Foot care practice and associated factors among patients with lymphoedema in Boreda district, Gamo zone, southern Ethiopia, 2020. Implications for elimination of podoconiosis and lymphatic filariasis

Background Lymphatic filariasis is ranked as the second leading cause of disability world-wide. The current global programme to eliminate lymphatic filariasis is based on the interruption of transmission and the alleviation of disability and suffering. Objective to assess foot care practice and associated factors among lymphoedema patients in Boreda district, Gamo zone Southern Ethiopia. Methods a community based cross sectional study was employed from December 2020 to June 2021 in Boreda district. Simple random sampling technique was used for selecting participants. Pretested structured interviewer administered questionnaire was prepared in English and translated to local language. Findings a total of 280 lymphedema patients were involved in this study. More than half 153 (54.6%) had poor practice towards foot care practice with 95% CI (48.7, 60.4%). Patients who fetched 50 l of water or below and wore shoes at the age above 20 years were negatively associated with foot care practice, (AOR = 0.383, 95%CI: 0.155, 0.945) and (AOR = 0.261, 95%CI: 0.107, 0.63), respectively. Patients who owned only one pair and two pairs were negatively associated with foot care practice (AOR = 0.04, 95%CI: 0.009, 0.182) and (AOR = 0.27, 95%CI: 0.087, 0.85), respectively. On the other hand, attending LMMDP service and frequency of adenolymphangitis once and twice or more per month were positively associated with foot care practice (AOR = 3.339, 95%CI: 1.53, 7.285) and (AOR = 8.15, 95% CI: 3.157, 21.058) and (AOR = 9.35, 95% CI: 3.118, 28.059), respectively. Conclusion this study indicated foot care practice among lymphedema patients in Boreda district was poor. Number of litre of water collected per day, age at which footwear first worn, number of shoes owned, attending LMMDP and frequency of adenolymphangitis were significantly associated with foot care practice. Standard foot care practice should be emphasized to control progression of lymphedema. Foot care practices like skin care, exercise and elevation, washing legs, bandaging and massaging are important factors that influence in reduction of lymphedema volume and acute attacks among people who are suffering from the diseases.


Introduction
Podoconiosis and lymphatic filariasis (LF) are neglected tropical diseases (NTDs) that affectthe world's poorest people and causes a significant economic, social and health burden to developing countries [1]. Podoconiosis or 'endemic non-filarial elephantiasis' is a tropical disease caused by exposure of bare feet to irritant alkaline clay soils. This causes an asymmetrical swelling of the feet and lower limbs due to lymphedema. Podoconiosis has a curable pre-elephantiasic phase. However, once elephantiasis is established, podoconiosis persists and may cause lifelong disability. The disease is associated with living in low-income countries in the tropics in regions with high altitude and high seasonal rainfall [2]. On the other hand, lymphatic filariasis or filarial elephantiasis, unlike podoconiosis is transmitted through the bite of an infected mosquito and mostly caused by an agent called Wuchereria bancrofti in Africa. It affected more than 36 million people globally and responsible for extremely complex physical, social and economic loss [3].
Lymphatic filariasis also known as filarial elephantiasis has its own impact on health, social and economic wellbeing of affected population in the world [4]. It is ranked as the second leading permanent disability. Physical and social lives as well as psychological wellbeing of patients with elephantiasis are significantly compromised due to the pain and discomfort, social stigmatization, restricted mobility, feelings of embarrassment and emotional distress that supplement these chronic disfiguring signs [5].
Globally, it is predicted that, 120-129 million people are infected with LF and of these; around 40 million have overt disease, accounting for 5.9 million disability adjusted life years (DALYs), with a concomitant loss of productivity and social stigmatization. Therefore, World Health Organization (WHO) identified LF as a major public health problem and is targeted by for elimination by 2020 [6].
Different literatures throughout the world revealed that practicing foot care has significantly reduced the frequency of acute attack secondary to lymphedema and progression of elephantiasis. Along with secondary infection and the resultant inflammation also seem to play major role in the skin changes seen in the limbs affected by lymphoedema, including the development of elephantiasis [7]. Also, Olszewski reported that simple hygiene, supplemented with antibiotic treatment have profound effect in preventing these acute episodes [8].
Shenoy et al. also demonstrated how well designed programme of foot care such as morbidity management and disability prevention (MMDP) program can significantly decrease the frequency of Adenolymphangitis attacks and also promote to alleviate the disability [9].
In such programmes, meticulous hygiene in treating the affected area needs to be incorporated with the creation of hope and understanding among the patients, their care providers and the community as a whole [10]. As the minimum package of care, managing the lymphoedema seen in LF and podoconiosis patients to manage morbidity is very similar. It is practical that lymphedema morbidity management and disability prevention (LMMDP) should be integrated to help improve cost-effectiveness and extend the reach of the programme [3]. This is particularly important in Ethiopia where there is a high burden of both diseases, with 29 of the 70 LFendemic districts considered to be co-endemic [11,12]. Recently training on Lymphedema Morbidity Management and Disability Prevention for health care providers and NTD focals from 20 selected districts of Southern Nation Nationality of People Region (SNNPR), Ethiopia was provided by Arba Minch University collaborative research and training centre for NTDs in collaboration with Ministry of Ethiopia. This will have impact on the way for elimination on podoconiosis by 2030 (i.e. reducing prevalence of podoconiosis below 1%; ensure 100% access to lymphedema management in all endemic districts and Ensure 70% regular shoe wearing and proper foot hygiene practice in all endemic districts) [12,13]. Despite many efforts done by Ministry of health Ethiopia, burden of podoconiosis still exist in the country with average prevalence of 4% and the highest proportion of cases are found in Southern nation and nationality region accounting prevalence of podoconiosis 8.3%. A more recent mapping data which is conducted in 2018 reported that a total of 16,929 leg lymphoedema was identified in the selected districts of SNNPR; out of this 1084 lymphoedema cases reported in Boreda district, Gamo zone [14].
The high number of leg lymphoedema cases in the current study area highlights the pressing need to deliver a basic package of care to those suffering from these disabling conditions, especially in areas with a high prevalence and/or high density of conditions where patients might be more readily found and the distribution of care easier. In this direction, it was essential to assess the current practices of foot care existing in the patients at community level, and no such information is available in Ethiopia. Hence, the present study was aimed to assess the foot care practices and associated factors among people living with lymphoedema in the rural communities of Gamo zone, SNNPR, Ethiopia, 2020.

Study setting and period
This study was conducted in Boreda district, Gamo zone, Southern Ethiopia from December 2020 to June 2021. Boreda is one of the districts in Gamo zone with high number of elephantiasis case. It is bordered on the Southeast by Mirab Abaya, on the Southwest by Chencha, on the west by Kucha, and on the North by the Wolayita Zone. There is about 1084 lymphoedema cases reported in the study area [14]. The district has 29 kebeles (an aggregate of villages and the smallest administrative unit in Ethiopia) and 5 health centres. Of the total kebeles, 10 were endemic for podoconiosis.

Study design and eligibility criteria
A community based cross-sectional study design was employed. Individuals who had leg lymphoedema in the study area were eligible for this study whereas severely ill patients were excluded from this study.

Population
All individuals who have leg lymphoedema in Boreda district were the source population and lymphedema cases in randomly selected kebeles were the study population.

Sample size and sampling procedure
Sample size was determined using standard procedures by considering the following assumptions: Z α/2 = significance level at 95% confidence interval = 1.96; P = 50%, to get the highest sample size on practice of foot care among patients; Degree of margin = 5%; 10% nonresponse rate, the final sample size was 422.
Since total number of cases in the study area was 1084 which is less than 10,000, we used finite population correction formula as follows: Hence, the final estimated sample size was 304. Of the total 10 podoconiosis endemic kebeles, six were randomly selected for data collection. Then number of lymphedema cases in each kebele was identified by health extension workers. The sample size was allocated proportionally to the size of cases in the selected districts. Finally, the study subjects were selected by using systematic sampling technique and selected cases were interviewed based on the pretested structured questionnaire ( Fig. 1).

Dependent variable
Foot care practice (Good or Poor)

Socio-demographic characteristics, economic factors, environmental factors, health related factors
Plan for data collection Data was collected by using pretested structured interviewer administered questionnaire which was developed by reviewing different literatures. Eight data collectors and four supervisors having diploma and above holders with health background and have experience on any research undertakings were recruited for data collection. Each randomly selected patient was subjected to an interview by using a pretested structured questionnaire and asked how she/he dealt with lymphoedema particularly about the treatment, and regular foot care. Subsequently each patient was asked whether she/he practiced the identified foot care measures. We developed nine most commonly recommended foot care measures by reviewing available literatures [15]. A patient was queried on each measure specifically and probed about different foot care practices in her/his daily life. The details of their socio-demographic, economic, personal hygiene and environmental factors, grade and duration of lymphoedema were recorded.

Operational definition
Lymphoedema: in this study lymphoedema was defined as lymphoedema of lower leg present for more than 1 year in a resident of podoconiosis or lymphatic filariasis endemic area, for which other causes-e.g. onchocerciasis, leprosy, Milroy syndrome, heart and liver failures have been excluded [16].

Data quality control
The data collection tool was reviewed by team members and then pretested on 5% of sample size outside actual study area. The tool was prepared in English then translated to local language by experienced translators and then back to English to check consistency. Data collectors and supervisors were trained on the tool and familiarized with it. Missing values and inconsistency of the data was checked by supervisors and investigators throughout data collection process.

Data processing and analysis
After checking completeness of the collected data, entry of data was done by Epi-info version 3.5.1 software and then exported to Statistical Package for Social Sciences (SPSS) version 25 for cleaning, coding and analysis. For quantifying the level of foot care practice, we used nine most commonly recommended foot care measures and the correct answer was given 1 and 0 score for incorrect response. Patients who practiced below the mean of practice question categorized as poor foot care practice and those patients who responded above the mean was considered as good foot care practice. Binary logistic regression analysis was employed to see association of independent variable with outcome variable. Factors which had p-value less than 0.25 during bivariate analysis were candidate for multivariate logistic analysis. Statistical significance was shown by 95% confidence interval and p-value<=0.05. Finally, the findings were presented in frequencies, graphs, tables and text.

Socio-demographic characteristic of the study subjects
Of the total expected study subjects, complete data were collected from 280 individuals with response rate of 92.1%. All (100%) of the study subjects were living in rural area of Boreda district. One hundred twenty one (43.2%), of the participants are in the age group above 50 years old. Female participants accounted for 169 (60.4%) of the total participants ( Table 1).

Practice of study participants towards lymphedema morbidity management and disability prevention
More than half 153 (54.6%) of the study subjects had poor practice of managing morbidity of lymphoedema with 95% confidence interval of (48.7, 60.4%) ( Table 2).
Factors associated with foot care practice among people living with lymphoedema In bivariate analysis, wealth index, number of litres collected per day, age at which shoes worn, number of shoes owned, duration of swelling occupation, age category, attended LMMDP treatment, experienced acute attack and frequency of acute attack became p-value less than 0.25 and therefore, were candidate for multivariate logistic regression model. After adjusting for other variables, number of litre collected per day per house, age at which shoes first worn, number of shoes owned, attended LMMDP treatment and frequency of acute attack were significantly associated with foot care practice. Patients who collected 50 l or below water were 38% less likely to have good foot care practice when compared to those patients who collected more than 50 l of water per day (AOR = 0.383, 95%CI: 0.155, 0.945). Study subjects who wore shoes at the age above 20 years were 26% less likely of having good foot care practice as compared to patients who wore shoes at age 20 years or below (AOR = 0.261, 95%CI: 0.107, 0.63). On the other hand, patients who owned only one pair and two pairs were 4 and 27% less likely to have good foot care practice in comparison with three or more pairs of shoes owned (AOR = 0.04, 95%CI: 0.009, 0.182) and (AOR = 0.27, 95%CI: 0.087, 0.85), respectively.

Home-environmental characteristics of lymphedema patients
Eighty nine (31.8%) of the study subjects said that one round walking distance to fetch safe drinking water was more than 30 min and more than three fourths fetch less    (Table 4).

Personal hygiene behaviour of lymphoedema patients in the study area
Regarding personal hygiene, 167 (59.6%) of the study subjects never walk barefooted whereas 33 (11.8%) and 73 (26.1%) become barefooted when farming and at home respectively. Most 196 (70%) of study participants started wearing shoes at the age of 20 years or below (Table 5).

Clinical history and characteristics of patients
Thirteen (4.6%) of the respondents have wounds on their legs. Of those who had wounds on their legs, 9 (69.2%) did not clean the wound (Table 6).

Accessibility to health care service
Of the total respondents, 116 (41.4%) did not attend LMMDP service because of different reason like didn't want 62(53.5%), health facility far from home 7 (6%) and no treatment centre available 47 (40.5%) ( Table 7).

Discussion
This community based cross sectional study was conducted to assess foot care practice and associated factors among people living with lymphedema in Boreda district, Southern Ethiopia. The result of this study found that more than half (54.6%) of study subjects had poor foot care practice. In contrast, a study done in Wolayta zone in 2016 showed that about 25.9% of the study subjects did not practiced stepwise treatment procedures   provided by Mossy Foot Association health workers [17]. This difference might be due to in our study area patients had less awareness and not well understood importance of practicing foot care and no much effort has been done to increase foot care practice.
In this study we found that patients who collected 50 l or below water per day were 38% less likely to have good practice of foot care when compared to those who collected more than 50 l of water per day. The possible reason might be the fact that accessibility to water is closely linked with personal hygiene practices i.e. the more they collect water daily, the more they take care of their foot. Ministry of health Ethiopia also recognized that high number of NTDs burden is linked with inadequate hygiene and sanitation conditions, and it is now recognized globally that prevention and treatment of NTDs must include water, hygiene and sanitation improvements in addition to mass drug administration [18].
According to this study the study subjects who used footwear first at the age of above 20 years old were 26% times less to practice foot care measures when compared to the counterpart. The lower the age of patients to begin footwear, the better patients take care of their foot. This might indicate that people who started shoe wearing at early ages take care of themselves than others. To our knowledge, there is no previous literature conducted to discuss with this finding. This result is the first in its kind.
The present study revealed that number of shoes owned by the patients was significantly associated with foot care practice. Those study subjects who owned only one and two shoes were 4 and 27% less likely to practice foot care in comparison with patients with three or more shoes owned, respectively. This result might indicate the more number of shoes owned by the patients the better they take care of their foot. In addition to that those patients who owned three or more pairs of shoes might be in a good economic status and had access to services of lymphedema and afford consumables easily for their feet.
We found that frequency of acute attack was significantly strongly associated with good practice of foot care. Those patients who experienced one and more than one acute attack per month were 8 and 9 times more likely to have good foot care practice than patients who faced one acute adenolymphangitis per year. The possible reason might be patients with more frequent acute attack of adenolymphangitis visit clinics for seeking treatment of the pain and thereby obtain information regarding foot care.
Although this study is the first in its kind to associate foot care practice with other variables, it has the following limitations: there might be recall bias regarding frequency of acute attack in a year and might not remember the exact age at which shoes first worn. This finding may not be generalizable to lymphoedema patients in Gamo zone because it is limited to Boreda district. In this study we did not use appropriate theory for designing questionnaire and is one of the potential weakness. Hence, acceptable theory for questionnaire design is recommended for future study [19].

Conclusion and recommendation
In conclusion, this study indicated foot care practice among people living with lymphoedema in Boreda district is poor. More than half of the study subjects had poor practice regarding foot care measures. In multivariable regression analysis variables like number of litre of water fetched per day, age at which used footwear first, number of shoes owned, attending LMMDP treatment and frequency of acute attack were significantly associated with foot care practice. Therefore, standard foot care practice should be emphasized to control progression of lymphedema and improve care of patients towards practice measures. Shoe wearing habit at early age and other preventive strategies on podoconiosis and