Hindawi

Journal of Diabetes Research

Volume 2020, Article ID 4106383, 6 pages
https://doi.org/10.1155/2020/4106383

Research Article
Prevalence of Diabetic Foot Ulcer and Associated Factors among
Adult Diabetic Patients on Follow-Up Clinic at Jimma Medical
Center, Southwest Ethiopia, 2019: An Institutional-Based
Cross-Sectional Study

Daba Abdissa ,1 Tesfaye Adugna ,2 Urge Gerema ,1 and Diriba Dereje 3

1
Department of Biomedical Sciences (Clinical Anatomy), College of Medical, Sciences, Institute of Health Sciences,
Jimma University, Ethiopia
2
Department of Biomedical Sciences (Medical Biochemistry), College of Medical, Sciences, Institute of Health Sciences,
Jimma University, Ethiopia
3
Department of Biomedical Sciences (Medical Physiology), College of Medical, Sciences, Institute of Health Sciences,
Jimma University, Ethiopia

Correspondence should be addressed to Daba Abdissa; [email protected]

Received 27 December 2019; Accepted 3 March 2020; Published 16 March 2020

Academic Editor: Munmun Chattopadhyay

Copyright © 2020 Daba Abdissa et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Diabetic foot ulceration is a devastating complication of diabetes mellitus and is a major source of morbidity and
mortality. So far, there are few published data on diabetic foot ulcers and its determinants among diabetic patients on follow-up
at Jimma Medical Center. Hence, the aim of this study was to assess the prevalence of diabetic foot ulcer and its determinants
among patients with diabetes mellitus at Jimma Medical Center. Methods. A hospital-based cross-sectional study was conducted
from June 1 to August 30, 2019, and systematic random sampling technique was applied. The total number of study subjects
who participated in the study was 277. Data were collected using an interview-administered structured questionnaire. Data were
entered into EpiData version 3.1 and exported to SPSS version 20 software for analysis. Analysis was done using descriptive
statistics and logistic regression. A variable having a p value of <0.25 in the bivariate model was subjected to multivariate
analysis to avoid confounding the variable’s effect. Adjusted odds ratios (AOR) were calculated at 95% confidence interval and
considered significant with a p value of ≤0.05. Result. The mean of age of participants was 50:1 ± 14:19 years. More than three-
fourths of participants (82.7%) were type 2 DM. The mean duration of diabetic patients was 6:00 ± 5:07 years. The prevalence of
diabetic foot ulcer was 11.6% among study participants. According to multivariate logistic regression analysis, previous history
of ulceration (AOR = 5:77; 95% CI: 2.37, 14.0) and peripheral neuropathy (AOR = 11:2; 95% CI: 2.8, 44.4) were independent
predictors of diabetic foot ulcer. Conclusion. The prevalence of diabetic foot ulcer was 11.6%. Previous history of ulceration and
peripheral neuropathy were associated with diabetic foot ulcer. The health care providers are recommended to thoroughly give
emphasis during follow-up of patients who had previous history of ulceration and peripheral neuropathy in order to decrease
the occurrence of diabetic foot ulcer.

1. Introduction Diabetic foot disease (DFD) is one of the diabetic compli-

cations associated with major morbidity, mortality, and
Diabetes has reached epidemic proportions worldwide. The reduced quality of life and is the most serious complication
International Diabetes Federation (IDF) estimates 425 mil- of diabetes mellitus [3, 4]. The incidence of DFD is still rising
lion people living with DM worldwide in 2017, estimated to [5]. According to the international consensus on diabetic
rise to 628 million by 2045. Sub-Saharan Africa is currently foot, a foot ulcer is defined as a full-thickness wound below
enduring the heaviest global burden of diabetes [1, 2]. the ankle in a diabetic patient, irrespective of duration [6].
2 Journal of Diabetes Research

The International Diabetes Federation estimates that at 2.5. Operational Definition. Diabetic foot ulcer: these are
least one limb is lost due to DFU somewhere in the world nontraumatic lesions of the skin on the foot distal to malleoli
every 30 seconds [7]. DFU is the most common cause of hos- of a person who has diabetes mellitus.
pitalization in diabetic patients and also has significant socio- Clinically suspected patient with Charcot foot: patients
economic impact [8, 9]. It is estimated that a person with having DM for a long period of time and presented with a
diabetes has a 25% lifetime risk of developing DFU [10]. low level of sensation, swelling, and foot associated with mid-
Patients with DFU have a greater than twofold increase in foot collapse.
mortality compared with nonulcerated diabetic patients Peripheral neuropathy: this is defined as a patient with
[11]. Five-year mortality rates after ulceration were around history version of MNSI questionnaire score ≥ 7, abnormal
40% [3]. Furthermore, the DFD and its long-term sequelae responses in the legs and/or if the lower extremity examina-
account for direct medical expenditures and lengthy periods tion version of MNSI scores ≥2.5 in the legs [18].
of disability [12] . Foot deformities: these are the presence of any of the fol-
According to a systematic review in 2017, the prevalence lowing structural abnormalities in one or both feet: hammer
of foot ulcers among diabetic patients ranges from 3% to 13% toes, claw-toes, hallux valgus, prominent metatarsal heads,
globally [13]. In Africa, with constrained resources, the prev- and amputations.
alence of DFU is higher. In sub-Saharan Africa, the burden of
DFU is increasing due to late diagnosis, poor awareness
2.6. Sample Size Calculation and Sampling Procedure. The
among patients, and poor access to health care [13, 14].
sample size was calculated using single population propor-
DFU is preventable, and frequency of lower limb ampu-
tion formula by considering the prevalence of diabetic foot
tations can be lowered by 49-87% by preventing the develop-
ulcer in Gondar, Ethiopia at 13.6% [19] at 95% confidence
ment of DFU. Evidence in the literature suggests that the
level and a 4% margin of error. It gives an initial sample size
early detection and treatment of diabetic foot complications
of 280. Since the source population of diabetic patients at the
could reduce the prevalence of ulceration by 44% to 85%
JMC clinic is less than 10,000, about 2500, by using the pop-
[15, 16]. Increased age, male gender, peripheral vascular dis-
ulation correction formula for a finite population, the final
ease, peripheral neuropathy, and renal disease were common
sample size was calculated to be 251. By taking into consider-
risk factors for death after ulceration [3]. Patients at risk of
ation a 10% nonresponse rate, the final sample size was 277.
developing DFU can easily be identified by clinical examina-
A systematic random sampling technique was employed
tion of the feet during follow-up [17]. Early screening of
to select study participants. The diabetes clinic runs twice
high-risk patients is important to prevent development of
weekly, and there were about 2500 diabetic patients on
foot ulcers and its associated morbidity. To date, data regard-
follow-up taken from the diabetes mellitus outpatient unit
ing prevalence and factors related to foot ulcers among
manager. These patients were our sampling frame, and the
diabetic patients in Jimma are relatively few, and point prev-
patients included in the sample were selected at every ninth
alence varies in previous studies. So, the aim of this study is to
interval. We got the interval by dividing the source popula-
solve this gap.
tion (2500) to the final sample size (277) and obtained nine.
The first patient was selected randomly from the first ninth
2. Methods by a lottery method, and the next patient was interviewed
2.1. Study Area and Period. This study was conducted in and examined every ninth interval until the required sample
Jimma Medical Center (JMC) which is located in Jimma was attained.
town, Jimma zone, 355 km to the southwest of Addis Ababa,
the capital city of Ethiopia. JMC is one of the largest hospitals 2.7. Data Collection Tool. Data were collected through a val-
in our country serving a very large catchment area in the idated, pretested, and structured questionnaire which was
Southwestern Oromia region. It gives different specialized developed after reviewing different literatures. The question-
clinical services including chronic follow-up for diabetes naire contains sociodemographic factors, behavioral vari-
mellitus, hypertension, and other chronic illnesses. The study ables, clinical variables, and anthropometric measurements.
was conducted from June 1 to August 30, 2019. Clinical variables were taken from the patient record
review, and anthropometric measurements were measured.
2.2. Study Design. An institution-based cross-sectional study
Body weight was measured while wearing light clothes by
was conducted among adult diabetic patients on the follow-
an adjusted weight scale. Height was measured by meter,
up clinic at Jimma Medical Center.
standing upright on a flat surface. Behavioral variables were
2.3. Population. The source population includes all adult assessed based on the WHO STEPwise approach for chronic
diabetic patients on the follow-up clinic at JMC, while the disease risk factor surveillance [20]. BMI was calculated as
study population was all adult diabetic patients who were kg/m2 to determine the nutritional status of the participant.
under routine follow-up at the JMC during the study period. Data collection was carried out by 2 BSC nurses and one
medical intern with supervision of the principal investigator.
2.4. Eligibility Criteria. Participants of age ≥ 18 years were After overnight fasting, blood samples were obtained for
included, and those who were seriously ill, gestational laboratory evaluation. The Michigan Neuropathy Screening
diabetic, diabetic patients who had traumatic ulcer, and Instrument was used to evaluate the presence of diabetic
clinically suspected of having Charcot foot were excluded. peripheral neuropathy (DPN) [21].
Journal of Diabetes Research 3

Table 1: Sociodemographic characteristics of patients with diabetes Table 2: Clinical and behavioral characteristics of patients with
mellitus at JMC 2019, Jimma, Ethiopia. diabetes mellitus at JMC 2019, Jimma, Ethiopia.

Variables Category Number Percentage Variables Category Number Percentage

Male 165 59.6 1 48 17.3
Sex Type of DM
Female 112 40.4 2 229 82.7
<30 32 11.6 <5 years 156 56.3
30 to 39 24 8.7 Duration of DM 5 to 10 years 73 26.4
Age (in years)
40 to 49 72 26 ≥10 years 48 17.3
≥50 149 53.8 <18.5 29 10.5
Married 224 80.9 18.5 to 24.9 189 68.2
BMI
Marital status Single 44 15.9 25-29.9 44 15.9
Others∗ 9 3.2 ≥30 15 5.4

Illiterate 86 31 Current 33 11.9

Primary 119 43 Alcohol intake Former 25 89
Education status
Secondary 34 12.3 Never 219 79.1
College and above 38 13.7 Current 14 5.1
Housewife 84 30.3 Smoking Former 41 14.8
Farmer 87 31.4 Never 222 80.1
Occupational status Employer 56 20.2 Active 115 41.5
Physical exercise
Private worker 36 13 Inactive 162 58.5
Others† 14 5.1
Yes 86 31
Urban 86 31 Comorbid hypertension
No 191 69
Residence
Rural 191 69
<200 mg/dl 204 26.4
<1000 Fasting blood sugar
83 30 ≥200 mg/dl 73 73.6
Income 1000 to 1999 33 11.9
Yes 90 32.5
(Ethiopian birr) 2000 to 2999 64 23.1 History of ulceration
No 187 67.5
≥3000 97 35
Yes 129 46.6
∗
Widowed and divorced; †retired and unemployed. Peripheral neuropathy
No 148 53.4
2.8. Data Analysis. The collected data were checked for com- Yes 97 35
pleteness and coded. Then, the data were entered into Epi- Foot deformity
No 180 65
Data version 3.1 and then exported to SPSS version 20.0 for
analysis. Descriptive statistics such as frequencies, percent-
ages, means, and standard deviations were computed as nec- completeness. Consequently, amendments and corrections
essary. Bivariate and multivariate logistic regression models were made.
were used to determine the degree of association between
the outcome and predictor variables. Variables having a p 2.10. Ethical Consideration. Ethical clearance was obtained
value of <0.25 in the bivariate model were subjected to mul- from the Jimma University Institutional Review Board. A
tivariate analysis to avoid confounding the variables’ effect. supportive formal letter was written to Jimma Medical Cen-
The goodness of fit of the multivariate model was checked ter. Data collection was done after permissions were obtained
with the Hosmer and Lemeshow test (p = 0:32). p value ≤ from hospital managers, and oral informed consent was
0.05 was taken as statistically significant. obtained from the study participants to start data collection.

2.9. Data Quality Assurance. Data quality was ensured 3. Result

through standardized data collection materials, and ques-
tionnaires were thoroughly checked for completeness and 3.1. Sociodemographic Characteristics of Participants. A total
consistency. To ensure the quality of data and cultural accep- of two hundred and seventy-seven participants were involved
tance of the tool, pretests of data collection tools were carried in this study. More than half (165) of the respondents were
out on 14 diabetes patients attending the Shenen Gibe hospi- males and the rest (112) were females. The mean age of the
tal diabetic clinic prior to actual data collection. After analyz- respondents was 50:1 ± 14:28 years. Regarding the marital sta-
ing pretest results, necessary modifications and corrections tus of the respondents, more than three-fourths (224, 80.9%)
were made. Every day, the collected data was checked for were married followed by singles (44, 15.9%) (Table 1).
4 Journal of Diabetes Research

Table 3: Independent predictors of diabetic foot ulcer among diabetic patients at JMC 2019, Jimma, Ethiopia.

Diabetic foot ulcer Bivariate analysis Multivariate analysis

Variables Category
Yes No p value COR (95% CI) p value AOR (95% CI)
<30 1 31 1 1 1 1
30-39 2 22 0.409 2.8 (0.24, 33.04) ∗∗
Age
40-49 9 63 0.167 4.4 (0.54, 36.5) ∗∗
≥50 29 129 0.133 4.8 (0.62, 37.2)
Current 8 23 0.023 2.91 (1.15, 7.33) ∗∗

Smoking 0.547 (0.156, ∗∗

Former 3 46 0.345
1.91)
Never 21 176 1 1 1 1
Active 10 105 1 1 1 1
Physical exercise
Inactive 22 140 0.21 1.65 (0.75, 3.63) ∗∗

Peripheral Yes 27 95 0.00 8.53 (3.17, 22.9) 0.001∗ 11.2 (2.8, 44.4)
neuropathy No 5 150 1 1 1 1
Yes 23 67 0.00 6.78 (2.99, 15.41) 0.00∗ 5.77 (2.37, 14.0)
History of ulceration
No 9 178 1 1 1 1
Current 1 32 0.136 0.21 (0.028, 1.62) ∗∗
Alcohol intake Ex-drinker 3 22 0.911 0.93 (0.26, 3.31)
Never 28 191 1 1 1 1
T1DM 3 45 0.216 0.46 (0.13, 1.57) ∗∗
Type of DM
T2DM 29 200 1 1
No 14 166 1 1 1 1
Foot deformity
Yes 18 79 0.009 0.37 (0.175, 782) ∗∗
∗
Value statistically significant. AOR: adjusted odds ratio; COR: crude odds ratio; CI: confidence interval 1-reference. ∗∗ Not statistically associated with diabetic
foot ulcer.

3.2. Clinical and Behavioral Characteristics of Participants. CI: 7.9, 15.5). This finding is in line with three independent
Greater than three-fourths (82.7%) of the participants were studies done in Ethiopia, 13.6% in Gondar, 12% in Mekelle,
type 2 DM. More than half (56.3%) of them were diagnosed and 14.8% in Arbaminch [19, 22, 23]. In addition, similar
with diabetes for less than 5 years, and almost one-third finding in North India (14.3%) and in Tanzania (15%)
(31%) had no comorbid hypertension. A total of 189 [24, 25]. However, this finding was lower than the study
(68.2%) of the study participants were in the normal category done in Addis Ababa, Ethiopia (31.1%) [26]; Telangana,
of BMI, whereas 44 (15.9%) of the participants were over- India (16%) [27]; and Jordan (4.6%) [28]. The possible rea-
weight. One hundred twenty-nine (46.6%) had diabetic son for such discrepancy might be due to difference in
peripheral neuropathy (Table 2). sample size used, study design, knowledge about foot self-
care, health-seeking behavior, and health infrastructure of
3.3. Factors Independently Associated with Diabetic Foot study participants.
Ulcer. Diabetic patients who had peripheral neuropathy were In contrast, the finding of the current study is higher than
11.2 times more likely to develop diabetic foot ulcer as com- a study conducted in Kenya which reported 4.6% [29];
pared with those who had no peripheral neuropathy Wollo, Ethiopia (4.4%) [30]; and Ghana which was 3.8%
(AOR = 11:2; 95% CI 2.8, 44.4; p = 0:001). Likewise, diabetic [31]. The possible difference might be due to difference in
patients who had a history of ulceration were 5.77 times more sample size, study design, and eligibility criteria.
likely to develop diabetic foot ulcer as compared with those The current finding demonstrated that participants
who had no history of ulceration (p value = 0.00; AOR = who had peripheral neuropathy were 11.2 times more
5:77; 95% CI 2.37, 14.0) provided other factors remain the likely to develop diabetic foot ulcer than diabetic patients
same (Table 3). without peripheral neuropathy (AOR = 11:2; 95% CI: 2.8,
44.4). This result is consistent with prior studies [19,
4. Discussion 27].This association is possibly because DPN promotes
ulcer formation by causing loss of protective pain sensa-
In the present study, the prevalence of diabetic foot ulcers tion, loss of pressure perception, and impairment of micro-
among diabetic patients attending JMC was 11.6% (95% circulation [32, 33].
Journal of Diabetes Research 5

Furthermore, according to the current finding, partici- approving the proposal. DD wrote the proposal, participated
pants who had a history of foot ulceration were 5.77 times in data collection, analyzed the data, and drafted the paper.
more likely to develop diabetic foot ulcer than those without DA and TA participated by revising and approving the
a previous history of foot ulceration (AOR = 5:77; 95% CI: proposal, participated in the data analysis, and revised subse-
2.37, 14). The result is consistent with prior studies in Ghana quent drafts of the paper. All authors read and approved the
and England [31, 34]. This association can be explained by final manuscript data analysis and revised subsequent drafts
biomechanical factors such as the degree of barefoot and of the paper.
in-shoe mechanical stress and the level of adherence to wear-
ing prescribed footwear. In addition, it may be due to the fact
that ulcer leads to microvascular dysfunction, macrovascular Acknowledgments
dysfunction, and peripheral nerve damage [35].
First of all, I would like to praise my God; without his help, all
5. Conclusion this would have been impossible. Also, I want to acknowledge
my data collectors, colleagues, and study participants. Lastly,
The prevalence of diabetic foot ulcer was 11.6% among study I would like to thank Jimma University Medical Center for
participants. Previous history of ulceration and peripheral providing relevant information.
neuropathy were independent predictors of diabetic foot
ulcer. The health care providers are recommended to give
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