Table 2. Effects of variables on level of foot care knowledge among diabetic patients.
*= significant value.
Table 3. Distribution of answers to questions related to level of foot care knowledge.
This study shows the abysmally poor foot care knowledge among diabetic amputees. This is worrisome for two reasons. First, the incidence of diabetes is rising and hence the incidence of complications including LEA is also expected to rise concomitantly  . Secondly, unilateral LEA places the contralateral limb at greater risk of re-amputation   . Thirdly, these patients have been to a healthcare facility where it is generally presumed that education about foot care will be communicated to them before discharge. Some authors have cited the busy clinic duty schedule of the doctors as part of the reasons for this poor communication  . In our hospital it may be worse, as the patient to doctor ratio is quite high, which may leave the doctor with little time to spend with each patient. Other studies have shown poor knowledge among diabetics with and without foot ulcers    .
While most of the patients know that diabetics are at high risk of foot ulcers and amputations (78.6%), only 50% know they should inspect their feet daily. Fifty-seven percent know they should see a doctor to examine their feet at least once per year. The poorest answers were that of keeping in-between the toes dry and never to use hot water bottle on their feet. This poor knowledge despite being aware of the risk of amputation in diabetics is likely a reflection of lack of proper education regarding foot care practices.
The commonest cause of foot trauma in diabetics is inappropriate foot wear  . This, in conjunction with foot deformities  , common in diabetics, can lead to callosities and ulcerations. Questions regarding foot wear showed that about half of them have poor knowledge in this regard. Half of the patients know they should inspect their feet daily, while a little more than half know that a professional should inspect at least once per year. This proportion is lower than that found by Muhammad et al. (70%)  .
Only duration of diabetes and educational level showed a significant association with foot care knowledge. It appears that the long standing diabetic might have had some time to receive some information about foot care. Most studies showed that educational level is associated with a higher level of foot care knowledge      . Only one study showed that educational level does not significantly affect foot care knowledge  . Age, gender, and prior amputation did not affect foot care knowledge. This agrees with other studies   .
Peripheral neuropathy is responsible for about 60% of diabetic foot ulcerations  . In our study, 71% of patients have peripheral neuropathy in the contralateral limb. With the loss of protective sensation and inability to sense micro-trauma, it becomes more imperative to emphasize regular foot care practices to this vulnerable group of patients. This will enable them to identify any foot lesion at the earliest stage.
5. Conclusions and Recommendations
It is clear that health care providers should put more effort in educating diabetic amputees on the risk factors for foot ulcerations, particularly on regular foot exam and appropriate foot wear. Giving them instructional leaflets before they are discharged from the hospitals will further cement such information in their memory. Such leaflets should be in plain and simple, easy to understand language.
Establishment of diabetic foot clinics, where periodic assessment of these patients will be undertaken cannot be over-emphasized. Such clinics have been shown to reduce the incidence of amputations   . Other measures such as mass campaigns and radio jingles have been shown to be effective in communicable diseases such as HIV/AIDS  . Since the incidence of diabetes is increasing  , and the burden of diabetic foot disease is expected to follow suit, it becomes necessary to sensitize the public about it.
Multicenter study to increase the number of participants would be more desirable.
The study only looked at knowledge and did not study practice. Knowledge does not automatically translate to practice and such assumption must not be made based on this study.
 Carrington, A.L., Abbott, C.A., Griffiths, J., Jackson, N., Johnson, S.R., Kulkarni, J., et al. (2001) A Foot Care Program for Diabetic Unilateral Lower-Limb Amputees. Diabetes Care, 24, 216-221.
 Frederiks, J.P. and Visagie, S. (2013) The Rehabilitation Programme and Functional Outcomes of Persons with Lower Limb Amputations at a Primary Level Rehabilitation Centre. South African Journal of Occupational Therapy, 43, 18-28.
 Hambleton, I.R., Jonnalagadda, R., Davis, C.R., Fraser, H.S., Chaturvedi, N. and Hennis, A.J. (2009) All-Cause Mortality after Diabetes-Related Amputation in Barbados. Diabetes Care, 32, 306-307.
 Nongmaithem, M., Bawa, A.P.S., Pithwa, A.K., Bhatia, S.K., Singh, G. and Gooptu, S. (2016) A Study of Risk Factors and Foot Care Behavior among Diabetics. Journal of Family Medicine and Primary Care, 5, 399-403.
 Ikpeme, I.A., Udosen, A.M., Ngim, N.E., Ikpeme, A.A., Amah, P., Bello, S., et al. (2010) Footcare Practices among Nigerian Diabetic Patients Presenting with Foot Gangrene. African Journal of Diabetes Medicine, 18, 10.
 Desalu, O.O., Salawu, F.K., Jimoh, A.K., Adekoya, A.O., Busari, O.A. and Olokoba, A.B. (2011) Diabetic Foot Care: Self Reported Knowledge and Practice among Patients Attending Three Tertiary Hospital in Nigeria. Ghana Medical Journal, 45, 60-65.
 Goie, T.T. and Naidoo, M. (2017) Awareness of Diabetic Foot Disease amongst Patients with Type 2 Diabetes Mellitus Attending the Chronic Outpatients Department at a Regional Hospital in Durban, South Africa. African Journal of Primary Health Care & Family Medicine, 8, 1170.
 Muhammad-Lutfi, A., Zaraihah, M. and Anuar-Ramdhan, I. (2014) Knowledge and Practice of Diabetic Foot Care in an In-Patient Setting at a Tertiary Medical Center. Malaysian Orthopaedic Journal, 8, 22-26.
 Dahiru, I.L., Amaefule, K.E., Okpe, I.O., Ibrahim, A. and Muazu, S.B. (2016) An Overview of Diabetic Foot Disease. Nigerian Journal of Basic and Clinical Sciences, 13, 1.
 Saurabh, S., Sarkar, S., Selvaraj, K., Kar, S.S., Kumar, S.G. and Roy, G. (2014) Effectiveness of Foot Care Education among People with Type 2 Diabetes in Rural Puducherry, India. Indian Journal of Endocrinology and Metabolism, 18, 106-110.
 Ren, M., Yang, C., Lin, D.Z., Xiao, H.S., Mai, L.F., Guo, Y.C., et al. (2014) Effect of Intensive Nursing Education on the Prevention of Diabetic Foot Ulceration among Patients with High-Risk Diabetic Foot: A Follow-Up Analysis. Diabetes Technology & Therapeutics, 16, 576-581.