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Clinic at Jimma Medical Center, Southwest Ethiopia, 2019: An Institutional-Based Cross-Sec…

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J Diabetes Res. 2020 Mar 15;2020:4106383. doi: 10.1155/2020/4106383

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, Diriba Dereje 3

Author information Article notes Copyright and License information

PMCID: PMC7102459 PMID: 32258165

Abstract

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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 <0.25
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

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

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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

Diabetes has reached epidemic proportions worldwide. The International Diabetes Federation
(IDF) estimates 425 million people living with DM worldwide in 2017, estimated to rise to 628
million by 2045. Sub-Saharan Africa is currently enduring the heaviest global burden of
diabetes [1, 2].

Diabetic foot disease (DFD) is one of the diabetic complications associated with major
morbidity, mortality, and reduced quality of life and is the most serious complication of
diabetes mellitus [3, 4]. The incidence of DFD is still rising [5]. According to the international
consensus on diabetic foot, a foot ulcer is defined as a full-thickness wound below the ankle in
a diabetic patient, irrespective of duration [6].

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The International Diabetes Federation estimates that at least one limb is lost due to DFU
somewhere in the world every 30 seconds [7]. DFU is the most common cause of
hospitalization in diabetic patients and also has significant socioeconomic impact [8, 9]. It is
estimated that a person with diabetes has a 25% lifetime risk of developing DFU [10]. Patients
with DFU have a greater than twofold increase in mortality compared with nonulcerated
diabetic patients [11]. Five-year mortality rates after ulceration were around 40% [3].
Furthermore, the DFD and its long-term sequelae account for direct medical expenditures and
lengthy periods of disability [12] .

According to a systematic review in 2017, the prevalence of foot ulcers among diabetic
patients ranges from 3% to 13% globally [13]. In Africa, with constrained resources, the
prevalence of DFU is higher. In sub-Saharan Africa, the burden of DFU is increasing due to late
diagnosis, poor awareness among patients, and poor access to health care [13, 14].

DFU is preventable, and frequency of lower limb amputations can be lowered by 49-87% by
preventing the development of DFU. Evidence in the literature suggests that the early detection
and treatment of diabetic foot complications could reduce the prevalence of ulceration by 44%
to 85% [15, 16]. Increased age, male gender, peripheral vascular disease, peripheral neuropathy,
and renal disease were common risk factors for death after ulceration [3]. Patients at risk of
developing DFU can easily be identified by clinical examination of the feet during follow-up
[17]. Early screening of high-risk patients is important to prevent development of foot ulcers
and its associated morbidity. To date, data regarding prevalence and factors related to foot
ulcers among diabetic patients in Jimma are relatively few, and point prevalence varies in
previous studies. So, the aim of this study is to solve this gap.

2. Methods

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2.1. Study Area and Period

This study was conducted in Jimma Medical Center (JMC) which is located in Jimma town,
Jimma zone, 355 km to the southwest of Addis Ababa, the capital city of Ethiopia. JMC is one of
the largest hospitals in our country serving a very large catchment area in the Southwestern
Oromia region. It gives different specialized clinical services including chronic follow-up for
diabetes mellitus, hypertension, and other chronic illnesses. The study was conducted from
June 1 to August 30, 2019.

2.2. Study Design

An institution-based cross-sectional study was conducted among adult diabetic patients on the
follow-up clinic at Jimma Medical Center.

2.3. Population

The source population includes all adult diabetic patients on the follow-up clinic at JMC, while
the study population was all adult diabetic patients who were under routine follow-up at the
JMC during the study period.

2.4. Eligibility Criteria

Participants of age ≥ 18 years were included, and those who were seriously ill, gestational
diabetic, diabetic patients who had traumatic ulcer, and clinically suspected of having Charcot
foot were excluded.

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2.5. Operational Definition

Diabetic foot ulcer: these are nontraumatic lesions of the skin on the foot distal to malleoli of a
person who has diabetes mellitus.

Clinically suspected patient with Charcot foot: patients having DM for a long period of time and
presented with a low level of sensation, swelling, and foot associated with midfoot collapse.

Peripheral neuropathy: this is defined as a patient with history version of MNSI questionnaire
score ≥ 7, abnormal responses in the legs and/or if the lower extremity examination version of
MNSI scores ≥2.5 in the legs [18].

Foot deformities: these are the presence of any of the following structural abnormalities in one
or both feet: hammer toes, claw-toes, hallux valgus, prominent metatarsal heads, and
amputations.

2.6. Sample Size Calculation and Sampling Procedure

The sample size was calculated using single population proportion formula by considering the
prevalence of diabetic foot ulcer in Gondar, Ethiopia at 13.6% [19] at 95% confidence level and
a 4% margin of error. It gives an initial sample size of 280. Since the source population of
diabetic patients at the JMC clinic is less than 10,000, about 2500, by using the population
correction formula for a finite population, the final sample size was calculated to be 251. By
taking into consideration a 10% nonresponse rate, the final sample size was 277.

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A systematic random sampling technique was employed to select study participants. The
diabetes clinic runs twice weekly, and there were about 2500 diabetic patients on follow-up
taken from the diabetes mellitus outpatient unit manager. These patients were our sampling
frame, and the patients included in the sample were selected at every ninth interval. We got the
interval by dividing the source population (2500) to the final sample size (277) and obtained
nine. The first patient was selected randomly from the first ninth by a lottery method, and the
next patient was interviewed and examined every ninth interval until the required sample was
attained.

2.7. Data Collection Tool

Data were collected through a validated, pretested, and structured questionnaire which was
developed after reviewing different literatures. The questionnaire contains sociodemographic
factors, behavioral variables, clinical variables, and anthropometric measurements.

Clinical variables were taken from the patient record review, and anthropometric
measurements were measured. Body weight was measured while wearing light clothes by an
adjusted weight scale. Height was measured by meter, standing upright on a flat surface.
Behavioral variables were assessed based on the WHO STEPwise approach for chronic disease
risk factor surveillance [20]. BMI was calculated as kg/m2 to determine the nutritional status
of the participant. Data collection was carried out by 2 BSC nurses and one medical intern with
supervision of the principal investigator. After overnight fasting, blood samples were obtained
for laboratory evaluation. The Michigan Neuropathy Screening Instrument was used to
evaluate the presence of diabetic peripheral neuropathy (DPN) [21].

2.8. Data Analysis

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The collected data were checked for completeness and coded. Then, the data were entered into
EpiData version 3.1 and then exported to SPSS version 20.0 for analysis. Descriptive statistics
such as frequencies, percentages, means, and standard deviations were computed as necessary.
Bivariate and multivariate logistic regression models were used to determine the degree of
association between the outcome and predictor variables. Variables having a p value of <0.25 in
the bivariate model were subjected to multivariate analysis to avoid confounding the variables'
effect. The goodness of fit of the multivariate model was checked with the Hosmer and
Lemeshow test (p = 0.32). p value ≤ 0.05 was taken as statistically significant.

2.9. Data Quality Assurance

Data quality was ensured through standardized data collection materials, and questionnaires
were thoroughly checked for completeness and consistency. To ensure the quality of data and
cultural acceptance of the tool, pretests of data collection tools were carried out on 14
diabetes patients attending the Shenen Gibe hospital diabetic clinic prior to actual data
collection. After analyzing pretest results, necessary modifications and corrections were made.
Every day, the collected data was checked for completeness. Consequently, amendments and
corrections were made.

2.10. Ethical Consideration

Ethical clearance was obtained from the Jimma University Institutional Review Board. A
supportive formal letter was written to Jimma Medical Center. Data collection was done after
permissions were obtained from hospital managers, and oral informed consent was obtained
from the study participants to start data collection.

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3. Result

3.1. Sociodemographic Characteristics of Participants

A total of two hundred and seventy-seven participants were involved in this study. More than
half (165) of the respondents were males and the rest (112) were females. The mean age of the
respondents was 50.1 ± 14.28 years. Regarding the marital status of the respondents, more than
three-fourths (224, 80.9%) were married followed by singles (44, 15.9%) (Table 1).

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Table 1.

Sociodemographic characteristics of patients with diabetes mellitus at JMC 2019,

Jimma, Ethiopia.

Variables Category Number Percentage

Sex Male 165 59.6
Female 112 40.4

Age (in years) <30 32 11.6

30 to 39 24 8.7
40 to 49 72 26
≥50 149 53.8

Marital status Married 224 80.9

Single 44 15.9
Others∗ 9 3.2

Education status Illiterate 86 31

Primary 119 43
Secondary 34 12.3
College and above 38 13.7

Occupational status Housewife 84 30.3

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Variables Category Number Percentage

Farmer 87 31.4
Employer 56 20.2
Private worker 36 13
Others† 14 5.1

Residence Urban 86 31
Rural 191 69

Income (Ethiopian birr) <1000 83 30

1000 to 1999 33 11.9
2000 to 2999 64 23.1
≥3000 97 35

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∗Widowed and divorced; †retired and unemployed.

3.2. Clinical and Behavioral Characteristics of Participants

Greater than three-fourths (82.7%) of the participants were type 2 DM. More than half (56.3%)
of them were diagnosed with diabetes for less than 5 years, and almost one-third (31%) had no
comorbid hypertension. A total of 189 (68.2%) of the study participants were in the normal

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category of BMI, whereas 44 (15.9%) of the participants were overweight. One hundred
twenty-nine (46.6%) had diabetic peripheral neuropathy (Table 2).

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Table 2.

Clinical and behavioral characteristics of patients with diabetes mellitus at JMC 2019,
Jimma, Ethiopia.

Variables Category Number Percentage

Type of DM 1 48 17.3
2 229 82.7

Duration of DM <5 years 156 56.3

5 to 10 years 73 26.4
≥10 years 48 17.3

BMI <18.5 29 10.5

18.5 to 24.9 189 68.2
25-29.9 44 15.9
≥30 15 5.4

Alcohol intake Current 33 11.9

Former 25 89
Never 219 79.1

Smoking Current 14 5.1

Former 41 14.8
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Variables Category Number Percentage

Never 222 80.1

Physical exercise Active 115 41.5

Inactive 162 58.5

Comorbid hypertension Yes 86 31

No 191 69

Fasting blood sugar <200 mg/dl 204 26.4

≥200 mg/dl 73 73.6

History of ulceration Yes 90 32.5

No 187 67.5

Peripheral neuropathy Yes 129 46.6

No 148 53.4

Foot deformity Yes 97 35

No 180 65

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3.3. Factors Independently Associated with Diabetic Foot Ulcer

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Diabetic patients who had peripheral neuropathy were 11.2 times more likely to develop
diabetic foot ulcer as compared with those who had no peripheral neuropathy (AOR = 11.2;
95% CI 2.8, 44.4; p = 0.001). Likewise, diabetic patients who had a history of ulceration were
5.77 times more likely to develop diabetic foot ulcer as compared with those who had no
history of ulceration (p value = 0.00; AOR = 5.77; 95% CI 2.37, 14.0) provided other factors
remain the same (Table 3).

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Table 3.

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

Variables Category Diabetic foot Bivariate analysis Multivariate

ulcer analysis
Yes No p value COR (95% p value AOR
CI) (95% CI)
Age <30 1 31 1 1 1 1
30-39 2 22 0.409 2.8 (0.24, ∗∗
33.04)
40-49 9 63 0.167 4.4 (0.54, ∗∗
36.5)
≥50 29 129 0.133 4.8 (0.62,
37.2)

Smoking Current 8 23 0.023 2.91 (1.15, ∗∗

7.33)
Former 3 46 0.345 0.547 ∗∗
(0.156,
1.91)
Never 21 176 1 1 1 1

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Variables Category Diabetic foot Bivariate analysis Multivariate

ulcer analysis
Yes No p value COR (95% p value AOR
CI) (95% CI)
Physical Active 10 105 1 1 1 1
exercise Inactive 22 140 0.21 1.65 (0.75, ∗∗
3.63)

Peripheral Yes 27 95 0.00 8.53 (3.17, 0.001∗ 11.2 (2.8,

neuropathy 22.9) 44.4)
No 5 150 1 1 1 1

History of Yes 23 67 0.00 6.78 (2.99, 0.00∗ 5.77

ulceration 15.41) (2.37,
14.0)
No 9 178 1 1 1 1

Alcohol intake Current 1 32 0.136 0.21 ∗∗

(0.028,
1.62)
Ex- 3 22 0.911 0.93 (0.26,
drinker 3.31)
Never 28 191 1 1 1 1

Type of DM T1DM 3 45 0.216 0.46 (0.13, ∗∗

1.57)

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Variables Category Diabetic foot Bivariate analysis Multivariate

ulcer analysis
Yes No p value COR (95% p value AOR
CI) (95% CI)
T2DM 29 200 1 1

Foot deformity No 14 166 1 1 1 1

Yes 18 79 0.009 0.37 ∗∗
(0.175,
782)

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∗Value statistically significant. AOR: adjusted odds ratio; COR: crude odds ratio; CI:
confidence interval 1-reference. ∗∗Not statistically associated with diabetic foot ulcer.

4. Discussion

In the present study, the prevalence of diabetic foot ulcers among diabetic patients attending
JMC was 11.6% (95% CI: 7.9, 15.5). This finding is in line with three independent studies done
in Ethiopia, 13.6% in Gondar, 12% in Mekelle, and 14.8% in Arbaminch [19, 22, 23]. In addition,
similar finding in North India (14.3%) and in Tanzania (15%) [24, 25]. However, this finding
was lower than the study done in Addis Ababa, Ethiopia (31.1%) [26]; Telangana, India (16%)
[27]; and Jordan (4.6%) [28]. The possible reason for such discrepancy might be due to

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difference in sample size used, study design, knowledge about foot self-care, health-seeking
behavior, and health infrastructure of study participants.

In contrast, the finding of the current study is higher than a study conducted in Kenya which
reported 4.6% [29]; Wollo, Ethiopia (4.4%) [30]; and Ghana which was 3.8% [31]. The possible
difference might be due to difference in sample size, study design, and eligibility criteria.

The current finding demonstrated that participants who had peripheral neuropathy were 11.2
times more likely to develop diabetic foot ulcer than diabetic patients without peripheral
neuropathy (AOR = 11.2; 95% CI: 2.8, 44.4). This result is consistent with prior studies [19,
27].This association is possibly because DPN promotes ulcer formation by causing loss of
protective pain sensation, loss of pressure perception, and impairment of microcirculation [32,
33].

Furthermore, according to the current finding, participants who had a history of foot
ulceration were 5.77 times more likely to develop diabetic foot ulcer than those without a
previous history of foot ulceration (AOR = 5.77; 95% CI: 2.37, 14). The result is consistent with
prior studies in Ghana and England [31, 34]. This association can be explained by
biomechanical factors such as the degree of barefoot and in-shoe mechanical stress and the
level of adherence to wearing prescribed footwear. In addition, it may be due to the fact that
ulcer leads to microvascular dysfunction, macrovascular dysfunction, and peripheral nerve
damage [35].

5. Conclusion

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The prevalence of diabetic foot ulcer was 11.6% among study participants. Previous history of
ulceration and peripheral neuropathy were independent predictors of diabetic foot ulcer. The
health care providers are recommended to give emphasis during follow-up of patients who had
a previous history of ulceration and manage the neuropathy thoroughly in order to decrease
the occurrence of diabetic foot ulcer. In addition, future efforts should be directed toward
educating both the healthcare professionals and patients about proper foot care.

5.1. Limitation of the Study

The duration of diabetes as measured in this study might not reflect the true duration of the
disease, because the time since diagnosis and actual diabetes onset might precede diagnosis
type 2 diabetes. Another limitation is the cross-sectional nature of the study which does not
confirm the definitive cause and effect relation.

We did not asses the vascular status of our study population, so that we could not asses the
prevalence of peripheral arterial disease.

Acknowledgments

First of all, I would like to praise my God; without his help, all this would have been impossible.
Also, I want to acknowledge my data collectors, colleagues, and study participants. Lastly, I
would like to thank Jimma University Medical Center for providing relevant information.

Abbreviations

AOR:

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Adjusted odds ratio

BMI:
Body mass index
CI:
Confidence interval
DM:
Diabetes mellitus
DFD:
Diabetic foot disease
DFU:
Diabetic foot ulcer
COR:
Crude odds ratio
JMC:
Jimma Medical Center.

Data Availability

The original data of this study could be available for the third body only up on authors request.

Conflicts of Interest

The authors of this study declare that they have no competing interests.

Authors' Contributions

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DA conceived the idea, wrote the proposal, analyzed the data, and drafted the [Link]
participated by revising and approving the proposal. DD wrote the proposal, participated in
data collection, analyzed the data, and drafted the paper. DA and TA participated by revising
and approving the proposal, participated in the data analysis, and revised subsequent drafts of
the paper. All authors read and approved the final manuscript data analysis and revised
subsequent drafts of the paper.

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Associated Data

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Data Availability Statement

The original data of this study could be available for the third body only up on authors request.

Articles from Journal of Diabetes Research are provided here courtesy of Wiley

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