Experiences and guidelines for footcare practices of patients witli diabetes meiiitus

The former Transkei is a predominantly rural region of the Eastern Cape Province. The poor infrastructure in this area results in inaccessibility of the available health services. The majority is ill equipped to deliver optimum diabetes care. There is an increase of lower limb amputations and lack of knowledge among patients with diabetes meiiitus in the former Transkei. These complications can be pre­ vented by patient education on self-management and ap­ propriate footcare procedures. This qualitative study was conducted to explore and describe the experiences and footcare practices of diabetic patients who live in the rural areas of Transkei. A sample of 15 participants was drawn from Umtata Hospi­ tal Diabetic Clinic register through predetermined selec­ tion criteria. The sample consisted of five men aged 49 74 years, and ten women aged 30 64 years. Five patients (two men and three women) had foot ulcers or an amputa­ tion, while ten patients had no obvious foot problems. Indepth phenomenological interviews were conducted with all 15 patients. Interviews were tape recorded in Xhosa, transcribed, and translated into English for analysis. Di­ rect observation of footcare was done with eight patients from the sample. Content analysis of the phenomenological interviews was facilitated by a protocol; and a checklist guided direct observation of footcare. A debate took place among the three coders to come to a consensus about the themes that emerged from their individual analyses. Cuba’s model of trustworthiness was utilised to ensure that the findings of this study reflect the truth. Ethical considera­ tions were based on the guidelines cited by the Demo­ cratic Nursing Organisation of South Africa (1998: 2.3.12.3.4) and the South African Medical Research Council (1993:32-44). Findings revealed predominantly negative experiences in the internal and external environments of the persons with diabetes meiiitus; as well as poor footcare knowledge and practices. The recommendations relate to improving dia­ betes meiiitus as well as their footcare knowledge and skills through education; promoting adherence to treat­ ment regimens; providing emotional support; improving their self-image; changing health beliefs; improving the quality of care in public health facilities; and increasing awareness among employers of persons with diabetes meiiitus. Opsomming Die voormalige Transkei is ’n oorwegend plattelandse streek in die Oos-Kaap. Die swak infrastruktuur in die gebied veroorsaak dat beskikbare gesondheidsdienste ontoeganklik is. Die meerderheid is swak toegerus om opti­ mum diabetiese sorg te lewer. Daar is ’n toename in amputasies van die onderste ledemate en ’n gebrek aan kennis onder pasiente met diabetes meiiitus in die voormalige Transkei. Hierdie komplikasies kan voorkom word deur pasiente op te voed om self beheer te neem van hul toestand asook om die toepaslike voetversorgingsprosedures te volg. Hierdie kwalitatiewe studie is u itgevoer om die ervarings en voetversorgingspraktyke van diabete wat in die plattelandse gebiede van Transkei woon, te verken en te beskryf. ’n Steekproef van 15 respondente is vanaf die Diabetes kliniekregister by die Umtata Hospitaal getrek deur middel van vooraf bepaalde seleksie-kriteria. Die steekproef het vyf mans tussen die ouderdomme van 49 74 jaar en tien vroue tussen 30 en 64 jaar oud ingesluit. Vyf pasiente (twee mans en drie vroue) het voetulkusse of ’n amputasie gehad, terwyl tien pasiente geen ooglopende voetprobleme gehad het nie. Fenomenologiese indiepte onderhoude is met al 15 pasiente gevoer. Onderhoude is in Xhosa op band vasgele, getranskribeer en in Engels vertaal vir analise. Regstreekse waameming van voetversorging is op agt van die pasiente in die steekproef gedoen. Inhoudsanalise van die fenomenologiese onderhoude is met behulp van ’n protokol vergemaklik; en ’n kontrolelys het die regstreekse voetversorgingsobservasies toegelig. ’n Bespreking tussen die drie kodeerders het eenstemmigheid bewerkstellig ten opsigte van die temas wat uit hul individuele analises voortgespruit het. Guba se model van vertrouenswaardigheid was gebruik om te verseker dat die bevindinge van hierdie studie die werklikheid weerspieel. Etiese oorwegings is op riglyne gebaseer wat in die Demokratiese Verplegingsorganisasie van Suid-Afrika (1998: 2.3.1-22.3.4) en die Suid-Afrikaanse Mediese Navorsingsraad (1993:32-44) vervat is. Bevindings het oorwegend negatiewe ervarings in verband met die interne en eksteme omgewings van mense met dia­ betes meiiitus onthul; sowel as swak voetversorgingskennis en praktyke. Die aanbevelings hou verband met die verbetering van diabetes m eiiitus asook voetversorgingskennis en vaardighede deur middel van

The former Transkei is a predominantly rural region of the Eastern Cape Province.The poor infrastructure in this area results in inaccessibility of the available health services.The majority is ill equipped to deliver optimum diabetes care.There is an increase of lower limb amputations and lack of knowledge among patients with diabetes meiiitus in the former Transkei.These complications can be pre vented by patient education on self-management and ap propriate footcare procedures.This qualitative study was conducted to explore and describe the experiences and footcare practices of diabetic patients who live in the rural areas of Transkei.A sample of 15 participants was drawn from Umtata Hospi tal Diabetic Clinic register through predetermined selec tion criteria.The sample consisted of five men aged 49 -74 years, and ten women aged 30 -64 years.Five patients (two men and three women) had foot ulcers or an amputa tion, while ten patients had no obvious foot problems.Indepth phenomenological interviews were conducted with all 15 patients.Interviews were tape recorded in Xhosa, transcribed, and translated into English for analysis.Di rect observation of footcare was done with eight patients from the sample.Content analysis of the phenomenological interviews was facilitated by a protocol; and a checklist guided direct observation of footcare.A debate took place among the three coders to come to a consensus about the themes that emerged from their individual analyses.Cuba's model of trustworthiness was utilised to ensure that the findings of this study reflect the truth.Ethical considera tions were based on the guidelines cited by the Demo cratic Nursing Organisation of South Africa (1998: 2.3.1-2.3.4) and the South African Medical Research Council (1993:32-44).
Findings revealed predominantly negative experiences in the internal and external environments of the persons with diabetes meiiitus; as well as poor footcare knowledge and practices.The recommendations relate to improving dia betes meiiitus as well as their footcare knowledge and skills through education; promoting adherence to treat ment regimens; providing emotional support; improving their self-image; changing health beliefs; improving the quality of care in public health facilities; and increasing awareness among employers of persons with diabetes meiiitus.

Introduction
Diabetes mellitus is rapidly emerging as a major public health problem in this country.It was estimated in 1996 that about 0.5 million people in South Africa had diabetes mellitus.Accord ing to the Working Group of the National Diabetes Advisory Board (1997:499), there is a high prevalence of diabetes mellitus in South Africa, with the Indian population leading with 10%.Since no recent national screening studies have been done, the exact number of people with diabetes mellitus is unknown, but certainly there are many of undiagnosed diabetes mellitus patients.
The main goal of therapy is to achieve levels of blood glucose as close to the non-diabetic state as feasible.Diabetes mellitus is a chronic disease and therefore requires sufferers to take responsibility in their own care.Patients must acquire the knowl edge and technical skills required for its management such as self-monitoring of urine and blood glucose, prevention and recognition of hyper / hypoglycaemia as well as other compli cations (Working Group of the National Diabetes Advisory Board, 1997: 502-508).There is evidence that long-term normoglycaemia and effective health promotion program on diabetes mellitus prevent, delay or attenuate this disease com plications (Huddle & Kalk, 2000:7).It is estimated that lower limb amputations are about twenty times more common in the diabetic than the non-diabetic popu lation (Huddle & Kalk, 2000: 41).There are no figures from Africa concerning the prevalence of the diabetic foot, but there is a perceived increase of foot problems among persons with diabetes mellitus in South Africa.A study on lower extremity amputations conducted by the researcher (1999) in Transkei revealed that the highest number of re-amputations and deaths occurred among persons with diabetes mellitus, 33% and 39% respectively (unpublished).This alarming statistic coupled with the shortfall of the Transkei healthcare delivery system in dia betes care warrants the empowerment of the patients so as to equip them with skills and knowledge required for the preven tion of foot complications.An 85% reduction of below knee amputations was achieved in Geneva consequent to a footcare teaching program for diabetic patients (Assal, Muhlhauser, Pemet, Gfeller, Jorgens & Berger, 1985: 608);Clement, 1995Clement, : 1210;;Gill, Mbanya & Alberti, 1997:212).But, the development of an appropriate footcare education programme for the dia betic patients in Transkei can only be based on their current levels of knowledge, attitudes and footcare practices.

Problem statement and research questions
There seems to be an increase of lower limb amputations and lack of diabetes-related knowledge among patients in the former Transkei, and yet the National Department of Health (1998: 18) emphasises the necessity for patients to acquire the relevant knowledge and skills for successful diabetes management This study is focussing on the experiences of patients with diabe tes mellitus and their existing footcare practices in this region in order to develop appropriate guidelines on foot care for them, hence the following research questions arise:

•
What are the experiences of patients in the rural areas of former Transkei concerning diabetes mellitus?• How do patients with diabetes mellitus in the former Transkei take care of their feet?• What guidelines can be described to facilitate a health promotion program on footcare for patients with dia -betes mellitus in the former Transkei in order to pre -vent complications?

Assumptions
The following theoretical assumptions are applicable: • Diabetes mellitus is an endocrine disease that impacts on the whole person, characterised by chronically el -evated blood glucose concentration and frequently accompanied by other clinical and biomedical abnormalities.

•
The patient with diabetes mellitus and the health care provider are spiritual beings who function in an inte -grated bio-psychosocial manner to facilitate promo -tion, maintenance and restoration of the health of that patient.

•
The patient with diabetes mellitus and the health care provider interact with their external environment, which is physical, social and spiritual in a holistic manner.

•
The interaction between the internal and the external

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Curatlonis May 2003 environment of the patient with diabetes meilitus in -fluences their lived experiences concerning diabetes as well as their footcare practices.
The health care provider, through the health delivery system, facilitates promotion, prevention, maintenance and restoration of the health of the patient with diabe -tes meilitus.

Terminology Diabetes Meilitus
Diabetes meilitus is a syndrome caused by a relative or absolute deficiency of insulin.It is characterised by chronically elevated blood glucose concentrations.The normal range is 3.5-7.()mmolA..The concept 'diabe -tes meilitus, diabetes and DM' will be used synony -mously in the text of this study, and will refer to Type II of this disease (Huddle & Kalk, 1994:4;Alberti & Zimmet, 1998:542-544;As.sal, et al, 1985:602).

Experiences
The experiences referred to in this study are patients' personal encountering of events around which posi -tive or negative attitudes are formed.These lived ex -periences will include self reported adherence to ad -vised treatment regimes; survival skills (such as pre -vention, recognition and treatment of: hyper / hypogly -caemia, complications and other co-exist -ing illnesses); emotions, beliefs as well as understand -ing resulting from living with diabetes (Palmer, 1994: 277-278).

Footcare
For purposes of this study footcare included self-re -ported footcare knowledge, values and attitudes to -wards footcare as well as the observed skills pos -sessed by the patients with diabetes meilitus, aimed at preserving and protecting their feet, and prevent ing foot complications.

Patients in the rural areas of Transkei
In this study patients refer to people (male and fe male) 30 to 74 years old, who suffer from diabetes meilitus, with and without foot problems, and reside in the former Transkei region of the Eastern Cape Prov -ince, which is classified as a rural area by the Rural Development Task Team and the Department of Land Affairs (1997: 18).

Research design
A qualitative, phenomenological, explorative, and descriptive design that is contextual in nature was used to explore and de.scribe the experiences and footcare practices of patients with diabetes in the rural areas of Transkei.Umtata Hospital dia betic clinic, as a referral center for all the district and day hos pitals, clinics and private practitioners in the Transkei region.
provided the accessible population of all the referred patients from which purposive sampling was done to select participants.A sample of 15 participants was drawn from diabetic clinic attendance register based on the following criteria: • Resident in Transkei for at least six months.
• Age 30 years and older.
• At least a 6-month confirmed diabetic by a medical practitioner.

•
Ability to communicate either in Xhosa or English.
• Patients with or without foot complications were se -lected.

Method of data collection
The data collection methods used were the in-depth interview and observation, both with structured and unstructured as pects.Field notes were also written immediately after leaving each participant.The interview process was based on the prin ciples described by Bums & Groves (1987:304-309);De Vos (1998: 300-311) and Maso & Wester (1996:43-57) and were applied accordingly.
Participants were interviewed at different venues such as their homes (n = 8), workplace (n = 1), day hospital where one came to collect treatment (n = 1), and in hospital wards where they were hospitalised (n = 5).They were all asked to respond to this question: "Ndicela undibalisele ukuba apha ebomini bakho kuthetha ukuthini ukuba nesifo seswekile, yaye nanje ngomntu onesi sifo, uzinonophela kanjani iinyawo zakho?" ("Please tell me what is it like to have and live with diabetes, and as a diabetic person, how do you take care of your feet?") Interviews were recorded on audiotape.
Data on foot care was obtained from the interviews and from direct observation.The observational method described by Polit & Hungler (1991:326 -328) and Bums & Grove ( 1987:304 -305), was used for exploring and describing how participants cut their toenails, but to guide the direct observation a check list was used.The participants were asked to demonstrate how they cut their toenails, using any instmment that they were familiar with.The researcher provided a nail clipper, a razor blade, a small pair of scissors and a nail file, which are the commonly used instmments for nail cutting.Spontaneous (unstmctured) observation regarding the appropriateness of foot wear, cleanliness of the feet and the presence of any other abnormalities such as corns and calluses, deformities, ulcers and amputations, were made whilst watching the nail cutting procedure.Further exploration was done around the findings from these observations on completion of the nail cutting pro cedure.

Method of data analysis
The taped interviews were transcribed verbatim and translated into English, and were taken back to the participants to confirm if the same meaning was retained.The jotted notes were writ ten up in full so as to give a clear description of the observa tional process.
A data analysis protocol was developed from a combination of

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Curatlonis May 2003 the framework described by Ritchie & Spencer (1994, in Baum, 1998: 167-168) and Tesch's (1990) method (in Cresswell, 1994: 155) to fa cilitate uniform ity in the analysis o f the phenomenological interviews.The analysis process involved the identification of themes derived from the objectives of the study, issues raised by participants and themes that occurred when reading the data.These themes were classified into physi cal, mental and spiritual and social experiences.Finally, related themes were grouped together and assigned to the two major themes: internal and external environmental experiences.Selfreports and direct observation -guided by a checklist, yielded data on footcare.Two co-coders with extensive experience in qualitative research (with doctoral and masters degrees) were used.

Trustworthiness
Principles described by Lincoln & Guba, (1985: 300) to ensure the trustworthiness of this study were applied as follows: Prolonged and varied field experience: The researcher is a bonafide Transkeian, and a registered nurse experienced in diabetes care at both primary and secondary health care set tings.

Authority of the researcher:
The researcher completed a mod ule in research methodology.She attended several workshops on qualitative methods as well as a diabetes management course in preparation for this study.Three supervisors with extensive experience in research guided the researcher in this study.The researcher previously conducted fieldwork for a similar study in another setting under the guidance of an experienced quali tative researcher who holds a doctorate in nursing.
Reflexivity: Field notes were written in relation to a description of the interview setting, the researcher's impression of the in formant, observations of non-verbal queues, as well as the researcher's own behaviour, feelings, hunches and interpreta tion of the whole interview process.

Member checking:
The researcher continually tested her data with the participants' during the interviews by asking for clari fication.The translated transcripts of the interviews were taken back to the participants to confirm accurate interpretation.
Triangulation of methods: Multiple data collection methods were used such as interviews, observation, and the field notes.Two independent coders analysed data.A combination of Tesch's (1990) method (in Cresswell, 1994:155) and Ritchie & Spencer's (1994, in Baum, 1998: 167-168) framework approach was used to develop a protocol for the descriptive content analysis of the phenomenological interviews.Findings were subjected to a literature control.

Dense description and audit trail:
A complete description of the research methods has been given and raw data are avail able.

Ethical considerations
The ethical standards set by the Democratic Nursing Organi-.sation of South Africa (1998:2.3.1 -2.3.4) and the South African  Medical Research Council (1993: 32-44), were adhered to in order to facilitate the ethical approach in conducting this study.
Considerations included obtaining informed consent from the hospital authorities as well as from the participants.Privacy, confidentiality and anonymity were ascertained.

internal environmental experiences
The intemal experiences related mainly to survival skills; knowl edge and insight regarding long term complications; adher ence to advised treatment regimes; a variety of health beliefs; and emotions resulting from living with diabetes mellitus.

Survival skills
The survival skills referred to by the participants related to management of acute complications of diabetes mellitus such as hyperglycaemia and hypoglycaemia.

Hyperglycaemia
Participants (n = 14) each recognised at least two of the general symptoms and signs of hyperglycaemia such as excessive thirst, drinking plenty of fluids, polyuria, hunger, generalised body weakness and tiredness.They also discussed relief of their symptoms after taking their treatment, as evidenced from the following citations, *' When my blood sugar is high, I want to drink a lot of water, I just feel thirsty.I pass a lot of urine,..." Two participants who both had a nursing background as well as a diabetes mellitus duration of 12 and 14 years mentioned blurring of vision.They said, " ... and I could not see from a distance, it looked as though there was mist in front of my eyes." All female participants (n= 9), except one, mentioned suffering vulval pruritis and vaginal discharge as the major manifesta tion of high blood sugar levels and this is what they said, " I was having vulval itching and a vaginal discharge.... I mean even now I can't say I feel like this or this as a diabetic person, except the itching vulva.";" ... But after the treatment it sub sides.";" ... I scratch until it becomes painful."" ... after every time we had sex I had this terrible itching and funny discharge.";" ... I had to avoid coming close to my husband..." Two participants mentioned experiencing needlelike pains all over their bodies as well as numbness on toes and fingertips 14 Curationis May 2003 when their blood sugar was raised, .and the finger tips and toes felt like I was frost bitten."One participant had complete lack of understanding regarding the signs of diabetes mellitus, " I was coughing so bad, they said I had diabetes.The cough is better now, that's why I have stopped taking the tablets.

Hypoglycaemia
Four participants recognised symptoms of hypoglycaemia such as dizziness, sweating, trembling and mental disorientation.Their responses were appropriate during the hypoglycaemic episodes and this is what they said: "I felt dizzy, I was sweating and my hands were shaking.I left home very early without eating.I was only given sweet water, and immediately felt bet ter."; " When it is too low ... If I can't get food immediately 1 just make myself sweet water and rest, then I become fine."None of the other 11 participants ever experienced or knew any symptoms of hypoglycaemia.

Knowledge and insight regarding long term complications
All the male participants (n = 5) mentioned impotence and this came out as their major concern, "... except for the lazy gentle man (the penis).If the dog cannot bark, what sees to the secu rity of ones home?That marriage is destroyed moss" Complications such as lower limb amputations, ulcers, blind ness and stroke were mentioned by five participants and were associated with diabetes, but were at a loss as to how to pre vent these.They said, " ... I was warned by my doctor in Vrystaat that I must avoid any injuries to my feet, or else I will lose them.";" ... but he (his cousin) was having sores between his toes and they had to be removed.I would not like that to happen to me."; "But I know that if you neglect your diabetes you may collapse and die, become blind, or even have a prob lem with wound healing.";"I don't know, but it scares me to think that one day I may have the same thing.I have observed that many patients here in the ward who have this gangrene and others who have been amputated are on diabetic treat ment.";"I need to be as healthy as possible.What can I do if I become blind, or have a stroke or have my legs cut off?";Sur prisingly, none of the participants presenting with foot probler(is associated lower limb amputations with diabetes.One participant associated stillbirths and abortions as well as tu berculosis (TB) with diabetes mellitus.

Adherence to advised treatment regimes
The components of a diabetic treatment regime reported by the participants were diet, hypoglycaemic agents (medication), blood glucose monitoring and physical activity.
Six participants understood the importance of diet as part of their treatment and reported adherence to sensible eating hab its."So I become strict with what I eat.... I avoid sweetened foods and drinks, I avoid fat meat and I prefer to use chicken, but honestly I like the skin which is supposed to be removed.";" I restrain myself (from eating the forbidden foods"; "Diabe tes is not a problem as long as I ... and never miss my meals.";" I am careful of what I eat.I eat small amounts of starchy foods such as rice, potatoes.I don't use animal fat like dripping.I eat a lot of apples and oranges, I used to like bananas, but I real ised that they make my sugar go up."Two participants re ported factors that prevented them from complying with the recommended diet.These included the unavailability in the local markets, cultural unacceptability and the costs of the rec ommended foods."He said I must never use maize meal, in stead I must use maltabella or brown bread.I cannot use that for 'umvubo' (mixture of sour milk and 'stiff pap), that is ba bies' food.You cannot eat what other people eat; you must buy very expensive things, and still have to take a taxi to Umtata to buy these.This grant is not enough.";"But I cannot afford these (recommended foods).I have been retrenched.I suppo.se it is because I am not eating right, that is why my blood sugar went up." Deliberate non-compliance was found with two participants, "But me, I had diabetes at a very early age, so I do not need tablets.That is my life as a diabetic, different hey?No medical treatment, I eat everything and look at m e ... I'm okay, but I warn my patients (she is a homeopath) that they should not eat red meat, poultry only is good for them, and like cancer, a person must do away with fats completely."; " I never stopped eating my meat at all, and I always take my tea with sugar.Why do they (ward doctors and nurses) give me sugar if I have diabetes?"All participants understood the importance of complying with their medical treatment, and they said, "As long as I take my tablets nothing goes wrong at all."; " I may die without treat ment.";"But now it (diabetes) has become uncontrollable, so I had to be admitted and treated with insulin...."; "He (the doc tor) stressed that I must never stop taking my tablets because my blood sugar will always go up.But I cannot stop my mix ture.So I use the tablets and the injection and my own mix ture."One participant was so empowered to the extent of regu larly adjusting her own dosages from time to time without con sulting a health care provider."Participants (n=4) who thought their diabetes was not very serious made these comments: " ... I am only using tablets, ...And even if I do not take it for a week, I still feel alright.";"But why should I take treatment if the sugar is not high?So, I keep my tablets for that time it goes high again.";" ...He also mentioned that my blood sugar was very high, so I have to use this insulin) for as long as it is still high.";"... we (him and his girlfriend) use the same type.We share them.So if she has surplus she gives them to me."One participant exclusively used traditional medicines to control her diabetes "It (the herbal mixture) is my only treatment for diabetes."Although she did not use oral hypoglycaemic therapy herself, she understood the importance of taking it with other diabetics as she cited, "It is difficult to treat those who get diabetes when they are a bit older with my mixture alone, like the 40's onwards.Such people cannot do without the help of the tablets." The participant who only used her traditional medicine for dia betes reported the importance of blood testing as a measure of controlling diabetes, " I have to keep on checking if my blood sugar is normal, so I go there (to the diabetic clinic) every month."This phenomenon of many African diabetic patients using herbal preparations even if attending 'orthodox' west ern -style hospital diabetic clinics had been ob.served by Gill, Mbanya & Alberti (1994:276).

Curationis May 2003
Only three participants mentioned the importance of exercise in the prevention of complications, one of them said, ..That is why I keep myself active at all times.I have a skipping rope; every evening I use it.On weekends I like walking just from my home to the field, it is about five km from my place."Two of these participants reported physical disabilities preventing them from doing any exercises, " . . .I used to do some drills (exercises), but now I cannot move them (legs) at all, 1 cannot bend my knees since I was in a car accident.. "Of late my legs and knees become painful and swollen and that prevents me now from walking."These comments confirm research find ings by Weiss & Hutchinson (2000: 528) that some clients with diabetes mellitus and hypertension ignored physical activity as part of their treatment stating some problems that inhibited them from exercising.Generally, exercise in the context of health has little meaning for the grown ups in the rural areas of Transkei.It is viewed as potentially exacerbating illness or physical weakness.
Fear of developing complications was expressed by three par ticipants, " it scares me to think that one day I may have this thing (gangrene)"; .. and I say no! How can I subject myself to the same pain (amputation and re-amputation)" no... n o ... I will not do that.";" I may lose the second foot very soon."One participant who had ulcers and a recent below knee amputa tion was scared of being rejected by family and friends was prominent among participants" Do you think my husband will be comfortable with me again?What about my children?I so wish I did not have to go back home.How do I face the people who know me?" Anger resulting from inability to fulfill their roles as breadwin ners was expressed by two male participants, and one of them resignedly said " A man must support his women and children, what do I do?"One participant acknowledged his frustration resulting from dependence on other people for his livelihood when he said " ... What do people say about me?In fact I do not want to know.Death is more welcome than this type of life.... this diabetes is a slow poison, 'iyakucikida' straight away (it tor tures you)."On the other hand one participant accepted de pendence as a cultural norm during disease episodes.She com mented, " ... the family takes over your life.You no longer make your own decisions regarding your health.You do as you are told" Participants (n= 2) who had seen relatives and friends suffer ing from diabetes related complications, feared suffering the same fate, and as explained by Foster (1997:56) their previous experiences coloured their view of diabetes.One of them hope lessly said " ... like cancer, nobody gets completely cured.... (silent) I am told that this (gangrenous left big toe) is caused by diabetes.All the people who had this thing never sur vived... cutting my leg will not change anything...." Feelings of worthlessness were more pronounced among im potent male participants (n=4).Vmik's citation (1998:4) that for many men a limp penis equates with a limp ego and loss of gender identity was confirmed when these men lamented as follows: " ... I could not be a m an,... even now I am a woman"; "All the men who have diabetes have lost their manhood.So once a man has diabetes, he must forget about many things.";" ...That marriage is destroyed moss.... "; " ...I cannot make my wife happy."Lack of understanding the pathophysiology of diabetes and its complication was found to be a source of confusion in two participants.One of them pointed out the confusion brought by health education messages , " We are told that sugar gives you energy, but if you have diabetes sweet things make you feel tired.Why? ..." Some belief systems also caused confu sion when participants had to make decisions regarding choices of therapy.One participant who had gangrene of the big toe was in such a dilemma and said "It (the herbal mixture) has stopped this poison from spreading to the whole foot.Now you see, there will not be any need of cutting my leg.... I am expected to go back to Umtata Hospital next week if I agree to be operated, but I will not, although the pain is unbearable."

Health beliefs
Participants held a wide spectrum of beliefs regarding causa tion and treatment of diabetes and its associated complica tions, ranging from magico-religious (witchcraft, ancestral spir its, and God), to the medical scientific conceptions.
Five participants associated diabetes, ulcers, amputations and impotence with witchcraft; hence traditional ways of treatment were sought."I cannot even...I do not know.I cannot under stand why this diabetes was so quick in destroying me.I know many people with diabetes for years and nothing like this hap pened to them.I suppose I am the first person to have diabetes on the legs."; "If someone makes you have diabetes, it is like a slow poison.It does not kill you instantly, but will sure do.";" The herbal remedy is very good, it has stopped the poison from spreading to the whole foot."" If it were not for my 'inyanga' (traditional healer) I would not be talking to you now.So if it was diabetes, why didn't that doctor help it, and yet a black man did?"; "But let me warn you.Never leave your nails lying around, the witches use the nails to make people develop ulcers)." Participants' cultural values were found to influence the par ticipants' (n= 4) attitudes towards diabetes mellitus, its treat ment and complications."The white people cannot cure ethnic diseases.They never give you any medicine (elixir)!Only these tablets?"; " ... if I can just visit his grave (her father's) and talk to him.I'm sure every thing will be alright" "I want to come before God complete.Even my (late) husband will not recog nise me if I die with one leg.";" Why do they give me free medicines for this diabetes?They know that it will never be cured.A real medicine is never free."In the Xhosa culture before treatment is initiated, a stipulated amount of money (imvulatasi) must be paid to the traditional healer as a way of inviting the ancestral spirits to assist in the healing of the sick person, followed by a final payment when the person is cured (researcher's personal knowledge).
Positive attitudes and well-developed internal health locus of control (n = 5) were found among participants who had diabe tes mellitus for periods longer than seven years as well as those who accepted the medical-scientific explanation regard ing this disease.They believed that successful control over diabetes mellitus was their personal responsibility." I will live for more years as long as I take my treatment and eat well, no problem"." You cannot depend on doctors and nurses for the 16 Curationis May 2003 rest of your life, it depends on you."Acceptance of being a diabetic was mentioned as the cornerstone towards better con trol, "As from then I accepted the fact that I had diabetes for life.And once you accept that, you become even more open to advice."Three participants did not take diabetes mellitus seriously.They referred to it as mild or not that strong, and or even thought that they were completely cured.To them serious diabetes meant the use of insulin and severe weight loss." My diabetes is not so severe"; "I am very thankful because mine is very mild."" The last time I went for a check up they said my sugar is gone."Anderson, Donnelli & Dedrick (1990: 242-243) found that pa tients treated with tablets or controlled on diet only believed that their disease was less serious than those using insulin, hence their warning to patients that one either has diabetes or not, there is nothing like a touch of diabetes or a mild diabetes.However, five participants considered diabetes a very serious disease, a killer, and likened it with cancer.This realisation motivated some participants to take serious control of their disease, "I had to accept that I had diabetes for life, and if I was not careful I will also die from it." "Diabetes is not a problem as long as I take my tablets and never miss my meals.""But I know that if you neglected your diabetes you may collapse and die, even have a problem with wound healing."whilst in others it fostered hopelessness."It is a terrible disease, very, very cruel.It does not kill you instantly, but will sure do" " ... and like cancer, nobody gets completely cured.All the people with cancer died."

External environmental experiences
Externally experiences related to diabetes mellitus care serv ices in public primary health facilities; and difficulties encoun tered in workplaces by employees who have diabetes mellitus.

Diabetes mellitus care services in public primary health care facilities
The unavailability of the treatment and the costs of transport to the nearest health facilities, were found to be barriers to proper diabetes mellitus care, thus contributing to defaulting.Nutbeam Thomas & Wise (1993:51) and Van Rensburg, Fourie, & Pretorius (1992: 30-32) cite similar factors resulting in inac cessibility of health care to those reported by the two partici pants; "There is always no medicines"; " Our clinic doesn't keep the kind of tablets that I use, so monthly I have to spend about R40.00 on transport to come to Umtata."Participants (n = 7) criticised the expertise and efficiency of health care providers in managing diabetes in public health care facilities.The following comments were made: "They do not care, nursing here is different from ...." "Doctors will never admit that they don't know your sickness."" Do they know diabetes?Not a single day have I ever been taught anything there, they do not know how to treat diabetes, they do not care.""Why was I admitted?I'm supposed to be given insulin, I never got it.""I have often been turned back without treat ment, because they don't have that machine for testing blood sugar.They cannot give you treatment without knowing how much your blood sugar is.... I do not have money to come to hospital every time just to check my sugar.There is no use of a clinic then if I still have to pay R60.00 monthly for transport.
and have to pay again in hospital ..." "Nurses are very busy here, they do not have time to talk, talk, talk, no."A profes sional nurse who also happened to be having diabetes mellitus confessed, "Truly speaking there is no time to teach our dia betic patients.We are short staffed.All we do is dishing out tablets.Moreover, none of us have been specially trained in diabetes management."This comment confirmed the findings by Goodman, Zwarenstein, Robinson, & Levitt (1997:308-309) that professional nurses without special expertise or adequate knowledge of diabetes are manning most of the primary health care centers.

Employment problems
Diabetes and its complications were found to threaten the par ticipants in relation to their sources of income.Some voiced that development of foot complications would lead to loss of income whilst others had already lost their jobs.These partici pants said " .. .1 have a business to run.I must be careful with my feet.";"What else can I do?With 4 children and a husband to take care of, I need to be as healthy as possible.My husband was retrenched 3 years ago.";"At the clinic they punctured the blisters.But since then I have been in and out of hospital, both feet are raw, raw, raw.I had to stop working."In the face of official non-discrimination policies in workplaces, covert discrimination still exists.Discrimination and labeling was encountered from employers by some, " My boss does not feel good about it.Sometimes her comments really hurt me, like 'sickly staff' or 'those in sheltered employment', you see." Krall, (1992" Krall, ( : 1636) ) identified some veiled difficulties of employ ment in some occupations for diabetic employees where many become first unemployed in times of higher levels of job una vailability, or find it difficult to get jobs in competition with non-diabetic applicants.

Footcare
Findings on footcare were from self-reports as well as direct observation.

Self-reported footcare
All the participants reported washing and applying emollients or moisturisers to their feet.One or two participants mentioned a few other appropriate footcare practices.These were: keep ing feet dry (n=2), always wearing shoes outdoors (n=2), keep ing feet warm (n= 1), avoiding scratches and injuries (n=2) and cutting nails immediately after washing feet whilst they are still soft(n=l).Two participants seemed not to value footcare as they care lessly asked, " What else can be done?" and "What is impor tant with feet?"Some participants were experiencing some mild forms of foot problems such as cold feet, excessive sweating, pains and cramps.These participants reported some inappro priate footcare practices such as soaking them in hot water or medicated lotions (n= 3), applying hot water bottles (n= 1), applying powder between toes (n= 1).These were meant to resolve the problems, of which some had disastrous outcomes, and this is what they said, "Of late my legs and knees become painful and swollen and that prevents me from walking.I have to soak them in hot water, put in a little bit of salt, then apply rubbing stuff.";"I always have cramps and pains on the legs and they also feel very cold, especially during the night.Some times I have to sleep with the hot water bottle to keep them warm.";"I also like putting powder between my toes because I sweat a lot."My mother decided to soak it (the foot) in hot water.It became like cooked meat, in so much that some pieces of flesh fell off.The whole leg was rotting.";"...I soak my feet in potassium permanganate solution, and then apply zambuk on this toe (the gangrenous toe)."

Observed footcare
Direct observation of nail cutting was done against a predeter mined checklist with eight (53%) out of the 15 participants that were interviewed.This sub sample was composed of five women (62.5%) and three (37.5%)men.Results of the observation proc ess as indicated in (Table 1) showed that: participants (n= 6) who used the correct instrument for cutting nails (a nail clip per) also cut their nails straight across, whilst two men used a razor or scalpel blade; three participants did not cut their nails too short; two did not cut nails down the comers; and four did not dig around their nails with their instruments to remove dirt.All (n = 8) participants smoothed off the nail edges with their cutting instruments so that no rough edges were left.Surprisingly, the two participants who mentioned the danger of barefoot walking were shoeless during the interview.Their comments, reaffirmed by Vijay, Snehalatha & Ramachandran (1997:10-12), justified this inappropriate practice as they said; "It will take me a long time to explain why I don't put on shoes indoors, ... I allowed you to come in with shoes because you are here for an ordinary visit.";" ... but indoors it doesn't mat ter."Although none of the participants wore inappropriate foot wear at the time of observation, one participant was found to have purple discoloration of both big toe nails.This was sus pected to be a result of pressure from wearing tight shoes.

Guidelines
In view of the findings of this study, the following guidelines, in line with the Working Group of the National Diabetes Advi sory Board (1997:502)   ers in Transkei, should be trained to give education regarding diabetes mellitus in their communities on an ongoing basis, and report to the nurses at the nearest health facility.They can also be responsible for distributing medication to persons with diabetic mellitus in their areas, to minimise the monthly travel ling by patients; and monitor the patients by checking blood pressure, urine testing and weighing them.Then patients can only go for medical review at agreed times.The available com munity resources such as shops and church leaders and other key figures like chiefs and their headmen can be utilised.Em ployers should be asked to keep the monthly medication sup plies for their employees who have diabetes mellitus, and only release them when going for medical review.As the traditional healers are widely used by the majority of diabetic persons, they should be given thorough education.ondiabetes mellitus They should be able to recognise manifestations of diabetes and its complications, and refer to the formal health facilities.

Guideline three: Providing emotional support
Individual and/or group counseling should be instituted de pending on the individual patient's preparedness.Family in volvement is of paramount importance to assist the patient to cope and adjust to the new lifestyle.The family should be given the same information and skills as their diabetic relative so as to be fully supportive and understanding.Patients should be encouraged to form associations (support groups).Nurse should act as co-ordinators in the formative stages of the groups to offer expert advice and counseling.Once the groups are well organised, they should be allowed to run independently, only utilising the nurses' expertise when necessary.

Guideline four: Improving the selfimage of persons with diabetes mellitus
Attention should be directed at improving the self-image of the patients, to see themselves as valued members of their families and communities.This can be achieved by educating families, friends, employers and the community at large in rela tion to diabetes mellitus and its complications.Community Health Workers (CHWs) can play an important role in this as pect as they can also do home visiting.The first step towards boosting their self-esteem would be to involve patients with diabetic mellitus in planning their own care.

Guideline five: Changing health beliefs of persons with diabetes mellitus
Ajzen &Fishbein (1980:81) advise that in order to influence behaviour, we have to expose people to information which will produce changes in their beliefs.It is suggested that changing of long term cultural beliefs should be addressed through health education in the home (home visits) and/or through one-toone contacts in the community (Airhihenbuwa, 1995:38-39).

Guideline six: improving the quality of diabetes care in public health facilities
Community Health Workers -known as Village Health Work-

Guideline seven: Increase diabetes awareness among employers of persons with diabetes mellitus
Employees should be issued with certificates whenever they present themselves to the health care provider for treatment.
The certificate should specify the reason for the consultation as well as the next appointment date.Should the employees experience any problems, the health care provider should make an appointment with the employer in order to discuss the health needs of that particular employee (with the consent of the con cerned employee).The employer can even take the responsi bility or make arrangements that his/her employees get their treatment at the workplace.Employers should be given exten sive education on diabetes mellitus to help them understand why their employees have to continue taking treatment.

Guideline eight: improving footcare knowledge and skills through education
Footcare education should be structured to offer the follow ing: 19 Primary prevention through good metabolic control Patients should be given a list of Halpin-Landry & Goldsmith's 'commandments of foot care' (1999:32) and an explanation of its purpose.

Recommendations
Apart from the guidelines, the implementation of the following recommendations can improve the quality of care to patients with diabetic mellitus in Transkei:

Recommendations for nursing practice
The 'supermarket approach' of health care delivery in primary health facilities is not suitable for effective care of diabetes mellitus.The researcher reaffirms the integrated horizontal ap proach for the control of several different non-communicable diseases recommended by the WHO (1994: 76) and Working Group of the National Diabetes Advisory Board (1997: 510).
The integrated horizontal approach entails combining patients with diabetes, hypertension and cardiovascular diseases in one club or group.These diseases are all managed through diet, physical exercise, change in lifestyle and cessation of smoking.In this system chronically ill patients are managed by a separate team of health providers from those attending to acute and minor ailments, hence the nurses can find it easier to educate these patients simultaneously.Staff dealing with dia betic patients must not often be rotated, and preferably nurses that are really interested in diabetes care should run the recom mended clubs.

Recommendations for nursing researcli
It is recommended that a similar study be undertaken in all public health care facilities in Transkei that treat diabetic per sons in order to identify any similarities or differences in expe riences as well as quality of care.Alternatively a questionnaire can be developed based on the identified themes and adminis tered to a representative sample of persons with diabetes in Transkei to validate the findings of this study.An educational intervention based on the generalisable findings should be developed as soon as possible to ascertain whether it can in fluence diabetes outcomes favorably.As nurses in Transkei are the bedrock of PHC services, an audit of their knowledge related to diabetes mellitus, their attitudes and practices in the interests of improved public sector primary care for patients with diabetes mellitus is mandatory.This will help identify edu cational and training needs in relation to diabetes care.

Recommendations for nursing education
All health workers who care for diabetic persons should be trained in the management of diabetes mellitus.The field of care of diabetes mellitus is highly dynamic, and therefore re quires the staff to keep up with the rapid changes through regular in-service education, workshops and any available lit erature.An opportunity must be created for interested nurses to undergo a special course, which will give them the theoreti cal and practical upgrading necessary to cope with the care of diabetes mellitus.The Diabetes Education Society of South Africa is already involved in the training and accreditation of diabetes nurse educators.

Limitations
The contextual nature of this study is the major limitation.Its findings are restricted to diabetic patients referred to Umtata Hospital diabetic clinic, with consequent inclusion of only pa tients from 11 out of 28 districts that constitute Transkei in the study.Each district has no less than 10 clinics, hence the rec ommendation to replicate the study in all public health facili ties.The inability to observe footcare in only 53.3% of the participants further limits the applicability of this study find ings to other settings.

Conclusion
In conclusion the study has revealed deficient survival skills; poor knowledge and insight regarding long term complications; non-adherence to advised treatment regimes; a variety of health beliefs; and emotions resulting from living with diabetes.Poor diabetes care services in public primary health facilities; and difficulties encountered by diabetic em ployees at their workplaces were also reported.Footcare knowledge was found to be very limited.Several inappropriate footcare practices were reported and also observed.In order to describe guidelines for a responsive health promotion programme on footcare, nurses in primary healthcare settings are central to the empowerment of the diabetic patients in Transkei.
and the European IDDM PolicyGroup  (1993), are suggested:Guideline one: Improving the {(nowledge and sl(ills in relation to diabetes mellitus and its management through educationPatient education must be provided shortly after diagnosis; in the months following diagnosis and at every clinic visit; and in the long term to reinforce periodically (annually).

Guideline two: Promoting adherence to diabetes mellitus treatment regimes
Counseling must take place in order to promote disease ac ceptance.During the counseling sessions the value of selfcare and compliance should be emphasised in order to achieve good metabolic control.Treatment regimes should be discussed with individual patients for realistic and achievable treatment goals to be set.Advice should be suited to the patients' culture and understanding.For example it would be inappropriate to ad vise a housewife in Transkei to go out jogging, whilst the same advice would be relevant for a man from the same area.Also with diet, emphasis should be put on what food items are avail able and acceptable to the person concerned, not on what is supposed to be eaten.The action of medication should be explained thoroughly to dispel any misconceptions and unre alistic expectations.
-tion and prompt referral to the next relevant level of healthcare.If amputation does become necessary, edu cation on the use of prosthesis is important, together with special attention to the remaining foot which is subject to new stresses.
prick' sensation; inspection of footwear; and review of selfcare behaviour.Newly diagnosed persons or patients newly presented to clinic with diabetes should have their feet examined at their first clinic visit.Sur veillance should be performed annually or more of ten if risk factors are detected.Risk factor management: Primary management once risk factors are found should involve repeated educa Curatlonis May 2003