Knowledge, Attitude, and Practices Related to Foot Care Among Diabetic Patients in Tabuk City, Saudi Arabia

Introduction Diabetic foot ulcer (DFU) is a prevalent complication of diabetes mellitus (DM), affecting approximately 15% of all diabetic patients. This condition poses significant challenges due to its association with major morbidity, mortality, high costs, and diminished quality of life. The incidence of diabetic foot complications among diagnosed diabetes cases is alarming, making it a primary concern in diabetes management. Diabetes mellitus, a chronic metabolic disorder, impacts nearly every system in the body. Methods In this study, a cross-sectional design was employed to assess the level of knowledge, attitude, and practices related to foot care among 432 diabetic patients in Tabuk City, Saudi Arabia. Results The participants' ages ranged from 18 to above 60 years, with (n = 206, 47.69%) being male and (n = 226, 52.31%) female. Type 2 diabetes was prevalent, constituting (n = 277, 64.12%) of cases, whereas (n = 187, 38.29%) had type 1 diabetes. Approximately (n= 224, 51.9%) of patients had been diagnosed with diabetes for less than 10 years. A significant portion (n= 302, 69.91%) of patients did not report any foot complaints. However, (n= 88, 20.37%) had a history of healed ulcers, and (n= 21, 4.9%) had undergone amputation due to diabetes. The majority of patients (n = 228, 52.78%) were under oral agent treatment. Conclusion The study population demonstrated adequate knowledge about diabetes management and exhibited positive attitudes toward diabetes and its related complications, particularly concerning foot care. While most patients displayed appropriate practices related to diabetic foot care, some participants showed inadequate adherence to essential procedures. Addressing these gaps in knowledge and practices is crucial for enhancing the overall management of diabetic foot complications among patients.


Introduction
Diabetes mellitus (DM) is a chronically debilitating medical condition that is spreading around the globe.According to the International Diabetes Federation Atlas, the prevalence of diabetes worldwide was predicted to be 9.3% (463 million people) in 2019, 10.2% (578.4 million) by 2030, and 10.9% (700.2 million) by 2045 [1,2].Furthermore, according to the International Diabetes Federation Atlas, 18.3% of adult Saudis were estimated to have diabetes.It is associated with a higher incidence of disease, mortality, and growing healthcare costs.Diabetes dramatically raises the risk of several chronic conditions, such as heart disease, retinopathy, hypertension, and foot difficulties [3].
A crippling consequence of diabetes mellitus, diabetic foot disease eventually affects up to 50% of individuals with type 1 and type 2 diabetes.The affected patient's years of life and quality of life are still being significantly reduced as a result of this condition.Moreover, it accounts for at least 12-15% of the total expenses related to diabetes, and as much as 40% in underdeveloped nations.Furthermore, the diabetic foot disease treatments that are currently offered are typically not as successful as they should be [4,5].This is mainly explained by the lack of understanding of its underlying mechanisms and available treatment options due to the low level of interest and funding for this complication's global research [6].
Diabetic foot significantly increases health care expenses, and improper foot care among diabetics is a primary cause of indisposition and early death.Overall, 3.3% of diabetic patients experienced foot problems; these included 2.05% foot ulcers, 0.19% gangrene, and 1.06% amputations [7].On the other hand, some argue that teaching patients about the complications associated with diabetes and the importance of taking good care of their feet will lower the risk of complications, enhance the quality of life, and ultimately increase the financial burden on both the individual and society at large [8].
The Saudi Ministry of Health is facing a major dilemma because, according to its 2018 statistical yearbook, there were 1280 cases of amputation as a result of diabetes mellitus in males and 765 cases in females [3].
The foot issues are considered the most preventable of all diabetes-related consequences [9].Proactive foot care and prevention are encouraged to lower the risk of amputation, costly resource utilization, and patient morbidity.Identifying risk factors, providing specialized podiatric care, and patient education are some of these strategies.It has been demonstrated that this strategy is both economical and efficient [10].
The incidence of diabetic foot ulcers and amputations can be effectively decreased by raising patient awareness, encouraging regular foot care routines, and helping diabetes patients maintain appropriate glycemic control [11].Many scientific associations and organizations now offer guidelines for appropriate foot care education [12].Thus, to improve awareness and encourage appropriate practices, the American Diabetic Association advised that all diabetic patients receive education regarding self-foot care [13].
The current study aimed to assess patients' knowledge and practices concerning diabetic foot care in Tabuk City, Saudi Arabia.As no similar study has been conducted in this area before, our research was designed to evaluate the level of knowledge and adherence to foot care practices among individuals diagnosed with diabetes mellitus.Implementing patient education strategies can significantly contribute to minimizing diabetic foot ulcers and amputations within the healthcare system.

Study design and area
In this cross-sectional study, our objective was to assess the knowledge, attitudes, and practices concerning foot care among diabetic patients in Tabuk City, Saudi Arabia.Data collection took place between July 10 and October 10, 2023, in diabetic clinics located within both civil and military hospitals.The selection of these clinics was done using a random sampling technique to ensure a representative sample for the study.Tabuk City is situated in the northwestern region of Saudi Arabia and is home to an estimated population of around 534,893 individuals, as per the latest data provided by the General Authority for Statistics in Saudi Arabia.

Study population and eligibility criteria
The study focused on diabetic patients aged 18 years and older, receiving care at diabetic centers in both civil and military hospitals in Tabuk City.Patients who were unable to provide the necessary information were excluded from the study.

Sample size
The sample size for this study was calculated using the following formula: Where: n = sample size; Z = z-score corresponding to the level of confidence desired (e.g., 1.96 for 95% confidence); P = expected prevalence of adequate knowledge and positive attitudes towards GDM management (assumed to be 50%); Q = 1 minus P; d = margin of error (assumed to be 5%).Assuming a 10% non-response rate, the final sample size was 432 diabetic patient

Sampling technique
Participants were chosen randomly utilizing a systematic random sampling method.In particular, every second individual receiving care at the diabetic centers during the study period was included.This method was employed to ensure the sample's representativeness, ensuring it closely mirrored the population, and to ensure a substantial number of participants for the study.

Data collection tools
A structured questionnaire with closed-ended questions was utilized for this study, adapted from a similar research conducted in Alkharj [14].The questionnaire comprised four sections: demographic details, patients' understanding of diabetes, its complications, and management, patients' attitudes, and their practices (see Appendices).To maintain consistency in data collection, data collectors were trained in the Arabization of the questions through a dedicated workshop, thus minimizing potential variations in data collection methods.

Data analysis plan
For our analysis, we employed the Statistical Package for Social Sciences (SPSS) version 28 (IBM Corp., Armonk, NY).Descriptive statistics were used to compile and summarize the data.To explore the relationship between knowledge, attitudes, and practices concerning foot care among diabetic patients and demographic characteristics, we utilized the Chi-square test and logistic regression analysis.Statistical significance was determined by a p-value less than 0.05; any result below this threshold was regarded as statistically significant.

Ethical consideration
Ethical clearance for this study was obtained from the Institutional Review Board (IRB) of King Salman Armed Forces Hospital, as evidenced by approval number KSAFH-REC-2023-516.Before participating in the trial, all individuals gave oral informed consent.Stringent measures were implemented to guarantee the confidentiality and privacy of the participants.

Results
Table       ).Moreover, the majority of the participants exhibited a positive attitude (higher than 75%) toward the advice provided by specialist consultants concerning foot care in diabetes within the studied group.In analyzing the association between participants' knowledge, attitudes, and practices as presented in Table 6, certain observations were made.Notably, no significant correlations were found for statements such as awareness about decreased sensation in diabetic feet, smoking's impact on foot circulation, and the need to inspect shoes for objects or tears.Similarly, foot gangrene awareness, assuming responsibility for regular podiatric visits, wearing specifically recommended shoes, opting for soft, closed, and comfortable footwear, going barefoot outdoors, and using warm water for foot washing showed no significant relationships.Additionally, regular toenail cutting and doctor visits, along with replacing shoes despite no damage, displayed no significant correlation.However, highly significant correlations were observed for recognizing decreased foot blood flow due to diabetes (P < 0.001), emphasizing the importance of foot care for flat feet (p = 0.07), leading a normal life with proper diabetes management (p = 0.001), daily foot checks, inspecting shoes daily (p < 0.001), frequent sock replacement (p = 0.08), inspecting feet for scuffs, and moisturizing feet daily (p < 0.001).These results highlight critical areas where diabetic patients' awareness and practices intersect, shedding light on essential aspects of foot care.

Discussion
Diabetic foot disease stands out as a prevalent and potentially fatal complication of diabetes mellitus (DM).Its persistence often leads to significant morbidity and premature mortality.The American Diabetes Association underscores the importance of an annual comprehensive foot examination for individuals with diabetes.Diligent foot care can effectively prevent the majority of foot-related complications.Although cultivating meticulous foot care practices demands dedication and time, self-care remains pivotal in averting potential problems.
This study enrolled 432 diabetic patients, with 64.2% (n = 277) diagnosed with type 2 diabetes, and the remaining 35.88% (n = 155) diagnosed with type 1 diabetes.The age range of the participants spanned from 18 to above 60 years.Among them, 52.31% (n = 226) were female, and 47.69% (n = 206) were male.The majority of the participants were of Saudi nationality, accounting for 94.21% (n = 407), while 5.79% (n = 25) were non-Saudi patients.
This study demonstrated that diabetic patients possessed a high level of knowledge concerning diabetes, its complications, and appropriate foot care practices, with over 70% of participants providing accurate responses to all questions.These findings contrast with studies conducted by Taksande et al., where patients displayed poor knowledge about diabetes and its complications [15], and another study in Iran in 2020, where only 15.2% of patients exhibited adequate knowledge about diabetes [16].However, our results align with a study conducted in Riyadh, Saudi Arabia, by Alshammari et al., which reported a good knowledge rate of 76.6% among the participants [17].
Our study found that the primary source of information for the participants was physicians and healthcare providers (n = 144, 33.3%).This percentage was notably higher than the 22% reported by Alshammari et al. [17] and significantly surpassed the 16.6% reported in other studies [18].
Participants exhibited more positive attitudes toward managing their diabetes than anticipated.Responses indicating regular exercise and dietary modifications to prevent further complications from diabetes were satisfactory (n = 301, 69.68%), as were those related to regular foot care and the examination of feet and footwear (n = 282, 65.28%).Moreover, participants displayed positive attitudes, with more than 75% endorsing the advice of specialist consultants regarding foot care in diabetes.These results align with a similar study conducted in the Aseer Region of Saudi Arabia [19].
Our study revealed inadequate practices among the participants, notably in the daily examination of their feet, with 227 participants (52.55%) failing to inspect their feet daily.Additionally, participants exhibited insufficient adherence to regular physician foot check-ups, as 260 patients (60.19%) did not visit physicians for regular foot examinations.Similar findings were reported by Vighnesh et al. [20] and supported by Al Amri et al. [19] in their respective studies.
Regarding the association between the knowledge, attitude, and practices of the participants and their responses, we observed varied associations, with approximately 47% exhibiting an association and nearly 53% lacking association.Female participants demonstrated higher knowledge levels than males on several aspects: understanding that diabetics can experience reduced blood flow (the female percentage was 94.75%, compared to 84% in males, p=<0.001),recognizing that diabetics may have reduced sensations (female association was 90.7%, compared to 85% in males, p=0.046), understanding the importance of inspecting the feet (92.5% in females compared to 85.9% in males, p=0.02), recognizing the significance of foot care due to the increased likelihood of flat feet (female association was 80.5% compared to 69.9% in males, p=0.007), acknowledging that regular medication intake reduces diabetes complications (90.7% in females compared to 85% in males, p=0.046), and understanding that exercise aids in preventing diabetic foot problems (82.3% in females compared to 74.8% in males, p=0.036).No significant gender differences were noted in other knowledge variables, consistent with findings from previous studies [20][21][22].
Our findings align with prior research, particularly concerning attitudes where women demonstrated higher associations than men.In terms of engaging in regular exercise to prevent further diabetes complications, women exhibited associations of 74.3%, compared to 64.6% in men (p = 0.018).Similarly, concerning wearing footwear indoors as recommended by foot care specialists, women's associations were 81%, while men's associations were 73.3% (p = 0.037).Additionally, regarding the ability to lead a normal life with appropriate diabetes measures, women's responses were 89.4%, surpassing men's responses at 77.7% (p = 0.001) [16,23].These results emphasize the gender disparities in attitudes toward diabetic foot care, highlighting the need for targeted educational interventions tailored to both genders.
In terms of practices, similar patterns were observed, with female associations significantly higher than males.Regarding daily foot examination, 56.6% of females responded affirmatively compared to 37.4% of males (p=0.001).When it came to checking shoes before wearing them, 69.5% of females practiced this habit, while only 51% of males did so (p=0.001).Changing socks daily was more prevalent among females, with 74.8% following this practice compared to 63.6% of males (p=0.008).Inspecting feet for marks resulting from shoes or socks was more common among females, with a response rate of 78.8%, while only 61.2% of males reported this practice (p=0.001).Additionally, the application of daily moisturizer on feet exhibited a significant gender difference, with 65% of females adhering to this practice, contrasting with 38.3% of males (p=0.001).These findings corroborate with studies by Navarro-Peternella et al. [24] and Ciarambino et al. [25], highlighting consistent gender disparities in diabetic foot care practices and emphasizing the need for targeted interventions to bridge these gaps.The study's questionnaire design had limitations as it only allowed for yes or no responses to questions about knowledge, attitude, and practices, which can be considered a drawback.While closed-ended questions simplify participant responses, they might have led to affirmative answers when participants were unsure, potentially inflating the perceived knowledge and attitude levels.To mitigate this bias, incorporating a "how often they should do it" would give more precise insight into their attitude and practices.Additionally, the study lacked information about participants' family history of diabetes, a factor important in understanding the genetic predisposition to type 2 diabetes.Genetic factors, including various gene mutations, have been associated with diabetes development.Addressing these limitations in future research can enhance the comprehensiveness of the study and provide a more nuanced understanding of the factors influencing participants' knowledge, attitudes, and practices related to diabetes management.

Conclusions
The study's findings highlight the need for targeted foot care interventions for patients with diabetes mellitus.In summary, our research revealed that nearly two-thirds of the diabetic patients studied possessed a strong understanding of diabetic foot issues.Furthermore, patients exhibited positive attitudes regarding the management of diabetic feet and the implications of diabetes on foot health.However, both the practice of daily foot checks and participants' willingness to consult a doctor for regular check-ups were insufficiently addressed.Despite these gaps, the Tabuk community demonstrates a commendable level of awareness, attitude, and practice concerning diabetes.

Section 2 :
Knowledge Diabetics are likely to develop foot ulcers Yes No Diabetics are likely to develop reduced blood flow in their feet Yes No Diabetics are likely to develop reduced sensation in their feet Yes No It is important to look at the soles because diabetics have reduced sensations Yes No It is important to inspect the feet, as wounds and infections may not heal quickly Yes No Poor circulation in feet may result from smoking Yes No It is important to look after the feet because they are more prone to be flat foot Yes No Taking medication regularly will reduce DM complication Yes No It is important to examine the inside of footwear for any object or tear Yes No Foot gangrene is one of the diabetic foot complications Yes No Do you think doing exercise will help you prevent diabetic foot?Can you perform regular exercise and change your food habits to prevent further diabetic complications?Yes No Can you take the responsibility of daily examination of your feet and foot-wear, as well as regular foot-care specialist consultation?Yes No Can you use special foot-wear advised by the foot-care specialist?Yes No Will you wear footwear indoors as advised by your foot-care specialist?Yes No Can you be able to live a normal life with appropriate measures for diabetes?Yes No Section 4: Practices Do you examine your feet daily?Yes No Yes 2023 Shaqran et al.Cureus 15(11): e48473.DOI 10.7759/cureus.48473

TABLE 1 : Sociodemographic characteristics of the study participants (n= 432)
N: Number of participants; %: Percent of participants

TABLE 2 : Clinical Information of the studied participants
N: Number of participants; %: Percent of participants

Table 3
demonstrates the participants' excellent knowledge of diabetes and its complications, as well as proper foot care practices for diabetic patients.In all the questions, the participants provided adequate answers exceeding 70%, indicating a high level of knowledge among the residents of Tabuk City.

TABLE 3 : Knowledge responses of the participants
N: Number of participants; %: Percent of participants

Table 4
presents the participants' attitudes toward managing diabetes.Responses regarding regular exercise and dietary changes to prevent further diabetic complications were favorable (n = 301, 69.68%).Additionally, participants displayed positive attitudes toward examining their feet and footwear, as well as practicing regular foot care (n = 282, 65.28%

Table 5
outlines the participants' practices related to diabetes management.It was observed that a significant number of participants, (n= 227, 52.55%), did not examine their feet daily, indicating an inadequate response in this aspect.Similarly, a considerable portion of the participants (n = 260, 60.19%) did not regularly visit a physician for foot check-ups, indicating a lack of regular medical monitoring.However, participants demonstrated positive practices in response to other questions, with more than 60% showing a favorable approach.

TABLE 5 : Practices responses of the participants
N: Number of participants; %: Percent of participants