Influence of - related knowledge on foot ulceration

Cynthia Formosa, Lourdes Vella Article points To investigate the relationship between diabetes-related knowledge 1. This study aimed to and foot ulceration among people with , the authors explore the relationship assessed diabetes knowledge in groups with and without foot between diabetes-related knowledge and foot ulceration. There was no significant difference in diabetes-related ulceration in a Maltese knowledge between the two groups, although the mean level of population with type 2 knowledge in the group with foot ulceration was greater. The authors’ diabetes. question current approaches to diabetes education and suggest that a 2. No significant difference new approach to diabetes education programmes is needed. in diabetes-related knowledge was found he incidence of diabetes is increasing Strine et al (2005) reported that 50–80% to exist between those worldwide and an estimated 1–4% of people with diabetes worldwide have with and without foot ulceration. T of people with type 2 diabetes significant knowledge deficits in relation to develop a foot ulcer each year (Boulton et al, the management of their condition. These 3. ulcers are 2005). This is of concern for both people data suggest that people are either not a global concern leading with diabetic foot ulceration and healthcare receiving diabetes education, or that the to patient morbidity and mortality, and providers, with episodes of ulceration strongly education offered is not effective. A fuller improvements in the associated with lower-extremity amputations, understanding of the factors that contribute approach to diabetes reduced quality of life, long periods of to suboptimal self-management, leading education may improve hospitalisation and substantial healthcare ultimately to distressing and costly diabetic outcomes. costs (Boulton et al, 2005). complications, is important if improvements Key words: Research suggests that the complications in diabetes outcomes are to be achieved - Diabetes-related of diabetes – including foot ulceration (Perrin et al, 2009). knowledge – could be prevented or ameliorated by Here, the authors explore the relationship - Foot ulcer prevention long-term good glycaemic control (UK between diabetes-related knowledge and foot - Health behaviours Prospective Diabetes Study Group, 1998; ulceration in a Maltese cohort. Jabbar et al, 2001). However, optimal long- term glycaemic control requires good self- Background management and, with less than a third of Ten percent of the Maltese population people with diabetes in Europe achieving has diabetes, compared with 2–5% of the good glycaemic control (HbA1c level ≤6.5% population in its neighbouring European Cynthia Formosa is a Lecturer [≤48 mmol/mol]; Liebl et al, 2002), it has countries (Rocchiccioli et al, 2005). and the Head of the School of been suggested that people with diabetes are Expectably, foot ulceration, and ulcer Podiatry, University of Malta. not being effectively educated and supported recurrence, is common in the Maltese Lourdes Vella is a Podiatrist, to achieve good self-management. population with diabetes (Galea et al, 2009). Department of Health, Malta.

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Page points Aim Results 1. Participants eligible for To determine whether diabetes-related All those who met the inclusion criteria were this study were Maltese, knowledge correlated with diabetic foot invited verbally and in writing and all agreed aged >45 years with ulceration. to participate (30/30 [15 with foot ulcers; 15 type 2 diabetes with no history of foot ulceration]; 100% 2. The outcome variable Methods response rate). Both groups were matched for measured for both groups Individuals were recruited from the Diabetes age, sex, education level, duration of diabetes, was diabetes-related Podiatry Clinic, Mater Dei Hospital, Malta current medications and weight. No more knowledge, assessed by (the only public hospital in Malta). An average than a 5-year difference was accepted for age the Diabetes Knowledge Questionnaire, which was of 5000 people attend the Diabetes Podiatry or duration of diabetes for people matched in read to participants in Clinic annually, with approximately 500 the two groups. one-to-one interviews in experiencing ulceration (Mater Dei Hospital, the Maltese language. 2007). Diabetes knowledge scores 3. No significant difference Participants eligible for this study were Table 1 shows the DKQ-24 scores for each was found between the Maltese, aged >45 years with type 2 diabetes group. When comparing knowledge scores Diabetes Knowledge (World Health Organization diagnostic between the two groups, no significant Questionnaire scores of criteria; WHO, 2011). People presenting with difference was found (P=0.671). However, the two groups, however the mean score of the case an active ulcer were invited to participate as the mean DKQ-24 score of the case group group was higher than the case group; people attending for routine was higher than that of the controls (18.53 vs that of the controls. podiatry care with no history of ulceration 18.07; Table 2). were invited to participate as the control group.

This study was approved by the Ethics HbA1c Board of the University of Malta. Mean HbA1c levels are shown in Table 3. No significant difference between the HbA1c Outcome measure levels of the two groups was found (P=0.312). The outcome variable measured for both groups was diabetes-related knowledge, Table 1. Comparison of Diabetes assessed by the Diabetes Knowledge Knowledge Questionnaire (DKQ-24) scores between the case and control groups. Questionnaire (DKQ-24; Garcia et al, 2001). Group DKQ-24 score, mean (SD)* This scale was developed for use in people with type 2 diabetes and is a reliable and Control (n=15) 18.07 (±0.76) valid measure that is easy to administer. Case (n=15) 18.53 (±0.78) Items include general diabetes information, *P=0.671. SD, standard deviation. urine and blood testing, diet and foot care. The DKQ-24 was read to participants in one- Table 2. Statistical analysis of the Diabetes Knowledge Questionnaire scores of the case and to-one interviews in the Maltese language control groups. (previously translated into Maltese by Formosa Between Within Total et al [2008]). groups groups As a surrogate measure of the application Sum of squares 1.633 284.667 250.300 of diabetes-related knowledge, mean HbA df 1 28 29 1c Mean square 1.633 8.881 levels of the two groups were recorded and F 0.184 compared. P-value 0.671 df, degrees of freedom. Statistical analysis Data were analysed using SPSS version 14 Table 3. Mean participant HbA1c levels. (IBM, Chicago, IL). Normality of distribution Group HbA1c, mean % (SD) was established using a Kolmogorov Smirnov Control (n=15) 7.3† (±1.3) test. One-way analysis of variance was used to Case (n=15) 7.8‡ (±1.3) determine differences in the mean. †56 mmol/mol; ‡62 mmol/mol. SD, standard deviation.

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However, the mean HbA1c in the case improved glycaemic control for greater Page points group was higher than in the controls (7.8% than 3–6 months, and the prevention of 1. Previous studies on the [62 mmol/mol] vs 7.3% [56 mmol/mol]). diabetic complications (Sánchez et al, 2005; relationship between Valk et al, 2005; Mauldon et al, 2006; diabetes-related Discussion Adolfsson et al, 2007). In a systematic knowledge and diabetes This is the first study to explore the relationship review, Dorresteijn et al (2010) concluded outcomes have reported conflicting results. between diabetes-related knowledge and foot that there was insufficient evidence to ulcer prevalence in a Maltese cohort. The show that knowledge acquired through 2. In a systematic review, evidence suggests that there is no significant health education interventions reduced the Dorresteijn et al (2010) concluded that there was difference in diabetes-related knowledge incidence of diabetic foot ulceration. insufficient evidence to between people with foot ulceration and those Many of the existing diabetes education show that knowledge with no history of ulceration. programmes have been criticised for being acquired through health Previous studies on the relationship centred on knowledge and physiological education interventions between diabetes-related knowledge outcomes, and placing little importance on reduced the incidence of diabetic foot ulceration and diabetes outcomes have reported a person’s beliefs and experience of living conflicting results (Norris et al, 2002; with their condition (Sigurdardottir et al, 3. Existing diabetes Tankova et al, 2004; Valk et al, 2005; 2007). Furthermore, knowledge alone does education programmes have been criticised for Formosa et al, 2008; Dorresteijn et al; not always lead to behavioural change little importance on 2010). Few have demonstrated what (Rafique and Shaikh, 2006), while culture a person’s beliefs and might intuitively be expected; that greater is known to strongly influence behaviour experience of living with diabetes-related knowledge translates into (Lifshitz, 2006). their condition. Influence of diabetes-related knowledge on foot ulceration

Page points Several studies have looked specifically at Diabetic foot health education programmes 1. Health behaviour is how culture affects the interpretation and – if they are to translate into positive complex and there experience of diabetes and its management behavioural changes and improve outcomes are numerous models (Lai et al, 2005; Carbone et al, 2007; for people with diabetes – must adopt designed to help Sowattanangoon et al, 2009). These studies appropriate approaches, which may require a understand its processes. highlight the need to recognise the importance combination of concepts from more than one 2. Diabetic foot health of culture, beliefs, lifestyle and priorities when of the health behaviour theories. The authors education programmes developing educational strategies, if they are suggest that the time has come to move away must adopt appropriate to translate into effective self-management from traditional diabetes-related education, approaches, which may require a combination (Formosa et al, 2008). To improve outcomes – which has failed in a number of settings to of concepts from more and returns on investments in education – the translate into sustained, positive outcomes. than one of the health educational approach adopted must be relevant Innovative approaches to diabetes education behaviour theories. to the population it serves and address cultural are needed in order to translate investment 3. Innovative approaches aspects of health beliefs. in self-management skills into long-term to diabetes education The higher incidence of type 2 diabetes improvements in the quality of life of people are needed in order to and its complications in Malta, as compared with diabetes, and decrease the incidence of translate investment with broadly similar surrounding populations, costly complications, including foot ulceration. in self-management skills into long-term suggests the contribution of uniquely One example of a diabetes education improvements in the Maltese traditions and cultural habits to the programme that has been demonstrated to quality of life of people pathophysiology of this condition. Mitchell achieve measurable improvements in outcomes with diabetes, and (2002) describes Maltese people as particularly is DESMOND (Diabetes Education and decrease the incidence reluctant to relinquish certain long-standing Self-Management for Ongoing and Newly of costly complications, including foot ulceration. traditions (e.g. festivals), which often centre Diagnosed; www.desmond-project.org.uk). on food. Many of the culturally valued This programme aims to support participants foods in Malta are not among those that in making sustained, positive lifestyle choices could be recommended as part of diet for the to improve their diabetes control, emphasising good management of diabetes, yet failing to both education at the time of diagnosis and participate in food traditions may interfere “toping-up” diabetes knowledge at later with social relationships. Thus, achieving stages (Lucas and Walker, 2004). In an change in health behaviour in the Maltese uncontrolled pilot study, the DESMOND population will require an understanding of, programme changed key illness beliefs, and and strategies for addressing, aspects of culture these changes predicted improved quality of that impact diabetes self-management. life and metabolic control at 3-month follow- Health behaviour is complex and there are up (Skinner et al, 2006). In a cohort reported numerous models designed to help understand on by Davies et al (2008), participation in the its processes (Cockburn, 2004). Most of the programme resulted in greater improvements prominent health behaviour theories (i.e. in weight loss, smoking cessation and beliefs

health belief model [Becker, 1974]; theories about illness, however no difference in HbA1c of reasoned action and planned behaviour levels up to 12 months after diagnosis. [Ajzen and Fishbein, 1980]; social cognitive theory [Bandura 1986]; transtheoretical Study limitations model [Prochaska and Di Clemente, 1986]) It is acknowledged that the present study is emphasise self-efficacy, that is, the development limited by the size of the recruited cohort and of self-management skills and self-confidence statistical significance for the outcomes measured by the person with the condition. They also may not have been reached for this reason. highlight the importance of social role models (family and peer groups), and the importance Conclusion of recognising that individuals in a population Previous studies have investigated the may be at different stages of change. relationship between diabetes-related

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knowledge and foot ulcer prevalence. This Liburd L C (2003) Food, identity, and African-American “Improvements in is the first study to explore the question in a women with type 2 diabetes: an anthropological perspective. Diabetes Spectr 16: 16–5 the approach to Maltese cohort, and the results were largely Liebl A, Mata M, Eschwège E, ODE-2 Advisory Board (2002) diabetes education – consistent with those of previous authors. The Evaluation of risk factors for development of complications in type II diabetes in Europe. Diabetologia 45: S23–8 with attention given evidence suggests that there is no significant Lifshitz A (2006) Cultural awareness: a prescription for more to local cultural difference in diabetes-related knowledge effective medicine. MedGenMed 8: 17 Lucas S Walker R (2004) An overview of diabetes education differences and between people with and without foot in the United Kingdom: past, present and future. Practical ulceration. 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