International Journal of Medical Sciences And Clinical Research
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VOLUME
Vol.05 Issue01 2025
PAGE NO.
45-51
10.37547/ijmscr/Volume05Issue01-06
Prevalence of Feet Problems and Protective Measures
among Diabetic Pilgrims During AL-Arba'een of Imam
Al-Hussain
Dr. Hassan Abdullah Athbi
Assistant Professor, PhD. /Adult Nursing Branch/College of Nursing/Kerbala University/Iraq
Methal Yaesen Abd
Fundamentals of Nursing Branch /College of Nursing/Kerbala University/Iraq
Huda Thaaer Muhsen
Kerbala Health Directorate/ Imam Hussain Medical City/Iraq
Meaid Qhttan Mousa
Kerbala Health Directorate/ Imam Hussain Medical City/Iraq
Received:
20 October 2024;
Accepted:
21 December 2024;
Published:
21 January 2025
Abstract:
Background: Pilgrims with diabetes are at high risk for foot problems due to decreased immunity,
neuropathies, and peripheral vascular disease. This study was done to assess the prevalence of foot problems and
protective measures adopted by diabetic pilgrims to prevent foot problems during AL-Arba'een of Imam Al-
Hussain.
Methods: A descriptive study was conduct at a mobile clinic in Holy Kerbala during AL-Arba'een of Imam Al-
Hussian from the period of 5th October 2019 to 10th July, 2024 in order to accomplish the early listed objectives.
A purposive sampling consists of 186 pilgrims who were diagnosed previously as diabetic patients. The data were
collected used a constructed questionnaire and therefore analyze used the statistical package for social science
(SPSS) version 24 through the application of descriptive statistical analysis (frequencies, percentage, and mean of
score).
Results: the most prevalent foot problems are foot blisters 52.6%, foot redness 55.9%, 73.1% and 89.7% have
foot/legs pain and numb respectively. Most diabetes pilgrims complain from foot, toes, or leg swelling; 86.5%,
and 91.9% of them their foot is sensitive to touch, and complains from feet hurt when walking; also 69.8% of
pilgrims have muscle cramps in legs or foot. Most of diabetic pilgrims were washed their feet frequently, 44% of
them are examined the water temperature before putting their feet in it, 39.7% of diabetic pilgrims are inspected
the soles of their feet while walking, 38.1% of them are changed their socks at least one time a day, and 52.1% of
diabetic pilgrims are inspected their shoes for a foreign div or torn linings before wearing.
Conclusions: Foot blisters, redness, foot/legs pain or numb; foot, toes, or legs swelling; foot sensitive to touch;
foot hurt when walking; also, muscle cramps in legs or foot are the most common foot problems among diabetic
pilgrims. The most important preventive measures that were done by diabetic pilgrims to prevent foot problems
are washed their feet every day, examined water temperature before putting their foot in it, inspect the soles of
their foot while walking, and inspect their shoes for foreign objects or torn linings before wearing.
Keywords:
Foot Problem; Protective Measures; AL-Arba'een of Imam Al-Hussain.
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Introduction:
Al-
A rba'een is a Shi’a Muslim religious
ritual, which occurs 40 days after Ashura day. It is
commemorating the martyrdom of Imam Hussain, the
grandson of Muhammad (peace be upon him), which
falls on the twentieth day of Safar. Al-Arba'een is the
largest religious mass gatherings worldwide, in which
more than 26 million people go to the city of Kerbala
on foot (Wikpedia, Arbeen. 2016). Religious mass
gatherings are increasingly common in Iraq and can
harbor considerable public health risks. Hajj is the most
thoroughly studied religious mass gathering. Many
studies have been conducted on described public
health consequences associated with Hajj. In Iraq,
numerous religious mass gatherings occur during the
year mostly in Kerbala. The public health impacts
associated with mass gatherings are incompetently
studying in Iraq (Chitheer, et al., 2020; Hantoosh, et al.,
2019; and Al-Lami, et al., 2010).
Foot problems frequently result from prolonged
walking and standing (Brehove, et al. 2000). Many of
the pilgrims walked on foot from Baghdad, a journey of
100 Km, some walked from as far as Basra, a journey of
nearly 700 Km. Hundreds of thousands of pilgrims came
from Iran; a journey that takes around a month on foot
(Ibtimes, Arbeen. 2016). In a similar situation, the Hajj
rituals often include walking many miles, which can
result in trauma to the foot, especially in those diabetic
people (Vinary, and Goldman, 2004). Alfelali, et al.,
(2014) reported that the risk of foot wounds among
Hajj pilgrims with diabetes is high due to the interplay
of decreased immunity, neuropathies, and peripheral
vascular disease. They emphasized that foot injuries
were the most common cause for hospitals admission,
fungal and bacterial infections were among the
commonest dermatological problems among pilgrims.
Inadequate foot care knowledge and poor foot
care practices are being recognized as major risk factors
for foot problems in people with diabetes (Chandalia,
et al., 2010, and George, et al., 2015). Preventive
measures such as used a protective footwear,
maintained regular diet and medications, and optimal
blood sugar control may help to decrease the risk of
foot problems in diabetic pilgrims (Alfelali, et al., 2014).
In light of this, "prevention is better than cure."
Determining the disease process, identifying disease
risk factors, and establishing management that
eventually lowers the risk should be the main goals of
disease prevention (Athbi and Hassan, 2019). A good
moisturizer applied two or three times a day will help
to keep the skin moist and healthy (Alsafadi, et al.,
2011), also daily checking of the foot for cuts or blisters
and wearing comfortable shoes are suitable for
avoiding feet problems. Diabetic patients should be
examined before to the trip to confirm that they are
physically capable of this ritual; also, they should be
examined periodically to identify early problems such
as foot harms (Vinary, and Goldman, 2004). Patients
should be closely adherence to their health-related
recommendations, that’s can be assessed by looking at
factors such as accuracy, consistency, and willingness
to follow treatment recommendations for prescription
medications, dietary modifications, and other lifestyle
behaviors (Athbi, et al., 2024). No previous studies have
been conducted to investigate foot problems and
preventive measures for pilgrims with diabetes
attending to Holly Kerbala in Iraq. This study aims to
identify foot problems and preventive measures
among diabetic pilgrims during AL-Arba'een of Imam
Hussain.
METHODS
Design of the study
: A descriptive quantitative study
was conducted at a mobile clinic in Holy Kerbala during
AL-Arba'een of Imam Hussian from the period of
5thOctober (2019) to 10th July (2024), in order to
assess foot problems and preventive measures among
diabetic pilgrims.
Sample of the study
: A non-probability (purposive)
sample of 186 pilgrims who were diagnosed previously
as a diabetic patient, those were found in the mobile
clinic at Holy Kerbala during AL-Arba'een of Imam
Hussian.
The study instrument and data collection
: The
researchers constructed an assessment tool after
reviews the related literature and relevant studies. The
questionnaires consisting of closed-ended questions. It
consists of three main parts as follow: A socio-
demographic characteristics sheet, consist of twelfth
items, which include age, sex, nationality, marital
status, residency, education level, current employment
status, div mass index, duration of diabetes, pre-
existing chronic diseases, proximal walking distance,
and participation number of attending to Kerbala
during AL-Arba'een of Imam Hussain. The second part
of the questionnaire was comprised of (16) items to
investigate foot problems among diabetic pilgrims. The
third part of the questionnaire consists of (17) items to
assess the protective measures of diabetic pilgrims to
protect their feet. The data are collected through the
use of early constructed questionnaires and by
interviewing techniques with subjects in the mobile
clinics by the using of the Arabic, Persian, and English
questionnaire version, and they were interviewed in a
similar way, in the same place, during AL-Arba'een of
Imam Al-Hussain. Content validity for the early-
developed instrument was determined by used a panel
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International Journal of Medical Sciences And Clinical Research (ISSN: 2771-2265)
of experts to examine the relevancy, clarity, and
adequacy of the questionnaire to measure the concept
of interest. A pilot study was conducted on (10) diabetic
pilgrims, which was selects from mobile clinics at Holy
Kerbala in order to identify the reliability of the
questionnaire.
Statistical data analysis
: The data were investigated by
using the IBM program of Statistical Package of Social
Sciences (SPSS) Version 24 through the application of
descriptive
statistical
analysis
(frequencies,
percentage, and mean of score).
RESULTS
Table (1): Distribution of diabetic pilgrims by their socio-demographic characteristics:
Socio-demographic characteristics
Frequency (f)
Percentage (%)
Age Groups
<20 -29
3
1.6
30 -39
25
13.4
40 - 49
48
25.8
50 - 59
69
37.1
≥ 60
41
22.0
Sex
Male
88
47.3
Female
98
52.7
Marital Status
Divorced/Separated
8
4.3
Widowed
29
15.6
Single
5
2.7
Married
144
77.4
Nationality
Bahrain
1
0.5
Saudi
1
0.5
Lebanon
1
0.5
Indian
1
0.5
Iran
50
26.9
Iraq
132
71.0
Residency
Rural
43
23.1
Urban
143
76.9
Education level
No formal education
76
40.9
Primary school
44
23.7
Secondary school
37
19.9
University graduated
29
15.6
Employment status
Farmer
9
4.8
Gainer
31
16.7
Housewife
87
46.8
Student
2
1.1
Retired
7
3.8
Employee
50
26.9
Table (2): Distribution of diabetic pilgrims by their medical information:
Items
Categories
Frequency
(f)
Percentage
(%)
Cumulative
Percentage %
Diabetic
duration
< 1 year
6
3.2
3. 2
1 – 5 years
90
48.4
51.6
> 5
90
48.4
100.0
Body mass
index
< 18.5
3
1.6
1.6
18.5 - 24.9
40
21.5
23.1
25 – 29.9
67
36.0
59.1
≥ 30
76
40.9
100.0
Pre-existing
chronic
disease
Asthma
3
1 .6
1.6
Stomach ulcer
1
0.5
2.1
Arthritis
15
8.1
10.2
Heart failure
7
3.8
14.0
Hypertension
84
45.2
59.1
Renal
2
1.1
60.2
Non
74
39. 8
100.0
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Table (3): Proximal walking distance and number of attending to Kerbala of diabetic pilgrims during AL-
Arba'een of Imam Al-Hussain:
Cumulative
Percentage %
Percentage
(%)
Frequency
(f)
Groups
Proximal walking
distance
25.3
25.3
47
< 50 Km
79.6
54.3
101
50 – 149 Km
83.3
3.8
7
150 – 249 Km
90.3
7.0
13
250 – 349 Km
100.0
9.7
18
≥ 350
44.6
44.6
83
< 5
Participation number
of attending to
Kerbala
78.5
33.9
63
5-10
100.0
21.5
40
≥ 10
Table (4): Statistical result of foot problems among diabetes pilgrims:
Type of foot problems
Number of pilgrims suffering
Yes
No
MS Severity
f
%
f
%
Foot blister
98
52.6
88
47.3
1.5
H
Foot injury
48
25.8
137
73.6
1.2
L
Foot redness (erythema)
104
55.9
82
44.0
1.5
H
Foot, toes, or legs swelling
132
70.9
54
29.0
1.7
H
Feeling hot in one foot in comparison to other
foot
80
43.0
106
56.9
1.4
L
Sore foot
32
17.2
154
82.7
1.1
L
Diabetic foot ulcer
58
31.1
128
68.1
1.1
L
Foot dryness and callosity
30
16.1
156
83.8
1.3
L
Foot mycosis
48
25.8
138
74.1
1.2
L
Foot tendonitis
96
51.6
90
48.3
1.5
H
Muscle cramps in legs or foot
130
69.8
56
30.1
1.6
H
Foot or legs numb
136
73.1
50
26.8
1.7
H
Foot or legs pain
167
89.7
19
10.2
1.8
H
Prickling (tingling) feelings in legs or foot
148
79.5
38
20.4
1.7
H
Foot sensitive to touch
161
86.5
25
13.4
1.8
H
Foot hurt when walking
171
91.9
15
8.0
1.9
H
MS = Mean of score; H=High level of severity (MS≥1.5); L=Low level of severity (MS<1.5).
Table (5): Statistical result of protective measures among pilgrims with diabetes mellitus to protect their
foot:
Protective measures
Responses
MS
Severity
Protective measures
Always
Sometimes
Never
f
%
f
%
f
%
Measure of glucose level
92
49.4
80
43.0
14
7.5
2.4
H
Maintaining regular diabetes diet
meal
96
51.6
55
29.5
35
18.8
2.3
H
Drinking plenty of water
138
74.1
41
22.0
7
3.7
2.7
H
Use of diabetes mellitus
medication as prescribed
114
61.2
28
15.0
44
23.6
2.3
H
Inspect the soles of your foot while
walking.
74
39.7
79
42.4
33
17.7
2.2
H
Do you wash your foot every day
109
58.6
60
32.2
17
9.1
2.4
H
Examine water temperature
before putting your foot in
82
44.0
71
38.1
33
17.7
2.2
H
Do you dry well between the toes
45
24.1
49
26.3
92
49.4
1.7
M
Using foot or baby powder
6
3.2
25
13.4
155
83.3
1.1
L
Using of vaseline or another
moisturizer
19
10.2
46
24.7
121
65.0
1.4
L
Using antiperspirant for foot
5
2.6
20
10.7
161
86.5
1.1
L
Wear cotton socks
70
37.6
41
22.0
75
40.3
1.9
M
Change socks at least one time a
day
71
38.1
69
37.0
46
24.7
2.1
H
Walk barefoot
11
5.9
40
21.5
135
72.5
1.3
L
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Using medical shoes
64
34.4
40
21.5
82
44.0
1.9
M
Do you ever wear shoes without
wearing any socks
10
5.3
39
20.9
137
73.6
1.3
L
Inspect your shoes for foreign
objects or torn linings before
wearing
97
52.1
47
25.2
42
22.5
2.2
H
M.S. = Mean of score; H=High level of severity (M.S.≥2); M=Moderate level of severity (M.S.≥1.5-<2); L=Low level of severity (M.S.<1.5).
DISCUSSION
This is the earliest study aims to assess the prevalence
and protective measures of foot problems among
diabetic pilgrims. The result of the present study
exposed that AL-Arba'een pilgrims complains from
many foot problems; the most common foot problems
among diabetic pilgrims are blisters and erythema,
many pilgrims failed to perform the basic preventive
measures such as foot protection. Regarding the socio-
demographical features of the study sample as shown
in table (1) the findings indicate that 37.1% and 25.8%
of pilgrims with diabetes were in the 50-59 and 40-49
age groups, respectively. Among all pilgrims more most
(52.7%) of them were females, and the majority
(77.4%) of them were married. Alakkas, (2015)
reported that out of 262 hajj pilgrims with diabetes 237
(90.5%) were male and 25 (9.5%) were female, 45.8%
and 43.5% of them were within the age group of 35-54,
and 55-74-year-old.
Concerning to educational level, the results indicates
that about 40.9% of diabetic pilgrims do not have
formal education, and 23.7% have primary school
education, this result disagrees with the results of the
study that was conducted by Chiwanga, (2015) exposed
that about 11.3% of respondents does not have any
formal education, and 62.6% of them had primary
education. In relation to the employment status, the
results reveal that 46.8% of the subjects were
housewives, and 26.9% were employees.
Regarding the pilgrim's nationality, the result indicates
that participants belonged to six different nationalities,
the majority (71%) of them were from Iraq, and the
most common being 26.9% from Iranian nationality.
Alfelali, et al., (2014) stated that is out of 197
respondents involved in a study to evaluate foot
injuries in pilgrims performing the Hajj with and
without diabetes mellitus: consequences for infection
control, revealed about 26% of pilgrims were from
Pakistan, and 20% were from Egypt. Concerning to
div mass index of the pilgrims as shown in table (2)
the result indicates that most of the diabetic pilgrims
(40.9%), and (36.0%) were obese and overweight
respectively. This result comes along with the results of
the study done by Sridhar, et al., (2014) to investigate
the foot ailments during Hajj, reported that one third
(29.5%) of the study sample were obese and slightly
more than one third (37.2%) were overweight.
Regarding the proximal walking distance and the
participation number in AL-Arba'een of Imam Hussain.
The result indicates that the majority (74.7%) of them
are walked approximately more than 50 Km in order to
reach the Imam Hussain Shrine, and 55.4% have had
more than five number of participations in AL-Arba'een
of Imam Hussian. Sridhar, et al., (2014) reported that
approximately 58 kilometers was the expected total
walking distance for the entire Hajj journey.
Concerning to preexisting chronic disease, the result
indicates that most (45.2%) of the pilgrims have had a
history of hypertension and 15.1% have other medical
conditions in addition to diabetes mellitus. This result
corresponding with the results of the study of Alfelali,
et al., (2014) indicated that thirteen individuals (22%)
out of the sixty (60) with diabetes had additional
medical issues, while 47 (78%) had diabetes alone.
After analysis of foot problems among diabetic pilgrims
as shown in table (4), the results indicate the blisters
and purulent ulcers were the most common foot
problems observed among AL-Arba'een pilgrims
walking to Holy Kerbala for long-distance. Blisters were
also the most common foot problems requiring medical
care among pilgrims. It is accounted about 52.6% of
pilgrims have blisters, and 55.9% have had foot redness
(erythema). These findings are corresponding with the
findings of the study that was done by Alfelali, et. al.,
(2014) shows that blisters and erythema are the most
frequently detected foot injuries and accounted 34%,
and 25% respectively. Another study by Sridhar, et al.,
(2014) reported that the prevalence of foot blisters is
high among the Hajj pilgrims and accounted for about
29.4% among diabetic pilgrims.
In addition to that, the findings demonstrate that
70.9% of diabetes pilgrims have complained of foot,
toes, or legs swelling, and 69.8% complains from
muscle cramps in legs or foot. This finding was in
disagreement with the study of Sridhar, et al., (2014)
revealed that out of 129 subjects involved in the study
only two pilgrims reported legs edema during Hajj.
On the other hand, the majority (73.1%), (89,7%),
(86.5%), and (91.9%) of diabetic pilgrims complain of
foot or leg numbness, foot or legs pain, foot sensitivity
to touch and foot hurt when walking respectively. This
can be attributed to the long-distance walking while
performing rituals during AL-Arba'een of Imam
Hussain. The study of Mehra, et al., (2008)
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demonstrated that most (40.6%) common symptom
among diabetic patients was foot numbness and was
more common in long-duration diabetes. Another
study conducted by Vinay, (2004) reported that the Hajj
rituals often involve walking many miles, which can
result in accidental foot trauma, especially in those
diabetic people.
About the preventive measures that were done by
diabetic pilgrims as shown in table (5), the result
indicates that diabetic pilgrims perform many
measures to prevent foot problems, about 61.2% of
diabetes pilgrims are the use of diabetic medication as
prescribed in order to control their blood glucose level,
58.6% of diabetes pilgrims wash their foot every day to
prevent foot problems, 44% of them are tested the
water temperature before putting their foot in it, 39.7%
of diabetic pilgrims are inspecting the soles of their foot
while walking, 38.1% of them are changing their socks
at least one time a day, and 52.1% of diabetic pilgrims
are inspected their shoes for a foreign div or torn
linings before wearing. Alfelali, et al., (2014) reports
that the use of suitably protective footwear and regular
control in medications are extremely suggested for
pilgrims' ideal foot care.
CONCLUSIONS
The study demonstrated that the most common foot
problems among diabetic pilgrims during AL-Arba'een
of Imam Hussain were foot blisters; foot redness
(erythema); foot/legs pain or numb; foot, toes, or legs
swelling; foot sensitive to touch; foot hurt when
walking; also muscle cramps in legs or foot. All of these
foot problems were because of walking for long
distances, and sometimes barefoot. The most
important preventive measures that were done by
diabetic pilgrims to prevent foot problems are washed
their feet every day, test water temperature before
putting their foot in it, inspect the soles of their foot
while walking, change their socks at least one time a
day, and inspect their shoes for foreign objects or torn
linings before wearing.
Recommendations
1.
Foot problems can be prevented through the
application of protective measures by diabetic pilgrims
to protect their feet.
2.
Establishing well-equipped specialized mobile
clinics, educational strategies for diabetic pilgrims
during AL-Arba'een of Imam Hussain.
3.
Educational advice on preventive measures
that’s should be applied to diabetic pilgrims to protect
their feet during travel could be beneficial for diabetic
pilgrims during AL-Arba'een of Imam Hussain.
4.
Another study should be conducted to
investigate factors that are contributing to the
occurrence of foot problems among diabetic pilgrims.
5.
To improve diabetes patients' understanding of
self-care techniques and routine diabetic foot
evaluation, frequent diabetic care should be provided.
Acknowledgment:
We gratefully acknowledge all diabetics pilgrims who
take part in this study during Arba'een of Imam Al-
Hussein for their cooperation, as well as special thanks
to all health-team members in the mobile clinic in Holy
Kerbala during AL-Arba'een of Imam Hussian for their
valued help during the data collection process.
Ethical Considerations
The ethical endorsement was achieved from the
Kerbala health directorate, as well as informed consent
was attained from all participants to signify their
enrolment in this study. Furthermore, authorization
was achieved from the Scientific Research Ethical
Committee at the Nursing College/University of
Kerbala.
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