Prevention Of Diabetic Foot Ulcers Research Articles

Mobile Health untuk Pemantauan Kaki dalam Mencegah Ulkus Kaki Diabetik

This study aimed to determine the use of mobile health in preventing diabetic foot ulcers. The method used in this study is a literature review, where the electronic database used is Pub Med and Clinical Key, published from 2015 to 2022. The keywords used are mobile health, diabetic foot care, and prevention of diabetic foot ulcers. The results show that using mobile health technology helps people with diabetes to monitor their feet independently to prevent diabetic foot ulcers. Components of mobile health that can be used include monitoring foot temperature, foot descriptions, and directed guides for foot care. In conclusion, Mobile Health can help people with diabetes to prevent the occurrence of diabetic foot. The Mobile Health application makes it easy for people with diabetes to carry out foot monitoring.
 
 Keywords: Mobile Health, Diabetic Foot Care, Prevention of Diabetic Foot Ulcers

Effectiveness of Percutaneous Flexor Tenotomies for the Prevention and Management of Toe-Related Diabetic Foot Ulcers: A Systematic Review.

There is a high prevalence of digital deformities in diabetic patients, particularly claw toe, which can result in ulceration, often located at the tip of the toe. These lesions are challenging to off-load with conventional devices and frequently lead to infection and high amputation rates. Recent guidelines recommend considering flexor tenotomies to manage these ulcerations and prevent complications. This review, which analyzed 11 studies, aimed to assess the effect of flexor tenotomies on the healing and prevention of diabetic foot ulcers (DFUs) at the toe tip. Satisfactory results were found, with a healing rate of 92% to 100% and a mean healing time of 2-4 weeks. Few mild complications were observed, and the recurrence rate was very low. Transfer lesions were the most prevalent, but simultaneous tenotomy of all toes can eliminate this risk. Flexor tenotomies are a simple, effective, and safe procedure for the treatment and management of DFUs located at the apex of the toes and should be considered part of the standard of care for diabetic feet.

SMART PREVENTIVE INSOLE FOR DIABETES

Smart wearable gadgets are powerful in diabetic foot ulcer (DFU) prevention. However, elements figuring out their recognition are poorly understood. This systematic evaluation pursuits to observe the literature on affected person and issuer views of clever wearable gadgets in DFU prevention. The methodological pleasant of the research ranged from low to moderate. Two research hired a quantitative have a look at layout and centered at the affected person perspective, whereas three research blanketed a mixed, quantitative/qualitative layout and explored affected person or provider (podiatrist) perspectives. Four research targeted on an insole gadget and one covered a clever sock device. The quantitative research validated that gadgets had been comfortable, properly designed and beneficial in stopping DFU. One combined layout observe suggested that sufferers did now no longer intend to undertake an insole tool in its cutting-edge layout due to malfunctions, a loss of consolation and alert intrusiveness, regardless of the overall notion that the tool became a beneficial device for foot threat monitoring. Two mixed design studies found that performance expectancy was a predictor of a podiatrist’s behavioral intention to recommend an insole device in clinical practice. Disappointing player studies negatively impacted the podiatrists’ purpose to undertake a clever device. The modern proof approximately affected person and issuer views on clever wearable generation is restrained via way of means of scarce methodological best and conflicting results. It is, thus, now no longer viable to attract definitive conclusions concerning acceptability of those gadgets for the prevention of DFU in human beings with diabetes.

Support for diabetes patients

My Care Shoe is a novel solution for prevention and treatment of diabetic foot ulceration based on flexible electronics. Ropar S.A., through its brand Ortomedical, together with a multidisciplinary consortium, developed this novel smart shoes solution.

PENGARUH EDUKASI KESEHATAN PERAWATAN KAKI TERHADAP PENGETAHUAN, SIKAP DAN PERILAKU PENCEGAHAN ULKUS KAKI DIABETIK

Background: Patients with diabetes mellitus have a 15% risk of developing diabetic foot ulcers. Diabetic foot ulcers will not occur if people with diabetes have the knowledge and are willing to take care of their feet regularly. The purpose of this study was to determine the effect of health education on knowledge , attitude and prevention of diabetic foot ulcers . Method : Quasy experiment research design pre test - post test control group design. The sample was DM patients who visited the Muliorejo Health Center, the sampling technique was purposive sampling with a sample size of 20 people in the treatment group and 20 people in the control group. The independent variable is health education, the dependent variable is knowledge, attitudes and preventive measures for diabetic foot ulcers. Data collection by questionnaire. Data were analyzed using the Wilcoxon Sign Rank Test and the Mann-Whitney Test. Results : The results showed: there was an effect of health education on knowledge (p= 0.000), attitudes (p= 0.000) and actions (p= 0.000) in preventing diabetic foot ulcers. Discussion : Health education as an effort to persuade people with DM to be responsible for their health by first increasing their knowledge and attitudes. Future research should use more reliable but simple instruments to measure knowledge and avoid measurement bias.

Effectiveness of a foot self-management intervention that utilized commercially available infrared thermometers: Mixed methods research incorporating a pilot RCT

ObjectiveTo evaluate the effectiveness of a foot self-management strategy that utilized a commercially-available infrared thermometer (CAIT) for prevention of diabetic foot ulcers. Research Design and MethodsIn this six-month pilot randomized controlled trial, Phase 2 of a three-phase mixed methods research study, 62 participants were randomized to a thermometer and education group (n = 34) and an education-only group (n = 26). Both groups received foot care education and were assessed by a certified orthotist. All participants recorded their number of steps and recorded a foot assessment in a logbook daily. The thermometer and education group also recorded their daily temperature assessment. A temperature difference of >4° Fahrenheit (F) between the two feet prompted participants to rest their feet. Participants were directed to see their healthcare provider if the temperature difference did not decrease to below 4° F in two days. Phase 3 of the study explored the Phase 2 results to understand the findings further. ResultsThe strategy improved foot assessment and action: the thermometer and education group had significantly more days with any assessment completed than the education-only group (150.98/180 vs. 119.84/180, p = 0.02). Phase 3 findings showed that the thermometer engaged participants, prompted action, and offered reassurance regarding foot health. ConclusionsA CAIT is a tool that could support foot self-management and may offer several benefits, such as promoting and providing structure for a foot assessment and direction for action. Clinical trial reg noNCT0306776 clinicaltrials.gov.

The Effectiveness Of Using Learning Media To Increase Knowledge And Preventive Measures Of Diabetic Foot Ulcers In Patients With Diabetes Mellitus

Background : Diabetic foot ulcer is one of the complications of DM's disease. Prevention of diabetic foot ulcers can be done by providing health education to improve the knowledge, attitudes, or actions of patients with diabetes mellitus but it is very necessary to provide a health education in order to be able to understand and able to do it. In fact diabetic ulcer numbers are increasing. It is necessary to increase the method and media delivery of the health education. Objective: The literature of this review aims to be to know the effectiveness of the use of media learning towards increased knowledge and preventive measures of diabetic foot ulcers as well as finding similarities, differences, advantages and disadvantages of the journals in review. Methods: This study uses review literature designs obtained from Google Scholar sources. The key word in this review literature search is the prevention of diabetic foot ulcers with dependent variable use of learning media and independent variables of knowledge and action. Results: Out of 5 studies gained 3 national journals and 2 international journals with the result that health education using the media has a significant influence on knowledge, attitude, and practice.

Hyperglycaemia-Linked Diabetic Foot Complications and Their Management Using Conventional and Alternative Therapies

Diabetes mellitus, a major cause of mortality around the globe, can result in several secondary complications, including diabetic foot syndrome, which is brought on by diabetic neuropathy and ischemia. Approximately 15% of diabetic patients suffer from diabetic foot complications, and among them 25% are at risk of lower limb amputations. Diabetic foot ulcers are characterized as skin lesions, gangrene, or necrosis, and may develop due to several reasons, including hyperglycemia and slower wound healing in diabetic patients. A management protocol involving wound cleaning, oral antibiotics, skin ointments, and removing dead tissue is currently followed to treat diabetic foot ulcers. In severe cases, amputation is performed to prevent the infection from spreading further. The existing therapy can be costly and present adverse side effects. Combined with a lack of vascular surgeons, this ultimately results in disability, especially in developing nations. There is a growing interest in the use of alternative therapies, such as medicinal plants, to discover more efficient and affordable treatments for diabetic foot syndrome. It has been observed that treatment with numerous plants, including Carica papaya, Annona squamosa, Catharanthus roseus, and Centella asiatica, promotes wound healing, reduces inflammation, and may decrease the number of amputations. However, little information is currently available on the prevention and management of diabetic foot ulcers, and additional research is necessary to completely understand the role of alternative therapies in the treatment of diabetic foot complications.

Preventive Nail Care Among Diabetic Patients: A Quality Improvement Initiative.

The purpose of this quality improvement initiative was to increase adherence to follow-up appointments in patients with diabetes mellitus for prevention of diabetic foot ulcers. The sample comprised 33 adults with diabetes mellitus being cared for at an outpatient wound care clinic affiliated with a large metropolitan hospital in the state of Mississippi, located in the Southern United States. This quality improvement approach used the Plan-Do-Study-Act method. Educational flyers and verbal instruction were provided to enhance adherence to preventive nail care and follow-up appointments. The goal for this quality improvement initiative was to increase adherence with preventive nail care and follow-up care. Participants were provided with educational flyers and verbal instruction that emphasized the importance of follow-up clinic appointments, which promoted increased attendance at follow-up appointments. The proportion of patients who did not attend follow-up appointments fell from 9.2% prior to the intervention to 5.8% after its introduction. This quality improvement initiative positively impacted practice at a local wound care clinic in Mississippi resulting in a clinically relevant reduction in no-show follow-up visits when compared to the previous year.

Effectiveness of Educational Program on Knowledge and Practices of Nurses Regarding Prevention of Diabetic Foot Ulcers at Tertiary Care Hospital, Lahore

Diabetes is a chronic disease that affects 4.2% of the world's population. Nurses effectively prevent foot ulcers and lower limb amputations by providing educational intervention and health care. Objective: To evaluate the effectiveness of a training program on nurses' knowledge and practices related to diabetic foot ulcer prevention. Methods: A quasi-experimental pre-post study was conducted in the diabetes clinic and medical departments of Sir Ganga Ram Hospital in Lahore, Pakistan. A total of 36 nurses were randomly selected. After obtaining informed consent, all female nurses aged 23 to 35 years with inadequate knowledge of diabetic foot ulcer prevention were included in the study. The nurses received a 16-week intervention. Nurses' knowledge was assessed using a validated instrument called the Nurses Knowledge Questionnaire related to Diabetic Foot Management Care and an observation checklist for nurses' practice related to neurovascular assessment of diabetic patients before and after the intervention. Data were entered and analyzed using SPSS version 24.0. Results: The results showed that most of the participants were from 26 to 30 years, 19 (52.8) were single with educational level of nursing diploma (50.0%). Participants were having 2 to 5 years of experience. After the intervention there were 4 (11.1%), 13 (36.1%) and 19 (52.8%) participants having poor, moderate and good knowledge respectively regarding prevention of diabetic foot ulcers. There was a significant difference between pre and post interventional score of practice and knowledge among nurses (p value <0.001). Conclusions: Nurses have poor knowledge and practice regarding diabetic foot care but after the intervention it increases significantly.

Knowledge, Attitude and Practice towards Prevention of Diabetic Foot Ulcer among Adult Diabetic Patients Attending at Follow-Up Clinic of Hawassa Comprehensive Specialized Hospital, Sidamma, Ethiopia

Diabetic foot ulcer is among the commonest complications of diabetic mellitus, attributing to a significant number of morbidity and mortality in diabetic patients, and enormous economic loss to the families and the country.

Effects of Special Therapeutic Footwear on the Prevention of Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective To reduce diabetic foot ulcer (DFU) occurrence or recurrence, diabetic therapeutic footwear is widely recommended in clinical practice for at-risk patients. However, the effectiveness of therapeutic footwear is controversial. Thus, we performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine whether special therapeutic footwear could reduce the incidence of DFU. Method We systematically searched multiple electronic databases (Medline, EMBASE, and EMB databases) to identify eligible studies published from inception to June 11, 2021. The database search, quality assessment, and data extraction were independently performed by two reviewers. Efficacy (i.e., incidence of DFU) was explored using the R'meta' package (version 4.15-1). To obtain more robust results, the random-effects model and the Hartung-Knapp-Sidik-Jonkman method were selected to assess pooled data. Metaregression analysis and sensitivity analysis were performed to explore heterogeneity, and publication bias was assessed by a visual inspection of funnel plots and the AS-Thompson test. Results Eight RCTs with a total of 1,587 participants were identified from the search strategy. Compared with conventional footwear, special therapeutic footwear significantly reduced the incidence of DFU (RR 0.49; 95% CI, 0.28-0.84), with no evidence of publication bias (P = 0.69). Unexpectedly, the effectiveness of special therapeutic footwear had a reverse correlation with the intervention time (coefficient = 0.085, P < 0.05) in the metaregression analysis. Conclusion Special therapeutic footwear with offloading properties is effective in reducing the incidence of DFU. However, the effect may decrease gradually over time. Despite undefined reasons, the optimal utility time and renewal frequency of special therapeutic footwear should be considered.

A plantar surface shear strain methodology utilising Digital Image Correlation

The increase in the global diabetic population is leading to an increase in associated complications such as diabetic foot ulceration (DFU), associated amputations, morbidity, which substantial treatment costs. Early identification of DFU risk is therefore of great benefit. International guidelines recommend off-loading is the most important intervention for healing and prevention of DFU, with current research focused on pressure measurement techniques. The contribution of strain to DFU formation is not well understood due to challenges in measurement. The limited data available in the literature suggest that plantar strain is involved in ulcer formation. As a consequence, there is a need for plantar strain measurement systems to advance understanding and inform clinical treatment. A method was developed to determine plantar strain based on a Digital Image Correlation (DIC) approach. A speckle pattern is applied to the plantar aspect of the foot using a low ink transference method. A raised walkway with transparent panels is combined with a calibrated camera to capture images of the plantar aspect throughout a single stance phase. Plantar strain is then determined using 2D DIC and custom analysis summarises these data into clinically relevant metrics. A feasibility study involving six healthy participants was used to assess the efficacy of this new technique. The feasibility study successfully captured plantar surface strain characteristics continuously throughout the stance phase for all participants. Peak mean and averaged mean strains varied in location between participants when mapped into anatomical regions of plantar interest, ranging from the calcaneus to the metatarsal heads and hallux. This method provides the ability to measure plantar skin strain for use in both research and clinical environments. It has the potential to inform improved understanding of the role of strain in DFU formation. Further studies using this technique can support these ambitions and help differentiate between healthy and abnormal plantar strain regimes.

Evaluation of foot ulcer incidence in diabetic patients at a diabetic foot ulcer prevention clinic over a 10-year period.

The present study aimed to evaluate diabetes patients over a 10-year period that visited our outpatient clinic for prevention of diabetic foot ulcers and then investigate the incidence and aetiology of diabetic foot ulcers. The Department of Diabetes and Metabolic Diseases of a university hospital was in charge of the clinic that provided diabetes patients with individual education via the use of visualisation techniques. In this prospective cohort study, a total of 942 diabetes patients who visited the clinic were evaluated for neuropathy, angiopathy and medical history between November 2006 and March 2017. Using the patients' medical records, diabetic foot ulcer development was evaluated between the day of the first visit and December 31, 2018, with 20 out of 942 participants developing these ulcers. Over a period of 12, 60 and 120 months, the diabetic foot ulcer cumulative incidence was 0.2%, 2.4% and 5.8%, respectively. A history of diabetic foot ulcers and the male sex were shown by a Cox regression analysis to be correlated with diabetic foot ulcer development (Hazard Ratio [HR] 11.55, 95%CI 4.600-29.004, p < 0.001; and HR 3.55, 95%CI 1.031-12.196, p=0.045, respectively). However, only five out of 20 participants with ulceration returned to the clinic for re-examination. In conclusion, a 12-month evaluation showed there was a low incidence of diabetic foot ulcers. These results might suggest that patients with a diabetic foot ulcer history need to undergo at least an annual follow-up in order to further reduce diabetic foot ulcer incidence, although studies involving control groups needs to be conducted, in presenting these as evidence.

Pathophysiology and prevention of diabetic foot ulcer

Pathophysiology and prevention of diabetic foot ulcer

IDF21-0257 The Feasibility of a Social Media-based Diabetic Foot Ulcer Prevention Program during the COVID-19 Pandemic in Canada

Background: Diabetic foot ulcer (DFU) is a costly complication associated with excessive disability and mortality. Due to the COVID-19 pandemic impact on the healthcare system, recent studies have anticipated an increased DFU incidence among people with diabetes (PWD). Therefore, continuous education and support are necessary to promote PWD adherence to foot self-care recommendations. However, available community and health facility-based DFU prevention programs for PWD are mostly face-to-face and restricted regarding access and its impact on sustaining foot self-care adherence. With the adaption of telehealth to improve healthcare access and support self-management, social media offers some benefits that healthcare professionals could explore to empower patients to prevent DFU, but evidence on its feasibility is limited. Aim: This study aims to determine the feasibility of social media as an alternative method to engage PWD in DFU prevention. Method: This feasibility study utilized a partially randomized preference trial design to explore PWD acceptance of a social media-based DFU prevention program and its efficacy on foot care adherence, self-efficacy, foot health status, and quality of life. The participants in the experimental group received self-management education and support via a private Facebook group platform alongside their routine health care. In contrast, the control received only routine health care. The study intervention was based on Social Cognitive theory with the education content adapted from the Wounds Canada Diabetes, Healthy Feet and You module. Two to three posts are scheduled daily in formats such as text, videos, photos, polls, and web links for three months. Data collection involves a validated questionnaire administered through QualtricsXM survey software at baseline, one, and three-month post-intervention with an interview. The data were analyzed using SPSS-27 and NVivo-12. The cut-off point for all study outcomes was > 70% except for the quality of life (50%). Results: A total of 32 participants were enrolled in the study (intervention [n=23] and control group [n=9]). The intervention implementation and data collection are still ongoing. The participants in the intervention and control group baseline characteristics were not statistically different. Most participants had a moderate to high DFU risk level, 62.5% and 28.1%, respectively. At baseline, 62.5% of the participants have poor adherence to foot self-management recommendations. Nineteen participants have completed the study (intervention [n=12] and control group [n=7]). The intervention acceptance mean-score was 83.08 ± 9.93 (range, 71 – 99%). The intervention led to significant improvement in participants' adherence to foot self-care recommendations (p=0.01). Participants accepted the intervention because it enhanced their awareness of DFU as a debilitating health condition. Also, the intervention resulted in a non-significant increase in participants' communication with healthcare professionals about foot problems, awareness of community resources, foot health status, and physical functioning. Discussion: Preliminary data revealed that social media is a feasible platform to engage PWD in DFU prevention. In addition, the intervention improved participants' foot self-care adherence, communication with healthcare professionals, community resources awareness, foot health status, and physical functioning. The overall study findings would inform recommendations for integrating social media into DFU prevention programs during and beyond the COVID-19 pandemic.

IDF21-0015 Can weekly ‘foot alerts’ using a bespoke mobile app improve patient diabetic foot care knowledge and practices in Kuwait

Background: Diabetic foot ulcers (DFU) are the leading cause of non-traumatic lower limb amputation, occurring every 20-secs. An important step in disrupting the pathway to amputation is improving patient awareness and foot care practices. Improvement in short-term knowledge and behaviour following education programs has been reported, but without sustained improvement. Two recent Cochrane reviews reported that not enough high-quality evidence existed to prove the effectiveness of patient education programs on the prevention of DFU, as delivery methods are not evidence-based, nor are the right patients targeted. We propose that patients who receive weekly foot alerts alongside their regular Podiatry appointments will have better foot care knowledge and behaviours at 12-months compared to a control group. Aim: This study aims to determine if targeted weekly diabetic foot alerts improve diabetic foot care behaviour and knowledge in patients with high and moderate diabetic foot risk classification, compared to participants who only receive regular podiatry interventions. Method: This randomized, investigator-blinded, two-armed, study aims to pilot an innovative approach to education delivery. Participants will be included if they have been classified as high or moderate risk of developing DFU using the NICE classification system. Ninety-eight Participants will be randomised to (1) control group, who will receive usual diabetic foot care education, including daily foot inspections, foot hygiene, and footwear advice, supplemented by an information leaflet or (2) intervention group, in addition to the diabetic foot care education and information leaflet given to the control group, participants will receive a 10-minute audio-visual pre-recorded presentation based on the foot care education and an application will be downloaded onto their smart phone. This application will deliver weekly foot alerts based on the presentation, repeating at 12-weekly intervals. Podiatry appointments will be scheduled depending on risk classification. Participants will complete an adapted Summary of Diabetes Self-Care Activities behaviour questionnaire (SDSCA) and a Foot Care Knowledge questionnaire at first Podiatry appointment and 12-months. Results: The primary outcome measure will compare means of each questionnaire between the two groups. It is anticipated that participants in the intervention group will have improved foot care knowledge and practices. Secondary outcomes will include assessing the association between participants knowledge and behaviour and the number of foot alert engagements, and the number of podiatry appointments. Lastly, the number of new DFUs and change in HbA1c will be compared between the two groups. Discussion: This novel approach to diabetic foot care education could have a significant impact on patients' foot health and quality of life. Moreover, the financial burden to healthcare facilities and governments may be lessened by improving foot care behaviour and reducing DFU frequency.

A cukorbeteg láb szövődményeinek ellátása a nemzetközi irányelv alapján

The prevalence of diabetes continues to increase worldwide, leading to a rising incidence of foot complications (neuropathy, angiopathy ulcus, infections). In the prevention of the diabetic foot complications the correct diagnosis of the actual conditions is essential, because the infected foot ulcers can lead to amputations of the lower extremities. Diabetic foot ulcers and infections are treated with daily wound care, antimicrobial therapy, surgical treatment, off-loading processes, hospitalization and rehabilitation. These processes are associated with high health care costs. In this paper the basic principles of prevention, classification and treatment of diabetic foot ulcers are summarized based on the publication of the International Working Group on the Diabetic Foot (IWGDF).

Material Selection for Diabetic Custom Insoles: A Systematic Review of Insole Materials and Their Properties

ABSTRACT Introduction Diabetic foot ulceration is one of the most significant causes of infection and amputation in neuropathic patients. Most often, the plantar surface of the foot is affected. Offloading the foot by custom-molded insoles is considered a crucial step in prevention of diabetic foot ulcers, although the most beneficial choice of materials is not well documented. This review focuses on identifying the most suitable materials and material compositions for offloading the diabetic foot. Materials and Methods A systematic review was performed with the aid of a clinical librarian on September 9, 2020. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Studies were included based on the following eligibility criteria: interventions in terms of material selection/properties with outcomes reported as either pressure reduction and/or ulcer prevention. Bench studies were also included. At each level of selection, records were reviewed by two independent reviewers. Clinical studies were appraised using the ROBINS-1 tool. Results Through database search, 1131 records were identified and an additional eight records were identified through references and other sources. After removal of duplicates, 927 records were screened, which resulted in 74 full-text records assessed for eligibility. Thirty-seven studies were included in the qualitative synthesis. Twelve studies examined material properties by bench testing. Five studies were based on finite element analysis. Nineteen clinical studies on material parameters were identified. Six studies supported the use of moderately deformable materials for insole production. Six studies showed better performance of combination material insoles in offloading and under sustained loading. Five studies concluded that increasing the thickness of insoles increased the offloading capabilities. Conclusions The diversity of studies and study designs to date precludes the ability to recommend one type of material over the other. Still some general considerations can be made. For solo-material insoles, moderately deformable materials are preferable, balancing the need for offloading with the need for durability. Increasing the thickness may increase the longevity of the insoles. Combining materials of different properties seems to enhance both the offloading capability and durability of insoles. Clinical Relevance When using a single-material design, moderately deformable materials are preferable. Combining materials of different properties enhances both the offloading capability and durability of insoles.

Cross-Sectional Study Concerning the Knowledge, Attitude, and Practice of People With Diabetes Regarding the Prevention of Foot Ulcers in a Community

Foot ulceration is a serious problem among people with diabetes. This study assessed the knowledge, attitude, and practice of 483 people with diabetes with regard to the prevention of diabetic foot ulcers (DFUs). Data were collected using a valid and reliable questionnaire, and logistic regression was carried out to predict the effect of statistically significant independent variables on the scores of dependent variables. A significant association was found between knowledge and attitude about DFU prevention. Individuals who were unmarried were more likely to have higher knowledge scores than those who were married, and those who had university and secondary education were more likely to have higher attitude and practice scores than other groups. Overall, however, only a small percentage of study participants achieved high scores for knowledge, practice, and attitude in this study.