I
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rna
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l J
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P
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ea
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I
J
P
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S)
Vo
l.
1
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No
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Ma
r
ch
20
2
5
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So
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R
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Dec
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2
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R
ev
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Ap
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2
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Ap
r
2
4
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2
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2
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Dia
b
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c
fo
o
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s
p
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q
u
a
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ty
o
f
li
fe
o
f
d
iab
e
tes
p
a
ti
e
n
ts.
In
d
iv
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u
a
l
f
a
c
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rs,
fa
m
il
y
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a
n
d
s
o
c
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su
p
p
o
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t
h
a
v
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a
n
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ti
n
g
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ia
b
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ti
c
fo
o
t
w
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n
d
s.
Th
is
re
se
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rc
h
a
ims
to
d
e
term
in
e
th
e
a
sp
e
c
ts
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f
so
c
ial
s
u
p
p
o
rt
in
p
re
v
e
n
ti
n
g
d
iab
e
ti
c
fo
o
t
wo
u
n
d
s.
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e
re
se
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rc
h
e
m
p
lo
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e
d
a
c
ro
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se
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ti
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l
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e
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n
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i
n
v
o
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in
g
1
2
0
re
sp
o
n
d
e
n
ts.
Th
e
M
o
d
ifi
e
d
Dia
b
e
ti
c
F
o
o
t
Ca
re
Be
h
a
v
i
o
r
(M
D
F
CB)
i
n
stru
m
e
n
t
wa
s
u
se
d
to
a
ss
e
ss
b
e
h
a
v
io
r
re
late
d
to
d
iab
e
ti
c
fo
o
t
c
a
re
.
Da
ta
a
n
a
ly
sis
wa
s
c
o
n
d
u
c
ted
u
sin
g
l
o
g
ist
ic
re
g
re
ss
io
n
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e
re
su
lt
s in
d
ica
ted
a
p
o
siti
v
e
c
o
rre
latio
n
b
e
twe
e
n
h
ig
h
lev
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ls
o
f
so
c
ial
su
p
p
o
r
t
a
n
d
th
e
p
re
v
e
n
ti
o
n
o
f
d
iab
e
ti
c
fo
o
t
wo
u
n
d
s.
In
a
ss
e
ss
in
g
p
a
ti
e
n
t
k
n
o
wle
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g
e
a
b
o
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t
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o
t
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re
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s
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u
n
d
th
a
t
2
0
p
e
o
p
le
(1
6
.
7
%
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h
a
d
p
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o
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k
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wle
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g
e
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d
it
i
o
n
a
l
ly
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l
o
w
fa
m
il
y
su
p
p
o
rt
wa
s
se
e
n
in
2
3
p
e
o
p
le
(1
9
.
2
%
),
lo
w
p
e
e
r
su
p
p
o
rt
in
1
7
p
e
o
p
le
(
1
4
.
2
%
),
a
n
d
lo
w
su
p
p
o
rt
fro
m
h
e
a
lt
h
wo
r
k
e
rs
i
n
1
5
p
e
o
p
l
e
(1
2
.
5
%
).
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u
rt
h
e
rm
o
re
,
4
2
p
e
o
p
le
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5
%
)
e
x
h
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it
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d
p
o
o
r
b
e
h
a
v
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r
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n
p
re
v
e
n
ti
n
g
f
o
o
t
wo
u
n
d
s.
Th
e
Ch
i
-
s
q
u
a
re
tes
t
re
v
e
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led
a
sig
n
ifi
c
a
n
t
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n
fl
u
e
n
c
e
o
f
k
n
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wle
d
g
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o
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e
h
a
v
io
r
f
o
r
p
re
v
e
n
ti
n
g
d
iab
e
ti
c
fo
o
t
wo
u
n
d
s
(p
-
v
a
l
u
e
0
.
0
0
1
).
M
e
a
n
wh
i
le,
th
e
c
o
rre
latio
n
b
e
twe
e
n
fa
m
il
y
su
p
p
o
rt,
p
e
e
r
su
p
p
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rt,
a
n
d
su
p
p
o
rt
fro
m
h
e
a
lt
h
w
o
rk
e
rs
in
r
e
latio
n
to
d
iab
e
ti
c
f
o
o
t
wo
u
n
d
p
re
v
e
n
ti
o
n
b
e
h
a
v
io
r
wa
s
si
g
n
if
ica
n
t,
wit
h
e
a
c
h
sh
o
win
g
a
p
-
v
a
lu
e
o
f
0
.
0
1
.
En
h
a
n
c
in
g
s
o
c
ial
su
p
p
o
r
t
is
i
d
e
n
ti
f
ied
a
s
a
n
e
ffe
c
ti
v
e
stra
teg
y
fo
r
re
d
u
c
i
n
g
t
h
e
risk
o
f
d
iab
e
ti
c
fo
o
t
w
o
u
n
d
s
a
n
d
t
h
e
ir
a
ss
o
c
iate
d
c
o
m
p
li
c
a
ti
o
n
s.
T
h
e
re
fo
re
,
e
ffo
rts
t
o
in
c
re
a
se
so
c
ial
su
p
p
o
rt
lev
e
ls
fo
r
d
iab
e
tes
p
a
ti
e
n
ts sh
o
u
l
d
b
e
c
o
n
si
d
e
re
d
a
n
i
n
teg
ra
l
p
a
rt
o
f
th
e
ir
c
a
re
re
g
ime
n
.
K
ey
w
o
r
d
s
:
Diab
etic
wo
u
n
d
p
r
ev
en
tio
n
Fam
ily
s
u
p
p
o
r
t
Hea
lth
ca
r
e
s
u
p
p
o
r
t
Hea
lth
p
r
o
m
o
tio
n
th
eo
r
y
Peer
g
r
o
u
p
s
u
p
p
o
r
t
T
h
is i
s
a
n
o
p
e
n
a
c
c
e
ss
a
rticle
u
n
d
e
r th
e
CC B
Y
-
SA
li
c
e
n
se
.
C
o
r
r
e
s
p
o
nd
ing
A
uth
o
r
:
Su
y
an
to
Su
y
a
n
to
Dep
ar
tm
en
t
o
f
Me
d
ical
an
d
S
u
r
g
ical
Nu
r
s
in
g
,
Facu
lty
o
f
Nu
r
s
in
g
,
Un
iv
e
r
s
itas
I
s
lam
Su
lt
an
Ag
u
n
g
Sem
ar
an
g
,
I
n
d
o
n
esia
E
m
ail:
s
u
y
an
to
@
u
n
is
s
u
la.
ac
.
id
1.
I
NT
RO
D
UCT
I
O
N
Diab
etes
m
ellitu
s
(
DM
)
p
o
s
es
a
s
ig
n
if
ican
t
g
lo
b
al
p
u
b
lic
h
ea
lth
ch
allen
g
e,
with
lo
n
g
-
ter
m
elev
ated
b
lo
o
d
g
lu
c
o
s
e
lev
els
co
n
tr
ib
u
t
in
g
to
s
er
io
u
s
m
ed
ical
c
o
m
p
li
ca
tio
n
s
[
1
]
.
T
h
e
ch
r
o
n
ic
co
n
d
i
tio
n
r
esu
lts
f
r
o
m
a
lack
o
f
in
s
u
lin
s
ec
r
etio
n
b
y
th
e
p
an
c
r
ea
s
o
r
th
e
b
o
d
y
'
s
in
ab
i
lity
to
u
tili
ze
p
r
o
d
u
ce
d
g
l
u
co
s
e
[
2
]
.
I
n
2
0
1
2
,
DM
ca
u
s
ed
1
.
5
m
illi
o
n
d
ea
th
s
g
l
o
b
ally
an
d
c
o
n
tr
ib
u
te
d
to
an
ad
d
itio
n
al
2
.
2
m
illi
o
n
d
ea
th
s
d
u
e
to
h
eig
h
te
n
ed
ca
r
d
io
v
ascu
lar
d
is
ea
s
e
r
is
k
[
3
]
.
Pro
jectio
n
s
s
u
g
g
est
th
at
b
y
2
0
3
5
,
5
9
2
m
illi
o
n
p
eo
p
le
wo
r
ld
wid
e
will
s
u
f
f
er
f
r
o
m
DM
,
with
a
co
n
c
en
tr
ati
o
n
in
l
o
w
-
in
co
m
e
an
d
in
ter
m
ed
iate
co
u
n
t
r
ies
[
4
]
.
Ad
d
r
e
s
s
in
g
th
is
ep
id
em
ic
r
eq
u
ir
es
co
m
p
r
eh
e
n
s
iv
e
s
tr
ateg
ies,
in
clu
d
in
g
p
r
e
v
en
tiv
e
m
ea
s
u
r
es,
ea
r
ly
d
etec
tio
n
,
a
cc
ess
ib
le
tr
ea
tm
en
t
o
p
tio
n
s
,
p
u
b
lic
awa
r
en
ess
ca
m
p
aig
n
s
,
an
d
g
lo
b
al
c
o
llab
o
r
atio
n
a
m
o
n
g
g
o
v
er
n
m
e
n
ts
an
d
h
ea
lth
ca
r
e
s
tak
eh
o
ld
er
s
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
4
,
No
.
1
,
Ma
r
ch
20
2
5
:
4
0
9
-
415
410
T
h
e
I
n
ter
n
atio
n
al
Diab
etes
Fed
er
atio
n
in
d
icate
s
th
at
d
iab
ete
s
p
r
ev
alen
ce
am
o
n
g
th
e
eld
e
r
ly
g
lo
b
ally
is
cu
r
r
en
tl
y
o
v
e
r
1
3
4
.
6
m
illi
o
n
,
p
r
o
jecte
d
to
r
is
e
to
2
5
2
.
8
m
illi
o
n
b
y
2
0
3
5
an
d
s
u
r
p
ass
th
i
s
f
ig
u
r
e
f
u
r
t
h
er
[
2
]
.
T
h
e
wo
r
ld
wid
e
p
r
ev
alen
ce
o
f
d
iab
etes
in
ad
u
lts
was
4
.
7
%
in
1
9
8
0
(
1
0
8
m
illi
o
n
p
e
o
p
le)
,
es
ca
latin
g
to
8
.
5
%
in
2
0
1
4
(
4
2
2
m
illi
o
n
p
eo
p
le)
.
Pr
o
jectio
n
s
f
o
r
2
0
4
0
esti
m
ate
a
s
tag
g
er
in
g
6
4
2
m
illi
o
n
ad
u
lts
af
f
ec
ted
b
y
d
iab
etes.
T
h
is
in
cr
ea
s
e
is
e
v
id
en
t
ac
r
o
s
s
ag
e
g
r
o
u
p
s
an
d
d
is
ea
s
e
ty
p
es,
with
a
p
p
r
o
x
im
ately
4
6
3
m
illi
o
n
p
e
o
p
le,
co
n
s
titu
tin
g
9
.
3
%
o
f
th
e
g
l
o
b
al
ad
u
lt
p
o
p
u
latio
n
a
g
ed
2
0
to
7
9
,
af
f
ec
ted
b
y
d
iab
etes
in
2
0
1
9
[
5
]
.
T
h
ese
s
tatis
tic
s
em
p
h
asize
th
e
u
r
g
en
t n
ee
d
f
o
r
g
lo
b
al
ef
f
o
r
ts
to
ad
d
r
ess
an
d
m
an
ag
e
th
e
escalatin
g
p
r
ev
ale
n
ce
o
f
d
iab
etes.
DM
p
r
esen
ts
v
ar
io
u
s
co
m
p
lic
atio
n
s
,
in
clu
d
in
g
f
o
o
t
w
o
u
n
d
s
th
at
d
em
an
d
m
eticu
l
o
u
s
atten
tio
n
an
d
co
o
r
d
in
ate
d
tr
ea
tm
en
t
b
y
a
h
ea
lth
ca
r
e
te
am
to
m
in
im
ize
am
p
u
tatio
n
s
[
6
]
.
Patien
t
ed
u
ca
tio
n
is
cr
u
cial
in
em
p
o
wer
in
g
in
d
iv
id
u
als
with
d
iab
etes
b
y
im
p
ar
tin
g
k
n
o
wle
d
g
e,
s
k
ills
,
an
d
s
elf
-
ca
r
e
ab
ilit
ies,
f
o
s
ter
in
g
s
elf
-
ef
f
icac
y
,
an
d
m
o
ti
v
atin
g
lif
esty
le
ch
an
g
es,
th
er
eb
y
en
h
an
cin
g
th
er
ap
y
co
m
p
lian
ce
an
d
awa
r
en
ess
o
f
co
m
p
licatio
n
s
[
5
]
.
Fam
ily
s
u
p
p
o
r
t
p
lay
s
a
p
i
v
o
tal
r
o
le
in
d
ia
b
etes m
an
ag
em
e
n
t,
as m
o
s
t c
a
r
e
o
cc
u
r
s
with
in
th
e
h
o
u
s
eh
o
ld
.
T
h
is
s
u
p
p
o
r
t
aid
s
in
im
p
r
o
v
in
g
th
e
well
-
b
ein
g
an
d
s
elf
-
m
an
ag
em
en
t
o
f
d
ia
b
etes
s
u
f
f
er
er
s
b
y
ass
is
tin
g
in
s
elf
-
ca
r
e
ac
tiv
ities
an
d
p
r
o
v
id
in
g
ess
en
tial
s
o
cial
an
d
em
o
tio
n
al
s
u
p
p
o
r
t
[
7
]
.
T
h
e
in
v
o
lv
em
en
t
o
f
b
o
th
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als
an
d
f
am
ily
m
em
b
e
r
s
is
in
teg
r
al
in
cr
ea
tin
g
a
co
m
p
r
eh
e
n
s
iv
e
an
d
ef
f
ec
tiv
e
s
u
p
p
o
r
t
s
y
s
tem
f
o
r
in
d
iv
i
d
u
als liv
in
g
with
d
iab
etes.
Self
-
m
an
ag
em
en
t
is
a
c
r
itical
asp
ec
t
o
f
d
iab
etes
tr
ea
tm
e
n
t,
b
u
t
th
e
g
r
o
win
g
d
iab
etic
p
o
p
u
latio
n
f
ac
es
ch
allen
g
es
in
r
ec
eiv
in
g
ad
e
q
u
ate
h
ea
lth
e
d
u
ca
tio
n
d
u
e
to
lim
ited
r
eso
u
r
ce
s
an
d
tim
e
co
n
s
tr
ain
ts
o
f
m
ed
ical
s
taf
f
.
R
ec
o
g
n
izin
g
th
is
g
ap
,
a
p
ee
r
s
u
p
p
o
r
t
ed
u
ca
tio
n
al
m
o
d
el
f
o
r
d
i
ab
etes
p
atien
ts
b
ec
o
m
es
cr
u
cial,
u
tili
zin
g
th
e
in
f
lu
en
ce
an
d
e
x
p
er
ie
n
ce
s
o
f
p
ee
r
s
to
d
eliv
er
ef
f
ec
tiv
e
p
r
o
g
r
a
m
s
[
8
]
.
Peer
-
ad
m
in
is
ter
ed
ed
u
ca
tio
n
,
o
f
ten
r
ef
er
r
ed
to
as
p
ee
r
co
u
n
s
elin
g
o
r
p
ee
r
e
d
u
ca
tio
n
,
in
v
o
lv
es
in
d
iv
id
u
als
with
s
im
ilar
b
ac
k
g
r
o
u
n
d
s
an
d
ex
p
er
ien
ce
s
s
h
ar
in
g
in
s
ig
h
ts
an
d
lear
n
in
g
f
r
o
m
ea
ch
o
th
er
,
p
r
o
v
id
in
g
a
v
alu
ab
le
co
m
p
lem
e
n
t
to
tr
ad
iti
o
n
al
h
ea
lth
ca
r
e
[
9
]
.
T
h
e
im
p
ac
t
o
f
o
n
lin
e
co
m
m
u
n
ities
o
n
p
ee
r
s
u
p
p
o
r
t,
d
em
o
n
s
tr
atin
g
th
at
th
ese
p
latf
o
r
m
s
o
f
f
er
em
o
tio
n
al
an
d
tech
n
ical
s
u
p
p
o
r
t
wh
ile
em
p
o
wer
in
g
in
d
i
v
id
u
als.
T
h
e
altr
u
is
tic
s
p
ir
it
with
in
s
o
ciety
co
n
tr
ib
u
tes
to
b
u
ild
i
n
g
s
elf
-
co
n
f
id
en
ce
a
m
o
n
g
d
iab
etes
p
atien
ts
,
em
p
h
asizin
g
th
e
p
o
ten
tia
l
o
f
p
ee
r
-
d
r
iv
en
ap
p
r
o
ac
h
es
in
en
h
an
cin
g
d
iab
etes
s
elf
-
m
an
ag
em
en
t.
D
i
a
b
e
t
es
p
a
t
i
e
n
t
s
r
e
q
u
i
r
e
r
o
u
ti
n
e
s
e
l
f
-
c
a
r
e
,
p
a
r
ti
c
u
l
a
r
l
y
i
n
f
o
o
t
c
a
r
e
,
w
h
i
c
h
c
a
n
r
e
d
u
c
e
t
h
e
r
i
s
k
o
f
c
o
m
p
l
i
c
a
t
i
o
n
s
b
y
4
9
%
t
o
8
5
%
.
A
s
t
u
d
y
i
n
M
a
l
a
y
s
i
a
h
i
g
h
l
i
g
h
t
ed
p
o
o
r
k
n
o
w
l
e
d
g
e
a
n
d
p
r
a
ct
i
c
es
r
e
g
a
r
d
i
n
g
f
o
o
t
c
a
r
e
a
m
o
n
g
d
i
a
b
e
t
e
s
p
at
i
e
n
ts
,
wi
t
h
s
i
g
n
i
f
i
c
a
n
t
r
is
k
f
a
ct
o
r
s
i
n
cl
u
d
i
n
g
w
o
r
k
a
c
t
i
v
it
i
es
,
i
n
a
p
p
r
o
p
r
i
a
t
e
f
o
o
t
w
e
a
r
,
a
n
d
g
o
i
n
g
b
a
r
e
f
o
o
t
a
t
h
o
m
e
[
1
0
]
.
A
d
d
r
e
s
s
i
n
g
t
h
i
s
c
h
a
l
le
n
g
e
c
a
l
ls
f
o
r
t
a
r
g
e
t
e
d
s
u
p
p
o
r
t
a
n
d
i
n
t
e
r
v
e
n
t
i
o
n
s
t
o
r
a
i
s
e
a
w
a
r
e
n
es
s
a
n
d
p
r
o
m
o
t
e
e
f
f
e
c
t
i
v
e
f
o
o
t
c
a
r
e
p
r
a
c
t
i
c
es
a
m
o
n
g
i
n
d
i
v
i
d
u
a
ls
w
i
t
h
d
i
a
b
et
es
.
T
h
is
s
t
u
d
y
a
i
m
ed
t
o
d
e
t
e
r
m
i
n
e
t
h
e
c
o
r
r
e
l
a
t
i
o
n
b
e
t
we
e
n
s
o
c
ia
l
s
u
p
p
o
r
t
w
i
t
h
d
i
a
b
e
ti
c
w
o
u
n
d
p
r
e
v
e
n
t
i
o
n
b
e
h
a
v
i
o
r
o
f
d
i
a
b
e
t
i
c
m
e
lli
t
u
s
p
a
ti
e
n
ts
.
2.
M
E
T
H
O
D
T
h
e
d
esig
n
o
f
th
is
r
es
ea
r
ch
is
cr
o
s
s
-
s
ec
tio
n
al,
a
d
escr
ip
tiv
e
co
r
r
elatio
n
s
tu
d
y
c
o
n
d
u
cted
in
Sem
ar
an
g
,
I
n
d
o
n
esia.
I
n
th
is
s
tu
d
y
,
1
2
0
r
e
s
p
o
n
d
en
ts
as
r
esear
ch
s
am
p
les
wer
e
d
iab
etes
m
illi
tu
s
(
DM
)
p
atien
ts
at
Sem
ar
an
g
h
ea
lth
ce
n
ter
s
.
Dete
r
m
in
in
g
th
e
s
am
p
le
s
ize
in
th
is
s
tu
d
y
u
s
es
t
h
e
R
u
le
o
f
T
u
m
b
f
o
r
m
u
la
with
th
e
m
ax
im
u
m
lik
ely
h
o
o
d
m
et
h
o
d
.
T
h
e
m
in
i
m
u
m
s
am
p
le
s
ize
is
1
0
0
-
1
5
0
r
esp
o
n
d
en
ts
o
r
5
-
1
0
tim
es
th
e
i
n
d
icato
r
(
o
b
s
er
v
e
d
v
ar
iab
le)
is
5
:1
i
n
d
icato
r
,
m
ea
n
in
g
th
e
p
a
r
am
eter
to
b
e
esti
m
ated
[
1
1
]
.
T
h
e
s
am
p
lin
g
tech
n
iq
u
e
u
s
ed
co
n
ce
cu
tive
s
am
p
lin
g
.
I
n
clu
s
io
n
c
r
iter
ia
in
clu
d
e
Ag
e
b
etwe
en
4
0
-
5
5
y
ea
r
s
,
d
u
r
atio
n
o
f
s
u
f
f
e
r
in
g
f
r
o
m
DM
1
-
5
y
ea
r
s
,
le
v
el
o
f
co
m
p
e
n
s
ato
r
y
awa
r
en
ess
,
liv
in
g
with
f
am
ily
(
n
u
clea
r
f
am
ily
/
ex
ten
d
ed
)
,
an
d
DM
p
atien
ts
with
an
I
n
ter
n
atio
n
al
W
o
r
k
in
g
Gr
o
u
p
o
n
t
h
e
Diab
etic
Fo
o
t
(
I
W
GDF
)
r
is
k
s
co
r
e
o
f
0
-
3
.
T
h
e
e
x
clu
s
io
n
cr
iter
ia
f
o
r
t
h
is
s
tu
d
y
wer
e
h
av
in
g
d
iab
etic
f
o
o
t
wo
u
n
d
s
,
v
is
u
al
an
d
h
ea
r
in
g
p
r
o
b
lem
s
,
an
d
co
m
p
licatio
n
s
m
icr
o
v
ess
els
(
C
K
D)
an
d
m
ac
r
o
v
ascu
lar
co
m
p
licati
o
n
s
(
s
tr
o
k
e)
.
T
h
is
r
esear
c
h
u
s
es
s
ev
er
al
in
s
tr
u
m
en
ts
,
in
clu
d
in
g
;
T
h
e
r
esear
ch
in
s
tr
u
m
en
t
u
s
ed
to
m
ea
s
u
r
e
k
n
o
wled
g
e
ab
o
u
t
f
o
o
t
ca
r
e
m
o
d
if
ied
d
iab
etic
f
o
o
t
ca
r
e
k
n
o
wled
g
e
(
MD
FC
K)
.
I
n
s
tr
u
m
en
t
s
o
s
ia
l
s
u
p
p
o
r
t
co
n
s
is
ts
o
f
an
in
s
tr
u
m
en
ts
f
am
ily
s
u
p
p
o
r
t
q
u
esti
o
n
n
a
ir
e
to
m
ea
s
u
r
e
f
am
ily
s
u
p
p
o
r
t.
I
n
s
tr
u
m
en
t
f
u
n
ctio
n
s
o
f
d
iab
et
es
p
ee
r
s
u
p
p
o
r
t
g
r
o
u
p
s
ca
le
(F
-
DPSG)
to
m
ea
s
u
r
e
p
ee
r
s
u
p
p
o
r
t
an
d
in
s
tr
u
m
en
t
s
u
p
p
o
r
t
f
r
o
m
h
ea
lth
wo
r
k
er
s
to
m
ea
s
u
r
e
s
u
p
p
o
r
t
f
r
o
m
h
ea
l
th
wo
r
k
er
s
.
Me
an
wh
ile,
to
m
ea
s
u
r
e
b
eh
av
io
r
t
o
p
r
ev
en
t
d
iab
etic
f
o
o
t
i
n
ju
r
ies
u
s
in
g
in
s
tr
u
m
en
ts
.
T
h
e
k
n
o
wled
g
e
in
s
tr
u
m
en
t
m
ea
s
u
r
es
th
e
le
v
el
o
f
u
n
d
er
s
tan
d
in
g
o
f
f
o
o
t
ca
r
e,
s
o
cial
ca
r
e
s
u
p
p
o
r
t
m
ea
s
u
r
e
f
am
ily
s
u
p
p
o
r
t,
p
ee
r
s
u
p
p
o
r
t,
an
d
h
ea
lth
w
o
r
k
er
s
u
p
p
o
r
t.
T
h
e
b
eh
av
io
r
al
in
s
tr
u
m
e
n
t
f
o
r
p
r
e
v
en
tin
g
d
iab
etic
f
o
o
t
wo
u
n
d
s
is
in
th
e
f
o
r
m
o
f
m
o
d
if
ied
d
iab
eti
c
f
o
o
t
ca
r
e
b
eh
av
io
r
(
MD
FC
B
)
to
m
ea
s
u
r
e
g
o
o
d
o
r
b
ad
b
eh
a
v
io
r
i
n
p
r
ev
en
tin
g
d
i
ab
etic
f
o
o
t
wo
u
n
d
s
.
T
h
e
r
esea
r
ch
in
s
tr
u
m
e
n
t u
s
ed
a
q
u
esti
o
n
n
air
e
p
r
ev
io
u
s
ly
test
ed
f
o
r
v
alid
ity
a
n
d
r
eliab
ilit
y
with
co
n
tr
u
ct
v
alid
ity
with
alf
a
C
r
o
n
b
ac
h
0
.
7
an
d
was d
ec
lar
ed
v
alid
an
d
r
eliab
l
e.
T
h
is
r
esear
ch
h
as
r
ec
ei
v
ed
a
n
eth
ical
test
with
n
u
m
b
er
3
0
9
/
A.
1
-
KE
PK/F
I
K
-
SA/VI
I
I
/2
0
2
2
.
Po
ten
tial
r
esp
o
n
d
en
ts
wh
o
f
it
th
e
r
esear
c
h
cr
iter
ia
h
av
e
b
ee
n
e
x
p
lain
ed
ab
o
u
t;
th
e
o
b
jectiv
es,
an
d
b
en
e
f
its
o
f
th
e
r
esear
ch
,
an
d
th
e
n
f
ill
in
in
fo
r
med
c
o
n
s
en
t
as
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r
o
o
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o
f
a
v
ailab
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y
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o
l
lo
win
g
th
is
s
tu
d
y
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Data
is
co
ll
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ted
an
o
n
y
m
o
u
s
ly
an
d
is
v
o
lu
n
tar
y
.
Data
was
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aly
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d
u
s
in
g
th
e
s
o
f
twar
e
SP
SS
2
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.
B
ef
o
r
e
an
aly
zi
n
g
t
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e
d
at
a,
r
esear
ch
er
s
ca
r
r
y
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
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Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
S
o
cia
l su
p
p
o
r
t a
s
a
ke
y
fa
ct
o
r
in
th
e
h
e
a
lth
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r
o
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tio
n
mo
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l:
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n
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en
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(
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u
ya
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to
)
411
o
u
t
ed
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to
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ee
if
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er
e
is
m
i
s
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in
g
d
ata.
T
h
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lts
o
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d
escr
ip
tiv
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al
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is
a
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e
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s
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cy
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ical
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ata
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ata
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3.
RE
SU
L
T
S
AND
D
I
SCU
SS
I
O
N
T
ab
le
1
p
r
esen
ts
av
e
r
ag
e
ag
e
o
f
th
e
s
u
r
v
ey
e
d
in
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iv
id
u
als
was
5
9
y
ea
r
s
.
R
esp
o
n
d
e
n
ts
r
ep
o
r
te
d
s
u
f
f
er
i
n
g
f
r
o
m
DM
f
o
r
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d
u
r
atio
n
o
f
f
i
v
e
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r
s
.
T
h
is
d
em
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g
r
ap
h
ic
in
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r
m
atio
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d
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s
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ap
s
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o
t
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th
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ch
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r
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ter
is
tics
o
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y
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o
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u
latio
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,
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ich
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n
b
e
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alu
ab
le
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o
r
u
n
d
er
s
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g
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e
co
n
tex
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p
o
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tial im
p
licatio
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s
o
f
th
e
f
in
d
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g
s
r
elate
d
t
o
f
o
o
t c
ar
e
k
n
o
wled
g
e,
s
u
p
p
o
r
t,
an
d
b
eh
av
i
o
r
.
T
ab
le
1
.
C
h
ar
ac
ter
is
tics
o
f
D
M
p
atien
ts
in
clu
d
ed
a
g
e
an
d
len
g
th
o
f
DM
V
a
r
i
a
b
l
e
M
e
a
n
±
S
D
M
e
d
i
a
n
M
i
n
-
ma
x
9
5
%
C
I
A
g
e
5
9
.
2
3
±
7
.
6
6
59
39
-
86
5
7
.
8
4
-
6
0
.
6
1
Le
n
g
t
h
o
f
D
M
5
.
0
6
±
1
.
8
1
5
2
-
10
4
.
7
3
-
5
.
3
9
T
ab
le
2
s
h
o
ws
th
at
r
esp
o
n
d
en
ts
'
k
n
o
wled
g
e
lev
els
r
eg
ar
d
in
g
d
iab
etic
f
o
o
t
ca
r
e
an
d
th
e
im
p
a
ct
o
f
s
o
cial
s
u
p
p
o
r
t
o
n
p
r
ev
e
n
tiv
e
b
eh
av
i
o
r
f
o
r
f
o
o
t
u
lcer
s
.
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t
was
f
o
u
n
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th
at
2
0
r
esp
o
n
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e
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ts
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ad
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t
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r
e,
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ee
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ed
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lay
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ig
n
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ican
t
r
o
le,
with
5
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f
r
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n
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en
ts
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ig
h
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am
ily
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8
5
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%
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ec
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ee
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,
a
n
d
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0
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s
ig
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m
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f
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als.
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ite
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k
n
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wled
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e,
6
5
%
o
f
r
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n
d
en
ts
ex
h
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ited
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r
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b
e
h
av
io
r
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in
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icatin
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th
at
s
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cial
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t
ca
n
en
h
a
n
ce
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r
e
v
en
tiv
e
ac
tio
n
s
.
T
h
ese
f
in
d
in
g
s
em
p
h
asize
th
e
n
ee
d
f
o
r
in
ter
v
e
n
tio
n
s
th
at
in
teg
r
ate
b
o
th
ed
u
ca
tio
n
a
n
d
s
o
cial
s
u
p
p
o
r
t
to
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ed
u
ce
t
h
e
r
is
k
o
f
d
iab
etic
f
o
o
t
u
lcer
s
T
ab
le
2
.
Dis
tr
ib
u
tio
n
o
f
k
n
o
w
l
ed
g
e,
f
am
ily
s
u
p
p
o
r
t,
p
ee
r
g
r
o
u
p
s
u
p
p
o
r
t,
h
ea
lt
h
ca
r
e
s
u
p
p
o
r
t a
n
d
d
iab
etic
wo
u
n
d
p
r
ev
e
n
tio
n
b
e
h
av
io
r
o
f
DM
V
a
r
i
a
b
l
e
F
r
e
q
u
e
n
c
y
(
%
)
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n
o
w
l
e
d
g
e
o
f
f
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o
t
c
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r
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l
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w
c
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r
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n
t
l
y
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e
i
g
h
t
2
0
(
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6
.
7
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2
(
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3
.
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%)
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8
(
4
0
%)
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a
mi
l
y
s
u
p
p
o
r
t
l
o
w
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r
r
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n
t
l
y
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e
i
g
h
t
2
3
(
1
9
.
2
%)
2
8
(
2
3
.
3
%)
6
9
(
5
7
.
5
%)
P
e
e
r
s
u
p
p
o
r
t
l
e
ss
G
o
o
d
1
7
(
1
4
.
2
%)
1
0
3
(
8
5
.
8
%)
H
e
a
l
t
h
c
a
r
e
s
u
p
p
o
r
t
l
o
w
c
u
r
r
e
n
t
l
y
h
e
i
g
h
t
1
5
(
1
2
.
5
%)
3
3
(
2
7
.
5
%)
7
2
(
6
0
%)
d
i
a
b
e
t
i
c
w
o
u
n
d
p
r
e
v
e
n
t
i
o
n
b
e
h
a
v
i
o
r
N
o
t
g
o
o
d
G
o
o
d
4
2
(
3
5
%)
7
8
(
6
5
%)
T
ab
le
3
c
o
n
clu
d
e
a
s
ig
n
if
ican
t
p
o
r
tio
n
o
f
DM
p
atie
n
ts
d
em
o
n
s
tr
ate
m
o
d
e
r
ate
to
h
ig
h
lev
els
o
f
f
o
o
t
ca
r
e
k
n
o
wled
g
e,
s
u
p
p
o
r
ted
b
y
g
en
er
ally
h
ig
h
f
am
ily
an
d
p
ee
r
g
r
o
u
p
s
u
p
p
o
r
t
as
well
as
g
o
o
d
h
ea
lth
ca
r
e
s
u
p
p
o
r
t.
Ho
wev
er
,
th
er
e
is
r
o
o
m
f
o
r
im
p
r
o
v
e
m
en
t
in
en
h
a
n
cin
g
f
a
m
ily
an
d
h
ea
l
th
ca
r
e
s
u
p
p
o
r
t,
p
ar
ticu
lar
ly
f
o
r
th
o
s
e
with
lo
w
s
u
p
p
o
r
t
lev
els.
T
ar
g
e
ted
in
ter
v
en
ti
o
n
s
ar
e
c
r
u
cial
to
ad
d
r
ess
th
e
n
o
tab
le
p
o
r
tio
n
o
f
p
atien
ts
ex
h
ib
itin
g
p
o
o
r
p
r
e
v
en
tiv
e
b
eh
a
v
io
r
,
em
p
h
asizin
g
th
e
n
ee
d
f
o
r
co
m
p
r
e
h
en
s
iv
e
s
tr
ateg
ies
to
en
h
a
n
ce
o
v
er
all
f
o
o
t
ca
r
e
i
n
th
is
p
atien
t
p
o
p
u
latio
n
.
T
h
e
v
a
r
iab
le
th
at
h
as
th
e
m
o
s
t
in
f
lu
e
n
ce
o
n
b
eh
av
i
o
r
to
p
r
ev
e
n
t
d
ia
b
etic
f
o
o
t
in
j
u
r
ies
is
f
am
ily
s
u
p
p
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r
t
(
p
v
alu
e
0
.
0
0
0
1
)
.
T
h
e
in
f
l
u
en
ce
o
f
k
n
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wled
g
e,
f
am
ily
s
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p
ee
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r
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,
an
d
h
ea
lth
w
o
r
k
er
s
u
p
p
o
r
t
o
n
b
eh
a
v
io
r
t
o
p
r
e
v
e
n
t
d
iab
etic
f
o
o
t
i
n
ju
r
ies.
T
h
er
e
is
a
r
elatio
n
s
h
ip
b
etwe
en
f
a
m
ily
s
u
p
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r
t,
p
ee
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p
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r
t,
a
n
d
h
ea
lth
wo
r
k
e
r
s
u
p
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o
r
t
with
d
iab
etic
f
o
o
t
wo
u
n
d
p
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ev
e
n
tio
n
b
eh
av
io
r
.
Pre
d
ict
o
r
s
o
f
d
ia
b
etic
f
o
o
t
wo
u
n
d
p
r
ev
e
n
tio
n
b
eh
av
i
o
r
:
T
h
e
lo
g
is
tic
r
eg
r
ess
io
n
test
was
u
s
ed
t
o
d
eter
m
in
e
th
e
v
ar
iab
les
th
at
m
o
s
t
in
f
lu
e
n
ce
th
e
b
eh
av
i
o
r
o
f
p
r
e
v
en
tin
g
d
ia
b
etic
f
o
o
t w
o
u
n
d
s
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
4
,
No
.
1
,
Ma
r
ch
20
2
5
:
4
0
9
-
415
412
T
ab
le
3
.
Mu
ltiv
ar
iate
a
n
aly
s
is
o
f
r
eg
r
ess
io
n
s
o
cial
s
u
p
p
o
r
t
f
a
cto
r
s
ass
o
ciate
d
with
d
iab
etic
wo
u
n
d
p
r
ev
e
n
tio
n
b
e
h
av
io
r
V
a
r
i
a
b
l
e
B
S
.
E
p
-
v
a
l
u
e
O
d
d
s
r
a
t
i
o
9
5
%
C
I
f
o
r
o
d
d
s
r
a
t
i
o
Lo
w
e
r
U
p
p
e
r
K
n
o
w
l
e
d
g
e
-
.
3
2
1
0
.
4
4
2
0
.
4
6
8
0
.
7
2
6
0
.
3
0
5
1
.
7
2
7
F
a
mi
l
y
s
u
p
p
o
r
t
2
.
2
.
1
7
0
.
4
6
1
0
.
0
0
0
1
9
.
1
7
7
3
.
7
2
1
2
2
.
6
3
5
P
e
e
r
g
r
o
u
p
su
p
p
o
r
t
3
.
1
1
3
0
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5
2
6
0
.
0
0
2
2
2
.
4
9
5
3
.
0
2
6
1
6
7
.
2
1
9
H
e
a
l
t
h
c
a
r
e
s
u
p
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o
r
t
1
.
5
2
8
1
.
0
2
3
0
.
0
0
4
4
.
6
1
0
1
.
6
4
5
1
2
.
9
2
2
Diab
etic
f
o
o
t
u
lcer
s
(
DFU)
was
a
s
ig
n
if
ican
t
r
is
k
o
f
lo
w
er
ex
tr
em
ity
am
p
u
tatio
n
an
d
co
n
tr
i
b
u
te
s
u
b
s
tan
tially
to
m
o
r
t
a
l
i
t
y
a
n
d
m
o
r
b
i
d
i
t
y
a
m
o
n
g
d
i
a
b
e
t
es
p
a
ti
en
t
s
[
1
2
]
.
DF
Us
a
ls
o
l
e
a
d
t
o
f
r
e
q
u
e
n
t
h
o
s
p
i
t
al
i
z
at
i
o
n
s
,
p
l
a
c
i
n
g
a
s
u
b
s
ta
n
t
i
a
l
b
u
r
d
e
n
o
n
b
o
t
h
i
n
d
i
v
i
d
u
a
l
s
a
n
d
s
o
c
i
e
t
y
[
1
3
]
.
E
f
f
e
c
t
i
v
e
p
r
e
v
e
n
t
i
o
n
a
n
d
t
r
e
a
t
m
e
n
t
o
f
D
FUs
i
n
v
o
l
v
e
m
u
l
t
i
d
is
ci
p
l
i
n
a
r
y
m
a
n
a
g
e
m
e
n
t
,
a
d
d
r
e
s
s
i
n
g
v
a
r
i
o
u
s
r
i
s
k
f
a
ct
o
r
s
s
u
c
h
as
b
l
o
o
d
g
l
u
c
o
s
e
le
v
e
l
s
,
b
l
o
o
d
p
r
e
s
s
u
r
e
,
l
i
p
i
d
l
e
v
el
s
,
a
n
d
s
m
o
k
i
n
g
c
e
s
s
a
ti
o
n
.
L
o
c
a
l
D
F
U
m
a
n
a
g
e
m
e
n
t
,
i
n
c
l
u
d
i
n
g
d
e
b
r
i
d
e
m
e
n
t
,
b
a
n
d
a
g
i
n
g
,
r
e
v
a
s
c
u
l
a
r
iz
a
t
i
o
n
,
s
t
e
m
c
e
l
l
d
e
co
m
p
r
e
s
s
i
o
n
,
a
n
d
o
x
y
g
e
n
t
h
e
r
a
p
y
,
i
s
c
r
u
c
i
a
l
f
o
r
s
u
c
c
e
s
s
f
u
l
o
u
t
co
m
e
s
[
1
4
]
.
P
a
t
i
e
n
ts
w
i
t
h
d
ia
b
e
t
es
p
l
a
y
a
v
it
a
l
r
o
l
e
in
f
o
o
t
c
a
r
e
,
a
s
p
r
o
p
e
r
s
el
f
-
c
a
r
e
r
e
d
u
c
e
s
t
h
e
r
is
k
o
f
f
o
o
t
i
n
j
u
r
i
es,
a
n
d
f
a
m
i
l
y
s
u
p
p
o
r
t
i
s
i
n
te
g
r
a
l
t
o
f
o
s
t
e
r
i
n
g
p
a
t
i
e
n
t
in
d
e
p
e
n
d
e
n
c
e
i
n
m
a
n
a
g
i
n
g
t
h
i
s
s
e
r
i
o
u
s
co
m
p
licatio
n
.
Fam
ily
s
u
p
p
o
r
t
is
s
i
g
n
i
f
i
c
a
n
t
l
y
a
s
s
o
ci
a
t
e
d
w
i
t
h
b
et
t
e
r
s
e
l
f
-
m
an
a
g
e
m
e
n
t
a
c
t
i
v
i
t
i
es
a
n
d
is
v
e
r
y
i
m
p
o
r
t
a
n
t
i
n
m
a
n
a
g
i
n
g
a
n
d
li
m
i
ti
n
g
t
h
e
p
r
e
v
a
l
e
n
c
e
o
f
d
i
a
b
et
e
s
[
1
5
]
.
L
a
c
k
o
f
f
a
m
i
l
y
s
u
p
p
o
r
t
f
o
r
p
a
ti
en
t
s
el
f
-
m
a
n
a
g
e
m
e
n
t
b
e
h
a
v
i
o
r
c
a
n
h
i
n
d
e
r
e
f
f
o
r
t
s
t
o
i
m
p
l
e
m
e
n
t
n
e
c
e
s
s
a
r
y
b
e
h
a
v
i
o
r
a
l
c
h
a
n
g
e
s
.
A
b
s
e
n
c
e
,
r
e
d
u
c
ti
o
n
,
o
r
l
o
s
s
o
f
f
a
m
i
l
y
s
u
p
p
o
r
t
d
u
e
t
o
d
i
f
f
e
r
e
n
c
es
i
n
g
e
n
d
e
r
a
n
d
c
u
l
t
u
r
e
i
n
d
i
f
f
e
r
e
n
t
f
a
m
i
l
i
es
ca
n
h
u
r
t
t
h
e
p
a
ti
e
n
t'
s
h
ea
l
t
h
.
L
i
v
i
n
g
t
o
g
e
t
h
er
w
i
t
h
p
e
o
p
l
e
i
n
t
h
e
s
a
m
e
h
o
u
s
e
d
o
e
s
n
o
t
g
u
a
r
a
n
t
e
e
s
u
p
p
o
r
t
i
n
d
i
a
b
e
t
es
m
a
n
a
g
e
m
e
n
t
.
I
t
i
s
t
h
e
r
ef
o
r
e
v
e
r
y
i
m
p
o
r
t
a
n
t
t
o
l
e
t
p
a
ti
e
n
t
s
n
a
r
r
at
e
t
h
ei
r
l
i
f
e
e
x
p
e
r
i
e
n
c
e
s
i
n
c
o
n
n
e
ct
i
o
n
w
it
h
t
h
e
s
u
p
p
o
r
t
o
f
t
h
e
i
r
f
a
m
il
y
m
e
m
b
e
r
s
[
1
6
]
.
Fam
ily
s
u
p
p
o
r
t
th
at
is
willin
g
to
p
r
o
v
id
e
atten
tio
n
will
m
ak
e
DM
p
atien
ts
f
ee
l
ca
r
ed
f
o
r
,
a
p
p
r
ec
iated
an
d
lo
v
ed
,
m
ak
e
s
o
m
eo
n
e
f
ee
l
ca
r
ed
f
o
r
,
ap
p
r
ec
iated
a
n
d
l
o
v
ed
[
1
7
]
.
Acc
ep
t
an
ce
f
r
o
m
a
p
ar
tn
er
w
h
o
s
u
f
f
er
s
f
r
o
m
DM
is
v
e
r
y
m
u
ch
n
ee
d
ed
,
s
u
ch
as
in
s
ex
u
al
m
atter
s
wh
i
ch
m
ay
b
e
d
is
tu
r
b
ed
,
th
is
ca
n
g
iv
e
r
is
e
t
o
a
n
x
iety
,
g
u
ilt,
an
d
f
ee
lin
g
s
o
f
f
ailu
r
e
a
s
well
as
co
m
m
u
n
icatio
n
p
r
o
b
lem
s
,
an
d
lo
s
s
o
f
s
ex
u
al
in
tim
ac
y
wh
ich
ca
n
lead
to
a
'
lim
b
o
s
tate
'
with
em
o
tio
n
al
em
p
tin
ess
an
d
r
ed
u
ce
d
q
u
ality
o
f
life
[
1
8
]
.
A
p
er
s
o
n
with
DM
ca
n
n
o
t
b
e
d
en
ie
d
as
a
d
is
ea
s
e
th
at
ca
n
d
is
r
u
p
t
th
e
s
u
f
f
er
er
'
s
well
-
b
ein
g
.
No
t
o
n
ly
d
o
th
ey
h
a
v
e
to
to
ler
ate
th
e
p
h
y
s
ical
s
y
m
p
to
m
s
o
f
th
e
d
is
ea
s
e,
its
co
m
p
licatio
n
s
,
an
d
th
e
s
id
e
ef
f
ec
ts
o
f
tr
ea
t
m
en
t,
b
u
t
th
e
y
also
h
a
v
e
to
s
tr
u
g
g
le
t
o
a
d
ap
t
t
h
eir
liv
es to
ac
co
m
m
o
d
ate
s
elf
-
ca
r
e
ac
tiv
ities
an
d
ad
h
er
e
t
o
r
ec
o
m
m
en
d
ed
m
an
ag
e
m
en
t
[
1
9
]
.
Hea
lth
ed
u
ca
tio
n
s
u
p
p
o
r
t
f
r
o
m
p
r
o
f
ess
io
n
al
h
ea
lth
s
er
v
ice
s
o
n
th
e
to
p
ic
o
f
m
a
n
ag
em
e
n
t
o
f
d
iab
etic
f
ee
t
n
ee
d
s
to
b
e
e
m
p
h
asized
,
s
u
ch
as
tr
ain
in
g
f
r
o
m
p
r
o
f
ess
io
n
al
h
ea
lth
wo
r
k
er
s
f
o
r
DM
p
at
ien
ts
.
I
n
a
s
u
r
v
e
y
o
f
>4
0
0
h
ea
lth
s
er
v
ice
p
r
o
v
id
e
r
s
in
lar
g
e
ter
tiar
y
ca
r
e
f
ac
ilit
ies,
ar
o
u
n
d
6
7
%
o
f
d
o
cto
r
s
r
ep
o
r
te
d
th
at
DM
p
atien
ts
h
ad
p
o
o
r
k
n
o
wled
g
e
o
r
n
o
k
n
o
wled
g
e
at
all
ab
o
u
t
d
iab
etic
f
o
o
t
u
lcer
s
[
2
0
]
.
T
h
e
s
u
p
p
o
r
t
p
r
o
v
id
ed
b
y
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als,
in
clu
d
in
g
in
f
o
r
m
atio
n
,
m
o
n
ito
r
in
g
,
an
d
ad
v
ic
e,
g
r
ea
tly
in
f
lu
en
ce
s
th
e
ex
ten
t
to
wh
ich
p
atien
ts
f
o
llo
w
f
o
o
t
ca
r
e
g
u
id
elin
es
[
2
1
]
.
Su
p
p
o
r
t
f
r
o
m
t
h
e
h
ea
lth
ca
r
e
s
y
s
tem
,
s
u
ch
as
ea
s
ily
ac
ce
s
s
ib
le
h
ea
lth
s
er
v
ices,
av
ailab
ilit
y
o
f
eq
u
ip
m
en
t,
an
d
ass
is
tan
ce
b
y
m
e
d
ical
p
er
s
o
n
n
el,
ca
n
in
cr
ea
s
e
p
atien
t
awa
r
en
ess
an
d
f
ac
ilit
ate
p
r
ev
en
tiv
e
ac
tio
n
s
.
T
h
en
e
m
o
t
io
n
al
an
d
p
r
ac
tical
s
u
p
p
o
r
t f
r
o
m
f
am
ily
an
d
p
ee
r
s
ca
n
m
o
tiv
ate
p
atien
ts
to
ca
r
r
y
o
u
t f
o
o
t c
ar
e
m
o
r
e
ac
cu
r
ately
an
d
r
eg
u
lar
ly
[
2
2
]
.
Peer
ed
u
ca
tio
n
h
as
p
r
o
v
e
n
ef
f
ec
tiv
e
in
im
p
r
o
v
in
g
s
elf
-
c
ar
e
b
eh
a
v
io
r
am
o
n
g
d
iab
ete
s
p
atien
ts
,
s
u
g
g
esti
n
g
its
ap
p
licab
ilit
y
in
d
iab
etes
p
r
ev
en
tio
n
a
n
d
m
a
n
a
g
em
en
t
ef
f
o
r
ts
in
I
r
an
an
d
s
u
r
r
o
u
n
d
in
g
r
eg
i
o
n
s
[
9
]
.
Ad
d
itio
n
ally
,
a
p
ilo
t
s
tu
d
y
o
n
l
u
p
u
s
p
atien
ts
,
th
e
p
ee
r
ap
p
r
o
ac
h
to
lu
p
u
s
s
elf
-
m
an
a
g
em
en
t
(
P
AL
S)
in
ter
v
en
tio
n
,
s
h
o
wed
p
o
s
itiv
e
tr
en
d
s
with
p
ar
ticip
an
ts
ex
p
er
ien
cin
g
lo
wer
d
is
ea
s
e
ac
tiv
ity
,
h
ig
h
er
q
u
ali
ty
o
f
life
,
r
ed
u
ce
d
p
ain
s
y
m
p
to
m
s
,
an
d
in
cr
ea
s
ed
s
o
ci
al
s
u
p
p
o
r
t
af
te
r
p
ar
ticip
ati
n
g
in
t
h
e
p
r
o
g
r
a
m
(
ef
f
ec
t
s
ize>
0
.
3
)
.
T
h
ese
f
in
d
in
g
s
h
ig
h
lig
h
t
th
e
p
o
te
n
tial
o
f
p
ee
r
-
b
ased
in
ter
v
en
tio
n
s
to
p
o
s
itiv
ely
im
p
ac
t
h
ea
lth
o
u
tco
m
es
an
d
th
e
well
-
b
ein
g
o
f
in
d
iv
id
u
als
m
an
a
g
in
g
c
h
r
o
n
ic
co
n
d
itio
n
s
lik
e
d
iab
etes
an
d
lu
p
u
s
.
Ad
d
itio
n
ally
,
b
o
th
m
en
tees
an
d
m
en
to
r
s
s
co
r
ed
v
er
y
h
ig
h
f
o
r
p
e
r
ce
iv
ed
cr
ed
ib
ilit
y
o
f
tr
ea
tm
en
t
a
n
d
s
e
r
v
ice
d
eliv
er
y
s
u
p
p
o
r
t
f
r
o
m
eit
h
er
n
u
r
s
es
o
r
o
t
h
er
p
eo
p
le
with
th
e
s
am
e
illn
ess
ar
e
ex
p
er
ts
in
th
e
m
a
n
ag
em
e
n
t
o
f
th
ei
r
illn
ess
an
d
o
f
ten
h
av
e
v
alu
a
b
le
s
elf
-
m
an
ag
em
en
t
s
tr
ateg
ies
to
s
h
ar
e
with
o
th
er
s
[
2
3
]
.
So
m
e
p
atien
ts
with
ch
r
o
n
ic
illn
ess
es
m
ay
f
ee
l
is
o
lated
if
th
e
y
d
o
n
o
t
h
av
e
o
th
er
s
in
th
eir
s
o
c
ial
cir
cle
wh
o
u
n
d
er
s
tan
d
th
e
n
a
tu
r
e
o
f
th
eir
co
n
d
itio
n
i
n
m
o
r
e
d
ep
th
[
2
4
]
.
T
h
e
r
e
s
u
lt
s
o
f
r
es
e
a
r
c
h
i
n
C
h
in
a
s
h
o
w
t
h
a
t
d
i
a
b
e
t
e
s
m
a
n
a
g
e
m
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n
t
f
o
c
u
s
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s
o
n
m
e
d
i
c
a
t
i
o
n
m
a
n
a
g
e
m
e
n
t
,
n
u
t
r
i
t
i
o
n
,
p
h
y
s
i
c
a
l
a
c
t
i
v
i
t
y
,
p
a
t
i
e
n
t
i
n
v
o
l
v
e
m
e
n
t
,
a
n
d
s
o
c
i
a
l
s
u
p
p
o
r
t
.
H
o
w
e
v
e
r
,
i
t
i
s
d
i
f
f
i
c
u
l
t
t
o
d
i
r
e
c
t
l
y
m
e
a
s
u
r
e
w
h
e
t
h
e
r
e
d
u
c
a
t
i
o
n
a
l
a
s
p
e
c
t
s
a
r
e
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f
f
e
c
t
i
v
e
i
n
k
n
o
w
l
e
d
g
e
a
n
d
s
e
l
f
-
c
a
r
e
b
e
h
a
v
i
o
r
[
2
5
]
.
G
o
o
d
k
n
o
w
l
e
d
g
e
w
i
t
h
t
h
e
s
u
p
p
o
r
t
o
f
f
a
m
i
l
y
,
p
e
e
r
s
,
a
n
d
h
e
a
l
t
h
w
o
r
k
e
r
s
h
a
s
a
s
i
g
n
i
f
i
c
a
n
t
i
m
p
a
c
t
o
n
f
o
o
t
w
o
u
n
d
p
r
e
v
e
n
t
i
o
n
b
e
h
a
v
i
o
r
i
n
d
i
a
b
e
t
e
s
p
a
t
i
e
n
t
s
.
T
h
e
s
e
f
a
c
t
o
r
s
a
r
e
t
h
e
f
o
c
u
s
o
f
e
d
u
c
a
t
i
o
n
a
n
d
i
n
t
e
r
v
e
n
t
i
o
n
p
r
o
g
r
a
m
s
t
o
e
n
s
u
r
e
d
i
a
b
e
t
e
s
p
a
t
i
e
n
ts
m
a
i
n
t
ai
n
g
o
o
d
f
o
o
t
h
e
a
l
t
h
[
1
4
]
.
P
a
t
i
e
n
ts
w
i
t
h
g
o
o
d
k
n
o
w
l
e
d
g
e
,
f
a
m
i
ly
s
u
p
p
o
r
t
,
p
e
e
r
s
u
p
p
o
r
t
,
a
n
d
h
e
a
l
t
h
c
a
r
e
p
r
o
v
i
d
e
r
s
u
p
p
o
r
t
a
r
e
m
o
r
e
l
i
k
e
l
y
t
o
a
d
o
p
t
f
o
o
t
i
n
j
u
r
y
p
r
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v
e
n
t
i
o
n
b
e
h
a
v
i
o
r
s
,
i
n
c
l
u
d
i
n
g
w
e
a
r
i
n
g
a
p
p
r
o
p
r
i
a
t
e
f
o
o
t
w
e
a
r
,
c
h
e
c
k
i
n
g
t
h
e
i
r
f
e
e
t
r
e
g
u
l
a
r
l
y
,
m
a
i
n
t
a
i
n
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n
g
c
le
a
n
l
i
n
es
s
,
a
n
d
a
v
o
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d
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n
g
a
c
t
i
v
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ti
e
s
t
h
a
t
c
o
u
l
d
h
a
r
m
t
h
e
f
e
e
t
[
2
6
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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Hea
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2252
-
8
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6
S
o
cia
l su
p
p
o
r
t a
s
a
ke
y
fa
ct
o
r
in
th
e
h
e
a
lth
p
r
o
mo
tio
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mo
d
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l:
I
n
flu
en
cin
g
…
(
S
u
ya
n
to
S
u
ya
n
to
)
413
Stu
d
ies
s
h
o
w
th
at
p
atien
t
s
wi
th
g
o
o
d
k
n
o
wled
g
e
ab
o
u
t
f
o
o
t
ca
r
e,
alo
n
g
with
s
u
p
p
o
r
t
p
r
o
v
id
ed
b
y
f
am
ily
,
p
ee
r
s
,
an
d
h
ea
lth
p
r
o
f
e
s
s
io
n
als,
ar
e
m
o
r
e
lik
el
y
to
a
d
o
p
t
f
o
o
t
wo
u
n
d
p
r
ev
en
tio
n
b
e
h
a
v
io
r
s
[
2
1
]
.
Patien
ts
r
o
u
tin
ely
ch
ec
k
th
eir
f
ee
t
f
o
r
s
ig
n
s
o
f
d
am
ag
e
o
r
in
ju
r
y
,
m
ai
n
tain
g
o
o
d
f
o
o
t
h
y
g
ien
e,
an
d
av
o
id
ac
tiv
ities
th
at
co
u
ld
c
o
m
p
r
o
m
is
e
th
e
in
teg
r
it
y
o
f
th
e
f
o
o
t
s
k
in
[
2
7
]
.
T
h
e
s
o
c
ial
s
u
p
p
o
r
t
an
d
k
n
o
wled
g
e
p
r
o
v
id
ed
b
y
th
e
p
eo
p
le
ar
o
u
n
d
th
e
p
atien
t,
alo
n
g
with
th
e
g
u
id
an
ce
a
n
d
ed
u
ca
tio
n
p
r
o
v
id
ed
b
y
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als,
p
lay
a
k
ey
r
o
le
in
en
co
u
r
a
g
in
g
p
atien
ts
to
tak
e
th
e
n
ec
ess
ar
y
p
r
ev
en
tiv
e
m
ea
s
u
r
es
to
p
r
o
tect
th
eir
f
o
o
t
h
ea
lth
[
2
8
]
.
Patien
ts
with
g
o
o
d
k
n
o
wled
g
e,
f
am
ily
s
u
p
p
o
r
t,
p
ee
r
s
u
p
p
o
r
t,
an
d
h
ea
lth
c
ar
e
p
r
o
v
id
er
s
u
p
p
o
r
t
ar
e
m
o
r
e
lik
ely
to
ad
o
p
t
f
o
o
t
in
ju
r
y
p
r
ev
en
tio
n
b
e
h
av
io
r
s
,
in
clu
d
in
g
wea
r
i
n
g
a
p
p
r
o
p
r
iate
f
o
o
twea
r
,
ch
ec
k
i
n
g
th
eir
f
ee
t
r
e
g
u
lar
ly
,
m
ain
tain
i
n
g
clea
n
lin
ess
,
an
d
av
o
id
i
n
g
ac
tiv
ities
th
at
co
u
ld
h
ar
m
t
h
e
f
ee
t
[
2
9
]
.
T
h
e
r
esu
lts
o
f
th
e
s
tu
d
y
s
h
o
w
th
at
k
n
o
wled
g
e
ab
o
u
t
f
o
o
t
ca
r
e,
s
u
p
p
o
r
t
f
r
o
m
f
am
ily
,
an
d
p
ee
r
s
,
an
d
s
u
p
p
o
r
t
f
r
o
m
h
ea
lth
wo
r
k
e
r
s
p
lay
an
im
p
o
r
tan
t
r
o
le
i
n
im
p
r
o
v
in
g
f
o
o
t
wo
u
n
d
p
r
ev
en
tio
n
b
eh
av
io
r
in
d
iab
etes
p
atien
ts
.
Go
o
d
k
n
o
wled
g
e
o
f
f
o
o
t
ca
r
e
allo
ws
p
atien
ts
to
ta
k
e
ap
p
r
o
p
r
iate
p
r
ec
a
u
tio
n
s
,
w
h
ile
em
o
tio
n
al
an
d
p
r
ac
tical
s
u
p
p
o
r
t
f
r
o
m
f
am
il
y
an
d
p
ee
r
s
h
elp
s
m
o
tiv
ate
p
ati
en
ts
to
tak
e
g
o
o
d
ca
r
e
o
f
th
eir
f
ee
t.
Su
p
p
o
r
t
f
r
o
m
h
ea
lth
wo
r
k
er
s
,
in
c
lu
d
in
g
ed
u
c
atio
n
an
d
r
e
g
u
lar
m
o
n
ito
r
in
g
,
a
ls
o
m
ak
es
a
s
ig
n
i
f
ican
t
co
n
tr
ib
u
tio
n
to
p
r
o
m
o
tin
g
d
iab
etes
f
o
o
t
wo
u
n
d
p
r
ev
en
tio
n
b
eh
av
i
o
r
.
Ov
e
r
all,
k
n
o
wled
g
e
an
d
s
u
p
p
o
r
t
f
r
o
m
v
a
r
io
u
s
p
ar
ties
h
av
e
a
p
o
s
itiv
e
in
f
lu
en
ce
o
n
f
o
o
t w
o
u
n
d
p
r
ev
e
n
tio
n
b
e
h
av
io
r
i
n
d
iab
etes
p
ati
en
ts
[
3
0
]
.
4.
CO
NCLU
SI
O
N
So
cial
s
u
p
p
o
r
t
p
lay
s
an
im
p
o
r
tan
t
r
o
le
in
in
cr
ea
s
in
g
p
atien
t
k
n
o
wled
g
e
a
n
d
awa
r
en
ess
r
eg
ar
d
in
g
th
e
r
is
k
o
f
d
iab
etic
f
o
o
t
wo
u
n
d
s
.
Su
p
p
o
r
t
f
r
o
m
f
am
ily
,
an
d
f
r
ien
d
s
,
h
av
in
g
s
u
f
f
icien
t
k
n
o
wled
g
e
ab
o
u
t
h
o
w
d
iab
etes
ca
n
af
f
ec
t
t
h
eir
f
o
o
t
h
ea
lth
.
T
h
is
k
n
o
wled
g
e
is
im
p
o
r
ta
n
t
t
o
p
r
e
v
en
t
f
o
o
t
in
j
u
r
ies
an
d
m
in
im
ize
th
e
r
is
k
o
f
co
m
p
licatio
n
s
.
T
h
e
s
o
cial
en
v
i
r
o
n
m
en
t
ca
n
in
c
r
ea
s
e
m
o
n
ito
r
i
n
g
o
f
th
e
co
n
d
itio
n
o
f
d
iab
etes
p
atien
ts
'
f
ee
t.
W
ith
s
o
cial
s
u
p
p
o
r
t,
p
atien
ts
ca
n
i
n
co
r
p
o
r
ate
ch
a
n
g
es,
in
clu
d
in
g
m
in
o
r
in
ju
r
ies
th
at
m
a
y
d
ev
elo
p
in
to
s
er
io
u
s
p
r
o
b
lem
s
if
n
o
t
ad
d
r
ess
ed
q
u
i
ck
ly
.
T
h
is
s
u
p
p
o
r
t
h
elp
s
in
ea
r
ly
d
etec
tio
n
o
f
d
iab
etic
f
o
o
t
wo
u
n
d
s
,
an
d
tim
ely
tr
ea
tm
en
t.
Ap
ar
t
f
r
o
m
its
ef
f
e
ct
o
n
p
r
ev
en
tin
g
d
iab
etic
f
o
o
t
wo
u
n
d
s
,
s
o
cial
s
u
p
p
o
r
t
also
h
as
a
p
o
s
itiv
e
im
p
ac
t
o
n
th
e
p
atien
t'
s
q
u
ality
o
f
life
.
E
m
o
tio
n
al
s
u
p
p
o
r
t
f
r
o
m
th
o
s
e
clo
s
est
to
y
o
u
ca
n
r
ed
u
ce
th
e
lev
els
o
f
s
tr
ess
an
d
d
ep
r
ess
io
n
th
at
ar
e
o
f
te
n
ass
o
ciate
d
with
d
iab
etes.
A
s
tab
le
em
o
tio
n
al
c
o
n
d
itio
n
ca
n
s
p
ee
d
u
p
th
e
w
o
u
n
d
-
h
ea
lin
g
p
r
o
ce
s
s
b
ec
au
s
e
p
atien
ts
ar
e
m
o
r
e
lik
ely
to
f
ee
l
p
o
s
itiv
e
an
d
m
o
tiv
ated
to
ta
k
e
g
o
o
d
ca
r
e
o
f
th
em
s
elv
es.
RE
F
E
R
E
NC
E
S
[
1
]
S
.
Ş
a
h
i
n
a
n
d
D
.
C
i
n
g
i
l
,
“
Ev
a
l
u
a
t
i
o
n
o
f
t
h
e
r
e
l
a
t
i
o
n
sh
i
p
a
m
o
n
g
f
o
o
t
w
o
u
n
d
r
i
sk
,
f
o
o
t
se
l
f
-
c
a
r
e
b
e
h
a
v
i
o
r
s,
a
n
d
i
l
l
n
e
ss
a
c
c
e
p
t
a
n
c
e
i
n
p
a
t
i
e
n
t
s
w
i
t
h
t
y
p
e
2
d
i
a
b
e
t
e
s
m
e
l
l
i
t
u
s,
”
Pri
m
a
ry
C
a
re
D
i
a
b
e
t
e
s
,
v
o
l
.
1
4
,
n
o
.
5
,
p
p
.
4
6
9
–
4
7
5
,
O
c
t
.
2
0
2
0
,
d
o
i
:
1
0
.
1
0
1
6
/
j
.
p
c
d
.
2
0
2
0
.
0
2
.
0
0
5
.
[
2
]
A
.
S
.
K
.
S
h
a
r
o
n
i
,
M
.
N
.
M
.
R
a
z
i
,
N
.
F
a
d
i
l
a
h
,
a
n
d
Y
.
E
.
M
a
h
m
o
o
d
,
“
S
e
l
f
-
e
f
f
i
c
a
c
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