Journal of Diabetology

: 2020  |  Volume : 11  |  Issue : 3  |  Page : 169--174

Foot self-care knowledge and practice evaluation among patients with diabetes

Liaqat A Khan1, Awaji Q Al-Nami1, Husain Al-Gaseer2, Ibrahim A Al-Neami3,  
1 Department of General and Laparoscopic Surgery, Sabya General Hospital, Jazan, Kingdom of Saudi Arabia
2 Department of General and Laparoscopic Surgery, Sabya General Hospital, Jazan
3 Department of Training and Scholarship Administration, Jazan, Kingdom of Saudi Arabia

Correspondence Address:
Dr. Liaqat A Khan
Department of General and Laparoscopic Surgery, Sabya General Hospital, Jazan.
Kingdom of Saudi Arabia


Background: Diabetes mellitus is a common major health problem and diabetic foot problems are important complications of diabetes. Patient’s awareness about proper foot care is important in preventing foot problems and amputations. Objective: This study aimed to assess the knowledge and practices of foot self-care in people with diabetes attending diabetic clinic of secondary care hospital in Jazan region, southwest of Saudi Arabia. Design: This was a hospital-based descriptive, cross-sectional study. Setting: This study was conducted in diabetic clinic of secondary care hospital. Materials and Methods: In this cross-sectional study, using non-probability convenience sampling, 132 respondents with diabetes fulfilling the inclusion criteria were assessed by a modified pretest two questionnaires that consisted of 11 questions, each were adopted to assess the foot-care knowledge and practices. Knowledge and practices regarding foot-care were classified as good, satisfactory, and poor depending upon the score.Each question was assigned 1 mark. A score ≥70% (8–11) was regarded as good, 50–69% (6–7) as satisfactory, and ≤50% (5 or less) as poor both for knowledge and practice of foot-care. Results: There were 103 (78.0%) male and 29 (22.0%) female patients with the mean age of 51.97 years ± 9.2195 standard deviation (SD). Mean score of knowledge about foot care was 8.37 ± 3.106 SD and median score was 10.0, whereas the mean score of practices about foot care was 8.14 ± 2.518 SD with median score of 8.0. A positive correlation was observed between the knowledge scores and the practice score (P < 0.001). Education has statistically significant impact on the knowledge (P = 0.001) and practices (P = 0.001) regarding foot care. Socioeconomic status had significant impact on knowledge and practices regarding foot care with P value of <0.05. Conclusion: This observational study revealed that many people with diabetes had negative behaviors toward foot -care. This simple quality initiative concludes the notion that people with diabetes should receive ongoing foot-specific education to prevent foot problems and complications.

How to cite this article:
Khan LA, Al-Nami AQ, Al-Gaseer H, Al-Neami IA. Foot self-care knowledge and practice evaluation among patients with diabetes.J Diabetol 2020;11:169-174

How to cite this URL:
Khan LA, Al-Nami AQ, Al-Gaseer H, Al-Neami IA. Foot self-care knowledge and practice evaluation among patients with diabetes. J Diabetol [serial online] 2020 [cited 2021 Feb 25 ];11:169-174
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Full Text


Diabetes mellitus is a chronic metabolic disorder affecting 425 million people worldwide and expected to rise to 629 million by year 2045. Of the total affected personnel in 2017, 39 million alone are in the Middle East and North African (MENA) countries, which could rise to 82 million by the year 2045.[1]

Diabetes mellitus affects almost every system of the body with significant morbidity and mortality. The most common and considered expensive complications to treat is foot complication.[2] Global prevalence of diabetic foot varies between 3% in Oceania to 13% in North America, with a global average of 6.4%. The prevalence of diabetic foot is higher in men and patients with type 2 diabetes as compared to women and patients with type 1 diabetes.[3]

Commonly affected individuals include but not limited to older age, longer duration of diabetes, smoking history, and hypertension. Patients with diabetes should examine their feet regularly, use proper footwear, and treat non-ulcerative pathology. The prioritized strategies for diabetic foot management include periodic evaluation and risk stratification for at risk feet and increase awareness and knowledge among health-care providers on management of diabetic foot.[1]

This study aimed at evaluating the knowledge and practices of foot self-care in individuals with diabetes in a secondary health-care facility.

 Materials and Methods

Study place design and participants

This was a hospital-based descriptive, cross-sectional study conducted in the diabetic clinic of Sabya General Hospital (SGH), a small town situated in the north of southwestern Jazan city of Saudi Arabia. The study participants included known patients with type 1 and type 2 diabetes, aged 25–65 years who had diabetes for at least 6 months and those with current or previous foot ulceration. Cognitive impairment that could affect independent self-care behavior was excluded from the study.

Sampling procedure

Under WHO software for sample size calculation, the sample size was 132, using 9.5% proportion of diabetes mellitus among the general population with 95% confidence interval and 5% margin of error. A non-probability convenience sampling was used.

Data collection procedure

Participants having either type 1 or type 2 diabetes fulfilling the inclusion and exclusion criteria attending diabetic clinic of SGH were enrolled in the study. SGH is a secondary care facility with a 200 bed capacity situated in the district of Sabya, running diabetic clinic twice a week besides daily outpatient departments in each basic speciality. Variables for this study were knowledge and practices of foot self-care among people with diabetes. Prior to initiation of the study, an ethical approval was made from the hospital and regional ethical committees. Participants who given written or verbal consent and fulfilling inclusion and exclusion criteria were enrolled in the study. Questionnaires used in our study included participant’s demographic details, foot self-care knowledge, and practices adapted to the local sociocultural context and prepared from the Nottingham Assessment of Functional Foot-care Questionnaire[4] (NAFF), American College of Foot and Ankle Surgeons,[5] and the Diabetes UK[6] and were translated into local Arabic language. Each questionnaire consisted of a set of 11 close-ended questions, with one score given for each correct answer. The score was graded as good, satisfactory, and poor if score was 8–11, 6–7 and 5 or less, respectively.

Data entry and statistical analysis

Data were entered and analysed using the International Business Machines (IBM) Statistical Package for Social Sciences (SPSS) version 16.0, New York, USA software program using descriptive statistics. Frequencies/percentages were calculated on qualitative variables, whereas mean and standard deviation (SD) were calculated for quantitative variables. Chi-square, Student’s t-test, and Spearman’s rank correlation test were applied when necessary. A p-value of 0.05 or less was considered as a test of significance.

Ethical consideration

Regional ethical committee approval was obtained prior to initiation of the study. Participants were informed of voluntarily participation and withdrawal from the study at any point with reading and signing a consent form. Participant’s privacy was respected and data confidentially ensured.


A total of 132 participants were enrolled in the study. Of the total participants, 103 (78.0%) were men and 29 (22.0%) women with a male-to-female ratio of 3.55. Age ranged from 25 to 65 of the study population with a mean age of whole sample 51.97 years ± 9.2195 SD.

Sociodemographic and other characteristics of the study group are shown in [Table 1].{Table 1}

The table shows that most patients were men with predominant type 2 diabetes and age ≥45 years on first diagnosis, having normal body mass index (BMI), educated, employed with a monthly income ≥3000 Saudi riyals using oral hypoglycemic medications, and having adequately controlled diabetes.

Mean score for knowledge about care was 8.37 ± 3.106 SD with median score of 10.0, whereas the mean score for practices about foot care was 8.14 ± 2.518 SD with median score of 8.0. Mean scores of knowledge and foot-care practices were significantly low in women compared to men with P < 0.05 [Table 2].{Table 2}

Percentage scoring of knowledge and practices about foot self-care among the respondents shows that most of the respondents have good knowledge and practices about foot self-care (scores 9–11), as shown in [Table 3] and [Figure 1].{Table 3} {Figure 1}

Spearman’s rank correlation coefficient revealed statistically significant correlation (P < 0.001) with coefficient accounted for 0.822 [Figure 2].{Figure 2}

Knowledge and practices about foot self-care were stratified against age, education, income, and gender to evaluate the effect modification of each. Age has no significant effect on knowledge and foot self-care however education has a statistically significant impact on knowledge (P = 0.001) and practices (P = 001) regarding foot self-care. Similarly, occupation has a statistically significant effect on the foot self-care knowledge (P = 0.006) and practices (P = 0.008), whereas the relation of gender about foot self-care knowledge (P = 0.038) and practices (P = 0.005) was also significant. Similarly per capita income and occupation has shown significant association with knowledge and practices regarding foot self-care with P < 0.05 in each case as shown in [Table 4][Table 5][Table 6][Table 7][Table 8].{Table 4} {Table 5} {Table 6} {Table 7} {Table 8}


Diabetes mellitus is a metabolic syndrome that negatively affects almost every system of the body that leads to multiple comorbid conditions including diabetic foot if not controlled adequately. Diabetic foot is a disabling complication, not uncommon among people with diabetes that in turn affect the quality of life in the affectee. The results of our study reinforce the importance of patient’s awareness and education programs for preventing and properly treating this condition.

Foot-care knowledge is of paramount importance for the prevention of foot related problems. Knowledge related to diabetic foot was good (scores 8–11) in 63% of respondents with 90% respondents answered yes for the daily use of antidiabetic medication, 86% for washing feet at least once a day. However, most other knowledge results were in the satisfactory or poor level. Regarding foot-care knowledge, only 52% of the respondents knew the importance of drying feet after washing in maintaining foot’s health and only 68% knew the importance of daily checking of foot in spite of the prolonged duration and chronic nature of this disease that was 72% in the study population. Diabetes and hypertension clinic is there in almost each health-care facility in southwestern Saudi Arabia; however, there is lack of well-structured educational programs that will improve the foot self-care knowledge and practices among people with diabetes.

Only knowledge and awareness are not enough in preventing diabetic foot complications until it is translated into daily health practices. Median scores in our study regarding foot self-care were low as 8 and 6 of total 11, in men and women, respectively, although somewhat higher as compared to previously reported scores and in line with other researchers in developed countries.[7]

The results of the questions about the need for special characteristics of the shoes are interesting and are of special importance. Only 66.0% of the respondents knew the importance of shoes for health. Of special importance was the practice related to the shoes as more than 98% of the study sample does not wear the fully covered shoes and more than 90.0% of the respondents regularly walk bare foot indoors and in near surroundings. In the study of Chandalia et al.,[8] 0.6% of the 300 people with diabetes walked barefoot outdoors and 45.0% walked barefoot indoors. Mahdi and Hasan[9] reported that 49.8% of the respondents did not wear the fully covered shoes.

Furthermore, 40.0% of the patients do not inspect inside of their shoes prior wearing. Schmidt et al.[10] in Germany also found deficit regarding self-control of shoes and socks in their study and recommended the need for more frequent education, especially for patients with a foot at risk.

In the studied sample, 55.0% of respondents did not dry after washing their feet and 34.0% did not use skin lotion or olive oil to keep their feet soft and 43.0% of the patients do not examine their feet and do not check their feet daily for the presence of any ulcer; however, this is slightly better than the study of Mahdi and Hasan.[9] Similarly, in the study of Gondal et al.[11] only 34.0% inspect their feet daily.

A total of 97.7% of participants in our study sample washed their feet daily. The behavior was most probably to the religious action of ablution as performed by Muslims without knowing that this activity is part of good foot self-care practices. Hasnain and Sheikh[12] in their study in Pakistan found 88.7% of people with diabetes washed their feet daily; this was due to the same culture and religion that both communities share.

The salient feature of our study is that 18.0% of the respondents had satisfactory knowledge, whereas 31.0% had satisfactory practices regarding foot self-care. This 13.0% increase in practices with less knowledge indicates that people are doing good practices without knowing that they are good for health, such as ablution to perform prayers as religious ritual.

The statistically significant relationship of knowledge and practices with occupation and income of the patient and the significant positive relationship between the educational level and foot-care practices indicates that the lower socioeconomic status is a risk factor for having patients with inadequate foot-care knowledge and practice, thus putting them at a high risk for having diabetic foot complications. Particular attention should be focused on patients with low education and socioeconomic level.[13],[14]

There was no statistically significant relationship of diabetes duration with knowledge and practices score in our study sample, contrary to the study of Bell et al.[15] that found better foot self-care practices in patients with diabetes ≥10 years. This signifies the need for more efforts to improve foot self-care knowledge and practices in our patients especially those with longer duration of the disease.

The most important aspect of our study is the positive correlation between the foot-care knowledge score and practice score and this reinforces the need for good education to enhance the foot-care knowledge and thus improving foot-care practices in our patients. Although Cochrane Reviews about patient education for preventing diabetic foot ulceration concluded that foot-care knowledge and patients self-reported behavior positively influenced by patient education in short term and that there is weak evidence suggesting that patient education alone may reduce foot ulceration and amputation incidence.[16] However, this should not undermine the importance of foot-care education as the reviewer mentioned that it could be the weakness in the methodology of the reviewed intervention, which affected the results.

In summary, the results of our study have shown a gap in the knowledge and practices of the patients with diabetes regarding their foot care in a diabetic clinic of a secondary care hospital. Foot-related complications of diabetes have a high socioeconomic impact and adversely affect the quality of life of the affectee; thus, improvement in foot-care knowledge by proper education is the most crucial tool for preventing lower leg complications. Also there is a need to motivate health personnel in educating people with diabetes about foot self-care and also practicing by themselves proper foot examination when and where required.

Limitations of the study

As our study was conducted in one diabetic clinic of a secondary care facility, it has limited generalizability.


Foot self-care knowledge and practices among people with diabetes in our study population are poor in patients with low income, educational level, and jobless. There is need for patient friendly and well-structured foot-care educational programs coupled with regular treating physician reinforcement to reduce the risk of diabetic foot complications. The educational program should focus more on vulnerable group stated above.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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