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Research Letter |

Preventing Diabetic Skin Ulcers in Latinos—No Small Feat: Development of a Spanish and English Survey for Fast Assessment of Lower Extremity Skin Care Practices FREE

Claudia Alejandra Muñoz, MD, MPH; Anne Lynn S. Chang, MD
Arch Dermatol. 2009;145(4):486-488. doi:10.1001/archdermatol.2009.15.
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According to the 2006 US Census,1 Latinos make up more than one-third of California's population. Latinos living in the United States in many cases do not speak or read English and have diverse educational and health care needs. The Centers for Disease Control and Prevention2 reported in 2004 that the age-adjusted prevalence of diabetes in Latino adults in California was nearly 11%. The goal of the present cross-sectional study was to evaluate the knowledge, attitudes, and practices of Latino adults with diabetes with respect to skin ulcer prevention on the lower extremities. A short survey tool was developed for clinicians to use in the busy clinic setting to efficiently assess the prevention needs of patients in this rapidly growing segment of the population.

A PubMed search was performed using the search terms diabetic, skin, ulcer, and lower extremity. Several questions on lower-extremity self-care practices and attitudes were adapted from existing survey instruments.3,4 Knowledge and other attitude questions (Figure 1, Table 1, and Table 2) were formulated using the specific guidelines of the National Institute of Diabetes and Digestive and Kidney Diseases to assure content validity.5 The survey was written in English (Figure 2) and translated into Spanish. The Spanish version was back-translated by a third person to assure correspondence in meaning.

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Figure 1.

Validated and reliable screening questions for lower extremity self-care practices of Latino adults with diabetes.

Graphic Jump Location
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Figure 2.

Survey of knowledge, attitudes, and practices of foot ulcer prevention among Latino adults.

Graphic Jump Location
Table Graphic Jump LocationTable 1. Self-reported Knowledge and Attitudes of Latino Adults With Diabetes Regarding Skin Care of the Lower Extremities
Table Graphic Jump LocationTable 2. Self-reported Practices of Latino Adults With Diabetes Regarding Skin Care of the Lower Extremitiesa

After approval by the Stanford institutional review board, the study was implemented in 3 free clinics and 1 county wound clinic in Northern California. These sites were chosen for their high proportion of Latino patients. All patients presenting to each clinic were offered the survey during 1 designated afternoon per week over 3 months. Those patients who were unable to read the survey obtained assistance from the study staff. The survey was pretested on 16 persons.

Data were analyzed using SPSS, version 16.0 (Chicago, Illinois). The Spearman ρ was used to correlate respondent characteristics with correct practices. Reliability analysis via the Cronbach α was performed to test internal consistency of the survey questions.

A total of 352 surveys were completed (91% response rate). Of these, 284 respondents self-identified as Latinos, with 67% completing the survey in Spanish. Of Latinos, 41.9% had diabetes. The mean age among Latinos with diabetes was 57 years. The mean age at diagnosis of diabetes was 46 years, and 22% of respondents with diabetes had a history of a lower-extremity ulcer.

Respondents with diabetes demonstrated a high rate of correct knowledge and attitudes regarding lower extremity skin care. Correct response rates exceeded 70% for all questions in these categories except for 2 items: two-thirds of Latinos with diabetes felt they should soak their feet, and one-third agreed or strongly agreed that “It is too difficult to check my own feet” (Table 1). Correct practices did not fare as well as correct knowledge and attitudes. Only half of Latino respondents with diabetes reported that they inspected their feet every day for the last 7 days. Fewer than half reported daily inspection of their shoes. Only 60% stated that they washed their feet and dried between their toes daily during the previous week (Table 2).

The number of years since diagnosis of diabetes was not correlated with any knowledge, attitude, or practice. Weak correlations existed between respondent characteristics, knowledge, attitudes, and lower-extremity skin-care practices. The Cronbach α for the survey as a whole was 0.74 (knowledge, 0.73; attitudes, 0.75; and practices, 0.80). Intraclass correlation coefficients ranged from 0.60 to 0.81. The survey took 5 to 10 minutes to complete.

Latinos with diabetes merit focused attention with respect to lower-extremity skin care, but busy clinicians do not have an easy-to-use tool to rapidly assess gaps in practices. Although knowledge and attitudes were found to be highly favorable in this study, the true clinical benefit can only be derived from consistent practices such as coupling daily foot inspections with ingrained daily habits. To our knowledge, this study was the first to survey the knowledge, attitudes, and practices regarding lower-extremity skin care of Latinos with diabetes. It will hopefully serve as a basis to further explore effective strategies to improve skin ulcer prevention in this and other groups at high risk of lower-extremity skin ulceration. The survey developed in this study is a fast, reliable method to assess patient practices, highlighting where deficits exist and prompting discussion of ways to resolve barriers to good lower-extremity skin care.

ARTICLE INFORMATION

Correspondence: Dr Muñoz, Department of Dermatology, Stanford University School of Medicine, 900 Blake Wilbur Dr, Stanford, CA 94305 (doctor.claudia@gmail.com).

Financial Disclosure: None reported.

Author Contributions: Dr Muñoz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Muñoz. Acquisition of data: Muñoz. Analysis and interpretation of data: Muñoz and Chang. Drafting of the manuscript: Muñoz. Critical revision of the manuscript for important intellectual content: Muñoz and Chang. Statistical analysis: Muñoz. Administrative, technical, and material support: Muñoz. Study supervision: Chang.

Additional Contributions: La Clìnica de la Raza, Arbor Free Clinic, Pacific Free Clinic, St Anthony Free Clinic, and Santa Clara County Medical Center Wound Clinic provided assistance in this study.

US Census Bureau Profile of General Demographic Characteristics: 2000: Census 2000 Summary File 1 (SF 1) 100-Percent Data.  See website here. Accessed May 28, 2008
Centers for Disease Control and Prevention (CDC), Health disparities experienced by Hispanics–United States. MMWR Morb Mortal Wkly Rep 2004;53 (40) 935- 937
PubMed
Pollock  RDUnwin  NCConnolly  V Knowledge and practice of foot care in people with diabetes. Diabetes Res Clin Pract 2004;64 (2) 117- 122
PubMed Link to Article
Toobert  DJHampson  SEGlasgow  RE The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care 2000;23 (7) 943- 950
PubMed Link to Article
National Institute of Diabetes and Digestive and Kidney Diseases—National Diabetes Information Clearinghouse Prevent diabetes problems: keep your feet and skin healthy. 2007. http://diabetes.niddk.nih.gov/dm/pubs/complications_feet/index.htm. Accessed May 28, 2008

Figures

Place holder to copy figure label and caption
Figure 1.

Validated and reliable screening questions for lower extremity self-care practices of Latino adults with diabetes.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Survey of knowledge, attitudes, and practices of foot ulcer prevention among Latino adults.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Self-reported Knowledge and Attitudes of Latino Adults With Diabetes Regarding Skin Care of the Lower Extremities
Table Graphic Jump LocationTable 2. Self-reported Practices of Latino Adults With Diabetes Regarding Skin Care of the Lower Extremitiesa

References

US Census Bureau Profile of General Demographic Characteristics: 2000: Census 2000 Summary File 1 (SF 1) 100-Percent Data.  See website here. Accessed May 28, 2008
Centers for Disease Control and Prevention (CDC), Health disparities experienced by Hispanics–United States. MMWR Morb Mortal Wkly Rep 2004;53 (40) 935- 937
PubMed
Pollock  RDUnwin  NCConnolly  V Knowledge and practice of foot care in people with diabetes. Diabetes Res Clin Pract 2004;64 (2) 117- 122
PubMed Link to Article
Toobert  DJHampson  SEGlasgow  RE The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care 2000;23 (7) 943- 950
PubMed Link to Article
National Institute of Diabetes and Digestive and Kidney Diseases—National Diabetes Information Clearinghouse Prevent diabetes problems: keep your feet and skin healthy. 2007. http://diabetes.niddk.nih.gov/dm/pubs/complications_feet/index.htm. Accessed May 28, 2008

Correspondence

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