Diabetic Patients' Knowledge and Practice Regarding Prevention of Diabetic Foot

Transcription

1 Med. J. Cairo Univ., Vol. 81, No. 2, March: , Diabetic Patients' Knowledge and Practice Regarding Prevention of Diabetic Foot ALI S. AL-ASMARY, A.B.F.M.*; OS SAMA A. MOSTAFA, Ph.D.** and YAHIA M. AL-KHALDI, A.B.F.M.*** The Departments of Joint Program Family Medicine, Aseer Region*, Family & Community, King Khalid College of Medicine** and Family Medicine***, Ministry of Health, Kingdom of Saudi Arabia Abstract Aim of Study: To assess knowledge and practice of diabetic patients as regard their feet care. Patients and Methods: This study was conducted at three primary health care centers (PHCCs) in Abha City, Kingdom of Saudi Arabia. A total of 432 diabetic patients were included in the present study sample which represented 25% of all registered diabetics in these three PHCCs. An interview questionnaire and a feet examination sheet were used. Results: More than half of patients suffered from hotness sensation in their feet (54.2%). Feet numbness was complained by 47.7% of patients, while feet tingling was complained by 37.7%. Good fasting blood sugar control was achieved only in 14.1% of diabetic patients. Only 41.4% of patients underwent feet examination by primary health care (PHC) physicians. One third of patients received educational brochures about foot care, while health education sessions on importance of and how to conduct foot care have been held only for 43.1% of patients. Some patients had abnormal color of feet skin (14.4%), nails abnormalities (12.7%), swelling (6.9%), deformity (7.4%), muscle atrophy (6%), foot skin cracks (10.2%), callus (6.9%) and amputation (1.4%). Palpation revealed temperature fluctuation occurred in 1.4% of cases, absent dorsalis pedis pulse (7.2%) or posterior tibial pulse (17.6%) and absent capillary refill (15.3%). There were diminished/lost vibration sense (12.3%), impaired sense of pressure (18.8%) and impaired Achilles tendon reflex (17.6%). Conclusions: Most diabetics do not receive the necessary educational materials about foot self-care and health education sessions on importance of and how to conduct foot care. PHC physicians do not provide the required routine foot examination to diabetic patients. Diabetic patients' knowledge and practices regarding diabetic foot care are generally unsatisfactory. Diabetics who have the least knowledge scores are those who are within the age group <40 years, females, non-married, illiterates, unemployed, type 2 diabetic patients, duration of diabetes less than 10 years, and those with bad fasting blood sugar control. Recommendations: Diabetic patients should receive health education covering all items related to prevention of diabetic foot and diabetic foot self-care. They should be encouraged Correspondence to: Dr. Ossama A. Mostafa, The Department of Family & Community, King Khalid College of Medicine to practice steps of self-care. A Special emphasis should be directed to: Females, illiterate, with recent diagnosis of diabetes. Diabetic patients with intact protective sensation and peripheral pulse should receive routine foot examination at least once/year. Patients with lost protective sensation and/or foot deformity are to be managed by a family physician and a diabetologist every 3-6 months. Diabetics with lost protective sensation or peripheral arterial disease or with a history of ulcer or amputation should be referred to a podiatrist or a specialty clinic and to be seen every 1-3 months. PHC physicians should receive training to provide ideal and proper routine foot examination and health education sessions to diabetic patients. Key Words: Diabetes mellitus Diabetic foot Primary Health Care Knowledge Practice. Introduction THE world is witnessing a growing pandemic of diabetes mellitus. Its rapid rise in incidence is of alarming concern to health care professionals. The main burden of this pandemic will fall primarily on developing countries [ii. The estimated number of diabetic patients will reach 300 million by 2025 [2]. Such a dramatic increase will have a significant impact on the limited health resources of the developing countries, as diabetes is a chronic disease with devastating complications [3]. Diabetes mellitus is a disease known for its multifaceted complications, and foot ulceration, which often results in lower extremity amputations, is one of the most common complications associated with the disease [4]. The prevalence of foot ulcers ranges from 4% to 10% among diabetic patients. This is reflected to an armual populationbased incidence of 1.0% to 4.1%, and the lifetime incidence of as high as 25% [5]. Diabetic foot ulcers frequently become infected and are a major cause of hospital admissions [6]. They also account for more than half of nontraumatic lower limb amputations in this patient 197

2 198 Diabetic Patients ' Knowledge & Practice Regarding population [7]. They impose tremendous medical and financial burden on healthcare systems with costs conservatively estimated as high as $45,000 per patient [8]. These estimations, however, do not include the deleterious psychosocial effects on the patient's quality of life because of impaired mobility and substantial loss of productivity [9]. Therefore the timely prevention and healing of diabetic ulcerations are fundamental for amputation prevention [4,10]. Family physicians have a leading role in ensuring that patients with diabetes receive early and optimal care for skin ulcers. However, several studies have found that foot examinations are infrequently performed by prima-ry care physicians on diabetic patients [iii. Prevention and prophylactic foot care have been advocated to decrease patient morbidity, the utilization of expensive resources, as well as the risk for amputations [6]. These interventions, which include the identification of risk factors, patient education, and intensive podiatric care [5], have been shown to be both cost-effective and costsaving [9]. The present study aims to assess knowledge and practice of diabetic patients as regard their own feet care and to calculate the prevalence of diabetic foot among them. Patients and Methods This study followed a cross sectional design. A simple random sample was followed to choose 3 primary health care centers within Abha City, Kingdom of Saudi Arabia. A simple random sample was followed in each PHCC to interview 25% of their registered adult diabetics aged >18 years. A total of 432 diabetic patients were included in this study sample during The researcher designed a study questionnaire (in simple Arabic Language) to collect data pertinent to this study during patients' interview. This questionnaire included the following: - Personal characteristic: Age, sex, nationality, occupation, educational, smoking status. - Present history related to diabetes: Type of diabetes, duration of diabetes (in years), associated comorbidty (e.g., retinopathy, nephropathy, coronary heart disease). - Provided medical care: Health education provision, foot examination, referral to a podiatric clinic. Assessment of knowledge about foot self-care and prevention of diabetic foot: This part included 10 questions which covered the necessary knowledge related to foot self care. A correct answer was given a score of (1), while if the answer is wrong or unknown to the patient, a score of (0) was given to that question. Consequently, scores can range from a high of (10), if all questions were correctly answered to (0), if all questions were unknown or incorrectly answered. Assessment of patient's daily practices related to foot self-care: This part included 10 questions which covered the necessary practices related to foot self care. A practiced item was given a score of "1", or a score of "0" if not practiced. Consequently, scores ranged from "10", (i.e., best practices for prevention of diabetic foot), to "0", (i.e., no prevention of diabetic foot is being practiced). The researcher also designed a patient examination sheet. It included the following: Feet examination: Inspection for signs of diabetic foot, palpation of peripheral circulation, sensory assessment (e.g., sense of vibration by 128 Hz tuning fork, sense of pressure by monofilament test 10 g), and Achilles tendon reflex. Infected diabetic foot ulcer was defined as the presence of purulent wound drainage or designated systemic or local inflammatory findings [12]. Diabetes control: As indicated by fasting blood sugar control, i.e., Good (<126 mg/dl); Accepted ( mg/dl) and Bad (>180 mg/dl) [13]. The Statistical Package for Social Sciences (SPSS ver 15.0) was used for computerized data entry and analysis. Descriptive statistics were calculated and the appropriate tests of significance were applied accordingly (e.g., unpaired t-test, and ANOVA). Differences were considered as statistically significant when the p<0.05. Results Table (1) shows that the age of most diabetic patients was above 50 years (75.5%). There were more males than females. About two-thirds of patients were married (68.1%). There was a high rate of illiteracy (44%). Most patients were either unemployed (45.8%) or retired (35.2%). Most patients were non-smokers (89.8%). The majority of patients had type 2 diabetes (97.2%). More than half of patients developed retinopathy (54.2%), 13.9% developed nephropathy while 16.2% had an associated heart disease. More than half of patients suffered from hotness sensation

3 Ali S. Al-Asmary, et al. 199 in their feet (54.2%). Feet numbness was complained by 47.7% of patients, while tingling in the feet was complained by 37.7%. During walking, about one third of patients experienced cramps (37.3%) and/or pain (32.6%). Good fasting blood sugar control was achieved only in 14.1% of diabetic patients. Bad control was observed in 45.8% of patients (Table 2). Only 41.4% of patients underwent feet examination by primary health care physician. About one third of patients received educational brochures about foot care in diabetes. Health education sessions on importance of and how to conduct foot care have been held only for 43.1% of patients. Referral to a podiatrist occurred in 7.9% of cases (Table 3). Knowledge of diabetic patients about items related to diabetic foot care was generally =satisfactory. The lmowledge items which were unknown to diabetic patients were signs that should be daily checked (49.1%), early management of an observed foot in the wound (56.9%) and what to do if the patient's foot is cold (56.9%). On the other hand, best answered lmowledge items were the seriousness of diabetic foot wounds (79.4%), importance of daily washing of feet (74.5%) and importance of drying the feet immediately after washing (72.5%). Out of a maximum of 10, the mean for total knowledge scores of patients was 6.63±2.64 (Table 4). Practices of most diabetic patients related to prevention of diabetic foot were generally =satisfactory. The least practiced were regularly applying moisturizing agents to the feet skin (24.5%) and daily checking for skin temperature (25.9%). On the other hand, mostly practiced were making sure that the shoes do not contain any harmful objects (89.8%) and daily wash of feet (91.4%). Out of a maximum of 10, the mean for total practices scores of patients was 6.05±2.02 (Table 5). Table (6) shows that the clinical examination of diabetic patients' feet revealed that 1.4% of patients underwent toe/foot amputations. Inspection revealed abnormal color of feet skin (14.4%), nails abnormalities (12.7%), swelling (6.9%), deformity (7.4%), muscle atrophy (6%), callus (6.9%) and foot ulcer (10.2%). Palpation revealed temperature fluctuation in 1.4% of cases, absent dorsalis pedis pulse (7.2%) or posterior tibial pulse (17.6%) and absent capillary refill in 15.3%. Some performed special tests revealed diminished/lost vibration sense (12.3), impaired sense of pressure, as indicated by monofilament test log (18.8%) and impaired Achilles tendon reflex (17.6%). Table (7) shows that mean knowledge scores differed significantly according to age of patients (p<0.001). Patients who aged years had the highest mean lmowledge scores (7.65±2.08), while those who aged years expressed the worst mean lmowledge scores (6.00±1.92). Male patients had a significantly higher mean knowledge score than females (7.07±2.57, 6.11±2.64, p<0.001). Knowledge scores differed significantly according to patients' marital status (p=0.003). Patients who were not married had the worst mean scores (5.46±3.18), while married patients had the highest mean scores (6.92±2.62). Levels of education had significant impact on patients' knowledge scores (p<0.001). Those who read and write had the highest mean knowledge scores (7.66±1.71), while illiterate patients had the least mean knowledge scores (6.05±2.67). As regard patients' occupation, employed patients had the highest mean lmowledge scores (7.49±2.46), while =employed patients had lowest mean knowledge scores (6.14±2.63). Differences in lmowledge scores according to patients' occupation were statistically significant (p<0.001). Nonsmokers had higher mean scores than smokers (6.68±2.61, 6.23±2.89, respectively). However, differences were not statistically significant. Patients with type 1 diabetes had significantly higher mean scores than patients with type 2 diabetes (8.17±1.80, 6.59±2.65, respectively, p=0.041). Mean lmowledge scores were significantly different according to fasting blood sugar control (p<0.001). The highest mean knowledge scores were of patients with acceptable blood sugar control (7.36±2.30). Table (8) shows that mean practice scores differed significantly according to age of patients (p<0.001). Patients who aged years had the highest mean practice scores (7.72±1.41). Male patients had a significantly higher mean practice score than females (6.44±1.99, 5.58±1.97, p<0.001). Practice scores differed significantly according to patients' marital status (p<0.001). Patients who were not married had the worst mean scores (5.71±2.27), while married patients had the highest mean scores (6.59±1.82). Levels of education had significant impact on patients' practice scores (p<0.001). Those who were illiterate had the lowest mean practice scores (5.18±1.96), while those who had university education had the highest mean practice scores (7.51±1.56). As regard patients' occupation, employed patients had the highest mean practice scores (7.67±1.52), while unemployed patients had lowest mean practice scores (5.43±1.90). Differences in practice scores according to patients' occupation were statistically significant (p<0.001). Nonsmokers had significantly

4 200 Diabetic Patients ' Knowledge & Practice Regarding higher mean scores than smokers (6.12±2.02, 5.39±1.92, respectively, p=0.022). Patients with type 1 diabetes had significantly higher mean scores than patients with type 2 diabetes (8.08±1.16, 5.99±2.01, respectively, p<0.001). Mean practice scores were significantly different according to fasting blood sugar control (p<0.001). The highest mean practice scores were of patients with acceptable blood sugar control (6.60±1.80). Table (1): Characteristics of study sample. Characteristics No. % Age groups: years years years >60 years Sex: Male Female Marital status: Not married Married Widowed Education: Illiterate Read & Write Primary/Intermediate/Secondary University Occupation: Employed Unemployed Retired Smoking status: Smoker Nonsmoker Table (2): Disease characteristics. Characteristics No. % Type of diabetes: Type Type Comorbidity: Retinopathy Heart disease Nephropathy Present history: Hotness Numbness Tingling Cramps during walking Pain during walking Fasting blood sugar control: Good Acceptable Bad Table (3): Provided diabetic foot-related primary health care. Health care No. % Feet have been clinically examined by primary health care physician Health educational brochures about foot care have been received Receiving health education sessions on foot care Referral to a podiatrist Table (4): Assessment of knowledge related to diabetic foot care. Knowledge items No. % Causes of diabetic foot Seriousness of diabetic foot wounds Early signs of diabetic foot Early management of an observed wound in the foot Signs of diabetic foot that should be daily checked What to do if your feet is cold Importance of daily washing of feet Importance of drying the feet immediately after washing Importance of careful and regular trimming of toes Importance of off-loading when there is a foot wound Total knowledge scores (Mean±SD) 6.63±2.64 Table (5): Assessment of healthy practices of patients. Practice items No. % Daily examination of feet Checking water's temperature before washing feet Daily wash of feet Drying of feet, especially between toes immediately after washing Daily checking feet skin temperature Regularly applying a moisturizing agent to the skin of feet Trimming toe nails carefully and regularly Avoiding walking with bare feet Making sure that the shoes do not contain any harmful objects Choice of the proper type of shoes Total practices scores (Mean±SD) 6.05±2.02

5 Ali S. Al-Asmary, et al. 201 Table (6): Results of clinical examination of feet. Results No. % Inspection: Abnormal color of feet skin Toe nails abnormality Toe/foot amputation Swelling of feet Foot deformity Muscle atrophy Presence of callus Presence of foot crack/ulcer Palpation: Temperature fluctuation Absent dosalis pedis pulse Absent posterior tibial pulse Absent capillary refill Special tests: Diminished or lost vibration sense Impaired sense of pressure Impaired Achilles tendon reflex Table (7): Mean knowledge scores according to some study variables. Results No. Mean±SD p-value Age groups: years years years >60 years Sex: Male Female Marital status: Not married Married Widowed Level of education: Illiterate Read & Write Primary/Intermediate/ Secondary University Occupation: Employed Unemployed Retired Smoking status: Smoker Nonsmoker Type of diabetes: Type 1 Type 2 Fasting blood sugar control: Good Acceptable Bad ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±2.71 < < <0.001 < <0.001 Table (8): Mean practice scores according to some study variables. Results No. Mean±SD p-value Age groups: years ± years ± years ±1.74 >60 years ±1.97 <0.001 Sex: Male ±1.99 Female ±1.97 <0.001 Marital status: Not married ±2.27 Married ±1.82 Widowed ±1.85 <0.001 Education: Illiterate ±1.96 Read & Write ±1.66 Primary/Intermediate/ ±1.85 Secondary University ±1.56 <0.001 Occupation Employed ±1.52 Unemployed ±1.90 Retired ±1.95 <0.001 Smoking status: Smoker ±1.92 Nonsmoker ± Type of diabetes: Type ±1.16 Type ±2.01 <0.001 Fasting blood sugar control: Good ±1.99 Acceptable ±1.80 Bad ±2.09 < Discussion The present study showed that duration of diabetes was mostly 10 years or more. More than half of patients have already developed retinopathy, 13.9% developed nephropathy while 16.2% had an associated heart disease. These findings are in agreement with those reported by Elhadd et al. [3], who noted that diabetes is a chronic disease with devastating complications, including premature atherosclerotic cardiovascular diseases, sight-threatening retinopathy, renal failure and neuropathic diseases. Among Saudi patients, the prevalence of retinopathy is 31% after a mean duration of diabetes greater than 10 years. The duration of diabetes and the incidence and severity of retinopathy are closely associated. In patients with type 1 diabetes, the incidence rose from 6.1% in those with diabetes duration <5 years, to 62% in those who had the disease for >10 years. For

6 202 Diabetic Patients ' Knowledge & Practice Regarding persons with type 2 diabetes the incidence rose from 10% to 50% for those with a similar duration of diabetes. Al-Khader [14] stated that there is a global increase in the scale of diabetic chronic kidney disease with a resultant increase in those requiring renal replacement therapy, in the aftermath of the diabetes pandemic worldwide. Saudi Arabia is no exception. Despite that data on diabetic nephropathy in Saudi are scarce, diabetes is responsible for 30% to 45% of those requiring dialysis [151. Al- Homrany and Abdelmoniem [16] reported that dipstick positive proteinuria was found in 54% of diabetic Saudi patients and this was associated with poor diabetes control. Al-Nuaim [17] stated that, among Saudis, glucose intolerance is a major risk factor for vascular events, especially myocardial infarction [18]. Alhumaidi [19] added that diabetes is a predictor of acute myocardial infarction in patients attending primary health care centers in southwest Saudi Arabia. This study showed that 54.2% of diabetic patients suffered from hotness sensation in their feet. Feet numbness was complained by 47.7% of patients, while tingling in the feet was complained by 37.7%. During walking, about one third of patients experienced cramps (37.3%) and/or pain (32.6%). Good fasting blood sugar control was achieved only by 14.1% of patients, while bad control was observed in almost half of patients (45.8%). Similar findings were reported by Al-Maskari and El-Sadig [20], who conducted their crosssectional survey to assess the prevalence of diabetes complications in Al-Ain district, United Arab Emirates. They reported symptoms including cramplike-pain in legs or feet, tingling, numbness, and burning sensations with a "stocking and glove distribution" in 35% of them. Good diabetes control was achieved by 38% of patients. This study showed that less than half of diabetic patients underwent feet examination by primary health care physicians. Educational brochures on foot self-care were received by about one third of patients. Health education sessions on importance of and how to conduct foot care have been held only for less than half of patients, while only 7.9% of patients were referred to a podiatrist. Al-Mahroos and Al-Roomi [21] emphasized that family physicians have a leading role in ensuring that patients with diabetes should receive early and optimal care and health education to prevent skin ulcers. However, foot examinations are infrequently performed by prima-ry care physicians on diabetic patients and the feet of hospitalized diabetics are also inadequately evaluated. Once the diabetic patient has been thoroughly assessed, he or she should be assigned to direct referral and subsequent therapy by the specialty clinician or team and frequency of follow-up by the family physician or specialist. Patients with intact protective sensation and intact peripheral pulse, generally do not need referral and should receive general foot care education and undergo comprehensive foot examination annually. Patients with lost protective sensation and/or foot deformity may be managed by a family physician and a diabetologist care every 3-6 months. Consideration should be given to an initial specialist referral to assess the need for specialized treatment and follow-up. Those with lost protective sensation, or peripheral arterial disease or with a history of ulcer or amputation should be referred to a foot care specialist or specialty clinic and seen every 1-3 months [22]. In India, Shah et al. [23] noted that the feet of only one third of diabetic patients (34.43%) are being regularly examined by primary health care physicians. However, most patients admitted receiving health education sessions by their family physicians (85.29%). In Greece, Papanas and Maltezos [24] advised that it is desirable to continue education of both physicians and general diabetic population on the magnitude of the problem and on the suitable preventative measures. Clinical examination of diabetic patients' feet within the present study revealed that 1.4% of patients underwent amputations. Signs of neurological and vascular impairment were frequently present, manifested as abnormal discoloration of feet skin (14.4%), nails abnormalities (12.7%), feet swelling (6.9%), deformity (7.4%), muscle atrophy (6%), skin cracks/ulcers (10.2%), callus (6.9%), temperature fluctuation (1.4%), absent dorsalis pedis pulse (7.2%) or posterior tibial pulse (17.6%) and absent capillary refill in 15.3%. Some patients had diminished/lost vibration sense (12.3%), impaired sense of pressure (18.8%) and impaired Achilles tendon reflex (17.6%). Eneroth et al. [25] reported that limb ischemia is an independent risk factor for amputation. Moreover, Diamantopoulos et al. [26] showed that limb ischemia was the major factor associated with worse outcome in diabetic foot infections. Connor

7 Ali S. Al-Asmary, et al. 203 [27] stated that three major pathologies, mutually interacting, result in the diabetic foot: Ischemia, neuropathy and infection. Ischemia was recognized as a manifestation of peripheral arterial disease, which is more common in diabetes, and affects multiple vessels, with a predilection for the infrapopliteal arteries (e.g., anterior tibial and posterior tibial arteries). Initially, PAD may be silent, and so diabetic patients may present late with severe peripheral tissue hypoxia threatening limb viability, especially in the face of superimposed infection. Generally, prognosis of PAD is worse in patients with diabetes [28]. Neuropathy is responsible for stockingdistribution sensory loss: The feet lose sensation of noxious stimuli, such as trauma induced by stepping on a sharp object or skin injury due to illfitting shoes. Initially, foot injury may be trivial, but remain unperceived, eventually leading to progressing deep tissue destruction. Moreover, intrinsic foot muscles are deprived of normal innervation. Loss of innervation may result in muscle atrophy and foot deformities, mostly prominent metatarsal heads and claw or hammer toes [28]. The prevalence of diabetic foot in the present study is higher than that stated by Boulton [29], who reported that, worldwide, the prevalence of the diabetic foot ranges between 1.4% and 5.9%. He added that foot ulceration and amputation are significantly inter-related in diabetes. More than 85% of amputations resulted from a previous ulcer. Importantly, diabetes is the foremost cause of nontraumatic lower extremity amputation in the Western world, amputation rates among diabetic patients being 15 times higher than in the non-diabetic subj ects. In the United Arab Emirates, Al-Maskari and El-Sadig [20] found that 39% had peripheral neuropathy and 12% had peripheral vascular disease. Trophic skin and nail abnormality were present in 3% of the sample population and symptoms including cramp-like-pain in legs or feet, tingling, numbness, and burning sensations with a "stocking and glove distribution" were frequently reported in 35% of them. There were no cases of foot deformity or amputation and only one case had previous history of lower extremity ulceration. Gale et al. [30] noted that it has been suggested that up to half of all lower-limb amputations could be avoided with improved measures to prevent foot ulceration. Consequently, to reduce the risk of ulceration, people with diabetes are encouraged to avoid behaviors that could cause a break in the skin on the feet and to perform daily preventive foot self-care, such as foot self-examination. The present study revealed that the lmowledge and practices of diabetic patients as regard diabetic foot care was generally =satisfactory. The knowledge items which were unknown to diabetic patients were signs that should be daily checked, early management of an observed foot in the wound and what to do if the patient's foot is cold. The least practiced were regularly applying moisturizing agents to the feet skin and daily checking for skin temperature. These findings are in agreement with those concluded by several authors. Gale et al. [30] noted that how people with diabetes know and actually care for their feet is largely unknown. Several studies concluded that most patients have insufficient knowledge about how to reduce the risk of ulceration. The supposition has generally been, therefore, that increasing the amount of advice and health education would lead to improved self-care, although there is little empirical support for this approach [31]. This study showed that mean lmowledge scores on foot care and diabetic foot prevention were least among patients within the age group <40 years, female, non-married, illiterate, unemployed patients. Moreover, mean knowledge scores were significantly low among type 2 diabetic with duration of diabetes less than 10 years with bad fasting blood sugar control. In addition, the mean practice scores related to foot care and prevention of diabetic foot were least among patients within the age group >60 years, females, widowed, illiterate, =employed and smoker patients. Moreover, mean practice score for type 2 diabetic patients with bad fasting blood sugar control. Knowledge scores of diabetic patients on prevention of diabetic foot and foot self-care are significantly and positively correlated with patients' scores for practices related to foot self-care. A few surveys have concluded that most diabetic patients have insufficient knowledge about how to reduce the risk of foot ulceration [31]. The supposition has generally been, therefore, that increasing the amount of advice and education would lead to improved self-care. Systematic reviews of educational interventions for improved preventive foot self-care have found short-term effects [30]. Karter et al. [32] emphasized that the associations between educational attainment and health behaviors are particularly important in diabetes, given the critical role of health behaviors, including

8 204 Diabetic Patients ' Knowledge & Practice Regarding diabetes self-management and health-related lifestyle. Studies in diabetic populations have reported persistent disparities in glycemic control [33], diabetes-related comorbidities [34], and diabetesrelated mortality [35], suggesting that factors other than health care access likely mediate the socioeconomic status-diabetes health relationship. Using a sample of managed care patients with diabetes, Karter et al. [32] identified the relationships between educational attainment and smoking, physical activity, self-monitoring of blood glucose, foot self-exam, and diabetes-related health-seeking behaviors. In addition, Shah et al. [23] added that there is an increasing amount of evidence that the patient education is the most effective way to lessen the complications of diabetes and its management. In conclusion, prevalence of diabetic foot among diabetic patients attending PHCCs in Abha is 6.9%. Fasting blood sugar of most of these diabetic patients is badly controlled. They do not receive the necessary educational materials about foot self care and health education sessions on importance of and how to conduct foot care. PHC physicians in Abha do not provide the required routine foot examination to diabetic patients. Knowledge of diabetic patients about items related to diabetic foot care is generally =satisfactory. Most unknown items are signs that should be daily checked, early management of an observed foot in the wound and what to do if the patient's foot is cold. Knowledge scores of diabetic patients on prevention of diabetic foot and foot self-care are significantly and positively correlated with patients' scores for practices related to foot self-care. Diabetic patients who have the lowest knowledge scores on foot care and diabetic foot prevention are within the age group <40 years, females, non-married, illiterates, =employed, type 2 diabetic patients, duration of diabetes less than 10 years, and those with bad fasting blood sugar control. Practices of diabetic patients as regard their own feet care are not satisfactory. The least practiced by these patients are regularly applying a moisturizing agent to the feet skin and daily checking for skin temperature. Mean practice scores related to foot care and prevention of diabetic foot are least among patients within the age group >60 years, females, widowed, illiterate, unemployed, smokers, type 2 diabetic, with bad fasting blood sugar control. It is recommended that diabetic patients should receive health education sessions and material, which should cover all items related to prevention of diabetic foot and diabetic foot self-care. All diabetic patients should be encouraged to practices all steps of self-care. Diabetic patients with intact protective sensation and intact peripheral pulse should receive routine foot examination at least once per year. Patients with lost protective sensation and/or foot deformity are to be managed by a family physician and a diabetologist care every 3-6 months. Diabetic patients with lost protective sensation, or peripheral arterial disease or with a history of ulcer or amputation should be referred to a foot care specialist or specialty clinic and seen every 1-3 months. PHC physicians should receive training to provide ideal and proper routine foot examination and health education sessions to diabetic patients. References 1- AMOS A., MCCARTHY D. and ZIMMIT P.: The rising global burden of diabetes and its complications: Estimates and projections to the year Diabet. 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