Managing the diabetic foot in resource-poor settings: challenges and solutions

Abstract

Diabetes mellitus is one of the most common noncommunicable diseases globally. In Africa, rates of diabetes are increasing, so there is a parallel increase of foot complications. Peripheral neuropathy is the main risk factor for foot ulceration in people with diabetes in developing nations, but peripheral arterial disease is also increasing in number owing to the change in lifestyle and increasing urbanization. Ulceration arising from peripheral neuropathy, peripheral arterial disease, and trauma are highly susceptible to secondary infection and gangrene, and are hence associated with increased morbidity and mortality. Government funding is very limited in many developing countries, and diabetes and its complications impose a heavy burden on health services. In particular, the outcomes of foot complications are often poor, and this is the result of various factors including lack of awareness of the need for foot care among patients, relatives, and health care providers; relatively few professionals with an interest in the diabetic foot and with the training to provide specialist treatment; nonexistent podiatry services; long distances for patients to travel to the clinic; delays among patients in seeking medical care, or the late referral of patients for specialist opinion; and lack of the awareness of the importance of a team approach to care, and the lack of training programs for health care professionals. Many of these can, however, potentially be tackled without exorbitant spending of financial resources. Cost-effective educational efforts should be targeted at both health care workers and patients. These include implementation of sustainable training programs for health care professionals with a special interest in foot care and focusing to disseminate the foot care information, on the prevention and management of the diabetic foot, to other health care professionals and to patients. The Step by Step foot program is an educational program that was first carried out in Tanzania and India. In conclusion, the only way to move forward in developing countries is educational programs on prevention and management of the diabetic foot. An interdisciplinary team approach is needed, and not multidisciplinary, for the management of the diabetic foot. Patients presenting early at a less severe stage will definitely lead to reduction in morbidity and death rates.

Diabetic foot ulcer disease in African continent: ‘From clinical care to implementation’ – Review of diabetic foot in last 60 years – 1960 to 2020

“…It is very common in the African continent that the patient is the income generator in a culturally extended family: thus, a foot ulcer episode is devastating and catastrophic for a patient and his family. [1][2][3]5,[10][11][12][19][20][21][22][23][24][25][26][27][28][29][30][31][32]41,42]. Amputations are not only devastating in their impact on people with diabetes and their families, leading to loss of independence and livelihood but they are also very expensive.…”

“…Amputations are not only devastating in their impact on people with diabetes and their families, leading to loss of independence and livelihood but they are also very expensive. In Africa, foot and lower-limb compliations are associated with high morbidity and mortality [1][2][3]5,[10][11][12][19][20][21][22][23][24][25][26][27][28][29][30][31][32]41,42]. Loss of earning due to unemployment or sick leave caused during the management of diabetic foot ulcer is an extra burden on to the patient, family, relatives, friends and the community at large [41,42].…”

“…Time is tissue, which means that medical assistance for DFUs should be sought as urgently as possible. It is not widely known that in a patient with a diabetic foot ulcer, days, weeks or months, may mean the difference in saving a toe, foot, leg, or even death [1][2][3][10][11][12][19][20][21][22][23][24][25]. Patients with diabetic foot problems cannot delay reporting to the health centre.…”

“…Patients with diabetic foot problems cannot delay reporting to the health centre. Abbas and colleague reported that reasons for late presentation in Africa include cultural, religious and customary behaviours [1][2][3][10][11][12][19][20][21][22][23][24][25]: patients may go through several stages before reporting to the health centre, including trying to attempt to treat lesions such as callus or corns, at home using a blade as well as using herbal medications. If this treatment fails, the patient's next move would be to see faith healers or herbal doctors.…”

“…By the time patient present to diabetic foot specialist, it is too late to save the foot or even to prevent the death of the patient. [1][2][3][10][11][12][19][20][21][22][23][24][25].…”