1.1

Introduction

Diabetes is a significant public health problem, in view of its prevalence, severity and socioeconomic cost . The prevalence of diabetes is increasing . Diabetic foot is one of the main causes of amputation worldwide, second only to road accidents . This condition can be defined as the set of disease manifestations affecting the foot as a result of the harmful effect of diabetes on the peripheral nerves and/or arterial circulation in the legs. It is often precipitated by the occurrence of infection .

The aim of the present study was to evaluate our patients’ level of awareness of the risk factors for diabetic foot and identify parameters influencing this knowledge.

1.2

Patients and methods

We performed a prospective study over a 7-month period from July 2008 to February 2009. We first identified all diabetic patients hospitalized or seen in consultation in the Dermatology and Endocrinology Departments at Ibn Sina University Hospital (Rabat, Morocco). The inclusion criteria were as follows; the provision of consent by the patient, age 16 or over and the prior provision of information on diabetes by the attending physicians. The patient–physician education sessions had taken place individually or in groups and were mainly based on verbal information, visual media (such as brochures, posters, flyers) and open days. Patients with recently diagnosed diabetes (i.e. within the previous 6 months) were excluded. We recorded the patients’ sociodemographic characteristics, the time since onset of diabetes, the type of diabetes, the medical history, the type of therapy, the socioeconomic status, the educational level and data from the dermatological examination (which always included an examination of the nails and the sole of the foot). All our patients had undergone a neurological examination with a monofilament test and, if necessary, an electromyogram. All the patients with diabetic neuropathy were being monitored by our colleagues in the Neurology Department. We screened for diabetic atherosclerosis in a clinical examination with palpation of the pulse, together with arterial Doppler ultrasonography and/or arteriography (depending on the patient’s financial resources). Compliance with various hygiene and dietary rules (foot inspection, treatment by a podiatrist, etc.) and the level of knowledge concerning the risks of the diabetic foot were evaluated in a questionnaire administered by same investigator.

We analyzed various factors potentially capable of influencing the level of knowledge of the risks of diabetic foot. The data were entered and analyzed with SPSS (version 13.0, Laboratory of Biostatistics Epidemiology and Clinical Research, Faculty of Medecine, University Mohamed V, Rabat, Morocco).

Quantitative variables were expressed as the mean ± standard deviation (SD). Qualitative variables were expressed as the percentage and the frequency. We used a Chi-squared test to compare percentages and a Student’s t test to compare means. A P -value < 0.05 was considered to be statistically significant.

1.3

Results

Ninety-one patients were included in the study. The mean ± SD age was 48 ± 13, with an age range of 17–75. The male/female gender ratio was 0.63. The study population’s sociodemographic and clinical characteristics are summarized in Table 1 : 74% of the patients had low socioeconomic status and 39.5% of the patients were illiterate. Type II diabetes concerned 64.8% of the cases. The time since onset of diabetes was 94 ± 79 months, on average, and ranged from 6 to 360 months. Sixty-seven percent of the patients were on insulin, 6.6% of the patients had a history of foot ulcers and 5.5% had undergone foot amputation. The data from the dermatological examination are presented in Table 1 .

Arterial damage was observed in 50.5% of cases ( n = 46) and neurological damage was noted in 73.6% of cases ( n = 67). Morphostatic disorders of the foot were found in 82.4% of cases ( n = 75) and comprised claw toe ( n = 41), pes cavus ( n = 27), hallux valgus ( n = 23) and quintus varus ( n = 7), with some patients suffering from several of these disorders. According to the 2007 International Consensus on the Diabetic Foot, 3.2% of our patients ( n = 3) were grade 0, 14.3% ( n = 13) were grade 1, 54.9% ( n = 50) were grade 2 and 27.4% ( n = 25) were grade 3 .

In terms of compliance with hygiene and dietary rules, 79% of the patients never checked their feet, 29% used sharp instruments, 36% took long foot baths (lasting over 5 minutes), 50% never dried their feet, 60% walked barefoot, 40% used a foot warmer, 54% applied traditional herbal remedies (including black henna), 58% wore tight socks and 35.5% wore inappropriate shoes.

In terms of the level of knowledge on the diabetic foot risk, 55% of patients were unaware of the degenerative complications, 45% were unaware of nutritional recommendations, 76% did not perform foot care and 85.5% did not pay attention to “warning sign” foot injuries.

In terms of the factors influencing poor awareness of the risk of foot problems, the educational level ( P < 0.001) and socioeconomic status ( P = 0.009) had an impact on knowledge of foot care. Good knowledge of the degenerative complications of diabetes was associated with low age ( P = 0.034), high educational level ( P = 0.001) and high socioeconomic status ( P = 0.009).

1.4

Discussion

Over 50% of our study population was poorly aware of the risk of foot problems in diabetes. A Tunisian study of a population of type II diabetics concluded that at least 40% had a poor level of knowledge concerning diabetes in general (i.e. its cause and characteristics) . To the best of our knowledge, there are no published studies concerning the evaluation of knowledge of diabetic foot risks . If one considers that Morocco and Tunisia have similar sociocultural contexts, one can conclude that our results may be explained by the patients’ low educational level and low socioeconomic status. Furthermore, studies in Western countries have also reported on a lack of awareness in diabetics . However, the cultural and socioeconomic differences between Morocco and Western countries limit the extent to which our conclusions can be extrapolated. Comparisons between studies are further complicated by differences in measurement parameters and sampling methods.

Our work revealed a low level of patient awareness in terms of the severity of diabetic foot complications and ways to prevent them. The patients’ knowledge mainly concerned diet, glycaemia monitoring and treatment procedures (e.g. insulin injection). In contrast, the patients hardly ever mentioned cardiovascular risk factors and complications such as diabetic foot. The patients’ explained their poor awareness of the risks of the diabetic foot by citing a lack of information, disease denial, low socioeconomic status and financial constraints. Moreover, our patients (most of whom were illiterate) reported poor understanding of medical advice, due to the use of scientific terms in French.

The chronic nature of the disease may also influence knowledge of the risks because many physicians believe that the longer patients have had the disease, the better informed they are. In our work, the mean time since onset of diabetes was 7.5 years and had no impact on risk awareness – in contrast with the findings of Ben Abdelaziz et al. . The time since onset of diabetes in our patients was probably underestimated, due to a period of subclinical diabetes.

Better knowledge of foot care was noted in patients with a good educational level and/or high socioeconomic status. Forty percent of study patients were illiterate, which explains (at least in part) the poor general compliance with hygiene and dietary rules. Seventy-five percent of patients came from a poor socioeconomic background and lacked health insurance; this limits access to care and is a clear risk factor for lower limb amputation in diabetics . In addition to these two factors, awareness of the degenerative complications of the diabetes (including the diabetic foot) was influenced by the patient’s age. The mean age of well-informed patients was 44 ± 11.8, versus 52 ± 14 for poorly informed patients.

In fact, we are not aware of any controlled studies that show that low educational level, poor hygiene and non-compliance with hygiene and dietary rules are risk factors for diabetic foot lesions or that educational level influences patient compliance with diabetes therapy or the risk of foot problems . According to guidelines on the management of the diabetic foot, education is essential and must address patients from grade 1 upwards . There is still no consensus on the education of diabetic patients in the absence of degenerative damage (atherosclerosis and/or neuropathy) . However, in our context, patients consult at a later stage in the disease process and early-stage screening is of greater value . Given the illiteracy of the general population in Morocco (and other developing countries), educational level will always play a more prominent role in treatment compliance.

From an anatomic point of view, the foot is the organ that is most exposed to mechanical stress and the consequences of diabetes-induced vascular and nerve damage . Biomechanical disorders of the foot are combined with a weakened ability to combat infections . This formidable combination testifies to the considerable risks to which the diabetic foot is exposed . The weakened defence against infection must be viewed with caution because diabetics with neither neuropathy nor atherosclerotic or morphostatic disorders do not have a diabetic foot risk or chronic ulcers and thus do not become infected more often. The risk of infection is directly related to the chronic nature of the wound, which in turn is related to the presence of neuropathy, delayed management and poor compliance with wound care. Atherosclerosis (often mentioned in situations with chronic ulceration) is present to a varying extent (in no more than 50% of cases).

Patient education constitutes a major lever in the prevention of diabetic complications ; it consists of the set of procedures that enable the patient to acquire the skills needed to pro-actively management his/her disease, treatment and monitoring . The patient’s pro-active participation increases successful glycaemia control and delays the appearance of disease complications . Moreover, it has been proved that maintenance of a normal HbA _1c level decreases the frequency of complications (e.g. diabetic retinopathy, neuropathy, arteriopathy and nephropathy) .

Patient education in diabetes is based on a number of well-established precautions . However, in our context, other measures should be taken into account. The use of “babouche” slippers (above all those with thin soles) should be avoided, given that shoe-related injury is one of the prime causes of foot ulcers in diabetics . Likewise, patients should not apply traditional plant-based or black henna preparations containing to paraphenylenediamine (PPD), a paraaminobenzene sensitizer that is added to henna to reduce the application time and intensify the tattoo’s colour . In diabetics, this product should be avoided, in view of both its allergenic activity and its irritating effect on the sole of foot, which may trigger ulceration. In our context, the use of Turkish baths encourages barefoot walking and increases the frequency of fungal infection. The feet must be dried carefully, especially after ablutions. Unfortunately, patient education has not proved its efficacy (in terms of evidence-based medicine) in reducing the recurrence of diabetic foot ulcers. It constitutes expert advice but should not be given when the diabetic foot risk is nil (as in grade 0 patients). Accurate grading is thus essential.

Foot fungal infections were found in 39.6% of patients and are considered to be severity factors in diabetics. The diabetic foot is an ideal environment for fungal growth and exposes the patient to a greater risk of additional bacterial infection .

All diabetics and their families should receive easily assimilated, locally provided patient education in the days and months following their diagnosis, with practical, appropriate message and by taking account of certain impairments (age, deafness, visual disorders, functional impairments, etc.) .

Several studies have shown that diabetes-focused patient education aimed at achieving long-term control of the condition enables the avoidance of atherosclerotic and/or neuropathic complications .

In Morocco, there are no specialist centres for the multidisciplinary management of the diabetic foot. However, specialized, multidisciplinary care and prevention programmes in several countries have enabled reductions of up to 80% in the amputation rate .

1.5

Conclusion

Our study revealed a lack of information in our diabetic patient population. Awareness-raising campaigns (with different types of information) and improved living standards would be needed to improve the current approach to the diabetic foot.

Diabetic foot is a complex, difficult-to-treat condition that requires a multidisciplinary approach and effective cooperation between healthcare stakeholders: the general practitioner, the diabetologist, the angiologist, the dermatologist, the surgeon, the podiatrist and the nurse .

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.