Diabetic Foot Self-Care Practi

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Diabetic Foot Self-Care Practices Among Adult

Diabetic Patients: A Descriptive Cross-Sectional
Study
This article was published in the following Dove Press journal:
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy
Namo Hirpha 1 Background: Adequate foot care and regular foot examinations along with optimal glyce
Ramanjireddy Tatiparthi 2 mic control are effective strategies to prevent foot ulceration.
Temesgen Mulugeta 3 Aim: The aim of this study was to describe the patterns of foot self-care practice among
1
diabetic patients attending an ambulatory clinic.
Department Hospital Pharmacy, Bako
For personal use only.
Primary Hospital, West Shewa, Oromia, Methods: A descriptive cross-sectional study was conducted at the ambulatory clinic of
Ethiopia; 2Institute of Health, School of Jimma Medical Center. A consecutive sampling technique was used. The data were analyzed
Pharmacy, Department of Pharmaceutics, by SPSS version 20 and descriptive statistics were used to describe the findings.
Jimma University, Jimma, Oromia,
Ethiopia; 3Institute of Health, School of Results: A total of 370 diabetic patients (55.9% male and 68.4% type 2) were interviewed. The
Pharmacy, Department of Clinical mean (±SD) age of the patients was 46.47±13.63 years. Over one-third (35.7%) of the patients had
Pharmacy, Jimma University, Jimma,
a previous history of foot ulcer. The majority of the patients self-inspect (92.5%) and wash (82.7%)
Oromia, Ethiopia
their foot at least daily, respectively. In this study, 12.2% of the patients never inspected the inside
of their footwear before putting them on and 42.4% of the patients never dry between their toes
after washing. Most (63.5%) of patients never used moisturizing creams to lubricate the dry skin. In
this study, 23.0% and 27.6% of the patients walk in sandals/slippers and in shoes without socks
most of the time, respectively. Only 27.3% of the patients changed their socks daily. Majority
(78.4% and 86.5%) of the patients never walk barefoot around and outside their house, respectively,
and 75.1% of the patients never put their feet near the fire.
Conclusion: Diabetic patients were not adequately self-inspect and wash their foot at least
daily, dry after wash and moisturize the dry skin. They walk barefoot, in sandals/slippers, and
in shoes without socks. Therefore, clinicians should counsel every diabetic patient about the
importance of foot self-inspection, foot hygiene, and the risk of walking barefoot, wearing
sandals/slippers, and shoes without socks at every follow-up visit.
Keywords: diabetes mellitus, foot self-care, practice, Jimma Medical Center
Background
Diabetes is a complex, chronic illness requiring continuous medical care with
multifactorial risk-reduction strategies beyond glycemic control.1 Foot ulceration
is a major complication of diabetes mellitus and is associated with high levels of
morbidity and mortality, as well as significant financial costs. The lifetime inci
dence rate of diabetic foot ulceration is 19–34%, with a yearly incidence rate of 2%.
Correspondence: Temesgen Mulugeta After successful healing, the recurrence rates of diabetic foot ulcers (DFU) are 40%
Institute of Health, School of Pharmacy,
Department of Clinical Pharmacy, within a year and 65% within 3 years.2
Jimma University, Jimma, Oromia, Ethiopia
Tel +251917734764
Poor diabetic foot care increases the risk of ulceration, infection, and limb loss.3
Email [email protected] A study done in the UK highlighted, 18.5% (14.2–22.7) of diabetic patients failed
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Hirpha et al Dovepress
to inspect their feet and 83% (79.1–86.9) did not have their urgently needed to treat diabetic foot disease
feet measured when they last purchased shoes. Practices preventatively.6 Prevention of these ulcers is of paramount
that put patients at risk included the use of direct forms of importance to reduce the patient and economic burden.2
heat on the feet and walking barefoot.4 Bell et al reported, Effective strategies for foot ulceration prevention include
the foot self-care behaviors performed with the highest educating patients, their families, and healthcare workers
frequency of 6–7 days were washing the feet (75.6%) about adequate foot care and regular foot examinations
and not soaking the feet (79.2%). Conversely, 23% of the along with optimal glycemic control. Counseling patients
participants reported not checking their feet at all, and regarding daily proper footwear and hygiene should be
54% did not inspect their shoes before wearing them.5 stressed during each clinic visit.13
In developing countries, foot ulcers and amputations Even though there are studies reporting foot self-care
are unfortunately very common. Poverty, a lack of sanita from different regions of Ethiopia, many of the reports
tion and hygiene, and barefoot walking often interact to were the numeric levels of foot self-care practice and
compound the impact of diabetic foot damage.6 Wanja associated socio-demographic and clinical factors;14–19
et al reported, among type 2 DM patients, the foot self- only two studies10,11 from the northern part of the country
care practice done correctly by most respondents were reported some elements of foot self-care practice.
washing feet daily by 85% and not wearing high-heeled Identifying the specific elements of foot self-care will
shoes (>2.5inches) by 81.1% while the worst performed help clinicians to educate the patients about the foot self-
practice was wearing sandals when performing outdoor care comprehensively. There was no similar study from
activities where only 15.7% were likely to have the correct our referral and teaching Medical center which reported
practice and 84.3% were likely to have the incorrect the patterns of foot self-care practice. Therefore, the aim of
practice.7 Desalu et al reported 61.4% of the patients this study was to assess the patterns of foot self-care
were unaware of the importance of inspecting the inside practice among diabetic patients attending a follow-up
of the footwear for objects. Poor foot practices include; visit at the ambulatory clinic, Jimma Medical Center.
89.2% not receiving advice when they bought footwear
and 88.6% failing to get appropriate size footwear.8
A meta-analysis result among Ethiopian diabetic Materials and Methods
patients showed 58% (95% CI: 41–74%) of the patients Study area and period: The study was conducted in Jimma
had a good level of foot-care practice.9 Seid and Isige Medical Center, Jimma, Oromia Region, Southwest
reported, about 60.7% of the diabetic patients inspect Ethiopia between March 1 and April 5, 2019. Jimma
their feet at least daily and 38.7% have never checked Medical Center is located 352 kilometers away from the
their shoes before they put them on. Also, 59.1% and capital city of Ethiopia toward Southwest. The hospital
69.3% of the patients never had a habit of drying their provides service to 15 million people with 1600 staff
feet and between toes, respectively. The majority of the members, 32 intensive care units, and 800 beds.20 The
patients (72.5%) reported never used the cream to moist Hospital provides service for approximately 3000 diabetic
urize their feet. About 66% of the patients cut toenails patients every Monday and Tuesday. The services are
about once a month. The majority; 73.5% and 82.7% of mostly provided by intern doctors.
the patients reported never walk barefoot in and outside Study design: A hospital-based descriptive cross-
the house, respectively. The majority of the patients sectional study.
(84.7%) have never put their feet near the fire.10 Aklilu Source population: All diabetic patients attending fol
et al reported 80.2% of the patients inspected their feet low-up at the ambulatory clinic of Jimma Medical Center.
regularly. However, only 31.0% of the patients inspect the Study population and selection: Diabetic patients aged
inside of their footwear. The majority (94.1%) of the greater than 18 years attending a follow-up visit during the
patients do not walk barefoot regularly.11 Diabetic patients data collection period at the ambulatory clinic of Jimma
who had not practiced foot self-care were 2.52 times more Medical Center were enrolled.
likely to develop a diabetic foot ulcer.12 Exclusion criteria: Newly diagnosed DM patients
Diabetic patients and health care providers to diabetic (≤1month duration), gestational diabetes, not volunteered
patients should familiarize themselves with the principles to participate, and patients with the previous amputation
of diabetic foot ulcer prevention.12 A paradigm shift is above the ankle were excluded.
4780 submit your manuscript | www.dovepress.com Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2020:13
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Dovepress Hirpha et al
Sample Size and Sampling Technique reliability of the 14 pretested items. Thus, Cronbach’s
Sample Size alfa value was 0.65.
The sample size was determined using a single popula
tion proportion formula. Here, we used the proportion Data Quality Assurance
(p) from a previously published study done in Felege A pretest was done before the actual data collection on the
Hiwot Referral Hospital, Bahir Dar city, North West same population (10% of the final sample size) which did not
Ethiopia.10 According to this study, about 55.0% of the include in the sample population. Correction and modifica
patients had good foot care practice with a 95% con tion were made on the questionnaire before applied to the
fidence interval (CI) and marginal error (d) of 5%. n= (z study depending on the result of the pretest. The data were
2 2 2 2
α/2) p × (1-p)/d , n= (1.96) × 0.55 × (1–0.55)/(0.05) checked for its completeness, accuracy, and consistency
=380. Since the source population was less than 10,000, every day.
the sample size was adjusted using the correction for
mula to get a minimum sample size required for the Operational Definition
study. And the total DM patients registered in the study In this study, the adequate practice of foot self-care by
hospital are 3000. Thus, the sample size was 337. patients was according to the recommendation by the
Ten percent of the final sample size was added for non- International Working Group on the Diabetic Foot
respondents (nf= 337 × 0.1 + 337 ≈370). Therefore, the (IWGDF) for the prevention of foot ulcers in diabetic
final sample size was 370. patients.2 Diabetic patients should inspect daily the entire
surface of both feet and the inside of the shoes that will be
Sampling Technique worn; wash the feet daily (with careful drying, particularly
A consecutive sampling technique was used in which between the toes); use emollients to lubricate dry skin; cut
consecutive patients were interviewed until the required toenails straight across. Diabetic patients should not walk
sample size was reached. To avoid double-counting of barefoot, in socks without shoes, or in thin-soled slippers,
cases, the ID of the participants who had undergone the whether indoors or outdoors.
interview was documented each day and any patient com
ing to the clinic on a specific day was counter checked
with the document before conducting the interview.
Data Analysis
The collected data were cleared, arranged, coded,
checked for completeness, and then analyzed by SPSS
Data Collection Techniques and version 20. The descriptive analysis was performed to
Instrument summarize socio-demographic and other clinical data.
The Diabetic foot self-care practice questionnaire was The results were presented in means (SD), frequency,
adapted from a validated instrument of Nottingham and percentage and narrated. Chi-square (χ2) was used
Assessment of Functional Foot care (NAFF).21 to compare the patients’ previous information about dia
Fourteen items were selected out of 29. The rest of the betic foot and the history of diabetic foot ulcer between
questions were discharged after the pretest as they are both sexes.
inappropriate to measure the intended behavior in our
context. The questionnaire was prepared in English and Ethical Consideration
translated to the local language, Afan Oromo and Ethical clearance was obtained from the Institutional
Amharic, the translated version was again translated Review Board committee of Jimma University. The
back to the English language to maintain the consistency Ethical Review Board of Jimma University accepted and
in the meaning of words or concepts of the data collec approved verbal informed consent. Verbal informed con
tion tool. The Afan Oromo and Amharic versions were sent was obtained from the study participants to confirm
used for data collection. Data were collected through their willingness for participation after explaining the
a face-to-face interview. The foot self-care practice objective of the study. Privacy and confidentiality of the
among patients was responded to a set of practice ques patients’ medical data were ensured during a patient inter
tions of “always, often, sometimes, and rarely/never”. view by using code rather than their name. On top of this,
Cronbach’s alfa was calculated to check for the internal participants were counseled about the proper foot care
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Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2020:13 4781
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measures that should be taken into account in their daily Clinical Characteristics of Study
life during the data collection period. Participants
Out of the 370 participants, 253 (68.4%) of them were
Result type two diabetes. Around half (48.6%) of the patients had
Socio-Demographic Characteristics an illness duration of less than 5years. The majority of the
Among 370 study participants, 207 (55.9%) were males. respondents (91.1%) had previous information about dia
The mean (±SD) age was (46.47±13.63). Most of the betic foot ulcer. Moreover, 132 (35.7%) of the patients had
a previous history of foot ulcer. There was no significant
patients were Muslim followers 292 (78.9%) and married
difference in the proportion between male and female
291 (78.6%). One hundred forty-five (39.2%) of the parti
patients in having information about diabetic foot ulcer
cipants could not read and write. Regarding the occupa
and the history of foot ulcer (P >0.05) (Table 2).
tional status of the respondents, 115 (31.1%) were farmers.
More than half of the patients lived in the urban area, 197
Diabetic Foot Self-Care Practices
(53.2). Quarter 92 (24.9%) of the respondents had
In this study, the practices of foot self-care were categor
a history of smoking (Table 1).
ized into three domains.
Foot Inspection
The patients were asked how frequently they examine their
feet, 73% of the patients were reported to inspect their foot

Table 1 Socio-Demographic Characteristics of Diabetic Patients more than once per day and 19.5% inspect their foot daily.
on Follow-Up at Ambulatory Clinic, Jimma Medical Center, 2019
However, regarding the inspection of their shoes before
Variables Frequency (%) putting them on, 12.2% of the patients never check for
Age (Mean±SD), years: 46.47±13.63 objects impeded in their shoes (Table 3)
Sex Male 207 (55.9) Foot Hygiene

Female 163 (44.1)
About half (48.4%) and one-third (34.3%) of patients wash
Marital status Married 291 (78.6) their feet daily and more than once daily, respectively.
Unmarried 44 (11.9) And, 42.4% of the patients never dried between their
Divorced 15 (4.1)
foot toes after wash. Regarding the use of moisturizing
Widowed 20 (5.4)
cream, 63.5% of the patients never used a moisturizing
Religion Orthodox 57 (15.4) cream on their feet to lubricate the dry skin. Among
Muslim 292 (78.9)
patients who practiced moisturizing, 26.5% of the patients
Protestant 21 (5.7)
Educational status Cannot read and write 145 (39.2)

Can read and write 53 (14.3) Table 2 Clinical Characteristics of Diabetes Patients on Follow-
Grade 1–8 75 (20.3) Up at Ambulatory Clinic, Jimma Medical Center (JMC), in 2019
Grade 9–12 44 (11.9)
College and above 53 (14.3) Variables Frequency
(%)
Occupational status Farmers 115 (31.1)
House wife 85 (23) Type of DM Type 1 117 (31.6)
Private employee 48 (13) Type 2 253 (68.4)
Government employee 44 (11.9) Duration of DM <5 years 180 (48.6)
Unemployed 30 (8.1%) 5–10 years 137 (37.0)
Student 24 (6.5) >10 year 53 (14.3)
Daily laborer 24 (6.5)
Having previous information about Yes 337 (91.1)
Residence Urban 197 (53.2) DFU No 33 (8.90)
Rural 173 (46.8)
Previous history of foot ulcer Yes 132 (35.7)
Habit of smoking Yes 92 (24.9) No 238 (64.3)
No 278 (75.1)
Abbreviations: DFU, diabetic foot ulcer; DM, diabetic mellitus.
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Table 3 Frequency Distribution of Patients’ Response to Questions Related to Foot Self-Inspection and Foot Hygiene Among Diabetic
Patients on Follow-Up in Ambulatory Clinic, Jimma Medical Center, 2019
Practice Domains Items Response Frequency Percentage
Foot inspection Examine (inspect) your feet More than once a day 270 73.0%
Once-daily 72 19.5%
4–6 times weekly 28 7.6%
Once a week or less 28 7.6%
Check shoes before put them on Often 204 55.1%

Sometimes 88 21.9%
Rarely 33 8.9%
Never 45 12.2%
Foot hygiene Wash feet More than once daily 127 34.3%
Once-daily 179 48.4%
Most days a week 45 12.2%
Few days a week 19 5.1%
Feet dry after washing Often 161 43.5

Sometimes 42 11.4%
Rarely 48 13%
Never 119 32.2%
Dry between feet toes after washing Always 147 39.7%

Often 18 4.9%
Sometimes 48 13%
Never 157 42.4%
Use moisturizing cream on feet Daily 108 29.2%

Once a week 21 5.7%
About once a month 6 1.6%
Never 235 63.5%
Put moisturizing cream between feet toes Daily 98 26.5%

Once a week 26 7%
About once a month 4 1.1%
Never 242 65.4%
Cut feet toe nail Once a week 47 12.7%

Once a month 256 69.2%
Less than once a month 54 14.6%
Never 13 3.5%
put moisturizing cream between their feet toes daily. Two- respectively. And most of the patients never put their
hundred fifty-six (69.2%) of the patients cut their feet toe feet near the fire (75.1%) (Table 4).
nails monthly (Table 3).
Discussion
Foot Self-Care Behaviors Patients with diabetes mellitus are at increased risk for pedal
Ideally, patients were encouraged never to walk bare ulceration due to microvascular, neuropathic, and biomecha
foot, in sandals/slippers, or in shoes without socks. In nical changes to the foot. All patients with diabetes should
this study, 23.0% and 27.6% of the patients walk in receive education on proper diabetic foot care. Prevention of
sandals/slippers and shoes without socks most of the diabetic foot complications includes identifying the at-risk
time, respectively. Only 27.3% of the patients changed foot, daily exam and inspection, patient/family/healthcare
their socks daily. Most of the patients never walk bare provider education, appropriate shoe gear, and proper and
foot around (78.4%) and outside (86.5%) their house, early treatment of pre-ulcerative lesions.3 In this study, we

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Table 4 Frequency Distribution of Patients’ Response to a study by Deribe and Woldemichael were government and
Questions Related to Foot Self-Care Behaviors Among Diabetic non-governmental employees compared to patients in this
Patients on Follow-Up in Ambulatory Clinic, Jimma Medical
study, where most of them were farmers and illiterate.
Center
Moreover, 25% of the diabetic patients on follow-up had
Foot self- Walk in sandals/ Most of the 85 23.0% a history of/current smokers, which might the risk factor for
care slippers time
the higher prevalence of a reported history of foot ulcer.
behaviors Sometimes 118 31.9%
Rarely 65 17.6%
Regarding the frequency of inspection of their foot, 73%
Never 102 27.6% of patients were reported to inspect their foot more than
once per day and 19.5% inspect their foot daily. The prac
Walk in shoes Most of the 102 27.6%
tice foot self-inspection in our study was higher when
without socks time
Sometimes 68 18.4% compared to a study by Seid and Isige, where 19.5% of
Rarely 59 15.9% the patients inspect their foot more than once daily and
Never 141 38.1% 41.2% inspect once daily.10 Desalu et al from Nigeria also
Change socks More than 9 2.4% reported, 40.9% of the patients inspected their foot
once a day regularly.8 However, our finding was comparable to
Everyday 101 27.3% a study by Aklilu et al.11 Having previous information
4–6 times 99 26.8% about diabetic foot self-care might the reason for the dis
a week
crepancy. In this study, 8.9% of the patients never had
Less than 4 161 43.5%

times a week
previous information about diabetic foot ulcer compared
to 84.0% of the patients in the study by Seid and Isige.10
Walk bare foot Often 21 5.7%
In this study, about 12% of the patients never check their
around the house Sometimes 17 4.6%
Rarely 42 11.4%
shoes before putting them on for objects impeded in their
Never 290 78.4% shoes. Again, our finding was much lower when compared
to 38.7%, 45.8% and 69.0% of the patients never inspect
Walk bare foot Often 18 4.9%
Sometimes 5 1.4%
inside their footwear in the study by Seid and Isige10 and
outside the house
Rarely 27 7.3% Dikeukwu22 Aklilu et al.11 This might be his might be
Never 320 86.5% because the majority of the patients (91.1%) in this study
Put feet near the Often 23 6.2%
had previous information about diabetic foot ulcer.
fire Sometimes 29 7.8% Concerning the frequency of foot wash, about half
Rarely 40 10.8% (48.4%) of the patients wash their foot once daily and
Never 278 75.1% 34.3% of the patients wash more than once daily. Seid and
Isige reported comparable findings, 49.5% wash their feet
more than once a day followed by once a day which
assessed patterns of practice of foot self-care by diabetic accounts for 44.1%.10 However, our findings were lower
patients on follow-up using the Nottingham Assessment of when compared to a study from South Africa and Kenya,
Functional Foot care tool.21 where 86.7% and 89.2% of the patients washed their feet
In this study, 35.7% of the diabetic patients on follow-up once daily.22,23 This might be due to the patients included in
had a previous history of diabetic foot ulcer which is higher both South Africa and Kenya studies were relatively elder
when compared to a study from North West Ethiopia, which adults. In our study, 32.2% of the diabetic patients never dry
reported 8.6% of the diabetic patients had a previous history their feet after washing, which was lower compared to the
of foot ulcer.18 This might be because 55.6% of the patients report by Seid and Isige, where 59.1% of the patients
in a study from Northwest Ethiopia had a diabetic duration of reported never dry their feet after wash.10 This might be
less than 5 years compared to 48.6% of the patients in this related to information differences related to foot care prac
study. In our study, 35.7% of the patients had a previous tice. Regarding the practice of drying between toes, 42.4%
history of foot ulcer. This finding was higher compared to of the patients never had the habit of drying between their
a study reported by Deribe and Woldemichael, where, 14.8% feet toes after wash. From Egypt, 33.6% of the patients
of the diabetic patients had a previous history of foot ulcer.15 never dry between their toes after washing their feet.24
This might be due to the most of the diabetic patients in The difference might be related to the socio-economic and
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cultural differences between the two countries. Moreover, the dry skin. They walk barefoot, in sandals/slippers, and
the patients from Egypt were more elders and had a longer in shoes without socks. Therefore, clinicians should coun
disease duration compared to our patients. sel every diabetic patient about the importance of foot self-
Regarding the use of moisturizing cream for foot, 29.2% inspection, foot hygiene, and the risk of walking barefoot,
of the patients used a moisturizing cream on their feet daily. wearing sandals/slippers and shoes without socks at every
And 26.5% of the patients put moisturizing cream between follow-up visit.
their feet toes daily. However, Mbisi et al reported a higher
number of patients (63.3%) use a moisturizing cream on Abbreviations
their feet daily and a few patients (5.4%) use a moisturizing DM, diabetic mellitus; JMC, Jimma Medical Center; SD,
cream between their toes daily.23 This might be due to a few standard deviation; DFU, diabetic foot ulcer.
patients in Mbisi et al’s study has an informal education
(18.2%) compared to this study where 39.2% of the patients Data Sharing Statement
cannot read and write. The investigators will provide data upon reasonable
Most of the patients (69.2%) cut feet toenail once request to the corresponding author.
monthly. Eighty-five (23.0%) of patients wear sandals/
slippers most of the time. Our finding was higher than Ethics Approval and Consent to
a report by Mbisi et al, where 45.5% of the patients cut
their toenail once monthly. Similarly, 1.7% of the patients
Participate
Ethical clearance was obtained from the Ethical Review

were reported to wear slippers most of the time.23 The
Board of Jimma University. The ethics approval was given
difference might be due to the age difference of patients
in accordance with the Declaration of Helsinki. Patients
between the studies, where most of the patients from the
were requested for verbal informed consent and confiden
Kenyan study were elders.
tiality of the patients’ data was maintained.
Regarding the foot self-care behaviors, 38.1% of the
patients never walk in shoes without socks. Wanja et al
reported, relatively a lower number of patients (27.6%) Author Contributions
never wear shoes without socks.7 The difference might be All authors made substantial contributions to conception and
related to the difference in residencies of the patients, where design, acquisition of data, or analysis and interpretation of
more than half (53.2%) of the patients in our study came data; took part in drafting the article or revising it critically for
from Urban compared to the patients from Wanja et al were important intellectual content; agreed to submit to the current
62% of them were rural dwellers. Most of the patients journal; gave final approval of the version to be published; and
responded never walk barefoot by 78.4% and 86.5% of agree to be accountable for all aspects of the work.
the patients around and outside their house, respectively.
This finding was relatively lower when compared to a report Funding
by Aklilu et al, where 94.1% of the patients did not walk No funding was accepted for this manuscript.
barefoot regularly.11 Dikeukwu reported 75.0% of the dia
betic patients reported not walking barefoot both in-home Disclosure
and outside.22 The difference in walking barefoot among The authors report no conflicts of interest for this work.
diabetic patients might be due to the difference in the socio
economic status between the populations. References
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Diabetic Foot Self-Care Practices Among Adult

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feet, 73% of the patients were reported to inspect their foot

Sex Male 207 (55.9) Foot Hygiene

Educational status Cannot read and write 145 (39.2)

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Check shoes before put them on Often 204 55.1%

Feet dry after washing Often 161 43.5

Never 119 32.2%

Dry between feet toes after washing Always 147 39.7%

Use moisturizing cream on feet Daily 108 29.2%

Put moisturizing cream between feet toes Daily 98 26.5%

Cut feet toe nail Once a week 47 12.7%

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Less than 4 161 43.5%

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Ethical clearance was obtained from the Ethical Review

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6. Ammar I, Jude E, Katia Langton FR, et al. International Diabetes 6156.1000579

knowledge of their disease, therapeutic goals, and self-management: 2007;24(4):207–211. doi:10.1002/pdi.1099

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