Factors influencing gestational diabetes self-care among pregnant women in a Syrian Refugee Camp in Jordan

AIM

The main objective of this study is to identify the level of self-care practices and the determinants of Gestational Diabetes Mellitus (GDM) among pregnant women residing in one of the refugee camps in Jordan.

METHOD

A cross-sectional study was conducted on a convenient sample of forty women diagnosed with GDM from the high-risk maternity clinic in one of the Syrian refugee camps in Jordan. The study used the Gestational Diabetes Management Self-Efficacy Scale (GDMSES), Diabetes Knowledge (DMK) assessment, and Diabetes Self-Care Activities Questionnaire (SDSCA) to measure the variables of interest. Descriptive analysis and Multiple logistic regression were used to assess for significant factors.

RESULTS

Significant associations were found between the subcategories of diet, exercise, and blood sugar control in both the self-efficacy and self-activity scales (p < 0.01, p < 0.01, p < 0.05), respectively. Two factors were associated with higher GDM self-care: diabetes knowledge and higher self-efficacy toward GDM self-care (p < 0.05).

CONCLUSION

The findings of this study highlight that pregnant women with GDM who have higher levels of self-efficacy and diabetes knowledge are more likely to achieve higher levels of GDM self-care. Beside developing health promotion programs to enhance women's self-efficacy in adhering to GDM care, adequate support and relevant resources to facilitate GDM management among refugee women are recommended. Future research for identifying other potential factors affecting GDM self-care among refugees is highly recommended.

Prevalence and Associated Factors of Toenail Onychomycosis Among Patients with Diabetes in Jordan

BACKGROUND

Toenail onychomycosis is common in patients with diabetes and it can increase the risk of secondary infections and foot complications. Despite several studies investigating the prevalence and associated factors of toenail onychomycosis from different parts of the world, there are no data from Jordan.

OBJECTIVE

To determine the prevalence and the associated factors of toenail onychomycosis among patients with diabetes in Jordan.

METHODS

A cross-sectional study was conducted on 375 patients with diabetes at the National Centre for Diabetes, Endocrinology, and Genetics in Amman, Jordan. Several socio-demographic and health-independent variables including foot self-care practices were collected. Toenail onychomycosis was assessed by a specimen culture and microscopic examinations. Descriptive and inferential statistics were used for data analysis.

RESULTS

The prevalence of toenail onychomycosis was 57.6% (n=216). Multiple logistic regression revealed four significant associated factors; the presence of neuropathy (β=1.87, p=0.02), being an ex-smoker (β=2.69, p=0.01), being treated by both insulin and oral hypoglycemics drugs (β=1.32, p=0.03), and using antibiotics in the last year (β=1.78, p=0.02).

CONCLUSION

The prevalence of toenail onychomycosis among patients with diabetes in Jordan is high. Regular foot screening and podiatric care are recommended especially among patients with diabetic neuropathy, current treatment by insulin and oral hypoglycemics drugs, previous history of smoking, and previous use of antibiotics.

A qualitative exploration of adherence to wearing removable cast walkers in patients with diabetic foot ulcers

OBJECTIVE

To explore adherence to wearing removable cast walkers (RCWs) among patients with diabetic foot ulcers (DFUs).

METHOD

A qualitative study was conducted by interviewing patients with active DFUs and using knee-high RCWs as their offloading treatment. The interviews were undertaken at two diabetic foot clinics in Jordan, using a semi-structured guide. Data were analysed through content analysis by developing main themes and categories.

RESULTS

Following interviews with 10 patients, two main key themes with a total of six categories were identified: theme 1-reporting of adherence levels was inconsistent, included two categories: i) a belief in achieving optimal adherence, and ii) non-adherence was often reported indoors; and theme 2-adherence was a consequence of multiple psychosocial, physiological and environmental factors, which included four categories: i) specific offloading knowledge or beliefs influenced adherence; ii) severity of foot disease influenced adherence; iii) social support benefitted adherence; and iv) physical features of RCWs (the usability of the offloading device) impacted adherence.

CONCLUSION

Patients with active DFUs reported inconsistent levels of adherence to wearing RCWs which, after deeper investigation, seemed to be due to participants' misperceptions of the optimal adherence. Adherence to wearing RCWs also seemed to be impacted by multiple psychosocial, physiological and environmental factors.

The Validity and Reliability of Self-Reported Adherence to Using Offloading Treatment in People with Diabetes-Related Foot Ulcers

Adherence to using offloading treatment is crucial to healing diabetes-related foot ulcers (DFUs). Offloading adherence is recommended to be measured using objective monitors. However, self-reported adherence is commonly used and has unknown validity and reliability. This study aimed to assess the validity and reliability of self-reported adherence to using removable cast walker (RCW) offloading treatment among people with DFUs. Fifty-three participants with DFUs using RCWs were included. Each participant self-reported their percentage adherence to using their RCW of total daily steps. Participants also had adherence objectively measured using dual activity monitors. After one week, a subset of 19 participants again self-reported their percentage adherence to investigate test-retest reliability. Validity was tested using Pearson's r and Bland-Altman tests, and reliability using Cohen's kappa. Median (IQR) self-reported adherence was greater than objectively measured adherence (90% (60-100) vs. 35% (19-47), p < 0.01). There was fair agreement (r = 0.46; p < 0.01) and large 95% limits of agreement with significant proportional bias (β = 0.46, p < 0.01) for validity, and minimal agreement for test-retest reliability (K = 0.36; p < 0.01). The validity and reliability of self-reported offloading adherence in people with DFU are fair at best. People with DFU significantly overestimate their offloading adherence. Clinicians and researchers should instead use objective adherence measures.

Factors Associated With Self-Efficacy of Foot Self-Care Among Patients With Diabetes Attending a Tertiary Care Center in Saudi Arabia

Several reports have shown self-efficacy to be a reliable way of predicting foot self-care behavior in patients with diabetes. However, at a global level in general, and in Saudi Arabia in particular, investigation of the factors related to self-efficacy in executing foot self-care continues to remain inadequate. This study endeavors to identify the factors associated with the self-efficacy of foot self-care among patients with diabetes in Saudi Arabia. From a tertiary diabetes care center in Saudi Arabia, 175 patients with diabetes were selected to participate in this cross-sectional study. Employing the Arabic version of the Foot Care Confidence Scale (FCCS), the principal end results and the sociodemographic, clinical, and psychosocial independent variables were collected and assessed. From the total reported FCCS score, the mean was found to be 28.1 ± 8.2. Multiple linear regression analysis indicated 2 independent factors were positively associated with a higher reported FCCS score; being middle-aged (< 60 years old) (β=0.31, P< .01) and having a higher score on the Foot Care Outcome Expectations Scale (FCOES) (β=0.36, P< .01). In conclusion, patients with diabetes in Saudi Arabia have a mild level of self-efficacy to perform the needed foot self-care. Therefore, this has turned the spotlight on the young or middle-aged < 60-year-old Saudi population with diabetes as the target group, making them the priority for future self-efficacy promotion programs to upgrade the level of foot self-care.

Differences in adherence to using removable cast walker treatment during daytime and nighttime weight-bearing activities in people with diabetes-related foot ulcers

AIMS

Patients' adherence to using knee-high offloading treatment is critical to effective healing of diabetes-related foot ulcers (DFUs). Previous studies have found that patients generally have low adherence to using removable knee-high offloading treatments, yet no study has investigated whether their adherence differs during daytime and nighttime. This study aimed to investigate the levels and factors associated with adherence to using knee-high removable cast walker (RCW) treatment during daytime and nighttime weight-bearing activities in people with DFUs.

METHODS

This was a secondary analysis of data collected from a multi-centre cross-sectional study investigating adherence to using knee-high RCWs among 57 participants with DFUs. All participants had multiple socio-demographic, physiological and psychosocial factors collected, before having their adherence to using RCWs during weight-bearing activity monitored over a 1-week period using the dual activity monitor method. Adherence data were categorised into daytime (06:00-18:00) and nighttime (18:00-06:00) periods and calculated separately. Multiple linear regression was used to identify factors associated with daytime and nighttime adherence.

RESULTS

Mean adherence to using RCW during weight-bearing activities in people with DFUs was higher during daytime compared with nighttime [39.9% (SD = 18.9) versus 20.4% (SD = 16.7), p < 0.001]. Factors independently associated with lower adherence during daytime were being male, longer diabetes duration, not having peripheral artery disease (PAD), and higher perceived RCW heaviness. Factors associated with lower adherence during nighttime were higher mean daytime steps, not having retinopathy and having dyslipidaemia.

CONCLUSIONS

Adherence to using RCWs during weight-bearing activities reduced significantly at nighttime compared with daytime among people with DFUs, and this was associated with different factors. Interventions to improve adherence, in research and clinical practice, should incorporate methods to target daytime or nighttime adherence specifically.

Factors Associated With Foot Self-Care in Patients With Diabetes-Related High-Risk Feet: A Cross-Sectional Design

Foot self-care has been commonly studied among people with diabetes. Previous research on foot self-care among those with diabetes-related high-risk feet is almost unavailable or very limited. The current study aims to fill this gap and provide a contemporary unprecedented analysis of this area of specialization. To assess the levels of, and factors associated with foot self-care among people with diabetes-related high-risk feet. A multi-center cross-sectional study from Jordan assessed the foot self-care of 107 participants with diabetes-related high-risk feet. Multiple socio-demographic, physiological, and psychosocial factors were collected, and the Arabic version of the diabetes foot self-care behavior scale was used to estimate the foot self-care of the study population. A multiple linear regression model was employed to identify factors associated with foot self-care. The mean score of foot self-care was 25.4 ± 7.1 (35 is the highest) indicating ~73% of adherence to foot self-care. Factors associated with higher foot self-care were being treated at the King Abdullah University Hospital (β = .30, P < .01) and reporting higher scores of patients' interpretations about neuropathy physical causes of foot ulcers (β = ".22," P = .02). People with diabetes-related high-risk feet reported a relatively adequate foot self-care practice. However, clinicians are still required to enhance foot self-care among this population. Health promotion programs may benefit from engaging people in understanding the pathophysiology of diabetes-related foot ulcers to improve foot self-care practices.

Factors associated with adherence to using removable cast walker treatment among patients with diabetes-related foot ulcers

INTRODUCTION

Adherence to using knee-high offloading treatment is critical for healing diabetes-related foot ulcers (DFUs). However, few studies have investigated patients' adherence to using knee-high offloading treatment. We aimed to investigate the levels and factors associated with adherence to using knee-high removable cast walker (RCW) treatment among patients with DFUs.

RESEARCH DESIGN AND METHODS

In this multicenter cross-sectional study, we investigated adherence to using knee-high RCWs in 57 participants with DFUs. All participants were clinically examined for multiple sociodemographic, physiological, and psychosocial factors. Each participant's adherence level to using RCWs was then objectively measured using dual activity monitors (attached to the wrist and RCW) over a 1-week period. Multiple linear regression was undertaken to determine those factors independently associated with adherence levels.

RESULTS

The mean adherence level to using RCWs was 33.6% (SD 16.5) of weight-bearing activity. Factors independently associated with lower adherence levels were being male, longer diabetes duration, not having peripheral artery disease (PAD), and having higher perceived RCW heaviness (p≤0.05). No associations were found with psychosocial factors.

CONCLUSIONS

Patients with DFUs adhered to using their RCWs on average for only a third of their prescribed weight-bearing treatment duration. Factors linked to lower RCW adherence levels were being male, longer diabetes duration, not having PAD, and perceived heavier RCWs. These findings highlight the importance of using gold standard non-removable knee-high offloading device treatment. Furthermore, these findings suggest, when gold standard devices are containdicated, that these factors be considered when prescribing the second choice RCW offloading treatment to optimise adherence. Regardless, further longitudinal studies are needed to confirm these factors.

Women with atrial fibrillation in the Middle East: utilization of oral anticoagulant agents in a population with bad baseline clinical profiles and risk scores

Background

Atrial fibrillation (AF) is the most common sustained arrhythmia in women and men worldwide and in the Middle East. Several studies have shown that women with AF are undertreated despite worse baseline clinical and risk profiles compared with men. It is largely unknown if this also applies to Middle Eastern AF patients.

Purpose

To evaluate baseline clinical features and utilization of guideline-recommended oral anticoagulant medications (OACs) in Middle Eastern women with AF.

Methods

The Jordan AF prospective multicenter study enrolled 2160 patients with AF, including 1164 (53.9%) women, in 20 hospital and outpatient clinics (May 2019 through January 2021).

Results

Nonvalvular AF was present in 1038 (91.0%) of women and 935 (94.6%) of men. Compared with men, women were older (mean age 69.2±11.5 years vs. 66.1±14.9 years, p&lt;0.001), and had higher prevalence of hypertension (79.1% vs. 69.5%, p&lt;0.001), diabetes (46.1% vs. 41.7%, p=0.04) and obesity (60.5% vs. 34.6%, p&lt;0.001). Women, however, had lower prevalence of two comorbidities; heart failure (21.5% vs. 28.6, p=0.001) and coronary artery disease (7.7% vs. 15.4%, p&lt;0.001) compared with men. Rate of utilization of oral anticoagulant agents (OACs) was higher in women than men with high and intermediate CHA2DS2 VASc scores (Table). Direct OACs were used in 64.0% of women and 63.3% of men with high risk score (p=NS). Multivariate analysis did not show sex to be an independent predictor of use of OACs.

Conclusions

Middle Eastern women with AF have worse baseline clinical and risk score profiles compared with men. In disagreement with other regional studies, the majority of these women received guideline-recommended OACs.

Funding Acknowledgement

Type of funding sources: None.

Cross-Cultural Adaptation and Reliability Testing of Arabic Versions of Several Diabetic Foot Psychosocial Scales

The main aims of this study were cross-cultural adaptation and reliability testing of an Arabic version of Foot Care Confidence Scale (FCCS), Foot Care Outcomes Expectations Scale (FCOES), Patient Interpretation of Neuropathy Scales (PINS), Neuropathy-specific Quality of Life Scales (NQOLS), and offloading-related Visual Analog Scales (VAS). Two phases of translation and reliability testing were conducted in Jordan. Phase 1 included 2 forward and backward translations with 2 panel consensuses (translators, clinicians, and experts). In Phase 2, Cronbach's alpha (α) and intraclass correlation coefficient (ICC) were used to test the internal consistency and stability (test-retest) of the Arabic scales in a sample of a total of 90 Jordanian participants with diabetic foot ulcers. Phase 1 resulted in Arabic translation and cross-cultural adaptation of the study scales. Phase 2 resulted in acceptable internal consistency of the translated scales (α = 0.74-0.91), except for the PIN "self/practitioner blame" and "acute ulcer onset" scales (α = 0.57, 0.49, respectively). Test-retest results (ICC) were: FCCS (0.85); FCOES (0.78); PINS (0.043-0.85); NQOLS (0.76-0.90); and offloading-related VAS (0.43-0.90). This study showed evidence of cultural appropriateness and reliability of most of the translated scales, for possible future implementation for the Arabic population.

Prevalence and Associates of Foot Deformities among Patients with Diabetes in Jordan

OBJECTIVES

To determine the prevalence of, and factors associated with, people with foot deformities, among patients with diabetes in Jordan.

METHODS

A cross-sectional study was conducted on 1000 diabetic participants recruited from the National Center for Diabetes, Endocrinology, and Genetics in Jordan. Participants had their feet clinically examined to detect the following foot deformity outcomes: Hallux valgus, claw/hammer toe, prominent metatarsal heads, limited joint mobility, pes cavus, Charcot foot, and amputations. Sociodemographic and health variables were also collected from participants' interviews, medical records, or clinical examination. Logistic regression was used to analyse associations between variables and each foot deformity outcome.

RESULTS

Of the 1000 diabetic patients: Hallux valgus was found in 17.4%, claw\hammer toe in 16%, prominent metatarsal head in 14.2%, limited joint mobility in 9.4%, pes cavus in 3.2%, Charcot foot in 2.1%, and amputations in 1.7%. Hallux valgus was associated with gender (p=0.012), age (p<0.01) and shoe choices (p=0.031); claw\hammer toe was associated with age (p=0.04), retinopathy (p<0.001), sensory and painful neuropathy (p<0.001); limited joint mobility was associated with age only (p=0.001); Charcot foot was associated with glycemic control (p=0.016), hypertension (p<0.000), sensory neuropathy (p<0.001), and painful neuropathy (p<0.001); and, amputations were associated with duration of diabetes (p<0.043), sensory neuropathy (p=0.001), and painful neuropathy (p=0.001).

CONCLUSION

Prevalence of different foot deformities in Jordan variedbetween 1.7% - 17.4%. Sociodemographic factors such as age, gender and shoes choices or presence of diabetes-related microvascular complications (neuropathy and retinopathy) or hypertension were independently associated with foot deformities among the Jordanian diabetic population.