Annals of African Medicine
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Table of Contents
Year : 2022  |  Volume : 21  |  Issue : 3  |  Page : 250-254  

Health-related quality of life of persons with diabetic foot ulcers in a cosmopolitan city in northwestern Nigeria

1 Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Medicine, Muhammad Abdullahi Wase Teaching Hospital, Kano, Nigeria
3 Department of Medicine, Murtala Muhammad Specialist Hospital, Kano, Nigeria

Date of Submission13-Feb-2021
Date of Decision11-May-2021
Date of Acceptance28-Jun-2021
Date of Web Publication26-Sep-2022

Correspondence Address:
Ibrahim Danjummai Gezawa
Department of Medicine, Aminu Kano Teaching Hospital, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aam.aam_2_21

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Background: Diabetic foot ulcer is one of the most serious and disabling complications of diabetes mellitus (DM). It is a major source of morbidity, mortality, and a leading cause of hospitalization. It constitutes a major burden to the patient, family, and health-care system as well as impairs quality of life (QoL). The aim of this study was to determine the QoL of persons with diabetic foot ulcers attending two major hospitals in a cosmopolitan city in northwestern Nigeria. Materials and Methods: We conducted a descriptive cross-sectional study at the diabetes outpatient clinics and wards of two major hospitals in Kano, Northwestern Nigeria. Sociodemographic characteristics, type of DM, duration of DM, and the presence of risk factors for foot ulcers were assessed. The QoL of patients with and without foot ulcer was determined a well-validated questionnaire for chronic diseases, short form 36 (SF 36) health-related QoL questionnaire. Results: We recruited 394 patients with DM (163 males and 231 females) with mean age and duration of DM of 50.8 ± 12.5 years and 7.72 ± 6.65 years, respectively. Ninety-five percent of the study participants had type 2 DM. Foot ulcers were present in 57 (14.5%) study participants. The QoL was generally poor (P < 0.001) in patients with DFU, compared with those without DFU in all domains of the SF 36, that indicated poor QoL in the physical, mental, and emotional well-being of the patients. Conclusion: Diabetic foot ulcers are quite common and impart significantly on the QoL of persons with DM affecting their physical, mental, and emotional well-being. Early detection and management of foot ulcers will reduce the burden of the disease and improve the QoL of affected individuals.

   Abstract in French 

Contexte: L'ulcère du pied diabétique est l'une des complications les plus graves et les plus invalidantes du diabète sucré (DM). C'est une source majeure de 14 morbidité, mortalité, et l'une des principales causes d'hospitalisation. Il constitue un fardeau majeur pour le patient, la famille et le système de soins de santé, car 15 ans et nuit à la qualité de vie (QoL). Le but de cette étude était de déterminer la qualité de vie des personnes atteintes d'ulcères de pied diabétique fréquentant deux 16 hôpitaux principaux dans une ville cosmopolite du nord-ouest du Nigéria. Matériaux et Méthodes: Nous avons mené une étude transversale descriptive 17 dans les cliniques externes de diabète et les salles de deux grands hôpitaux à Kano, nord-ouest du Nigeria. Des caractéristiques sociodémographiques, le type 18 de DM, la durée de DM, et la présence des facteurs de risque pour des ulcères de pied ont été évalués. La qualité de vie des patients avec et sans ulcère de pied était 19 déterminé un questionnaire bien-validé pour les maladies chroniques, questionnaire court-connexe de qol de la forme 36 (SF 36). Résultats: Nous avons recruté 394 patient avec le DM (163 mâles et 231 femelles) avec l'âge moyen et la durée du DM de 50,8 ± 12,5 ans et 7,72 ± 6,65 ans, respectivement. 20 Quatre-vingt-quinze pour cent des participants à l'étude présentaient un DM de type 2. Des ulcères du pied étaient présents dans 57 (14,5 %) participants à l'étude. Le QoL était généralement pauvre (P < 0,001) dans les patients avec DFU, comparé à ceux sans DFU dans tous les domaines du SF 36, qui a indiqué le QoL pauvre dans le bien-être physique, mental, 22, et émotionnel des patients. Conclusion: Les ulcères diabétiques de pied sont tout à fait communs et transmettent de manière significative sur la QoL de 23 personnes avec le DM affectant leur bien-être physique, mental, et émotionnel. La détection et la prise en charge précoces des ulcères du pied réduiront le fardeau de la maladie et amélioreront la qualité de vie des personnes touchées.
Mots-clés: Ulcère du pied diabétique, Qualité de vie liée à la santé, Nord-Ouest du Nigéria, questionnaire abrégé

Keywords: Diabetic foot ulcer, Health-related quality of life, Northwestern Nigeria, short form 36 questionnaire

How to cite this article:
Habibu RA, Uloko AE, Gezawa ID, Ramalan MA, Muhammad FY, Abubakar UI, Muhammad A. Health-related quality of life of persons with diabetic foot ulcers in a cosmopolitan city in northwestern Nigeria. Ann Afr Med 2022;21:250-4

How to cite this URL:
Habibu RA, Uloko AE, Gezawa ID, Ramalan MA, Muhammad FY, Abubakar UI, Muhammad A. Health-related quality of life of persons with diabetic foot ulcers in a cosmopolitan city in northwestern Nigeria. Ann Afr Med [serial online] 2022 [cited 2023 Mar 21];21:250-4. Available from:

   Introduction Top

A large part of the burden of diabetes mellitus (DM) and related health-care costs are due to the development of chronic complications, which may occur long before clinical manifestations of the disease. An estimated 2.5% of persons with DM develop diabetes foot lesions each year and about 25% will develop foot lesions during their lifetime of which about 14%–24% will require an amputation.[1]

Foot complications account for more hospital admissions than any other complications of diabetes, with major outcomes being foot ulcers and amputation. Foot ulcers (complicated by infection and gangrene) may lead to prolonged hospital stay, amputation, and mortality.[2] Diabetic foot ulceration has significant impact on the health of affected individuals. Thus, diabetic foot ulcer (DFU) has a toll on these patients' quality of life (QoL) and life expectancy, as well as on the health-care system characterized by longer hospitalization and increased cost of ambulatory care.[1],[3] Conflicts and tension commonly arise from added pressure and burden brought about by increased morbidity and reduced mobility resulting from foot lesions.[4],[5]

The QoL of an individual is important for health and it is a measure of physical, social, and spiritual well-being. Foot ulcers have negative effects on the Qol of affected individuals. Patients with DFU suffer loss of mobility and increasing morbidity, difficulties with work, poor income, and reduction in social activities.[5] Low health-related QoL (HRQL) scores have been associated with negative variables such as living alone, recurrent ulcers, existence of other DM complications, and major amputation.[6] The presence of type 2 DM, older age, longer duration of ulcers, and severity of Wagner's grade were all significant predictors of lower HRQL scores.[7]

In Nigeria, few studies have assessed the QoL of patients with diabetic foot lesions. Ikem et al.,[8] in Ile-Ife, southwestern Nigeria, used the World Health Organization QoL (WHO QoL) Brief to access QoL of patients with DFU and found that patients with DFU had significantly poorer scores on physical and psychological domains, overall QoL, and overall health score compared with those without DFU.

There is a paucity of studies on the QoL of patients with DFU in our setting. We, therefore, set out to establish the effect of foot ulcers on the QoL of persons with diabetes in Kano, Northwestern Nigeria, using the SF36 instrument.

   Materials and Methods Top

We conducted a cross-sectional descriptive study at the diabetes outpatient clinic and wards of two major hospitals in Kano, northwestern Nigeria. The study was conducted over a period of 6 months. Systematic sampling technique was used to recruit 394 consecutive patients with diabetes attending the clinics and those admitted on the wards. Patients who had end-stage renal disease, heart failure, stroke, and malignancies and other comorbidities that could affect QoL were excluded from the study. The Ethical Committee of the two hospitals approved the study. Trained interviewers administered a structured questionnaire to obtain information on the sociodemographic and clinical characteristics of the study participants. The QoL score was assessed using the short form 36 (SF36) questionnaire.

The SF36 is a generic HRQL instrument that allows results to be compared across studies and populations.[9].It is also an instrument that is used to compare patients with and without a disease condition.[9] The SF36 questionnaire consists of 36 items grouped into eight domains that include physical functioning, role physical, body pain, social functioning, role emotional, mental health, general health, and vitality. Scores were calculated for each domain; two summary scores ranging from 0 (worst possible health status) to 100 (best possible health status) were calculated. The scores on the eight domains were aggregated into two distinct summary scores (physical and mental scale). In the physical function scale, physical impairment was assessed. The role physical assessed the burden of the disease on daily life, while the role emotional scale assessed the impairment in daily life due to emotional problems from diabetes foot disease. The SF 36 has satisfactory reliability and validity even in Nigerians and is the most thoroughly tested and accepted measure for assessing psychometric properties in chronic medical conditions.[9],[10]

Data analysis

Data collected were analyzed using the Statistical Package for the Social Sciences version 16 (SPSS Inc. Chicago, IL USA). Continuous variables were expressed as means (SD). Categorical data (variables) were expressed as proportions. The Student t-test was used to compare means, while the Chi-square test was used to compare proportions. Nonparametric tests were used for analyzing data with skewed distribution. In all statistical comparisons, P < 0.05 was considered statistically significant.

   Results Top

The mean age of the study participants was 50.8 ± 12.5 years. There were more females (231, 58.6%), 95.7% had type 2DM, 77% of them were married, 61.2% had formal education, and 62% had a form of employment. The mean duration of DM was 7.72 ± 6.65 years and 240 (60%) of the study participants had various complications of DM.

Of the 394 patients recruited in this study, 57 (14.5%) were found to have DFU. [Table 1] shows the sociodemographic and clinical variables of patients with and without foot ulcers. It showed that there is a significant difference in the age of patients with DFU compared to those without foot ulcers. It also showed that those with foot ulcers had a longer duration of DM compared to those without foot ulcers. The body mass index of patients with foot ulcers was also higher than in those without foot ulcers, a finding that was more significant among the females. [Table 2] shows the laboratory variables of the study subjects. Subjects with foot ulcers had both short and long-term poor glycemic control compared to those without foot ulcers. However, there was no difference in the lipid profile of the study subjects. [Table 3] shows the comparison between patients with DFU and those without foot ulcer in terms of their health related quality of life. Patients with foot ulcers had significantly poorer health related quality of life than patients without foot ulcers in all eight domains and median summary scores (p< 0.001). The worst scores were recorded in the role physical and role emotional domains.
Table 1: Sociodemographic and clinical characteristics of study participants

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Table 2: Laboratory characteristics of study participants

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Table 3: Comparison of health-related quality of life of those with and without diabetes foot ulcer using the SF36 questionnaire

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   Discussion Top

Diabetes foot disease is one of the most serious consequences of DM with an increase in morbidity, mortality, as well as a known cause of reduced HRQL in both patients and their caregivers. Due to the rising prevalence of Diabetes Mellitus Foot Syndrome (DMFS), the year 2005 was dedicated to the prevention of diabetic foot.[11] The global lower extremity study group estimated that DM accounted for 25%–90% of all leg amputations, that is about 5 out of 6 major limb amputations, and that 50% of amputees will lose the contralateral limb within 1 year.[12],[13].Many studies have shown that DFU affects patients' social and family lives with increased family tension for patients and caregivers, coupled with financial hardship, as well as reduction in their daily activities and leisure time.[4],[5],[14]

In this study, the HRQL of patients was assessed using the SF36 instrument. Based on this, it was observed that the patients with DFU had poorer scores in all the domains of the SF36 questionnaire compared with those without foot ulcers, which is consistent with reports from previous studies.[7],[15],[16],[17]

The differences in scores between the two groups were more than 10 points, which represents a clinically important difference for SF 36 scores. The largest difference in median scores between both the groups was in the domains of physical functioning, role limitation to physical health, and emotional health, which were consistent with studies conducted in France and Iran.[7],[18]. These differences in the QOL of patients with DFU may be due to the presence of other chronic complications of DM, problems with daily activities, social life, and emotional instability due to the presence of foot lesions. Similarly, the summary scores of the physical and mental scores of the SF 36 showed poorer Qol in patients with foot ulcer compared with those without ulcers, which is in tandem with reports from previous studies.[6],[7],[16]

In Nigeria, Ikem et al.[8] assessed the Qol of patients with diabetic foot disease using the WHO QoL brief and found that patients with DFU had significantly poorer scores on physical and psychological domains, overall Qol, and overall health score, compared with those without DFU. The study also noted that depression was a major predictor of poor HRQL in patients with foot lesions.

The limitations of our study include the modest sample size and our inability to determine the effect of sociodemographic and clinical variables on the QoL of our study participants.

   Conclusion Top

Our study showed that the QoL of patients with DFU is poorer than in those without DFU. Reducing the incidence of DM and its subsequent complications will go a long way in reducing the burden of DM and its effect on both the patients and their caregivers.

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Conflicts of interest

There are no conflicts of interest

   References Top

Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet 2005;366:1719-24.  Back to cited text no. 1
Prompers L. Diabetes foot disease in European perspective. In: Results from the European Study Group on Diabetes and the Lower Extremities (Eurodiale).PhD Thesis, Maastricht University; 2008. p. 10-8.(Accessed November 2019).  Back to cited text no. 2
Boulton AJ. The global impact of the diabetic foot. Epidemiology, risk factors and the status of care. Diabetes Voice 2005;50:5-7.  Back to cited text no. 3
Goodridge D, Trepman E, Embil JM. Health related quality of life in diabetics with foot ulcers. Literature review. J Ostomy Con Nurs 2005;32:368-77.  Back to cited text no. 4
Brod M. Quality of life issues in patients with diabetes and lower extremity ulcers: Patients and caregiver. Qual life Res 1998;7:375-2.  Back to cited text no. 5
Ragnarson Tennvall G, Apelqvist J. Health-related quality of life in patients with diabetes mellitus and foot ulcers. J Diabetes Complications 2000;14:235-41.  Back to cited text no. 6
Valensi P, Girod I, Baron F, Moreau-Defarges T, Guillon P. Quality of life and clinical correlates in patients with diabetic foot ulcers. Diabetes Metab 2005;31:263-71.  Back to cited text no. 7
Ikem RT, Ikem IC, Ola BA. Relationship between Depression, Cognitive function and Quality of Life of Nigerians with DFU. Acta Endocrinologica 2009;5:75-83.  Back to cited text no. 8
Ware JE Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473-83.  Back to cited text no. 9
Arogundade FA, Zayed B, Dabe M, Barsoum RS. Correlation between short form health survey and Karnofsky performance scale in patients on haemodialysis. Natl Med Assoc 2004;96:1661-7.  Back to cited text no. 10
Pedrosa HC, Leme LA, Novases C. The diabetic foot in South America: Progress with the Brazilian save the diabetic foot project. Int Diabetes Monit 2004;16:17-23.  Back to cited text no. 11
Reiber GE, Lipsky BA, Gibbons GW. The burden of diabetic foot ulcers. Am J Surg 1998;176:5S-10.  Back to cited text no. 12
Marshal CA, Slansby G. Lower limb amputation. Surgery 2004;22:335-7.  Back to cited text no. 13
Nabuurs – Franseen MH, Huijberts MS, Nieuwenhuijzen Kruseman AC, Williams J, Schaper NC. Health related quality of life of diabetic foot ulcers patients and their caregivers. Diabetologia 2005;48:1906-10.  Back to cited text no. 14
Akina F, Yildinm A, Gozu H, Sargin H, Orbey E, Sargin M. Assessment of health related quality of life of patients with Type 2 DM in Turkey. Diab Res Clin Pract 2008;79:117-23.  Back to cited text no. 15
Mazlina M, Shamsul AS, Jeffery FA. Health-related quality of life in patients with diabetic foot problems in Malaysia. Med J Malaysia 2011;66:234-8.  Back to cited text no. 16
Fejfarová V, Jirkovská A, Dragomirecká E, Game F, Bém R, Dubský M, et al. Does the diabetic foot have a significant impact on selected psychological or social characteristics of patients with diabetes mellitus? J Diabetes Res 2014;2014:371938.  Back to cited text no. 17
Yekta Z, Pourali R, Nezhadrahim R, Ravanyar L, Ghasemi-Rad M. Clinical and behavioral factors associated with management outcome in hospitalized patients with diabetic foot ulcer. Diabetes Metab Syndr Obes 2011;4:371-5.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3]


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