Assessment of Patient's Knowledge and Practice Regarding their Diabetic Foot in Chamchamal District (AL-Slemani City)

Background: Diabetic foot is common in the diabetic population; it is one of the most incapacitating chronic Complications resulting from poor disease management. Objective: The study aims to assess knowledge and practice of Diabetic patients, for their foot, and to find out the relationship between knowledge and practice with some Sociodemographic characteristics such as (Age, gender, level of education. Marital Status , monthly income, residential area). Methodology: Descriptive study was carried out at Chamchamal District, from the outpatient of Chamchamal evening Public Clinic and Chronic Disease Control Center, for the period of 15 th November 2013 up to 10 th of October 2014. To reach the objectives of the present study, a non-probability (purposive) sample of (75) patients with diabetic foot who attend the above center. For the purpose of data collection, a questionnaire was designed of (47) items. To measure the validity of instrument the researcher exposed the instruments to (16) experts. A pilot study was carried out to check the reliability of the questionnaire. Data were collected through the use of interview, and were analyzed through the application of descriptive statistics. Results: Results of the study revealed that there was a significant relationship between Knowledge and practice by level of education and monthly income and there was also a significant relationship between practices by Occupation. Conclusions: Diabetic patient's knowledge was deferent level in education and monthly income, and diabetes practice was deferent level in level of education, occupation, and monthly income in a statistically significant manner. Recommendations: The study recommended that Patients with diabetic foot need ongoing educational programs in order to increase their knowledge and understanding in addition to regular evaluation of self-care skills by the diabetes educator. Formal diabetes education programs, generally conducted by diabetes nurses and nutrition specialists, are often very effective and training nursing personnel regarding management of physical and psychological problems of patients is essential to increase their knowledge and practices skills.


INTRODUCTION:
Diabetes mellitus (DM) is one of the most common non-communicable diseases globally, and its related complications result in increasing disability, reduced life expectancy and enormous health costs for virtually every society (1) .
Diabetes mellitus is a metabolic disorder in which the body has a deficiency of and/or a resistance to insulin (2) .It is a syndrome of chronic hyperglycemia due to relative insulin deficiency, resistance or both.About 10-15% of diabetic patients develop foot ulcers at some stage in their lives.Diabetic foot problems are responsible for nearly 50% of all diabetes related hospital admission (3) .It is an insidious disease, with the risk of developing it increasing with age.It was formerly associated with advanced age and usually diagnosed after age 40, today, DM II is diagnosed in earlier ages due to increased obesity and increasing body mass index beyond the ideal body weight; this decreases sensitivity to insulin, thus causing receptor defects (4) .It is a public health problem and the leading cause of morbidity and mortality worldwide.Global diabetes incidence is increasing rapidly; this rise in prevalence of DM is likely to bring a concomitant increase in its complications among diabetic patients.One important complication of DM is the Foot problems; these complications constitute an increasing public health problem and are a leading cause of hospital admission, amputation and mortality in diabetic patients (5) .
Education is the key element in successful management of diabetes, as knowledge about diabetes empowers patients to play an active role in effective diabetes self-management.Patient education is an ongoing process, which should be aimed at helping patients to overcome behavioral and psychological barriers, improve self-management skills, and become empowered to make informed Choices.The diabetes educational process is a key aspect of DM management (6) .
Daily foot care and inspection can prevent the development of foot ulcers and the sub sequent complications that lead to amputation--one of the biggest threats to adults with diabetes.Preventive behavior focus on not going barefoot, Performing/receiving proper foot care, and wearing properly fitting shoes.Foot-specific patient education is an essential element of a health system diabetic foot program (7) .The study aims to assess knowledge and practice of Diabetic patients, for their foot, and to find out the relationship between knowledge and practice with some Sociodemographic characteristics such as (Age, gender, level of education.marital Status, monthly income, residential area).

METHODOLOGY:
Quantitative design (a descriptive study) has been conducted to assess the knowledge and practice of the patients with diabetic foot during the period of 15th November 2013 up to 10th October 2014.The present study was carried out in Chamchamal district, from the outpatient of Chamchamal evening Public Clinic and Chronic Disease Control Center.A non-probability (purposive) sample of (75) patients, males and females who were definitely diagnosed as having Diabetic foot and were selected from patients who attended at the outpatient of Chamchamal evening Public Clinic and Chronic Disease Control Center, which represent a Vital Governmental health agency in Chamchamal district.To reach the objective of the study, a questionnaire was designed and constructed by the researcher to assess the knowledge and selfcare of patients with Diabetic foot.Such construction was employed through review of literatures and related studies.The study instrument compressed of a total of (47) items, which were distributed through the followings: -Demographic Information sheet: This sheet consists of (8) items, which include: age, gender, level of educational, marital status, occupation, monthly income, residential area, and duration of diabetes mellitus.
-121 --Some contributing factors which have relation with diabetes mellitus: This part includes (3)  items, which are: Body mass index (BMI), Smoking, and Drinking Alcohol.-Source of Patients information about disease: This part includes (6) sub items.
-Knowledge: This part includes (18) items related to the knowledge of the patients about their disease.
-Practice: This part includes (17) items related to the self-care of the patients about their disease.
The content Validity of the questionnaire was determined through a panel of ( 16) experts.Reliability of the questionnaire was determined through the use of stability method (test -retest approach), and the computation of a Cronbach Alpha Correlation Coefficient.The findings indicated that correlation coefficient was (r = 0.91) for the Knowledge, and (r = 0.83) for practice of the study sample, which indicated acceptable reliability for the questionnaire.This table reveals that (44%) of the study sample's age were ≥ 60 years old, majority of them were male (57.3%) most of them were illiterate (53.3%), the majority of them was married (94.7 %) with barely sufficient monthly income (61.3%),about (34.7%) were house wives who live in urban area (72%), and (34.7 %) of the study sample had experience of (D.M) for 10 years and above.Concerning the Body Mass Index, (38.7) of the study sample were overweight and the majority of them not smoking (84%), the remaining (16%) smoking (11-20) cigarettes (8%) for more than 15 years.Patients who quit smoking for (15) years ago were (6.7%), the majority of them not drinking alcohol (98.7%).Most of patient's sources of information about disease are from television (37.3%).Table 2 indicates that the mean of scores are low on items (1), and moderate on items (2, 3, 4, 7, and 11), while highly significant, on the remaining items.Table 3 indicates that the mean of scores are highly on items (2, 5, 6), and moderate on items (3, 4, 7, 14, 15) while low significant on the remaining items.Table 4 shows that there is statistically significant correlation between Knowledge and practice.Table 5 shows that the mean knowledge for males (42.49) is statistically significantly higher than for females (39.84).Table 6 shows that there were highly significant relationship between the patient's level of education and their knowledge.Table 7 shows that there were highly significant relationship between the patient's level of education and their practices.

DISCUSSION:
Diabetes mellitus is most prevalent in middle-aged and elderly populations; with the highest rates occurring in persons aged 65 years and older, as the sixth leading cause of death in the US, which is agree with the present study (8) .
There are poor differences in knowledge by age group.In appears that knowledge is lowest in the oldest age group which is similar to the finding of a study by Al-Maskari et al., (2013), though Al-Maskari found a significant variation by knowledge by age group, likely because of the higher power of this study (n=575).Despite the larger sample size, Al-Maskari also did not find a significant variation in practice by age group (9) .
The mean score of knowledge for males (42.49) is statistically significantly higher than for females.Though the mean practice for males (32.09) is greater than for females (31.78), the difference is not statistically significant.Lavery, et al., (1996) declared that gender was not statistically significant in their study.In contrast, gender differences between men and women in the development of diabetic foot problems have been observed in other studies.This is may be according to the number of men who came to the diabetic center during data collection (10) .Kamel, et al., (1999) also found that poor Knowledge and Self-Care scores were related to level of education, but the scores are very low for all different levels of education.There were also statistically significant differences in means for practice by Monthly Income, with individuals with Insufficient Incomes (29.38) again lower than those with sufficient (34.69) or Barely Sufficient (32.09) incomes (11) .
Findings related to the impact of average monthly incomes have been mixed, with some studies (Oladele and Barnett (2006), Dunlop et al., 2000), who found that there is not a statistically significant association of average monthly income with knowledge and practice.The present study showed that there is no significant relationship between residential area and either knowledge or practice (12) and (13) .Though there was no statistically significant difference