International Journal of
Environmental Research
and Public Health
Article
Diabetic Foot Assessment and Care: Barriers and Facilitators in
a Cross-Sectional Study in Bangalore, India
Sudha B. G. 1, * , Umadevi V. 1 , Joshi Manisha Shivaram 2 , Pavan Belehalli 3 , Shekar M. A. 3 ,
Chaluvanarayana H. C. 3 , Mohamed Yacin Sikkandar 4 and Marcos Leal Brioschi 5
1
2
3
4
5
*
Citation: B. G., S.; V., U.; Shivaram,
J.M.; Belehalli, P.; M. A., S.; H. C., C.;
Sikkandar, M.Y.; Brioschi, M.L.
Diabetic Foot Assessment and Care:
Barriers and Facilitators in a
Department of Computer Science and Engineering, B.M.S. College of Engineering, Bangalore 560019, India
Department of Medical Electronics, B.M.S. College of Engineering, Bangalore 560019, India
Department of Podiatry, Karnataka Institute of Endocrinology and Research, Bangalore 560019, India
Medical Equipment Technology, College of Applied Medical Sciences, Majmaah University,
Al Majmaah 11952, Saudi Arabia
Medical Thermography Service, Neurology Department, Hospital das Clínicas, Sao Paulo University,
Sao Paulo 01246-903, Brazil
Correspondence: sudhagrr@gmail.com
Abstract: (1) Background: This cross-sectional study aims to highlight the assessment and foot care
practices in an advanced clinical setting, the clinical characteristics of the patients, and to understand
the barriers and facilitators for effective foot care from the perspectives of healthcare practices,
resources, and patients’ socioeconomic and cultural practices, and other aspects in terms of new
technologies for effective foot care such as infrared thermography. (2) Methods: Clinical test data from
158 diabetic patients and a questionnaire to assess the foot care education retention rate were collected
at the Karnataka Institute of Endocrinology and Research (KIER) facility. (3) Results: Diabetic foot
ulcers (DFUs) were found in 6% of the examined individuals. Male patients were more likely to have
diabetes complications, with an odds ratio (OR) of 1.18 (CI = 0.49–2.84). Other diabetes problems
raised the likelihood of DFUs by OR 5 (CI = 1.40–17.77). The constraints include socioeconomic
position, employment conditions, religious customs, time and cost, and medication non-adherence.
The attitude of podiatrists and nurses, diabetic foot education, and awareness protocols and amenities
at the facility were all facilitators. (4) Conclusions: Most diabetic foot complications might be avoided
with foot care education, regular foot assessments as the standard of treatment, and self-care as a
preventive/therapeutic strategy.
Cross-Sectional Study in Bangalore,
India. Int. J. Environ. Res. Public
Health 2023, 20, 5929. https://
Keywords: barriers; diabetic foot assessment; foot care practices; foot complications epidemiology;
facilitators; foot care education; thermography
doi.org/10.3390/ijerph20115929
Academic Editor: Noël
Christopher Barengo
Received: 8 March 2023
Revised: 25 April 2023
Accepted: 19 May 2023
Published: 23 May 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
1. Introduction
According to the International Diabetes Federation (IDF), India ranks second in the globe
and first in Southeast Asia with around 74 million people with diabetes in 2021, accounting for
one in every seven people worldwide [1]. Diabetes management costs around USD 114.4 per
person per year in India [1]. The theme for World Diabetes Day 2021-23 is ‘Access to Diabetes
Care’ [2], emphasizing the significance of diabetes treatment access.
In India, DFUs affect 15% of patients with diabetes during their lifetime. Evidence
from the published literature showed 100,000 leg amputations/year due to diabetes-related
problems and an expense of approximately USD 1960 for complete treatment of DFUs.
In India, 25% of the diabetic population develop DFUs, of which 50% become infected,
requiring hospitalization, while 20% need amputation. DFUs contribute to approximately
80% of all non-traumatic amputations in India annually. In addition, India is the most
expensive country for DFU care, as 5.7 years (68.8 months) of an average patient’s income
is required to pay for complete DFU therapy. In total, 50% of DFU patients who have
one amputation suffer another amputation within the next 2 years [3]. The mortality rate
Int. J. Environ. Res. Public Health 2023, 20, 5929. https://doi.org/10.3390/ijerph20115929
https://www.mdpi.com/journal/ijerph
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following amputation [4–6] rises from 13–40% in 1 year to 39–80% in 5 years. This scenario
necessitates a routine examination of the foot for the existence of any abnormalities. The
problem is to properly adopt foot care while keeping costs in mind.
Diabetes-related foot care is one of the most ignored aspects of diabetes care in India.
Due to social, religious, and economic compulsions, many people walk barefoot. Poverty
and lack of education lead to the usage of inappropriate footwear and late presentation of
foot lesions. [7]. Hence this study is an effort in closing the gap in knowledge of the barriers
and facilitators specific to Indian population.
Foot treatments include diabetes-related foot education, therapeutic footwear, and
routine foot care. Patients’ attention to foot care and self-management is the key to success
among all the aspects that might aid in these duties. A combination of healthcare personnel
and patient education, multidisciplinary foot ulcer treatment, prevention, and regular
monitoring can lower amputation rates by 49–85% [8]. As a result, the IDF and WHO have
set aims to cut amputation rates by up to 50% [9]. The International Working Group on the
Diabetic Foot (IWGDF) recommendations [10] aided in the study design and methods.
This study was conducted at the Karnataka Institute of Endocrinology and Research
(KIER, formerly known as the Karnataka Institute of Diabetology (KID)), an autonomous
institute specialized in comprehensive diabetes care with a separate Department of Podiatry
to deal with diabetes-related foot complications that is fully supported by the government
in Bengaluru, Karnataka, India.
This study adds to prior research on diabetes-related foot complications [11–13], which
focused on the clinical features of patients living with diabetes, personal attitudes, and
habits, especially in industrialized nations.
Diabetes is common in older people usually, and hence, diabetes-related foot complications were more common in older persons with a longer history of diabetes, a higher
BMI (Body Mass Index), hypertension, diabetes-related retinopathy, and smoking history.
It was more common in men than in women, and it was more common in type-2 diabetes
patients [11]. According to a study conducted in the rural districts of Udupi, Karnataka
by Vibha et al. [12], advanced age, low social economic status, low literacy rate, unemployment, smokeless tobacco use, sedentary lifestyle, and longer duration of diabetes
mellitus (DM) were all significantly associated with diabetic foot syndrome (DFS). It was
also shown that “BMI, waist circumference, clinical parameters such as blood pressure,
glycated hemoglobin, and presence of hypertension, hypercholesterolemia, and medication
adherence, frequency of consulting physician, gender and religion” were not related to
DFS. Another piece of research that is similar to ours is by Guell, Cornelia, and Nigel [13],
who conducted an exploratory qualitative study in the Caribbean country of Barbados.
According to the findings of the study, both healthcare practitioners and patients are more
preoccupied with glycemic management, which has eclipsed the importance of foot care.
The second obstacle noted by patients was opposition to new care responsibilities by healthcare providers, and the last barrier mentioned by patients was appointment/accessibility
to podiatry services. Patient training sessions offered in all public care institutions for
improving diabetes patients’ self-management were envisioned as possible facilitators.
A holistic unbiased view of regular foot assessment, clinical characteristics and socioeconomic status, foot care education retention rate of patients, and other aspects in terms of
new technologies for effective foot care such as infrared thermography is reported here.
The aim is to identify barriers and enablers to optimal diabetes-related foot care.
2. Materials and Methods
2.1. Research Design
This is a cross-sectional analytical study. The data of patients with diabetes were
obtained at KIER and authorized by the Institutional Ethical Committee (Approval No:
IEC-KIER/10/28.10.2017). The research was carried out over a year in 2019. All participants
engaged in the study provided written informed consent. According to “Recommenda-
Int. J. Environ. Res. Public Health 2023, 20, 5929
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tions for the conduct, reporting, editing, and publication of scholarly work in medical
journals” [14], the study was framed and organized for reporting.
2.2. Study Population
The study included 158 diabetic patients (103 men and 55 women) with DM.
Convenience non-probabilistic sampling was utilized in this study since it is part of
another cohort study that involves the recording of thermal images of the foot to analyze
and categorize the risk of diabetic foot problems [15,16]. Patients who came to the clinic for
a routine foot exam, infection, discomfort, swelling, numbness, or wound dressing in the
leg or DFU were chosen.
Sample size calculation was based according to Jyothylekshmy V et al. [17], where
49.45% of the study population had peripheral neuropathy, and 41.51% had non-healing
ulcers. Diabetes is responsible for 40% to 72% of all lower-extremity amputations, with
diabetic foot ulcer recurrence in 52% of the study group [18] and a 51% incidence of DFS [12].
As a result, we used 40% as the prevalence of at least one diabetic foot condition that leads
to ulcer and hence amputation. Precision is considered to be one-fifth of the prevalence. As
a result, the sample size for a 95% confidence level is around 145.
Adults over the age of 18 with type-1 or type-2 diabetes were eligible. Patients with
diabetes who attend frequent foot evaluations, wound dressing, or follow-ups and who
can provide informed permission demonstrating that they understand the study’s goal and
methods were included.
Patients without diabetes attending the center for wound treatment or presently
involved in another research study were excluded.
2.3. Clinical Foot Assessment and Foot Care Management Practices
The diabetes-related foot evaluation, information gathered, wound management, and
treatment provided in the clinic are shown in Figure 1. This is accomplished by the diabetesrelated foot examination and foot care management strategies recommended [19–21].
A typical foot evaluation regime in the center comprises the following: monofilament
test (using 10 g filament), vibration perception test (VPT) (normal—<15 volts; grade I—16
to 25 volts; grade II—26 to 50 volts), hot perception test (HPT) and cold perception test
(CPT) to identify the risk of small fiber neuropathy as shown in Table 1, pedography
(to measure maximum peak pressure (MPP) and pressure distribution as an image), and
vascular Doppler study.
Table 1. Heat perception test used to classify the risk of small fiber neuropathy (◦ C).
Condition
Perception
Temperature
Normal
Hot
Cold
<42.4 ◦ C
>19 ◦ C
Mild
Hot
Cold
42.5–45.4 ◦ C
15–19 ◦ C
Moderate
Hot
Cold
45.5–48 ◦ C
11–15 ◦ C
Severe
Hot
Cold
>48 ◦ C
<10 ◦ C
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Figure1.1.Diabetic
Diabeticfoot
footassessment
assessmentand
andwound
woundmanagement/care
management/careprovided
providedininthe
thecenter.
center.
Figure
evaluate
sensory function
thecenter
foot incomprises
diabetes patients,
we followed
the IDF
ATotypical
footthe
evaluation
regime inofthe
the following:
monofilament
guidelines
[10],
which recommend
at least 4 sites
(first, third,
and fifthvolts;
metatarsal
test
(using 10
g filament),
vibration perception
test (VPT)
(normal—<15
grade heads,
I—16
and the hallux). In India, cracked heel and flat foot is common, leading to infections in
to 25 volts; grade II—26 to 50 volts), hot perception test (HPT) and cold perception test
these areas as well. Therefore, we have considered 6 sites (including medial longitudinal
(CPT) to identify the risk of small fiber neuropathy as shown in Table 1, pedography (to
arch and the heel) for testing on each foot. The monofilament was applied perpendicular
measure maximum peak pressure (MPP) and pressure distribution as an image), and vasto the skin with enough pressure to bend it into a “C” shape. The patient was in a lying
cular Doppler study.
position with their eyes closed, and the examiner tested each site consecutively, alternating
To evaluate the sensory function of the foot in diabetes patients, we followed the IDF
between the left and right foot. The results of the monofilament test were recorded in the
guidelines [10], which recommend at least 4 sites (first, third, and fifth metatarsal heads,
patient’s medical records and used to guide treatment and management of the patient’s
and the hallux). In India, cracked heel and flat foot is common, leading to infections in
diabetes-related foot conditions.
these areas as well. Therefore, we have considered 6 sites (including medial longitudinal
The same 6 sites were considered for the VPT, HPT, and CPT tests. The study particiarch and the heel) for testing on each foot. The monofilament was applied perpendicular
pants were lying down with their eyes closed during all these tests.
to the skin with enough pressure to bend it into a “C” shape. The patient was in a lying
A vascular Doppler study is used to examine the risk of vascular ulcers using a
position
their eyes
closed, PAD
and the
examinerarterial
tested each
site consecutively,
portablewith
Doppler.
To identify
(peripheral
disease),
the ABI (anklealternatbrachial
ing
between
the
left
and
right
foot.
The
results
of
the
monofilament
test
were
recorded
in
index) is automatically measured. Table 2 depicts the risk of vascular
foot
ulcers
as found
the
patient’s
medical
records
and
used
to
guide
treatment
and
management
of
the
pain the care center.
tient’s diabetes-related foot conditions.
The same 6 sites were considered for the VPT, HPT, and CPT tests. The study participants were lying down with their eyes closed during all these tests.
Int. J. Environ. Res. Public Health 2023, 20, 5929
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Table 2. Classification of risk of vascular foot ulcer (ankle brachial index—ABI).
Condition
ABI
Risk Classification
Normal
0.9–1.2
Risk is small
Definite vascular disease
0.6–0.9
Risk is moderate and depends
on other risk factors
Severe vascular disease
Less than 0.6
Risk is very high
Following the foot examination, patients take the records to a podiatrist for interpretation and guidance based on the test results. In general, the patients were recommended
to take drugs for neuropathy, exercise for pain, eat a healthy diet, and undergo additional
testing such as an X-ray to rule out Charcot arthropathy and osteomyelitis. If an existing
corn, callus, bruise, or wound is discovered, cleaning, debriding, corn and callus removal,
and correct dressing are performed, and regular follow-ups are encouraged. Patients who
come in for wound care would have these done on a daily or alternate-day basis. This is
repeated until the wound heals/is treated surgically or is amputated in the event of nonhealing wounds or spreading infection. Regardless of the presence of foot issues, podiatrists
advise all patients to check their feet once a day for cracks, bruises, pricks, or sores.
2.4. Foot Care Education Retention Rate
In addition to the regular assessments, information on the foot care education retention
is also collected for this study. Diabetes education and care influence diabetes care outcomes [22], and hence foot problems. As a result, the rate of foot care education retention
was determined using a questionnaire (Table 3). The clinical practice guidelines on the
diabetic foot provided by the IDF in [20] were used to frame these questions. If the patient
answers ‘yes’ to a question, he or she receives a score of one. A score of 1 indicates that the
patient replied ‘yes’ to one of the ten questions presented.
Table 3. Questionnaire for calculating foot care education retention.
Q.No.
Question
1.
Do you inspect your foot regularly?
2.
Do you wear footwear regularly while walking?
3.
Do you wash your feet regularly with warm water?
4.
Do you keep your foot dry?
5.
Do you wear special soft shoes?
6.
Do you apply moisturizer?
7.
Do you go for regular foot monitoring?
8.
Do you regularly check your blood sugar levels?
9.
Do you cut your nails regularly?
10.
Do you report the presence of blisters/corns to a foot specialist?
3. Results
3.1. Baseline Characteristics of Patients
Table 4 shows the baseline characteristics of patients who attend the facility.
Int. J. Environ. Res. Public Health 2023, 20, 5929
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Table 4. Baseline and diabetes-related foot characteristics.
Baseline Characteristics
All Subjects (Mean ± Standard Deviation)
Age (years)
Gender
Female
Male
Diabetes duration (year)
Type 1 DM
Type 2 DM
Education
Diploma or no degree
University degree
Job profile
Low
Medium
High
No job
58 ± 12
55
103
11 ± 7
27
131
122
36
57
37
12
52
Diabetic foot characteristics
Present (in %)
Absent (in %)
Burning
Numbness
Diabetic peripheral
neuropathy (DPN)
Heredity
Trauma
Deformity
Foot care training
History of/leading to
amputation
Special footwear
Previous other
diabetes-related complications
Diabetic foot ulcer
50
50
49
43
48
51
57
52
5
13
60
95
87
40
2
98
18
82
35
65
6
94
The male preponderance seen in this investigation was consistent with prior studies [22,23]. Patients with type-2 diabetes outnumbered those with type-1 diabetes, implying
that type-2 diabetes patients are more vulnerable to diabetes-related foot problems. These
findings are consistent with worldwide findings [11].
Numbness is seen in around 50% of patients, according to Table 4. DPN was verified
by VPT and HPT, and the frequency of DPN in our sample of 43% is consistent with earlier
investigations in India [24]. Based on the questionnaire in Table 3, the foot care education
retention rate indicated in Figure 2 was determined. The most favorable responses were
obtained for questions 1, 2, 9, and 10.
Figure 2. Foot care education retention rate among the subjects.
Figure 2. Foot care education retention rate among the subjects.
Only 30.5% of patients acknowledged receiving foot care instruction. This is low because a group of skilled podiatric nurses provided foot care instruction to all patients registered with the hospital.
3.2. Statistical Test Results
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Only 30.5% of patients acknowledged receiving foot care instruction. This is low
because a group of skilled podiatric nurses provided foot care instruction to all patients
registered with the hospital.
3.2. Statistical Test Results
To see if amputations and foot care education retention rates are related, we ran a chisquare independence test on the data. The statistical test result indicates that the statistical
test is significant (p-value < 0.05), and so, amputations are dependent on the retention rate
of foot care instruction (at 99% confidence level).
Males have a higher risk of diabetes problems than females. Male patients had a
greater risk of diabetes complications than female patients, with an odds ratio of 1.18
(CI = 0.49–2.84). This is supported by several additional investigations [11].
Males have a greater training retention rate than females. Male patients appear to
recall lower-level foot care instruction more than female patients, with an odds ratio of 0.89
(CI = 0.40–1.96).
The presence of prior diabetes problems enhanced the likelihood of DFUs with OR 5
(CI = 1.40–17.77).
3.3. Risk Classification of Patients
The International Diabetes Federation (IDF) Z-card or the diabetic foot screening
pocket chart [25], presented in Table 5, provides standards for health professionals to identify, assess, and treat diabetes-related foot patients earlier in the “window of presentation”
between when neuropathy is diagnosed and prior to developing an ulcer.
Table 5. Risk classification (extracted) from IDF Z-card.
Risk Category
0
1
2
3
History of Ulceration,
Amputation or
Neuropathic Fracture
Very High
Assessment
Normal Plantar
Sensation
Loss of Protective
Sensation (LOPS)
LOPS with either High
Pressure or Poor Circulation
(Peripheral Arterial Disease)
or Structural Foot
Deformities or
Onychomycosis
Risk Classification
Low
Moderate
High
The risk classification of our research participants is shown in Figure 3. This is based
on the guidelines in the diabetic foot screening pocket chart [25] and the extract from the
pocket chart Z-card.
Figure 3.
3. Risk
Risk patient
patient classification
classification of
of study
study participants
participants as
as per
per the
the IDF
IDF Z-card.
Z-card.
Figure
Figure 3 shows that the percentage of patients at low and moderate risk is higher
than the percentage of patients at high and very high risk. This demonstrates that once a
risk is identified early on, it is possible to control the progression to high and very high
risk. Nonetheless, the proportion of very-high-risk patients is slightly higher than the pro-
Figure 3. Risk patient classification of study participants as per the IDF Z-card.
Int. J. Environ. Res. Public Health 2023, 20, 5929
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Figure 3 shows that the percentage of patients at low and moderate risk is higher
than the percentage of patients at high and very high risk. This demonstrates that once a
risk is identified early on, it is possible to control the progression to high and very high
Figure 3 shows that the percentage of patients at low and moderate risk is higher than
risk. Nonetheless, the proportion of very-high-risk patients is slightly higher than the prothe percentage of patients at high and very high risk. This demonstrates that once a risk
portion of high-risk patients. This is because of the fact that once it enters risk category 3,
is identified early on, it is possible to control the progression to high and very high risk.
the chances of controlling further complications are slim because it is at a very advanced
Nonetheless, the proportion of very-high-risk patients is slightly higher than the proportion
stage.
of high-risk patients. This is because of the fact that once it enters risk category 3, the
chances of controlling further complications are slim because it is at a very advanced stage.
3.4. Barriers and Facilitators
Despite
allFacilitators
examinations and wound care, there are still impediments to good foot
3.4. Barriers
and
careDespite
that areall
comparable
to those
the are
literature
[26–30]. Thetohurdles
and
examinations
and documented
wound care, in
there
still impediments
good foot
facilitators
particular
to
diabetes-related
foot
care
as
recognized
by
health
professionals
care that are comparable to those documented in the literature [26–30]. The hurdles and
[28] are also
applicable
to this center (See
Figure
4),recognized
and there are
issues professionals
in terms of public
facilitators
particular
to diabetes-related
foot
care as
by health
[28]
health
health systems
for diabetes
treatment
and
management
Another
study
are
alsoand
applicable
to this center
(See Figure
4), and
there
are issues[29].
in terms
of public
[20] showed
thatsystems
patient for
knowledge
attitudes,
self-care, and[29].
socioeconomic
level
all
health
and health
diabetes and
treatment
and management
Another study
[20]
play
important
roles
in
good
foot
care
as
assessed
by
multidisciplinary
healthcare
providshowed that patient knowledge and attitudes, self-care, and socioeconomic level all play
ers. However,
is skewed
because
it only included
the opinionshealthcare
of healthcare
profesimportant
rolesthis
in good
foot care
as assessed
by multidisciplinary
providers.
sionals.
However, this is skewed because it only included the opinions of healthcare professionals.
Figure4.4.Facilitators,
Facilitators,barriers
barriersand
andpotential
potentialfacilitators.
facilitators.
Figure
3.4.1. Barriers
Lack of Awareness
Patients who visit the foot care facility for the first time are unaware of the diabetesrelated foot issues that might emerge and the associated difficulties. The importance of
foot care and frequent foot examination is often overlooked. This is confirmed by the
research of Soumya et al. and Saurabh et al. [31,32]. People aren’t aware that ill-fitting
shoes, harsh bottoms, and going barefoot can lead to diabetes-related foot issues. Patients
ignore foot examinations and only glance at their feet when there is blood on the floor, or
the cut becomes painful. This is confirmed by a statistical test that shows that persons with
diabetes for a longer period retain more foot care knowledge.
Religious Practices
Men and women throughout most of the country go barefoot to local sites and temples,
as is customary with any religious activity, as recorded in Vibha et al. [12] and Guell
et al. [13]. Few men and women, particularly in South India, do not wear footwear even
for a month when on pilgrimage to specific temples. They consider it a religious activity.
Int. J. Environ. Res. Public Health 2023, 20, 5929
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Fasting during Ramzan (a religious festival) contributes to poor diabetes control and, as a
result, poor diabetes-related foot outcomes.
Time and Cost Factor
Most patients arrive early in the morning to perform fasting glucose testing, postprandial sugar tests, diet counseling, ECG checks, and then meet with a diabetes-related
expert if necessary. They may also be requested to perform eye examinations and foot
assessment tests. It takes two days to conduct all of the tests and meet the podiatrist. The
tests for foot examination take at least 30 min for each patient. The IWGDF [10] advises foot
evaluation at least once a year for diabetes patients without current difficulties and once
every 6 months or 3 months for individuals at risk, depending on the risk or complication
involved. Patients going from adjacent communities must factor in travel time and expense,
which is a significant obstacle to efficient wound treatment.
Socio-Economic Factor
People in the educated middle and upper middle classes (which account for only 12%
of our research group) had higher levels of awareness and foot care knowledge. When a
patient’s financial situation is bad, individuals begin to ignore foot issues due to the lack
of financial assistance. People are also less alert when they live in places where there is a
dearth of understanding about the complications and how to prevent them. This is similar
to what Agha et al. discovered in [26].
Working Environment Factor
Diabetes-related foot sufferers have additional problems in the workplace. For example, a man working in the construction business had blisters on his foot as a result of
contact with cement and sharp things such as steel, while another man developed web
space infection as a result of continual soaking of his foot due to housekeeping activities.
Figure 5 depicts the visual and infrared thermal images that were captured.
(A)
(B)
Figure
another
patient’s
foot
Figure 5.
5. (A)
(A) A
A patient’s
patient’sfoot
footfrom
fromaaconstruction
constructionsite
sitewith
witha ablister
blisterand
and(B)
(B)
another
patient’s
foot
from
a
housekeeping
occupation
with
a
web
space
ulcer.
from a housekeeping occupation with a web space ulcer.
Access to
Access
to Specialized
Specialized Foot
Foot Care
Care and
and Increasing
Increasing Number
Number of
of Patients
Patients
In Bangalore,
foot
care
facilities
where
the the
same
typetype
of test
In
Bangalore, there
thereare
arethree
threespecialized
specialized
foot
care
facilities
where
same
of
is performed.
There
are are
no specialized
centers
in adjacent
areas,
thus
individuals
from
a
test
is performed.
There
no specialized
centers
in adjacent
areas,
thus
individuals
from
100
from
a 100km
kmradius
radiusininKarnataka
Karnatakacome
cometotothis
thisfacility.
facility.The
Thefacility
facilityserves
serves patients
patients not
not just
just from
including Andhra
Andhra Pradesh
Pradesh and
and Tamil
Tamil Nadu.
Nadu.
Karnataka but also from neighboring states including
The number
of
patients
continues
to
rise,
putting
a
strain
on
podiatrists.
When
an
operation
number of patients continues to rise, putting a strain on podiatrists. When an operato amputate
a footaor
toeor
is scheduled,
patientpatient
waitingwaiting
times increase,
forcingforcing
the facility
tion
to amputate
foot
toe is scheduled,
times increase,
the
to limitto
the
number
of newof
patients
enrolled.
This isThis
a major
concern
for patients
who
facility
limit
the number
new patients
enrolled.
is a major
concern
for patients
who travel significant distances (approximately 100 km from Hindupur in Andhra Pradesh and Krishnagiri in Tamil Nadu) to see the podiatrist.
Dependency by the Patient
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travel significant distances (approximately 100 km from Hindupur in Andhra Pradesh and
Krishnagiri in Tamil Nadu) to see the podiatrist.
Dependency by the Patient
Patients with diabetes, particularly women, expect someone to accompany them to the
facility. Owing to this dependency, the visit gets delayed, and hence, the wound becomes
infected. This further causes delay in the therapeutic procedure. Similarly, patients with
limited mobility also expect a member of their family to accompany them to the care facility.
Such dependencies postpone effective treatment at the appropriate moment, resulting in
poor wound care results. Eight patients had arrived in pairs. Three of the pairings were
husband and wife, while the fourth was a mother and son.
Communication Gap
In total, 75% of patients see both a diabetes specialist and a foot care specialist and
receive medical prescriptions from both. When the foot care professional instructs the
patient to discontinue the drug after a certain length of use, some individuals misinterpret
it for the complete set of prescriptions and stop taking all medications, including diabetes
medicines. This is a serious issue since it raises blood glucose levels, causing nerve damage.
Certain people quit taking their drugs abruptly before the time limit because they have
produced some undesired side effects without informing their doctor. This, once again,
impedes successful therapy. Few people do not finish their antibiotic course, and as a result,
they develop resistance to some of the antibiotics, requiring the doctor to provide a larger
dose of another potent and expensive antibiotic to combat the infection.
Poor Blood Glucose Level Monitoring
Many patients only check their blood glucose levels once a year, and others go even
longer periods. Diabetes management failure results in poor diabetes-related foot care
outcomes [28]. Despite the fact that the aforementioned hurdles impede good foot care
treatment and wound management, some facilitators attempt to enhance foot care wound
management at the center, as shown in the next section.
3.4.2. Facilitators
The presence of highly experienced surgeons and nurses for quick action—limb
salvage surgery and vascular surgery—are facilitators, as is assessment of various diabetes
problems such as nephropathy, retinopathy, and cardiology under one roof. Self-foot care
and patient education, as documented in [30–32], are also major facilitators here, resulting
in a decreased proportion of high-risk patients. Diet counseling to keep blood glucose
levels under control, physiotherapy to alleviate discomfort and promote mobility, provision
for purchasing specialist diabetes-related footwear within the facility, and the surgeons’
attitude and degree of care and concern for patients are also facilitators.
3.4.3. Potential Facilitators
Emerging technologies [33] such as laser Doppler flowmetry, elastography, infrared
thermography, plantar pressure, and pressure gradient system for DFUs, as well as other
rehabilitation modalities such as off-loading devices and electrotherapy, might be useful.
Also available are foot care education experts in addition to podiatric doctors to give
information and instruction to patients. Furthermore, as indicated in [34], health education
on diabetes by school instructors would have a significant influence on the awareness
of diabetes as a disease, as well as its prevention and treatment, which would enhance
the result of diabetes-related complications. During a pandemic, digital/virtual diabetes
clinics [35] potentially enhance diabetes-related foot care outcomes.
Monitoring self-care activities by delivering automated SMS reminders to examine the
foot regularly will also be helpful. Healthcare on the go, such as mHealth [36], might be
investigated because it has been demonstrated to be possible and acceptable. Identifying
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patients who might serve as foot care education specialists would improve diabetes-related
foot outcomes [37,38]. The authors reported using a non-invasive and non-contact screening technology, such as an infrared thermal image-based diagnostic system, as part of
their larger investigation [15,16]. Infrared thermography and visual systems are used in
remote monitoring systems to save time and travel, as documented in [39]. Rural foot care
camps are being organized. Rehabilitation and mental therapy are provided to impacted
individuals. In addition, new specialist foot care clinics with suitable resources could be
established in surrounding rural regions.
3.5. Strength and Limitations of the Study
This is the first population-based research on diabetes-related foot care practices in
metropolitan Bengaluru, conducted in partnership with the center by an external contributor. It discusses foot examination and management strategies, as well as the prevalence of
diabetes-related foot and associated problems. The study also examines the challenges and
enablers of good foot care. The findings of this study indicate that excellent practices and
foot care education lower the occurrence of diabetes-related foot problems.
A high-sample-size investigation is required for more exact results. Recent global
developments warrant a targeted investigation on the effect of the COVID-19 pandemic on
foot care practices in order to identify further gaps and requirements that might bring more
value to this research. Surprisingly, the influence of COVID-19 on the treatment and care of
diabetes and its consequences described by Raman et al. [40] likewise shows comparable
obstacles to those presented here.
Although our study provides valuable insights into the topic, caution should be taken
when applying the findings to other populations or settings. Further research is needed to
confirm the results and explore potential differences across populations.
4. Conclusions
According to the algorithm for “prevention of diabetes mellitus and diabetes-related
foot” [41,42], our study identifies as barriers a lack of awareness, neglect of self-care and
socioeconomic status, limited resources to cater to an increasing number of patients, and
difficulty accessing facilities from rural areas. The presence of highly skilled surgeons and
nurses with the correct mindset, as well as the center’s amenities under one roof, proved
to be the most effective and supporting facilitators. An important finding from this study
is that, even 20 years after Viswanathan’s [38] study, the necessity and implementation of
foot care must be reaffirmed and improved to ensure a reduction in risk of deterioration.
Significantly, the retention rate of foot care education is lower, which is a highly hopeful
feature that underlines the importance of improving foot care education and monitoring to
minimize the prevalence of DFUs. Patients who took diabetic foot education seriously had
a decreased risk of lower-limb amputation evident from the statistical test results.
DPN, corns or calluses, previously treated foot ulcers, diabetic retinopathy, cardiovascular disease, and diabetic nephropathy are among the numerous consequences. This is
consistent with research that found a strong association [24] between knowledge score and
gender, diabetes duration, employment, level of education, place of residence, having DFU,
hospital stay history, and amputation history.
Our analysis found 18.9% of the participants to be part of the very-high-risk group.
This shows that the institute is quite good at addressing ‘at-risk’ patients such that they
do not develop diabetic foot ulcers (DFU is 6%). Alternative means of assessment and
remote monitoring, which need patient involvement, might be viewed as a way forward to
avoid/bypass some of the hurdles stated. This study also asks for a government push to
establish additional such institutes in distant locations, as well as to hold mobile awareness
camps to highlight the underappreciated importance of foot care.
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Author Contributions: Conceptualization, S.B.G., U.V. and P.B.; methodology, S.B.G., U.V., J.M.S.
and P.B.; software, S.B.G.; validation, J.M.S., S.M.A., C.H.C., M.L.B. and M.Y.S.; formal analysis, S.B.G.
and U.V.; investigation, S.B.G., U.V. and P.B.; resources, S.B.G., U.V. and M.Y.S.; data curation, S.B.G.;
writing—original draft preparation, S.B.G.; writing—review and editing, S.B.G., U.V., P.B., S.M.A.,
M.L.B. and J.M.S.; supervision, U.V. and P.B.; project administration, C.H.C. and S.M.A. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Ethics Committee of Karnataka Institute of
Endocrinology and Research (Approval No: IEC-KIER/10/28.10.2017).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The datasets created or analyzed at the Karnataka Institute of Endocrinology and Research (KIER) for the current study are not publicly available because they contain
information that could jeopardize ongoing research and compromise participants’ privacy or consent,
but are available from the corresponding author on reasonable request.
Acknowledgments: B.M.S. College of Engineering supported this study by providing an infrared
camera which was pivotal for the research under the Technical Education Quality Improvement
Programme (TEQIP-III) of the MHRD, Government of India.
Conflicts of Interest: The authors declare no conflict of interest.
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