Prevalence and risk factors for diabetic foot complications among people living with diabetes in Harare, Zimbabwe

Prevalence and risk factors for diabetic foot complications among people living with diabetes in Harare, Zimbabwe | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence and risk factors for diabetic foot complications among people living with diabetes in Harare, Zimbabwe Oppah Kuguyo, Doreen Macherera Mukona, Vasco Chikwasha, Lovemore Gwanzura, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3182157/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Mar, 2024 Read the published version in BMC Public Health → Version 1 posted 12 You are reading this latest preprint version Abstract Background Diabetic foot (DF) is one of the most common diabetes-related complications, however, the prevalence and associated risk factors of DF are not well characterized among people living with diabetes (PLWD) in Zimbabwe. This study aims to determine the prevalence of diabetic foot and associated risk factors in PLWD in Zimbabwe. Methods This was a cross-sectional study, employing a mixed-methods approach was used to obtain data. A total of 352 PLWD were recruited from 16 primary care clinics across Harare. Face-to-face interviews and patient record reviews were used to collect sociodemographic and clinical data. Screening for DF included sole pressure, peripheral neuropathy, ankle-brachial index, deep tendon reflexes, ulceration, and amputation were performed. Self-administered questionnaires were used to assess knowledge, attitudes, and practices (KAPs). Scoring for KAPs was done using Bloom’s cutoff, and regression analyses were used to associate variables with DF risk. Results This group was made up of 82 men and 279 women. The combined mean age was 57.9 ± 14 years, and the age was comparable by gender (p > 0.05). More than a quarter (n = 21) of men and 15% (n = 41) ofwomen had Type 1 diabetes. The distribution of diabetes type significantly differed by gender (p < 0.001). DF was observed in 53% of PLWD. Abnormal ankle-brachial index (53%) and peripheral neuropathy (53%), foot ulceration (17%) and amputations (3%) were observed. Peripheral neuropathy increased the risk of ulceration (OR = 1.7; 95% CI = 1.1–2.6; p = 0.019), while insulin adherence was protective against amputation (OR = 0.1; 95% CI = 0.1–0.9; p = 0.049). Most (87%) of the group demonstrated good DF knowledge and the importance of adhering to medication to prevent DF. However, 96% did not know that smoking was a risk of DF. Nearly two-thirds (63%) of the group demonstrated poor attitudes and practices. Poor attitudes and practices were not predictors of diabetic foot ulceration risk (p > 0.05). Conclusion Our findings report a high prevalence of DF (53%) in PLWD in Zimbabwe. However, DF is not routinely assessed in Zimbabwe. Adherence to insulin was found to protect against DF, underscoring the need for policy revisions to include screening and increasing insulin adherence to prevent DF as integral primary care for PLWD. Diabetes Diabetic foot Diabetic foot in Zimbabwe KAP Peripheral Neuropathy Insulin Figures Figure 1 Figure 2 Figure 3 Article highlights Diabetic foot (DF) complications can lead to amputations, yet foot care is not routinely monitored in Zimbabwe. Our study describes the DF burden and the associated risk factors among people living with diabetes (PLWD) in Zimbabwe. More than half had DF, and 3% were amputated. Insulin adherence was found to protect against amputations. Our study highlights a need for routine DF screening for PLWD. Our findings also underscore the need for education and awareness tools for patients to adhere to prescribed insulin towards improved diabetes management and preventing complications such as DF. Introduction Diabetes is one of the leading causes of hospitalizations and deaths globally, posing severe financial implications, especially in developing countries where high comorbidity is coupled with constrained manpower and rampant poverty ( 1 ). The prevalence of diabetes continues to rise in Zimbabwe, and in 2018, about 850,000 people, or 5.7% of the total Zimbabwean population, were estimated to be living with diabetes ( 2 ). The estimated cost of treatment for people living with diabetes (PLWD) in Zimbabwe is about US $ 1300 per year per patient, while care for diabetes-related complications such as diabetic foot (DF) bear a cost burden of US $ 2884 per annum ( 3 ). These high costs are a major barrier to adherence to prescribed care in Zimbabwe where health care is an out-of-pocket expense and in an environment of high unemployment ( 4 ). National health insurance subscriptions are low in Zimbabwe, and there are limited government aid schemes for chronic illnesses such as diabetes ( 3 ). Moreover, this high-cost burden translates to delayed treatment and increased mortality risk – posing a significant public health threat. DF encompasses lower extremity complications such as peripheral neuropathy, peripheral arterial disease (PAD), soft tissue infection, and ulceration ( 5 ). More than one-third of PLWD develop DF in their lifetime, and in 20% of DF cases, amputations in the lower extremities are observed ( 6 ). Of great significance, is diabetic foot ulceration which accounts for 25% of DF, precedes most (> 85%) diabetes-related amputations and increases the risk of diabetes-related mortality by 2.5-fold ( 6 , 7 ). Risk factors of DF include older age, low education, low socioeconomic status, alcohol consumption, smoking, high body mass index (BMI), type of diabetes, poor blood circulation, cardiovascular disease, nephropathy, retinopathy, and claudication ( 8 ). Moreover, good foot care has been shown to prevent 50–80% of DF complications, so good knowledge, attitudes and practices are key to preventing DF ( 9 – 11 ). Equally, poor knowledge and attitudes about DF care translate to poor practices and increase the risk of developing DF ( 12 ). Evidence from studies in diverse socioeconomic settings shows that the prominence of risk differs between populations, due to context-related factors. Therefore, there is a need to conduct research in diverse socioeconomic settings to identify local specific risk factors of DF. Several studies have investigated DF in Zimbabwe and a wide-ranging prevalence of 1–33% has been reported ( 13 – 16 ). Longer duration of diabetes, absent pedal pulses, and peripheral neuropathy were found as risk factors for foot ulceration in these populations ( 17 ). There are also very few studies that analyze the knowledge, attitudes and practices of DF in PLWD in Zimbabwe, However, these studies are few, have interrogated small sample sizes, and focused on single institutions. The Zimbabwe Diabetic Foot Project (ZDFP) was established to decrease the burden of DF in Zimbabwe. As a first step, the project sought to use a multi-centre approach to understand the burden of DF in Harare, the capital city of Zimbabwe; understand the context-specific risk factors of DF in Zimbabwe; and build the capacity of nurses at the forefront of managing PLWD as previously described ( 18 , 19 ). The current paper aims to determine the prevalence of DF, and associated risk factors among PLWD attending public health clinics across Harare. Methods Ethical approval Ethical approval for the project was granted by the national ethics committee, the Medical Research Council of Zimbabwe (approval number: MRCZ/A/1923). All study protocols were in accordance with the Declaration of Helsinki, 2013. Study design and setting The study utilized a mixed-methods approach. A cross-sectional study design was employed to recruit participants from 16 outpatient diabetes treatment facilities in the public sector, located in Harare, Zimbabwe. The treatment facilities included 14 primary care clinics and 2 referral hospitals that were conveniently selected because of the availability of a registered general nurses at the forefront of managing diabetes who received diabetic foot screening training as part of the ZDFP (18,19). The trained registered general nurses were responsible for recruitment and data collection. Qualitative data were also collected to assess the knowledge, attitudes, and practices in relation to DF risk. Participant Recruitment A consecutive sample of 352 participants was recruited between February 2015 and February 2016. To be considered eligible for recruitment into the cohort, participants had to (i) have a confirmed diagnosis of diabetes, (ii) be aged over 18 years, (iii) be seeking medical attention for diabetes at the targeted outpatient facilities, and (iv) provide consent to participate. Pregnant women and individuals admitted for inpatient care were excluded from the study. Informed consent was obtained from all study participants. All participants were informed of the study verbally and provided written consent to indicate agreement to participate. All participants were assigned a unique identifier that was used throughout the study to maintain confidentiality. Data collection Data were collected through face-to-face interviews, retrospective patient record reviews, and prospective foot screenings. All data was captured onto a standardised case report form to ensure uniform data capture. De-identified case report forms were stored in a lockable cupboard with limited access and electronic back-ups were stored in a secure laptop. Face-to-face interviews Participants provided data on age, sex, literacy status, socioeconomic status, employment status, and behavioural factors such as smoking habits, and alcohol consumption history. Data on family history of diabetes and cardiovascular disease was also recorded. Patient record reviews Specific data related to diabetes were collected from the patient clinical records, including body mass index (BMI), type of diabetes treatment, duration of diabetes, comorbid conditions, status and history of hypertension, coronary heart disease, cerebrovascular stroke, claudication, revascularization, renal transplantation, dialysis, or laser photocoagulation. In addition, a history of amputations, foot infections, nephropathy, retinopathy, as well as symptoms of diabetes-related neuropathy data were also collected. Diabetic foot screening General foot assessment A general foot examination for the presence of discoloured toenails, calluses, fissures, corns, and interdigital infection, condition of toenails and toe hair, as well as joint flexibility, was performed. A visual inspection for active foot ulceration or healed ulcer wounds as well as amputation of toes or limbs was conducted as markers for diabetic foot ulceration (DFU). Sole pressure assessment Deformities that may result in repetitive and excessive pressure of the foot were assessed by visual inspection by the registered general nurse, including hallux valgus, pes planus (flat foot), pes cavus (high arch), hammer toe, and Charcot joint. Confirmation of the presence of these conditions was made by a foot imprint captured on a Foot Imprinter Harris Mat FM1111 (Diabetik Foot Care India Pvt Ltd, India) and shown to a podiatrist for accurate determination. Distal neuropathy assessment A Semmes Weinstein Monofilament (SWM) 5.07 was used to evaluate sensory neuropathy in the lower extremities. The SWM 5.07 applies 10 grams of force to evaluate the loss of protective sensation in the hand or foot. In this study, 9 test sites on the feet were assessed, namely, 3 plantar sites on each foot, the hallux, third toe, and fifth toe; the base of the first, third, and fifth metatarsals, the heel, and 2 central sites. Each test site was assessed in triplicate in a blinded and arrhythmic manner. Correct perception of the SWM in 2 out of 3 times at each site was given a score of 1, while lack of perception less than 1 of 3 times was given a score of 0. The total peripheral neuropathy score was calculated by adding the sum for each foot and normal sensory function was defined as a total of at least 6 out of 9 sites, while less than 5 was considered to indicate the presence of peripheral neuropathy. Areas with ulcers, calluses, necrotic tissue, and scars were avoided during the test. Deep tendon reflexes The patellar and Achilles reflexes were assessed using the knee and foot jerk tests. A patellar hammer was used to lightly tap the patellar tendon and Achilles tendon, on a relaxed leg. A normal reaction would be an extension of the lower leg or the foot toward the plantar surface, respectively. Each test was conducted in duplicate on each foot. Reflexes were graded as 0 (Absent), 1+ (Hypoactive), 2 (Normal), 3 (Hyperactive without involuntary muscle contraction) and, 4+ (Hyperactive with involuntary muscle contraction). Only 2+ was considered normal in our study and absent or hyperactive reflexes in at least one lower limb were noted as abnormal. Peripheral vascular disease Pulses in the dorsalis pedis and posterior tibialis were also recorded and assessed for rate, rhythm, and amplitude using the SonoTrax vascular doppler ultrasound (EdanUSA, San Diego, California, USA). An amplitude of 3+ was considered a normal pulse for each test site, and less than 2.9 was considered abnormal. Peripheral vascular disease (PVD) was assessed by calculating the ratio of systolic blood pressure in dorsalis pedis to posterior tibialis, and PVD was defined by a ratio of <0.9 while a range of 0.9-1 was considered normal function. Ankle-brachial index The ankle-brachial index (ABI) was calculated using the ratio of ankle blood pressure to arm (brachial) blood pressure. An ABI of 0.9-1 was considered normal and signified the absence of PVD, while 1.2 were excluded due to potential arterial stiffness. Self-care deficit assessment Participants were assessed for self-care deficit by checking if the participant (i) was able to see the bottom of their feet, (ii) wore poor fitting footwear, (iii) had not received prior foot care education, (iv) had a foot ulcer but had not reported foot problems to the healthcare provider, and (v) did not take steps to reduce risk of injury. The self-care deficit was defined by a ‘yes’ answer to any of the following questions. Diabetic Foot Risk scoring The risk of developing DF ulcers within two years was calculated using the clinical prediction rule (CPR) that was developed and validated by Chappell and collaborators (2021). The scoring parameters consider three fundamentals, namely, sensitivity to a 10g monofilament, absence of pedal pulses and history of ulceration/amputation. The risk scoring was then classified using the precise CPR scoring parameters and sensitivity to 10g monofilament = 1 point, absence of one pedal pulse = 1 point, and history of ulceration or amputation = 2 points. The total risk was then calculated as the sum of the CPR score, and therefore, extrapolated from the risk table. Knowledge, Attitudes and Practices Assessment At recruitment, a semi-structured questionnaire was administered to participants to assess the knowledge, attitudes, and practices (KAP) of DF. The questionnaire was made available in the three main languages spoken in Zimbabwe – English, Shona and Ndebele. The questionnaire was made up of the knowledge section, which comprised 5 multiple-choice questions with yes, no or unsure as the selected responses. The attitudes and practices section had 6 short answer questions. Questions in the survey instrument included the knowledge of diabetes medications to prevent complications, wound management and behavioural factors such as smoking affecting DF. Additional knowledge questions included the frequency of patient’s foot examination, foot inspection and care in the presence of callosities, cuts and wounds, and washing of feet as previously recommended by the American College of Foot and Ankle Surgeons as well as the Diabetes UK guidelines (20, 21). To minimize guessing effect, the unsure response was added on each question. Incorrect or unsure responses were given a score of 0, while the correct response was assigned a score value of 1. The maximum total KAP score was 11 and a higher score implied better knowledge of diabetes and DF. The KAP levels were then defined as good or poor based on Bloom’s cut off point (22). Therefore, knowledge scores >60% ( i.e. at least 3 out of 5 correct responses) were regarded as having good knowledge. Scores of >80% (i.e. at least 5 out of 6 correct responses) in the attitude and practice section indicated good attitude/practice, while 60-79% (i.e. 4 out of 6 correct responses) indicated moderate attitudes/practices and <59% (<3 out of 6 correct responses) meant poor attitudes/practices. Data Analysis All data were captured into RedCap R and analysed using STATA version 12 (StataCorp LLC, Station College, TX, USA). Continuous data were summarised as mean± standard deviation or median (interquartile ranges) while categorical data were expressed as frequencies and percentages. The Chi-squared test was used to test for association between categorical variables. Univariate and multivariate logistic regression analyses were used to identify risk factors associated with DFU and amputation. A threshold of p<0.05 was considered statistically significant in this study. Results This cohort was made up of 352 participants with a confirmed diagnosis of diabetes (Table 1). Combined mean age was 57.9 ±14 years. Oral hypoglycaemics were the most common treatment. Smoking 44 (12.5%) and alcohol consumption 15 (4%) were recorded and these factors differed by gender (p<0.05) (Table 1). Glycated haemoglobin (HbA1c) values obtained from the patient records were available for 35 (10%) participants. Mean HbAic was 7.9% ±2.6. Normal A1c levels (<5.6%) were detected in 20% (n=7), while 2.9% (n=1) were pre-diabetic (5.7%<A1c6.5%). Table 1. Demographic data (n=352) Characteristic Male (n=82) n (%) Female (n= 270) n (%) p-value Mean Age ± SD (years) min-max 57 ± 17 14-88 58 ± 13 12-86 0.945 BMI (kg/m 2 ) 0.044 Underweight (30.0) 16 (20) 63 (23) Diabetes type <0.001 I 21 (26) 41 (15) II 61 (74) 229 (85) Diabetes duration (years ) 0.820 16 12 (15) 39 (14) Type of treatment* 0.533 Oral hypoglycaemics 55 (67) 199 (74) Insulin 30 (37) 59 (22) Diet 5 (6) 23 (9) Smoking <0.01 Never smoked 44 (51) 217 (80) Past smoker 22 (25) 30 (11) Current smoker 21 (24) 23 (9) Number of cigarettes per day (n=44) 0.614 <5 13 (62) 15 (65) 6-10 7 (33) 8 (35) 20 1 (5) 0 (0) Alcohol consumption history (n=15) 10 (12) 5 (2) 0.006 * some patients were receiving two or more modalities Prevalence of Diabetic Foot complications DF complications were detected in 53% of the participants. Foot examinations were conducted, and 33 (9%) of participants had discoloured toenails, with fungi (n=13), fissures (n=19) with low temperature (22%; n=80) (Table 2). Half of the group presented with distal peripheral neuropathy. Fifty-nine participants (17%) presented with diabetic foot ulcers, 16 were men and 43 were women. The distribution of foot ulcers was comparable by gender (p=0.451). Lower limb amputations were observed in 7 (3%) participants, for which more males (n=4) were amputated than women (n=3) (p=0.03). Table 2. Prevalence of diabetic foot risk factors (n=352) Diabetic foot complication Frequency (%) Discoloured toenails 33 (9) Fungal nail 13 (4) Abnormal foot skin colour 53 (15) Lack of joint flexibility 26 (7) Gait instability 27 (8) Foot Deformities Hallux Valgus 14 (5) Flat foot 4 (1) Hammer toe 11(3) Calluses 5(1) Fissures 19 (5) Distal neuropathy Unsteadiness in walking 176 (50) Burning, aching pain or tenderness 176 (50) Prickling sensation on legs and feet 123 (35) Numbness of feet/legs 179 (51) Loss of touch sensation in feet 172 (50) Ankle Brachial Index (n=276) Normal 126 (46) Sub-clinical 121 (44) Severe 26 (9) Foot ulcers 59 (17) Amputation 7 (3) Abnormal ankle reflex 67 (19) Abnormal patellar reflex 17 (5) Other diabetes-related complications reported in this cohort, retinopathy (n=166) was the most common, followed by hypertension (n=86), coronary artery disease (n=79), claudication (n=38), cerebrovascular stroke (n=9), renal disease (n=17) and revascularisation (n=1) (Figure 1). The frequency of hypertension (p=0.010) and coronary artery disease (CAD) (p=0.048) was significantly higher in women than in men (Figure 1). Risk factors of diabetic foot complications Analyses for the prevalence of DF complications stratified by the duration of diabetes were computed (Figure 2) and a significantly higher frequency of history of foot ulceration for individuals with a long history of diabetes [11-15 years: p<0.001; more than 15 years: p<0.001] was observed. Univariate regression analysis was performed to identify the risk factors of diabetic complications (Figure 3). In a multivariate model, only distal neuropathy (burning, aching pain, or tenderness) was a significant risk factor for diabetic foot ulcers (OR= 1.7; 95% confidence interval=1.1-2.6; p=0.019) (Table 3). Insulin adherence was a protective factor for amputation (OR=0.1; 95% CI=0.1-0.9; p=0.049) in both univariate and multivariate analyses (Table 3). Table 3. Multivariate model analyses for the factors associated with diabetic foot ulcers and amputation Predictor Covariates Odds ratio (95% CI) p Diabetic Foot Ulcers Age 1.0 (1.0-1.1) 0.165 BMI 1.1 (1.0-1.2) 0.272 Gender 0.7 (0.2-2.6) 0.564 Duration of diabetes 1.0 (0.9-1.1) 0.850 Retinopathy 2.1 (0.7-6.4) 0.198 Foot colour 5.9 (0.9-37.7) 0.061 Renal disease 3.4 (0.4-31.7) 0.290 PAD 1.1 (0.5-2.6) 0.823 Unsteady walking 0.7 (0.4-1.5) 0.407 Burning, aching pain or tenderness of feet 1.7 (1.1-2.6) 0.019* Prickling sensation 0.9 (0.6-1.4) 0.742 Numbness of feet 1.1 (0.7-1.7) 0.831 Amputation Age 1.0 (0.9-1.1) 0.917 Gender 0.6 (0.1-3.9) 0.549 Type of diabetes 1.5 (0.2-11.8) 0.698 Insulin adherence 0.1 (0.1-0.9) 0.049* Oral hypoglycemics adherence 0.7 (0.1-5.4) 0.692 Foot ulcer 5.0 (0.6-40.0) 0.127 Retinopathy 2.7 (0.3-27.8) 0.393 Both foot ulceration and amputation Age 1.0 (1.0 – 1.1) 0.448 Gender 0.9 (0.3 – 2.5) 0.864 Type of diabetes 0.6 (0.1 – 3.2) 0.553 Duration of diabetes 1.0 (1.0 – 1.1) 0.149 Renal disease 1.6 (0.3 – 7.1) 0.563 Unsteady walking 1.3 (0.8 – 2.0) 0.234 Burning, aching pain or tenderness of feet 1.4 (1.0 – 1.9) 0.061 Prickling sensation 1.0 (0.7 – 1.4) 0.859 Numbness of feet 0.9 (0.7 -1.2) 0.497 Insulin 0.6 (0.2 – 1.9) 0.403 Oral hypoglycaemics adherence 1.1 (0.5 – 6.1) 0.383 Diet 1.4 (0.1 – 13.8) 0.797 Hypertension 2.1 (0.5 - 8.9) 0.297 *indicates adjusted p-value. Self-care deficit assessment More than one-third (34%) of the cohort demonstrated a high self-care deficit, while 63% were at an intermediate deficit, irrespective of gender (p>0.05) (Table 4). In total, 232 participants (66%) were wearing inappropriate shoes. In multivariate regression models, self-care deficit was associated with fungal nails (OR=26.6; 95% CI=2.5-286.4; p=0.007), peripheral neuropathy (OR=3.5; 95% CI= 1.1-11.2; p=0.034) and wearing inappropriate footwear (OR=7.3; 95% CI=1.6-34.4). Self-care deficit was not a predictor for foot ulceration (OR=1.5; 95% CI=0.9-2.5; p=0.166) or amputation (OR=0.8; 95% CI=0.2-3.2; p=0.793). Table 4: Frequency and factors associated with self-care deficit. Frequency n (%) OR (95% CI) p All Male (n=82) Female (n=270) Self-care deficit High 120 (34) 30 (37) 90 (33) 1 ref. Intermediate 221 (63) 49 (60) 172 (64) 0.8 (0.4-1.6) 0.550 Low 11 (3) 3 (3) 8 (3) 0.9 (0.1-7.1) 0.893 PAD* 1.0 (0.6-1.7) 0.900 PN* 3.6 (2.3-5.8) <0.001 Retinopathy* 1.8 (0.4-8.5) 0.454 Arterial stiffness* 0.1 (0.0-1.3) 0.083 Inappropriate footwear 6.0 (1.5-23.7) 0.011 Fungal nail 6.9 (1.3-36.2) 0.022 *univariate regression analysis to associate self-care knowledge Predicting risk of developing diabetic foot ulcers The risk for foot ulceration within 2 years was computed using the clinical prediction rule scoring criteria as designed by Chappell and collaborators (2021). In total 288 participants had complete data for risk scoring to be computed, and 31% exhibited low risk of foot ulceration (risk= 2.4%; 95% CI= 1.4 – 3.9%) within 2 years. Six participants (2.1%) had a 51% risk (95% CI= 38 - 64%) of developing foot ulcers within two years (Table 5). Table 5. Frequency of CPR scoring for diabetic foot ulcers within two years (n= 288) Score Risk score (95% CI) n (%) 0 2.4 (1.4 – 3.9)* 90 (31.2) 1 6.0 (3.5 – 9.5) † 121 (42.0) 2 14 (8.5 – 21.0) † 42 (14.6) 3 29 (19 - 41) † 29 (10.1) 4 51 (38 - 64) † 6 (2.1) * - low risk of foot ulceration within 2 years that does not require intervention. † - high risk of foot ulceration within 2 years that require intervention Assessment of knowledge of DF Most of the participants in this study correctly responded that regular medication was important to prevent diabetes-related complications, foot care was important to prevent injuries, wounding, infections, and ulceration (Table 6). However, more than 96% did not know that smoking can exacerbate DF. Table 6. Responses for the knowledge-related factors (n=290) Question n (%) DM patients should take medication regularly to prevent DM complications? Yes 263 (90.7) No 4 (1.4) Unsure 23 (7.9) DM patients should look after their feet because they may not feel a minor injury to their feet? Yes 248 (85.5) No 6 (2.1) Unsure 36 (12.4) DM patients should look after their feet because wounds and infection may not heal quickly? Yes 267 (92.0) No 7 (2.1) Unsure 17 (5.9) DM patients should look after their feet because they may get a foot ulcer? Yes 226 (77.9) No 18 (6.2) Unsure 46 (15.9) DM patients should not smoke because smoking causes poor circulation and increases risk of diabetic foot? Yes 9 (3.1) No 51 (17.6) Unsure 230 (79.3) Attitudes and Practice Assessment Frequency of correct responses for attitude and practice–related factors is illustrated in Table 7. More than half of the group were either unsure (37%) or incorrectly responded (~18%) to finding redness/blood between toes. In total, 18% (n=52) said they would apply home remedies such as methylated spirit, petroleum jelly products, Eucalyptus oil-based vapor-rub e.g. Vicks VaporRub, astringent baby powder, povidone iodine e.g. Betadine, table salt or crushed paracetamol. An estimated 38% (n=109) responded that in the presence of skin lesions or corns, they were unsure of what to do, while 35 of the 52 incorrect responses were to file or cut off the corn/lesion at home. Six respondents indicated that they would do nothing. Table 7. Responses given for the attitudes and practices (n=290) n (%) How often do you think you should inspect your feet? Correct response (Daily) 146 (50.3) Incorrect response 46 (15.9) Unsure 98 (33.8) If you found redness/bleeding between your toes, what is the first thing you do? Correct response (Clean it and seek medical attention) 152 (52.4) Incorrect response 52 (17.9) Unsure 86 (29.7) What would you do if you had a corn/hard skin lesion? Correct response (Seek medical attention for trimming) 127 (43.8) Incorrect response 54 (18.6) Unsure 109 (37.6) How often do you think your feet should be washed? Correct response (At least once on a daily basis) 256 (88.3) Incorrect response 1 (0.3) Unsure 33 (11.4) What temperature of water do you think you should wash your feet in? Correct response (Warm) 228 (78.6) Incorrect response 30 (10.3) Unsure 30 (10.3) How often do you think you should inspect the inside of your footwear for objects or torn lining? Correct response (Before each wear) 225 (77.6) Incorrect response 9 (3.1) Unsure 56 (19.3) Knowledge, Attitudes and Practices in relation diabetic foot The total scoring for knowledge attitudes and practices was conducted using Bloom’s cut off, and about 87% of the group demonstrated high knowledge about risk factors of DF (Table 8). A total of 36% demonstrated poor, while ~27% had moderate attitudes and practices towards DF prevention. Table 8. Total scoring for the KAP questionnaire using Bloom’s cut off categories (n=299) Section Category Score range (Blooms range in %) n (%) Knowledge (out of 5) High 3 - 5 (60 - 100) 259 (86.6) Low 0 - 2 (0 - 59) 40 (13.4) Attitudes and practices (out of 6) High 5 – 6 (80 – 100) 111 (37.1) Moderate 4 (60 - 79) 80 (26.8) Poor 0 – 3 (< 59) 108 (36.1) Association of knowledge, attitudes and practices with diabetic foot ulcer risk. There was no association between knowledge (OR=0.9; 95% CI=1.7-1.2; p=0.575), attitudes and practices (OR=1.0; 95% CI=0.9-1.2’ 0.968; p=0.968) with increased risk of developing diabetic foot ulcers in two years. Discussion Complications of diabetes such as foot ulceration and consequently lower limb amputations can be prevented when detected early, and the lack of data on these complications can translate to under-management for PLWD. In Zimbabwe, only one known study, conducted in 1961, has reported on the prevalence of foot ulcers among PLWD (1%) (13). Findings from the present study reported a significantly higher prevalence of foot ulceration (17%), a trend that is expected given the increasing burden of diabetes in Zimbabwe since 1961 (4; 23). The prevalence of DFU presented in our study also corresponds with prevalences reported in low- and middle-income countries (LMICs) such as Sudan (18%), Tanzania (15%), India (16%) and Cameroon (12%) (6, 24-27). Other LMICs such as Ethiopia (31%) and Jordan (70%) have reported a higher frequency of DFUs, while high-income countries such as the UK and Australia observe a lower prevalence of DFU (<2.5%) compared to the data reported here (28-32). These stark dissimilarities can be ascribed to the availability of podiatric care programs as part of primary care in high-income countries that allow for early detection and treatment of DFUs, whereas such services are not well established in LMICs (31, 32). In a previous publication, we reported a lack of co-ordinated programs to effectuate DF care, as well as a lack of chiropody services and podiatric specialists in Zimbabwe (19). Implementing foot training programs in the Zimbabwean health care system is fundamental to improving foot ulcer case finding, promoting early detection and consequently providing early interventions. An example is the “Step by Step foot program” (SbS) that was established to educate healthcare workers on diabetic foot problems and management. The SbS has trained >300 physicians and paramedics from India, Bangladesh, Sri Lanka, Nepal, and Tanzania, resulting in DF case finding, reduced prevalence of foot ulcers and amputation rates (1, 33-34, 36). It is also reported that the SbS has trained some healthcare workers from Democratic Republic of Congo, Guinea, Botswana, Malawi, Kenya, Ethiopia, Egypt, Zimbabwe, Nigeria, Pakistan, Saudi Arabia, Barbados, St Lucia, St Maarten, St Kitts and the British Virgin Islands (1, 33-36). Another similar initiative, the “Train the foot trainer” program has also trained healthcare workers from more than 70 LMICs across the world (35). A challenge reported by these projects has been a lack of sustainable integration of these programs into the public health systems (1). Adoption and integration of foot screening programs through the government systems in Zimbabwe would be key to make DF screening sustainable in Zimbabwe. A longer duration with diabetes was associated with an increased risk of diabetic foot ulcers in the topical data. Our findings are consistent with the literature (37, 38). Longer duration of diabetes is associated with a higher rate of microvascular and macrovascular complications such as peripheral neuropathy, and cumulative effects of poor glycaemic control (38). Consistently, the topical data also showed that adherence to insulin therapy is protective against amputations. Insulin is associated with inflammation reduction, revascularization and wound healing, thereby acting as a protective factor against diabetes-related complications and amputations, in concordance with the topical data (39,40). However, for PLWD in Zimbabwe, there can be a disrupted supply chain of essential medications, such as insulin, which can impede adherence, and can be exacerbated for people who have lived with diabetes for longer (4, 16, 41). In 2022, 44% of the 9 million Zimbabweans at working age were employed, with a wage range for low- to high-skilled employees of USD100-931 respectively (42, 43). Given the high cost of insulin per month (USD135), affordability is very limited, and there are challenges to subscribe for medical aid which allows people to access subsidised medications and healthcare (42, 43). Moreover, with these limited funds, affordability of laboratory tests such as HbA1c, and adherence to the specific dietary requirements for glycaemic control may also be a challenge for PLWD in Zimbabwe. This study also reported a high prevalence of peripheral neuropathy (53%) and peripheral arterial disease (PAD) (53%), in agreement with a previous study from Zimbabwe (18). Both peripheral neuropathy and PAD are key indicators for foot at risk of DFU, and in the present study, a high prevalence (68%) of foot ulceration risk that requires immediate medical attention was reported, resonating with Mukona et. al. (18). The prevalence of peripheral neuropathy and PAD reported in this study are significantly higher than those recorded in the USA (6% and 9.5% respectively), possibly because of lack of foot screening services in Zimbabwe (44, 45). Evidence of the impact of regular foot screening to reduce DF has been widely published, including in an Australian study that confirmed that non-indigenous populations who frequently visited the clinic and received regular foot screening had a lower prevalence of DF compared to indigenous populations who had poor health-seeking behaviours and limited resources in their community health facilities (30, 46). Taken together, there is an emphasis on the urgent need for regular foot screening as an integral part of care for PLWD in Zimbabwe. However, although published data highlights urgent need for DF services in Zimbabwe, such services are not yet available due to a lack of coordinated guidelines for foot screening and limited resources or manpower for podiatric care (4,19,16). Due to these health system-related challenges in screening and management of DF, it is equally vital to engage patients to be a part of the holistic diabetes care journey, not only in glycaemic control but also in conducting self-screening for complications such as foot care. From the current data, good knowledge of DF was demonstrated by the participants, however, poor attitudes and practices towards DF were found. Correspondingly, >90% of participants were found to be in DF self-care deficit. It is likely that although participants may know practices that increase risk of DF, poor attitudes and may be ascribable to the low socioeconomic background of the cohort, that may hinder the recommended practices that can prevent DF. Moreover, our study found that 97% of respondents did not know that smoking can affect blood circulation, and therefore increase the risk of DF. This demonstrates a need to emphasise the role of behavioural risk factors such as smoking in diabetes-related complications and to further the understanding of why PLWD need to modify their lifestyle and improve their diet. Similar programs have been implemented, at no cost to the patient, in the United Kingdom to encourage PLWD to take an active role in diabetes management (47-49). An example is the Dose Adjustment For Normal Eating (DAFNE) course, a program that has been administered to PLWD in the UK since 2002, and has improved the quality of life, blood-glucose control, and reduced diabetes-related hospitalisation (49-50). With adequate resources and political will, programs such as DAFNE can be tailored to the socioeconomic conditions and adopted in Zimbabwe as a way to educate PLWD. In addition, there are also mobile health tools that have been developed to promote foot care for PLWD, such as the MyFootCare mobile application in Australia (51). The MyFootCare promotes self-monitoring for ulcers, helps to identify precursors of DF, drives foot care monitoring and promotes general self-care (51). Therefore, such mobile health tools can be adopted in Zimbabwe for PLWD with smartphones, as an additional part of the educational and awareness package. Conclusions This study shows a high prevalence of diabetic foot ulcers among PLWD in Harare, Zimbabwe; and distal peripheral neuropathy was a major risk factor for foot ulceration. These findings indicate a need for regular foot screening as an integral part of primary care. This study also reports on the protective role of insulin against amputations, underscoring the need to increase insulin administration in PLWD, to prevent diabetes-related complications. Altogether our study, and the previous studies on diabetes in Zimbabwe highlight a need for policies that drive equitable access to diabetes medications such as insulin as well as screening facilities for DF, as a step towards preventing diabetes-related complications e.g., DF. This study also reported on poor attitudes and practices of DF, corresponding with the self-care deficit was also demonstrated in this cohort. This highlights a need for education and training initiatives to be established for PLWD to promote self-care, as a key prevention against DF. Declarations Ethics approval and consent to participate Ethical approvals for this study were obtained from the national ethics review committee, Medical Research Council of Zimbabwe (MRCZ/A/1923). All study participants provided informed consent to participate in writing. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors have no competing interests to declare. Funding This study was supported by a grant from the International Diabetes Federation (RN13-004) as part of the IDF-BRIDGES Translational Research program. AM is the lead recipient of the grant. Authors’ contributions O.K. co-ordinated the ZDFP, analysed the data, and wrote the manuscript. D.M. contributed to data analysis, reviewed and edited the manuscript. V.C. reviewed and edited the manuscript. L.G. co-investigator of the ZDFP and researched data. J.C. , trained the nurses to perform foot screening, researched data, reviewed and edited the manuscript. A.M. is the PI of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the final version of the manuscript. Acknowledgements The authors thank Chengeto Muhaso and Simbarashe Nyandoro the data collection and capturing team for the ZDFP. References Abbas ZG, Boulton AJM. Diabetic foot ulcer disease in the African continent: ‘From clinical care to implementation’ – Review of diabetic foot in last 60 years – 1960 to 2020. Diabetes Research and Clinical Practice 2021;183:109155. Chirombe M, Ngara B, Chibvongodza R, Charuka V, Zhou DT (2018) Glucose control in Diabetic patients attending Parirenyatwa Group of Hospitals in Zimbabwe. The Open Journal of Clinical Biochemistry. 2018;8:12-19. Mutowo MP, Lorgelly PK, Laxy M, Renzaho AMN, Mangwiro JC, Owen AJ. The hospitalization costs of diabetes and hypertension complications in Zimbabwe: Estimations and Correlations. J Diabetes Res 2016:9754230. Mureyi D, Katena NA, Monera-Penduka T. Perceptions of diabetes patients and their caregivers regarding access to medicine in a severely constrained health system: A qualitative study in Harare, Zimbabwe. PLOS Global Public Health 2022;2(3):e0000255. Bowling FL, Foley KJ, Boulton AJM. Chapter 14: Diabetic Foot. Diabetic Neuropathy 2022;223-224. Naemi R, Chockalingam N, Lutale JK, Abbas ZG. Can a combination of lifestyle and clinical characteristics explain the presence of foot ulcer in patients with diabetes. Journal of Diabetes and Its Complications 2019;33(6):437-444. Patel J, Zamzam A, Syed M, Blanchette V, Cross K, Albalawi Z, Al-Omram M, Mestral C (2022) A scoping review of foot screening in adults with diabetes mellitus across Canada. Canadian Journal of Diabetes 2022;46(5):435-440 e2 Lin C, Liu J, Sun H. Risk factors for lower extremity amputation in patients with diabetic foot ulcers: a meta‐analysis. PLoS One 2020;15(9):e0239236. Abdulghani HM, AlRajeh AS, AlSalman BH, AlTurki LS, AlNajashi NS, Irshad M, Alharbi KH, AlBalawi YE, AlSuliman YA, Ahmad T (2018) Prevalence of diabetic comorbidities and knowledge and practices of foot care among diabetic patients: a cross-sectional study. Diabetes Metab Syndr Obes. 11 417-425. https://doi.org/10.2147%2FDMSO.S171526 Durai V, Samya V, Akila GV, Shriraam V, Jasmine A, Muthuthandavan AR, Gayathri T, Mahadevan S (2021) Self-care practices and factors influencing self-care among type 2 diabetes mellitus patients in a rural health center in South India. J Educ Health Promot.10(151). Mosa BD, Mohammed S, Ashuro J, Omer Z, Ahmedin A, Hayiso D, Hailu D (2021) Knowledge, attitude and practice towards prevention of diabetic foot ulcer among adult diabetic patients attending at follow-up clinic of Hawassa comprehensive specialised hospital, Sidamma, Ethiopia. International archives of Nursing and Health Care. 8(3):177. https://doi.org/10.23937/2469-5823/1510177 Nazar CMJ, Bojerenu MM, Safdar M, Marwat J (2016) Effectiveness of diabetes education and awareness of diabetes mellitus in the United Kingdom: a literature review J Nephropharmacol. 5(2): 110-115. Gelfand M, Carr WR. Diabetes mellitus in the Africans in Rhodesia. Cent Afr J Med 1961;7(9):41-48. Gelfand M, Forbes JI. Diabetes mellitus in the Rhodesian Africa. S Afr Med J 1963;30(37):1208-1213. Sibanda M, Sibanda E, Jonsson K. A prospective evaluation of lower extremity ulcers in a Zimbabwean population. Int Wound J 2009;6:361-366. Mukona D, Martin L, Zvinavashe M. Knowledge and practices regarding exercise in type 2 diabetes patients aged 20-69 years. IOSR-JNHS 2019;8(3):1-7. Mukona D, Ngwende G, Mataruse A, Gwaunza L. Prevalence of foot at risk for ulceration in adult diabetic clinic at a tertiary centre in Zimbabwe. EC Endocrinology and Metabolic Research 2019; 4.4. Kuguyo O, Muhaso C, Nyandoro S, Chirenda C, Chikwasha V, Mageza AC, Gwanzura L, Mukona DM, Matimba A. Perspectives of healthcare workers on factors influencing diabetes management and diabetic foot problems in Zimbabwe. JEDMSA 2020;25(3):57-62. Kuguyo O, Chirenda J, Chikwasha V, Mukona DM, Mageza A, Gwanzura L, Matimba A. Needs assessment of diabetic foot services in Zimbabwe. Diabetes Research and Clinical Practice 2022;188:1099925. American Diabetes Association. Foot care in patients with diabetes mellitus. Diabetes Care 1998; 21:S54–5. Pollock RD, Unwin NC, Connolly V. Knowledge and practice of foot care in people with diabetes. Diabetes Res ClinPract 2004; 64:117–22. Bloom BS (1968) Learning for mastery. Instruction and curriculum. Regional Education Laboratory for the Carolinas and Virginias, topical papers and reprints, number 1. Eval Comment. 1(2): 12. Chirombe M, Ngara B, Chibvongodze R, Charuka V, Zhou DT (2019) Glucose control in diabetic patients attending Parirenyatwa Group of Hospitals in Zimbabwe. The Open Clinical Biochemistry Journal. 8: 12-19. http://dx.doi.org/10.2174/2588778501808010012 Almobarak AO, Awadalla H, Osman M, Ahmed MH. Prevalence of diabetic foot ulceration and associated risk factors: an old and still major public health problem in Khartoum, Sudan? Ann Transl Med 2017;5:340. Shahi SK, Kumar A, Kumar S, Singh SK, Gupta SK, Singh TB. Prevalence of diabetic foot ulcer and associated risk factors in diabetic patients from North India. The Journal of Diabetic Foot Complications.2012;4(3):83-91. Tindong M, Palle JN, Nebongo D, Aminde LN, Mboue-Djieka Y, Mbarga NTF, Deyahe, MY, Choukem SP.Prevalence, clinical presentation, and factors associated with diabetic foot ulcer in two regional hospitals in Cameroon. Int J Low Extrem Wounds 2018;17(1):42-47. Abdissa D, Adugna T, Gereme U, Dereje D. Prevalence of diabetic foot ulcer and associated factors among adult diabetic patients on follow-up clinic at Jimma medical center, Southwest Ethiopia, 2019: An institutional-based cross-sectional study. J Diabetes Res 2020:4106383. Aboorajooh E, Alqaisi TM, Yassin M, Yassin M, Alqpelat E, Abofaraj A, Alrawajih T, Alzoubi H, Iubad MA. Diabetic foot ulcer in Southern Jordan: A cross-sectional study of clinical and microbiological aspects. Ann Med Surg (Lond) 2022;76: 103552. Palladino R, More A, Greenfield G, Anokye N, Pigott E, Willis T, Edward G, Majeed A, Kong WM. Evaluation of the North-West London diabetes foot care transformation project: a mixed-methods evaluation. International Journal of Integrated Care 2022;22(2):4,1-9. Zhang Y, van Netten JJ, Baba M, Cheng Q, Pacella R, McPhail SM, Cramb S, Lazzarini PA. Diabetes-related foot disease in Australia: a systematic review of the prevalence and incidence of risk factors, disease and amputation in Australian populations. Journal of Foot and Ankle Research 2021;14(8). British Diabetic Association (2023) Diabetes UK: Your annual diabetes foot check. Accessible online via: https://www.diabetes.org.uk/guide-to-diabetes/complications/feet/what-can-i-expect-at-my-annual-foot-check#:~:text=Everyone%20with%20diabetes%20should%20have,these%20can%20lead%20to%20amputations. Accessed on: 31 May 2023 Diabetes Australia (2023) Diabetes and Your Feet. Accessible online via: https://www.diabetesaustralia.com.au/living-with-diabetes/preventing-complications/foot-care/ Accessed on: 31 May 2023 Abbas ZG (2013) Preventive foot care and reducing amputation: a step in the right direction for diabetes care. Diabetes Manage. 3(5): 427-435. Abbas ZG, Lutale JK, Bakker K, Baker N, Archibald LK (2011) The “Step by Step” diabetic foot project in Tanzania: a model for improving patient outcomes in less developed countries. Int Wound J. 8(2): 169-75. https://doi.org/10.1111/j.1742-481x.2010.00764.x Baker N, Van Acker K, Urbancic-Rovan V, Abbas ZG, Morbach SS (2017) The world wide implementation of the “Train the Foot Trainer” program. The Diabetic Foot Journal. 20(2): 71-6. Bakker K, Abbas ZG, Pendsey S (2006) Step by Step, improving diabetic foot care in the developing world. Practical Diabetes International. 23(8): 365-369. https://doi.org/10.1002/pdi.1012 Al Rubeaan K, Al Derwish M, Quizi S, Youssef SN, Subhani SN, Ibrahim HM et al (2015) Diabetic foot complications and their risk factors froma large retrospective cohort study. PLoS ONE. 10: http://dx.doi.org/10.1371/journal.pone.0124446 McDermott K, Fang M, Boulton AJM, Selvin E, Hicks CW (2023) Etiology, Epidemiology, and disparities in the burden of diabetic foot ulcers. Diabetic Care. 46(1):L 209-221. Vatankhah N, Jahangiri Y, Landry GJ, Moneta GL, Azarbal AF. Effect of systemic insulin treatment on diabetic wound healing. Wound Repair Regen 2017;25(2): 288-291. Korkmaz I, Bingol O, Karlidag T, Keskin OH, Kilic E, Ozdemir G. Lower extremity amputations due to diabetes; risk factors for amputations and the role of imaging methods in determining the level of amputation. Diabetes Epidemiology and Management 2021;4:100036. Machirori Y (2021) Yemurai Machirori: living with diabetes, struggling to be seen. Bull World Health Organ. 99(4): 248-9. https://doi.org/10.2471%2FBLT.21.030421 Trading Economics (2023) Zimbabwe Living Wage Individual. Accessed online: https://tradingeconomics.com/zimbabwe/living-wage- individual#:~:text=Living%20Wage%20Individual%20in%20Zimbabw e%20averaged%20305.00%20USD%2FMonth%20from,updated%20on%20Ju ne%20of%202023. Accessed on: 06 June 2023. Zimbabwe National Statistics Agency (2023) Accessible online via: https://www.zimstat.co.zw Accessed on: 17 Jul 2023 Hicks CW, Selvin E (2019) Epidemiology of peripheral neuropathy and lower extremity disease in diabetes. Curr Diab Rep. 19(10): 86. https://doi.org/10.1007%2Fs11892-019-1212-8 Baba M, Davis WA, Norman PE, Davis TM. Temporal changes in the prevalence and associates of diabetes-related lower extremity amputations in patients with type 2 diabetes: the Fremantle diabetes study. Cardiovasc Diabetol. 2015;14(1):152. Elghazaly H, Howard T, Sanjay S, Mohamed OG, Sounderajah V, Mehar Z, Davies AH, Jaffer U, Normahani P. Evaluating the prognostic performance of bedside tests used for peripheral arterial disease diagnosis in the prediction of diabetic foot ulcer healing. Cardiovascular and metabolic risk 2022;11(2):e003110. Heller S, Lawton J, Amiel S, Cooke D, Mansell P, Brennan A, Elliott J, Boote J et al (2014) Improving managemene of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A Mixed method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes. National Institutes for Health and Excellence Type 1 diabetes in adults: diagnosis and management guidance and guidelines | NICE. Available from: https://www.nice.org.uk/guidance/ng17 Last accessed on: 18 Nov 2023. Coates E, Amiel S, Baird W, Benaissa M, Brennan A, Campbell, Chadwick P, Chater T, Choudhary P, Cooke D et al (2021) Protocol for a cluster randomised controlled trial of the DAFNE plus (Dose Adjustment for Normal Eating) intervention compared with 5X1 DAFNE: a lifeling approach to promote effective self-management in adults with type 1 diabetes. BMJ Open. 11(1): e040438. https://doi.org/10.1136/bmjopen-2020-040438 Rankin D, Cooke DD, Elliott J, Heller SR, Lawton J, and the UK NIHR DAFNE study group (2012) Supporting self-management after attending a structured education programme: a qualitative longitudinal investigationof type 1 diabetes patients’ experiences and views. BMC Public Health.12, 652. https://doi.org/10.1186/1471-2458-12-652 Brown R, Ploderer B, Seng L, Lazzarini PA, Van Netten JJ (2017) MyFootCare: a mobile self-tracking tool to promote self-care amongst people with diabetic foot ulcers. http://dx.doi.org/10.1145/3152771.3156158 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Mar, 2024 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 28 Nov, 2023 Reviewers agreed at journal 22 Nov, 2023 Reviewers agreed at journal 13 Oct, 2023 Reviews received at journal 08 Oct, 2023 Reviews received at journal 02 Oct, 2023 Reviewers agreed at journal 20 Sep, 2023 Reviewers agreed at journal 20 Sep, 2023 Reviewers invited by journal 20 Sep, 2023 Editor assigned by journal 16 Sep, 2023 Editor invited by journal 14 Aug, 2023 Submission checks completed at journal 14 Aug, 2023 First submitted to journal 18 Jul, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3182157","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":226185130,"identity":"5bb8e3f8-e8b3-4998-a8f9-14e15ef92227","order_by":0,"name":"Oppah Kuguyo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYFACNgjFDyISCkjRItkA0mJAihaDA2CSCA38DGxpkl/bDssZn1+d+OGBAYM8v9gB/FokG9iOScu2HTY2u/F2swTQYYYzZyfg12JwgL1NWrLtcOK2G2c3gLQkGNwmVsvmGWc3/yBSC9sxyY9ALRv4e7cRZ4tkM1uyNcO5dGOJG7zbLBIMJAj7hZ+9zfDmjzJrOf7+s5tv/qiwkeeXJqCFgRmIeBiaGRgkwColCCiHAsYfDHVA+w4Qp3oUjIJRMApGHgAAWqNBzFyORnAAAAAASUVORK5CYII=","orcid":"","institution":"University of Zimbabwe","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Oppah","middleName":"","lastName":"Kuguyo","suffix":""},{"id":226185133,"identity":"24c326f0-2229-42e0-9054-30eee0bb4d12","order_by":1,"name":"Doreen Macherera Mukona","email":"","orcid":"","institution":"University of Zimbabwe","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Doreen","middleName":"Macherera","lastName":"Mukona","suffix":""},{"id":226185134,"identity":"a7c4300a-eb1c-4455-b82b-c9981528ad70","order_by":2,"name":"Vasco Chikwasha","email":"","orcid":"","institution":"University of Zimbabwe","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Vasco","middleName":"","lastName":"Chikwasha","suffix":""},{"id":226185136,"identity":"53739aa4-e83b-403b-a6a0-f76fb1a36248","order_by":3,"name":"Lovemore Gwanzura","email":"","orcid":"","institution":"University of Zimbabwe","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lovemore","middleName":"","lastName":"Gwanzura","suffix":""},{"id":226185137,"identity":"3cef6143-70a6-41c8-ad0f-837416266aff","order_by":4,"name":"Joconiah Chirenda","email":"","orcid":"","institution":"University of Zimbabwe","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Joconiah","middleName":"","lastName":"Chirenda","suffix":""},{"id":226185138,"identity":"d10c235f-7a9b-4d95-b0d7-e3083fd1fc71","order_by":5,"name":"Alice Matimba","email":"","orcid":"","institution":"University of Zimbabwe","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alice","middleName":"","lastName":"Matimba","suffix":""}],"badges":[],"createdAt":"2023-07-18 15:29:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3182157/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3182157/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-023-17610-7","type":"published","date":"2024-03-04T15:01:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":41793456,"identity":"8d96ea48-1ea2-4da0-a455-dbd0b4357dbc","added_by":"auto","created_at":"2023-08-19 00:02:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":12091,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFrequency of complications that are associated with diabetes complications such as diabetic foot ulcers. \u003c/strong\u003e\u0026nbsp;* indicates the frequency difference is statistically significant when stratified by gender.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3182157/v1/ecd159cb0d299146d6df1dac.png"},{"id":41793455,"identity":"3e1a3f69-0be4-4f07-a740-09f191c57045","added_by":"auto","created_at":"2023-08-19 00:02:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13777,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFrequency of diabetic foot complications stratified by duration of diabetes (n=352). \u003c/strong\u003e*indicates a statistically significant difference (p\u0026lt;0.05).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3182157/v1/a357e3953a932cbd7895fffb.png"},{"id":41794149,"identity":"18a5e5af-c218-48ad-9576-f55303ce74ad","added_by":"auto","created_at":"2023-08-19 00:10:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":24443,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eUnivariate regression analysis describing risk factors of diabetic foot complications. \u003c/strong\u003eOdds ratio and 95% confidence intervals are depicted. Only statistically significant variables (p\u0026lt;0.05) were illustrated in this plot.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3182157/v1/d13185fee08626d44f8bcf1e.png"},{"id":52432219,"identity":"056739fb-5a41-404a-8e73-86541c4aab0d","added_by":"auto","created_at":"2024-03-11 15:11:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":959049,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3182157/v1/40734fbd-5580-4731-bdd7-11723cd69645.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence and risk factors for diabetic foot complications among people living with diabetes in Harare, Zimbabwe","fulltext":[{"header":"Article highlights","content":"\u003cp\u003eDiabetic foot (DF) complications can lead to amputations, yet foot care is not routinely monitored in Zimbabwe. Our study describes the DF burden and the associated risk factors among people living with diabetes (PLWD) in Zimbabwe. More than half had DF, and 3% were amputated. Insulin adherence was found to protect against amputations. Our study highlights a need for routine DF screening for PLWD. Our findings also underscore the need for education and awareness tools for patients to adhere to prescribed insulin towards improved diabetes management and preventing complications such as DF.\u0026nbsp;\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eDiabetes is one of the leading causes of hospitalizations and deaths globally, posing severe financial implications, especially in developing countries where high comorbidity is coupled with constrained manpower and rampant poverty (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The prevalence of diabetes continues to rise in Zimbabwe, and in 2018, about 850,000 people, or 5.7% of the total Zimbabwean population, were estimated to be living with diabetes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The estimated cost of treatment for people living with diabetes (PLWD) in Zimbabwe is about US\u003cspan\u003e$\u003c/span\u003e1300 per year per patient, while care for diabetes-related complications such as diabetic foot (DF) bear a cost burden of US\u003cspan\u003e$\u003c/span\u003e2884 per annum (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These high costs are a major barrier to adherence to prescribed care in Zimbabwe where health care is an out-of-pocket expense and in an environment of high unemployment (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). National health insurance subscriptions are low in Zimbabwe, and there are limited government aid schemes for chronic illnesses such as diabetes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Moreover, this high-cost burden translates to delayed treatment and increased mortality risk \u0026ndash; posing a significant public health threat.\u003c/p\u003e \u003cp\u003eDF encompasses lower extremity complications such as peripheral neuropathy, peripheral arterial disease (PAD), soft tissue infection, and ulceration (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). More than one-third of PLWD develop DF in their lifetime, and in 20% of DF cases, amputations in the lower extremities are observed (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Of great significance, is diabetic foot ulceration which accounts for 25% of DF, precedes most (\u0026gt;\u0026thinsp;85%) diabetes-related amputations and increases the risk of diabetes-related mortality by 2.5-fold (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRisk factors of DF include older age, low education, low socioeconomic status, alcohol consumption, smoking, high body mass index (BMI), type of diabetes, poor blood circulation, cardiovascular disease, nephropathy, retinopathy, and claudication (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Moreover, good foot care has been shown to prevent 50\u0026ndash;80% of DF complications, so good knowledge, attitudes and practices are key to preventing DF (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Equally, poor knowledge and attitudes about DF care translate to poor practices and increase the risk of developing DF (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Evidence from studies in diverse socioeconomic settings shows that the prominence of risk differs between populations, due to context-related factors. Therefore, there is a need to conduct research in diverse socioeconomic settings to identify local specific risk factors of DF.\u003c/p\u003e \u003cp\u003eSeveral studies have investigated DF in Zimbabwe and a wide-ranging prevalence of 1\u0026ndash;33% has been reported (\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Longer duration of diabetes, absent pedal pulses, and peripheral neuropathy were found as risk factors for foot ulceration in these populations (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). There are also very few studies that analyze the knowledge, attitudes and practices of DF in PLWD in Zimbabwe, However, these studies are few, have interrogated small sample sizes, and focused on single institutions. The Zimbabwe Diabetic Foot Project (ZDFP) was established to decrease the burden of DF in Zimbabwe. As a first step, the project sought to use a multi-centre approach to understand the burden of DF in Harare, the capital city of Zimbabwe; understand the context-specific risk factors of DF in Zimbabwe; and build the capacity of nurses at the forefront of managing PLWD as previously described (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The current paper aims to determine the prevalence of DF, and associated risk factors among PLWD attending public health clinics across Harare.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical\u0026nbsp;approval for the project was granted by the national ethics committee, the Medical Research Council of Zimbabwe (approval number: MRCZ/A/1923). All study protocols were in accordance with the Declaration of Helsinki, 2013.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study utilized a mixed-methods approach. A cross-sectional study design was employed to recruit participants from 16 outpatient diabetes treatment facilities in the public sector, located in Harare, Zimbabwe. The treatment facilities included 14 primary care clinics and 2 referral hospitals that were conveniently selected because of the availability of a registered general nurses at the forefront of managing diabetes who received diabetic foot screening training as part of the ZDFP (18,19). The trained registered general nurses were responsible for recruitment and data collection. Qualitative data were also collected to assess the knowledge, attitudes, and practices in relation to DF risk.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eParticipant Recruitment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA consecutive sample of 352 participants was recruited between February 2015 and February 2016. To be considered eligible for recruitment into the cohort, participants had to (i) have a confirmed diagnosis of diabetes, (ii) be aged over 18 years, (iii) be seeking medical attention for diabetes at the targeted outpatient facilities, and (iv) provide consent to participate. Pregnant women and individuals admitted for inpatient care were excluded from the study. Informed consent was obtained from all study participants. All participants were informed of the study verbally and provided written consent to indicate agreement to participate. All participants were assigned a unique identifier that was used throughout the study to maintain confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eData collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through face-to-face interviews, retrospective patient record reviews, and prospective foot screenings. All data was captured onto a standardised case report form to ensure uniform data capture. De-identified case report forms were stored in a lockable cupboard with limited access and electronic back-ups were stored in a secure laptop.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eFace-to-face interviews\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants provided data on age, sex, literacy status, socioeconomic status, employment status, and behavioural factors such as smoking habits, and alcohol consumption history. Data on family history of diabetes and cardiovascular disease was also recorded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003ePatient record reviews\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSpecific data related to diabetes were collected from the patient clinical records, including body mass index (BMI), type of diabetes treatment, duration of diabetes, comorbid conditions, status and history of hypertension, coronary heart disease, cerebrovascular stroke, claudication, revascularization, renal transplantation, dialysis, or laser photocoagulation. In addition, a history of amputations, foot infections, nephropathy, retinopathy, as well as symptoms of diabetes-related neuropathy data were also collected.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eDiabetic foot screening\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eGeneral foot assessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA general foot examination for the presence of discoloured toenails, calluses, fissures, corns, and interdigital infection, condition of toenails and toe hair, as well as joint flexibility, was performed. A visual inspection for active foot ulceration or healed ulcer wounds as well as amputation of toes or limbs was conducted as markers for diabetic foot ulceration (DFU).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eSole pressure assessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDeformities that may result in repetitive and excessive pressure of the foot were assessed by visual inspection by the registered general nurse, including hallux valgus, pes planus (flat foot), pes cavus (high arch), hammer toe, and Charcot joint. Confirmation of the presence of these conditions was made by a foot imprint captured on a Foot Imprinter Harris Mat FM1111 (Diabetik Foot Care India Pvt Ltd, India) and shown to a podiatrist for accurate determination.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eDistal neuropathy assessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA Semmes Weinstein Monofilament (SWM) 5.07 was used to evaluate sensory neuropathy in the lower extremities. The SWM 5.07 applies 10 grams of force to evaluate the loss of protective sensation in the hand or foot. In this study, 9 test sites on the feet were assessed, namely, 3 plantar sites on each foot, the hallux, third toe, and fifth toe; the base of the first, third, and fifth metatarsals, the heel, and 2 central sites. Each test site was assessed in triplicate in a blinded and arrhythmic manner. Correct perception of the SWM in 2 out of 3 times at each site was given a score of 1, while lack of perception less than 1 of 3 times was given a score of 0. The total peripheral neuropathy score was calculated by adding the sum for each foot and normal sensory function was defined as a total of at least 6 out of 9 sites, while less than 5 was considered to indicate the presence of peripheral neuropathy. Areas with ulcers, calluses, necrotic tissue, and scars were avoided during the test.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eDeep tendon reflexes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe patellar and Achilles reflexes were assessed using the knee and foot jerk tests. A patellar hammer was used to lightly tap the patellar tendon and Achilles tendon, on a relaxed leg. A normal reaction would be an extension of the lower leg or the foot toward the plantar surface, respectively. Each test was conducted in duplicate on each foot. Reflexes were graded as 0 (Absent), 1+ (Hypoactive), 2 (Normal), 3 (Hyperactive without involuntary muscle contraction) and, 4+ (Hyperactive with involuntary muscle contraction). Only 2+ was considered normal in our study and absent or hyperactive reflexes in at least one lower limb were noted as abnormal.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003ePeripheral vascular disease\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePulses in the dorsalis pedis and posterior tibialis were also recorded and assessed for rate, rhythm, and amplitude using the SonoTrax vascular doppler ultrasound (EdanUSA, San Diego, California, USA). An amplitude of 3+ was considered a normal pulse for each test site, and less than 2.9 was considered abnormal. Peripheral vascular disease (PVD) was assessed by calculating the ratio of systolic blood pressure in dorsalis pedis to posterior tibialis, and PVD was defined by a ratio of \u0026lt;0.9 while a range of 0.9-1 was considered normal function.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eAnkle-brachial index\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe ankle-brachial index (ABI) was calculated using the ratio of ankle blood pressure to arm (brachial) blood pressure. An ABI of 0.9-1 was considered normal and signified the absence of PVD, while \u0026lt;0.9 signified ABI and \u0026gt;1.2\u0026nbsp;were excluded due to potential arterial stiffness.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eSelf-care deficit assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were assessed for self-care deficit by checking if the participant (i) was able to see the bottom of their feet, (ii) wore poor fitting footwear, (iii) had not received prior foot care education, (iv) had a foot ulcer but had not reported foot problems to the healthcare provider, and (v) did not take steps to reduce risk of injury. The self-care deficit was defined by a \u0026lsquo;yes\u0026rsquo; answer to any of the following questions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eDiabetic Foot Risk scoring\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe risk of developing DF ulcers within two years was calculated using the clinical prediction rule (CPR) that was developed and validated by Chappell and collaborators (2021). The scoring parameters consider three fundamentals, namely, sensitivity to a 10g monofilament, absence of pedal pulses and history of ulceration/amputation. The risk scoring was then classified using the precise CPR scoring parameters and sensitivity to 10g monofilament = 1 point, absence of one pedal pulse = 1 point, and history of ulceration or amputation = 2 points. The total risk was then calculated as the sum of the CPR score, and therefore, extrapolated from the risk table.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eKnowledge, Attitudes and Practices Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt recruitment, a semi-structured questionnaire was administered to participants to assess the knowledge, attitudes, and practices (KAP) of DF. The questionnaire was made available in the three main languages spoken in Zimbabwe \u0026ndash; English, Shona and Ndebele. The questionnaire was made up of the knowledge section, which comprised 5 multiple-choice questions with yes, no or unsure as the selected responses. The attitudes and practices section had 6 short answer questions. Questions in the survey instrument included the knowledge of diabetes medications to prevent complications, wound management and behavioural factors such as smoking affecting DF. Additional knowledge questions included the frequency of patient\u0026rsquo;s foot examination, foot inspection and care in the presence of callosities, cuts and wounds, and washing of feet as previously recommended by the American College of Foot and Ankle Surgeons as well as the Diabetes UK guidelines (20, 21). To minimize guessing effect, the unsure response was added on each question. Incorrect or unsure responses were given a score of 0, while the correct response was assigned a score value of 1. The maximum total KAP score was 11 and a higher score implied better knowledge of diabetes and DF. The KAP levels were then defined as good or poor based on Bloom\u0026rsquo;s cut off point (22). Therefore, knowledge scores \u0026gt;60% (\u003cem\u003ei.e.\u003c/em\u003e at least 3 out of 5 correct responses) were regarded as having good knowledge. Scores of \u0026gt;80% \u003cem\u003e(i.e.\u003c/em\u003e at least 5 out of 6 correct responses) in the attitude and practice section indicated good attitude/practice, while 60-79% (i.e. 4 out of 6 correct responses) indicated moderate attitudes/practices and \u0026lt;59% (\u0026lt;3 out of 6 correct responses) meant poor attitudes/practices.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eData Analysis\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll data were captured into RedCap\u003csup\u003eR\u003c/sup\u003e and analysed using STATA version 12 (StataCorp LLC, Station College, TX, USA). Continuous data were summarised as mean\u0026plusmn; standard deviation or median (interquartile ranges) while categorical data were expressed as frequencies and percentages. The Chi-squared test was used to test for association between categorical variables. Univariate and multivariate logistic regression analyses were used to identify risk factors associated with DFU and amputation. A threshold of p\u0026lt;0.05 was considered statistically significant in this study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis cohort was made up of 352 participants with a confirmed diagnosis of diabetes (Table 1). Combined mean age was 57.9 \u0026plusmn;14 years. Oral hypoglycaemics were the most common treatment. Smoking 44 (12.5%) and alcohol consumption 15 (4%) were recorded and these factors differed by gender (p\u0026lt;0.05) (Table 1). Glycated haemoglobin (HbA1c) values obtained from the patient records were available for 35 (10%) participants. Mean HbAic was 7.9% \u0026plusmn;2.6. Normal A1c levels (\u0026lt;5.6%) were detected in 20% (n=7), while 2.9% (n=1) were pre-diabetic (5.7%\u0026lt;A1c\u0026lt;6.4%) and 71% (n=27) diabetic (A1c\u0026gt;6.5%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDemographic data (n=352)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"620\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale (n=82)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale (n= 270)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Age \u0026plusmn; SD (years)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003emin-max\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e57 \u0026plusmn; 17\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14-88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e58 \u0026plusmn; 13\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12-86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e0.945\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.044\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eUnderweight (\u0026lt;18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e14 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e31 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eNormal (18.6 \u0026ndash; 24.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e30 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e77 (29) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eOverweight (25.0-29.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e22 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e99 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eObese (\u0026gt;30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e16 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e63 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e21 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e41 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e61 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e229 (85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes duration (years\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e0.820\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e21 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e50 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e1.1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e28 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e90 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e6-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e12 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e46 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e11-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e9 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e45 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e12 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e39 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of treatment*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e0.533\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eOral hypoglycaemics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e55 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e199 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eInsulin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e30 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e59 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eDiet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e5 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e23 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eNever smoked\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e44 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e217 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003ePast smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e22 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e30 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003eCurrent smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e21 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e23 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of cigarettes per day (n=44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e0.614\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e13 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e15 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e6-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e7 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e8 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.24154589371981%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol consumption history (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.19645732689211%\" valign=\"top\"\u003e\n \u003cp\u003e10 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.806763285024154%\" valign=\"top\"\u003e\n \u003cp\u003e5 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.75523349436393%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* some patients were receiving two or more modalities\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrevalence of Diabetic Foot complications\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDF complications were detected in 53% of the participants. Foot examinations were conducted,\u003c/p\u003e\n\u003cp\u003eand 33 (9%) of participants had discoloured toenails, with fungi (n=13), fissures (n=19) with low temperature (22%; n=80) (Table 2). Half of the group presented with distal peripheral neuropathy. Fifty-nine participants (17%) presented with diabetic foot ulcers, 16 were men and 43 were women. The distribution of foot ulcers was comparable by gender (p=0.451). Lower limb amputations were observed in 7 (3%) participants, for which more males (n=4) were amputated than women (n=3) (p=0.03).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Prevalence of diabetic foot risk factors (n=352)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetic foot complication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eDiscoloured toenails\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e33 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eFungal nail\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e13 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eAbnormal foot skin colour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e53 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eLack of joint flexibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e26 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eGait instability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e27 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eFoot Deformities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eHallux Valgus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e14 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eFlat foot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e4 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eHammer toe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e11(3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eCalluses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;5(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eFissures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e19 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eDistal neuropathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eUnsteadiness in walking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e176 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eBurning, aching pain or tenderness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e176 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003ePrickling sensation on legs and feet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e123 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eNumbness of feet/legs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e179 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eLoss of touch sensation in feet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e172 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eAnkle Brachial Index (n=276)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e126 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eSub-clinical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e121 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e26 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eFoot ulcers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e59 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eAmputation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e7 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eAbnormal ankle reflex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e67 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.82352941176471%\" valign=\"top\"\u003e\n \u003cp\u003eAbnormal patellar reflex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.176470588235293%\" valign=\"top\"\u003e\n \u003cp\u003e17 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOther diabetes-related complications reported in this cohort, retinopathy (n=166) was the most common, followed by hypertension (n=86), coronary artery disease (n=79), claudication (n=38), cerebrovascular stroke (n=9), renal disease (n=17) and revascularisation (n=1) (Figure 1). The frequency of hypertension (p=0.010) and coronary artery disease (CAD) (p=0.048) was significantly higher in women than in men (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk factors of diabetic foot complications\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalyses for the prevalence of DF complications stratified by the duration of diabetes were computed (Figure 2) and a significantly higher frequency of history of foot ulceration for individuals with a long history of diabetes [11-15 years: p\u0026lt;0.001; more than 15 years: p\u0026lt;0.001] was observed.\u003c/p\u003e\n\u003cp\u003eUnivariate regression analysis was performed to identify the risk factors of diabetic complications (Figure 3). In a multivariate model, only distal neuropathy (burning, aching pain, or tenderness) was a significant risk factor for diabetic foot ulcers (OR= 1.7; 95% confidence interval=1.1-2.6; p=0.019) (Table 3). Insulin adherence was a protective factor for amputation (OR=0.1; 95% CI=0.1-0.9; p=0.049) in both univariate and multivariate analyses (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Multivariate model analyses for the factors associated with diabetic foot ulcers and amputation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.3044925124792%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.587354409317804%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCovariates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds ratio (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.650582362728786%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.3044925124792%\" rowspan=\"12\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetic Foot Ulcers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.587354409317804%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e1.0 (1.0-1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.650582362728786%\" valign=\"top\"\u003e\n \u003cp\u003e0.165\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.1 (1.0-1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.272\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e0.7 (0.2-2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.564\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eDuration of diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.0 (0.9-1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.850\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eRetinopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e2.1 (0.7-6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.198\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eFoot colour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e5.9 (0.9-37.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eRenal disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e3.4 (0.4-31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.290\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003ePAD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.1 (0.5-2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.823\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eUnsteady walking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e0.7 (0.4-1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.407\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eBurning, aching pain or tenderness of feet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.7 (1.1-2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.019*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003ePrickling sensation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e0.9 (0.6-1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.742\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eNumbness of feet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.1 (0.7-1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.831\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.3044925124792%\" rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmputation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.587354409317804%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e1.0 (0.9-1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.650582362728786%\" valign=\"top\"\u003e\n \u003cp\u003e0.917\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e0.6 (0.1-3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.549\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eType of diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.5 (0.2-11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.698\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eInsulin adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e0.1 (0.1-0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.049*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eOral hypoglycemics adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e0.7 (0.1-5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.692\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eFoot ulcer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e5.0 (0.6-40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.127\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eRetinopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e2.7 (0.3-27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.393\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.3044925124792%\" rowspan=\"13\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBoth foot ulceration and amputation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.587354409317804%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e1.0 (1.0 \u0026ndash; 1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.650582362728786%\" valign=\"top\"\u003e\n \u003cp\u003e0.448\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e0.9 (0.3 \u0026ndash; 2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.864\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eType of diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e0.6 (0.1 \u0026ndash; 3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eDuration of diabetes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.0 (1.0 \u0026ndash; 1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eRenal disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.6 (0.3 \u0026ndash; 7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.563\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eUnsteady walking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.3 (0.8 \u0026ndash; 2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eBurning, aching pain or tenderness of feet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.4 (1.0 \u0026ndash; 1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003ePrickling sensation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.0 (0.7 \u0026ndash; 1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.859\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eNumbness of feet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e0.9 (0.7 -1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.497\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eInsulin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e0.6 (0.2 \u0026ndash; 1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.403\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eOral hypoglycaemics adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.1 (0.5 \u0026ndash; 6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.383\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eDiet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e1.4 (0.1 \u0026ndash; 13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.797\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.545271629778675%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.784708249496983%\" valign=\"top\"\u003e\n \u003cp\u003e2.1 (0.5 - 8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.670020120724345%\" valign=\"top\"\u003e\n \u003cp\u003e0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*indicates adjusted p-value.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-care deficit assessment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore than one-third (34%) of the cohort demonstrated a high self-care deficit, while 63% were at an intermediate deficit, irrespective of gender (p\u0026gt;0.05) (Table 4). In total, 232 participants (66%) were wearing inappropriate shoes. In multivariate regression models, self-care deficit was associated with fungal nails (OR=26.6; 95% CI=2.5-286.4; p=0.007), peripheral neuropathy (OR=3.5; 95% CI= 1.1-11.2; p=0.034) and wearing inappropriate footwear (OR=7.3; 95% CI=1.6-34.4). Self-care deficit was not a predictor for foot ulceration (OR=1.5; 95% CI=0.9-2.5; p=0.166) or amputation (OR=0.8; 95% CI=0.2-3.2; p=0.793).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Frequency and factors associated with self-care deficit.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.113671274961597%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.39016897081413%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.357910906298002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.138248847926267%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale (n=82)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale (n=270)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-care deficit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e120 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e30 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e90 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003eref.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003eIntermediate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e221 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e49 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e172 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e0.8 (0.4-1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003e0.550\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e11 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e3 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e8 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e0.9 (0.1-7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003e0.893\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003ePAD*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e1.0 (0.6-1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003e0.900\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003ePN*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e3.6 (2.3-5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003eRetinopathy*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e1.8 (0.4-8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003eArterial stiffness*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e0.1 (0.0-1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003eInappropriate footwear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e6.0 (1.5-23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.073619631901842%\" valign=\"top\"\u003e\n \u003cp\u003eFungal nail\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.656441717791411%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.950920245398773%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.865030674846626%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.33128834355828%\" valign=\"top\"\u003e\n \u003cp\u003e6.9 (1.3-36.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122699386503067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*univariate regression analysis to associate self-care knowledge\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePredicting risk of developing diabetic foot ulcers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe risk for foot ulceration within 2 years was computed using the clinical prediction rule scoring criteria as designed by Chappell and collaborators (2021). In total 288 participants had complete data for risk scoring to be computed, and 31% exhibited low risk of foot ulceration (risk= 2.4%; 95% CI= 1.4 \u0026ndash; 3.9%) within 2 years. Six participants (2.1%) had a 51% risk (95% CI= 38 - 64%) of developing foot ulcers within two years (Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Frequency of CPR scoring for diabetic foot ulcers within two years (n= 288)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.837004405286343%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.52863436123348%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk score (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.634361233480178%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.837004405286343%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.52863436123348%\" valign=\"top\"\u003e\n \u003cp\u003e2.4 (1.4 \u0026ndash; 3.9)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.634361233480178%\" valign=\"top\"\u003e\n \u003cp\u003e90 (31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.837004405286343%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.52863436123348%\" valign=\"top\"\u003e\n \u003cp\u003e6.0 (3.5 \u0026ndash; 9.5)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.634361233480178%\" valign=\"top\"\u003e\n \u003cp\u003e121 (42.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.837004405286343%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.52863436123348%\" valign=\"top\"\u003e\n \u003cp\u003e14 (8.5 \u0026ndash; 21.0)\u003csup\u003e\u0026nbsp;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.634361233480178%\" valign=\"top\"\u003e\n \u003cp\u003e42 (14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.837004405286343%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.52863436123348%\" valign=\"top\"\u003e\n \u003cp\u003e29 (19 - 41)\u003csup\u003e\u0026nbsp;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.634361233480178%\" valign=\"top\"\u003e\n \u003cp\u003e29 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.837004405286343%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.52863436123348%\" valign=\"top\"\u003e\n \u003cp\u003e51 (38 - 64)\u003csup\u003e\u0026nbsp;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.634361233480178%\" valign=\"top\"\u003e\n \u003cp\u003e6 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* - low risk of foot ulceration within 2 years that does not require intervention.\u003c/p\u003e\n\u003cp\u003e\u0026dagger; - high risk of foot ulceration within 2 years that require intervention\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAssessment of knowledge of DF\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost of the participants in this study correctly responded that regular medication was important to prevent diabetes-related complications, foot care was important to prevent injuries, wounding, infections, and ulceration (Table 6). However, more than 96% did not know that smoking can exacerbate DF.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. Responses for the knowledge-related factors (n=290)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM patients should take medication regularly to prevent DM complications?\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e263 (90.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e4 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e23 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM patients should look after their feet because they may not feel a minor injury to their feet?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e248 (85.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e6 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e36 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM patients should look after their feet because wounds and infection may not heal quickly?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e267 (92.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e7 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e17 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM patients should look after their feet because they may get a foot ulcer?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e226 (77.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e18 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e46 (15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM patients should not smoke because smoking causes poor circulation and increases risk of diabetic foot?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e9 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e51 (17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e230 (79.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAttitudes and Practice Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFrequency of correct responses for attitude and practice\u0026ndash;related factors is illustrated in Table 7. More than half of the group were either unsure (37%) or incorrectly responded (~18%) to finding redness/blood between toes. In total, 18% (n=52) said they would apply home remedies such as methylated spirit, petroleum jelly products, Eucalyptus oil-based vapor-rub \u003cem\u003ee.g.\u003c/em\u003e Vicks VaporRub, astringent baby powder, povidone iodine e.g. Betadine, table salt or crushed paracetamol.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;An estimated 38% (n=109) responded that in the presence of skin lesions or corns, they were unsure of what to do, while 35 of the 52 incorrect responses were to file or cut off the corn/lesion at home. Six respondents indicated that they would do nothing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7. Responses given for the attitudes and practices (n=290)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow often do you think you should inspect your feet?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eCorrect response (Daily)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e146 (50.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eIncorrect response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e46 (15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e98 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIf you found redness/bleeding between your toes, what is the first thing you do?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eCorrect response (Clean it and seek medical attention)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e152 (52.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eIncorrect response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e52 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e86 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat would you do if you had a corn/hard skin lesion?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eCorrect response (Seek medical attention for trimming)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e127 (43.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eIncorrect response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e54 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e109 (37.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow often do you think your feet should be washed?\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eCorrect response (At least once on a daily basis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e256 (88.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eIncorrect response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e33 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat temperature of water do you think you should wash your feet in?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eCorrect response (Warm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e228 (78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eIncorrect response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e30 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e30 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow often do you think you should inspect the inside of your footwear for objects or torn lining?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eCorrect response (Before each wear)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e225 (77.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eIncorrect response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e9 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.22259136212625%\" valign=\"top\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e56 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eKnowledge, Attitudes and Practices in relation diabetic foot\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe total scoring for knowledge attitudes and practices was conducted using Bloom\u0026rsquo;s cut off, and about 87% of the group demonstrated high knowledge about risk factors of DF (Table 8). A total of 36% demonstrated poor, while ~27% had moderate attitudes and practices towards DF prevention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8. Total scoring for the KAP questionnaire using Bloom\u0026rsquo;s cut off categories (n=299)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.81198003327787%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.92179700499168%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore range (Blooms range in %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.643926788685524%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge (out of 5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.81198003327787%\" valign=\"top\"\u003e\n \u003cp\u003eHigh\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.92179700499168%\" valign=\"top\"\u003e\n \u003cp\u003e3 - 5 (60 - 100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.643926788685524%\" valign=\"top\"\u003e\n \u003cp\u003e259 (86.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.46031746031746%\" valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.945578231292515%\" valign=\"top\"\u003e\n \u003cp\u003e0 - 2 (0 - 59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.594104308390023%\" valign=\"top\"\u003e\n \u003cp\u003e40 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttitudes and practices (out of 6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.81198003327787%\" valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.92179700499168%\" valign=\"top\"\u003e\n \u003cp\u003e5 \u0026ndash; 6 (80 \u0026ndash; 100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.643926788685524%\" valign=\"top\"\u003e\n \u003cp\u003e111 (37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.46031746031746%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.945578231292515%\" valign=\"top\"\u003e\n \u003cp\u003e4 (60 - 79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.594104308390023%\" valign=\"top\"\u003e\n \u003cp\u003e80 (26.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.46031746031746%\" valign=\"top\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.945578231292515%\" valign=\"top\"\u003e\n \u003cp\u003e0 \u0026ndash; 3 (\u0026lt; 59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.594104308390023%\" valign=\"top\"\u003e\n \u003cp\u003e108 (36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAssociation of knowledge, attitudes and practices with diabetic foot ulcer risk.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no association between knowledge (OR=0.9; 95% CI=1.7-1.2; p=0.575), attitudes and practices (OR=1.0; 95% CI=0.9-1.2\u0026rsquo; 0.968; p=0.968) with increased risk of developing diabetic foot ulcers in two years.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eComplications of diabetes such as foot ulceration and consequently lower limb amputations can be prevented when detected early, and the lack of data on these complications can translate to under-management for PLWD. In Zimbabwe, only one known study, conducted in 1961, has reported on the prevalence of foot ulcers among PLWD (1%) (13). Findings from the present study reported a significantly higher prevalence of foot ulceration (17%), a trend that is expected given the increasing burden of diabetes in Zimbabwe since 1961 (4; 23).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The prevalence of DFU presented in our study also corresponds with prevalences reported in low- and middle-income countries (LMICs) such as Sudan (18%), Tanzania (15%), India (16%) and Cameroon (12%) (6, 24-27). Other LMICs such as Ethiopia (31%) and Jordan (70%) have reported a higher frequency of DFUs, while high-income countries such as the UK and Australia observe a lower prevalence of DFU (\u0026lt;2.5%) compared to the data reported here (28-32). These stark dissimilarities can be ascribed to the availability of podiatric care programs as part of primary care in high-income countries that allow for early detection and treatment of DFUs, whereas such services are not well established in LMICs (31, 32). In a previous publication, we reported a lack of co-ordinated programs to effectuate DF care, as well as a lack of chiropody services and podiatric specialists in Zimbabwe (19). Implementing foot training programs in the Zimbabwean health care system is fundamental to improving foot ulcer case finding, promoting early detection and consequently providing early interventions. An example is the \u0026ldquo;Step by Step foot program\u0026rdquo; (SbS) that was established to educate healthcare workers on diabetic foot problems and management. The SbS has trained \u0026gt;300 physicians and paramedics from India, Bangladesh, Sri Lanka, Nepal, and Tanzania, resulting in DF case finding, reduced prevalence of foot ulcers and amputation rates (1, 33-34, 36). It is also reported that the SbS has trained some healthcare workers from Democratic Republic of Congo, Guinea, Botswana, Malawi, Kenya, Ethiopia, Egypt, Zimbabwe, Nigeria, Pakistan, Saudi Arabia, Barbados, St Lucia, St Maarten, St Kitts and the British Virgin Islands (1, 33-36). Another similar initiative, the \u0026ldquo;Train the foot trainer\u0026rdquo; program has also trained healthcare workers from more than 70 LMICs across the world (35). A challenge reported by these projects has been a lack of sustainable integration of these programs into the public health systems (1). Adoption and integration of foot screening programs through the government systems in Zimbabwe would be key to make DF screening sustainable in Zimbabwe.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A longer duration with diabetes was associated with an increased risk of diabetic foot ulcers in the topical data. Our findings are consistent with the literature (37, 38). Longer duration of diabetes is associated with a higher rate of microvascular and macrovascular complications such as peripheral neuropathy, and cumulative effects of poor glycaemic control (38). Consistently, the topical data also showed that adherence to insulin therapy is protective against amputations. Insulin is associated with inflammation reduction, revascularization and wound healing, thereby acting as a protective factor against diabetes-related complications and amputations, in concordance with the topical data (39,40). However, for PLWD in Zimbabwe, there can be a disrupted supply chain of essential medications, such as insulin, which can impede adherence, and can be exacerbated for people who have lived with diabetes for longer (4, 16, 41).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In 2022, 44% of the 9 million Zimbabweans at working age were employed, with a wage range for low- to high-skilled employees of USD100-931 respectively (42, 43). Given the high cost of insulin per month (USD135), affordability is very limited, and there are challenges to subscribe for medical aid which allows people to access subsidised medications and healthcare (42, 43). Moreover, with these limited funds, affordability of laboratory tests such as HbA1c, and adherence to the specific dietary requirements for glycaemic control may also be a challenge for PLWD in Zimbabwe.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This study also reported a high prevalence of peripheral neuropathy (53%) and peripheral arterial disease (PAD) (53%), in agreement with a previous study from Zimbabwe (18). Both peripheral neuropathy and PAD are key indicators for foot at risk of DFU, and in the present study, a high prevalence (68%) of foot ulceration risk that requires immediate medical attention was reported, resonating with Mukona et. al. (18). The prevalence of peripheral neuropathy and PAD reported in this study are significantly higher than those recorded in the USA (6% and 9.5% respectively), possibly because of lack of foot screening services in Zimbabwe (44, 45). Evidence of the impact of regular foot screening to reduce DF has been widely published, including in an Australian study that confirmed that non-indigenous populations who frequently visited the clinic and received regular foot screening had a lower prevalence of DF compared to indigenous populations who had poor health-seeking behaviours and limited resources in their community health facilities (30, 46).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Taken together, there is an emphasis on the urgent need for regular foot screening as an integral part of care for PLWD in Zimbabwe. However, although published data highlights urgent need for DF services in Zimbabwe, such services are not yet available due to a lack of coordinated guidelines for foot screening and limited resources or manpower for podiatric care (4,19,16). Due to these health system-related challenges in screening and management of DF, it is equally vital to engage patients to be a part of the holistic diabetes care journey, not only in glycaemic control but also in conducting self-screening for complications such as foot care. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;From the current data, good knowledge of DF was demonstrated by the participants, however, poor attitudes and practices towards DF were found. Correspondingly, \u0026gt;90% of participants were found to be in DF self-care deficit. It is likely that although participants may know practices that increase risk of DF, poor attitudes and may be ascribable to the low socioeconomic background of the cohort, that may hinder the recommended practices that can prevent DF.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Moreover, our study found that 97% of respondents did not know that smoking can affect blood circulation, and therefore increase the risk of DF. This demonstrates a need to emphasise the role of behavioural risk factors such as smoking in diabetes-related complications and to further the understanding of why PLWD need to modify their lifestyle and improve their diet. Similar programs have been implemented, at no cost to the patient, in the United Kingdom to encourage PLWD to take an active role in diabetes management (47-49). An example is the Dose Adjustment For Normal Eating (DAFNE) course, a program that has been administered to PLWD in the UK since 2002, and has improved the quality of life, blood-glucose control, and reduced diabetes-related hospitalisation (49-50). With adequate resources and political will, programs such as DAFNE can be tailored to the socioeconomic conditions and adopted in Zimbabwe as a way to educate PLWD. In addition, there are also mobile health tools that have been developed to promote foot care for PLWD, such as the MyFootCare mobile application in Australia (51). The MyFootCare promotes self-monitoring for ulcers, helps to identify precursors of DF, drives foot care monitoring and promotes general self-care (51). Therefore, such mobile health tools can be adopted in Zimbabwe for PLWD with smartphones, as an additional part of the educational and awareness package.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study shows a high prevalence of diabetic foot ulcers among PLWD in Harare, Zimbabwe; and distal peripheral neuropathy was a major risk factor for foot ulceration. These findings indicate a need for regular foot screening as an integral part of primary care. This study also reports on the protective role of insulin against amputations, underscoring the need to increase insulin administration in PLWD, to prevent diabetes-related complications. Altogether our study, and the previous studies on diabetes in Zimbabwe highlight a need for policies that drive equitable access to diabetes medications such as insulin as well as screening facilities for DF, as a step towards preventing diabetes-related complications \u003cem\u003ee.g.,\u003c/em\u003e DF. This study also reported on poor attitudes and practices of DF, corresponding with the self-care deficit was also demonstrated in this cohort. This highlights a need for education and training initiatives to be established for PLWD to promote self-care, as a key prevention against DF.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approvals for this study were obtained from the national ethics review committee, Medical Research Council of Zimbabwe (MRCZ/A/1923). All study participants provided informed consent to participate in writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a grant from the International Diabetes Federation (RN13-004) as part of the IDF-BRIDGES Translational Research program. AM is the lead recipient of the grant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eO.K. co-ordinated the ZDFP, analysed the data, and wrote the manuscript. D.M. contributed to data analysis, reviewed and edited the manuscript. V.C. reviewed and edited the manuscript. L.G. co-investigator of the ZDFP and researched data. J.C. , trained the nurses to perform foot screening, researched data, reviewed and edited the manuscript. A.M. is the PI of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Chengeto Muhaso and Simbarashe Nyandoro the data collection and capturing team for the ZDFP.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbbas ZG, Boulton AJM. Diabetic foot ulcer disease in the African continent: \u0026lsquo;From clinical care to implementation\u0026rsquo; \u0026ndash; Review of diabetic foot in last 60 years \u0026ndash; 1960 to 2020. Diabetes Research and Clinical Practice 2021;183:109155. \u003c/li\u003e\n\u003cli\u003eChirombe M, Ngara B, Chibvongodza R, Charuka V, Zhou DT (2018) Glucose control in Diabetic patients attending Parirenyatwa Group of Hospitals in Zimbabwe. The Open Journal of Clinical Biochemistry. 2018;8:12-19. \u003c/li\u003e\n\u003cli\u003eMutowo MP, Lorgelly PK, Laxy M, Renzaho AMN, Mangwiro JC, Owen AJ. The hospitalization costs of diabetes and hypertension complications in Zimbabwe: Estimations and Correlations. J Diabetes Res 2016:9754230. \u003c/li\u003e\n\u003cli\u003eMureyi D, Katena NA, Monera-Penduka T. Perceptions of diabetes patients and their caregivers regarding access to medicine in a severely constrained health system: A qualitative study in Harare, Zimbabwe. PLOS Global Public Health 2022;2(3):e0000255. \u003c/li\u003e\n\u003cli\u003eBowling FL, Foley KJ, Boulton AJM. Chapter 14: Diabetic Foot. Diabetic Neuropathy 2022;223-224. \u003c/li\u003e\n\u003cli\u003eNaemi R, Chockalingam N, Lutale JK, Abbas ZG. Can a combination of lifestyle and clinical characteristics explain the presence of foot ulcer in patients with diabetes. Journal of Diabetes and Its Complications 2019;33(6):437-444. \u003c/li\u003e\n\u003cli\u003ePatel J, Zamzam A, Syed M, Blanchette V, Cross K, Albalawi Z, Al-Omram M, Mestral C (2022) A scoping review of foot screening in adults with diabetes mellitus across Canada. Canadian Journal of Diabetes 2022;46(5):435-440 e2 \u003c/li\u003e\n\u003cli\u003eLin C, Liu J, Sun H. Risk factors for lower extremity amputation in patients with diabetic foot ulcers: a meta‐analysis. PLoS One 2020;15(9):e0239236. \u003c/li\u003e\n\u003cli\u003eAbdulghani HM, AlRajeh AS, AlSalman BH, AlTurki LS, AlNajashi NS, Irshad M, Alharbi KH, AlBalawi YE, AlSuliman YA, Ahmad T (2018) Prevalence of diabetic comorbidities and knowledge and practices of foot care among diabetic patients: a cross-sectional study. Diabetes Metab Syndr Obes. 11 417-425. https://doi.org/10.2147%2FDMSO.S171526 \u003c/li\u003e\n\u003cli\u003eDurai V, Samya V, Akila GV, Shriraam V, Jasmine A, Muthuthandavan AR, Gayathri T, Mahadevan S (2021) Self-care practices and factors influencing self-care among type 2 diabetes mellitus patients in a rural health center in South India. J Educ Health Promot.10(151).\u003c/li\u003e\n\u003cli\u003eMosa BD, Mohammed S, Ashuro J, Omer Z, Ahmedin A, Hayiso D, Hailu D (2021) Knowledge, attitude and practice towards prevention of diabetic foot ulcer among adult diabetic patients attending at follow-up clinic of Hawassa comprehensive specialised hospital, Sidamma, Ethiopia. International archives of Nursing and Health Care. 8(3):177. https://doi.org/10.23937/2469-5823/1510177 \u003c/li\u003e\n\u003cli\u003eNazar CMJ, Bojerenu MM, Safdar M, Marwat J (2016) Effectiveness of diabetes education and awareness of diabetes mellitus in the United Kingdom: a literature review J Nephropharmacol. 5(2): 110-115. \u003c/li\u003e\n\u003cli\u003eGelfand M, Carr WR. Diabetes mellitus in the Africans in Rhodesia. Cent Afr J Med 1961;7(9):41-48. \u003c/li\u003e\n\u003cli\u003eGelfand M, Forbes JI. Diabetes mellitus in the Rhodesian Africa. S Afr Med J 1963;30(37):1208-1213. \u003c/li\u003e\n\u003cli\u003eSibanda M, Sibanda E, Jonsson K. A prospective evaluation of lower extremity ulcers in a Zimbabwean population. Int Wound J 2009;6:361-366.\u003c/li\u003e\n\u003cli\u003eMukona D, Martin L, Zvinavashe M. Knowledge and practices regarding exercise in type 2 diabetes patients aged 20-69 years. IOSR-JNHS 2019;8(3):1-7. \u003c/li\u003e\n\u003cli\u003eMukona D, Ngwende G, Mataruse A, Gwaunza L. Prevalence of foot at risk for ulceration in adult diabetic clinic at a tertiary centre in Zimbabwe. EC Endocrinology and Metabolic Research 2019; 4.4. \u003c/li\u003e\n\u003cli\u003eKuguyo O, Muhaso C, Nyandoro S, Chirenda C, Chikwasha V, Mageza AC, Gwanzura L, Mukona DM, Matimba A. Perspectives of healthcare workers on factors influencing diabetes management and diabetic foot problems in Zimbabwe. JEDMSA 2020;25(3):57-62. \u003c/li\u003e\n\u003cli\u003eKuguyo O, Chirenda J, Chikwasha V, Mukona DM, Mageza A, Gwanzura L, Matimba A. Needs assessment of diabetic foot services in Zimbabwe. Diabetes Research and Clinical Practice 2022;188:1099925.\u003c/li\u003e\n\u003cli\u003eAmerican Diabetes Association. Foot care in patients with diabetes mellitus. Diabetes Care 1998; 21:S54\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003ePollock RD, Unwin NC, Connolly V. Knowledge and practice of foot care in people with diabetes. Diabetes Res ClinPract 2004; 64:117\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eBloom BS (1968) Learning for mastery. Instruction and curriculum. Regional Education Laboratory for the Carolinas and Virginias, topical papers and reprints, number 1. Eval Comment. 1(2): 12. \u003c/li\u003e\n\u003cli\u003eChirombe M, Ngara B, Chibvongodze R, Charuka V, Zhou DT (2019) Glucose control in diabetic patients attending Parirenyatwa Group of Hospitals in Zimbabwe. The Open Clinical Biochemistry Journal. 8: 12-19. http://dx.doi.org/10.2174/2588778501808010012\u003c/li\u003e\n\u003cli\u003eAlmobarak AO, Awadalla H, Osman M, Ahmed MH. Prevalence of diabetic foot ulceration and associated risk factors: an old and still major public health problem in Khartoum, Sudan? Ann Transl Med 2017;5:340.\u003c/li\u003e\n\u003cli\u003eShahi SK, Kumar A, Kumar S, Singh SK, Gupta SK, Singh TB. Prevalence of diabetic foot ulcer and associated risk factors in diabetic patients from North India. The Journal of Diabetic Foot Complications.2012;4(3):83-91. \u003c/li\u003e\n\u003cli\u003eTindong M, Palle JN, Nebongo D, Aminde LN, Mboue-Djieka Y, Mbarga NTF, Deyahe, MY, Choukem SP.Prevalence, clinical presentation, and factors associated with diabetic foot ulcer in two regional hospitals in Cameroon. Int J Low Extrem Wounds 2018;17(1):42-47. \u003c/li\u003e\n\u003cli\u003eAbdissa D, Adugna T, Gereme U, Dereje D. Prevalence of diabetic foot ulcer and associated factors among adult diabetic patients on follow-up clinic at Jimma medical center, Southwest Ethiopia, 2019: An institutional-based cross-sectional study. J Diabetes Res 2020:4106383.\u003c/li\u003e\n\u003cli\u003eAboorajooh E, Alqaisi TM, Yassin M, Yassin M, Alqpelat E, Abofaraj A, Alrawajih T, Alzoubi H, Iubad MA. Diabetic foot ulcer in Southern Jordan: A cross-sectional study of clinical and microbiological aspects. Ann Med Surg (Lond) 2022;76: 103552. \u003c/li\u003e\n\u003cli\u003ePalladino R, More A, Greenfield G, Anokye N, Pigott E, Willis T, Edward G, Majeed A, Kong WM. Evaluation of the North-West London diabetes foot care transformation project: a mixed-methods evaluation. International Journal of Integrated Care 2022;22(2):4,1-9. \u003c/li\u003e\n\u003cli\u003eZhang Y, van Netten JJ, Baba M, Cheng Q, Pacella R, McPhail SM, Cramb S, Lazzarini PA. Diabetes-related foot disease in Australia: a systematic review of the prevalence and incidence of risk factors, disease and amputation in Australian populations. Journal of Foot and Ankle Research 2021;14(8). \u003c/li\u003e\n\u003cli\u003eBritish Diabetic Association (2023) Diabetes UK: Your annual diabetes foot check. Accessible online via: https://www.diabetes.org.uk/guide-to-diabetes/complications/feet/what-can-i-expect-at-my-annual-foot-check#:~:text=Everyone%20with%20diabetes%20should%20have,these%20can%20lead%20to%20amputations. Accessed on: 31 May 2023\u003c/li\u003e\n\u003cli\u003eDiabetes Australia (2023) Diabetes and Your Feet. Accessible online via: https://www.diabetesaustralia.com.au/living-with-diabetes/preventing-complications/foot-care/\u003cu\u003e \u003c/u\u003eAccessed on: 31 May 2023\u003c/li\u003e\n\u003cli\u003eAbbas ZG (2013) Preventive foot care and reducing amputation: a step in the right direction for diabetes care. Diabetes Manage. 3(5): 427-435.\u003c/li\u003e\n\u003cli\u003eAbbas ZG, Lutale JK, Bakker K, Baker N, Archibald LK (2011) The \u0026ldquo;Step by Step\u0026rdquo; diabetic foot project in Tanzania: a model for improving patient outcomes in less developed countries. Int Wound J. 8(2): 169-75. https://doi.org/10.1111/j.1742-481x.2010.00764.x\u003c/li\u003e\n\u003cli\u003eBaker N, Van Acker K, Urbancic-Rovan V, Abbas ZG, Morbach SS (2017) The world wide implementation of the \u0026ldquo;Train the Foot Trainer\u0026rdquo; program. The Diabetic Foot Journal. 20(2): 71-6. \u003c/li\u003e\n\u003cli\u003eBakker K, Abbas ZG, Pendsey S (2006) Step by Step, improving diabetic foot care in the developing world. Practical Diabetes International. 23(8): 365-369. https://doi.org/10.1002/pdi.1012 \u003c/li\u003e\n\u003cli\u003eAl Rubeaan K, Al Derwish M, Quizi S, Youssef SN, Subhani SN, Ibrahim HM et al (2015) Diabetic foot complications and their risk factors froma large retrospective cohort study. PLoS ONE. 10: http://dx.doi.org/10.1371/journal.pone.0124446\u003c/li\u003e\n\u003cli\u003eMcDermott K, Fang M, Boulton AJM, Selvin E, Hicks CW (2023) Etiology, Epidemiology, and disparities in the burden of diabetic foot ulcers. Diabetic Care. 46(1):L 209-221.\u003c/li\u003e\n\u003cli\u003eVatankhah N, Jahangiri Y, Landry GJ, Moneta GL, Azarbal AF. Effect of systemic insulin treatment on diabetic wound healing. Wound Repair Regen 2017;25(2): 288-291. \u003c/li\u003e\n\u003cli\u003eKorkmaz I, Bingol O, Karlidag T, Keskin OH, Kilic E, Ozdemir G. Lower extremity amputations due to diabetes; risk factors for amputations and the role of imaging methods in determining the level of amputation. Diabetes Epidemiology and Management 2021;4:100036. \u003c/li\u003e\n\u003cli\u003eMachirori Y (2021) Yemurai Machirori: living with diabetes, struggling to be seen. Bull World Health Organ. 99(4): 248-9. https://doi.org/10.2471%2FBLT.21.030421\u003c/li\u003e\n\u003cli\u003eTrading Economics (2023) Zimbabwe Living Wage Individual. Accessed online: \u003cbr\u003ehttps://tradingeconomics.com/zimbabwe/living-wage-\u003cbr\u003eindividual#:~:text=Living%20Wage%20Individual%20in%20Zimbabw\u003cbr\u003ee%20averaged%20305.00%20USD%2FMonth%20from,updated%20on%20Ju\u003cbr\u003ene%20of%202023. Accessed on: 06 June 2023.\u003c/li\u003e\n\u003cli\u003eZimbabwe National Statistics Agency (2023) Accessible online via: https://www.zimstat.co.zw Accessed on: 17 Jul 2023\u003c/li\u003e\n\u003cli\u003eHicks CW, Selvin E (2019) Epidemiology of peripheral neuropathy and lower extremity disease in diabetes. Curr Diab Rep. 19(10): 86. https://doi.org/10.1007%2Fs11892-019-1212-8\u003c/li\u003e\n\u003cli\u003eBaba M, Davis WA, Norman PE, Davis TM. Temporal changes in the prevalence and associates of diabetes-related lower extremity amputations in patients with type 2 diabetes: the Fremantle diabetes study. Cardiovasc Diabetol. 2015;14(1):152.\u003c/li\u003e\n\u003cli\u003eElghazaly H, Howard T, Sanjay S, Mohamed OG, Sounderajah V, Mehar Z, Davies AH, Jaffer U, Normahani P. Evaluating the prognostic performance of bedside tests used for peripheral arterial disease diagnosis in the prediction of diabetic foot ulcer healing. Cardiovascular and metabolic risk 2022;11(2):e003110. \u003c/li\u003e\n\u003cli\u003eHeller S, Lawton J, Amiel S, Cooke D, Mansell P, Brennan A, Elliott J, Boote J et al (2014) Improving managemene of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A Mixed method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes. \u003c/li\u003e\n\u003cli\u003eNational Institutes for Health and Excellence Type 1 diabetes in adults: diagnosis and management guidance and guidelines | NICE. Available from: https://www.nice.org.uk/guidance/ng17 Last accessed on: 18 Nov 2023. \u003c/li\u003e\n\u003cli\u003eCoates E, Amiel S, Baird W, Benaissa M, Brennan A, Campbell, Chadwick P, Chater T, Choudhary P, Cooke D et al (2021) Protocol for a cluster randomised controlled trial of the DAFNE plus (Dose Adjustment for Normal Eating) intervention compared with 5X1 DAFNE: a lifeling approach to promote effective self-management in adults with type 1 diabetes. BMJ Open. 11(1): e040438. https://doi.org/10.1136/bmjopen-2020-040438 \u003c/li\u003e\n\u003cli\u003eRankin D, Cooke DD, Elliott J, Heller SR, Lawton J, and the UK NIHR DAFNE study group (2012) Supporting self-management after attending a structured education programme: a qualitative longitudinal investigationof type 1 diabetes patients\u0026rsquo; experiences and views. BMC Public Health.12, 652. https://doi.org/10.1186/1471-2458-12-652 \u003c/li\u003e\n\u003cli\u003eBrown R, Ploderer B, Seng L, Lazzarini PA, Van Netten JJ (2017) MyFootCare: a mobile self-tracking tool to promote self-care amongst people with diabetic foot ulcers. http://dx.doi.org/10.1145/3152771.3156158 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Diabetes, Diabetic foot, Diabetic foot in Zimbabwe, KAP, Peripheral Neuropathy, Insulin","lastPublishedDoi":"10.21203/rs.3.rs-3182157/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3182157/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDiabetic foot (DF) is one of the most common diabetes-related complications, however, the prevalence and associated risk factors of DF are not well characterized among people living with diabetes (PLWD) in Zimbabwe. This study aims to determine the prevalence of diabetic foot and associated risk factors in PLWD in Zimbabwe.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional study, employing a mixed-methods approach was used to obtain data. A total of 352 PLWD were recruited from 16 primary care clinics across Harare. Face-to-face interviews and patient record reviews were used to collect sociodemographic and clinical data. Screening for DF included sole pressure, peripheral neuropathy, ankle-brachial index, deep tendon reflexes, ulceration, and amputation were performed. Self-administered questionnaires were used to assess knowledge, attitudes, and practices (KAPs). Scoring for KAPs was done using Bloom\u0026rsquo;s cutoff, and regression analyses were used to associate variables with DF risk.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThis group was made up of 82 men and 279 women. The combined mean age was 57.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14 years, and the age was comparable by gender (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). More than a quarter (n\u0026thinsp;=\u0026thinsp;21) of men and 15% (n\u0026thinsp;=\u0026thinsp;41) ofwomen had Type 1 diabetes. The distribution of diabetes type significantly differed by gender (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). DF was observed in 53% of PLWD. Abnormal ankle-brachial index (53%) and peripheral neuropathy (53%), foot ulceration (17%) and amputations (3%) were observed. Peripheral neuropathy increased the risk of ulceration (OR\u0026thinsp;=\u0026thinsp;1.7; 95% CI\u0026thinsp;=\u0026thinsp;1.1\u0026ndash;2.6; p\u0026thinsp;=\u0026thinsp;0.019), while insulin adherence was protective against amputation (OR\u0026thinsp;=\u0026thinsp;0.1; 95% CI\u0026thinsp;=\u0026thinsp;0.1\u0026ndash;0.9; p\u0026thinsp;=\u0026thinsp;0.049). Most (87%) of the group demonstrated good DF knowledge and the importance of adhering to medication to prevent DF. However, 96% did not know that smoking was a risk of DF. Nearly two-thirds (63%) of the group demonstrated poor attitudes and practices. Poor attitudes and practices were not predictors of diabetic foot ulceration risk (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur findings report a high prevalence of DF (53%) in PLWD in Zimbabwe. However, DF is not routinely assessed in Zimbabwe. Adherence to insulin was found to protect against DF, underscoring the need for policy revisions to include screening and increasing insulin adherence to prevent DF as integral primary care for PLWD.\u003c/p\u003e","manuscriptTitle":"Prevalence and risk factors for diabetic foot complications among people living with diabetes in Harare, Zimbabwe","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-08-19 00:01:56","doi":"10.21203/rs.3.rs-3182157/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-11-28T07:08:42+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"b4b0368c-67e2-424c-bbc3-645ab53b6dec_SNPRID","date":"2023-11-22T13:24:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110ea595-4922-4368-8729-cf90dc029e76","date":"2023-10-14T01:17:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-10-08T16:05:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-10-03T01:19:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31a4c279-0020-40e9-96db-9afec944072f","date":"2023-09-20T10:18:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"cedec0a9-78a0-4b2d-bcfd-4dc80a7a22c1_SNPRID","date":"2023-09-20T10:17:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-09-20T10:14:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-09-16T08:17:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-08-14T07:17:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-08-14T07:15:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2023-07-18T15:24:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"86b3efb9-2744-47a9-902c-196aec141136","owner":[],"postedDate":"August 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-03-11T15:07:57+00:00","versionOfRecord":{"articleIdentity":"rs-3182157","link":"https://doi.org/10.1186/s12889-023-17610-7","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2024-03-04 15:01:33","publishedOnDateReadable":"March 4th, 2024"},"versionCreatedAt":"2023-08-19 00:01:56","video":"","vorDoi":"10.1186/s12889-023-17610-7","vorDoiUrl":"https://doi.org/10.1186/s12889-023-17610-7","workflowStages":[]},"version":"v1","identity":"rs-3182157","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3182157","identity":"rs-3182157","version":["v1"]},"buildId":"ApUGefWb6u5IBVtyqm6d5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}