Name: Duong Thi Binh

Student No: GNS 1070023

Assignment 2
Complete theory
and intervention (factors or interview guideline) report

1. Title: Knowledge, attitude and practices of foot self-care in older adults

with type 2 diabetes.
2. Introduction (10%)
Diabetes Mellitus is the most common chronic condition affecting the older adults,

place an enormous burden on the health care system and health care resources. Globally,

425 million people were living with diabetes in 2017 and increase to 629 million people

in 2045. Vietnam is the one of 10 countries with the highest rate of diabetes in the world

with the proportion of patients increasing by 5.5% per year (IDF, 2017). Diabetes is an

important health condition for the aging population. In 2017, the number of people 65-

99 years living with diabetes is 122.8 million, and the prevalence is 18.8%. The number

of deaths due to diabetes from age 60-99 years counts for more than 60% of all deaths

attributable to diabetes among 18-99 age group (IDF, 2017). The expenses of diabetes

is estimated at accounting for 12% of total adult costs (ADA, 2018). Type 2 diabetes

accounting for around 90% of all cases of diabetes and most commonly seen in older

adults. Diabetes if not good control, will lead to serious complications such as

cardiovascular disease (CVD), Diabetic eye disease (DED), Diabetic nephropathy (DN)

and Diabetic foot and Nerve damage (neuropathy) (WHO, 2016). Diabetic foot is one

of the most frequent complications of diabetes due to the disability that it generates and

its repercussions on the daily activities of patients. Diabetic foot is a severe chronic

complication, and it consists of lesions is the deep tissues associated with neurological

disorders and PVD in the lower limbs(IWGDF, 2019). Global prevalence of diabetic

foot average of 6.3% and is higher among people with type 2 diabetes and People with

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type 2 diabetes have a higher rate of diabetic foot than people with type 1 diabetes

(Zhang et al., 2017). Diabetic foot can be prevented and limited through foot self-care.

Foot self-care was considered to be important. However, the foot self-care of diabetics

is still not yet inadequately and correctly interested in, especially in the elderly

(Tewahido & Berhane, 2017) (Bell et al., 2005; Bobirca, Mihalache, Georgescu, &

Patrascu, 2016; Eh, McGill, Wong, & Krass, 2016; Nguyen Thi Bich Dao, 2012),

(Miikkola, Lantta, Suhonen, & Stolt, 2019). Previous research has shown that

knowledge of diabetic foot care is still lacking in diabetic patients. Majority of studies

had shown that participants had poor diabetic foot care practice as compared to the

median score. Almost people are not aware of the effectiveness of self-care. (Fan,

Sidani, Cooper-Brathwaite, & Metcalfe, 2014; Kafaie, Noorbala, Soheilikhah, &

Rashidi, 2012). Not many studies have conducted surveys on knowledge, attitudes and

practices on diabetic foot self-care on the elderly people with diabetes in VietNam.

This study aims to examine the relationship between demography, knowledge,

attitude and foot self-care practices in older adult with type 2 diabetes mellitus. The
study also identify the influencing factors of foot self-care practices in older adults with
type 2 diabetic. From that, we make suggestions for self-care management of diabetic
elderly people.

3. Content of the theory (15%)

Major Assumptions of Orem’s Theory:
- Nurses deliberately and purposefully perform nursing as a helping service to
others
- People are willing and capable of performing self-care for themselves and for
dependent family members (children).
- Health, well-being, and human development is dependent on self-care as a necessity
in life
- Individuals are influenced by culture and education
- Communication and human interaction fosters and teaches self-care
- Deliberate and systematic actions are performed to meet self-care
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- Each person possesses interests, powers, talents, values, capabilities, and personal
dispositions
- Each individual is self-reliant and responsible for his or her own care and others in
his or her family needing care
- People are separate from their environment and others
Self-care is defined by Orem as the practice of activities for the maintenance of life,
health and well-being, carried out by the individual for his/her own benefit. When
carried out effectively, they contribute to the maintenance of the integrity and
functionality of humans (Orem, 2001).
A patient’s ability to manage his/her own health, that is, to maintain a healthy state,
to recover fully from an injury or illness, or to regain as optimal a level of function as
possible, depends on numerous interrelated factors. Orem referred to these influences
as basic conditioning factors: age, developmental state, environment, family system,
gender, health care system, health status, pattern of living, resource availability and
adequacy, and sociocultural beliefs.

Theoretical framework

4. Intervention (factors or interview guideline) with guiding theory (15%)

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 The theoretical framework underpinning the study was Orem’s self-care theory.
One of the major assumptions of the theory focuses on the importance of people being
self-reliant and responsible for their own care. In addition, when an individual has
knowledge of a potential health problem, they can institute health-promoting self-care
behavior such as foot care. The active participation of the patient, by means of self-care
activities, constitutes the main key for the control of diabetes mellitus (DM), since
patients and their family members are responsible for over 95% of the treatment.
When health changes occur, the ability to make necessary adaptations to those
changes is influenced by a wide range of variables that include understanding the
changes necessary, the readiness and motivation to change, and the motor and sensory
abilities to execute those activities. In patients with Diabetic foot complication,
researchers found that although many patients indicate a readiness for instituting
changes in self-care behaviors, their compliance with those behaviors is negatively
influenced by deficiencies in knowledge about Foot self-care (Chiwanga & Njelekela,
2015; Ekore, Ajayi, Arije, & Ekore, 2010; Magbanua & Lim-Alba, 2017; Muhammad-
Lutfi, Zaraihah, & Anuar-Ramdhan, 2014; Taksande, Thote, & Jajoo, 2017).
Self-care in diabetes has been defined as an evolutionary process of
development of knowledge or awareness by learning to survive with the complex nature
of the diabetes in a social context.
Proper foot self-care is commonly described as including nail and skin care,

washing and drying the feet each day, doing foot exercises, and wearing socks and shoes

that fit and are made of appropriate materials.(Miikkola et al., 2019)

Demographic Characteristics (Age,

gender, ethnicity, education, During
of diabetes, Previuos history and
current DFU, received advice on
foot care)

Knowledge of foot self-care

Practice of Foot self-care

Attitude of foot self-care

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 5. Outcome Measurements (10%)
The research instrument included demographic details, the knowledge of foot self-
care questionnaire, Diabetic foot care self-efficacy scale (DFCSES) and the Nottingham
Assessment of Functional Footcare (NAFF) Scale. The questionnaire was translated
into Vietnamese and was back translated to check for consistency. It is pilot tested
before use.
Participant demographic data include age, gender, ethnicity, educational level,
duration of T2DM diagnosis, Previous history and current DFU, Received advice on
foot care and Source of information.
The study used a 15-item questionnaire answerable with “yes,” “no” and “I don’t
know” on knowledge of diabetic foot care developed by Hasnain et al., and used by the
groups of Muhammad-Lufti and Seid. Knowledge score was determined based on the
proportion of correct answers. The level of knowledge was assessed as good if the score
was more than 70% (11 to 15 correct answers out of 15). Scores of 50 to 70% (8 to 10
correct answers) were categorized as satisfactory knowledge. Scores less than 50% (7
or below correct answers) were evaluated as poor knowledge.
The DFCSES instrument (9 items) was developed by Quarles to conduct attitude.
The self-efficacy items are addressed using an interval scale ranging from 0 to 10, with
0 indicating “feeling not capable” and “being feeling the most capable” . The Turkish
version of the tool was found to have a high level (α= .86) of internal consistency.
Responses to questions of consists of Pictures 29 the translated NAFFC were
recorded on a categorical scale (scored 0 to 3) according to the frequency of occurrence
of the behavior. The NAFFC consists of independent questions. Scoring on practice
was arbitrarily gauged as good for scores more than 70% (61 and above). Scores of 50
to 70% (43 to 60) were considered satisfactory practice. Scores less than 50% (42 and
below) were labeled as poor practice. In the Chinese version scale, the Cronbach's alpha
coefficient was 0.77, test-retest reliability was 0.74
6. Research Evidence (10%)

Author Purpose Study Sa Varia Instrum Results Suggestion

/year/coun design mple/se bles ents
try tting
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 Yildiri Examine A 368 - Dem - The Gender ,history May be a
m Usta, the role of descriptiv outpatie ographic foot care of a foot wound, guide for health
Y./ 2019/ predictors of e and nts/ - Life behaviour nephropathy, professionals
Turkey foot care analytic Hospita style questionnai duration subscale who are
behaviours study l choices re (FCBQ) ofthe illness interested in
- Kno - Diabet perception scores patients with
wledge es attitude and personal control diabetes.
- Attit scale subscale of the Conduct
ude (DAS) health belief scores further studies
- Beli - Illness were significant on the role of
efs perception predictors of foot barriers as
- Heal questionnai care behaviours. predictors of
th re (IPQ) foot care
perceptio - Health behaviours.
n belief
- Soci model scale
al support (HBMS)
- Multid
imensional
scale of
perceived
social
support
(MSPSS).
Faraja - Knowle A 404  Dam - Prevalence: 1. Establish
S. dge and cross- Outpati ographic Open- 15 % foot coordinated
Chiwanga practice of sectional ents, /  Kno ended ulcers, 44 % foot care
/2015/ foot self-care study clinics wledge of question as peripheral services within
East - Barriers foot care suggested neuropathy, 15 % the diabetic
Africa  Foot by K. peripheral vascular clinic
care Kaliyaperu disease 2. Institute
practices mal - Knowledge: early
1. The mean management,
The knowledge score and provide
Summary was 11.2 ± 6.4 /23 continuous foot
of Diabetes 2. Similar care education
Self-Care among patients with to patients and
Activities DFU and those health care

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 (SDSCA) without DFU. providers.
measure 3. Low
mean scores were
Modified associated with lack
Neuropathy of formal education
Disability (8.3 ± 6.1), diabetes
Score duration of < 5 years
(NDS) (10.2 ± 6.7) and not
receiving advice on
foot care (8.0 ± 6.1)
- Foot care
practices
Foot self-care
was significantly
higher in patients
who had received
advice on foot care
and in those whose
feet had been
examined by a
doctor at least once.

Rosa Relations Descr 200 - A - The majority 1. Educ

Bohorque hip between iptive patients Damogra demograph of the participants ate the
z Robles/ knowledge correlatio / phic ic had poor knowledge importance of
2017/ and foot care nal study primary - Questio (mean = 48.00, daily foot care
Mexico practices care Knowled nnaire. SD ± 22.58) and practices and
clinic ge poor foot care patiens level of
- The Foot practices (mean = risk for
Practices Care 46.90, SD ± 20.45). developing
Knowledge -A negative foot ulcers.
and relationship
Practice between
Questionna participant’s
ire. knowledge and
practices of foot
Podiatry care and risk of
Examinatio developing a

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 n diabetes foot ulcer
Questionna - No
ire relationship
between
sociodemographic
variables and the
risk of developing
diabetes foot ulcers.
Stacey The Descr 223  Lev The - No significant Adds to the
Wendling, relationship iptive patients el of Self- Foot Care correlation was body of
Vera between the correlatio efficacy Confidence identified between knowledge
Beadle/ level of self- nal study  Foot Scale the level of self- regarding self-
2015/ efficacy and self-care (FCCS) efficacy and efficacy and
performance behaviors The performance of foot diabetic foot
of foot self- Nottingha self-care behaviors self-care
care m - Males scoring behaviors.
Assessment higher than females.
of
Functional
Footcare
(NAFF)
survey
Yunck - Determi Cohor Thr  Edu The - At baseline, The need
en J / ne the t study ee cational Problem the key messages of for research
2018/ retention of podiatri topics Areas in 14 (58%) patient investigating
Australia foot health sts and  Deli Diabetes participant more effective
information 24 very Questionna responses differed methods to
6 months patients methods ire (PAID) from their deliver key
post delivery / discussed podiatrists and 15 education to
of education. hospital during (63%) differed 6 this population
- Determi and the months later. to aid retention
ne the type commu consultati - Education and therefore
and delivery nity on covered up to seven assist
method of health separate topics, behaviour
diabetes- sites including change
specific foot neurological impact
health of diabetes, vascular
information supply and general

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 foot care. The
majority of
consultations (n =
23, 96%) covered
three or more topics,
including
neurological impact
of diabetes, vascular
supply and general
foot care.

7. Data collection and analysis (20%)

This study sampling consists of adults aged 65 or older, have been diagnosed with

type 2 diabetes mellitus, presented with or without diabetic foot problem, the ability to

communicate sufficiently and consent to participate in the study.

Research conducted at medical clinics of Da Nang hospital in Da Nang City,

Vietnam.

Collection method: Collect data by face-to-face interviews based on questionnaires

for about 20-30 minutes by investigator. Before participating in the study, participants

was introduced to the study, the purpose of the study, and agreed to fill out the consent

form.

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 CONSENT FORM

This is to consent to be part of the study to be conducted on “Knowledge, attitude

and practices of foot self-care in older adults with type 2”. I have fully informed that
in signing the consent is to give permission to the researcher to access my personal
medical information related to the study.
I will fill out the questionnaire based on the best objective knowledge I have. I
understand fully the intention of the study and willingly consented to take part in the
survey. The information provided will be kept confidential and used for study purpose
only.
Name: ____________________ Surname: ___________________
Signature: _________________ ID: ________________________
Date: _____________________

Researcher’s name: __________ Signature: ____________________

RECRUITING PROCEDURE

The title of the study: Knowledge, attitude and practices of foot self-care in
older adults with type 2
Researcher: Duong Thi Binh, BScN, Duy Tan University
Master’s Thesis project, Fooyin University

Thesis Advisor:

The recruiting procedure will be conducted by the researcher in the following steps:
1. Self-introduction. 2. The purpose of study. 3. What the participants have to do. 4.
Explanation of the benefits from the study. 5. Can you withdraw from the study? 6.
Who will know of study? 7. Consent. 8. Questions from Participants for clarification.

1. Self-Introduction will be involving brief introduction of researchers: Self-

introduction; background including career and study current pursuing (Duy Tan
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University, Da Nang, 2010 - 2019).

2. Purpose of study: This study aims to examine the relationship between

demography, knowledge, attitude and foot self-care practices in older adult with type 2
diabetes mellitus. The study also identify the influencing factors of foot self-care
practices in older adults with type 2 diabetic. From that, we make suggestions for self-
care management of diabetic elderly people.

3. What the participants have to do: After consenting to be part of the study,
you are expected to answer a questionnaire. The questionnaire will take approximately
20 - 30 minutes. The questionnaire contains mainly questions asking about health
history and demographic (such as age, gender, education, during in diabetes, history
DFU, etc), Knowledge, attitude and practices of foot self – care (Risks of diabetic foot
prevention, daily foot sefl-care, foot protection, how to manage foot abnormalities).
None of your personal information will be required in this questionnaire. You will be
given an identity number and that will be entered on the questionnaire, but “NOT
YOUR NAME” so it is confidential. I will not know which paper belongs to whom.
Your completed questionnaires will become part of the study data only.

4. Explanation of benefits from the study: There is no direct benefit of the study
although there will be an indirect benefits in a way that we will explore your condition,
examine how is your condition related to some associated factors such as demographic,
knowledge, attitude and practices of foot self – care. The outcome of the study will help
to make suggestions for self-care management of diabetic elderly people. This is very
important as diabetes is a lifelong disease and foot self – care behaviours is important
to prevent diabetic foot complications, especially amputation. In addition, the study
result will be used to understand important information that could help improve the
managemet of diabetes in Vietnam. This means that our future generation, your
grandchildren or great grandchildren will be benefited from the study.

5. Can you withdraw from the study? Yes you can withdraw or refuse to take
part in the study and refusing will not affect the care you receive from the health care
professionals.

6. Who will know of the study? The research will look at personal information
for the past 4 weeks and collect information on health history and demographic, Risks

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of diabetic foot prevention, daily foot sefl-care, foot protection, management foot
abnormalities. Your name will be not on the copy I take back to the university as all the
questionnaires will have codes on them. Your completed questionnaires will be part of
the study therefore your answers will be used in the study only. I will take all the
questionnaires back to Duy Tan University for data analysis and kept there safely. No
name will ever be used in any presentations or publications of the study results. No
personal information will be in the questionnaire therefore confidentiality will be
strictly maintained.

7. Consent: When you agree to be part of the study, you will need to sign consent
form and this will allow me to include you in the study.

8. Participant’s Question: The participants are encouraged to ask questions for

clarifications on the questionnaire. They are also allowed to ask further questions
regarding their rights as a participant in the study. Once the participants agreed and had
signed the consent form, the questionnaire will be given

NB: The recruiting procedure will be carried out before participants consult
clinicians/medical assistants/diabetes nurse. After the participants completed the
questionnaire then they can progress to check-up health. This will help with the
recruiting process as well as work flow of patients at the outpatient clinic sites.
The Statistical Package for Social Science (SPSS) version 20.0 (SPSS Inc., Chicago,
IL, USA) was used for all analyses. All tests were 2-sided, and statistical significance
was considered at P < 0.05. Descriptive statistics (frequencies, percentages, means and
standard deviation) were used to describe maternal demographic, knowledge, attitudes
and practice of foot self-care. Pearson correlations were calculated to determine the
relationship between demographic, knowledge, attitude and practices of foot self-care.
Variable Descriptive statistics

Age Mean. Standard

Gender: frequencies, percentages
Ethnicity frequencies, percentages
Educational frequencies, percentages
Level
During of frequencies, percentages
diabetes:
Diabetic foot frequencies, percentages
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 ulcer:
Received advice frequencies, percentages
on foot: care
Source of frequencies, percentages
information:
Previous history frequencies, percentages
DFU:

Current DFU: frequencies, percentages

Knowledge of Mean, standard deviation,
foot self-care
Attitude of foot Mean, standard deviation,
self-care
Practice of foot Mean, standard deviation,
self-care

Variables vs Measure Inferential Statistics

Demography vs Practice T-Test, Pearson
correlations
Knowledge vs Practice T-Test, Pearson
correlations
Attitude vs Practice T-Test , Pearson
correlations

8. Ethical consideration (5%)

The study is approved by hospitals and health care facilities, where collect research

data. The participants receive information about the study before answer the

questionnaire. All participants accept to the study and sign a written consent form and

can withdraw from the study at any time. All information is treat confidentially.

9. Main point of discussion (5%)

- Participants characteristics: ratio of Male / female, Average age, ….
- Knowledge of foot self-care: The average score of knowledge, ratio of patients
with the poor score, the average score and the good level accounted. Mistakes
in knowledge of foot care are often encountered by patients
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 - Attitude of foot self-care: The mean score of patients' attitude. Percentage of
patients who are aware of the importance of daily leg checks.
- Practice of foot self-care: The average score of the practice, correct practice rate
- Relationship between demographics, knowledge, attitudes, and foot care
behavior
This study sampled an elderly population, some of whom suffer from several ageing
problems (e.g., hearing problems and blurred vision) that could influence the study’s
results. Cross-sectional sampling may lead to bias and the respondents were recruited
from only a hospital, which may not represent the whole population.

10. Conclusions (5%)

It is necessary to firstly develop knowledge, awareness of diabetes mellitus and the
related complications, one amongst which is foot care. Certain educational strategies
should be established for both the consultant physician, nurse and also the common
man to create awareness for effective foot care.
11. References (5%)

ADA. (2018). Economic Costs of Diabetes in the U.S. in 2017. Diabetes Care, dci180007.
doi:10.2337/dci18-0007
Bell, R. A., Arcury, T. A., Snively, B. M., Smith, S. L., Stafford, J. M., Dohanish, R., &
Quandt, S. A. (2005). Diabetes foot self-care practices in a rural triethnic
population. Diabetes Educ, 31(1), 75-83. doi:10.1177/0145721704272859
Bobirca, F., Mihalache, O., Georgescu, D., & Patrascu, T. (2016). The New Prognostic-
Therapeutic Index for Diabetic Foot Surgery--Extended Analysis. Chirurgia
(Bucur). 111(2), 151-155.
Chiwanga, F. S., & Njelekela, M. A. (2015). Diabetic foot: prevalence, knowledge, and
foot self-care practices among diabetic patients in Dar es Salaam, Tanzania - a
cross-sectional study. J Foot Ankle Res, 8, 20. doi:10.1186/s13047-015-0080-y
Eh, K., McGill, M., Wong, J., & Krass, I. (2016). Cultural issues and other factors that
affect self-management of Type 2 Diabetes Mellitus (T2D) by Chinese
immigrants in Australia. Diabetes Res Clin Pract, 119, 97-105.
doi:10.1016/j.diabres.2016.07.006
Ekore, R. I., Ajayi, I. O., Arije, A., & Ekore, J. O. (2010). Knowledge of and attitude to
foot care amongst Type 2 diabetes patients attending a university-based
primary care clinic in Nigeria. African journal of primary health care & family
medicine, 2(1), 175. doi:10.4102/phcfm.v2i1.175
Fan, L., Sidani, S., Cooper-Brathwaite, A., & Metcalfe, K. (2014). Improving foot self-
care knowledge, self-efficacy, and behaviors in patients with type 2 diabetes at
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 low risk for foot ulceration: a pilot study. Clin Nurs Res, 23(6), 627-643.
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IDF (Ed.) (2017). IDF Diabetes Atlas 8th edition. Diabetes Care www.diabetesatlas.org:
International Diabetes Federation
IWGDF. (2019). IWGDF Guidelines on the prevention and management of diabetic foot
disease. IWGDF Guidelines www.iwgdfguidelines.org: The International
Working Group on the Diabetic Foot
Kafaie, P., Noorbala, M. T., Soheilikhah, S., & Rashidi, M. (2012). Evaluation of patients'
education on foot self-care status in diabetic patients. Iran Red Crescent Med J,
14(12), 829-832. doi:10.5812/ircmj.1138
Magbanua, E., & Lim-Alba, R. (2017). Knowledge and Practice of Diabetic Foot Care in
Patients with Diabetes at Chinese General Hospital and Medical Center. Journal
of the ASEAN Federation of Endocrine Societies, 32(2), 123-131.
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Miikkola, M., Lantta, T., Suhonen, R., & Stolt, M. (2019). Challenges of foot self-care in
older people: a qualitative focus-group study. J Foot Ankle Res, 12, 5.
doi:10.1186/s13047-019-0315-4
Muhammad-Lutfi, A. R., Zaraihah, M. R., & Anuar-Ramdhan, I. M. (2014). Knowledge
and Practice of Diabetic Foot Care in an In- Patient Setting at a Tertiary Medical
Center. Malays Orthop J, 8(3), 22-26. doi:10.5704/MOJ.1411.005
Nguyen Thi Bich Dao, V. T. L. ( 2012). INVESTIGATION OF KNOWLEDGE, ATTITUDE AND
BEHAVIOR CONCERNING FOOT SELF-CARE IN PATIENTS WITH TYPE 2 DIABETES
AT CHO RAY HOSPITAL.
Taksande, B. A., Thote, M., & Jajoo, U. N. (2017). Knowledge, attitude, and practice of
foot care in patients with diabetes at central rural India. Journal of family
medicine and primary care, 6(2), 284-287. doi:10.4103/2249-4863.219994
Tewahido, D., & Berhane, Y. (2017). Self-Care Practices among Diabetes Patients in
Addis Ababa: A Qualitative Study. PLoS One, 12(1), e0169062.
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WHO. (2016). Global report on diabetes. World Health Organization
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Zhang, P., Lu, J., Jing, Y., Tang, S., Zhu, D., & Bi, Y. (2017). Global epidemiology of diabetic
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