Chapter 4

Chapter 4: Data Analysis and Results
Introduction
Diabetic foot ulcers are major complications of diabetes. DFU has been associated with over 5.2% of all deaths in the world. DFU accounts for 2–32% of all complications associated with diabetes. Patients with DFU end up with complications such as neuropathy, infections and lower extremity amputation. Unfortunately, some of these complications of DFU result in high costs of hospitalization and morbidity and mortality of patients (Mohamed et al., 2017). It is estimated that most patients with diabetic neuropathy, infections, and foot deformities end up with amputation and half of the patients have a second amputation in five years (Prajsnar et al., 2015). DFU has an economic burden on hospitals, individuals, families, and the community. It lowers the patient’s self-esteem and decreases the patient’s quality of life (Mohammed et al., 2016). It is estimated that the cost of treating DFU in the USA is approximately $116 billion a year. In the UK, it is estimated to cost between £639 and £662 per year
Diabetic foot ulcer is considered a phenomenon or complication of diabetes. Patients with diabetes are considered to get one or more complication of diabetes in their lifetime. The World Health Organization (WHO) states that over 25% of patients suffering from diabetes have different and unique complications. Patients’ complications are specific to patients; some have non-healing wounds, narcosis, infections, and amputations which untreated can cause death (Vassilev ; Kavrakov, 2014). Over 200 million people are affected with diabetes worldwide. Diabetes and peripheral artery disease are the main causes (Vassilev ; Kavrakov, 2014)
Descriptive findings
The project involved qualitative and quantitative approaches. This project was conducted in an outpatient clinic in Detroit, Michigan which has the highest population with diabetes. The clinic is both outpatient and urgent care and admits over 125 patients per day. They have three providers and the clinic operates five days a week. The majority of the patients have been diagnosed with diabetes. The clinical services are offered from 8 a.m. to 7 p.m. The clinic is staffed with physicians, nurse practitioners, physician assistants, nurses, and other nursing assistants (Babelgaith, Baidi, Al-Arifi, Alfadly, ; Wajid, 2015). The population consisted of patients with Type 2 diabetes (DM2), both male and female, from the Detroit metropolitan area, who have had diabetes for over two years. A convenience sample of 150 patients was screened for research. Characteristics include age, sex, education, foot deformity, neuropathy, and sensation. The inclusion criteria included adults aged 18 and older, both male and female. All patients were seen on a routine scheduled visit. Exclusion criteria included patients with amputations, cardiovascular disease, and those on dialysis (Babelgaith et al., 2015; Kotru ; Joshi, 2017).
Data collection process involved questionnaires that were used to extract information from patients. Structured interviews were used. The purpose of structured interviews was to make sure patients provided the necessary information that was focused on risk factors for developing DFU (Nugent et al., 2015). Data was collected according to the questions and. The data was collected according to research questions including self-care and self-management behaviors such as foot care and footwear behaviors, smoking, diet, and exercise (Toobert et al., 2000).
The project assessed if lifestyle and self-education could significantly affect patient risk for developing DFU. A convenience sample of 50 patients was screened with ages ranging from 18 to 65. Tables and charts indicated characteristics of social demographics including age, gender, and duration with the disease. Other characteristics included diet, blood sugar testing, foot care, footwear, and smoking (Toobert et al., 2000; Ren et al., 2016).
Table 1 is a sociodemographic and a profile of patients with a history of diabetes with a risk of developing diabetic foot ulcers: (n=27) females and (n=23) males.
Table 1.
Patients with History of Diabetes with Risk of Developing DFUs females (n=27), males (n=23)
Variables Mean Standard Deviation
Gender 1.5366 .50485
Time/duration with diabetes 9.1220 4.57818
Diet 3.7077 1.47044
Exercise 3.2927 1.63162
Smoking 1.0244 .98711
Foot care 3.8293 2.08450
Medication 5.3659 2.15356

Table 2 is a descriptive of mean value and standard deviation of the domain of quality of life for patients at risk of developing diabetic foot ulcers.
Table 2.
Mean Value and Standard Deviation of the Domain of Quality of Life for Patients at Risk of Developing DFUs
Quality of Life Mean Standard Deviation
Emotional 3.3902 1.51456
Physical 2.6341 1.33709
Social 3.12239 1.12239
Functional 2.3171 1.03535
Pain 3.0732 1.0432
General 2.5366 .92460
Mental 3.7000 1.50555

Table 3 is comparing the mean values for quality of life for patients at risk of developing DFU according to gender with standard deviation (SD).
Table 3.
Comparison of Mean Values for Quality of Life for Patients at Risk of Developing DFU According to Gender with Standard Deviation (SD)
Quality of Life Gender
Male(n=23) (SD) Gender
Female (n=27) (SD)
Emotions 3.3684 (1.6) 3.4091 (1.5)
Physical 2.6842 (1.4) 2.5909 (1.3)
Social 3.4737 (1.0) 2.8282 (1.1)
Functional 2.5789 (1.2) 2.0909 (1.0)
Pain 2.8421 (.89) 3.2727 (1.1)
General 2.4737 (.69) 2.5909 (.92)
Mental 3.5263 (1.4) 3.8571 (1.5)

The project was aimed at assessment and evaluation of the risk factors for diabetic foot ulcer. Patient education and prevention of risks for developing DFU were addressed. The study involved a convenience sample of 50 patients from a clinic in Detroit, Michigan. The project was approved by the internal review board (IRB). Patients signed consent forms before assessments and at the beginning of the study. The population sample was assessed, and then they were given questionnaires administered by the Centers for Disease Control and Prevention (CDC) which are online for public use. E-mails from the CDC were obtained. The study was designed to correct information on patient health risk behaviors, diet, and assessments of patient feet. Data was collected using satisfied questionnaires from the CDC, and the patient’s history and knowledge were assessed (Sando, 2018). According to McBride (2016), there was a link between patients’ diabetic foot care and poor foot care behaviors from patients affected by the condition. Further studies indicated that most of the patients with DFU blamed their diseases on other people such as health care providers for not managing their care. Patients can be given all the care from practitioners, but if they did not manage their care at home, there was a poor outcome which most of the time was due to poor self-care.
Data Analysis procedures
The project assessed if lifestyle and self-education could significantly affect patient risk for developing DFU. A convenience sample of 50 patients was screened with ages ranging from 18 to 65. Tables and charts indicated characteristics of social demographics including age, gender, and duration with the disease. Other characteristics included diet, blood sugar testing, foot care, and smoking (Toobert et al., 2000).
A total of 50 patients was included in the (n-27), 53.7% females, and (n-23), 46.3% males participated. Two sets of questionnaires were used. One addressed socio-demographics and another assessed the quality of life of patients with diabetes and had a risk of developing diabetic foot ulcers. Variables included gender, duration with diabetes, diet, smoking, foot care, exercise, and medication. The second set of questionnaires assessed the patient’s quality of life (Lima Neto et al., 2016). The questions included short form health surveys (SF-36). The questions included 36 questions that were grouped into seven domains. The same questions have been used all over the world and are translated into many languages. The domains are grouped into emotional, mental, physical, social, pain, general, and functional (Lima Neto et al., 2016).
Data analysis was defined using SPSS version 24. Descriptive statistics were computed for all variables including age, gender, and duration with the disease. Fisher exact test Chi-square and ANOVA were used to assess and check statistically the difference between the genders, age, and duration with the disease. Other prescriptive data was analyzed using frequencies, mean and standard deviation for both male and female (Lima Neto et al., 2016).
Results
All data were analyzed, and all questions from the project were answered. Out of the 50 participants, 23 (46.3 %) were male, and 27 (53.7%) were female. Duration with diabetes was measured which had an average of 9.1 years. Most patients were smokers. The highest percentage of patients did not take their medication on a daily basis or as prescribed by their providers. It was noted that exercise and a decrease in smoking also helped to reduce the risk of developing diabetic foot ulcers in both genders. More males assessed their feet compared to their female counterparts. Patients with uncontrolled blood sugars and with many years with diabetes developed diabetic neuropathy. It was noted that self-foot care and controlling blood sugars decreased complications associated with diabetic neuropathy. Patients who managed their diabetes well had positive outcomes. It was also noted that most patients who were affected by complications of DFU were over 50 years old. Similar studies by Lima Neto et al. (2016) indicated that most patients affected by complications such as DFU were senior citizens.
The mean age for males was 52.6 and 53.5 for females. More males exercised compared to females. Female patients practiced dieting more than male Chiwanga and Njelekela (2015) found that the majority of diabetic patients did not inspect their feet regularly. There was a great need for professionals to educate patients about foot care and risky behaviors such as cutting toenails with sharp objects like knives and razor blades. Patients that received foot care education from providers improved their foot assessment habits. Providers and nurses improved their habits of assessing their feet. Providers were encouraged to always evaluate the patient’s foot, educate patients, and improve the patient’s skills (Chiwanga & Njelekela, 2015). Ginzburg, Hoffman, and Azuri (2017) also state that patients who were educated about foot care improved from 26% to 94%. In 2017.
On the domain related to quality of life, patients with diabetes scored low on physical health. Most patients complained of peripheral neuropathy compared to generalized pain. Most patients scored higher on mental and social aspects in relationship to DFU. On the physical aspect, males were affected more compared to female. Although there were differences in terms of quality of life, of male and female affected by diabetes, there was very minimal statistical difference between the two genders in terms of quality of life. Further studies are recommended to learn more about quality of life for patients with a history of diabetes at risk of developing DFU (Lima Neto et al., 2016).
Summary
The project provided more knowledge on DFU. The knowledge of diabetic foot ulcers among diabetic patients was to help reduce complications of peripheral neuropathy, infections, wounds, and amputation (Chiwanga & Njelekela, 2015). Appropriate on the risk factors affecting the development of diabetic foot ulcers will mean the avoidance of injuries and infections. Other risk factors facilitating the development of diabetic foot ulcers included the formation of calluses, hyperkeratotic foot, and deformity of the foot with increase chances of developing DFU. Through proper knowledge and education of foot care, which could be demonstrated by health care providers such as clinicians and nurses, patients could participate in taking care of their feet to prevent the risk of developing DFU. The knowledge they provide would improve patient’s education on proper foot care and proper footwear. Therefore, the knowledge gained would help the patient in providing care to their feet in an efficient manner (Chiwanga ; Njelekela, 2015).
It is also important for providers and clinician to be educated to help raise awareness about risk factors and why it is crucial to identify patients who are at risk for developing DFU. Patients’ knowledge about podiatry services and follow-up with an endocrinologist will help decrease complications of DFU. It is important for healthcare providers, clinics, and healthcare facilities to include routine foot care services for their diabetic patients. Continuous education for both patients and providers would improve patient positive outcomes (Chiwanga & Njelekela, 2015).
Some of the articles indicated that more studies were encouraged on the role of clinicians and other medical personalities in reminding patients of the need for assessing their feet every day (Chiwanga & Njelekela, 2015). Further projects are encouraged on the role of patients in non-compliance with their care, and research focusing in this area was to help to determine the necessary interventions needed to prevent diabetic foot ulcers (McBride, 2016). Other studies indicated that foot alone has not improved or influenced patient participation in direct foot care. More research is needed to evaluate the relationship between diabetic foot ulcers and other health behaviors in promoting healthy foot care. Future studies in testing practical behaviors and interventions that promote patient’s knowledge on taking care of their lower extremities were to improve patient outcomes (McBride, 2016). The role of the family in supporting patients with a risk of developing DFU was recommending for further studies (Simplício De Oliveira et al., 2016).
The recommendations of the practice were to involve what had been learned throughout these projects. Other facts that were known included little knowledge on contributions of nurses and other healthcare professionals in speeding more time in teaching patients preventive habits that could decrease the development of diabetic foot ulcer (Simplício De Oliveira et al., 2016). There is a great need for clinicians and other providers to educate and contribute to raising awareness of the risk factors contributing to diabetic foot ulcers. Other healthcare facilities such as hospital and skilled nursing centers should practice routine examination of patients with diabetic foot ulcers. There is a need for programs which would provide continuous education on prevention of DFU (Chiwanga ; Njelekela, 2015).

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Chapter 5: Summary, Conclusions, and Recommendations
Introduction
A diabetic foot ulcer is one of the complications of diabetes. It is estimated that patients with diabetes account for over 366 million cases around the world today. It is also estimated that the number of patients with diabetes will increase to 552 million by 2050 (Babelgaith et al., 2015). Countries with the highest cases of diabetes include Saudi Arabia, Egypt, Oman, and Kuwait. In most of these countries, patients have very little knowledge about the complications of diabetes such as DFU. It is important for health care professionals such as doctors, clinicians, and nurses to incorporate educational programs into patient visits to improve quality of life and create positive outcomes. Many studies on preventing complications of diabetes have concluded that patients with controlled blood sugars, controlled hemoglobin, hypertension, and cholesterol had reduced and delayed complications of diabetes such as DFU (Babelgaith et al., 2015).
This project was designed to assess patients’ knowledge and health behaviors towards prevention of complication of diabetes such as diabetic foot ulcers. Studies indicated that most patients diagnosed with DFU have had the diagnosis for over 20 years. Some of the symptoms included diabetic neuropathy and peripheral vascular disease which led to complications such as lower extremity ulcers, infections which could lead to amputation and mortality and morbidity (Jan et al., 2016). This project was important because it assessed and evaluated the reasons why most patients ended up with complications such as DFU. Complications of diabetes such as infections end up in 85% as a result of amputation. Patients’ education was important in preventing such complications. The main purpose of this was to find out the risk factors associated to the development of diabetic foot ulcers and developing plans and measures to be taken to prevent complications such as DFU (Jan et al., 2016).
Foot ulcers can be categorized into two groups: those that occur due to trauma and ill-fitting shoes, and those that occur due to obesity and being overweight. Some of the wounds are caused by a small bruise due to trauma that ends up being a non-healing wound (Jan et al., 2016). According to Gupta, Haq, and Singh (2016), diabetic foot ulcers cause hospitalizations when the patient’s foot is infected. Five percent of patients with diabetes develop DFU and end up in the hospital every year. Some of the factors that increase the risk for trauma include neuropathy, arthritis, and atherosclerosis. Since diabetic ulcers are deeper and slower in healing, the wounds are easily infected. Once there is an infection, there is room for tissue damage, which causes gangrene and eventually lower extremity amputation. Understanding diabetic foot ulcers, the risks factors for prevention, and education will contribute to a decrease in complications such as DFU, infections, and mortality and morbidity in all patients (Gupta et al., 2016).
According to the American Diabetes Association, some of the reasons for DFU include peripheral arterial disease (PAD) and diabetes (Turns, 2015). Peripheral neuropathy is characterized by numbness and tingling. Motor neuropathy causes the formation of calluses and foot deformities such as claw foot or hammer toes. The deformities in premiere places can cause ulceration. Autonomic neuropathy is called so by the dry skin which may cause cracking of skin and introduction of infections. Infections can be serious and can cause osteomyelitis, which is an infection of the bones. Untreated DFU can cause lower extremity amputation. Other causes for DFU are Charcot arthroplasty that is caused by inflammation of lower extremity. Risk factors include trauma to bone, diabetes, and sensory motor neuropathy (Turns, 2015). Understanding the reasons for DFU, preventive measures, and the necessary education to prevent the complication of diabetes will improve the patient’s quality of life, self-esteem, and prevent complications associated to diabetes (Turns, 2015).

Summary of Findings and Conclusions
A summary of diabetic foot care activities and self-care items were provided to all patients. All activities were measured from the previous seven days and it was numbered from 0–7. A measurement of 0 meant the patient performed 0 activities for the last seven days, and a measurement of 7 meant the patient performed activities for all seven days. All questions were the same for both males and females. The second questions had health survey questionnaires with 36 questions assessing quality of life for all patients with diabetes and at risk of developing a diabetic foot ulcer.
All data were analyzed, and all questions from the project were answered. One-hundred-fifty (150) patients were screened, but only fifty (50) patients qualified for the study. Out of the 50 participants, 23 (46.3 %) were male, and 27 (53.7%) were female. Duration with diabetes was measured which had an average of 9.1 years. Most patients were smokers. The highest percentage of patients did not take their medication on a daily basis or as prescribed by their providers. It was noted that exercise, decrease in smoking also helped to reduce the risk of developing diabetic foot ulcers in both genders. More males assessed their feet more compared to their female counterparts. Patients with uncontrolled blood sugars and with many years with diabetes developed diabetic neuropathy. It was noted that self-foot care and controlling blood sugars decreased complications associated with diabetic neuropathy. Patients who managed their diabetes well had positive outcomes. In the project, it was also noted that most patients who were affected with complications of DFU were over 50 years of age.
Similar studies by Lima Neto et al. (2016) indicated that most patients affected by complications such as DFU were senior citizens. The mean age for males was 52.6 and 53.5 for females. More males exercised compared to females. Female patients practiced dieting more than male patients. Females smoked more than male patients.
In their study of foot care practices, Chiwanga and Njelekela (2015) found that the majority of diabetic patients did not inspect their feet regularly. There was a great need for professionals to educate patients about foot care and risky behaviors such as cutting toenails with sharp objects such as knives and razor blades. Patients who received foot care education from providers improved their foot assessment habits. Providers and nurses improved their habits of assessing their feet. Providers were encouraged to always evaluate patient’s foot, educate patients, and improve patient’s skills (Chiwanga ; Njelekela, 2015). Ginzburg et al. (2017) also state that patients who were educated about foot care improved from 26% to 94%.
On domain related to quality of life, patients with diabetes scored low on physical health. Most patients complained of peripheral neuropathy compared to generalized pain. Most patients scored higher on mental and social aspects in relationship to DFU. On the physical aspect, males (2.6) SD=1.4 were affected more compared to females (2.5) SD=1.3. Females (3.3) SD=1.5, were more affected emotionally compared to males (3.3) SD=1.6. Females (3.2) SD=1.1 experienced Although there were differences in terms of quality of life between males and females affected by diabetes, there was very minimal statistical difference between the two genders in terms of quality of life. Further studies were recommended to study more about quality of life for patients with a history of diabetes at risk of developing DFU (Lima Neto et al., 2016).
Patients with lower extremity neuropathy were at a higher risk of developing DFU. Appropriate education on diabetic foot care will reduce injuries and complications such as amputation among patients with diabetes. Proper footwear and education from providers will increase better foot care habits (Chiwanga ; Njelekela, 2015). Intervention by multidisciplinary committees such as nurses, dieticians, and clinicians will decrease injury and improve foot care. A patient’s quality of life decreases with injuries such as DFU. Further studies were recommended to improve patient quality of life and provide the education necessary to prevent complications (Ginzburg et al., 2017).
The summary of the findings included data and data analysis relative to clinical questions as indicated in Tables 1, 2 and 3. Summary of the findings was included in the study organized by clinical questions above (Fain, 2013).
Implications, Practical and Theoretical
The project provided more knowledge on DFU. The knowledge of diabetic foot ulcers among diabetic patients will help reduce complications of peripheral neuropathy, infections, wounds, and amputation (Chiwanga & Njelekela, 2015). More projects on the risk factors affecting the development of diabetic foot ulcers will mean the avoidance of injuries and infections. Other risk factors facilitating the development of diabetic foot ulcers include the formation of callus, hyperkeratotic foot, and deformity of the foot with increase chances of developing DFU. Through proper knowledge and education of foot care, which can be demonstrated by health care providers such as clinicians and nurses, patients can participate in taking care of their feet to prevent the risk of developing DFU. The knowledge they provide will improve the patient’s education on proper foot care and proper footwear. Therefore, the knowledge gained will help the patient in providing care to their feet in an efficient manner (Chiwanga ; Njelekela, 2015).
It is also impotent for providers and clinicians to be educated to help raise awareness about risk factors and why it is crucial to identify patients who are at risk for developing DFU. Patients’ knowledge about podiatry services and follow-up with an endocrinologist will help decrease complications of DFU. It is important for healthcare providers, clinics, and healthcare facilities to include routine foot care services on their diabetic patients, and continuous education for both patients and providers will improve patient positive outcomes (Chiwanga & Njelekela, 2015).
Strength and weakness
Most patients went through a series of questions about honesty before they participated in the project. All instruments used were appropriate and measurable for validity. A standardized questionnaire and rating scale was used for all participants for reliability purpose. All questions were on an 8th-grade reading level for all the participants to understand. According to Fain (2013)The project was conducted in the inner city of Detroit. Most of the suburbs were not covered because patients were seen in their homes and in clinics. The qualitative and quantitative designs were used to compare results from the project. Both complemented each other (Fain, 2013).
The project was limited to patients of Detroit and can only be generalized to Detroit. Limitations of the project included concentrating on only on adults with diabetes. Patients with other comorbidities were excluded from the study. In the future, there is a need to include patients with other complications such as coronary artery diseases. The project was conducted for a short time. Longitudinal studies are recommended for diabetic patients with a risk of developing complications such as DFU. A convenient sample of 150 subjects was screened for the project, and only 50 participated in this project. Further studies are recommended for more subjects to be included in the project in order to have a randomized sample. There was limited data on risk factors for patients at risk of developing DFU. The study was limited to information from the past five years. More projects are needed to close the gap of behaviors contributing to risk of developing DFU (Fain, 2013).

Recommendations for Future Projects
In future projects, younger patients from 10–18 years of age should be included in the study. Most patients stated that their providers did not mention about foot care at all. Some of the articles indicate that more studies are encouraged on the role of clinicians and other medical personalities in reminding patients of the need for assessing their feet every day (Chiwanga & Njelekela, 2015). Further projects are encouraged on the role of patients in non-compliance with their care, and research focusing in this area will help determine the necessary interventions needed to prevent diabetic foot ulcers (McBride, 2016). Other studies have indicated that foot alone has not improved or influenced patient participation in direct foot care. More projects is needed to evaluate the relationship between diabetic foot ulcers and other health behaviors in promoting healthy foot care. Future studies in testing practical behaviors and interventions that promote the patient’s knowledge on taking care of their lower extremities will improve patient outcomes (McBride, 2016). The role of the family in supporting patients with a risk of developing DFU is recommended for further studies (Simplício De Oliveira et al., 2016).
Recommendations for Future Practice
The recommendations of the practice will involve what has been learned throughout this project. Other facts that are known include little knowledge on contributions of nurses and other healthcare professionals in spending more time in teaching patients preventive habits that can decrease the development of diabetic foot ulcer (Simplício De Oliveira et al., 2016). There is a great need for clinicians and other providers to educate and contribute to raising awareness of the risk factors contributing to diabetic foot ulcers. Other healthcare facilities such as hospitals and skilled nursing centers should practice routine examination of patients with diabetic foot ulcers. There is a need for programs which will provide continuous education on prevention of DFU (Chiwanga ; Njelekela, 2015). Gupta et al. (2016) recommend that providers who diagnose patients with diabetes and educate patients early have a chance of decreasing complications of DFU. They state that providers should involve multidisciplinary committee to work with diabetic patients at risk of developing DFU. A multidisciplinary group that includes nurses, providers, nutritionists, physical therapists and other assistive personnel will help diabetic patients develop plans that are specific to patient’s needs to prevent complications of DFU. Patients with diabetic foot ulcers should be treated for infections and assessed for narcosis to prevent further damage caused by complications of DFU. Foot assessment and foot care for all patient with diabetes is recommended with every visit.
Patients should be treated for both physical and emotional aspects affecting their health. More providers should provide education that will improve patient’s quality of life. Treatment and education should also focus on elderly patients who are at risk of developing diabetic foot ulcers and other complication such as heart diseases and decreased perfusion to lower extremities (Lima Neto et al., 2016). Other recommendations for future practice include monitoring blood sugar with every visit and hemoglobin A1C, with every three months, measuring blood pressure with every visit. Assessment of lipid profile such as high-density lipids, low density lipids, and total cholesterol will help patients understand other risk factors that will complicate their disease and the healing process. Patient’s body mass index (BMI) should be measured with every visit to understand risks of developing complications of diabetes (Babelgaith et al., 2015).
Jan et al. (2016) state that it is important for clinicians to review over all diabetic foot ulcer and educational programs for long term and short term complications of diabetes. Providers should constantly remind patients the need for participating in their care, and for compliance with foot and medication to help decrease complications of DFU. The also recommend more studies on longitudinal on effectiveness of education and training that can be used in outpatient clinics to promote self-management and self-care. Patients should be reminded complications of diabetes with every visit. Providers should also set goals of reducing diabetes blood sugar levels to normal level with the help of their patients. Continued care should be incorporated in all patients with diabetes with a risk of developing DFU (Babelgaith et al., 2015).
According to Jan et al. (2016), peripheral neuropathy, improper foot wear, trauma to lower extremity, poor glycemic levels and increased lipids and obesity should all be addressed with patients who have history of diabetes at risk of developing DFU. Early diagnosis will save lives.