Department of Public Health and Caring sciences Section of Caring Science
Knowledge and practices regarding foot care
among patients with Type 2 diabetes in Ho Chi
Minh City, Vietnam
A quantitative study
Authors:
Supervisor:
Sofia Hellenberg
Pranee Lundberg
Stina Thunberg
Co- supervisor:
Nguyen Thi Phuong Lan
Examiner:
Clara Aarts
Thesis in Caring Sciences 15 ECTS credits
1 ABSTRACT
Introduction: Previous research shows that knowledge and practice was low in type 2
diabetes patients and that women had better practice/self-care than men.
Aim: The aim of this study was to investigate the knowledge and practices regarding
foot-care among patients with type 2 diabetes in Ho Chi Minh City, Vietnam, and also investigate if there was any difference between genders in knowledge and practicing of foot care.
Method: This study was a descriptive and cross-sectional design with quantitative method.
The data was collected at the out-patient clinic of the University Medical Center in Ho Chi Minh City, Vietnam and 100 patients participated voluntarily to answer questionnaire. Orem’s self-care theory was used as theoretical framework. Data were analysed by using statistics.
Result: The result shows that more than 70% of the patients had good knowledge of foot care
and no significant differences between the genders in the knowledge. Their foot care practices were various. There was significant difference between men and women about using a hot water bottle or heating pad on the feet, and more women than men did. For type of shoes, there were differences between genders in wearing broad, round toes and shoes made of leather or canvas, and more men than women did.
Conclusion: The knowledge of foot care was good, but the practice of foot care was low.
There was not found any significant difference between the genders in knowledge, but some differences in the foot care practices. More information about foot care is needed to prevent complications with type 2 diabetes.
2 SAMMANFATTNING
Introduktion: Tidigare forsknings resultat visar att kunskapen om egenvård och utförande av
fotvård hos patienter med diabetes typ 2 var låg. Kvinnorna var dock bättre på att utföra egenvården än männen.
Syfte: Syftet med denna studie var att undersöka kunskapen och utförandet av egenvård hos
patienter med diabetes typ 2 i Ho Chi Minh City, Vietnam, samt att undersöka om det fanns några skillnader mellan män och kvinnor i kunskapen om egenvård inom fotvård samt dess utförande.
Metod: För att undersöka detta gjordes en kvantitativ tvärsnittsstudie med hjälp av enkäter.
Det var 100 patienter på en mottagning vid University Medical Center, Ho Chi Minh City, Vietnam, som deltog frivilligt. Orems egenvård teori användes som teoretiskt ramverk i detta arbete. Data analyserades av statistik.
Resultat: Resultatet i denna studie påvisar att mer än 70 % av patienternas visade god
kunskap och inga signifikanta skillnader fanns mellan kvinnor och män gällande kunskapsnivån. Utförandes av fotvården visade sig dock vara varierande och det fanns signifikanta skillnader mellan kvinnor och män gällande fotvården. Kvinnor använde sig oftare av varma pads och flaskor på deras fötter än vad männen gjorde. Kvinnor och män använde också olika typer av skor. Männen använde oftare breda skor med rundad tå, skor av läder eller canvas skor än vad kvinnorna gjorde.
Slutsats: Kunskapen om fotvård hos diabetes patienter i Ho Chi Minh City var god, dock var
utförandet av fotvården varierande i denna studie. Det visades ingen signifikant skillnad mellan kvinnor och män angående kunskapsnivån, dock fanns det skillnader angående
utförandet av fotvården. Det behövs fortsatt information om fotvård för att patienter med typ 2 diabetes ska förhindra komplikationer
3 CONTENTS
1. Introduction 5
1.1 Type 2 diabetes mellitus 5
1.2 Prevalence of type 2 diabetes in the world 5
1.3 Type 2 diabetes in Vietnam 6
1.4 Risk factors 6
1.5 Complications 6
1.6 Foot ulcer 7
1.7 Self-care and treatment of diabetes 8
1.8 Knowledge about diabetes and foot care in type 2 diabetes patients 9
1.9 Practice of foot care in type 2 diabetes patients 10
2. Theoretical framework 11 3. Rationale of research 12 4. Aim 12 5. Research questions 12 6. Methods 13 6.1 Design 13 6.2 Settings 13 6.3 Sample 13
6.4 Data collection method 16
6.5 Procedure 16
6.6 Data analysis 17
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8. Results 18
8.1 Demographic information 18
8.2 History of foot problems 19
8.3 Current foot or leg problems 19
8.4 Knowledge of foot care 19
8.5 Foot care practice 20
8.6 Foot care education 24
9. Discussion 25
9.1Results discussion 26
9.1.1 Knowledge of foot care among the patients with type 2 diabetes 26
9.1.2. Foot care practices among patients with type 2 diabetes. 26
9.1.3. Difference between genders in knowledge and practice of foot care 27
9.2 Method discussion 28
9.3 Theoretical framework discussion 29
9.4 Clinical implication 30
9.5 Further research study 30
9.6 Acknowledgement 31
10. References 32
5 1. INTRODUCTION
1.1 Type 2 diabetes mellitus
Type 2 diabetes is a chronic disease that develops when the pancreas does not produce enough insulin, or when the body is unable to use the insulin it produces effectively. The hormone insulin is regulating the blood sugar. If the blood sugar is too high over a long time it can lead to serious damage on the body’s systems, especially the blood vessels and nerves (World health organization, [WHO] 2013). Type 2 diabetes develops when the body fails to use its own insulin. The most common reason is high body weight and/or inactivity (Almås, 2001). Symptoms of type 2 diabetes are increased urination, thirst and fatigue mentally and
physically. Some people also get bad eyesight. The symptoms often develop very slowly and some people do not get any symptoms at all, which makes it difficult to defect the disease (FASS, 2011). The patient can be diagnosed in three ways: glycosylated hemoglobin test, fasting glucose and oral glucose test. After the diagnosis is determined the patient have to do home monitoring and do regular check up’s at the local nurse (Heart, 2012).
1.2Prevalence of type 2 diabetes mellitus in the World
About 347 million people around the world have diabetes and 90 % of the affected have diabetes type 2 (WHO, 2013). In 1980 the prevalence of people with diabetes was 153 million in the world. Reasons for the increase of type 2 diabetes are obesity, inactivity, urbanization, adverse dietary and that people get older (Maruthur, 2013). The biggest increase is in Asia, Middle East and in America (Insulin, 2011). Type 2 diabetes occurs in both high- and low-income countries. However, the low-low-income countries are bearing the majority of the burden. Increased supervision of the diabetes contributed to an increased prevalence of diabetes in high income countries (Maruthur, 2013).
6 1.3 Type 2 diabetes in Vietnam
Type 2 diabetes is on it is rise in Vietnam. In 2000 the prevalence of people with diabetes in Vietnam was 792,000 (WHO, 2000). In 2012 experts believed that approximately two million people had diabetes in Vietnam. About 60 % of them are unaware of their condition and remain undiagnosed (WHO, 2012). In 2004 the prevalence of type 2 diabetes was 3.8% in Ho Chi Minh City, Vietnam. The people in Ho Chi Min City with a high level of education had a lower prevalence of type 2 diabetes, compared to people with lower level of education (Duc Son et al., 2004). In 2008 almost seven percent of the adults in age 30 – 69 years had diabetes in Ho Chi Minh City (WHO, 2012).
1.4 Risk factors
Type 2 diabetes is a common disease which usually affects older people, however it is
beginning to be more common in younger ages. The disease often develops gradually and can be inherited, but it can also be due to the lifestyle (Almås, 2001). A “key” risk factor for developing type 2 diabetes is overweight and obesity. Other risk factors are ageing, genetics, previous gestational diabetes and family history of type 2 diabetes (Mc Naughtun,
2013). Physical inactivity, stress and smoking are also risk factors for type 2 diabetes (Almås, 2001). In the study of Tomisaka et al. (2002) about risk factors for type 2 diabetes among Asian women, they found that Vietnamese women were at high risk to develop type 2
diabetes because of their high obesity levels and their carbohydrate intake was higher than the other Asian women in the study.
1.5 Complications
In 2004 three - four million people around the world died in complications of high blood sugar and 80% of the deaths due to diabetes occur in low- and middle-income countries. In the next ten years they are projected to rise about 50 % (WHO, 2013). High blood sugar during a long time can results in a lot of complications for the patient. The acute
7
neuropathy and nephropathy. Neuropathy means that the nerves are damaged, which affects the sensitivity in the hands, feet or both, but it can also give the patients tingling, burning and/or tearing in the outer extremity. This can lead to ulcers in the lower extremity. Diabetic patients are also more susceptible to infections than other patients (Brown & Edwards. 2005).
1.6 Foot ulcers
Foot complications are common in type 2 diabetes patients. Diabetes may cause nerve damage that can take away the feeling in the feet, which can make the patients unable to feel stones in their shoes or blisters on their feet. The blood circulation to the feet can also be reduced which can make it difficult for ulcers on the feet to heal. This complication can lead to an infection or a non-healing ulcer, and in the worst case it can lead to amputation
(American College of Foot and Ankle Surgeons, [ACFAS] 2009). Sensory neuropathy and peripheral vascular disease is the main reason for foot ulcers but also clotting abnormalities, immune functions, smoking and neuropathy play an important role. Peripheral vascular disease make it hard for the nutrition and oxygen to get to the ulcer making it hard for it to heel and in the worst case it can lead to amputation (Brown and Edwards, 2005). Diabetic foot ulcers can also have negative psychological and social effects. For example it can lead to reduced social activities and employments. It can also have negative effects on the diabetes patient mental health and at the relationship to family and friends (Goodridge, Trepman & Embil, 2005).
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it is common to have the disease without knowing for many years, especially where health care systems are rudimentary.
1.7 Self-care and treatment of diabetes
The primary treatment of type 2 diabetes is self-care because it improves the patients’ health and prevents complications. Many of the risk factors can be prevented with changes of lifestyle for people with high risk (Marques, Silva, Coutinho & Lopes, 2013). The lifestyle changes involve eating healthy food, loss in weight for people with obesity, regular exercises, foot care and meetings with health care providers regularly. The patients have to learn about the disease, self-monitoring the glucose and how the treatment works (Almås, 2001). The self-care is a partnership between the patient and the health care provider. The health care provider gives information of self-care and mentoring in self-care to let the patient perform it (Marques et al., 2013).
The health care provider’s education for the diabetes patient is important for their self-care of the disease. If the information to the patient is not clear, the patient can forget it or may not understand it, the patient can also miss out important facts. This can cause lack of the self-care or ignorance of the healthy lifestyle for the patient (Tham, Ong, Tan &How, 2004). Increased participation in decision-making about diabetes care is associated with an
increasing understanding of care in diabetes (Quinn et al., 2011). The competence of self-care can decrease in elderly age. Marques et al. (2013) found that very few (6 %) of the elderly with type 2 diabetes had the competence to provide their self-care. Low level of education and bad eyesight was contributing factors and this group needs more help and instruments for performing their self-care.
Medication may be needed if blood glucose is not adequately controlled with the primary treatment. The aim of treatment is to lower the blood glucose levels and reduce the risk of complications. Preventive measures to prevent foot problems should begin immediately after diabetes diagnosis is established (Almås, 2001).
Mull, Nguyen and Mull (2001) found that many Vietnamese people used herbal medicine to treat their type 2 diabetes. They thought herbal medicine was much safer than Western
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Vietnamese patients have not achieved a good control of their diabetes and one reason is that they do not have knowledge of how the insulin works and about their disease. There was a strong aversion to use insulin injections among the Vietnamese people because the needle was painful, the insulin created an imbalance in the body, gave blindness, was addictive and the insulin showed that a person was seriously ill and had a chronic disease. In Helman (2001), Vietnamese in USA and England said that their diabetes has their roots in psychological emotions, like feeling sad and being stressed. They also thought the weather could be the reason of their symptoms. They explained their disease with imbalance between the “hot” and “cold” substance in their body. They thought that insulin is a “hot” substance and could lead to substance illness; therefore, they prefer to use traditional Chinese medicine and herbs.
1.8 Knowledge of diabetes and foot care in Type 2 diabetes patients
The study of Pollock, Unwin & Connolly (2004) showed that the type 2 diabetes patients knowledge was low. Those with high risk generally had better knowledge than the patients that had lower risk for foot complications and amputation. Females had higher knowledge than the males. The patients who had received information or advice previously had better knowledge. Also the patients in the study of Khamseh, Vatankhah & Baradaran (2007) had low knowledge about foot care practice. The patients who had a history of diabetes in ten years or more had better knowledge about foot care practice than those who had diabetes less than ten years and 70 % of the patients said that they had not received advice or information about foot care.
Khamseh et al. (2007) and Quinn et al. (2011) showed that the type 2 diabetes patients with higher education had better knowledge than those with lower education. Quinn et al. (2011) also described that the patients with lower education needed more information about their diagnosis. Tham et al. (2004) found that people with type 2 diabetes, which have been educated in diabetes, have better knowledge about the disease and in changing practices in their self-care. In addition, Kavanagh et al. (2010) found that lower education and income are associated with higher levels of glucose, waist circumference and blood pressure when compared to people with higher education and income. Kafaie., Rashidi., Sedigheh
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had inadequate knowledge about foot-care. After completing the training most of the patients (85 %) had sufficient information to be able to perform proper self-care of their own feet.
1.9 Foot care practice
Foot care is important for preventing foot ulcers among type 2 diabetes patients. The patients have to inspect their feet daily and check for cuts, redness, blisters, swelling or nail problems (ACFAS, 2009). They shall wash their feet daily with warm water and a mild soap, but it’s important to test the water temperature before washing the feet. Finally the patients shall dry their feet and especially between the toes (Brown & Edwards, 2005). The patient will use a moisturizer after bath, but not between the toes because that could encourage a fungal
infection. The patients shall cut the nails straight across and file the edges and wear clean, dry socks and change them daily and keep the feet dry and warm (ACFAS, 2009). Use warm water and mild soap when cleaning the cuts on the feet and cover with clean dressing and separate overlapping toes with cotton. The patient has to report skin infections or non-healing sores to health care provider immediately. Avoid prolonged sitting, standing and crossing of legs (Brown & Edwards, 2005). The patient shall not walk barefoot because the patient can step on something or get a cut in the foot (ACFAS, 2009). The patient shall avoid open-toe, open-heel and high-heel shoes. Leather shoes are preferred before plastic ones. Shake the shoe before putting it on (Brown & Edwards, 2005).
Several studies have shown that the practice of good foot care is very low (Pollock et al., 2004; Khamseh et al., 2007;Bhupendra, Anand, Sangram, Dilip & Ravinder, 2008). In the study of Pollock et al. (2004) 83% of the patients failed to inspect their feet. Khamseh et al. (2007) found that it was 60% who failed to inspect their feet and 42 % did not trim their nails. Also the patients in the study of Bhupendra et al. (2008) did not inspect their feet in the right way and 76,4 % did not wash their feet properly and 56,4 % walked barefoot outside and inside.
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more health care for acute foot ulcers problem. They showed a passive attitude and had a more pessimistic view of the future (Goodridge et al., 2005).
2. THEORETICAL FRAMEWORK
Dorothea Orem´s theory of self-care and self-care deficit was used as theoretical framework for this study. The theory highlights the importance of self-care and the goal is normal function, development, health and well-being. The theory is based on two key concepts, self-care and self-self-care deficit. The first key-point (self-self-care) is based on why and how people self-care for themselves and the second key-point (self- care deficit) describes and explains why people can be helped through nursing and a nurse.
Self-care depends on the health of the person, interest for maintaining living, function, well-being etc. Self- care is affected by age, unable to perform the self-care well-well-being and interest of performing the self-care that is needed
The nurse have to identify five methods to help the patient
“ Acting for or doing for another”
“Guiding and directing”
“Providing physical or psychological support”
“Providing and maintaining an environment that supports personal development”
“Teaching”
(Alligood & Tomey, 2009).
12 3. RATIONALE OF RESARCH
In Ho Chi Minh City, type 2 diabetes has become more common and the disease is expanding fast. Important determinants of the increased prevalence of the disease are industrialization, development with sedentary lifestyles and shift of dietary habits with much carbohydrate (Duc Son et al., 2004). Foot ulcers are complications due to diabetes, and foot-care is an important prevention measure that should be concurrently started with the settling of the diabetes diagnoses (Almås, 2001). High level of education increased the degree of self-care and understanding of their diabetes diagnosis which makes it important to inform the patients with diabetes (Tham et al., 2004). To prevent foot ulcers among type 2 diabetes patients in Ho Chi Minh City, it is important to find out what their knowledge is and practice of foot care and investigate if there are some differences between the genders regarding knowledge and practice in foot care. The results of this study will provide more information in order to develop an appropriate intervention program concerning foot care.
4. AIM
The purpose of this study was to investigate the knowledge and practices regarding foot-care among patients with type 2 diabetes in Ho Chi Minh City, Vietnam.
5. RESEARCH QUESTIONS
1. What knowledge about foot care do the patients with Type 2 diabetes have?
2. How have they practiced their foot care?
13 6. METHOD
6.1 Design
The study was a descriptive and comparative cross-sectional design. This method was chosen because it is time-effective and provides a lot of data (Eliasson, 2006).
6.2 Setting
The data for the project was collected at the outpatient department at the University Medical Center, in Ho Chi Minh City, Vietnam. Ho Chi Minh City is set in the south part of Vietnam and is the largest city in the country. The data was collected during one week in November, 2013. In one day around 150 – 180 patients are visit the outpatient department, 80 % (120 – 140 patients) of them had the diagnose type 2 diabetes. The most common reason for the type 2 diabetes patients to visit the outpatient clinic was to check up their diabetes.
6.3 Sample
A purposive sample was used for selecting the participants. The outpatients who could participate in the study were the ones that met the inclusion criteria at the diabetic out-patient clinic during the data collection period. 100 patients were asked to participant in this study and all of them participated.
The inclusion criteria to participate were:
1. Patients with type 2 diabetes, both male and female, with an age over 18 years
2. They are able to write and read or can be helped to fill in the questionnaire
3. They are living in Ho Chi Minh City in Vietnam
4. They should not have any mental disease or dementia
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Demographic information of the type 2 diabetes patients
The total number of patient participated in the study was 100; 32 (32%) men and 68 (68%) women. The age of the participants was between 32 – 86 years, and the mean age of them was 57.3 years (SD 9.2). The most common education for the women was primary school (35.3%) while men had secondary school education (28.1%). For men the most common work was merchant (25.0%) and for women was house duty (32.4%). About 19 (63.3%) of men and 19 (28.4%) of women answered that their income was enough. Three (10%) of men and 16 (28.1%) of women had income less than 2,000,000 VND (= 95 $/month). Of the patients there were 88 (91.7%) who did not smoke and 83.3 % did not drink alcohol at all. About 32
(32.3%) patients had their diabetes for one year or less and 56 (57.1%) responded that they did not have a history of diabetes in the family. 49 (49 %) used control diet and medicine to treat their diabetes and 93 (93.9%) controlled their diabetes regular. See Table 1 a, b.
Table 1a. Demographic information of the patients with type 2 diabetes
Demographic information
Total (n=100) Male (n=32) Female (n=68)
N % Mean ±SD N % Mean ±SD N % Mean ±SD Gender 100 100.0 32 32.0 68 68.0 Age 31-40 41-59 51-60 61-70 >70 7 15 42 27 9 7.0 15.0 42.0 27.0 9.0 57.34 ± 9.29 7 6 10 7 2 21.9 18.8 31.2 21.9 6.2 57.34 ± 9.29 0 9 32 20 7 0 13.2 47.1 29.4 10.3 59.76 ± 9.29 Marital status Single Married Widowed Missing 7 78 10 5 7.4 82.1 10.5 3 27 1 1 9.7 87.1 3.2 4 51 9 4 6.2 79.7 14.1 Religion Catholic Buddhism No religion Other Missing 10 68 17 4 1 10.1 68.7 17.2 4.0 4 17 10 1 0 12.5 53.1 31.2 3.1 6 57 7 3 1 9.0 76.1 10.4 4.5 Education Primary school Secondary school High school
15 Occupation Worker Government officer Technician Merchant Farmer House duty Other 1 8 4 28 12 22 25 1.0 8.0 4.0 28.0 12.0 22.0 25.0 1 1 3 8 6 0 8 3.1 18.8 9.4 25.0 18.8 0.0 25.0 0 2 1 2 6 22 17 0.0 2.9 1.5 29.4 8.8 32.4 25.0 Children No Yes, 1 – 2 Yes, 3 – 5 Yes, >6 11 34 40 15 11.0 34.0 40.0 15.0 5 15 10 2 15.6 46.9 31.2 6.2 6 19 30 13 8.8 34.0 40.0 15.0
How many people who are living at home 0 1 – 2 3 -5 >6 2 30 51 17 2.0 30.0 51.0 17.0 1 8 18 5 3.1 25.0 56.0 15.6 1 22 33 12 1.5 32.4 48.5 17.6 Income Enough Barley enough Totally inadequate Missing 38 47 12 3 39.2 47.4 13.4 19 8 3 2 63.3 26.7 10.0 19 38 10 1 28.4 56.7 14.9
Table 1b. Demographic information (continue).
Demographic information
Total (n=100) Male (n=32) Female (n=68)
N % Mean ±SD N % Mean ±SD N % Mean ±SD
Income per month (VDN)
<1.999.999 2.000.000 – 5,000 000 5.000.001 – 10.000 000 10. 000 001 – 15.000 000 > 15. 000 0001 Missing 19 38 14 6 10 13 21.8 43.7 16.1 6.9 11.5 3 11 5 4 7 2 10.0 32.7 16.7 13.3 23.3 16 27 9 2 3 11 28.1 47.4 15.8 3.5 5.3 Smoking No Yes, 1 – 5 cigarettes/day Yes 6 – 10 cigarettes/day Missing 88 2 2 8 91.7 2.1 2.1 4.2 23 2 2 5 74.2 6.5 6.5 12.9 65 0 0 3 100.0 0.0 0.0
Drinking alcohol. Glas/day.
No Yes, 1 – 2 glas/day Yes, 3 – 5 glas/day Yes, 6 or more Missing 80 13 2 1 5 83.3 13.5 2.1 1.0 16 12 2 1 2 51.6 38.7 6.5 3.2 64 1 0 0 3 98.5 1.5 0.0 0.0
Years living with diabetes
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Family History with diabetes
No Yes Missing 56 42 2 57.1 42.9 17 15 0 53.1 46.9 39 27 2 59.1 40.9 Treatment of diabetes Control diet Take medicine Inject insulin Other
Control diet and medicine Take medicine and inject insulin Control diabetes and inject insulin Control diabetes, take medicine and inject insulin 2 24 2 1 49 9 2 11 2.0 24.0 2.0 1.0 49.0 9.0 2.0 11.0 0 11 0 1 13 4 0 3 0.0 34.4 0.0 3,6 40.6 12.5 0.0 9.4 2 13 2 0 36 5 2 8 2.9 19.1 2.9 0.0 52.9 7.4 2.9 11.8
Regular follow up diabetes treatment No Yes Missing 6 93 1 6.1 93.9 3 29 0 9.4 90.6 3 64 1 4.5 95.5
Help with diabetes at home
Wife/husband Children My relative No one
Wife/husband and children Other 15 11 3 60 4 7 15.0 11.0 3.0 60.0 4.0 7.0 5 2 2 18 3 2 15.6 6.2 6.2 56.2 6.2 9.4 10 9 1 42 4 2 14.7 13.2 1.5 61.8 5.9 2.9
6.4 Data Collection Method
A questionnaire in English has been developed by Dr. Pranee Lundberg, Associate Professor, at the Department of Public Health and Caring Sciences, Uppsala University and Ms Nguyen Thi Phuong Lan, Nursing Lecturer, at the Department of Nursing, University of Medicine and Pharmacy in Ho Chi Minh City (Appendix 1). The questionnaire was based on literature (Bijoy et al., 2012; Pollock et al., 2004) and also adjusted to Vietnamese culture. The
questionnaire was translated to Vietnamese and then it was translated back and forth for face validity of the questionnaire. The questionnaire was pilot tested by our co- supervisor Nguyen Thi Phuong Lan in Ho Chi Ming City, before data collection.
17 6.5 Procedure
The project was the collaboration between the Department of Public Health and Caring Sciences, Uppsala University, Sweden and the University of Medicine and Pharmacy in Ho Chi Minh City, Vietnam, by Linnaeus-Palme Exchange Programme.
Our Co- supervisor, Nguyen Thi Phuong Lan, contacted the Director of the Medical Centre for permission to carry out the study. The nurses at the clinic were informed about the study and helped us to give information to the patients with type 2 Diabetes. The participants were informed about the study and their rights to participate. The co-supervisor together with the authors gave both oral and written information to the outpatients at the diabetes clinic about the study and their right for participation. The patients who were interested to participate received a questionnaire to answer during the waiting time at the clinic. The patients gave it back after finishing. If some patients had problem to fill in the questionnaire or had questions during answering the questionnaire, Ms. Nguyen Thi Phuong Lan and a few Vietnamese lecturers helped the participants to fill in the questionnaire. It took around 15 – 20 minutes to answer the questionnaire.
6.6 Data analysis
Analysis of data from the questionnaire was done using the statistic program, SPSS (The Statistical Package of Social Science).
The answers about demographic information in Part I, A (questions 1 – 17) was coded into numbers and then registered in the SPSS-program using descriptive statistic.
The B and C part (Questions 18 – 23) in Part one were based on a nominal scale and we used numbers and percent to investigate the participant’s history of foot problems and current foot problems.
To analyze research question 1, “What knowledge about foot care do the patients with Type 2 diabetes have?”, we analyzed the answers in part two about Knowledge (Question 25) with numbers and percent. In part II the participant could answer true or false of 15 questions. The “True” answer of all questions is the right answer. Fifteen questions were regarding
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score is more than 70% (11-15), Satisfactory knowledge: If score is 50-70% (10-8), and Poor knowledge: Scores less than 50% (<8)(Bijoy et al., 2012).
To analyze the research question 2, “How have they practiced their foot care?”, we analyzed the answers in part III about practice (Questions 26 – 46) with numbers and percent.
To answer research question three, “Is there any difference between the genders regarding knowledge about foot care and its practice?”, we analyzed the answer in part two about knowledge (Question 25) and the answers in part three about practice (Questions 26 – 46) by using Chi squared test.
The significant difference between men and women has a determined p-value ≤0.05. The results were presented by using tables and text.
7. ETHICAL CONSIDERATIONS
19 8. RESULTS
8.2 History of foot problems
About 85 (85%) of the participants answered that they never have had a foot ulcer and 87 (87.9%) have never had a sore or cut on the leg or foot that took more than two weeks to heal. Only one (1%) answered that they had amputated a leg or foot.
8.3 Current foot or leg problems
About 96 (96%) of the patients reported that they did not have an ulcer, sore or blister on the feet at this moment. 58 (58%) answered that they had numbness, tingling, pins, needles or itching on their feet.
8.4 Knowledge of foot care
Of the participants 74 (74%) had good knowledge about foot care. There was no significant difference between men and women about knowledge of foot care (p>0.05).See Table 2.
Table 2. Knowledge of foot care, score test
Knowledge of foot care Total (N=100) N % Men (N=32) N % Women (N=68) N % >70 % Good knowledge (11- 15 right). 74 74.0 22 68,8 52 76.5 50 – 70 %, Satisfactory knowledge (8-10 right). 18 18.0 7 21.9 11 16.2 < 50 % Poor Knowledge (Less than 8 right).
8 8.0 3 9.4 5 7.4
P-value = 0.712, X2 = 0.679
Note: p≤0.05 = significant difference.
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to dry the feet, to keep the skin soft to prevent dryness, and to inspect the feet´s every day. Half of the patients reported that they should not apply lotion in the interdigital spaces. There were no significance differences between genders concerning the items of knowledge of foot care. See Table 3.
Table 3.Knowledge of foot care among the patients with type 2 diabetes.
Knowledge of foot care Total (n=100) Male (n=32) Female (n=68) X2 p-value No n (%) Yes n (%) No n (%) Yes n (%) No n (%) Yes n (%)
Importance of taking anti-diabetes treatment to prevent complication 5 (5.0) 95 (95.0) 2 (6.2) 30 (93.8) 2 (6.2) 65 (95.6) 0.155 0.694
Daily washing the feet 4 (4.0) 96 (96.0) 2 (6.2) 30 (93.8) 2 (2.9) 66 (97.1) 0.620 0.431
Using warm water for washing/bathing 29 (30.0) 71 (70.0) 12 (37.5) 20 (62.5) 17 (25.0) 51 (75.0) 0.651 0.199 Checking temperature of water before using
37 (37.0) 63 (63.0) 13 (40.6) 19 (59.4) 24 (35,3) 44 (64,7) 1.625 0.607
Drying the feet after washing 15 (15.0) 85 (85.0) 6 (18.8) 26 (81.2) 9 (13.2) 59 (86.8) 0.519 0.471
Talcum powder usage for keeping interdigital spaces dry 54 (54.0) 46 (46.0) 21 (65.6) 11 (34.4) 33 (48.5) 35 (51.5) 2.560 0.110
Keeping skin of the feet soft to prevent dryness
16 (84.0) 84 (84.0) 5 (16.0) 27 (84.0) 11 (16.2) 57 (83.8) 0.005 0.944
Lotion not to be applied to the interdigital spaces
50 (50.0) 50 (50.0) 15 (46.9) 17 (53.1) 35 (51.5) 33 (48.5) 0.184) 0.668)
Daily changes of socks 26 26.0) 74 (74.0) 10 (31.2) 22 (68.8) 16 (23.5) 52 (76.5) 0.674 0.412
Trimming nails of feet straight with care
9 (9.0) 91 (91.0) 5 (14.6) 27 (84.4) 4 (9.0) 64 (91.0) 2.522 0.112
Inspection of feet once a day by yourself 17 (17.0) 83 (83.0) 4 (14.6) 27 (84.4) 44 (17.6) 56 (82.4) 0.063 0.802
Wearing comfortable coat shoes 9 (9.0) 91 (91.0) 1 (3.1) 31 (96.9) 2 (2,9) 66 (97.1) 0.003 0.960
Checking the shoes from inside before wearing
15 (15.0) 85 (85.0) 5 (15.6) 27 (84.4) 10 (14.7) 58 (85.3) 0.014 0.901
Not walking bare foot 13 (13.0) 87 (87.0) 2 (6.2) 30 (93.8) 11 (16.2) 57 (83.8) 1.896 0.169
Warning signs for which consultation is required 5 (5.0) 95 (95.0) 3 (9.4) 29 (90.6) 2 (2.9) 66 (97.1) 1.896 0.168 Note: p≤0.05 = significant difference.
8.5 Practice of foot care
21
22 Table 4. Foot care practices among patients with type 2 diabetes.
Foot care practices Total (n=100) Male (n=32) Female (n=68) X2 p-value No n (%) Yes n (%) No n (%) Yes n (%) No n (%) Yes n (%)
I can reach and see the bottoms of my feet (M=1 woman) 8 (8.1) 91 (91.9) 3 (9.4) 29 (90.6) 5 (5.4) 62 (61.6) 0.107 0.744 I examine my feet? (M=0) 10 (10.0) 90 (90.0) 3 (9.4) 29 (90.6) 7 (10,3) 61 (89.7) 2.114 0.715
I wash my feet every day
(M=0) 6 (6.0) 94 (94.0) 2 (6.2) 30 (93.8) 4 (5.9) 64 (94.1) 0.005 0.942 Dry my toes (M= 0) 35 (35.0) 65 (65.0) 12 (37.5) 20 (62.5) 23 (33.8) 33.8 (66.2) 0.129 0.719
I use a moisturizing cream on my feet (M=1 man) 90 (90.9) 9 (9.1) 29 (93.5) 2 (6.5) 61 (89.7) 7 (10.3) 0.380 0.537
I cut my own toenails
(M=0) 48 (48.0) 52 (52.0) 18 (56.2) 14 (43.8) 30 (44.1) 38 (55.9) 5.816 0.121
I ever soak my feet
M=1 woman) 78 (78.8) 21 (21.2) 27 (84.4) 5 (15.6) 51 (67.1) 16 (32,9) 0.883 0.347
I always test water temperature before my foot in (M=1 woman) 78 (78.8) 20 (20,2) 27 (87.1) 4 (12.9) 52 (76.5) 16 (23.4) 1.491 0.222
I use medicated products for warts, corns or calluses
M=0) 93 (93.0) 7 (7.0) 31 (96.9) 1 (3.1) 62 (91.2) 6 (8.8) 1.085 0.297
I put moisturizing creams or lotions between my toes
(M=1 men) 92 (92.9) 7 (7.1) 29 (93.5) 2 (6.5) 63 (92.6) 5 (7.2) 0.026 0.871
I ever walk around in my bare feet (M=1 women) 69 (63.6) 36 (36.4) 21 (65.6) 11 (34.4) 42 (62.7) 25 (37.3) 0.081 0.776
I ever wear shoes without wearing any socks
M=0) 67 (67.0) 33 (33.0) 20 (62.5) 12 (37.5) 47 (69.1) 21 (30.9) 0.431 0.511
I use a hot water bottle or heating pad on my feet
(M=0) 90 (90.0) 10 (10.0) 32 (100.0) 0 (0.0) 58 (85.3) 10 (14.7) 5.229 0.002*
I sit with my leg crossed
(M=0) 31 (31.0) 69 (69.0) 9 (28.) 23 (71.9) 22 (32.4) 46 (67.6) 0.182 0.670
I think I have taken care my feet in correct way
(M=0) 28 (28.0) 72 (72.0) 5 (15.6) 27 (84.4) 23 (43.8) 45 (66.2) 3.575 0.059
Note: p≤0.05 = significant difference., M= Missing, * = significant difference
92 (92%) of the participants used sandals and 37 (37, 0%) used cotton socks. There was a significant difference between men and women concerning the use of shoes with round toes (p=0.002). Nine (28.1%) men who used round toes shoes, but only three (4.4%) of the women. There was also a significant difference between genders in using shoes of leather or canvas (p=0.000). 11 (34.4%) of the men and two (2.9) women used leather or canvas shoes. See Table 5.
23
Types of shoes Total (n=100) Male (n=32) Female (n=68) X2 p-value No n (%) Yes n (%) No n (%) Yes n (%) No n (%) Yes n (%) Pointed toes 90 (95.0) 5 (5.0) 29 (90.6) 3 (9.4) 66 (95.0) 2 (5.0) 1.896 0.168
Broad, round toes 88 (88.0) 12 (12.0) 23 (71.9) 9 (28.1) 65 (95.6) 3 (4.4) 11.587 0.001* High heels 100 (100.0) 0 (0.0) 32 (100.0) 0 (0.0) 68 (100.0) 0 (0.0) Sandals 8 (8.0) 92 (92.0) 2 (6.2) 30 (93.8) 6 (8.8) 62 (91.2) 0,196 0.658 Flip flops/thongs 12 (12.0) 88 (88.0) 6 (18.8) 26 (81.2) 6 (8.8) 62 (91.2) 2.030 0.154 Athletic/sneakers/runners 94 (94.0) 6 (6.0) 28 (87.5) 4 (12.5) 66 (97.1) 2 (2.9) 3.525 0.060
Shoes made of leather or canvas 87 (87.0) 13 (13.0) 21 (65.6) 11 (34.4) 66 (97.1) 2 (2.9) 19.010 0.000*
Types of socks Total (n=100) Male (n=32) Female (n=68) X2 p-value No n (%) Yes n (%) No n (%) Yes n (%) No n (%) Yes n (%) Cotton 63 (63.0) 37 (37.0) 17 (53.1) 15 (46.9) 46 (67.6) 22 (32.0) 1.969 0.161 Wool 99 (99.0) 1 (1.0) 32 (100.0) 0 (0.0) 67 (98.5) 1 (1.5) 0.475 0.491 Acrylic/synthetic 93 (93.0) 7 (7.0) 32 (100.0) 0 (0.0) 61 (87.7) 7 (10.3) 3.452 0.060 Knee highs 100 (100.0) 0 (0.0) 32 (100.0) 0 (0.0) 68 (100.0) 0 (0.0) Prescription/compression 97 (97.0) 3 (3.0) 32 (100.0) 0 (0.0) 65 (95.6) 3 (3.0) 1.455 0.228 Not know 94 (94.0) 6 (6.0) 29 (90.6) 3 (9.4) 65 (95.6) 3 (4.4) 0.950 0.330 Others 54 (54.0) 46 (46.0) 18 (56.2) 14 (43.8) 36 (52.9) 32 (47.1) 0.096 0.757 Note: p≤0.05 = significant difference, * = significant difference.
8.6 Foot care education
24 Table 6. Foot care education among patients with type 2 diabetes.
Foot care education Total (n=100) Male (n=32) Female (n=68) X2 p-value No n (%) Yes n (%) No n (%) Yes n (%) No n (%) Yes n (%)
I have ever attended a class on how to care for my feet 93 (93) 7 (7) 30 (93.8) 2 (6.2) 63 (92.6) 4 (7.4) 0.041 0.840
I have ever read handouts on foot care 80 (80) 20 (20) 24 (75) 8 (25) 56 (82.4) 12 (17.6) 0.735 0.391
I would like a handout on how to care for my feet
15 (15) 85 (85) 6 (18.8) 26 (81.2) 9 (13.2) 59 (86.8) 0.519 0.471 Note: P≤0.05 = significant difference, * = significant difference.
Most patients 39 (39%) thought that media was the most effective way for increasing
knowledge and practice of foot care. There was no difference between genders concerning the opinion about the most effective ways. See Table 7.
Table 7. The opinions of the patients about the most effective way for increasing knowledge
and practice of foot care.
Most effective ways for Total (n=100) Male (n=32) Female (n=68) X2 p-value
increasing knowledge and practice No n (%) Yes n (%) No n (%) Yes n (%) No n (%) Yes n (%) Receiving handout/brochure 65 (65.0) 35 (35.0) 20 (62.5) 12 (37.5) 45 (66.2) 23 (33.8) 0.571 0.752
Health education in group 96 (96.0) 4 (4.0) 30 (93.8) 2 (6.2) 66 (97.1) 2 (2.9) 0.620 0.431 Individual health education 78 (78.0) 22 (22.0) 24 (75.0) 8 (25.0) 54 (79.4) 14 (20.6) 0.247 0.619
Media such as TV, radio, etc. 61 (61.0) 39 (39.0) 18 (56.2) 14 (43.8) 43 (62.2) 25 (36.8) 0.446 0.504 Others 93 (93.0) 7 (7.0) 29 (90.6) 3 (9.4) 64 (94.1) 4 (5.9) 0.408 0.523 Note: P≤0.05 = significant difference, * = significant difference.
9. DISCUSSION
Previous research shows that knowledge and practice is low in type 2 diabetes patients and that women had better practice/self-care then the men. The results in this study showed that the knowledge about foot care was high in the type 2 diabetes patients. There was 74.0 % who had good knowledge and only 8.0 % had poor knowledge. There was no significant difference between genders concerning knowledge. The result of foot care practice was more
25 9.1. Result discussion
9.1.1. Knowledge of foot care among the patients with type 2 diabetes
Of the type 2 diabetes patients who participated in the study 74.0 % had good knowledge in foot care. This is a great number compared to several other studies where the type 2 diabetes patients had poor knowledge in foot care (Pollock et al., 2004; Khamseh et al., 2007).
The patients who had received information or advice previously had better knowledge than those who hadn´t got any information (Pollock et al., 2004). In this study the patients had good knowledge even though the majority of the patients had not attended a class in foot care or read handouts about diabetes. One possible reason for good knowledge about foot care can be that the majority of patients mentioned that media was the best way for increasing
knowledge and practicing of foot care and maybe the patients can search information by themselves through media. However, many of patients would like to have a handout about foot care to improve their knowledge.
About 54% of the patients answered wrong concerning the use of talcum powder usage for keeping interdigital spaces dry. Also 50.0 % answered that it was not right to apply lotion to the interdigital spaces on the feet. This shows that half of the patients in this study still did not know about correct foot care. Many patients had low education (primary school or secondary school), and this can affect their understanding. Quinn et al. (2011) found that the patients with low education need more information about their diagnosis, and also need to be educated about diabetes (Tham et al. 2004).
9.1.2. Foot care practices among patients with type 2 diabetes.
The results of foot care practice among patients was variedand are in agreement with several other studies (Pollock et al., 2004; Khamseh et al., 2007;Bhupendra et al., 2008) which showed that the practice of foot care in type 2 diabetes is low.
26
It is important to test the water before washing the feet, but only 20.2 % reported that they did so even if 60.0 % answered that they knew that. About 33.0 % reported that they walked around barefoot while 87.0 % answered that it was not good to walk around barefoot. Only 9% used moisturizing cream on their feet and 69 % sit with their leg crossed even do it is not good for the circulation (Brown and Edwards (2005). This can explain that the patients have lack of motivation to change of their lifestyle and that health care professionals cannot motivate, support and give feedback to the patients about self-care. Another reason may be that the patient didn’t have relatives and friends to support for his/her foot care (Kneckt et al., 2000). In addition, Rätsep, Oja, Kalda & Lember (2007) showed that economy can have an important role of the lack in self-care.
The majority of the patients used sandals and flip-flops and only 13 % used shoes of leather. Brown & Edwards (2005) recommend that the patient shall avoid open-toe and open-heel shoes and use leather shoes. Contributing factors may be the hot weather in Vietnam which makes it more convenient to us flip-flops and sandals than leather shoes. Leather shoes are more expensive. Health care professionals should be aware of this when providing education to the patients.
9.1.3. Difference between genders in knowledge and practice of foot care
In the study of Pollock et al. (2004) the women had higher knowledge about foot care than men, and this is in contrast with the results of this study that there was no significant difference between genders in knowledge of foot care. It may be due to that both male and female have got good information about foot-care when they visited the doctors at the hospital. Another reason can be that the participation group in this study is too small to show differences between genders.
27
diabetes centers with implementation of primary prevention programs has to be developed to prevent complications. It is important to increase the practicing of foot care in a correct way.
More men than women used shoes with round toes and leather/canvas shoes. The authors believe that one possible reason may be that there were more men who worked as government officers and merchants and they used this kind of shoes in their work.
Many of the type 2 diabetes patients had a low income and the women had generally lower income than the men. Financing problems for the women can be a reason for the lack in their practice of foot care (Rätsep et al., 2007). People in higher social classes have easier to adapt and change their habits and lifestyle and that can be one reason for the difference between genders (Chan et al., 2001). Another possible reason can be that the women had a lack of motivation to change their life style (Rätsep et al., 2007).
More women participating in the study visited the clinic the days for data collection. Goodridge et al. (2005) found that women was more active in their self-care and men searched more health care for acute problems, and this can explain why there were more women visiting the clinic these days.
9.2 Method discussion
Not much research is done about type 2 diabetes in Ho Chi Minh City, Vietnam, and more research was needed. Therefore this quantitative study was used to investigate the knowledge and practice in foot care among men and women with type 2 diabetes. The descriptive and comparative cross- sectional design with questionnaires in suitable to use when the time is limited and it can collect more data (Eliasson, 2006). Quantitative method was used because of its strength of generalizability reliability and objectivity (Weinreich, 2006). A purposive sample was used for this study. The sample method was chosen because of the small amount of time.
28
patients who had a difficulty to fill in the questionnaire, but most of the patients needed help. Many patients that thought the questionnaire was too long and complicated to fill in. Ms. Nguyen Thi Phuong Lan interviewed them and filled in the answer for them. Therefore, it is hard for the authors to know how the questions were read, if the patients answeredtruthfully, and this may affect the results. The help to fill in the questionnaires could have harmed the ethical considerations due to that the questioners have some sensitive questions, such as their social status Due to the help the patients were given the reliability could have been decreased, because the authors do not know if the data were trustworthy from the beginning. However, the authors believe that the quantitative method was the most suitable method to answer the research questions.
The validity of the questionnaires is high because it is based upon several studies (Bijoy et al., 2012; Pollock et al., 2004) and a pilot study was done by Ms Nguyen Thi Phungon Lan. The questionnaires was developed by the two supervisors (Appendix 1). The questionnaires were also translated in to Vietnamese language by Ms Nguyen Thi Phuong Lan and were adjusted to Vietnamese culture. A pilot test had also been done by the co- supervisor Nguyen Thi Phuong Lan in Ho Chi Ming City, before the data collection.
The authors believe that the generalizability is low because of the small sample (100 questionnaires) and cannot be transferred to a larger group/population. The authors believe that they could be objectivity to the result, even if they were interviewed, due to that they did not be a big part of the data collection because of the language barrier. In the result there were no missing data in the knowledge part. In the practices part there was four missing women and two missing men. See table 4. The authors do not think that the missing data affect the result. The reason for the missing could be that the patients might not understand the question or that the questions did not have an answer that they agreed with.
9.3 Theoretical framework discussion
29
when they are affected of limitations and help them to give capacity to regain the self-care (Kirkevold, 2000).
When the patients already have knowledge about foot care, it is important that the nurse motivate the patients to practice their foot care (Rätsep et al., 2007). This agrees with Dorothea Orem’s theory that nurses should guide and teach patient about self-care
management concerning foot care, give physical and psychological support, and empower patient to increase his/her self-confidence so that patient can regain the capacity of self-care. Orem also means that self-care depends on the health of the person, wellbeing, interest of maintaining living and function and the age can affect the self-care (Alligood & Tomey, 2009).Type 2 diabetes often affects older people and many patients mentioned that economy was an important role for their self-care. It is important that the nurse should be aware of this when guiding and teaching patients.
9.4 Clinical implication
The results of this study can be used to increase understanding among health care
professionals to develop an intervention program of self-care management for type 2 diabetes patients to provide knowledge and practice of foot care in Vietnam. This can be applied to other developing countries. The study also provides an opportunity for information and feedback to the nurses, doctors and other health professionals, all to improve the self- care of type 2 diabetes foot care and prevent complications. Sweden is a multicultural society, the results of this study can also be used to increase awareness of health care professionals when provide health education to patients from different cultures.
9.5 Further research study
30 9.6 Acknowledgement
We would like to thank Swedish Council for Higher Education through its exchange programme Linnaeus-Palme that made this study possible. We specially want to thank our supervisor Dr. Pranee Lundberg, Associate Professor at the Department of Public Health. We also want to thank our co-supervisor Ms Nguyen Thi Phuong Lan, Nursing Lecturer, at the Department of Nursing, University of Medicine and to Pharmacy in Ho Chi Minh City, for all help to hand out the questionnaires. Without her it would not been possible to write and implement this study. We also thank to all patients who participated voluntarily in this study.
9.7 Conclusions
31 10. REFERENCES
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Duc Son, L. E. N. T., Kusama, K., Hungt, N. T. K., Loant, T. T. H., Van Chuyen, N., Kunii. (2004). Prevalence and risk factors for diabetes in Ho Chi Minh City, Vietnam.Diabetic Medicine, 21, 371-376.
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Goodridge, D., Trepman, E., Embil, J.M., (2005). Health – related quality of life in diabetic patients with foot ulcers. The Wound, Ostomy and Continence Nurses Society, 42(1) 368 – 376.
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35 Appendix 1 Questionnaire
Knowledge and practice of foot care in Vietnamese people with
Type 2 diabetes
Please mark (X) your answer for every question. Part I: BACKGROUND
A. Demographic information
1. Gender 1. Man 2. Woman
2. Age __________ years
3. Marital status
1. Single 2. Married 3. Separated 4. Divorced
5. Widowed 6. Other, _____________________
4. What is your religion?
1. Catholic 2. Protestant 3. Buddhism 4 . Muslim
5. No religion 4 . Other (Specify)………
5. Education
1. Primary school 2. Secondary school
3. High school 4. Secondary level after high school/College 5. Bachelor 6.Other, _____________________
6. Occupation
1.Worker 2.Government officer 3.Technician 4.Merchant
36
7. Do you have children?
1. No 2. Yes
8. How many people do you live with at home? _____________
9. How adequate is your income to meet your daily living expenses?
1. Enough 2.Barely enough 3.Totally inadequate
10. How much income do you have per month? _______________________ VDN
11. Do you smoke? 1. No 2. Yes, how many cigarette/day? _______
12. Do you drink alcohol? 1. No 2. Yes, how much do you drink per day? _______
13. For how long have you been living with Diabetes? __________________
14. Does your family have any history of Diabetes? 1. No 2. Yes
15. What kinds of diabetes treatment do you use? (you can mark more than one) 1. Control diet 2. Take medicine
3. Inject insulin 4. Other (specify) ______________
16. Do you follow up regularly your diabetes treatment with the doctor? 1. No 2. Yes
17. Who is person to take care or help you about diabetes at home? (you can mark more than one)
1. My wife/husband 2. My children 3. My relative
4. No one 5. Other (specify) _________________
B. History of foot problems
37
1. No 2. Yes, How many? __________
19. Have you ever had a sore or cut on your foot or leg that took more than two weeks to heal?
1. No 2. Yes, How many? __________
20. Have you ever had an amputation of a toe, foot, or leg? 1. No 2. Yes (If yes, when (date): _______
C. Current foot or leg problems
21. Do you have an ulcer, sore, or blister on your feet at this time? 1. No 2. Yes
22. Do you have blood or discharge on your socks? 1. No 2. Yes
23. Do you have any calluses on your feet? 1. No 2. Yes
38 Part II: Knowledge of foot care
25. Please mark “X” for your answer in each item.
Items True False
Importance of taking antidiabetes treatment to prevent complications
Daily washing the feet
Using warm water for washing/bathing
Checking temperature of water before using
Drying the feet after washing
Talcum powder usage for keeping interdigital spaces dry
Keeping skin of the feet soft to prevent dryness
Lotion not to be applied in the interdigital spaces
Daily change of socks
Trimming nails of feet straight with care
Inspection of feet once a day by respondents
Wearing comfortable coat shoes
Checking the shoes from inside before wearing
Not walking bare foot
Warning signs for which consultation is required
Part III: Foot care practice
26. Can you reach and see the bottoms of your feet? 1. No 2. Yes
27. Do you examine your feet?
39
If yes, how often?
1. Every day 2. 2-6 times a week 3. Once a week or less 4. When I have a problem
28. Do you wash your feet every day? 1. No 2. Yes
29. Do you dry well between the toes? 1. No 2. Yes
30. Do you use a moisturizing cream on your feet? 1. No 2. Yes
31. Do you cut your own toenails? 1. No 2. Yes If no, who does this for you?
1. Family member 2. Foot care nurse 3. Podiatrist 4. Other (specify): ______________
32. What kind of shoes do you wear? (Check all that apply)
1. Pointed toes 2. Broad, round toes 3. High heels 4. Sandals 5. Flip flops/thongs 6. Athletic/sneakers/runners 7. Shoes made of leather or canvas
33. What kind of socks do you wear? (Check all that apply) 1. Cotton 2.Wool
3.Acrylic/synthetic 4. Knee highs 5. Prescription/compression 6. Not know
7. Other (specify)………
34. Do you ever soak your feet?
1. No 2. Yes
35. Do you always test water temperature before your foot in? 1. No 2. Yes
40
1. No 2. Yes
37. Do you put moisturizing creams or lotions between your toes? 1. No 2. Yes
38. Do you ever walk around in your bare feet?
1. No 2. Yes
39. Do you ever wear shoes without wearing any socks?
1. No 2. Yes 3. Never use socks when wearing shoes
40. Do you use a hot water bottle or heating pad on your feet? 1. No 2. Yes
41. Do you sit with your legs crossed?
1. No 2. Yes
42. Do you think you have taken care your feet in correct way? 1. No 2. Yes
Foot care Education
43. Have you ever attended a class on how to care for your feet? 1. No 2. Yes
44. Have you ever read any handouts on foot care?
1. No 2. Yes
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46. What kind do you think is the most effective way for increasing your knowledge and practice of foot care?
1. Receiving handout/brochure 2. Health education in group 3. Individual health education 4. Media such as TV, radio, etc.
5. Others (specify) ____________________________
