Characteristics of participants
Overall, 20 patients with Diabetes were selected in this study. The characteristics of the study participants are shown in Table 1. The majority of patients were women, had no formal education, were farmers and had been diagnosed with diabetes within five years of the study. Most of the participants had at least one comorbid condition and the commonest was Hypertension, but fewer had a history of foot ulcer and one had an amputation.
Table 1
Characteristics of participants
Characteristics
|
Participants (N = 20)
|
Percentage (%)
|
Sex
|
|
|
Female
|
15
|
75
|
Male
|
5
|
25
|
Age (years)
|
|
|
≤ 49
|
4
|
20
|
50–59
|
5
|
25
|
60–69
|
7
|
35
|
≥ 70
|
4
|
20
|
Education
|
|
|
No education
|
14
|
70
|
Basic education
|
6
|
30
|
Occupation
|
|
|
No occupation
|
4
|
20
|
Farmer
|
12
|
60
|
Trader
|
3
|
15
|
Security guard
|
1
|
5
|
Duration since diagnosis (years)
|
|
|
< 1
|
1
|
5
|
1–5
|
12
|
60
|
6–10
|
4
|
20
|
> 10
|
3
|
15
|
Comorbidities
|
|
|
No other condition
|
4
|
20
|
Hypertension
|
14
|
70
|
Peptic ulcer disease
|
2
|
10
|
Diabetes foot disease history
|
|
|
No history of ulceration
|
15
|
75
|
Previous ulceration
|
3
|
15
|
Active ulcer
|
1
|
5
|
Previous amputation
|
1
|
5
|
Thematic analysis of the interview transcripts identified four main themes: knowledge of diabetes and its related complications; Beliefs and experiences about foot complications of diabetes; Diabetes self-management practices and Experience with diabetes foot assessment. Each of these themes
Knowledge of diabetes and its related complications
Participants had good understanding of diabetes and its symptoms, but with limited knowledge about the risk factors and complications. Three-quarters of the patients in this study defined diabetes as a condition associated with high blood glucose levels, and described the disease based on the individual symptoms they experienced such as dizziness, frequent urination and tremors. Although few (n = 5) participants recalled a family history of diabetes, they could not associate it as a risk factor.
“Yes, I was aware of the diabetes condition because both parents had diabetes,” (60-year-old female farmer)
Stroke and Hypertension were well-known complications of diabetes among two-thirds of the respondents; only two of the participants cited foot ulcer and vision problems as possible complications of diabetes, with one participant not knowing about any diabetes complications.
I know diabetes can lead to stroke, and one can develop an ulcer that will be difficult to manage and heal (48-year-old female respondent)
The main source of diabetes knowledge among the study participants was from attending diabetes clinic and participants placed positive value on the education they received from the diabetes clinic, but others based their knowledge of diabetes on their personal experiences.
“Yes, the education is beneficial, and the educators seek to clarify any concerns anyone may have as well.” (65-year-old male with 7 years duration of diabetes)
With regards to self-management practices, most of the participants were confident they had received enough education on dietary management of diabetes. However, more than half of the participants reported having received very limited education with regards to foot care practices.
Beliefs and experiences about diabetes foot complications
There were varied perspectives with regards to patients’ beliefs and experience of diabetes foot complications. The majority of respondents who had no previous history of foot ulcer were ignorant of the causes of diabetes foot ulcers, while others with previous foot ulcer or an active ulcer were aware of diabetes foot complications. Likewise, patients with long duration of diabetes (more than 5 years) who experienced abnormal sensations/symptoms on the foot were particularly more alert of diabetic foot complications as compared to their counterparts with short duration of diabetes (less than 2 years) and with no abnormal feet problems. Other patients had knowledge because an immediate relative with diabetes had a chronic diabetes foot ulcer.
“… an aunt of mine died from a complicated foot ulcer. She had a sore on the foot which spread through to her bones and other parts of the body.” (59-year-old female respondent with 18 years history of diabetes)
About five of the participants mentioned there was an association between glycaemic control and foot complications. Some attributed the causes of diabetes foot ulcers to a noticeable open sore from an external injury. Although most of the participants reported symptoms like numbness, tingling and burning sensations, they did not know its association with diabetes, and they resorted to self-medication.
“Yes, I learnt that if you have diabetes and develop a cut from anything sharp, it leads to diabetes foot problems. However, I suddenly saw this ulcer developed coupled with sudden pains in my feet akin to having an electric shock without having a prior cut or wound.” (49-year old female with less than a year history of diabetes)
Few patients also remarked that the slow healing rate of foot ulcers in diabetes was a major problem.
I have been told that when someone with diabetes develops an ulcer, it may become problematic if unattended to (49-year-old with less than a year history of diabetes)
Despite the lack of concrete knowledge about diabetes foot complications, slightly over half of the subjects knew that lower limb amputations could occur in people with diabetes. Their knowledge stemmed from direct personal experiences or indirect involvement with victims of diabetes-related lower limb amputations.
Diabetes self-management practices
Overall, participants exhibited general knowledge on the day-to day activities they undertake for their diabetes management. The main aspects of their management mentioned included: dietary practices, exercises, medicines adherence and foot care practices. These are described under sub-themes below;
Nutrition therapy
In all cases, patients referred to diet as the core component of their diabetes self-management practice. Almost all patients (90%) had knowledge about dietary practices and believed that engaging in good eating habits had beneficial effects on their blood glucose levels. Most participants emphasised “no or low sugar consumption” in their meals.
“Please, from the education, we’re told not to eat sugar. As a result, I don’t take sugar. Even though I like tea, I make raw tea without sugar….” (75-year female respondent)
Furthermore, some of the patients controlled their portion sizes as well as incorporating fruits and vegetables in their diets. One respondent indicated “…Previously, if you are used to eating 2 balls of banku [a staple food made from corn dough and cassava dough], now you must eat 1 ball only. If I was eating 4 fingers of boiled plantain, I should eat two”
“I know it’s about my diet. I must take lots of vegetable soup, ‘nkontomire’ [cocoyam leaves sauce] and garden-eggs” (added by a 65-year old female)
Despite the majority who knew about portion size control, there was still some level of confusion regarding the dietary recommendations. This was due to the several misperceptions and confusing messages from the media and other contacts on the specific foods to eat. Some of the foods advised as preferable for people with diabetes could either be expensive, hard to come by or were simply not consistent with traditional recipes.
“with respect to the food aspect; getting the recommended food has been a problem. I have been advised to eat plantain [and not cassava because cassava has lots of starch] as my main food which I find it difficult to eat most times” (82-year-old female)
Exercise
Exercise was one of the least mentioned self-management practices undertaken by the respondents. Only two out of the 20 participants replied engaging in any form of exercise as part of their diabetes self-management or having knowledge of the benefits of exercising. Some narrated walking long distances to their farmlands that keeps them physically active.
“I have been told to engage in exercises. When you exercise in the mornings, it helps reduce your high blood sugar levels.” (a 49-year-old male respondent)
Adherence to Medication
Most patients said they were compliant with their medications, as well as visiting the clinic regularly for their repeat prescriptions.
“I take my medicine regularly and attend review appointments a” (80-year-old female)
Foot care practices
In contrast to dietary practices which majority of patients followed recommendations from their healthcare providers, more than half (n = 13) were limited in their knowledge in diabetes foot care practices. Some patients indicated that they had not received any education on foot care practices.
“we discuss about the dietary management of the disease but not about foot care practices”(46-year-old male farmer).,
The few who had received some information reported inspecting their feet occasionally or wearing appropriate footwear to protect themselves, especially low-heeled shoes to prevent wounds from accidents.
“the previous staff mentioned that for patients with diabetes, we should moisturise our feet by applying shea butter on our legs and feet, if possible….I also realised that for people with diabetes, wearing a high-heel can cause you to fall. Therefore, it is better to wear a low-level shoe” (59-year-old female)
Furthermore, some of the participants who were farmers were conversant with measures to protect themselves from developing a cut or sore at their workplace.
“I wear protective clothing like socks and long trousers before putting on shoe to protect my foot from risk of injury whilst working on the farm” (63-year female farmer)
Some of the patients, however, engaged in behaviours that put them further at risk for foot complications. For instance, some patients said they treated their leg wounds at home.
“If I get hurt deeply, I will report to the facility. However, with minor sores, I manage them myself at home” (67-year-old female with a one-year history of diabetes)
Other patients, while attempting to engage in healthy behaviours, rather put themselves at risks of injury.
“Sometimes I do not put on footwear. I learnt that when I walk on gravels with my barefoot, it provides some form of healing and improved circulation.” (82 years with 10 years duration of diabetes)
Experiences with Diabetes foot assessment
When asked if they have undergone any form of diabetes foot assessment, 90% of the respondents reported never having their feet checked as part of their routine management plan. A few who had a previous foot ulcer or amputation shared experiences of having their feet examined for treatment purposes whilst on admission. Some patients otherwise noted that their care providers were willing to attend to them if they had any problems with their feet.
“No, my foot has not been assessed before. However, we are being told to report any foot problems or ulcers when we notice them.” (65 year old male with 7 years duration of diabetes)