diabetic foot disease. Commonly, diabetic foot disease develops in areas of the foot exposed to continuous pressure, friction and repetitive trauma. Harmful footwear such as those with rough interiors, high heels and narrow foreparts, is one of the major precipitating causes implicated in the progression to diabetic foot disease and amputation. Evidence shows that knowledge is associated with better attitudes and practices of foot care, and should consequently bring clinical benefit, although this is not always the case as the quality of care offered at primary healthcare level in our settings is often unsatisfactory (Goie, 2016).
Despite the fact that there is a number of literatures explaining about diabetic complications particularly diabetic foot disease and the importance of foot care among patients with diabetes, still there is a limited number of published data on the knowledge and practice of foot care specifically in the context of Sub-Saharan Africa Tanzania being inclusive(Chiwanga & Njelekela, 2015).
The purpose of this study is to assess the level of knowledge that the patients with diabetes mellitus have regarding proper foot care because this is what influences their practice of foot care to avoid development of diabetic foot disease. The results from this study will give a way forward on designing awareness programs to patients with diabetes mellitus hence contribute in reduction of the incidences of diabetic foot disease and limb amputation which could be prevented.

BROAD OBJECTIVE
To assess the knowledge of foot care among patients with diabetes mellitus attending diabetic clinic at Muhimbili National Hospital from December2018 to February 2019.
SPECIFIC OBJECTIVES
I. To determine the level of knowledge that the patients with diabetes attending the diabetic clinic at Muhimbili National Hospital have regarding foot care.

II. To identify the factors which are likely to influence the level of knowledge on foot care among patients with diabetes.

RESEARCH QUESTIONS
I. What level of knowledge do patients with diabetes have regarding foot care¬?
II. Do patients with diabetes understand the factors contributing or aggravating the development of diabetic foot ulcer?
III. Do patients with diabetes understand the precautions and the practices they have to consider in order to avoid development of diabetic foot ulcer?

HYPOTHESIS
Patients with diabetes who have the knowledge on foot care are less likely to develop diabetic foot disease compared to those who do not have knowledge.

CONCEPTUAL FRAMEWORK
It has been constructed from different literatures that the foot care knowledge among patients with diabetes interacts with several other factors to determine whether the patient will develop diabetic foot disease or not. The independent variable is the knowledge on diabetic foot care and the dependent variable is the development of diabetic foot disease. The relationship between these variables is summarized in the figure below.

LITERATURE REVIEW
A study conducted at China on current foot care knowledge among patients with diabetes showed that the foot care knowledge and practice is poor particularly on two aspects that are inspecting the shoe before wearing and daily foot checking(Li et al., 2014). Most of the patients will consider such practices only when they have already developed diabetic foot disease.

The study conducted in Dar es salaam, Tanzania showed that 194 patients (48.0 %) had received information about foot care. Duration of diabetes had no effect on whether patients received information or not (p =0.158). The majority of patients received education from nurses (83.5 %); only 16.6 % received foot care information from doctors; and 6.2 % were educated by other sources, such as the media(Chiwanga & Njelekela, 2015).

Another study showed that Most of the studied patients 62.5% had an acceptable and good foot care practices. There results of the study reveals that there was a significant association between patients’ educational level and monthly income and overall assessment of preventive foot care practices.(Noaman, 2017)

The study done in South Africa about awareness of diabetic foot disease among patients with type 2 diabetes mellitus attending chronic outpatient department at a regional hospital in Durban, Most participants said that foot examination was their own responsibility. More than 90% of participants had not received any previous form of diabetic foot care education from any source(Goie, 2016). 65% of participants reported to examine their feet every day, and 22.2% examined their feet only when they had a problem. 94% of participants who did not cut their own toenails had it done by a family member. Of the 265 participants who trimmed their toenails, 79.3% trimmed their nails along the edges and 20.7% trimmed them straight(Goie, 2016)

In another study done in India, the analysis showed that 60.9% of the participants were aware of the importance of blood glucose control in preventing foot complication. The vast majority (86.9 %) of the study population understood that patient with diabetes are required to practice special foot care. The majority of participants 67.6% were aware of the importance of wearing special shoes to minimize risk of foot problems; also 79.4% of them were knowledgeable that they should regularly inspect their feet. A large proportion of our participants 81.5% were aware of the need for medical consultation when infection develops in their feet(Sutariya ; Kharadi, 2016).This demonstrate the high level of knowledge to this particular group.

REFERENCES
Chiwanga, F. S., ; Njelekela, M. A. (2015). Diabetic foot: Prevalence, knowledge, and foot self-care practices among diabetic patients in Dar es Salaam, Tanzania – a cross-sectional study. Journal of Foot and Ankle Research, 8(1), 1–7. https://doi.org/10.1186/s13047-015-0080-y
Fomboh, R. N. (2017). Knowledge and Practice on Diabetic Foot Prevention and Self-care by Patients at the Bamenda Regional Hospital , Cameroon Knowledge and Practice on Diabetic Foot Prevention and Self-care by Patients at the Bamenda Regional Hospital , Cameroon, (August).
Goie, T. (2016). Awareness of diabetic foot disease amongst patients with type 2 diabetes mellitus attending the chronic outpatients department at a regional hospital in Durban , South Africa. African Journal of Primary Health Care ; Family Medicine, 8(1), 1–8.
Li, R., Yuan, L., Guo, X., Lou, Q., ; Zhao, F. (2014). ScienceDirect The current status of foot self-care knowledge , behaviours , and analysis of influencing factors in patients with type 2 diabetes mellitus in China. International Journal of Nursing Sciences, 1(3), 266–271. https://doi.org/10.1016/j.ijnss.2014.05.023
Noaman, A. A. (2017). Assessment of Preventive Foot Care Practices among Patients with Diabetes Mellitus Type II. J Fac Med Baghdad, 244(593). Retrieved from http://iqjmc.net/wp-content/uploads/2017/10/11Aqeel-A.-Noaman.pdf
Sutariya, P. K., ; Kharadi, A. (2016). Knowledge and practice of foot care among the patients of diabetic foot?: a hospital based cross-sectional study, 3(4), 1850–1855.