Department of Public Health and Caring sciences

Section of Caring Science

Knowledge and practices regarding foot care

among patients with Type 2 diabetes in Ho Chi

Minh City, Vietnam

A quantitative study

Authors: Supervisor:

Sofia Hellenberg Pranee Lundberg

Stina Thunberg Co- supervisor:

Nguyen Thi Phuong Lan

Examiner:

Clara Aarts

Thesis in Caring Sciences 15 ECTS credits

The Bachelor Programme of Science in Nursing 180 ECTS credits, 2013

1

ABSTRACT

Introduction: Previous research shows that knowledge and practice was low in type 2

diabetes patients and that women had better practice/self-care than men.

Aim: The aim of this study was to investigate the knowledge and practices regarding foot-

care among patients with type 2 diabetes in Ho Chi Minh City, Vietnam, and also investigate

if there was any difference between genders in knowledge and practicing of foot care.

Method: This study was a descriptive and cross-sectional design with quantitative method.

The data was collected at the out-patient clinic of the University Medical Center in Ho Chi

Minh City, Vietnam and 100 patients participated voluntarily to answer questionnaire. Orem’s

self-care theory was used as theoretical framework. Data were analysed by using statistics.

Result: The result shows that more than 70% of the patients had good knowledge of foot care

and no significant differences between the genders in the knowledge. Their foot care practices

were various. There was significant difference between men and women about using a hot

water bottle or heating pad on the feet, and more women than men did. For type of shoes,

there were differences between genders in wearing broad, round toes and shoes made of

leather or canvas, and more men than women did.

Conclusion: The knowledge of foot care was good, but the practice of foot care was low.

There was not found any significant difference between the genders in knowledge, but some

differences in the foot care practices. More information about foot care is needed to prevent

complications with type 2 diabetes.

Key words: Diabetes Mellitus, Knowledge, Foot Care, Gender, Ho Chi Minh City

2

SAMMANFATTNING

Introduktion: Tidigare forsknings resultat visar att kunskapen om egenvård och utförande av

fotvård hos patienter med diabetes typ 2 var låg. Kvinnorna var dock bättre på att utföra

egenvården än männen.

Syfte: Syftet med denna studie var att undersöka kunskapen och utförandet av egenvård hos

patienter med diabetes typ 2 i Ho Chi Minh City, Vietnam, samt att undersöka om det fanns

några skillnader mellan män och kvinnor i kunskapen om egenvård inom fotvård samt dess

utförande.

Metod: För att undersöka detta gjordes en kvantitativ tvärsnittsstudie med hjälp av enkäter.

Det var 100 patienter på en mottagning vid University Medical Center, Ho Chi Minh City,

Vietnam, som deltog frivilligt. Orems egenvård teori användes som teoretiskt ramverk i detta

arbete. Data analyserades av statistik.

Resultat: Resultatet i denna studie påvisar att mer än 70 % av patienternas visade god

kunskap och inga signifikanta skillnader fanns mellan kvinnor och män gällande

kunskapsnivån. Utförandes av fotvården visade sig dock vara varierande och det fanns

signifikanta skillnader mellan kvinnor och män gällande fotvården. Kvinnor använde sig

oftare av varma pads och flaskor på deras fötter än vad männen gjorde. Kvinnor och män

använde också olika typer av skor. Männen använde oftare breda skor med rundad tå, skor av

läder eller canvas skor än vad kvinnorna gjorde.

Slutsats: Kunskapen om fotvård hos diabetes patienter i Ho Chi Minh City var god, dock var

utförandet av fotvården varierande i denna studie. Det visades ingen signifikant skillnad

mellan kvinnor och män angående kunskapsnivån, dock fanns det skillnader angående

utförandet av fotvården. Det behövs fortsatt information om fotvård för att patienter med typ 2

diabetes ska förhindra komplikationer

Nyckelord: Diabetes Mellitus typ 2, Kunskap, Fotvård, Kön, Ho Chi Minh City

3

CONTENTS

1. Introduction 5

1.1 Type 2 diabetes mellitus 5

1.2 Prevalence of type 2 diabetes in the world 5

1.3 Type 2 diabetes in Vietnam 6

1.4 Risk factors 6

1.5 Complications 6

1.6 Foot ulcer 7

1.7 Self-care and treatment of diabetes 8

1.8 Knowledge about diabetes and foot care in type 2 diabetes patients 9

1.9 Practice of foot care in type 2 diabetes patients 10

2. Theoretical framework 11

3. Rationale of research 12

4. Aim 12

5. Research questions 12

6. Methods 13

6.1 Design 13

6.2 Settings 13

6.3 Sample 13

6.4 Data collection method 16

6.5 Procedure 16

6.6 Data analysis 17

7. Ethical considerations 18

4

8. Results 18

8.1 Demographic information 18

8.2 History of foot problems 19

8.3 Current foot or leg problems 19

8.4 Knowledge of foot care 19

8.5 Foot care practice 20

8.6 Foot care education 24

9. Discussion 25

9.1Results discussion 26

9.1.1 Knowledge of foot care among the patients with type 2 diabetes 26

9.1.2. Foot care practices among patients with type 2 diabetes. 26

9.1.3. Difference between genders in knowledge and practice of foot care 27

9.2 Method discussion 28

9.3 Theoretical framework discussion 29

9.4 Clinical implication 30

9.5 Further research study 30

9.6 Acknowledgement 31

10. References 32

Appendix 1 Questionnaire 36

5

1. INTRODUCTION

1.1 Type 2 diabetes mellitus

Type 2 diabetes is a chronic disease that develops when the pancreas does not produce enough

insulin, or when the body is unable to use the insulin it produces effectively. The hormone

insulin is regulating the blood sugar. If the blood sugar is too high over a long time it can lead

to serious damage on the body’s systems, especially the blood vessels and nerves (World

health organization, [WHO] 2013). Type 2 diabetes develops when the body fails to use its

own insulin. The most common reason is high body weight and/or inactivity (Almås, 2001).

Symptoms of type 2 diabetes are increased urination, thirst and fatigue mentally and

physically. Some people also get bad eyesight. The symptoms often develop very slowly and

some people do not get any symptoms at all, which makes it difficult to defect the disease

(FASS, 2011). The patient can be diagnosed in three ways: glycosylated hemoglobin test,

fasting glucose and oral glucose test. After the diagnosis is determined the patient have to do

home monitoring and do regular check up’s at the local nurse (Heart, 2012).

1.2Prevalence of type 2 diabetes mellitus in the World

About 347 million people around the world have diabetes and 90 % of the affected have

diabetes type 2 (WHO, 2013). In 1980 the prevalence of people with diabetes was 153 million

in the world. Reasons for the increase of type 2 diabetes are obesity, inactivity, urbanization,

adverse dietary and that people get older (Maruthur, 2013). The biggest increase is in Asia,

Middle East and in America (Insulin, 2011). Type 2 diabetes occurs in both high- and low-

income countries. However, the low-income countries are bearing the majority of the burden.

Increased supervision of the diabetes contributed to an increased prevalence of diabetes in

high income countries (Maruthur, 2013).

The prevalence of type 2 diabetes varies across regions. In 2008 the prevalence of diabetes

was highest in Oceania (>15 %). The lowest prevalence of diabetes was in the high-income

region of North America and of Asia-pacific region. Australia and Western Europe had also a

low prevalence (Maruthur, 2013). Globally more than 60 % of people with diabetes is in

Asian countries. The prevalence of diabetes and impaired glucose tolerance are high in all

Asian countries and are expected to increase further (Ramachandran, Snehalatha, Samith-

Shetty & Nanditha, 2012).

6

1.3 Type 2 diabetes in Vietnam

Type 2 diabetes is on it is rise in Vietnam. In 2000 the prevalence of people with diabetes in

Vietnam was 792,000 (WHO, 2000). In 2012 experts believed that approximately two million

people had diabetes in Vietnam. About 60 % of them are unaware of their condition and

remain undiagnosed (WHO, 2012). In 2004 the prevalence of type 2 diabetes was 3.8% in Ho

Chi Minh City, Vietnam. The people in Ho Chi Min City with a high level of education had a

lower prevalence of type 2 diabetes, compared to people with lower level of education (Duc

Son et al., 2004). In 2008 almost seven percent of the adults in age 30 – 69 years had diabetes

in Ho Chi Minh City (WHO, 2012).

1.4 Risk factors

Type 2 diabetes is a common disease which usually affects older people, however it is

beginning to be more common in younger ages. The disease often develops gradually and can

be inherited, but it can also be due to the lifestyle (Almås, 2001). A “key” risk factor for

developing type 2 diabetes is overweight and obesity. Other risk factors are ageing, genetics,

previous gestational diabetes and family history of type 2 diabetes (Mc Naughtun,

2013). Physical inactivity, stress and smoking are also risk factors for type 2 diabetes (Almås,

2001). In the study of Tomisaka et al. (2002) about risk factors for type 2 diabetes among

Asian women, they found that Vietnamese women were at high risk to develop type 2

diabetes because of their high obesity levels and their carbohydrate intake was higher than the

other Asian women in the study.

1.5 Complications

In 2004 three - four million people around the world died in complications of high blood

sugar and 80% of the deaths due to diabetes occur in low- and middle-income countries. In

the next ten years they are projected to rise about 50 % (WHO, 2013). High blood sugar

during a long time can results in a lot of complications for the patient. The acute

complications of diabetes mellitus are hyperglycemia, hypoglycemia and ketoacidosis.

Chronic complications of diabetes mellitus are angiopathy. This complication can give

cerebrovascular, cardiovascular, peripheral vascular disease, retinopathy, blindness,

7

neuropathy and nephropathy. Neuropathy means that the nerves are damaged, which affects

the sensitivity in the hands, feet or both, but it can also give the patients tingling, burning

and/or tearing in the outer extremity. This can lead to ulcers in the lower extremity. Diabetic

patients are also more susceptible to infections than other patients (Brown & Edwards. 2005).

1.6 Foot ulcers

Foot complications are common in type 2 diabetes patients. Diabetes may cause nerve

damage that can take away the feeling in the feet, which can make the patients unable to feel

stones in their shoes or blisters on their feet. The blood circulation to the feet can also be

reduced which can make it difficult for ulcers on the feet to heal. This complication can lead

to an infection or a non-healing ulcer, and in the worst case it can lead to amputation

(American College of Foot and Ankle Surgeons, [ACFAS] 2009). Sensory neuropathy and

peripheral vascular disease is the main reason for foot ulcers but also clotting abnormalities,

immune functions, smoking and neuropathy play an important role. Peripheral vascular

disease make it hard for the nutrition and oxygen to get to the ulcer making it hard for it to

heel and in the worst case it can lead to amputation (Brown and Edwards, 2005). Diabetic foot

ulcers can also have negative psychological and social effects. For example it can lead to

reduced social activities and employments. It can also have negative effects on the diabetes

patient mental health and at the relationship to family and friends (Goodridge, Trepman &

Embil, 2005).

In Fuller (2013) it is found that amputation related to foot ulcer is very common in Vietnam

and creeps lower in age. It often starts with a small scrape and develops to a hard treated

ulcer. The doctors believe that foot ulcers in type 2 diabetes patients are very common in

Vietnam because of lack of wearing shoes to protect their feet. It is more common to use

sandals, go barefoot or have flip-flops which do not protect the foot. The doctors in Ho Chi

Minh City mean that the situation in Vietnam is severe, however, it cannot be more specific

because it is a lack of data about diabetes and foot care which have been analyzed. One of the

doctors in Ho Chi Minh City said that it is getting worse every day and a pandemic is coming

in a few years. Diabetes is a result from a new urban lifestyle, no exercise, migration from the

countryside to the big cities and working in factories instead of the fields, but the normal

patient in Vietnam is not obese. They also point out that the symptoms emerges gradually, so

8

it is common to have the disease without knowing for many years, especially where health

care systems are rudimentary.

1.7 Self-care and treatment of diabetes

The primary treatment of type 2 diabetes is self-care because it improves the patients’ health

and prevents complications. Many of the risk factors can be prevented with changes of

lifestyle for people with high risk (Marques, Silva, Coutinho & Lopes, 2013). The lifestyle

changes involve eating healthy food, loss in weight for people with obesity, regular exercises,

foot care and meetings with health care providers regularly. The patients have to learn about

the disease, self-monitoring the glucose and how the treatment works (Almås, 2001). The

self-care is a partnership between the patient and the health care provider. The health care

provider gives information of self-care and mentoring in self-care to let the patient perform it

(Marques et al., 2013).

The health care provider’s education for the diabetes patient is important for their self-care of

the disease. If the information to the patient is not clear, the patient can forget it or may not

understand it, the patient can also miss out important facts. This can cause lack of the self-

care or ignorance of the healthy lifestyle for the patient (Tham, Ong, Tan &How, 2004).

Increased participation in decision-making about diabetes care is associated with an

increasing understanding of self-care in diabetes (Quinn et al., 2011). The competence of self-

care can decrease in elderly age. Marques et al. (2013) found that very few (6 %) of the

elderly with type 2 diabetes had the competence to provide their self-care. Low level of

education and bad eyesight was contributing factors and this group needs more help and

instruments for performing their self-care.

Medication may be needed if blood glucose is not adequately controlled with the primary

treatment. The aim of treatment is to lower the blood glucose levels and reduce the risk of

complications. Preventive measures to prevent foot problems should begin immediately after

diabetes diagnosis is established (Almås, 2001).

Mull, Nguyen and Mull (2001) found that many Vietnamese people used herbal medicine to

treat their type 2 diabetes. They thought herbal medicine was much safer than Western

medicine because herbal medicine cools the body and brings it back into balance, but if herbal

medicine did not work they would consider Western medicine. Three-quarters of the

9

Vietnamese patients have not achieved a good control of their diabetes and one reason is that

they do not have knowledge of how the insulin works and about their disease. There was a

strong aversion to use insulin injections among the Vietnamese people because the needle was

painful, the insulin created an imbalance in the body, gave blindness, was addictive and the

insulin showed that a person was seriously ill and had a chronic disease. In Helman (2001),

Vietnamese in USA and England said that their diabetes has their roots in psychological

emotions, like feeling sad and being stressed. They also thought the weather could be the

reason of their symptoms. They explained their disease with imbalance between the “hot” and

“cold” substance in their body. They thought that insulin is a “hot” substance and could lead

to substance illness; therefore, they prefer to use traditional Chinese medicine and herbs.

1.8 Knowledge of diabetes and foot care in Type 2 diabetes patients

The study of Pollock, Unwin & Connolly (2004) showed that the type 2 diabetes patients

knowledge was low. Those with high risk generally had better knowledge than the patients

that had lower risk for foot complications and amputation. Females had higher knowledge

than the males. The patients who had received information or advice previously had better

knowledge. Also the patients in the study of Khamseh, Vatankhah & Baradaran (2007) had

low knowledge about foot care practice. The patients who had a history of diabetes in ten

years or more had better knowledge about foot care practice than those who had diabetes less

than ten years and 70 % of the patients said that they had not received advice or information

about foot care.

Khamseh et al. (2007) and Quinn et al. (2011) showed that the type 2 diabetes patients with

higher education had better knowledge than those with lower education. Quinn et al. (2011)

also described that the patients with lower education needed more information about their

diagnosis. Tham et al. (2004) found that people with type 2 diabetes, which have been

educated in diabetes, have better knowledge about the disease and in changing practices in

their self-care. In addition, Kavanagh et al. (2010) found that lower education and income are

associated with higher levels of glucose, waist circumference and blood pressure when

compared to people with higher education and income. Kafaie., Rashidi., Sedigheh

Soheilikhah &Taghi (2004) investigated self-care among patients with type 2 diabetes and

helped them by training in self-care for diabetic ulcers. The results showed that the patients

10

had inadequate knowledge about foot-care. After completing the training most of the patients

(85 %) had sufficient information to be able to perform proper self-care of their own feet.

1.9 Foot care practice

Foot care is important for preventing foot ulcers among type 2 diabetes patients. The patients

have to inspect their feet daily and check for cuts, redness, blisters, swelling or nail problems

(ACFAS, 2009). They shall wash their feet daily with warm water and a mild soap, but it’s

important to test the water temperature before washing the feet. Finally the patients shall dry

their feet and especially between the toes (Brown & Edwards, 2005). The patient will use a

moisturizer after bath, but not between the toes because that could encourage a fungal

infection. The patients shall cut the nails straight across and file the edges and wear clean, dry

socks and change them daily and keep the feet dry and warm (ACFAS, 2009). Use warm

water and mild soap when cleaning the cuts on the feet and cover with clean dressing and

separate overlapping toes with cotton. The patient has to report skin infections or non-healing

sores to health care provider immediately. Avoid prolonged sitting, standing and crossing of

legs (Brown & Edwards, 2005). The patient shall not walk barefoot because the patient can

step on something or get a cut in the foot (ACFAS, 2009). The patient shall avoid open-toe,

open-heel and high-heel shoes. Leather shoes are preferred before plastic ones. Shake the shoe

before putting it on (Brown & Edwards, 2005).

Several studies have shown that the practice of good foot care is very low (Pollock et al.,

2004; Khamseh et al., 2007;Bhupendra, Anand, Sangram, Dilip & Ravinder, 2008). In the

study of Pollock et al. (2004) 83% of the patients failed to inspect their feet. Khamseh et al.

(2007) found that it was 60% who failed to inspect their feet and 42 % did not trim their nails.

Also the patients in the study of Bhupendra et al. (2008) did not inspect their feet in the right

way and 76,4 % did not wash their feet properly and 56,4 % walked barefoot outside and

inside.

In practice of foot care it showed that there was a difference between those with high

education and those with lower, but no difference in how long the patients have had type 2

diabetes. It was 70 % of the patients did not wear footwear after the hospitals guidelines

(Khamseh et al., 2007). The attitude regarding self-care of diabetic patients with foot ulcers

may be different for men and women. Women were more active in self-care and preventive

care and they searched for more information and tried to adapt to the situation. Men searched

11

more health care for acute foot ulcers problem. They showed a passive attitude and had a

more pessimistic view of the future (Goodridge et al., 2005).

2. THEORETICAL FRAMEWORK

Dorothea Orem´s theory of self-care and self-care deficit was used as theoretical framework

for this study. The theory highlights the importance of self-care and the goal is normal

function, development, health and well-being. The theory is based on two key concepts, self-

care and self-care deficit. The first key-point (self-care) is based on why and how people care

for themselves and the second key-point (self- care deficit) describes and explains why people

can be helped through nursing and a nurse.

Self-care depends on the health of the person, interest for maintaining living, function, well-

being etc. Self- care is affected by age, unable to perform the self-care well-being and interest

of performing the self-care that is needed

The nurse have to identify five methods to help the patient

“ Acting for or doing for another”

“Guiding and directing”

“Providing physical or psychological support”

“Providing and maintaining an environment that supports personal development”

“Teaching”

(Alligood & Tomey, 2009).

Dorothea Orem means that nursing-care is needed when the patient is affected of limitations

which make it difficult to practice their self-care of example on their feet. The nursing care

will give possibility for the patient to regain the capacity of self-care (Kirkevold, 2000).

Therefore, this theoretical framework was used to investigate if the patients with type 2

diabetes have the capacity to take care of their own feet.

12

3. RATIONALE OF RESARCH

In Ho Chi Minh City, type 2 diabetes has become more common and the disease is expanding

fast. Important determinants of the increased prevalence of the disease are industrialization,

development with sedentary lifestyles and shift of dietary habits with much carbohydrate

(Duc Son et al., 2004). Foot ulcers are complications due to diabetes, and foot-care is an

important prevention measure that should be concurrently started with the settling of the

diabetes diagnoses (Almås, 2001). High level of education increased the degree of self-care

and understanding of their diabetes diagnosis which makes it important to inform the patients

with diabetes (Tham et al., 2004). To prevent foot ulcers among type 2 diabetes patients in Ho

Chi Minh City, it is important to find out what their knowledge is and practice of foot care

and investigate if there are some differences between the genders regarding knowledge and

practice in foot care. The results of this study will provide more information in order to

develop an appropriate intervention program concerning foot care.

4. AIM

The purpose of this study was to investigate the knowledge and practices regarding foot-care

among patients with type 2 diabetes in Ho Chi Minh City, Vietnam.

5. RESEARCH QUESTIONS

1. What knowledge about foot care do the patients with Type 2 diabetes have?

2. How have they practiced their foot care?

3. Is there any difference between the genders regarding knowledge about foot care and its

practice?

13

6. METHOD

6.1 Design

The study was a descriptive and comparative cross-sectional design. This method was chosen

because it is time-effective and provides a lot of data (Eliasson, 2006).

6.2 Setting

The data for the project was collected at the outpatient department at the University Medical

Center, in Ho Chi Minh City, Vietnam. Ho Chi Minh City is set in the south part of Vietnam

and is the largest city in the country. The data was collected during one week in November,

2013. In one day around 150 – 180 patients are visit the outpatient department, 80 % (120 –

140 patients) of them had the diagnose type 2 diabetes. The most common reason for the type

2 diabetes patients to visit the outpatient clinic was to check up their diabetes.

6.3 Sample

A purposive sample was used for selecting the participants. The outpatients who could

participate in the study were the ones that met the inclusion criteria at the diabetic out-patient

clinic during the data collection period. 100 patients were asked to participant in this study

and all of them participated.

The inclusion criteria to participate were:

1. Patients with type 2 diabetes, both male and female, with an age over 18 years

2. They are able to write and read or can be helped to fill in the questionnaire

3. They are living in Ho Chi Minh City in Vietnam

4. They should not have any mental disease or dementia

5. They are willing to participate

14

Demographic information of the type 2 diabetes patients

The total number of patient participated in the study was 100; 32 (32%) men and 68 (68%)

women. The age of the participants was between 32 – 86 years, and the mean age of them was

57.3 years (SD 9.2). The most common education for the women was primary school (35.3%)

while men had secondary school education (28.1%). For men the most common work was

merchant (25.0%) and for women was house duty (32.4%). About 19 (63.3%) of men and 19

(28.4%) of women answered that their income was enough. Three (10%) of men and 16

(28.1%) of women had income less than 2,000,000 VND (= 95 $/month). Of the patients there

were 88 (91.7%) who did not smoke and 83.3 % did not drink alcohol at all. About 32

(32.3%) patients had their diabetes for one year or less and 56 (57.1%) responded that they

did not have a history of diabetes in the family. 49 (49 %) used control diet and medicine to

treat their diabetes and 93 (93.9%) controlled their diabetes regular. See Table 1 a, b.

Table 1a. Demographic information of the patients with type 2 diabetes

Demographic

information

Total (n=100) Male (n=32) Female (n=68)

N % Mean

±SD

N % Mean

±SD

N % Mean

±SD

Gender 100 100.0 32 32.0 68 68.0

Age

31-40

41-59

51-60

61-70

>70

7

15

42

27

9

7.0

15.0

42.0

27.0

9.0

57.34

±

9.29

7

6

10

7

2

21.9

18.8

31.2

21.9

6.2

57.34

±

9.29

0

9

32

20

7

0

13.2

47.1

29.4

10.3

59.76

±

9.29

Marital status

Single

Married

Widowed

Missing

7

78

10

5

7.4

82.1

10.5

3

27

1

1

9.7

87.1

3.2

4

51

9

4

6.2

79.7

14.1

Religion

Catholic

Buddhism

No religion

Other

Missing

10

68

17

4

1

10.1

68.7

17.2

4.0

4

17

10

1

0

12.5

53.1

31.2

3.1

6

57

7

3

1

9.0

76.1

10.4

4.5

Education

Primary school

Secondary school

High school

Secondary level after high

school/College

Bachelor

Other

26

25

22

6

12

9

26.0

25.0

22.0

6.0

12.0

9.0

2

9

7

4

9

1

6.2

28.1

21.9

12.5

28.1

3.1

24

16

15

2

3

8

35,3

23,5

22,1

2,9

4,4

11,8

15

Occupation

Worker

Government officer

Technician

Merchant

Farmer

House duty

Other

1

8

4

28

12

22

25

1.0

8.0

4.0

28.0

12.0

22.0

25.0

1

1

3

8

6

0

8

3.1

18.8

9.4

25.0

18.8

0.0

25.0

0

2

1

2

6

22

17

0.0

2.9

1.5

29.4

8.8

32.4

25.0

Children

No

Yes, 1 – 2

Yes, 3 – 5

Yes, >6

11

34

40

15

11.0

34.0

40.0

15.0

5

15

10

2

15.6

46.9

31.2

6.2

6

19

30

13

8.8

34.0

40.0

15.0

How many people who are living

at home

0

1 – 2

3 -5

>6

2

30

51

17

2.0

30.0

51.0

17.0

1

8

18

5

3.1

25.0

56.0

15.6

1

22

33

12

1.5

32.4

48.5

17.6

Income

Enough

Barley enough

Totally inadequate

Missing

38

47

12

3

39.2

47.4

13.4

19

8

3

2

63.3

26.7

10.0

19

38

10

1

28.4

56.7

14.9

Table 1b. Demographic information (continue).

Demographic

information

Total (n=100) Male (n=32) Female (n=68)

N % Mean

±SD

N % Mean

±SD

N % Mean

±SD

Income per month (VDN)

<1.999.999

2.000.000 – 5,000 000

5.000.001 – 10.000 000

10. 000 001 – 15.000 000

> 15. 000 0001

Missing

19

38

14

6

10

13

21.8

43.7

16.1

6.9

11.5

3

11

5

4

7

2

10.0

32.7

16.7

13.3

23.3

16

27

9

2

3

11

28.1

47.4

15.8

3.5

5.3

Smoking

No

Yes, 1 – 5 cigarettes/day

Yes 6 – 10 cigarettes/day

Missing

88

2

2

8

91.7

2.1

2.1

4.2

23

2

2

5

74.2

6.5

6.5

12.9

65

0

0

3

100.0

0.0

0.0

Drinking alcohol. Glas/day.

No

Yes, 1 – 2 glas/day

Yes, 3 – 5 glas/day

Yes, 6 or more

Missing

80

13

2

1

5

83.3

13.5

2.1

1.0

16

12

2

1

2

51.6

38.7

6.5

3.2

64

1

0

0

3

98.5

1.5

0.0

0.0

Years living with diabetes

0 - 1 year

2 – 3 years

4 – 5 years

5 – 7 years

8 – 10 years

>10

Missing

32

19

15

6

11

16

1

32.3

19.2

15.2

6.1

11.1

16.2

12

6

3

2

2

6

1

38.7

19.4

9.7

6.5

6.5

19.4

20

13

12

4

9

10

0

29.4

19.1

17.6

5.9

13.2

14.7

16

Family History with diabetes

No

Yes

Missing

56

42

2

57.1

42.9

17

15

0

53.1

46.9

39

27

2

59.1

40.9

Treatment of diabetes

Control diet

Take medicine

Inject insulin

Other

Control diet and medicine

Take medicine and inject insulin

Control diabetes and inject insulin

Control diabetes, take medicine and

inject insulin

2

24

2

1

49

9

2

11

2.0

24.0

2.0

1.0

49.0

9.0

2.0

11.0

0

11

0

1

13

4

0

3

0.0

34.4

0.0

3,6

40.6

12.5

0.0

9.4

2

13

2

0

36

5

2

8

2.9

19.1

2.9

0.0

52.9

7.4

2.9

11.8

Regular follow up diabetes

treatment

No

Yes

Missing

6

93

1

6.1

93.9

3

29

0

9.4

90.6

3

64

1

4.5

95.5

Help with diabetes at home

Wife/husband

Children

My relative

No one

Wife/husband and children

Other

15

11

3

60

4

7

15.0

11.0

3.0

60.0

4.0

7.0

5

2

2

18

3

2

15.6

6.2

6.2

56.2

6.2

9.4

10

9

1

42

4

2

14.7

13.2

1.5

61.8

5.9

2.9

6.4 Data Collection Method

A questionnaire in English has been developed by Dr. Pranee Lundberg, Associate Professor,

at the Department of Public Health and Caring Sciences, Uppsala University and Ms Nguyen

Thi Phuong Lan, Nursing Lecturer, at the Department of Nursing, University of Medicine and

Pharmacy in Ho Chi Minh City (Appendix 1). The questionnaire was based on literature

(Bijoy et al., 2012; Pollock et al., 2004) and also adjusted to Vietnamese culture. The

questionnaire was translated to Vietnamese and then it was translated back and forth for face

validity of the questionnaire. The questionnaire was pilot tested by our co- supervisor Nguyen

Thi Phuong Lan in Ho Chi Ming City, before data collection.

The questionnaire consists of 46 questions which are divided into three parts: (1) Background,

(2) Knowledge of foot care and (3) Foot care practice including foot care education. The first

part in the questionnaire is divided into A, B and C part. The A part is about the participants’

demographic background such as age, gender, education, family, smoke and alcohol habits.

The B part is about the participant´s foot problem history and C part is questions about foot

and leg problem. The second part is about knowledge of foot care. Finally, the last part is

about how to practice foot care including foot care education.

17

6.5 Procedure

The project was the collaboration between the Department of Public Health and Caring

Sciences, Uppsala University, Sweden and the University of Medicine and Pharmacy in Ho

Chi Minh City, Vietnam, by Linnaeus-Palme Exchange Programme.

Our Co- supervisor, Nguyen Thi Phuong Lan, contacted the Director of the Medical Centre

for permission to carry out the study. The nurses at the clinic were informed about the study

and helped us to give information to the patients with type 2 Diabetes. The participants were

informed about the study and their rights to participate. The co-supervisor together with the

authors gave both oral and written information to the outpatients at the diabetes clinic about

the study and their right for participation. The patients who were interested to participate

received a questionnaire to answer during the waiting time at the clinic. The patients gave it

back after finishing. If some patients had problem to fill in the questionnaire or had questions

during answering the questionnaire, Ms. Nguyen Thi Phuong Lan and a few Vietnamese

lecturers helped the participants to fill in the questionnaire. It took around 15 – 20 minutes to

answer the questionnaire.

6.6 Data analysis

Analysis of data from the questionnaire was done using the statistic program, SPSS (The

Statistical Package of Social Science).

The answers about demographic information in Part I, A (questions 1 – 17) was coded into

numbers and then registered in the SPSS-program using descriptive statistic.

The B and C part (Questions 18 – 23) in Part one were based on a nominal scale and we used

numbers and percent to investigate the participant’s history of foot problems and current foot

problems.

To analyze research question 1, “What knowledge about foot care do the patients with Type 2

diabetes have?”, we analyzed the answers in part two about Knowledge (Question 25) with

numbers and percent. In part II the participant could answer true or false of 15 questions. The

“True” answer of all questions is the right answer. Fifteen questions were regarding

knowledge about foot care. Each correct answer was given one mark. Good knowledge: If

18

score is more than 70% (11-15), Satisfactory knowledge: If score is 50-70% (10-8), and Poor

knowledge: Scores less than 50% (<8)(Bijoy et al., 2012).

To analyze the research question 2, “How have they practiced their foot care?”, we analyzed

the answers in part III about practice (Questions 26 – 46) with numbers and percent.

To answer research question three, “Is there any difference between the genders regarding

knowledge about foot care and its practice?”, we analyzed the answer in part two about

knowledge (Question 25) and the answers in part three about practice (Questions 26 – 46) by

using Chi squared test.

The significant difference between men and women has a determined p-value ≤0.05. The

results were presented by using tables and text.

7. ETHICAL CONSIDERATIONS

The study has got approval from the ethical committee at the University of Medicine and

Pharmacy in Ho Chi Minh City. The participants were informed about the study and their

rights before they participated in the study. It was anonymous and voluntarily to participate

and the data was analyzed confidently. The participants could drop out any time without any

consequences. The International Council of nurses (ICN) code of ethics for nurses (2012) was

used in this study for ethical considerations concerning respect for customs, values and beliefs

for the individual, family and community and respect for the human rights. During the data

collection it was important to let the participant fill in the questionnaire in seclusion, because

the questionnaire could have some private questions.

19

8. RESULTS

8.2 History of foot problems

About 85 (85%) of the participants answered that they never have had a foot ulcer and 87

(87.9%) have never had a sore or cut on the leg or foot that took more than two weeks to heal.

Only one (1%) answered that they had amputated a leg or foot.

8.3 Current foot or leg problems

About 96 (96%) of the patients reported that they did not have an ulcer, sore or blister on the

feet at this moment. 58 (58%) answered that they had numbness, tingling, pins, needles or

itching on their feet.

8.4 Knowledge of foot care

Of the participants 74 (74%) had good knowledge about foot care. There was no significant

difference between men and women about knowledge of foot care (p>0.05).See Table 2.

Table 2. Knowledge of foot care, score test

Knowledge of foot care Total

(N=100)

N %

Men

(N=32)

N %

Women

(N=68)

N % >70 % Good knowledge

(11- 15 right). 74 74.0 22 68,8 52 76.5

50 – 70 %, Satisfactory

knowledge (8-10 right).

18 18.0 7 21.9 11 16.2

< 50 % Poor Knowledge

(Less than 8 right).

8 8.0 3 9.4 5 7.4

P-value = 0.712, X2 = 0.679

Note: p≤0.05 = significant difference.

For each item of the knowledge of foot care, the majority of the patients (>90%) reported that

it is important to take anti-diabetes medication, to wash their feet every day, and to consult

when warning signs had occurred. About 71 (71%) reported that they should use warm water

when they are washing the feet. Most of the patients (>80%) also reported that it is important

20

to dry the feet, to keep the skin soft to prevent dryness, and to inspect the feet´s every day.

Half of the patients reported that they should not apply lotion in the interdigital spaces. There

were no significance differences between genders concerning the items of knowledge of foot

care. See Table 3.

Table 3.Knowledge of foot care among the patients with type 2 diabetes.

Knowledge of foot care Total (n=100) Male (n=32) Female (n=68) X2 p-value

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

Importance of taking anti-

diabetes treatment to

prevent complication

5

(5.0)

95

(95.0)

2

(6.2)

30

(93.8)

2

(6.2)

65

(95.6)

0.155 0.694

Daily washing the feet 4

(4.0)

96

(96.0)

2

(6.2)

30

(93.8)

2

(2.9)

66

(97.1)

0.620 0.431

Using warm water for

washing/bathing

29

(30.0)

71

(70.0)

12

(37.5)

20

(62.5)

17

(25.0)

51

(75.0)

0.651 0.199

Checking temperature of

water before using

37

(37.0)

63

(63.0)

13

(40.6)

19

(59.4)

24

(35,3)

44

(64,7)

1.625

0.607

Drying the feet after

washing

15

(15.0)

85

(85.0)

6

(18.8)

26

(81.2)

9

(13.2)

59

(86.8)

0.519

0.471

Talcum powder usage for

keeping interdigital spaces

dry

54

(54.0)

46

(46.0)

21

(65.6)

11

(34.4)

33

(48.5)

35

(51.5)

2.560

0.110

Keeping skin of the feet

soft to prevent dryness

16

(84.0)

84

(84.0)

5

(16.0)

27

(84.0)

11

(16.2)

57

(83.8)

0.005 0.944

Lotion not to be applied to

the interdigital spaces

50

(50.0)

50

(50.0)

15

(46.9)

17

(53.1)

35

(51.5)

33

(48.5)

0.184) 0.668)

Daily changes of socks 26

26.0)

74

(74.0)

10

(31.2)

22

(68.8)

16

(23.5)

52

(76.5)

0.674 0.412

Trimming nails of feet

straight with care

9

(9.0)

91

(91.0)

5

(14.6)

27

(84.4)

4

(9.0)

64

(91.0)

2.522 0.112

Inspection of feet once a

day by yourself

17

(17.0)

83

(83.0)

4

(14.6)

27

(84.4)

44

(17.6)

56

(82.4)

0.063 0.802

Wearing comfortable coat

shoes

9

(9.0)

91

(91.0)

1

(3.1)

31

(96.9)

2

(2,9)

66

(97.1)

0.003 0.960

Checking the shoes from

inside before wearing

15

(15.0)

85

(85.0)

5

(15.6)

27

(84.4)

10

(14.7)

58

(85.3)

0.014 0.901

Not walking bare foot 13

(13.0)

87

(87.0)

2

(6.2)

30

(93.8)

11

(16.2)

57

(83.8)

1.896 0.169

Warning signs for which

consultation is required

5

(5.0)

95

(95.0)

3

(9.4)

29

(90.6)

2

(2.9)

66

(97.1)

1.896 0.168

Note: p≤0.05 = significant difference.

8.5 Practice of foot care

There was a significant difference between men and women concerning the use of hot water

or heating pads on their feet (p=0.002).10 (14.7%) women used it on their feet and no men

reported that they did it. Of the participants 90 (90%) reported that they examine their feet and

72 (72.0 %) of them thought that they take care of their feet in a correct way. There were only

9.1 % who used moisturizing cream on their feet. There was 23(43.8%) of women and 5

21

(15.6%) of men who thought that they did not take care of their feet in correct way, but there

was no significant difference between genders. See Table 4.

22

Table 4. Foot care practices among patients with type 2 diabetes.

Foot care practices Total (n=100) Male (n=32) Female (n=68) X2 p-value

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

I can reach and see the

bottoms of my feet

(M=1 woman)

8

(8.1)

91

(91.9)

3

(9.4)

29

(90.6)

5

(5.4)

62

(61.6)

0.107 0.744

I examine my feet?

(M=0)

10

(10.0)

90

(90.0)

3

(9.4)

29

(90.6)

7

(10,3)

61

(89.7)

2.114 0.715

I wash my feet every day

(M=0)

6

(6.0)

94

(94.0)

2

(6.2)

30

(93.8)

4

(5.9)

64

(94.1)

0.005 0.942

Dry my toes

(M= 0)

35

(35.0)

65

(65.0)

12

(37.5)

20

(62.5)

23

(33.8)

33.8

(66.2)

0.129 0.719

I use a moisturizing cream

on my feet

(M=1 man)

90

(90.9)

9

(9.1)

29

(93.5)

2

(6.5)

61

(89.7)

7

(10.3)

0.380 0.537

I cut my own toenails

(M=0)

48

(48.0)

52

(52.0)

18

(56.2)

14

(43.8)

30

(44.1)

38

(55.9)

5.816 0.121

I ever soak my feet

M=1 woman)

78

(78.8)

21

(21.2)

27

(84.4)

5

(15.6)

51

(67.1)

16

(32,9)

0.883 0.347

I always test water

temperature before my

foot in

(M=1 woman)

78

(78.8)

20

(20,2)

27

(87.1)

4

(12.9)

52

(76.5)

16

(23.4)

1.491 0.222

I use medicated products

for warts, corns or calluses

M=0)

93

(93.0)

7

(7.0)

31

(96.9)

1

(3.1)

62

(91.2)

6

(8.8)

1.085 0.297

I put moisturizing creams

or lotions between my toes

(M=1 men)

92

(92.9)

7

(7.1)

29

(93.5)

2

(6.5)

63

(92.6)

5

(7.2)

0.026 0.871

I ever walk around in my

bare feet

(M=1 women)

69

(63.6)

36

(36.4)

21

(65.6)

11

(34.4)

42

(62.7)

25

(37.3)

0.081 0.776

I ever wear shoes without

wearing any socks

M=0)

67

(67.0)

33

(33.0)

20

(62.5)

12

(37.5)

47

(69.1)

21

(30.9)

0.431 0.511

I use a hot water bottle or

heating pad on my feet

(M=0)

90

(90.0)

10

(10.0)

32

(100.0)

0

(0.0)

58

(85.3)

10

(14.7)

5.229 0.002*

I sit with my leg crossed

(M=0)

31

(31.0)

69

(69.0)

9

(28.)

23

(71.9)

22

(32.4)

46

(67.6)

0.182 0.670

I think I have taken care

my feet in correct way

(M=0)

28

(28.0)

72

(72.0)

5

(15.6)

27

(84.4)

23

(43.8)

45

(66.2)

3.575 0.059

Note: p≤0.05 = significant difference., M= Missing, * = significant difference

92 (92%) of the participants used sandals and 37 (37, 0%) used cotton socks. There was a

significant difference between men and women concerning the use of shoes with round toes

(p=0.002). Nine (28.1%) men who used round toes shoes, but only three (4.4%) of the

women. There was also a significant difference between genders in using shoes of leather or

canvas (p=0.000). 11 (34.4%) of the men and two (2.9) women used leather or canvas shoes.

See Table 5.

Table 5.Types of shoes and socks which the patients with type 2 diabetes wear.

23

Types of shoes Total (n=100) Male (n=32) Female (n=68) X2 p-value

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

Pointed toes 90

(95.0)

5

(5.0)

29

(90.6)

3

(9.4)

66

(95.0)

2

(5.0)

1.896 0.168

Broad, round toes 88

(88.0)

12

(12.0)

23

(71.9)

9

(28.1)

65

(95.6)

3

(4.4)

11.587 0.001*

High heels 100

(100.0)

0

(0.0)

32

(100.0)

0

(0.0)

68

(100.0)

0

(0.0)

Sandals 8

(8.0)

92

(92.0)

2

(6.2)

30

(93.8)

6

(8.8)

62

(91.2)

0,196 0.658

Flip flops/thongs 12

(12.0)

88

(88.0)

6

(18.8)

26

(81.2)

6

(8.8)

62

(91.2)

2.030 0.154

Athletic/sneakers/runners 94

(94.0)

6

(6.0)

28

(87.5)

4

(12.5)

66

(97.1)

2

(2.9)

3.525 0.060

Shoes made of leather or

canvas

87

(87.0)

13

(13.0)

21

(65.6)

11

(34.4)

66

(97.1)

2

(2.9)

19.010 0.000*

Types of socks Total (n=100) Male (n=32) Female (n=68) X2 p-value

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

Cotton 63

(63.0)

37

(37.0)

17

(53.1)

15

(46.9)

46

(67.6)

22

(32.0)

1.969 0.161

Wool 99

(99.0)

1

(1.0)

32

(100.0)

0

(0.0)

67

(98.5)

1

(1.5)

0.475 0.491

Acrylic/synthetic 93

(93.0)

7

(7.0)

32

(100.0)

0

(0.0)

61

(87.7)

7

(10.3)

3.452 0.060

Knee highs 100

(100.0)

0

(0.0)

32

(100.0)

0

(0.0)

68

(100.0)

0

(0.0)

Prescription/compression 97

(97.0)

3

(3.0)

32

(100.0)

0

(0.0)

65

(95.6)

3

(3.0)

1.455 0.228

Not know 94

(94.0)

6

(6.0)

29

(90.6)

3

(9.4)

65

(95.6)

3

(4.4)

0.950 0.330

Others 54

(54.0)

46

(46.0)

18

(56.2)

14

(43.8)

36

(52.9)

32

(47.1)

0.096 0.757

Note: p≤0.05 = significant difference, * = significant difference.

8.6 Foot care education

For foot care education the majority of the patients reported that they had not attended a class

in foot care (93%) and that they had not read handouts about diabetes (83%). They (85%) also

reported that they would like to get handouts with information of foot care. There was no

significant difference between genders regarding foot care education. See Table 6.

24

Table 6. Foot care education among patients with type 2 diabetes.

Foot care education Total (n=100) Male (n=32) Female (n=68) X2 p-value

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

I have ever attended a

class on how to care for

my feet

93

(93)

7

(7)

30

(93.8)

2

(6.2)

63

(92.6)

4

(7.4)

0.041 0.840

I have ever read handouts

on foot care

80

(80)

20

(20)

24

(75)

8

(25)

56

(82.4)

12

(17.6)

0.735 0.391

I would like a handout on

how to care for my feet

15

(15)

85

(85)

6

(18.8)

26

(81.2)

9

(13.2)

59

(86.8)

0.519 0.471

Note: P≤0.05 = significant difference, * = significant difference.

Most patients 39 (39%) thought that media was the most effective way for increasing

knowledge and practice of foot care. There was no difference between genders concerning the

opinion about the most effective ways. See Table 7.

Table 7. The opinions of the patients about the most effective way for increasing knowledge

and practice of foot care.

Most effective ways for Total (n=100) Male (n=32) Female (n=68) X2 p-value

increasing knowledge and

practice

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

No

n (%)

Yes

n (%)

Receiving

handout/brochure

65

(65.0)

35

(35.0)

20

(62.5)

12

(37.5)

45

(66.2)

23

(33.8)

0.571 0.752

Health education in group 96

(96.0)

4

(4.0)

30

(93.8)

2

(6.2)

66

(97.1)

2

(2.9)

0.620 0.431

Individual health

education

78

(78.0)

22

(22.0)

24

(75.0)

8

(25.0)

54

(79.4)

14

(20.6)

0.247 0.619

Media such as TV, radio,

etc.

61

(61.0)

39

(39.0)

18

(56.2)

14

(43.8)

43

(62.2)

25

(36.8)

0.446 0.504

Others 93

(93.0)

7

(7.0)

29

(90.6)

3

(9.4)

64

(94.1)

4

(5.9)

0.408 0.523

Note: P≤0.05 = significant difference, * = significant difference.

9. DISCUSSION

Previous research shows that knowledge and practice is low in type 2 diabetes patients and

that women had better practice/self-care then the men. The results in this study showed that

the knowledge about foot care was high in the type 2 diabetes patients. There was 74.0 % who

had good knowledge and only 8.0 % had poor knowledge. There was no significant difference

between genders concerning knowledge. The result of foot care practice was more

varied and had some significant differences between men and women. The result of

knowledge was high but there is still lack in the practice of foot care.

25

9.1. Result discussion

9.1.1. Knowledge of foot care among the patients with type 2 diabetes

Of the type 2 diabetes patients who participated in the study 74.0 % had good knowledge in

foot care. This is a great number compared to several other studies where the type 2 diabetes

patients had poor knowledge in foot care (Pollock et al., 2004; Khamseh et al., 2007).

The patients who had received information or advice previously had better knowledge than

those who hadn´t got any information (Pollock et al., 2004). In this study the patients had

good knowledge even though the majority of the patients had not attended a class in foot care

or read handouts about diabetes. One possible reason for good knowledge about foot care can

be that the majority of patients mentioned that media was the best way for increasing

knowledge and practicing of foot care and maybe the patients can search information by

themselves through media. However, many of patients would like to have a handout about

foot care to improve their knowledge.

About 54% of the patients answered wrong concerning the use of talcum powder usage for

keeping interdigital spaces dry. Also 50.0 % answered that it was not right to apply lotion to

the interdigital spaces on the feet. This shows that half of the patients in this study still did not

know about correct foot care. Many patients had low education (primary school or secondary

school), and this can affect their understanding. Quinn et al. (2011) found that the patients

with low education need more information about their diagnosis, and also need to be educated

about diabetes (Tham et al. 2004).

9.1.2. Foot care practices among patients with type 2 diabetes.

The results of foot care practice among patients was varied and are in agreement with several

other studies (Pollock et al., 2004; Khamseh et al., 2007;Bhupendra et al., 2008) which

showed that the practice of foot care in type 2 diabetes is low.

In this study 90.0 % of the patients examined their feet. This is contrary to the results of

Pollock et al. (2004) that 83% of the patients failed to inspect their feet. It seems that patients

in this study have daily routines to inspect their feet and have searched for information in

practice of foot care.

26

It is important to test the water before washing the feet, but only 20.2 % reported that they did

so even if 60.0 % answered that they knew that. About 33.0 % reported that they walked

around barefoot while 87.0 % answered that it was not good to walk around barefoot. Only

9% used moisturizing cream on their feet and 69 % sit with their leg crossed even do it is not

good for the circulation (Brown and Edwards (2005). This can explain that the patients have

lack of motivation to change of their lifestyle and that health care professionals cannot

motivate, support and give feedback to the patients about self-care. Another reason may be

that the patient didn’t have relatives and friends to support for his/her foot care (Kneckt et al.,

2000). In addition, Rätsep, Oja, Kalda & Lember (2007) showed that economy can have an

important role of the lack in self-care.

The majority of the patients used sandals and flip-flops and only 13 % used shoes of leather.

Brown & Edwards (2005) recommend that the patient shall avoid open-toe and open-heel

shoes and use leather shoes. Contributing factors may be the hot weather in Vietnam which

makes it more convenient to us flip-flops and sandals than leather shoes. Leather shoes are

more expensive. Health care professionals should be aware of this when providing education

to the patients.

9.1.3. Difference between genders in knowledge and practice of foot care

In the study of Pollock et al. (2004) the women had higher knowledge about foot care than

men, and this is in contrast with the results of this study that there was no significant

difference between genders in knowledge of foot care. It may be due to that both male and

female have got good information about foot-care when they visited the doctors at the

hospital. Another reason can be that the participation group in this study is too small to show

differences between genders.

More women than men reported that they use hot water bottle or heating pad on their feet.

This makes it seem that women had low awareness of diabetes and complications as Rätsep et

al. (2007) found. It is important that knowledge of diabetes and practice of foot care should be

educated to patients (Tham et al. 2004) and they have more individual information about their

diagnosis (Quinn et al., 2011). To increase the practicing in correct way Pollock et al., (2004)

mean that there is a need to motivate health providers in educating the type 2 diabetes patients

about self-care and also let them practicing by themselves. Also countrywide network of

27

diabetes centers with implementation of primary prevention programs has to be developed to

prevent complications. It is important to increase the practicing of foot care in a correct way.

More men than women used shoes with round toes and leather/canvas shoes. The authors

believe that one possible reason may be that there were more men who worked as government

officers and merchants and they used this kind of shoes in their work.

Many of the type 2 diabetes patients had a low income and the women had generally lower

income than the men. Financing problems for the women can be a reason for the lack in their

practice of foot care (Rätsep et al., 2007). People in higher social classes have easier to adapt

and change their habits and lifestyle and that can be one reason for the difference between

genders (Chan et al., 2001). Another possible reason can be that the women had a lack of

motivation to change their life style (Rätsep et al., 2007).

More women participating in the study visited the clinic the days for data collection.

Goodridge et al. (2005) found that women was more active in their self-care and men

searched more health care for acute problems, and this can explain why there were more

women visiting the clinic these days.

9.2 Method discussion

Not much research is done about type 2 diabetes in Ho Chi Minh City, Vietnam, and more

research was needed. Therefore this quantitative study was used to investigate the knowledge

and practice in foot care among men and women with type 2 diabetes. The descriptive and

comparative cross- sectional design with questionnaires in suitable to use when the time is

limited and it can collect more data (Eliasson, 2006). Quantitative method was used because

of its strength of generalizability reliability and objectivity (Weinreich, 2006). A purposive

sample was used for this study. The sample method was chosen because of the small amount

of time.

The authors of this study verified the reliability of the data and the questionnaires were

reviewed twice by both the authors before it was entered in to SPSS. When the data was

entered into SPSS both of the authors checked the data two more times so the data were

entered correctly in order to be trustworthy and no data would be printed wrong. The

questionnaire was supposed to be answered in private and help could be supervised to the

28

patients who had a difficulty to fill in the questionnaire, but most of the patients needed help.

Many patients that thought the questionnaire was too long and complicated to fill in. Ms.

Nguyen Thi Phuong Lan interviewed them and filled in the answer for them. Therefore, it is

hard for the authors to know how the questions were read, if the patients answered truthfully,

and this may affect the results. The help to fill in the questionnaires could have harmed the

ethical considerations due to that the questioners have some sensitive questions, such as their

social status Due to the help the patients were given the reliability could have been decreased,

because the authors do not know if the data were trustworthy from the beginning. However,

the authors believe that the quantitative method was the most suitable method to answer the

research questions.

The validity of the questionnaires is high because it is based upon several studies (Bijoy et al.,

2012; Pollock et al., 2004) and a pilot study was done by Ms Nguyen Thi Phungon Lan. The

questionnaires was developed by the two supervisors (Appendix 1). The questionnaires were

also translated in to Vietnamese language by Ms Nguyen Thi Phuong Lan and were adjusted

to Vietnamese culture. A pilot test had also been done by the co- supervisor Nguyen Thi

Phuong Lan in Ho Chi Ming City, before the data collection.

The authors believe that the generalizability is low because of the small sample (100

questionnaires) and cannot be transferred to a larger group/population. The authors believe

that they could be objectivity to the result, even if they were interviewed, due to that they did

not be a big part of the data collection because of the language barrier. In the result there were

no missing data in the knowledge part. In the practices part there was four missing women

and two missing men. See table 4. The authors do not think that the missing data affect the

result. The reason for the missing could be that the patients might not understand the question

or that the questions did not have an answer that they agreed with.

9.3 Theoretical framework discussion

The patients in the study had good knowledge about foot care, but some did not practice their

foot care in a correct way. It means that they don’t have the capacity to perform their self-

care. Dorothea Orem means that the nurse should help the patient with practice of self-care

29

when they are affected of limitations and help them to give capacity to regain the self-care

(Kirkevold, 2000).

When the patients already have knowledge about foot care, it is important that the nurse

motivate the patients to practice their foot care (Rätsep et al., 2007). This agrees with

Dorothea Orem’s theory that nurses should guide and teach patient about self-care

management concerning foot care, give physical and psychological support, and empower

patient to increase his/her self-confidence so that patient can regain the capacity of self-care.

Orem also means that self-care depends on the health of the person, wellbeing, interest of

maintaining living and function and the age can affect the self-care (Alligood & Tomey,

2009).Type 2 diabetes often affects older people and many patients mentioned that economy

was an important role for their self-care. It is important that the nurse should be aware of this

when guiding and teaching patients.

9.4 Clinical implication

The results of this study can be used to increase understanding among health care

professionals to develop an intervention program of self-care management for type 2 diabetes

patients to provide knowledge and practice of foot care in Vietnam. This can be applied to

other developing countries. The study also provides an opportunity for information and

feedback to the nurses, doctors and other health professionals, all to improve the self- care of

type 2 diabetes foot care and prevent complications. Sweden is a multicultural society, the

results of this study can also be used to increase awareness of health care professionals when

provide health education to patients from different cultures.

9.5 Further research study

The aim of this study was to investigate what knowledge the patients had about foot care, how

they practice their foot care and if there was some gender differences. In further research it

would be interesting to investigate more about why patients with type 2 diabetes do not

practice their foot care and from where they were given the information about their

knowledge. It would also be interesting to investigate a correlation between the patients’

income and their foot care practice.

30

9.6 Acknowledgement

We would like to thank Swedish Council for Higher Education through its exchange

programme Linnaeus-Palme that made this study possible. We specially want to thank our

supervisor Dr. Pranee Lundberg, Associate Professor at the Department of Public Health. We

also want to thank our co-supervisor Ms Nguyen Thi Phuong Lan, Nursing Lecturer, at the

Department of Nursing, University of Medicine and to Pharmacy in Ho Chi Minh City, for all

help to hand out the questionnaires. Without her it would not been possible to write and

implement this study. We also thank to all patients who participated voluntarily in this study.

9.7 Conclusions

The knowledge of foot care was good, but the practice of foot care was poor among patients

with type 2 diabetes in this study. More information about the importance of foot care practice

is needed to prevent complications from type 2 diabetes in Ho Chi Minh City, Vietnam. The

poor foot care practice can not only be explained by poor information, and low income of the

patients. There was no significant difference between genders in knowledge but there were

some differences between genders concerning foot care practices. It is important to give

individual information to the patients and follow up their self-care of foot care.

31

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Appendix 1 Questionnaire

Knowledge and practice of foot care in Vietnamese people with

Type 2 diabetes

Please mark (X) your answer for every question.

Part I: BACKGROUND

A. Demographic information

1. Gender 1. Man 2. Woman

2. Age __________ years

3. Marital status

1. Single 2. Married

3. Separated 4. Divorced

5. Widowed 6. Other, _____________________

4. What is your religion?

1. Catholic 2. Protestant

3. Buddhism 4 . Muslim

5. No religion 4 . Other (Specify)…………………

5. Education

1. Primary school 2. Secondary school

3. High school 4. Secondary level after high school/College 5.

Bachelor 6.Other, _____________________

6. Occupation

1.Worker 2.Government officer

3.Technician 4.Merchant

5.Farmer 7.House duty

8. Other, ______________________

36

7. Do you have children?

1. No 2. Yes

8. How many people do you live with at home? _____________

9. How adequate is your income to meet your daily living expenses?

1. Enough 2.Barely enough 3.Totally inadequate

10. How much income do you have per month? _______________________ VDN

11. Do you smoke? 1. No 2. Yes, how many cigarette/day? _______

12. Do you drink alcohol? 1. No 2. Yes, how much do you drink per day? _______

13. For how long have you been living with Diabetes? __________________

14. Does your family have any history of Diabetes?

1. No 2. Yes

15. What kinds of diabetes treatment do you use? (you can mark more than one)

1. Control diet 2. Take medicine

3. Inject insulin 4. Other (specify) ______________

16. Do you follow up regularly your diabetes treatment with the doctor?

1. No 2. Yes

17. Who is person to take care or help you about diabetes at home? (you can mark more than

one)

1. My wife/husband 2. My children 3. My relative

4. No one 5. Other (specify) _________________

B. History of foot problems

18. Have you ever had a foot ulcer?

37

1. No 2. Yes, How many? __________

19. Have you ever had a sore or cut on your foot or leg that took more than two weeks to

heal?

1. No 2. Yes, How many? __________

20. Have you ever had an amputation of a toe, foot, or leg?

1. No 2. Yes (If yes, when (date): _______

C. Current foot or leg problems

21. Do you have an ulcer, sore, or blister on your feet at this time?

1. No 2. Yes

22. Do you have blood or discharge on your socks?

1. No 2. Yes

23. Do you have any calluses on your feet?

1. No 2. Yes

24. Do you have any numbness, tingling, pins and needles, or itching sensation in your feet?

1. No 2. Yes

38

Part II: Knowledge of foot care

25. Please mark “X” for your answer in each item.

Items True False

Importance of taking antidiabetes treatment to prevent complications

Daily washing the feet

Using warm water for washing/bathing

Checking temperature of water before using

Drying the feet after washing

Talcum powder usage for keeping interdigital spaces dry

Keeping skin of the feet soft to prevent dryness

Lotion not to be applied in the interdigital spaces

Daily change of socks

Trimming nails of feet straight with care

Inspection of feet once a day by respondents

Wearing comfortable coat shoes

Checking the shoes from inside before wearing

Not walking bare foot

Warning signs for which consultation is required

Part III: Foot care practice

26. Can you reach and see the bottoms of your feet?

1. No 2. Yes

27. Do you examine your feet?

1. No 2. Yes

39

If yes, how often?

1. Every day 2. 2-6 times a week

3. Once a week or less 4. When I have a problem

28. Do you wash your feet every day? 1. No 2. Yes

29. Do you dry well between the toes? 1. No 2. Yes

30. Do you use a moisturizing cream on your feet? 1. No 2. Yes

31. Do you cut your own toenails? 1. No 2. Yes

If no, who does this for you?

1. Family member 2. Foot care nurse

3. Podiatrist 4. Other (specify): ______________

32. What kind of shoes do you wear? (Check all that apply)

1. Pointed toes 2. Broad, round toes

3. High heels 4. Sandals

5. Flip flops/thongs 6. Athletic/sneakers/runners

7. Shoes made of leather or canvas

33. What kind of socks do you wear? (Check all that apply)

1. Cotton 2.Wool

3.Acrylic/synthetic 4. Knee highs

5. Prescription/compression 6. Not know

7. Other (specify)………

34. Do you ever soak your feet?

1. No 2. Yes

35. Do you always test water temperature before your foot in?

1. No 2. Yes

36. Do you use medicated products for warts, corns or calluses?

40

1. No 2. Yes

37. Do you put moisturizing creams or lotions between your toes?

1. No 2. Yes

38. Do you ever walk around in your bare feet?

1. No 2. Yes

39. Do you ever wear shoes without wearing any socks?

1. No 2. Yes 3. Never use socks when wearing shoes

40. Do you use a hot water bottle or heating pad on your feet?

1. No 2. Yes

41. Do you sit with your legs crossed?

1. No 2. Yes

42. Do you think you have taken care your feet in correct way?

1. No 2. Yes

Foot care Education

43. Have you ever attended a class on how to care for your feet?

1. No 2. Yes

44. Have you ever read any handouts on foot care?

1. No 2. Yes

45. Would you like a handout on how to care for your feet?

1. No 2. Yes

41

46. What kind do you think is the most effective way for increasing your knowledge and

practice of foot care?

1. Receiving handout/brochure

2. Health education in group

3. Individual health education

4. Media such as TV, radio, etc.

5. Others (specify) ____________________________

Thank you for your answer!