WHO estimated that diabetes will be one of the leading cause of death in the world by 2030? Mathers CD, Loncar D. 2006 Globally every year more than I million limbs are lost due to diabetes. WHO. 2016 The diabetic foot ulcer prevalence was 8-17% and leads to lifelong disability, repeated, prolonged hospitalization, financial crisis to the families and health care system. Stockl K, Vanderplas A, Tafesse E, Chang E. 2004 Half of the diabetic foot ulcer complications happens due to foot infection. Dang CN, Boulton A.J.  2003, Pinzur MS, Slovenkai MP, Trepman E,Shields NN, 2005

Out of pocket expenditure for the treatment of Non communicable disease has increased drastically in people belonging to lower socioeconomically class spend recently  Sharma K. 2013. Prevalence estimates of diabetes in India ranges from 5.6% to 12.4% in urban areas and 2.4% to 2.7% in rural areas. Kurian.B,Qurieshi M.N , Ganesh.R, Leelamon.K. 2016 However there is a remarkable advancement available in the field of diabetology, the disease is doubling at alarming rate and it is having been observed that rural public has very little knowledge about diabetes. Sivapriya.T , John. 2019. Around 6% of people are affected by foot disease due to infection, ulceration and destruction of foot tissues, can destroy the patient’s social life and source of income and 0.03% to 1.5% of diabetic patients needed amputation. But most of the foot related complications can be prevented by proper foot screening and foot care. Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A,  2021

With this view a community-based study was undertaken to assess the knowledge of foot care and knowledge regarding foot care practices among patients with diabetes mellitus.

 

2.    SUBJECTS AND METHODS

2.1.        STUDY DESIGN

A community based cross-sectional study was initiated to assess the knowledge of foot care and knowledge regarding foot care practice and its associated factors among type 2 diabetes patients, visiting the diabetic clinic at Rural Primary Health Centre Puducherry south India, from December 2020 to March 2021.

 

2.2.         SAMPLE AND SAMPLING METHOD

Type 2 diabetes clients in the age group of 40-60 years were selected using the convenience sampling method for the study. Both sex were included in the study. Subjects who were non –cooperative, migrants, pregnant women, mental illness, or who were not willing to participate in the study were excluded. Based on the previous study, the expected proportion of people with knowledge regarding diabetic foot care practice was determined to be 62%. The minimum sample size for the study was calculated to be 94 using the following formula n = 4pq/d2 where p: expected proportion (0.62), Z1-p: alpha error 1.96 (confidence interval 95%), d: absolute precision (10%). Asmelash.D, Abdu.N, Tefer.S, Baynes.W.H,Derbew 2019 In this study 107 subjects included.

 

 

 

 

 

2.3.        QUESTIONNAIRE

In this study, the investigator used a self-developed validated pretested questionnaire to assess the knowledge of foot care, knowledge regarding foot care practice and its associated factors among type 2 diabetes patients.

The questionnaire had two parts. The first part included demographic information on gender, age, education, income and occupation, clinical variables of diabetes mellitus and the second part assessed the study participant’s knowledge of foot care, and knowledge regarding foot care practice. The knowledge of foot care section included 20questions regarding foot care. For correct response score 1 was given and the scores are further categorized as "Good knowledge" (Score range: 15-20,) “Fair knowledge" (Score range: 11 -14) and the “Poor knowledge" (Score range: 0-10). Knowledge regarding foot care practice included 12 questions towards their practice related to foot care and the response options were yes or no.  The Scores range from 0-12, comprised three parts, categorized "Good practice" (Score range10-12,), Fair practice" (Score range: 6 -9) and the poor practice " (Score range: 0-5). The tool Validity index score was .8. Before conducting the main study, a pilot study was conducted to check the feasibility, ensure reliability and the validity of the tool for the study.

Data collection procedure

After explaining about the study and ensuring their confidentiality of the data. Data was collected from December 2020 to March 2021 through semi structured interview technique, guided by a validated pretested questionnaire.

 

2.4.        ETHICAL APPROVAL OF RESEARCH

The study was approved by the Institutional Ethics Committee of AG Padmavathi College of nursing Pondicherry, (Ref.no.AGP/IEC/2020/17X007). The participants (40-60 years were informed about the study and given the verbal consent. The participation was voluntary and without compensation. The questions did not involve any personally identifiable information. All the information was kept confidential and used for the purpose of this study only.

 

2.5.        ANALYTICAL METHODS

The SPSS version 21 was used to analyse the data. The correlation was analysed by the Pearson correlation coefficient (Knowledge of foot care and knowledge regarding foot care practice) and to determine the association of knowledge with selected demographic variable was analysed by Chi-square test, P-value < 0.05 was considered statistically significant.

 

 

 

 

 

 

 

3.    RESULTS

 

Table 1 Distribution of Study Participants According to their Socio Demographic Characters                                                                                                                                                                               N=107
Variable	No	Percentage
Gender
Male	38	35.5
Female	69	64.5
Age
40-50 yrs	53	49.5
51-60 yrs	54	50.5
Religion
Hindu	101	94.4
Muslim	5	4.7
Christian	1	.9
Marriage
Married	105	98.1
Widow	2	1.9
Education
Illiterate	32	29.9
Primary	11	10.3
Secondary	0	0
High school	48	44.9
Higher secondary	13	12.1
Graduates	3	2.8
Occupation
House wife	52	48.6
Cooli	34	31.8
Skilled worker	8	7.5
Government job	1	.9
Private job	3	2.8
Business	6	5.6
Retired	3	2.8
Income
No income	50	46.7
<2000	27	25.2
2000-5000	19	17.8
5000-10000	11	10.3
Food habits
Vegetarian	106	99.1
Non vegetarian	1	.9
History of Smoking
Yes	26	24.3
No	81	75.7
History of Alcohol
Yes	26	24.3
No	81	75.7
History of Tobacco
Yes	5	4.7
No	102	95.3

 

Table 1 shows that Out of the 107 subjects, 107were considered eligible for analysis giving a response rate of 100%. Age wise distribution shows that 50.5% of them were >51-60 years of age. Majority of these diabetic patients belonged to Hindu religion 94.4%, 29.9% of them illiterate, 24.3% of them having the habits of smoking and alcohol consumption and 4.7 % of them having tobacco habits

 

Table 2 Characteristics of patients with type 2 diabetes mellitus                                                                                                                                                            N=107
Variable	No	Percentage
Regularity of Treatment
Yes	93	86.9
No	14	13.1
Mode of treatment
Oral pills	107	100%
Insulin	0	0
Family history of Diabetes
Yes	7	6.5
No	100	93.5
Duration of disease
< I yr	6	5.6
1-3 yrs	49	45.8
>3-5 yrs	52	48.6
Regular follow up
Yes	93	86.9
No	14	13.1
Status of glycaemic control
Good	0	0
Fair	47	43.9
Poor	60	56.1
Eye check up
Yes	8	7.5
No	99	92.5
Renal check up
Yes	2	1.9
No	105	98.1
Cardiovascular
Yes	19	17.8
No	88	82 .2
Source of information
Doctor	37	34.6
Nurses	40	37.4
Media	20	18.7
Relatives	10	9.3

 

Table 2 shows that out of 107 diabetes patients 86.9% of them in regular treatment, 6.5% of them has family history of diabetes mellitus, 48.6% of them has the history of duration of disease >3 to 5 years and 37.4% of them received source of information from nurses, 86.9% of them in regular follow up ,56.1% of them poor glycaemic control,92.5% of them did not undergo eye check-up ,91.8% of them not undergone renal and 82.2% of them not undergone cardiovascular check-up.

 

Table 3 Level knowledge and knowledge regarding practice score towards foot care among diabetes patients.                                                                                                                                            N=107
Variable	Good	Fair	Poor
Knowledge of foot care	7(6.5%)	25(23.4%)	75(70.1%)
Knowledge regarding Practice of foot care	30(28%)	47(43.9 %)	30(28%)

 

Table 3 shows that Among 107 diabetes patients 70.1%of them had poor knowledge and 28% of them had poor Knowledge regarding practice of foot care.

 

Table 4 Mean foot care knowledge and knowledge regarding practice score towards foot care among diabetes patients.                                                                                                               N=107
Variable	Mean ± SD
Knowledge of foot care	6.88 ± 4.39
Knowledge regarding Practice	6.87 ± 2.85
Total	13.75±7.24

 

Table 4 shows that the mean scores of knowledges and practice were 6.88±4.19, 6.87 ±2.85 respectively. The overall mean KP score was 13.75 ±7.29

 

 

 

Table 5 Correlation (Pearson) between foot care Knowledge & Knowledge regarding Practice score towards foot care among Diabetic patients.
Levels	r value	p value
Knowledge of foot care & Knowledge regarding Practice of foot care.	0.822	.000*
Statistically significant at ** p < 0.01

 

Table 5 that there was highly significant (<0.001) relationship between foot care Knowledge & Knowledge regarding Practice score towards foot care

 

Table 6 Association of level of knowledge with socio demographic variables                                                                                                                                                 N=107
Socio demographic variables	Level of knowledge			df	X2	p-value
	Good	Fair	Poor
Gender 2
Male	3	13	22	2	4.383	0.031
Female	4	12	53
Education
Illiterate	0	9	23
Primary	0	4	07	8	47.49	.005
Secondary	0	0	0
High school	3	9	36
Higher secondary	1	3	09
Graduates	3	0	0
Occupation
House wife	2	12	38
Cooli	1	6	27	12	36.34	0.000
Skilled worker	0	1	7
Government job	0	1	0
Private job	2	0	1
Business	1	2	2
Retired	1	3	0
Income
No income	2	10	38
<2000	0	8	19	6	10.31	.013
2000-5000	3	6	10
5000-10000	2	1	8
History of Smoking
Yes	3	15	12	2	10.26	.001
No	4	10	63
History of Alcohol
Yes	4	17	60	6	2.87	.036
No	3	8	15
Duration of disease
< I yr	1	0	5
1-3 yrs	2	9	38	4	5.72	.041
>3-5 yrs	4	16	32
Regular check up
Yes	7	16	42
No	0	09	33	2	5.343	.015
Cardiovascular check-up
Yes	7	0	19	2	9.857	.001
No	0	25	56

 

Table 6 shows that that the Association of knowledge with demographic variables revealed that there was highly significant association (<0.05) with gender, education, occupation, income, smoking alcohol consumption, duration of illness regularity of treatment and regular cardio vascular check-up.

 

4.    DISCUSSION

This study is intended to illustrate the knowledge and practices of the general public across the various demographic groups of rural people towards type 2 diabetes and identify the socioeconomic factors that affect them. It was observed in our study that 70.1% of them had poor knowledge, poor practice 28% towards diabetic foot care. These findings were supported by D.S.D et.al concluded in their study that 27% of them had poor knowledge and 35% of them had poor practice towards diabetic foot care D S D., Vincent J., Saju C.R. 2020 and Saurabh S, Sarkar S, Selvaraj K, Kar SS, Kumar SG, Roy G. 2014 who reported in their study that nearly 53% of them had good knowledge and 44,7 % of them had poor practices towards foot care. Saurabh S, Sarkar S, Selvaraj K, Kar SS, Kumar SG, Roy G. 2014

Another study conducted by Pitchai.P et.al concluded in their study that among rural population only 8% of them had good Knowledge and 48% of them had poor practices of diabetic foot care as compared to urban population that 58% of them had good Knowledge and 6% of them had poor practices. Pitchai P, Joshi J. 2015

In contrast a study conducted by George H et all have reported that 75% of participants had good knowledge and 67% of them had good practice towards diabetic foot care. George H, Rakesh PS, Krishna M, Alex R, Abraham VJ, George K, et al In this study the overall mean KP score was 13.75 ±7.29. The results concur with those reported by Fatemah M et.al found that most Patients (79.3%) had good knowledge, and less than one third of patients (30.8%) practiced good Diabetic foot care, the mean knowledge score of the respondents was 12.7 ± 2.7 and mean practice score was 55.7 ± 9.2 and also concluded that knowledge regarding foot care was good and self-foot care practice was satisfactory. F.M. Alsaleh, K.S. AlBassam, Z.K. Alsairafi et al. The result of current study revealed that the highly significant (<0.001) relationship between knowledge and practice. These findings in dis agreement with Vighnesh CS, Rangaswamy S, Arthi M. 2019who reported insignificant strong correlation between knowledge and practice of foot care (r = 0.79). In this study knowledge got statistically significant association (<0.05) with significant association (<0.05) with gender, education, occupation, income, smoking alcohol consumption, duration of illness regularity of treatment and regular cardio vascular check-up.  A study conducted by George H et.al reported education and socioeconomic status were significantly associated with knowledge of diabetic care. George H, Rakesh PS, Krishna M, Alex R, Abraham VJ, George K, et al.

In this study Age wise distribution shows that 50.5 %of them were >51-60 years of age. Majority of these diabetic patients belonged to Hindu religion 94.4%, 98.1% of them married, 29.9% of them illiterate, 24.3% of them having the habits of smoking and alcohol consumption and 4.7 % of them having tobacco habits. The findings were similar to the study conducted Shrivastava PS et.al Shrivastava PS, Shrivastava SR, Ramasamy J (2015)

Out of 107 diabetes patients 86.9% of them in regular treatment, 6.5% of them has family history of diabetes mellitus, 48.6% of them has the history of duration of disease >3 to 5 years and 37.4% of them received source of information from nurses, 86.9% of them in regular follow up ,56.1% of them poor glycaemic control,92.5% of them did not undergo eye check-up ,91.8% of them not undergone renal and 82.2% of them not undergone cardiovascular check-up.

 

5.    CONCLUSION

The study revealed that the knowledge foot care and knowledge regarding foot care practices of diabetic patients were poor. It is an urgent need of the hour to conduct health educational programme to make awareness among rural people for better control and management of the disease.

 

Availability of data and materials

All data generated during this study are included in the article. Raw data would remain confidential and would not be shared.

Ethical approval of research

The study was approved by the Institutional Ethics Committee of AG Padmavathi College of nursing Pondicherry, (Ref.no.AGP/IEC/2020/17X008). The participants (40-60 years were informed about the study and given the verbal consent. The participation in survey was voluntary and without compensation. The survey questions did not involve any personally identifiable information. All the information was kept confidential and used for the purpose of this study only.

 

ACKNOWLEDGEMENT

We express our sincere gratitude to the medical officer, staffs of Ariyur primary health centre and all the participants for taking part in the survey.

 

 

 

 

REFERENCES

Asmelash.D, Abdu.N, Tefer.S, Baynes.W.H,Derbew 2019. Cherie.Knowledge,Attitude,and Practice towards glycaemic control and its Associated Factors among Diabetes Mellitus Patients, Journal of Diabetes Research.1-9.https://doi.org/10.1155/2019/2593684.. Accessed on May 11th. Retrived from https://doi.org/10.1155/2019/2593684

D S D., Vincent J., Saju C.R. 2020; Knowledge, Attitude and Practice of Diabetic Patients about Their Foot Care in Rural Thrissur, Kerala. Journal of Medical Care Research and Review. 374−378.Retrived from https://doi.org /10.15520/mcrr.v3i6.98.

Dang CN, Boulton A.J.  2003; Changing perspectives in diabetic foot ulcer management. Int J Low Extrem Wounds 2:4-12. Retrived from https://doi.org/10.1177/1534734603002001002

F.M. Alsaleh, K.S. AlBassam, Z.K. Alsairafi et al., Knowledge and practice of foot self-care among patients with diabetes attending primary healthcare centres in Kuwait: A cross-sectional study, Saudi Pharmaceutical Journal, https://doi.org/10.1016/j.jsps.2021.04.006.

George H, Rakesh PS, Krishna M, Alex R, Abraham VJ, George K, et al. Foot care knowledge and practices and the prevalence of peripheral neuropathy among people with diabetes attending a secondary care rural hospital in southern India. J Fam Med Primary Care 2013; 2:27-3.

Kurian.B,Qurieshi M.N , Ganesh.R, Leelamon.K. 2016; A community based study on knowledge of diabetes mellitus among adults in a rural population of Kerala. Intl J of Non-communi Dis. 1, 59-64. Retrived from https://doi.org/10.4103/2468-8827.191925

Mathers CD, Loncar D. 2006 ; Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 3, e442. Retrived from https://doi.org/10.1371/journal.pmed.0030442

Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A,  2021 Diabetic foot, BMJ; 359:1:1-7.

Mohan.V, Sandeep.S, Deepa.R, Shah.B, Varghese.C. 2007; Epidemiology of type 2 diabetes: Indian scenario.Indian J Med Res. 175,217-30.

Nicolucci A, Kovacs Burns K, Holt RIG, Comaschi M, Hermanns N, Ishii H, et al. 2013; Diabetes Attitudes, Wishes and Needs second study (DAWN2TM): Cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabet Med J Br Diabet Assoc. 30(7), 767-77. Retrived from https://doi.org/10.1111/dme.12245

Pinzur MS, Slovenkai MP, Trepman E,Shields NN, 2005;  DiabetesCommittee of American Orthopaedic Foot and Ankle Society.Guidelines for diabetic foot care: Recommendations endorsedby the diabetes committee of the American orthopaedic foot and ankle society. Foot Ankle Int 26:113-9. Retrived from https://doi.org/10.1177/107110070502600112

Pitchai P, Joshi J. 2015; Knowledge and practice of foot care amongst diabetics in India: comparison between urban and rural setting- a reality check. Int J Health Sci Res. 5(4):181-189.

Saurabh S, Sarkar S, Selvaraj K, Kar SS, Kumar SG, Roy G. 2014; Effectiveness of foot care education among people with type 2 diabetes in rural Puducherry, India. Indian J Endocr Metab 18 :106-10. Retrived from https://doi.org/10.4103/2230-8210.126587

Sharma K. 2013; Burden of non-communicable diseases in India: Setting priority for action. Int J Med Sci Public Health. 2,7-11. Retrived from https://doi.org/10.5455/ijmsph.2013.2.7-11

Shrivastava PS, Shrivastava SR, Ramasamy J (2015) An Epidemiological Study to Assess the Knowledge and Self Care Practices among Type 2 Diabetes Mellitus Patients Residing in Rural Areas of Tamil Nadu. Biol Med S3: 002. doi: 10.4172/0974-8369.S3-002. Retrived from https://doi.org/10.4172/0974-8369.1000s3002

Sivapriya.T , John. 2019; S A Cross Sectional Study on Knowledge, Attitude and Practice of Type 2 Diabetes Mellitus Subjects about Diabetes, JKIMSU. 8(1), 14-21.

Stockl K, Vanderplas A, Tafesse E, Chang E. 2004; Costs of lower-extremity ulcers among patients with diabetes. Diabetes Care 27 :2129-34. Retrived from https://doi.org/10.2337/diacare.27.9.2129

Subhashini S, Shah PB. 2016; Awareness and practice regarding foot self-care among patients of known type 2 diabetes mellitus in a rural area India. Int J Community Med Public Health 3 :861-4. Retrived from https://doi.org/10.18203/2394-6040.ijcmph20160917

Vighnesh CS, Rangaswamy S, Arthi M. 2019 ; Awareness and practices of foot care in patients with diabetes mellitus in an urban area in Puducherry. Galore International Journal of Health Sciences & Research. 4(3) : 150-157.

WHO. 2016; Global report on diabetes: A summary.Int J Noncommun Dis 1-3. Retrived from https://doi.org/10.4103/2468-8827.184853.