INTRODUCTION If you did not seek treatment for your illness,

326 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. 3 27 f e c tiv e n e ss o f t h e D ia b e tic F o ot C are P ro g ram m e in a P rim ar y C are S e tt in g Figure 1: Evaluation of problems faced in the implementation of foot care program among diabetic patients Is the current diabetic foot care programme implemented effectively? Patient factor Staff problems Limited strips Tools Staff not interested Communication barrier Budget to trained staff Staff over burden Patient’s lifestyle Limited awareness Poor compliance to medication Improper appointment Organization of diabetic clinic Unorganized staffing Over-crowded patient Time Communication barrier Foot wear Inadequate tools in certain places Place for foot examination Rate of diabetic foot complication Assessment Poor education Easily understood? Poor blood sugar control Poor compliance with programme Manual procedure Process of foot care Inadequate training in using tools Limited staffing Staff turnover Limitedinadequate training of staff Check-list Organization of the clinic Figure 1. Evaluation of problems faced in the implementation of foot care program among diabetic patients 328 Efectiveness of the Diabetic Foot Care Programme in a Primary Care Setting

2.0 OBJECTIVES

2.1 General Objective

To assess the effectiveness of the current diabetic foot care programme implemented in the primary care setting at Larut Matang and Selama LMS district, Perak.

2.2 Specific Objectives

1. To evaluate the extent of implementation of the programme in the following areas: a. Percentage of health clinics implementing the programme b. Percentage of diabetic patients covered 2. To evaluate the quality and problems in the implementation of the programme in the following areas: a. Knowledge of patients who have received training b. Availability of resources facilities, diabetic team and material c. Ability of staff in delivering diabetic foot care education to the patient d. Problems faced by the staff in implementing diabetic foot care programme 3. To intervene on the current foot care programme and re-evaluate the knowledge of patients who receive the new training. 4. To make recommendations on improving the current diabetic foot care programme.

3.0 METHODOLOGY

3.1 Overview of Research Design

This study is a cross-sectional study on the implementation of diabetic foot care programme in the District of LMS, Perak. This study was conducted within 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 clinic 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. See Figure 2 Phase One: Evaluation on the quality and problems of the current diabetic foot care programme For phase one, data collection was done using 3 methods: 1. Questionnaires for trained health staff on the diabetic foot care programme implementation. 329 Efectiveness of the Diabetic Foot Care Programme in a Primary Care Setting 5 Figure 2: Methodology flowchart Intervention Intervention was done to three selected clinics which include 2 clinics situated in the rural area Redang Panjang Clinic and Kuala Sepetang Clinic and 1 clinic situated in an urban area Kamunting Clinic: a Standardisation of the diabetic foot care module b Modification of current education program focused and stressed on foot care in on session rather than educating patient on every aspect of diabetes c Diabetic patients in these clinics were given training and education on foot care management Phase 2 Pre Intervention Evaluation All the 10 clinics within the District of LMS were evaluated on: a Implementation of the program in the clinics and number of diabetic patients registered. b Patient’s foot care knowledge c Availability of resources which include facilities, man power and equipment. d Ability of the health staff to demonstrate foot examination for diabetic patients Phase 1 Post Intervention Evaluation The 3 selected clinics for intervention were evaluated on: a Patient’s foot care knowledge Figure 2. Methodology flowchart