Peripheral neuropathy and peripheral vascular disease related to diabetes cause a wide range of foot problems. Although the role of peripheral neuropathy is not clearly understood (Kalish and Hamdan, 2010), it causes nerve damage and is considered the primary contributing factor for impaired sensation and other problems (Ulbrecht et al, 2004). Peripheral neuropathy can increase sensitivity to pain, and the reported symptoms include burning, numbness and tingling (Jambart et al, 2011). This is due to degeneration of the sensory, motor and autonomic functions of the nervous system (Kalish and Hamdan, 2010). As a result, people with diabetes are at heightened risk of impaired motor function, reduced sensation and poor healing, and diabetic foot ulcers.
Previous research has demonstrated the importance of culturally oriented foot care (Abu-Qamar and Wilson, 2011). Therefore, to develop foot care programmes for use in local contexts, it is necessary to identify local patterns of diabetic foot problems.
Jordan has a high prevalence of diabetes, estimated as 17.1%, which is a 4% increase within a period of 10 years (Ajlouni et al, 2008). More recent data from Jordan documented a 92% increase in diabetes prevalence over an 11 year period. However, it should be acknowledged that these recent figures are from a specific district in northern Jordan, Al-Mafraq (Irshaid, 2014). The country has an alarming prevalence of poorly controlled diabetes, which appears to be climbing – estimated to be 54% in 2008 and 65% in 2010 (Ajlouni et al, 2008; Khattab et al, 2010).
Poor diabetes control is believed to be integral in the development of peripheral neuropathy (Obrosova, 2009). People in the Middle East are more likely to have poorly controlled diabetes than those in Western countries, leading to a higher prevalence of diabetic peripheral neuropathy (Jambart et al, 2011).
Research on the diabetic foot in Jordanians with diabetes is scarce. Jordan has the third highest prevalence of diabetic painful peripheral neuropathy in the Middle East (Petropoulos et al, 2016).
Consequently, Jordan was chosen to conduct a study (Abu-Qamar and Wilson, 2012), designed to collect information to enhance the understanding of diabetic foot problems within the local context, reveal foot problems reported by Jordanians with diabetes and therefore inform decision making.
This article examines reports on foot problems which were identified by participants themselves and self-treated using complementary therapies. It is interesting to examine foot problems identified and treated by patients outside the professional healthcare context. Findings of this study can be translated to similar settings.
In Jordan, complementary therapies are practices transferred from generation to another with no supporting evidence. The use of complementary remedies is common in Jordan, especially in rural areas and when there is no response to conventional medical treatment. Recently, a few studies have examined the therapeutic effects of medicinal plants that can be used to treat certain conditions, but did not include diabetic foot problems. Importantly, complementary therapies in Jordan are often prescribed by untrained and unlicensed people (Abu-Qamar and Wilson, 2012).
Methods
Study design
This research arose from a larger descriptive cross-sectional study investigating foot care services in Jordan. Participants (n=1,100) were recruited from eight healthcare facilities in the southern part of Jordan and one affiliated with a university in Amman. Details on ethical approval and recruitment have been published elsewhere (Abu-Qamar and Wilson, 2012).
Research assistants interviewed the participants who had consented to take part in the study. The interviews were guided by a semi-structured questionnaire and aimed to collect data on a wide range of foot care aspects, such as foot hygiene, shoes and nail care. The questionnaire also collected participants’ health profiles and demographic data. During the interviews, 68 participants provided narrative details on foot problems for which they had used complementary remedies (Abu-Qamar and Wilson, 2012).
Content analysis was used to summarise and interpret the interview data and describe the foot problems explained in the narrative responses. An identification number was given to each questionnaire, and then the responses were copied into a designed sheet from which the details were inserted into a Word document to facilitate data analysis. Accuracy of the insertion was checked independently against the original questionnaire text.
Keywords related to the purpose of using complementary therapies were identified in the narrations. These were grouped into categories of foot problems. The process of finding the keywords was multifaceted and the approaches included reading the narrations individually in different sequences using hard copies as well as electronic copies of the Word documents.
Results
Participants’ demographic profile
Participants’ demographic characteristics are shown in Table 1. The age of participants ranged from 20 to 91 years with a mean of 59 years.
Participants were asked to elaborate on foot problems for which they used complementary therapies sourced outside the professional healthcare context. Out of 68 responses, 24 (35.3%) did not provide details on the purpose of using complementary therapies. Analysis of the 44 responses revealed a wide range of foot problems that were categorised into three main groups: irritant skin conditions, skin integrity and sensation problems.
Types of complementary therapies
Complementary therapies identified in this study include: wormwood (Artemisia monosperma), dried olive leaves (oleuropein), olive oil, sage, henna, chamomile and other herbs. More details on these complementary therapies are available in the previous publication (Abu-Qamar and Wilson, 2012).
Irritant skin conditions
Participants reported two forms of irritant skin conditions, eczema (n=1) and fungal infections (n=4).
Eczema was mentioned in one response. Four participants said they used complementary therapies to treat or prevent fungal infections. One participant said complementary therapy “was used as a precautionary action to prevent fungus”. In the other three cases, treatment of acute fungal infection was the purpose. One participant mentioned pasting “henna on the feet to treat fungus”. Another participant reported that the treatment was non-beneficial: “I used herbs for fungus, and I have not had benefits from them.”
Skin integrity
Topical remedies were used to treat problems relating to skin integrity – ulcers, injuries or corns – in 18 (26.5%) participants.
In 11 (16.2%) responses, the reported purposes were treatment of ulcers or wounds. Of these, six participants mentioned the words wound or injury, with responses including “for wounds of the feet”, “treating a post amputation wound” and “on the wound that resulted from amputating my [toe]”. Disinfection was cited in three narrations:
“To disinfect wounds.”
“To disinfect the feet when they incur an injury.”
“Yes, I wash them [the feet] with water and disinfectant.”
One participant reported healing occurred after a topical application “on the dead wound which was on my foot; it healed”.
Four participants indicated that they used complementary therapy to treat ulcers. These ulcers could be new (“for the treatment of the new foot ulceration”) or fissures (“for feet fissuring, from the herbalist”). One participant did not add details about the ulcers, other than to say “treats ulcerations of the feet”.
In seven responses, the removal of corns was the reason for seeking complementary therapy. Details were brief without information about when the treatment was sought or/and the frequency of usage.
Sensation problems
This category incorporated pain, hotness and softness. In eight responses, treatment of foot pain or numbness was the purpose of using complementary remedies. The responses contained a range of details including: the problem, purpose of using the treatment, name of the remedy and method of application (Table 2).
Discussion
This paper reports on a range of foot problems that were self-treated with complementary therapies by Jordanians with diabetes. Therapies used included olive oil, sage, wormwood, henna, chamomile and herbs.
Foot problems identified by the participants were grouped into three main categories: irritant skin conditions, skin integrity and sensation. This is different from a previous study which reviewed medical notes and reported four categories: dermatological, neurological, musculoskeletal and vascular (Tantisiriwat and Janchai, 2008). A reason for the variation in categories is that in the current study, the names of the categories reflected the participants’ views and the scope of the study was different to the case note review cited above.
Diabetes education
Diabetes education programmes aim to teach people about their condition, to manage blood glucose for optimal control, and carry out self-care. Delivering education that is tailored for the individual needs of each patient will maximise benefits from these programmes. Tailoring should include the content of the educational material and method of delivery in the local cultural context. For example, illiterate patients require different methods of health education, possibly involving family members and/or peers to help in delivering the message to the patients.
Foot pain is a common complaint among people with diabetes, because peripheral neuropathy increases sensitivity to pain (Obrosova, 2009). It would be beneficial to increase patients’ awareness of the role of good blood glucose control in reducing the incidence and the severity of diabetes complications (Inzucchi et al, 2012).
Education programmes should highlight the negative consequences of using heat therapy, hot household objects (such as foot spas) or hot water bottles for numbness, because of the danger of burns (Thng et al, 1999, Jose et al, 2005). Participants in this study reported their use of complementary remedies to treat numbing feet, itching, alleviate heat and/or moisturise the feet.
Health education programmes should also include information on the correct treatment of fungal infections, the importance of appropriate footwear and keeping toenails short.
The importance of ongoing management to reduce the chance of infection should be stressed. For example, diabetes increases the likelihood of fungal infection because high blood glucose level encourages fungal growth, and suppresses the immune system (Santhosh et al, 2011; Islam et al, 2006). Patients should be warned that if fungal infections are not treated, cellulitis and secondary bacterial infection may develop (Bristow and Spruce, 2009).
Patient education should emphasise the importance of correct daily practice to reduce the chance of foot problems. Furthermore, the education programmes will increase patient awareness that routine health examinations should also be sought, so that minor symptoms, which are difficult to recognise by patients themselves, will be identified in a timely manner (Bristow and Spruce, 2009).
A previous analysis of the responses from the current study found that lower limb amputation occurred when foot problems were treated with complementary remedies outside the professional healthcare context (Abu-Qamar and Wilson, 2012). It is of concern that participants sought treatment at an advanced stage of diabetic foot disease without having received previous professional assistance because unwise use of complementary therapies may potentially worsen the disease process.
Other research has claimed that before seeking medical advice patients often try household items, including chemicals with damaging effects (Shankhdhar et al, 2008). Therefore, patients’ awareness of safe practices should be increased to prevent undesirable outcomes such as amputation (Edmonds and Foster, 2005).
Strengths and weaknesses
Foot problems identified in this study were self-reported by a small number of participants without confirmation of the diagnoses by healthcare professionals. The interview-based nature of the study suggests that participants’ responses might not be exactly recorded, not fully understood, or misinterpreted. However, the qualitative nature of the study can be considered a strong point as it allowed the participants’ voices to be reflected in the study findings.
Findings of the present study have limited information on the consequences of using complementary therapies for the treatment of diabetic foot problems. Consequences of complementary therapy usage were mentioned by only two participants, one reported the non-beneficial use of complementary therapy and the second reported healing as a treatment outcome. However, other research reported amputation as an outcome of using complementary therapies (Abu-Qamar and Wilson, 2012). Therefore, additional research is required to explore outcomes of using complementary applications for painful diabetic peripheral neuropathy, as well as benefits of health education.
Conclusion
Foot problems reported in this manuscript are common complaints among people with diabetes as well as among the general population, especially older people. Therefore, people may consider such problems to be minor issues, and underestimate how serious they can be in those with diabetes.
Treatment outside the professional context may be sought from traditional healers, including the use of homemade remedies.
Diabetes education programmes have an important role in raising patients’ attention to the importance of regular foot inspection in order to discover minor foot problems and access the appropriate treatment from a healthcare professional. Additionally, non-professionally recommended self-treatment is an unsafe practice that in all probability will aggravate minor foot problems.
Acknowledgment
The study was funded by a grant from the Abdul Hameed Shoman Fund for Supporting Scientific Research.
