Introduction

The prevalence of diabetes mellitus (DM) is still increasing year by year [1] and it is estimated that the number of people with diabetes will increase 1.5 times from 463 million in 2019 to 700 million in 2045 [2]. According to World health organisation data in 2019 diabetes mellitus was direct cause of 1.5million deaths [3]. The prevalence of DM in Oman has increased over the past three decades in parallel with rapid economic growth, urbanization, and changes in lifestyle behaviours [4]. According to NCD survey in Oman the prevalence of DM is 14.5% [5].

Diabetic foot syndrome (DFS) is one of the common and most devastating preventable complications of diabetes mellitus (DM). It is associated with morbidity and premature mortality due to long-term complications. Lower extremity disease, which includes foot ulceration, peripheral neuropathy, peripheral arterial disease, or amputation, is twice as common as in people with diabetes when compared with healthy individuals. In Oman, around half (47 %) of all lower limb amputations are performed in those with diabetes [6].

A study conducted in 2002, highlighted the importance of proper education and awareness programs in changing attitudes toward DM. The study clearly shown that diabetes education and care management can significantly improve patient outcomes, glycaemic control and quality of life a study in India found inverse relation between knowledge and diabetic foot complications, which is more the knowledge less the complications [7,8].

However, a knowledge, attitude and practice gap still exists in T1DM management .Our study was conducted to assess the KBP among100 adult Omani patients with T1DM in a diabetic clinic at Bausher polyclinic. The findings of this study will help in designing effective educational program for prevention and control of this dreaded disease in Oman.

Patients and Methods

This cross sectional descriptive study was conducted during November 2019 – December 2019 at the outpatient clinic of Basher polyclinic in Muscat region of Sultanate of Oman by using a questionnaire to evaluate the KBP of Omani patients diagnosed with T1DM.

100 T1DM patients participated in the study. Inclusion criteria were: patients aged between 16 to 30 years who are known to have diabetes were included in the study. Exclusion criteria were 1) patients who denied consent to be part of the study. 2) Patients who already had diabetic foot syndrome, amputated foot, or foot ulcers and 3) patients with type 2 Diabetes Mellitus.

The questionnaire was combined, modified, revised and validated to better align with the Omani diabetes and Omani diabetic foot guidelines.¹³ the revised questionnaire covered six domains: demographic details, patient-reported diabetes-related foot disease, foot self-care, diabetes care education, foot care education, and professional foot care. A questionnaire containing 24 closed-ended and multiple choice type questions on KBP was developed to investigate the relationship between knowledge attitudes and practice of T1DM patients. The questionnaire includes knowledge of measures to prevent diabetic foot, attitudes to prevent it and self-care practices of the person with T1DM. One point was awarded for each correct answer. The questionnaire was beta-tested 5 patients to assess the validity, suitability of content, clarity and flow of questions. Necessary corrections and modifications were made based on the results of the pilot study. The questionnaire was prepared in English but prior to use in the study, was translated to Arabic. The Arabic version of the questionnaire was reviewed for language, clarity, and structure and was administered in face-to-face interviews to collect the data.

(Appendix 1).

A total of 9 items were included in the knowledge section which included elementary knowledge of diabetes, benefits of exercise, complications of diabetes, prevention of diabetic foot. For the nine items knowledge question, the maximum attainable score was ‘9’ and the minimum score was ‘0’. Likewise, in the Belief section, a total of 8 items were included which consisted of respondents Belief towards diabetes. A 6-point Likert scale was used to measure attitude.

Data were analysed in a database created using a Microsoft Office Excel 2007™ spreadsheet, and later transferred to SPSS (Statistical Package for the Social Sciences) version: 17.0 To calculate statistical measurements and standard de-Viation for variables addressed in the collection instrument.

Results

Profile of the study population:

The demographic baseline characteristics of the study population are shown in (Table 1). 39%of the patients were aged between 26 to 30 years there were females (50%) and 50 % males than males. 40% of them were in college and 25% of them in higher secondary school while the remainder were educated with different levels .Nearly one quarter (30%) were working .5% were illiterate and 53% had diabetes for more than 10 years (Table 1).

Knowledge

Out of 100 subjects, 57% did not know the causes of diabetes .85% of subjects knows the ‘normal’ blood glucose values. 20% of subjects did not know the causes of diabetic foot syndrome and one-fourth (25%) of the subjects did not know symptoms of diabetic foot syndrome. Just over one-fifth(25%), thought that their doctor alone was responsible for foot examination 25% did not know about diabetes complications 36% did not know how to prevent diabetic foot syndrome, 24% did not know risk factors that cause the disease. Only 40% thought they should examine their own feet. (Figure 1 & Table 2).

Beliefs

The majority acknowledged that walking barefoot and that “diabetic foot syndrome” are big problems 85% and 90% respectively. 80% subjects accepted that patients with diabetes could not eat everything even if they are compliant with medications. One-fifth (20%) thought that checking their blood sugar was the responsibility of their doctor only. Smaller proportions of respondents believed that diabetes cannot be fully treated (25%) and that uncontrolled diabetes is not serious (7%) (Figure1& Table 2).

Practices

60% of subjects reported they were checking water temperature before its use, 80% denied walking barefoot, and 64% stated that they check with their doctor if they have a foot problem. Moreover, 50% stated that they have been physically active and 40% reported physical activity 5 times a week .Furthermore, 50% reported drying their feet after washing, 60% use warm water for washing feet, 38% check their feet regularly. Finally, more than half 55% confirmed checking their blood sugar regularly. (Figure1 & Table 2).

Discussion

Knowledge is an essential requirement for better compliance with medical therapy. It is a hypothesis that good KBP have impact on adequate diabetes control. Even though 40% of subjects were studying in university and 30% of subjects is working, they had insufficient knowledge regarding the symptoms, complications, prevention and control of their disease condition. Awareness of complications of diabetes was not good among the patients in this study. 57% of the patients in our study did not know the cause of DM; 25% did not know about diabetes complications; 20% don’t know the cause of diabetic foot syndrome; 25% don’t know about symptoms of diabetic foot .Several studies in India observed an inverse relationship between diabetic foot ulcer and foot care knowledge as well as practice as seen in our study also. [9-13]. While, another study in England as a developed country, also stated poor knowledge of diabetes among ethnic groups [14].

In our study, overall, it was found that T1DM patients had insufficient knowledge regarding the symptoms, complications, prevention and control of their disease condition. However, a study from Malaysia reported a good knowledge, attitude and practice score among diabetic patients [15]. The differences in the results of studies may be due to the differences in educational level of the diabetic patients and accessibility of information and diabetes education. It is well established that patient contributions are very important for better management of diabetes.

In terms of attitude/beliefs a considerable disposition to practice self-examination and self-care was detected Although 85% agreed that walking bare foot carries high risk for development of diabetic foot complications 7% believe DM is not a serious problem and one-fourth (25%) still believed DM is not fully treatable. However in relation to practice, there is significant gaps were observed only 55% regularly monitoring blood glucose levels and only 50% checking feet daily regularly Only 50% were engaged in exercise. This finding could be related to a lack of knowledge and lack of organized diabetes education services in the diabetes clinic. Our findings indicate that knowledge, beliefs and practices must be interconnected in order to achieve successful preventive foot care.

Awareness of complications of diabetes was not good among the patients in this study. This may be due to the some factors such as inappropriate ways of providing information and lack of time due to the patient loads and lack of continuity in education by health care providers. A study in Nigeria observed that foot care and education to prevent complications were least suggested by doctors.[16]. It has been also reported in a study from Pakistan that appropriate educational program can have effect on the attitude of the people about diabetes [17]. Another study showed that serious diabetes education could improve glycaemic control and quality of life of diabetic patients [18,19]. This recommends the necessity for an awareness program, patient counselling and education on self-care management of the diabetic patients to improve their knowledge regarding diabetes with the emphasis on lifestyle modifications, and this process should be continuous not only in primary set up but also in any level of management the patient will go to and also not only for health educators but all who offer the service should share in this process.

Is it only patient who is responsible or HCPs also need to be addressed as caregivers especially in such low educational level patients. Therefore, a joint effort on part of the health care professionals and the patient is required to provide and receive education, respectively, about foot care to reduce foot problems. Our study reveals the importance of self-care, which is mainly aimed for normal function, development, health, and well-being of the patient. However, the lack of knowledge due to low education status and the lack of timely information provided by the caring physician to the patient need to be analysed deeply.

Our study revealed a medium level of knowledge, belief and practice for the majority of T1DM patients in basher polyclinic. T1DM patients usually are dependent on insulin for disease control while ignoring other healthy lifestyle modifications in practice. Low awareness about the diabetes among T1DM patients affects their ability of self-management and therefore have a negative impact on outcome of diabetes. What we really need is dialogue with the patient utilizing a Behaviour Change Counselling (BCC ) such as motivational interviewing (MI) approach which works on the philosophy that the patient and health care professional must work together to explore the difficulties of changing foot care management in a non-judgmental approach. This is achieved by the use of open-ended questions, reflection and summary with clear goals and specific strategies to develop a commitment to change and ensure this belief is translated to practice.

Limitations

The sample size is small and single centred study, so the findings of the study cannot be generalized to the all diabetes mellitus subjects in Oman. Multi centred study with larger sample size from different institutions will enhance the generalizability of the findings for future studies.

Conclusion

This study revealed a suboptimal level of KBP for the majority of T1DM patients in the study population, who usually are dependent on drugs for disease control while ignoring practical lifestyle modifications. Lack of awareness about diabetes among patients, affects their ability to self-manage and therefore has a negative impact on outcomes. We need a structured, well-designed behaviour counselling and interviews by health care workers.

Recommendation

We recommend the ministry of health , Oman to implement continuous awareness program, counselling and education on selfcare management of patients with diabetes mellitus such as BCC, Motivational interviewing involving both patients and health care professional together to explore the difficulties of changing diabetes and foot care management to improve their knowledge regarding diabetes mellitus with the emphasis on lifestyle modifications.

Acknowledgments

The authors are grateful to Dr. Thamra al Ghafry

(DG,Muscat) for inspiring, editing, and proofreading, and also for Dr. Hanan al Mahrooqi (Bausher polyclinic) for support. We are also grateful to Dr. Hamad al Harthy and Dr. Mohamed al Hinaii (Alnahda Hospital) for continued support during the study.

Authors’ contributions

All authors contributed to the conception, conduct of the study. They contributed to the drafting, revision, and final approval of the manuscript.

Funding and sponsorship: None

Conflict of interest: The author declares that there is no conflict of interests.

Compliance with ethical principles: Institutional approval and informed written consent was obtained from all respondents.

Figures

Tables

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