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Efectiveness of the Diabetic Foot Care Programme in a Primary Care Setting
ABSTRACT
Effectiveness of the Diabetic Foot Care Programme in a Primary Care Setting
Awisul Islah Ghazali
1
, Mohd Ikhwan Mohd Rusli
2
, Geok-Ping Chiew
2
, Shafina MohdYunus
2
, Abdul Karim Mohamad
2
, Syed Mud Puad Syed Amran
2
, Amar-Singh HSS
3,6
, Sondi Sararaks
4
, Ranjit Kaur Praim Singh
5
1 Taiping Hospital 2 Larut Matang Selama District Health Office
3 Clinical Research Centre Perak 4 Institute for Health Systems Research
5 Perak State Health Department 6 Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak
Introduction and Objectives
Diabetes is a major and growing health problem in most countries causing considerable amount of disability, premature mortality, and loss of productivity as well as imposing
increased demands on healthcare facilities. In Malaysia, the prevalence of diabetes mellitus
has steadily increased over the years with an estimate of 0.65 in 1960, to 2.00 in 1982. Foot problems are a leading cause of hospitalisation and it was estimated that 15
of the people in the United States with diabetes will develop a serious foot condition some time in their lives. Currently, the diabetic foot care programme in Malaysia is
based on the Clinical Practice Guideline CPG on the Management of Diabetic Foot that was issued in 2003 by the Ministry Of Health. For the district of Larut Matang Selama
LMS, 6000 diabetic patient have been officially recorded into the diabetes registry and this number is increasing every year. A number of activities have been put in place to
reduce the complication rate, and the nationwide diabetic foot care programme is one of them. This study aimed to evaluate the effectiveness of the implementation of the
foot care programme in the District of LMS. The assessment covered the extent of the implementation, knowledge of the patient and the delivery of the programme by the
healthcare personnel.
Methodology
This study is a cross-sectional study on the implementation of a newly designed diabetic foot care programme in the District of LMS in Malaysia. This study was conducted over
a period of eleven months from January 2007 to November 2007. All health clinics in the district were involved. The study was carried out during the diabetic clinic days in
each of the clinics involved. The study was divided into two phases. An evaluation on the quality and problems arising from the foot care programme was done in the first phase,
followed by an intervention phase and a re-evaluation of the patients who had received the new training.
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Efectiveness of the Diabetic Foot Care Programme in a Primary Care Setting
Results
210 out of the 7017 registered patients were surveyed in phase 1 of this study. Only 42.3 of them had been exposed to diabetic foot care education and their average knowledge
score was 7.5 SD 2.8. It is shown that there is statistical significance in terms of average knowledge score between those who were exposed and those who were not exposed
p value = 0.04. When evaluation on health workers was done on diabetic foot care demonstration, a mean of 14.1 SD 2.9 out of the maximum possible score of 23 was
obtained.
In phase 2 of the study, 3 clinics were selected to participate in this intervention programme. 113 patients out of the 1214 registered patients from all the 3 clinics were involved in this
programme. The average score of selected patients before the intervention was 6.5 SD 2.8, which is significantly lower than the average score of 15.9 SD 4.4 post intervention
p value 0.001.
Conclusion
From this study, it is shown that despite the centralised effort to improve the diabetic foot care knowledge, knowledge score remained low amongst diabetic patients. The
extent of the problems heightens with the discovery of less than satisfactory knowledge score even amongst healthcare workers in this study. But, with the proper and effective
implementation of the diabetic foot care programme using well structured modules by trained personnel, diabetic patients’ knowledge can be improved. Thus, it is recommended
that proper implementation of such programme should be considered and reinforced by all relevant stakeholders including policy makers.
Keywords
effectiveness, diabetic foot care programme, primary care setting
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Efectiveness of the Diabetic Foot Care Programme in a Primary Care Setting
1.0 INTRODUCTION
Diabetes is a major and growing health problem in most countries causing considerable amount of disability, premature mortality, and loss of productivity as well as imposing
increased demands on healthcare facilities.
2
The disease also contributes significantly to the growing burden of chronic diseases. Diabetes is one of the four most prominent
diseases besides cardiovascular disease CVD, cancer and chronic respiratory disease that contribute significantly to the global burden of disease, disability and death.
Two major clinical forms of diabetes was recognized by World Health Organisation WHO, namely Type- 1 Diabetes previously known as Insulin-Dependent Diabetes Mellitus IDDM
and Type-2 Diabetes previously known as Non-Insulin-Dependent Diabetes Mellitus NIDDM.
2
In 1995, WHO estimated 135 million people worldwide living with diabetes and the number was projected to increase to 300 million by 2025.
2
Factors contributing to the increase include inappropriate diet, consumption of high energy food and lack of exercise. Up to
6 of the total healthcare expenditure in industrialised countries is spent on diabetes mellitus care.
9
In 2000, in United States, diabetes is the sixth leading cause of death and is currently the leading cause of both blindness and end-stage renal disease.
In Malaysia, the prevalence of diabetes mellitus has steadily increased over the years with an estimate of 0.65 in 1960, to 2 in 1982. Another survey was carried out by the
National Health and Morbidity Survey in 1986. In this survey, the prevalence of Diabetes Mellitus was estimated to be at 6.3. However in 1996, the Second National Health and
Morbidity survey has shown that the national prevalence of diabetes and Impaired Glucose Intolerance in Malaysia were 8.3 and 4.8 respectively. A total of 700,000 to 900,000
people were estimated to have diabetes in 1999 based on the prevalence among adults aged 30 and above. This concludes that there were 8 diabetics in every 100 adults.
2
Diabetes mellitus is a heterogeneous group of disorders characterized by hyperglycemia and glucose intolerance. Hyperglycemia is abnormally high blood glucose level, beyond
the normal range roughly 70-150mgml of plasma. Glucose intolerance is a pathological stage in which blood glucose level is less than 140mg100ml 7.8mmolL of plasma upon
fasting and above 200mg100ml 11.1 mmolL plasma at 30, 60 or 90 minutes during a glucose tolerance test. This condition is seen frequently in diabetes mellitus but can also
occur with other diseases and malnourishment. Glucose is produced by the digestion of starchy foods such as rice, potatoes, bread, and from sugars in sweet food.
7
The Diabetic Care Data Collection Project DCDCP conducted in 1997 shows that more than half of the diabetic patients were poorly controlled. 73 of diabetics had a HbA1c
of 7.5 or worse and 68 had a fasting blood glucose of 7.8mmolL or worse.
2
Diabetes- related complications can be reduced by controlling blood sugar levels.
6
Uncontrolled
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Efectiveness of the Diabetic Foot Care Programme in a Primary Care Setting
diabetes mellitus patients are susceptible to complications such as heart diseases, strokes, high blood pressure, blindness, kidney diseases, nervous system diseases, amputations,
dental diseases and complications during pregnancy. Biochemical imbalances that cause acute life-threatening events such as diabetic ketoacidosis DKA and hyperosmolar non-
ketotic coma are often caused by uncontrolled diabetes. Diabetic patients are more susceptible to other illnesses such as pneumonia or influenza and are more likely to die
of complications compared to the people who do not have diabetes.
8
When circulation or nerves are impaired, diabetic patients may develop serious foot problems more quickly and they tend to develop more complications compared to
healthy people.
4
Diabetic neuropathy is the most common and potentially dangerous foot problem.
5
It can cause insensitivity or loss in ability to feel pain, heat or cold.
4
Foot problems are a leading cause of hospitalisation and it was estimated that 15 of all people
in the United States with diabetes, will develop a serious foot condition some time in their lives. In the United States, more than 50,000 people each year with diabetes have a foot
or leg amputated due to diabetes complications.
10
These amputations can be prevented with early detection and prompt treatment. Diabetic patients tend to disregard lesions,
burns, bunions and other foot maladies. Diabetic neuropathy can also affect the muscles of the feet causing deformity such as hammertoes. More than 60 percent of non-traumatic
lower-limb amputations occur among people with diabetes and 30 percent of diabetics suffer from peripheral vascular disease.
2
Currently, the diabetic foot care programme in Malaysia is based on the Clinical Practice Guideline CPG on the Management of Diabetic Foot, which was issued in 2003 by the
Ministry Of Health. The CPG had been compiled by a committee comprising of orthopaedic and vascular surgeons from the public and private sectors. The CPG helps identify patients
at risk for foot complications and also serves as a guide for the management of foot disorders in Malaysian diabetic patients. This guideline consists of diagnostic methods
and evaluation, identification of risks factors, classification of diabetic foot problems with its appropriate treatment and management. According to this guideline, 30 of the total
diabetes registry should be evaluated under Quality Assurance Program to assess the effectiveness of the programme.
For the district of Larut Matang Selama LMS, 6000 diabetics have been officially recorded into the diabetes registry and this number is increasing every year. A number
of activities have been put in place to reduce the complication rate and the foot care programme is one of them.
This study aims to evaluate the effectiveness of the implementation of the foot care programme in the District of LMS.
