Plantar ulcer occurrence among leprosy patients in Northern Nigeria: A study of contributing factors.

Background: The study was conducted in three major leprosy referral hospitals in Northern Nigeria, which are NKST Rehabilitation Hospital, Benue State, Yadakunya Leprosy Hospital, Kano, and National Tuberculosis/Leprosy Training Hospital, Zaria. The main objective of the study was to investigate factors responsible for the occurrence of ulcers among leprosy patients reporting to the leprosy referral hospitals. Materials and
Methods: An analytic study of case-control design was used, with patients having plantar ulcers as cases and those without as control. Semi-structured was administered to all cases and controls.
Results: A total of 242 patients were studied; 124 patients (51.2%) had plantar ulcers whereas 118 (48.8%) had no ulcers (controls). A Chi-square test was used in the analysis to compare cases and controls. The study found differences between cases and controls with respect to patients release from treatment (RFT), gender, availability and utilization of footwear, age, occupation, and educational status. Footwears were provided to most patients, i.e. 60.8% late (i.e., after developing plantar ulcers); however, there was very good utilization of the footwears among those who had the footwears, 65.3%. Knowledge of self-care was higher among 64.5% of cases compared to only 28.1% of the controls.
Conclusion: Ulcer still remains a major problem among leprosy patients, especially RFT (76.6%) and most cases are provided with footwear late. Self-care knowledge is higher among cases than controls.

INTRODUCTION

Plantar ulcers and ulcer care constitute a large problem in the management of leprosy. Most of the hospital beds are occupied by ulcer cases.[1]

Plantar ulceration is the most common serious disability in leprosy and is usually caused by a “previous ulcer,” and the prevention of the first ulcer must be the priority in any leprosy program.[2] These ulcers usually result from repetitive stress on the foot. High pressures, deformities, and joint limitations increase the risk of ulcer occurrence in insensitive feet.[3] Several studies demonstrated a relationship between sensory loss and the risk of ulceration. It is agreed that loss of light touch is not really a disability, but if a patient cannot localize a firm touch, he is liable to suffer frequent injury; this is known as loss of “protective sensation.”[3]

Many programs provide protective footwear to patients, but at what level are this risk group patients identified. The standard WHO pencil stimulus is used in most developing countries. However, studies have shown that a monofilament method has a proven value in mild nerve damage but is not routinely used in the field. Another very useful test is biothesiometer, which currently is only of excremental use in leprosy, although widely used in diabetes. A study in East Africa demonstrated that threshold values and protective sensation values for sensation loss can be found in leprosy patients, but for the value to be effective, different values have to be found and used for shoe wearing and nonshoe wearing patients.[3]

People affected by leprosy have been taught how to carry self-care, but a large number (which can only be guessed) are able to prevent chronic or recurrent ulceration of their anesthetic feet, without an appropriate foot wear.[4]

As integration proceeds, there is an increasing need for empowering patients with the responsibility of their own ulcer prevention and also empowering the peripheral health units for basic surgical treatment of ulcers.[5]

Self-care is an important aspect of ulcer care and prevention in leprosy. Nearly 10% of ulcer cases relapse in the 1st year after treatment and healing.[4] Plantar ulcers are the most common ulcers in leprosy, and the best preventive measures are self-care training, daily treatment with soaking, and oiling along with the use of protective devices.[45]

Emphasis should be placed on ulcer prevention through surgical techniques, self-care, and health education.[6]

MATERIALS AND METHODS

Study area

This study was undertaken in three leprosy referral hospitals in Northern Nigeria. The choice of the centers was purely based on the annual reports, which shows 30%–60% of plantar ulcer occurrences among leprosy patients in the selected states.[789]

The hospitals are NKST, Mkar, NTBLTC, Zaria, Yadakunya Hospital, Kano. NKST Rehabilitation Hospital is located at Mkar, near Gboko, about 100 km east of Makurdi, Benue State capital. The hospital has an 114-bed capacity and is the referral center for leprosy for Benue State. The hospital offers orthopedic services to other adjoining states - Taraba, Adamawa, Nasarawa, Kogi, Northern part of Akwa Ibom State, as well as FCT, Abuja, and parts of Enugu State.

The National Tuberculosis and Leprosy Training Center (NTBLTC) Hospital, Zaria, serves as the training facility for tuberculosis (TB) and leprosy supervisors in the country. It is a partially integrated hospital. The major activities are treatment and care of TB and leprosy patients, maternal and child health care, training of medical students, and health staff on practical experience.

The Yadakunya Hospital is one of the largest and busiest leprosy referral hospitals in Northern Nigeria. With a bed capacity of 182, it serves Kano and adjoining Jigawa, parts of Katsina, Kaduna, Yobe, and Borno states. The center provides treatment of general medical cases, orthopedics, and leprosy rehabilitative services.

Methods

The methodology was an analytical study of the case–control design. It involves comparison of two groups of leprosy patients reporting to the referral hospitals, one without plantar ulcers (controls) and those with plantar ulcers (cases). Questionnaires with both open-ended and closed questions were administered to all cases and controls. The variables analyzed in this study were formulated from the questionnaire administered.

The study population consists of patients that presented to the three leprosy referral hospitals within the period January 1999 to December 2000 whether admitted or outpatient. All leprosy patients with or without plantar ulcers seen in the selected facilities within the study period were included, which makes a determination of sample size unnecessary. The hospital records were first of all reviewed and the list of the patients that qualify based on the above criteria compiled before they are traced for interviewing. Patients with eye ulcers are excluded from the study.

Permission was sought from the various authorities responsible for these referral hospitals to carry out the research in their centres. Ten health workers were trained to assist in the administering the questionnaire in the hospitals and the field.

The data were analyzed by tabulating the cases and controls to certain variables such as patients release from treatment (RFT), patients on multidrug therapy (MDT), age, gender, availability and utilization of footwear, occupation, educational status, ulcer relapse, and knowledge on self-care practice. While for the health-care workers, level of training was assessed against their knowledge on leprosy. Chi-square test was used in testing the variables.

Self-care practice among patients was assessed based on daily soaking and oiling, use of protective glove when cooking, use of protective pads when using hands implements, rest in between activity, and the frequency of the applications of self-care measures at home. Those who scored three and above were graded aware, whereas those who score two or below were graded not aware.

RESULTS

A total of 242 patients were studied; 51.2% of the study population had ulcers and 69.4% of them are RFT patients. The sex ratio was 0.64 with most of them were males.

Among all cases, 76.6% are RFT (i.e., 54.8% males and 21.8% females) compared to only 23.4% of cases were on MDT (i.e. 12.9% males and 10.5% females). While 61.8% of the controls are RFT (38.1% males and 23.7% females) compared to 38.1% of them were on MDT. See details in Table 1. Males - χ2 = 6.01; P < 0.05, df-1, odds ratio = 2.46. Females - χ2 = 0.58; P > 0.05; odds ratio = 1.41.

Table 1

Descriptive table is showing cases and control about gender, MDT, and RFT of the study population

Type of patients	Sex	Cases	Controls	Total
RFT	Male	68 (54.8%)	45 (38.1%)	113 (46.7%)
	Female	27 (21.8%)	28 (23.7%)	55 (22.7%)
MDT	Male	16 (12.9%)	26 (22%)	42 (17.4%)
	Female	13 (10.5%)	19 (16.1%)	32 (13.2%)
Total		124 (100%)	118 (100%)	242 (100%)

Age distribution among the study population shown in Table 2, indicates that only 3.7% of all participants (cases and control) are below the age of 14 years; While among cases, 1.6% are children compared to 98.4% of ulcer cases among adult (χ2 = 3.15; P > 0.05; df = 1; odds ratio = 0.26).

Table 2

Age distribution among the study population

Ages	Cases	Control	Total
0-14	2 (1.6%)	7 (6.0%)	9 (3.7%)
>14	122 (98.4%)	111 (94%)	233 (96.3%)
Total	124 (100%)	118 (100%)	242 (100%)

Table 3 shows the availability of protective footwear among the study population. Only 30.9% of the study population have a protective footwear (19.7% males and 11.2% females); more cases (21.9%) had footwear compared to only 9% of the controls with the foot wear; and 59% of cases had no foot wear (χ2 = 12.99; P < 0.001; odds ratio = 2.93).

Table 3

Footwears provision among cases and controls

Footwear	Sex	Cases	Control	Total
Provided	Males	31 (13.3%)	15 (6.4%)	46 (19.7%)
	Females	20 (8.6%)	6 (2.6%)	26 (11.2%)
Not provided	Males	54 (23.2%)	53 (22.7%)	107 (45.9%)
	Females	19 (8.250)	35 (15%)	54 (23.2%)
Totals		124	109	233 (100%)

Questionnaire for nine patients was not filled making the total of 233 patients

The study shows that 65.3% of those with the footwear use it continuously, whereas 23.6% use it when need arises and only 11.2% are not using it [Table 4].

Table 4

Frequencies of usage of the footwear among cases and controls

Frequencies	Cases	Control	Total
When need arises	10 (13.9%)	7 (9.7%)	17 (23.6%)
Continuous	36 (50%)	11 (15.3%	47 (65.3%)
Not using	5 (7.0%)	3 (4.2%)	8 (11.2%)
Total	51	21	72 (100%)

The study found that most cases (60.8%) were provided with footwear after developing ulcers, whereas only 9.8% had footwears before ulcer occurrence. This is depicted in Table 5.

Table 5

The timing of footwear provision among cases with footwear

Time of provision of footwear	Frequency
Before ulcer occurrence	5 (9.8%)
When the ulcer occurs	15 (29.4%)
After ulcer occurrence	31 (60.8%)
Totals	51 (100%)

Most of the study populations were farmers (42.6%). Table 6 shows that 45% of cases and 40% of control are all farmers, followed by 23% of cases and 27% of control were unemployed.

Table 6

The pattern of ulcer occurrence with occupation among cases and control

Occupation	Cases	Control	Total
Farmer	56 (45%)	47 (40%)	103 (42.6%)
Trader	16 (13%)	17 (14%)	33 (13.6%)
Civil servant	4 (3%)	1 (1%)	5 (2%)
Begger	10 (8%)	2 (2%)	12 (5%)
Unemployed	28 (23%)	32 (27%)	60 (24.8%)
Others	10 (8%)	19 (16%)	29 (12%)
Total	124 (100%)	118 (100%)	242 (100%)

Most of the leprosy patients shown in Table 7 had no formal education (84.3%). Among ulcer cases, 90.3% have no formal education, when compared to 77.9% of the controls without formal education (χ2 = 10.24; df = 2; P < 0.05).

Table 7

The pattern of ulcer occurrence with educational status among cases and control

Educational status	Cases	Control	Total
Non-formal	112 (90.3%)	92 (77.9%)	204 (84.3%)
Primary	6 (4.8%)	21 (17.8%)	27 (11.2%)
Post-primary	6 (4.8%)	5 (4.2%)	11 (4.5%)
Total	124 (100%)	118 (100%)	242 (100%)

Among all cases of ulcers, 64.5% are aware of self-care practice and 35.5% not aware of self-care.

While only 28.1% of controls are aware of the self-care and 71.9% are not aware of the self-care practice.

Table 8 shows males (χ2 = 15.22; P < 0.01; odds ratio = 4.51) and females (χ2 = 8.60; P < 0.01; odds ratio = 4.36).

Table 8

Self-care awareness among cases and control in leprosy patients

Self-care awareness	Sex	Cases	Control	Total
Aware	Males	57 (47.1%)	14 (17.1%)	71 (35%)
	Females	21 (17.4%)	9 (11%)	30 (14.8%)
Not aware	Males	28 (23.1%)	31 (37.8%)	59 (29%)
	Females	15 (12.4%)	28 (34.1%)	43 (21.2%)
Total		121 (100%)	82 (100%)	203 (100%)

Thirty-nine (39) questionnaires were not filled, making the total population of 203

DISCUSSION

Plantar ulcers occur in many leprosy patients not because of the leprosy disease but because of its neuropathic effects leading to increased risk for trauma and burns leading to ulcers. The pathogenesis illustrated in Figure 1. If all patients at risk are identified early and supported with appropriate protective footwear and health education on self-care, most of the ulcers are preventable.

Figure 1

Pathogenesis for planter ulcers among leprosy patients

This study shows that 51.2% of the leprosy patients had ulcers and the occurrence is high among males (67.7%). Even though data on occurrence of ulcer with gender are scanty, studies in India, Burkina Faso, Malawi, Nigeria, China, and Brazil reported a high rate of disabilities among males with a ratio of more than two.[610] Table 1 shows a χ2 of 6.01; P < 0.05; and odds ratio of 2.46, this implies that a male RFT patient is 2.46 times likely to develop an ulcer than a male patient on MDT, but this difference is not significant among the females patients. This is likely related to relatively high exposures of the males to certain activities, for example, farming and high mobility.

Most cases were RFT patients (76.6%). “The release of patients from treatment following satisfactory course of MDT of relatively short duration has, understandably, given many of them the impression that the disease is cured and that self-care and follow-up are unnecessary; they became overconfident and tend to forget or ignore the advice given concerning foot inspection, soaking, and the use of protective footwears.[11]

Age as a factor for ulcer occurrence, the study population shows in Table 2, indicates that only 3.7% of them are below the age of 14 years, and only 1.6% had ulcers compared to 98.4% of ulcer cases among adult (χ2 = 3.15; P > 0.05; df = 1; odds ratio = 0.26).

Protective footwears are provided to all leprosy patients with at least one anesthetic point on foot; therefore, all leprosy patients are assessed using bold pen at diagnoses, on monthly bases for patients on MDT, and two weekly for all patients with leprosy reactions.[12] The protective sensation threshold is usually assessed using Semmes-Weinstein Monofilament, and several studies have shown that any foot that can detect 10 g of the monofilament is highly unlikely to develop ulceration.[13] The challenge in Nigeria is ensuring that the use of bold pen still elicits 10 g monofilament among all leprosy patients by different health-care workers.

The protective footwear has the following characteristics; cushioned soft insole, hard under sole, adjustable straps (i.e., no nails or metals on the shores), and heel support.[12] In Table 3, of the study population, only 30.9% of the patients had protective footwears, of which of 21.9% are cases and only 9% are controls. Only 9% of the controls had footwear compared to 37.7% without footwear. This may mean in late detection of patients in need and in adequate distribution of footwears within programs. While Table 4 shows that 88.5% of those with the wears use them appropriately, which may imply good acceptability and utilization of the foot wears obtained in the program if made available to the patients. However, only 65.3% of the patients use the footwears continuously, whereas 23.6% use the foot wear when need arises.

However, Table 5 shows that the timing of the footwear provision is mostly late, with only 9.8% of cases with footwear getting them before the development of ulcers. Therefore, the detection of “risk group” and provision of the foot wear could be very late in the program.

Most of the patients (42.6%) are farmers, and there is no significant difference between the cases and controls in relation to occupation [Table 6]. Although it is difficult to dissociate farming from other occupations in our settings, further study could be carried out comparing high-risk occupations among our patients.

Educational status has significance influence on ulcer occurrence; the results show that 90.3% of the cases had no formal education compared to only 9.7% of cases having some formal education (i.e., primary and postprimary) [Table 7].

Self-care is defined as “health care, which the individual provides to him/herself without outside professional assistance.[1415] Such care may be based on instruction provided by the professionals.”[315] The strategy of self-care is for patients to use common, simple, available, and sustainable tools in their homes and surroundings to prevent or manage their basic medicosocial problems with less dependence on hospital facilities.[151617]

Self-care awareness is higher among cases (64.5%), compared to only 28.5% of the controls were aware. This shows that most of our program place more emphases on the self-care for the management of cases rather than preventive measures; there are evidence that self-care groups bring about decline in ulcers (41%), increase use of foot wears (43%), and a significant proportion of families practicing and helping each other. A study by DFIT in India also shows a reduction of prevalence of plantar ulcers by 50%.[1617] Empowering all patients with the knowledge of self-care. All the patients should be aware of having potentials to develop ulcers even after RFT, and therefore self-care practice should not be drop. “Unless special measures referred as ‘disability prevention practices’ are taken continued indefinitely, persons having leprosy-related impairment will inevitably worsen in their impairment-disability status irrespective of whether their deformities are corrected or not or they have been rehabilitated or not.”[15]

CONCLUSION

Plantar ulcer occurrence is higher 76.6% among patients RFT and most “risk groups” are detected late for an intervention. There is a good utilization of the program footwear if made available to the patients.

The self-care awareness and practice place more emphases on case management rather than prevention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.