research on diabetic foot care

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• J Family Med Prim Care
• v.11(7); 2022 Jul

Foot care knowledge, attitude and practices of diabetic patients: A survey in Diabetes health care facility

Maha obaid alharbi.

Family Medicine Academy, Qassim Health Cluster, Saudi Arabia

Amel Abdalrahim Sulaiman

Background:.

Among diabetes complications, diabetic foot disease (DFD) is the most common and the most preventable complication. This study aimed to assess the level of knowledge, attitude and practice of foot care among type two diabetes mellitus (DM) patients attending the Diabetic and Endocrine Center at King Fahad Specialist Hospital in Buraydah-Qassim region, Saudi Arabia.

A descriptive cross-sectional facility-based study was conducted randomly among type two diabetic patients; respondents were 260 patients. Participants were interviewed using a pretested semi-structured questionnaire.

Of the total studied patients, 54.2% were males with median age of 58 years. Majority 56.5% of patients had good knowledge and 56.9% had good practices regarding diabetic foot care. The mean knowledge score was 4.0 (±1.86) out of 6. About 39.2% of participants received advice regarding foot care from their physicians. Only 41.5% of the patients examined their feet daily, 41.9% carefully dried between the toes after washing, and 40.8% were walking barefooted at home. About 68.5% of the participants had a history of diabetic foot complications. A significant statistical association was found between the good knowledge and patients’ age, educational level, family monthly income, duration of diabetic illness and having prior knowledge regarding foot care ( P -value <0.05). While, good practice of the participants towards the diabetic foot care was found to be statistically associated with the family monthly income and the prior knowledge regarding diabetic foot care ( P -value <0.05).

Conclusion:

Our study revealed that more than half of the participants had good knowledge and practices of diabetic foot care. However, the role of physicians and medical staff in annual foot examination and health education is crucial. An awareness program implementation for diabetic foot care is highly needed.

Introduction

Worldwide, diabetes mellitus (DM) is a major health problem that is increasing in its prevalence.[ 1 ] According to the International Diabetes Federation Atlas in 2019, global prevalence of diabetes was estimated to be (9.3%) (463 million people) rising to (10.2%) (578.4 million) by 2030 and (10.9%) (700.2 million) by 2045[ 2 ] Furthermore, in Saudi Arabia, according to the International Diabetes Federation Atlas, it was recently reported that about 18.3% of the adult Saudi population suffered from DM.[ 3 ] It has been found to be associated with a high rate of mortality, morbidity and increasing health care cost.[ 4 ] Several long-term complications are enhanced many folds by DM such as hypertension, heart disease, retinopathy and foot complications.[ 5 , 6 ]

Among diabetes complications, diabetic foot disease (DFD) is the most common.[ 7 ] DFD is the foot condition of diabetic patients with ulcers accompanied by peripheral vascular disease and/or lower limb diabetic neuropathy.[ 8 ] Multiple factors can precipitate DFD like abnormal joint mobility or foot pressure, trauma, foot deformity, peripheral vascular disease or peripheral neuropathy being the most common.[ 9 ] Neuropathy often leads to clinically significant morbidities, such as pain, sensation loss, diabetic foot ulcer (DFU), gangrene and amputations. The only available measure with proven effectiveness in preventing or at least halting the progression of diabetic neuropathy is optimal metabolic control.[ 10 ] However, it should be instituted at an early stage to be effective since, as is the case with other late diabetes complications, the late phases of diabetic neuropathy are poorly reversible or even irreversible.[ 11 , 12 , 13 ] Up to 50% of those who complaining of diabetic peripheral neuropathy are asymptomatic and if not recognized, and unless preventive foot care is applied, patients are at risk of injury.[ 14 ]

More than 10 percent of people with type 2 diabetes mellitus have one or two risk factors for foot ulceration at the time of diagnosis and a lifetime risk of 15%.[ 15 ] Since the DM type 2 can be diagnosed several years after onset, complications have already occurred.[ 16 ] Worldwide prevalence of DFU is 6.3% which is much more among DM type 2 (6.4%).[ 17 ] Various studies done in our kingdom have explored prevalence of DFU and showed varying results which ranged from 26.0% to 61.8%.[ 1 , 18 ] DFU prevalence in Qassim region is 10.8% and the prevalence of a toe, foot or leg amputation is 2.5%.[ 19 ]

DFD is the most common cause of hospital admission among diabetic patients, accounting for up to 25% of all diabetic hospital admissions.[ 20 ] DFD affects nearly 50% of patients and accounts for almost 80% of all lower-limb non-traumatic amputations.[ 21 , 22 ] According to the Saudi Ministry of Health’s 2018 statistical year book, the number of cases of amputation as a complication of DM was 1280, 765 in men and women, respectively, making the ministry of health facing a significant challenge.[ 23 ] Of all the complications related to diabetes, those occurring in the foot are considered the most preventable.[ 24 ] Prevention and prophylactic foot care are promoted to reduce patient morbidity, expensive resource use and amputation possibilities. These interventions include risk factors identification, intensive podiatric care and patient education. Such approach, has been shown to be both cost-effective and cost saving.[ 25 ] The effective way to reduce the incidence of diabetic foot ulcers and amputations are through proper awareness and by practicing a daily routine of foot care, and maintaining a good glycemic control among diabetic patients.[ 26 ] Nowadays, many scientific societies and organizations provide guidelines on proper education and practice in foot care.[ 27 ] Therefore, the American Diabetic Association recommended that all diabetic patients should be educated about self-foot care to increase their knowledge and prompt good practices.[ 14 ] In the present study, we assessed the knowledge, attitude and practice (KAP) of diabetic foot care among Saudi diabetic patients.

Subjects and Methods

A cross-sectional study was conducted among 260 type two Saudi diabetic patients. The participants were selected by systematic random sampling. The study was conducted at the Diabetic & Endocrine Center at King Fahad Specialist Hospital in Buraidah City, Qassim Region. Ethical approval for study conduction and publication was obtained from the Regional Research Ethics Committee, registered at National Committee of Bio & Med ethics (NCBE). The researcher mentioned the study purpose to the participants and written consent was obtained from each participant before starting the data collection. The data was collected by using pretested semi-structured questionnaire. The questionnaire was adapted from a validated and reliable instrument.[ 28 ] This study was carried during a period of 1 year from October 1, 2019 to September 2020. The data was cleaned, entered and analyzed by using computerized program SPSS version 21.0. Frequency, percentage represented categorical variables while range, mean and ± standard deviation represented continuous variables. Chi-square test was used to assess association between variables. The results with P value < 0.05 were considered statistically significant.

A total of 260 patients were interviewed of them 141 (54.2%) were males. The mean age was 60 years (±11.7), (Median: 58 years) and (Range: 30-87 years). Less than one-third of the patients were illiterate, 66 (25.4%). Most of the patients, 204 (78.5%), were married. Half of them, 132 (50.8%), had a total monthly family income which ranged from 5,001 to 10,000 Saudi Riyal. Moreover, 120 (46.2%) had a history of diabetic illness for more than 10 years, while 9 (3.5%) patients had a duration of diabetes for less than 1 year. Regarding the smoking status, a few, 34 (13.1%), from the total number of the patients, were smokers. All of them were males. Furthermore, we found that 68.5% of the patients had history of diabetic foot complications. [ Table 1 ].

Socio-demographic characteristics of the study participants ( n =260)

Considering knowledge of the participants, we had found that 147 (56.5%) had good knowledge about diabetic foot disease where the mean knowledge score was 4.0 (±1.86) out of 6. Most of participants had good knowledge that uncontrolled DM can lead to diabetic foot complications and diabetic patients may probably develop lack of sensation in their feet. However, less than half of the participants knew that smoking causes poor foot circulation.

Considering the attitude, most of the patients replied that diabetic patients are required to practice special foot care (81.5%), 76.5% said that diabetic patients should be responsible for self-foot examination and (70.4%) replied that diabetic patients should have an annual feet examination by specialists (podiatrists), however, only 42.8% replied that self-foot examination should be on a daily basis. Moreover, majority, 182 (70%), of the participants preferred to receive education about diabetic foot care from the medical staff.

In general, practical level of patients was good at 56.9% where mean practice score for the participants was 7.17 (± 2.69). The most common practices reported by patients were washing their feet daily (100%), applying moisturizer on the feet (67.3%), drying their feet properly after washing (65%), inspecting their shoes from inside before wearing (61.2%) and wearing fitting (closed) shoes (60.8%) [ Table 2 ].

Diabetic patients’ knowledge, attitude and practices assessment towards diabetic foot care ( n =260)

Moreover, considering the practice of patients toward diabetic foot care, we found that most of participants 202 (77.7%) did not get their feet examined annually by a specialist (podiatrist).

The majority of the study population, 148 (56.9%), were receiving knowledge about diabetic foot care. Participants reported that health care workers were the most common source of knowledge about diabetic foot care (54.0%) (doctors and nurses). Other sources included friends or relatives (18%), social media (15.6%) and mass media or the Internet (12.4%) [ Table 3 ].

The source of knowledge about diabetic foot care (n=148)

*Multiple answered question

The good knowledge scores were found to be strongly statistically associated with the participants’ age ( P = 0.009), educational level ( P = 0.044), family monthly income ( P = 0.005), duration of diabetic illness ( P = 0.006) and having prior knowledge regarding foot care ( P < 0.001). The good practice of the participants towards the diabetic foot care was found to be statistically associated with the family monthly income ( P = 0.017) and the prior knowledge regarding diabetic foot care ( P < 0.001) [ Table 4 ].

Statistical association between the level of knowledge and practice of diabetic patients and different variables, ( n =260)

*significant at 5% level

A strong statistical association was detected between patients’ good knowledge of diabetic foot self-care and good practice ( P -value = 0.001) [ Table 5 ].

Association between the level of knowledge and the level of practices of the participants about foot self-care, ( n =260)

This study showed that 56.5% of the diabetic patients had a good knowledge of diabetic foot care. Which is higher than a study done in Iran 15.2%,[ 29 ] Jorden (41.5%),[ 30 ] and many studies conducted in Saudi Arabia (55.1%),[ 31 ] (38%).[ 32 ] Some studies had a higher good knowledge rate in comparison to our study finding such as study done in Saudi Arabia (76.6%),[ 28 ] Malaysia (58%)[ 33 ] and India.[ 34 ] These variations can be attributed to different study populations, settings, designs, differences in the tools used to measure the KAP and methods of data collection. Moreover, differences in the performance of health systems in different countries could also explain the differences.

The study revealed that 56.9% of the participants received knowledge in the past about diabetic foot care. This finding was comparable with the previous studies done in Dubai (61.7%)[ 7 ] and in Tanzania (48%).[ 35 ] In contrast, in some of the previous studies, the diabetic patients had low or never received information about the diabetic foot care, such as a study done in Pakistan (57%)[ 26 ] of the participants. They had never received any information regarding foot care, and in a study done in Riyadh only 36.7%[ 36 ] of the participants received education about foot care.

Health education for diabetic patients regarding diabetic foot care should be mandatory as part of diabetic patient care at primary health care centers and diabetic clinics at hospitals.

Our study revealed that the source of information was mainly from doctors (39.2%). This finding is much better than what the previous studies reported (16.6%),[ 35 ] (22%),[ 28 ] and (37.8%).[ 37 ] The important role of the doctors is not only to give education but also to translate this knowledge into proper practice. Diabetic foot care knowledge level was significantly associated with participants who received pervious knowledge and education regarding diabetic foot care ( P -value < 0.05). This finding is in accordance with a study done in Dubai[ 7 ] and new study done in Asser, Saudi Arabia.[ 38 ] Raising awareness of diabetic patients about foot care and diabetic foot complications usually gives better outcome. Moreover, this study shows that better knowledge among participants with high level of education ( P - value = 0.044) was in agreement with the previous studies.[ 1 , 33 , 39 , 40 ]

It is found that the patients with middle and elderly age group had better knowledge about diabetic foot care in comparison to young adults patients ( P -value = 0.009). This could be due to the long experience and knowledge that the patients learned during the long course of the disease. The significant association between the good knowledge and long duration of DM also had been approved in this study in concordance with the newly study done in Iran[ 29 ] and in a contrast study done in India.[ 40 ] In fact, patients with long duration of DM regularly visited their physicians and spent more time to build good knowledge preventing them from future diabetic foot complications. It is mandatory for the medical staff to understand the significance of health education and counseling and implement awareness for diabetic patients.[ 41 ] Also, in our study, we found strong relationship between the good knowledge and the patients’ socioeconomic status ( P -value = 0.005). This was similar to the finding in a previous research.[ 30 ]

This study also highlights that patients who had good knowledge had a better practice toward diabetic foot care ( P -value < 0.001). This is similar with previous studies.[ 1 , 26 , 29 , 35 , 42 , 43 ] However, it was inconsistent to a study done in Dubai, where the participants who had previously received knowledge had poor practice.[ 7 ] Moreover, there was better practice among patients who had a good family income. This matches with the results from previous studies[ 4 , 42 ] and inconsistent to the study done in Jorden.[ 30 ]

Less than half (41.5%) of the participants examined their feet daily, about 42% of them dried their feet between the toes after washing. This finding was lower than the previous studies[ 7 , 28 , 39 ] but better than a study recently conducted in Riyadh, Saudi Arabia.[ 44 ] Majority of the patients (61.2%) inspected their shoes before wearing; this rate was higher than many studies.[ 44 , 45 , 46 ] Moreover, almost all of the patients (100%) washed their feet; this is a logic finding as the Islamic religion commands washing of the feet five times per day before prayers. Less than half of the patients (40.8%) walked barefoot inside their homes which could be risky for them in case they got foot injury.

Another important finding in our study is the percentage for annual foot examination by specialist (podiatrist) as recommended by American Diabetic Association.[ 14 ] This examination was done for only 22.3% of our participants, which was lower than (34.2%) reported in a study conducted in Riyadh, Saudi Arabia.[ 36 ] In a study done in Dar es Salaam, Tanzania (27.5%), where the participants reported that the doctors had examined their feet at least once since their initial diagnosis.[ 35 ]

Our study had some limitations. Questionnaires consists of many questions responded by either yes or no and it will influence the validity of the data.[ 47 ]

Good knowledge and practices in more than half of the participants may be due to reporting bias, which is a social desirability bias where respondents prefer to give answers which are assumed good.

Our study was conducted only in one diabetic center; hence the findings cannot be generalizable to the population in Qassim region or in Saudi Arabia.

To decrease diabetic foot complications, it is recommended to strengthen the current health education programs to raise the patients’ awareness about diabetic foot care by using different activities based on international guidelines. The health care providers should be properly trained about patients’ foot care education as it is approved by our study that the medical staff is the main source of information. In addition, most of the participants preferred to take knowledge from them. Ensure the importance of the annual foot examination for every diabetic patient by a podiatrist for early detection of ulcers and/or injuries to prevent serious complications. Make group counseling and voluntary peer support groups at health facilities to encourage sharing of experience and information about foot self-care. To conclude, our study showed that more than half of the participants had good level of knowledge and practices about diabetic foot care. Middle and elderly age groups participants, highly educated, high family income, who had long duration DM of more than 10 years and who received previous knowledge regarding diabetic foot care tend to be more knowledgeable about diabetic foot care. Strong statistical association was detected between good knowledge and better practices of the diabetic patients towards foot care. The strengthening of health education awareness for diabetic patients will improve the patients’ practices and prevent further foot complications. Further investigations depending on large-scale sample in different regions of the kingdom should be conducted.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

• - Google Chrome

Intended for healthcare professionals

• Access provided by Google Indexer
• My email alerts
• BMA member login
• Username * Password * Forgot your log in details? Need to activate BMA Member Log In Log in via OpenAthens Log in via your institution

Search form

• Advanced search
• Search responses
• Search blogs
• News & Views
• Rapid access to...

Rapid access to multidisciplinary diabetes foot care teams

• Related content
• Peer review

This article has a correction. Please see:

• Correction for vol. 368, p. - March 10, 2020
• Jonathan Valabhji , national clinical director for diabetes and obesity
• NHS England and NHS Improvement, London, UK
• jonathan.valabhji{at}nhs.net

Urgent referral is critical for people with new foot ulcers

Limb loss is the most feared complication of diabetes, and infected foot ulceration its most common antecedent. Management guidelines for foot ulcers in people with diabetes vary internationally, but the UK’s National Institute for Health and Care Excellence (NICE) recognises the need for rapid assessment and treatment by a multidisciplinary diabetes foot care team. 1 Implementation of foot care teams has been shown to reduce rates of major amputation in adults with diabetes by 39-56%, 2 and recent data suggest that early referral is associated with better outcomes. 3

Although much of diabetes care has moved from secondary to primary care, management of foot ulceration has predominantly and appropriately remained within hospital settings. Almost £1bn (€1.2bn; $1.3bn) a year, 0.9% of the NHS budget for England, is spent on treating diabetic foot ulcers and amputation. 4 Diabetic foot ulcers result from the microvascular complication of peripheral neuropathy leading to an insensate and sometimes deformed foot. This can be variably exacerbated by the macrovascular complication of peripheral vascular disease, whereby impaired blood flow compromises healing.

Improvement through audit

The National Diabetes Footcare Audit, established in 2014, is a continuous audit of diabetic foot disease in England and Wales, enabling services to measure their performance against NICE guidelines and peer units and permitting assessment of factors associated with clinical outcomes nationally. Audit data from over 33 000 new diabetic foot ulcers suggest that early referral to multidisciplinary foot care teams is associated with better outcomes at 12 weeks. 3 Aligned to this, NICE guidelines recommend that people with new ulcers be referred to a foot care team within one working day, for triage within one further working day. 1

In a field characterised by a paucity of evidence from randomised controlled trials, such rapid access to multidisciplinary care is not consistently incorporated into guidelines internationally: recommendations must sometimes accommodate local or national issues relating to funding flows, as well as any mismatch between demand and supply of specialist care. Varying recommendations are well documented 5 and can lead to confusion and uncertainty among primary care health professionals about who to refer, when, and where, potentially leading to worse outcomes for patients.

In an attempt to harmonise recommendations internationally, the International Working Group on the Diabetic Foot produces guidance on most aspects of classification, prevention, and management of diabetic foot disease every four to five years, but it has not specifically addressed organisation of care relating to speed of access to multidisciplinary foot care teams. 6

Demographic shift

The past 20 years have been characterised by reductions in cardiovascular event rate and improved survival in people with and without diabetes, although relative risk of cardiovascular disease remains higher in those with diabetes, particularly type 1. 7 Microvascular complications tend to occur in parallel and relate to duration of diabetes, so people with peripheral neuropathy often also have retinopathy and nephropathy.

Age is the main determinant of cardiovascular complications, however, 8 and the characteristics of patients referred to multidisciplinary foot care teams have therefore shifted. Rather than younger people with predominantly neuropathic foot disease that could usually be treated successfully (but who often subsequently died prematurely of cardiovascular events), clinics now see more older people who have survived myocardial infarctions and strokes, often with cognitive impairment, in whom peripheral vascular disease is a greater contributor to foot ulceration and ulcer healing is more challenging.

The role of vascular surgical interventions to promote ulcer healing has therefore increased in importance, but a more holistic approach to multimorbidity has also emerged as an essential component of multidisciplinary management. 9 For example, palliative care is increasingly discussed as an alternative to amputation for patients with intractable, necrotic, or gangrenous ulcers, no prospect of satisfactory healing, and when amputation is not in a patient’s best interests or consistent with their wishes.

Improving access

Since the first report of a reduced incidence of major amputation associated with multidisciplinary foot care teams in 1986, 10 access to these teams has slowly improved across England, and 83% of hospitals now have one. 11 Although variation remains, the overall incidence of major amputation across England is one of the lowest internationally at 8 a year for every 10 000 people with diabetes, 12 and amputation incidence across the UK compares favourably with that in other countries in the Organisation for Economic Cooperation and Development. 13

Since 2017, NHS England has invested around £25m in improving access to multidisciplinary foot care teams for people with diabetic foot disease, and the NHS long term plan, published in January 2019, committed to ensuring that all hospitals in England provide these services by 2024. 14 However, to realise the benefits, patients, families, and healthcare professionals must all appreciate the need for rapid referral to a specialist foot care team when a foot ulcer develops, preferably within one working day.

I thank Chris Mieszkowski, patient representative on the National Diabetes Audit Partnership Board, for feedback on an earlier draft.

Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. JV declares he is consultant diabetologist and professor of practice (diabetes) at Imperial College Healthcare NHS Trust and established the multidisciplinary diabetes foot service at St Mary’s Hospital, London, in 2002; he chairs the National Diabetes Audit partnership board and has been directly involved in the NHS England diabetes programme investment of NHS transformation funds into the management of diabetic foot disease.

Provenance and peer review: Commissioned; not externally peer reviewed.

• ↵ National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. 2015. https://www.nice.org.uk/guidance/ng19/resources/diabetic-foot-problems-prevention-and-management-pdf-1837279828933
• Albright RH ,
• Manohar NB ,
• Murillo JF ,
• ↵ NHS Digital. National Diabetes Foot Care Audit fourth annual report. 2019. https://files.digital.nhs.uk/FC/18ED7F/NDFA%204AR%20-%20Main%20Report%20v1.1.pdf
• Chadwick P ,
• Parker CN ,
• Van Netten JJ ,
• Parker TJ ,
• Hinchliffe RJ ,
• Apelqvist J ,
• Lipsky BA ,
• Schaper NC ,
• IWGDF Editorial Board
• ↵ NHS Digital. National Diabetes Audit, 2017-18. Report 2a: complications and mortality (complications of diabetes). 2020. https://files.digital.nhs.uk/91/084B1D/National%20Diabetes%20Audit%2C%202017-18%2C%20Report%202a.pdf
• ↵ NHS Digital. National Diabetes Audit, 2017-18. Report 2b: complications and mortality (characteristics associated with adverse cardiovascular outcomes and diabetic complications). 2020. https://files.digital.nhs.uk/64/0AFA78/National%20Diabetes%20Audit%2C%202017-18%2C%20Report%202b.pdf
• Whitty CJM ,
• MacEwen C ,
• Goddard A ,
• Edmonds ME ,
• Blundell MP ,
• Morris ME ,
• Thomas EM ,
• Cotton LT ,
• ↵ NHS Digital. National diabetes inpatient audit hospital characteristics, 2018. 2019. https://files.digital.nhs.uk/D9/2BEDFE/NaDIA%202018%20-%20Full%20Report%20V1.0.pdf
• Jeffcoate W ,
• Valabhji J ,
• ↵ Dayan M, Ward D, Gardner T, Kelly E. How good is the NHS? 2018. https://www.ifs.org.uk/uploads/HEAJ6319-How-good-is-the-NHS-180625-WEB.pdf
• ↵ NHS England. The long term plan. 2019. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

Advertisement

Diabetic foot disease: a systematic literature review of patient-reported outcome measures

• Published: 09 June 2021
• Volume 30 , pages 3395–3405, ( 2021 )

Cite this article

• Alberto J. Pérez-Panero 1 ,
• María Ruiz-Muñoz   ORCID: orcid.org/0000-0003-0454-2758 1 ,
• Raúl Fernández-Torres 1 ,
• Cynthia Formosa 2 ,
• Alfred Gatt 2 &
• Manuel Gónzalez-Sánchez 3  

1833 Accesses

7 Citations

Explore all metrics

Diabetic foot disease is one of the most serious and expensive complications of diabetes. Patient-reported outcome measures (PROMs) analyse patients’ perception of their disability, functionality and health. The goal of this work was to conduct a systematic review regarding the specific PROMs related to the evaluation of diabetic foot disease and to extract and analyse the values of their measurement properties.

Electronic databases included were PubMed, CINAHL, Scopus, PEDro, Cochrane, SciELO and EMBASE. The search terms used were foot, diabet*, diabetic foot, questionnaire, patient-reported outcome, self-care, valid*, reliabil*. Studies whose did not satisfy the Critical Appraisals Skills Programme (CASP) Diagnostic Study Checklist were excluded. The measurement properties extracted were: Internal Consistency, Test–retest, Inter-rater and Intra-rater, Standard Error of Measurement, Minimum Detectable Measurement Difference, Content Validity, Construct Validity, Criterion Validity and Responsiveness.

The PROMs selected for this review were 12 questionnaires. The Diabetic foot self-care questionnaire (DFSQ-UMA) and the Questionnaire for Diabetes Related Foot Disease (Q-DFD) were the PROMs that showed the highest number of completed measurement properties.

According to the results, it is relevant to create specific questionnaires for the evaluation of diabetic foot disease. It seems appropriate to use both DFSQ-UMA and Q-DFD when assessing patients with diabetic foot disease.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Similar content being viewed by others

Validity and reliability of the Greek version of the Diabetic Foot Ulcer Scale — Short Form (DFS-SF)

Development of the Italian clinical practice guidelines for the treatment of diabetic foot syndrome: design and methodological aspects

A systematic review of measurement properties of patient-reported outcome measures for use in patients with foot or ankle diseases, availability of data and material.

Data transparency.

Singh, R., Kishore, L., & Kaur, N. (2014). Diabetic peripheral neuropathy: Current perspective and future directions. Pharmacological Research. 80 , 21–35.

CAS   PubMed   Google Scholar  

Faruque, L. I., Wiebe, N., Ehteshami-Afshar, A., Liu, Y., Dianati-Maleki, N., Hemmelgarn, B. R., Manns, B. J., & Tonelli, M. (2017). Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials. CMAJ, 189 (9), E341–E364. https://doi.org/10.1503/cmaj.150885

Article   PubMed   PubMed Central   Google Scholar  

Salvo, P., Calisi, N., Melai, B., Dini, V., Paoletti, C., Lomonaco, T., Pucci, A., Di Francesco, F., Piaggesi, A., & Romanelli, M. (2017). Temperature-and pH-sensitive wearable materials for monitoring foot ulcers. International Journal of Nanomedicine, 12 , 949.

CAS   PubMed   PubMed Central   Google Scholar  

Shaw, J. E., Sicree, R. A., & Zimmet, P. Z. (2010). Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Research and Clinical Practice, 87 (1), 4–14.

Pérez-Panero, A. J., Ruiz-Muñoz, M., Cuesta-Vargas, A. I., & Gónzalez-Sánchez, M. (2019). Prevention, assessment, diagnosis and management of diabetic foot based on clinical practice guidelines: A systematic review. Medicine (Baltimore), 98 (35), e16877.

Google Scholar  

Melmed, S., Polonsky, K. S., Larsen, P. R., & Kronenberg, H. M. (2015). Williams textbook of endocrinology (13th ed.). . Elsevier.

Lepäntalo, M., Apelqvist, J., Setacci, C., Ricco, J. B., De Donato, G., Becker, F., Robert-Ebadi, H., Cao, P., Eckstein, H. H., De Rango, P., & Diehm, N. (2011). Chapter V: diabetic foot. European Journal of Vascular and Endovascular Surgery., 42 , S60-74.

PubMed   Google Scholar  

Driver, V. R., Fabbi, M., Lavery, L. A., & Gibbons, G. (2010). The costs of diabetic foot: the economic case for the limb salvage team. Journal of Vascular Surgery, 52 (3 Suppl), 17S-22S.

International Diabetes Federation. Clinical Practice Recommendation on the Diabetic Foot: A guide for health care professionals. International Diabetes Federation , 2017

Cuesta-Vargas, A. I., & González-Sánchez, M. (2014). Ability to discriminate between healthy and low back pain sufferers using ultrasound during maximum lumbar extension. Archives of Physical Medicine and Rehabilitation, 95 (6), 1093–1099.

González-Sánchez, M., Velasco-Ramos, E., Muñoz, M. R., & Cuesta-Vargas, A. I. (2016). Relationship between patient-reported outcome measures (PROM) and three measures of foot-ankle alignment in patients with metatarsal head pain: a cross-sectional study. J Foot Ankle Res., 9 , 49.

PubMed   PubMed Central   Google Scholar  

Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A., et al. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of Clinical Epidemiology., 62 (10), e1-34.

Mokkink, L. B., Terwee, C. B., Patrick, D. L., Alonso, J., Stratford, P. W., Knol, D. L., et al. (2010). The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: An international Delphi study. Quality of Life Research, 19 (4), 539–549.

Mokkink, L. B., Terwee, C. B., Patrick, D. L., Alonso, J., Stratford, P. W., Knol, D. L., et al. (2010). The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. Journal of Clinical Epidemiology, 63 (7), 737–745.

Chin, Y.-F., & Huang, T.-T. (2013). Development and validation of a diabetes foot self-care behavior scale. Journal of Nursing Research., 21 (1), 19–25.

Bann, C. M., Fehnel, S. E., & Gagnon, D. D. (2003). Development and validation of the diabetic foot ulcer scale???Short form (DFS-SF). PharmacoEconomics, 21 (17), 1277–1290.

Kontodimopoulos, N., Veniou, A., Tentolouris, N., & Niakas, D. (2016). Validity and reliability of the Greek version of the diabetic foot ulcer scale—short form (DFS-SF). Hormones (Athens, Greece), 15 (3), 394–403.

Macioch, T., Sobol, E., Krakowiecki, A., Mrozikiewicz-Rakowska, B., Kasprowicz, M., & Hermanowski, T. (2017). Health related quality of life in patients with diabetic foot ulceration—translation and Polish adaptation of Diabetic Foot Ulcer Scale short form. Health and Quality of Life Outcomes, 15 (1), 15.

Hui, L. F., Yee-Tak Fong, D., Yam, M., & Yuk, I. W. (2008). Translation and validation of the Chinese diabetic foot ulcer scale—short form. Patient., 1 (2), 137–145.

Lee, Y.-N. (2019). Translation and validation of the Korean version of the Diabetic Foot Ulcer Scale-Short Form. International Wound Journal, 16 (Suppl 1), 3–12.

Abetz, L., Sutton, M., Brady, L., McNulty, P., & Gagnon, D. D. (2002). The Diabetic Foot Ulcer Scale (DFS): A quality of life instrument for use in clinical trials. Practical Diabetes International., 19 (6), 167–175.

Martin, R. L., Hutt, D. M., & Wukich, D. K. (2009). Validity of the Foot and Ankle Ability Measure (FAAM) in Diabetes Mellitus. Foot & Ankle International., 30 (4), 297–302.

Cervera-Garvi, P., Ortega-Avila, A. B., Morales-Asencio, J. M., Cervera-Marin, J. A., Martin, R. R., & Gijon-Nogueron, G. (2017). Cross-cultural adaptation and validation of Spanish version of The Foot and Ankle Ability Measures (FAAM-Sp). J Foot Ankle Res., 10 , 39.

Çelik, D., Malkoç, M., & Martin, R. (2016). Evidence for reliability, validity and responsiveness of Turkish Foot and Ankle Ability Measure (FAAM). Rheumatology International, 36 (10), 1469–1476.

Borloz, S., Crevoisier, X., Deriaz, O., Ballabeni, P., Martin, R. L., & Luthi, F. (2011). Evidence for validity and reliability of a French version of the FAAM. BMC Musculoskeletal Disorders., 12 (1), 40.

Uematsu, D., Suzuki, H., Sasaki, S., Nagano, Y., Shinozuka, N., Sunagawa, N., & Fukubayashi, T. (2015). Evidence of validity for the Japanese version of the Foot and Ankle Ability Measure. Journal of Athletic Training, 50 (1), 65–70.

González-Sánchez, M., Li, G. Z., Ruiz Muñoz, M., & Cuesta-Vargas, A. I. (2017). Foot and ankle ability measure to measure functional limitations in patients with foot and ankle disorders: a Chinese cross-cultural adaptation and validation. Disability and Rehabilitation, 39 (21), 2182–2189.

Mazaheri, M., Salavati, M., Negahban, H., Sohani, S. M., Taghizadeh, F., Feizi, A., et al. (2010). Reliability and validity of the Persian version of Foot and Ankle Ability Measure (FAAM) to measure functional limitations in patients with foot and ankle disorders. Osteoarthritis and Cartilage., 18 (6), 755–759.

Sartorio, F., Vercelli, S., Bravini, E., Bargeri, S., Moroso, M., Plebani, G., & Ferriero, G. (2014). Foot and ankle ability measure: Cross-cultural translation and validation of the Italian version of the ADL module (FAAM-I/ADL). Medicina del Lavoro, 105 , 357–365.

Moreira, T. S., de Magalhães, L. C., Silva, R. D., Martin, R. L., & de Resende, M. A. (2016). Translation, cross-cultural adaptation and validity of the Brazilian version of the Foot and Ankle Ability Measure questionnaire. Disability and Rehabilitation, 38 (25), 2479–2490.

Weel, H., Zwiers, R., Azim, D., Sierevelt, I. N., Haverkamp, D., van Dijk, C. N., et al. (2016). Validity and reliability of a Dutch version of the Foot and Ankle ability measure. Knee Surgery, Sports Traumatology, Arthroscopy, 24 (4), 1348–1354.

Arunakul, M., Arunakul, P., Suesiritumrong, C., Angthong, C., & Chernchujit, B. (2015). Validity and reliability of Thai version of the Foot and Ankle Ability Measure (FAAM) subjective form. Journal of the Medical Association of Thailand, 98 (6), 561–567.

Nauck, T., & Lohrer, H. (2011). Translation, cross-cultural adaption and validation of the German version of the Foot and Ankle Ability Measure for patients with chronic ankle instability. British Journal of Sports Medicine., 45 (10), 785–790.

Navarro-Flores, E., Morales-Asencio, J. M., Cervera-Marín, J. A., Labajos-Manzanares, M. T., & Gijon-Nogueron, G. (2015). Development, validation and psychometric analysis of the diabetic foot self-care questionnaire of the University of Malaga, Spain (DFSQ-UMA). Journal of Tissue Viability., 24 (1), 24–34.

Garcia-Paya, I., Lescure, Y., Delacroix, S., & Gijon-Nogueron, G. (2019). Cross-cultural Adaptation and Validation of the French Version of the Diabetic Foot Self-care Questionnaire of the University of Malaga. Journal of the American Podiatric Medical Association, 109 (5), 357–366.

Kateel, R., Augustine, A. J., Ullal, S., Prabhu, S., Bhat, R., & Adhikari, P. (2017). Development and validation of health related quality of life questionnaire (Indian scenario) in diabetic foot ulcer patients. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 11 , S651–S653.

Vileikyte, L., Gonzalez, J. S., Leventhal, H., Peyrot, M. F., Rubin, R. R., Garrow, A., Ulbrecht, J. S., Cavanagh, P. R., & Boulton, A. J. (2006). Patient Interpretation of Neuropathy (PIN) Questionnaire: An instrument for assessment of cognitive and emotional factors associated with foot self-care. Diabetes Care, 29 (12), 2617–2624.

Dhawan, V., Spratt, K. F., Pinzur, M. S., Baumhauer, J., Rudicel, S., & Saltzman, C. L. (2005). Reliability of AOFAS Diabetic Foot Questionnaire in Charcot Arthropathy: Stability, Internal Consistency, and Measurable Difference. Foot & Ankle International., 26 (9), 717–731.

Kostuj, T., Krummenauer, F., Schaper, K., Stief, F., Zettersten, K., Baums, M. H., Meurer, A., & Lieske, S. (2014). Analysis of agreement between the German translation of the American Foot and Ankle Society’s Ankle and Hindfoot Scale (AOFAS-AHS) and the Foot Function Index in its validated German translation by Naal et al. (FFI-D). Archives of Orthopaedic and Trauma Surgery., 134 (9), 1205–1210.

Van Lieshout, E. M., De Boer, A. S., Meuffels, D. E., Den Hoed, P. T., Van der Vlies, C. H., Tuinebreijer, W. E., & Verhofstad, M. H. (2017). American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score: A study protocol for the translation and validation of the Dutch language version. British Medical Journal Open, 7 (2), e012884.

Sayyed-Hosseinian, S. H., Hassankhani, G. G., Bagheri, F., Alavi, N., Shojaie, B., & Mousavian, A. (2018). Validation of the Persian version of the American Orthopedic Foot and Ankle Society Score (AOFAS) Questionnaire. The Archives of Bone and Joint Surgery, 233 , 233–239.

Analay Akbaba, Y., Celik, D., & Ogut, R. T. (2016). Translation, cross-cultural adaptation, reliability, and validity of Turkish version of the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale. Journal of Foot and Ankle Surgery, 55 (6), 1139–1142.

Rodrigues, R. C., Masiero, D., Mizusaki, J. M., Imoto, A. M., Peccin, M. S., Cohen, M., & Alloza, J. F. M. (2008). Tradução, adaptação cultural e validação do" American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale". Acta Ortopédica Brasileira, 16 (2), 107–111.

Ahn, J., Del Core, M. A., Wukich, D. K., Liu, G. T., Lalli, T., VanPelt, M. D., & Raspovic, K. M. (2018). Scoring Mental Health Quality of Life with the SF-36 in patients with and without Diabetes Foot complications. The International Journal of Lower Extremity Wounds, 17 (1), 30–35.

Bagheri, Z., Jafari, P., Mahmoodi, M., & Dabbaghmanesh, M. H. (2017). Testing whether patients with diabetes and healthy people perceive the meaning of the items in the Persian version of the SF-36 questionnaire similarly: a differential item functioning analysis. Quality of Life Research, 26 (4), 835–845.

Palomo-López, P., Losa-Iglesias, M. E., Becerro-de-Bengoa-Vallejo, R., López-López, D., Rodríguez-Sanz, D., Romero-Morales, C., & Calvo-Lobo, C. (2019). Specific foot health-related quality-of-life impairment in patients with type II versus type I diabetes. International Wound Journal, 16 (1), 47–51.

Ferreira, A. F. B., Laurindo, I. M. M., Rodrigues, P. T., Ferraz, M. B., Kowalski, S. C., & Tanaka, C. (2008). Brazilian version of the foot health status questionnaire (FHSQ-BR): cross-cultural adaptation and evaluation of measurement properties. Clinics (São Paulo, Brazil), 63 (5), 595–600.

Cuesta-Vargas, A., Bennett, P., Jimenez-Cebrian, A. M., & Labajos-Manzanares, M. T. (2013). The psychometric properties of the Spanish version of the Foot Health Status Questionnaire. Quality of Life Research, 22 (7), 1739–1743.

Vileikyte, L., Peyrot, M., Bundy, C., Rubin, R. R., Leventhal, H., Mora, P., Shaw, J. E., Baker, P., & Boulton, A. J. (2003). The development and validation of a neuropathy- and Foot Ulcer—Specific. Diabetes Care, 26 , 2549–2555. https://doi.org/10.2337/diacare.26.9.2549

Article   PubMed   Google Scholar  

Victorson, D., Cavazos, J. E., Holmes, G. L., Reder, A. T., Wojna, V., Nowinski, C., Miller, D., Buono, S., Mueller, A., Moy, C., et al. (2015). Validity of the Neurology Quality-of-Life (Neuro-QoL) measurement system in adult epilepsy. Epilepsy & Behavior, 31 , 77–84. https://doi.org/10.1016/j.yebeh.2013.11.008

Article   Google Scholar  

Xie, G., Chen, L., Yang, S., Tao, J., Chan, C. C. H., Heinemann, A. W., Cella, D., Lai, J. S., Correia, H., & Wong, A. W. K. (2018). Simplified Chinese translation of 13 adult item banks from the Quality of Life in Neurological Disorders (Neuro-QoL) . BMC Health Services Research, 18 , 825. https://doi.org/10.1186/s12913-018-3631-7

Xavier, A. T., Foss, M. C., Marques Junior, W., dos Santos, C. B., Onofre, P. T. B. N., Pace, A. E. Cultural adaptation and validation of the Neuropathy- and Foot Ulcer—Specific Quality of Life instrument (NeuroQol) for Brazilian Portuguese—Phase 1.  Revista Latino-Americana de Enfermagem.  2011;19:1352–1361. doi: https://doi.org/10.1590/S0104-11692011000600011 .

Bergin, S. M., Brand, C. A., Colman, P. G., & Campbell, D. A. (2009). A questionnaire for determining prevalence of diabetes related foot disease (Q-DFD): Construction and validation. Journal of Foot and Ankle Research, 2 , 1–10.

Castillo-Tandazo, W., Flores-Fortty, A., Feraud, L., & Tettamanti, D. (2013). Spanish translation, cross-cultural adaptation, and validation of the Questionnaire for Diabetes-Related Foot Disease (Q-DFD). Vascular Health and Risk Management, 9 , 501.

Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33 , 159–174. https://doi.org/10.2307/2529310.

Article   CAS   PubMed   Google Scholar  

Campo-Arias, A., Oviedo, H.C. Propiedades Psicométricas de una Escala: la Consistencia Interna. Rev salud pública [Internet]. 2008; 10(5). Available online: Retrieved 10 May, 2020, from http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0124-0642008000500015&lng=es&nrm=iso&tlng=es

Anguita, J. C., Labrador, J. R., Campos, J. D., Casas Anguita, J., Repullo Labrador, J., & Donado Campos, J. (2003). La encuesta como técnica de investigación. Elaboración de cuestionarios y tratamiento estadístico de los datos (I).  Atención primaria ,  31 (8), 527-538

Stetson, B., Schlundt, D., Rothschild, C., Floyd, J. E., Rogers, W., & Mokshagundam, S. P. (2011). Development and validation of the personal diabetes questionnaire (PDQ): A measure of diabetes self-care behaviors, perceptions and barriers. Diabetes Research and Clinical Practice, 91 (3), 321–332.

Ortega-Avila, A. B., Cervera-Garvi, P., Ramos-Petersen, L., Chicharro-Luna, E., & Gijon-Nogueron, G. (2019). Patient-reported outcome measures for patients with diabetes mellitus associated with foot and ankle pathologies: A systematic review. Journal of Clinical Medicine, 8 (2), 146. https://doi.org/10.3390/jcm8020146

Article   PubMed Central   Google Scholar  

Lee, J., Lee, E. H., Chae, D., & Kim, C. J. (2020). Patient-reported outcome measures for diabetes self-care: A systematic review of measurement properties. International Journal of Nursing Studies, 105 , 103498. https://doi.org/10.1016/j.ijnurstu.2019.103498

Skovlund, S. E., Lichtenberg, T. H., Hessler, D., & Ejskjaer, N. (2019). Can the routine use of Patient-reported outcome measures improve the delivery of person-centered diabetes care? A Review of recent developments and a case study. Current Diabetes Reports, 19 (9), 84. https://doi.org/10.1007/s11892-019-1190-x

Chen, Y. T., Tan, Y. Z., Cheen, M., & Wee, H. L. (2019). Patient-reported outcome measures in registry-based studies of Type 2 Diabetes Mellitus: A systematic review. Current Diabetes Reports, 19 (11), 135. https://doi.org/10.1007/s11892-019-1265-8

Fernández-Torres, R., Ruiz-Muñoz, M., Pérez-Panero, A. J., García-Romero, J., & Gónzalez-Sánchez, M. (2020). Instruments of choice for assessment and monitoring Diabetic Foot: A systematic review. Journal of Clinical Medicine, 9 (2), 602. https://doi.org/10.3390/jcm9020602

Fernández-Torres, R., Ruiz-Muñoz, M., Pérez-Panero, A. J., García-Romero, J. C., & Gónzalez-Sánchez, M. (2020). Clinician assessment tools for patients with Diabetic Foot disease: A systematic review. Journal of Clinical Medicine, 9 (5), 1487. https://doi.org/10.3390/jcm9051487

Download references

This research received no external funding.

Author information

Authors and affiliations.

Department of Nursing and Podiatry, University of Málaga, Arquitecto Francisco Peñalosa, s/n. Ampliación campus de Teatinos, 29071, Málaga, Spain

Alberto J. Pérez-Panero, María Ruiz-Muñoz & Raúl Fernández-Torres

Podiatry Department, Faculty of Health Sciences, Block A, Level 1, Mater Dei Hospital, University of Malta, Msida, MSD 2090, Malta

Cynthia Formosa & Alfred Gatt

Department of Physiotherapy, University of Málaga, Arquitecto Francisco Peñalosa, s/n. Ampliación campus de Teatinos, 29071, Málaga, Spain

Manuel Gónzalez-Sánchez

You can also search for this author in PubMed   Google Scholar

Contributions

Conceptualization, MR-M and MG-S; Methodology, AJP-P; Validation, AJP-P and RF-T; Formal Analysis MR-M. and MG-S.; Investigation, MR-M. and MG-S; Resources, AJP-P and RF-T; Data analysis, RF-T. and AJP-P.; Writing—Original Draft Preparation, AJP-P; Writing—Review & Editing, MR-M and MG-S.; Visualization, CF and AG; Supervision CF and AG; Project Administration, CF and AG.

Corresponding author

Correspondence to María Ruiz-Muñoz .

Ethics declarations

Conflict of interest.

The authors declare no conflict of interest.

Consent to participate

The authors declare their consent to participate.

Consent for publication

The authors declare their consent to publish this work.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Pérez-Panero, A.J., Ruiz-Muñoz, M., Fernández-Torres, R. et al. Diabetic foot disease: a systematic literature review of patient-reported outcome measures. Qual Life Res 30 , 3395–3405 (2021). https://doi.org/10.1007/s11136-021-02892-4

Download citation

Accepted : 22 May 2021

Published : 09 June 2021

Issue Date : December 2021

DOI : https://doi.org/10.1007/s11136-021-02892-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Diabetes complications
• Questionnaire
• Find a journal
• Publish with us
• Track your research

• Open access
• Published: 06 August 2022

A qualitative study of barriers to care-seeking for diabetic foot ulceration across multiple levels of the healthcare system

• Tze-Woei Tan   ORCID: orcid.org/0000-0002-6658-9482 1 , 2 ,
• Rebecca M. Crocker 3 ,
• Kelly N. B. Palmer 3 ,
• Chris Gomez 4 ,
• David G. Armstrong 1 , 2 &
• David G. Marrero 3  

Journal of Foot and Ankle Research volume  15 , Article number:  56 ( 2022 ) Cite this article

6226 Accesses

12 Citations

5 Altmetric

Metrics details

Introduction

The mechanisms for the observed disparities in diabetes-related amputation are poorly understood and could be related to access for diabetic foot ulceration (DFU) care. This qualitative study aimed to understand patients’ personal experiences navigating the healthcare system and the barriers they faced.

Fifteen semi-structured interviews were conducted over the phone between June 2020 to February 2021. Participants with DFUs were recruited from a tertiary referral center in Southern Arizona. The interviews were audio-recorded and analyzed according to the NIMHD Research Framework, focusing on the health care system domain.

Among the 15 participants included in the study, the mean age was 52.4 years (66.7% male), 66.7% was from minority racial groups, and 73.3% was Medicaid or Indian Health Service beneficiaries. Participants frequently reported barriers at various levels of the healthcare system.

On the individual level, themes that arose included health literacy and inadequate insurance coverage resulting in financial strain. On the interpersonal level, participants complained of fragmented relationships with providers and experienced challenges in making follow-up appointments. On the community level, participants reported struggles with medical equipment.

On the societal level, participants also noted insufficient preventative foot care and education before DFU onset, and many respondents experienced initial misdiagnoses and delays in receiving care.

Conclusions

Patients with DFUs face significant barriers in accessing medical care at many levels in the healthcare system and beyond. These data highlight opportunities to address the effects of diabetic foot complications and the inequitable burden of inadequately managed diabetic foot care.

Peer Review reports

Diabetic foot ulceration (DFU) is a common and often catastrophic complication for people with diabetes. In the United States, people with diabetes have an up to 34% lifetime risk of developing a foot ulcer [ 1 , 2 ], a medical complication that increases their five-year mortality rate by 2.5 times [ 3 , 4 ]. Moreover, foot ulceration is a causal factor for up to 85% of diabetic patients who subsequently undergo lower extremity amputation [ 1 , 5 ]. As compared to the overall United States population, people with diabetes are more likely to undergo lower extremity amputation and repeat amputations [ 1 , 6 ]. The annual medical cost associated with DFU care in the United States is an additional $9–13 billion on top of other costs associated with diabetes [ 7 ].

Moreover, DFUs and subsequent amputations are unevenly patterned along lines of racial and ethnic minority status, low socio-economic status, low insurance coverage rates, and geographic isolation. African American, Hispanic, and Native American adults with diabetes have higher prevalence of DFUs and amputation than their White counterparts [ 8 , 9 , 10 ]. Across the board, patients in the lowest income quartiles experience higher odds of amputation and death due to peripheral artery disease [ 11 , 12 ]. In addition, those with suboptimal or no medical insurance are at an elevated risk of major amputation [ 13 ]. This illuminates a glaring and yet unabated public health problem, especially among minority and low-income populations [ 8 , 9 , 12 , 13 , 14 , 15 , 16 ].

The mechanisms of these observed disparities in DFU incidence and progression are poorly understood [ 9 , 11 , 17 , 18 ]. There is evidence, however, indicating that access to affordable and quality medical care, preventive services, and limb salvage care is an important contributing factor to disparities in amputation rates [ 19 , 20 , 21 ]. This qualitative study aimed to understand patients’ personal experiences with DFUs in a safety net health system, including their processes of navigating the healthcare system and the barriers they faced. The themes elicited in the study concerning multiple barriers at varying levels of the healthcare system will help to improve health care delivery in a population experiencing elevated risks of diabetes-related ulceration and amputation.

This qualitative study was designed to better understand the various challenges faced by patients with a history of DFUs and lower extremity amputations as they managed their conditions and sought medical care. Semi-structured interviews were conducted between June 2020 to February 2021 and the results were analyzed according to the “Health Care System” domain of the National Institute on Minority Health and Health Disparities Research Framework [ 22 ]. The University of Arizona Institutional Review Board approved the study in July 2019 (Protocol Number 1906749805).

Participants

Patients were selected from the Southwestern Academic Limb Salvage Alliance (SALSA), a multidisciplinary limb salvage care team located in Tucson, Arizona, to participate in semi-structured interviews. SALSA treats over 5,000 patient visits annually for diabetic foot problems, of which 40% are from racial and ethnic minority groups. It is the primary referral center for limb salvage and care for minorities and patients with low socioeconomic status in suburban and rural Arizona. Participants were identified and approached for participation during scheduled clinic appointments or by follow-up phone calls by our research team. We purposely sampled participants, using criterion sampling, to reflect the diverse range of race/ethnicity, gender, history of DFU, foot infection, minor amputation (below the ankle), and major amputation (ankle or above) treated by SALSA [ 23 ].

Interview guide and data collection

The research team jointly developed a semi-structured interview guide to encourage patient perspectives regarding their living experiences with foot ulceration and how they sought care for DFUs. Interviews were conducted in the patients’ preferred language (English or Spanish). Three research team members experienced in qualitative interviews (R.M.C., K.N.B.P., and D.G.M.) completed 15 interviews over the phone, lasting 40–60 min each. Interviews were recorded with consent using the “Tape A Call” mobile application ( www.tapeacall.com ) or via the University of Arizona Health Sciences Zoom Platform. The interviews were conducted in phases to allow for simultaneous analysis and redirection of subsequent data collection.

The research team used the Dedoose software version 9.0.17 (SocioCultural Research Consultants, LLC, Los Angeles, CA) to assist in data storage, coding, and data analysis. Audio files of the interviews were transcribed into the language spoken. After a quality assurance check, the transcriptions were uploaded into the software. The transcripts were independently reviewed and coded by three members of the research team (R.M.C., K.N.B.P., and T-W.T.). Data for this article were analyzed according to the NIMHD Research Framework (2017) that includes a multilevel approach including individual, interpersonal, community, and societal-level factors. While this model includes several domains, for the purposes of this paper we are focusing only on the Health Care System domain. This framework has been used in health disparities research to conceptualize and evaluate a wide array of determinants that promote or worsen health disparities [ 24 ]. Team members met regularly to compare coding results and resolve discrepancies by discussion and consensus.

The study sample included 15 participants (Table 1 ). The mean age was 54.2 years. Eleven participants (73.3%) were Medicaid or Indian Health Program beneficiaries and 80% of participants were either unemployed or had retired. All participants had history of at least one DFU, 12 had a history of foot infection, eight underwent minor amputations, and one had a major amputation. Four patients underwent at least one open surgery or endovascular procedure due to peripheral artery disease. During the interviews, participants frequently reported barriers at various levels of the health care system (Table 2 , Fig.  1 ).

Patient reported barriers at all levels influence of the health care system domain

Individual Level of Influence

Health literacy.

While most participants were aware of the risks of foot infection and amputation, there were significant gaps in their health literacy that compromised their ability to make informed decisions about when and how to seek medical care. Most notably, although all participants had a history of DFUs, many were unfamiliar with the term “ulcer” and expressed confusion when interviewers asked questions using that term. This finding, which reflects poor communication by providers and medical staff, resulted in most participants using alternate terms such as “blister,” “callous,” “cut,” “infection,” and “injury” to describe their foot abnormalities. This confusion in terminology was critical, as many patients described not initially seeking medical care because they interpreted their foot abnormality to be a common, everyday problem rather than one warranting medical attention. As one participant described: “Nobody ever really said what I’m looking for just anything that is not normal, I guess. But like I said, I have never heard of a diabetic foot ulcer.” (57-year-old Hispanic male, history of DFU).

In addition, participants described gaps in their health literacy related to the specifics of foot ulcer progression and the appropriate management strategies to prevent amputation. Most participants did not have a solid understanding of warning signs for when medical care should be secured for foot problems or what type of medical care should be sought. One frustrated participant stated: “If I had gotten better, like a different type of information that they could’ve given me, that might’ve helped me improve this ulcer to be going away. From what I have been given, you know, it’s just hard. I don’t know if it’s my foot itself or if it’s the medication. I don’t know. I don’t know if I am a unique case, I know there are people out there that have one foot. And they are able to get, probably, their ulcer better” (29-year-old Native female, history of DFU and recurrent foot infection).

Insurance coverage

While all participants had medical care coverage under Medicaid, Medicare, Indian Health Services or commercial insurance, the majority described significant medical expenses and financial strain related to their diabetes care in general, and in many cases to DFU care in particular. Most of the participants reported multiple recurring expenses such as medications (particularly insulin), co-payments for specialist visits and procedures, and the need for extensive travel, a financial strain that was frequently exacerbated by temporary or permanent loss of employment and under-employment. One participant said that following his second toe amputation: “I was in the hospital for 15 days, 13 days. They are charging me a copay, but I don’t have money to pay it. I am currently not working. I have social security and they don’t give me very much and it’s not enough to cover the copay.” (67-year-old Hispanic male, commercial insurance). In addition, many described substantial out-of-pocket payments for ancillary supplies, such as diabetic footwear and wound dressings due to inadequate insurance coverage, which often resulted in participants being unable to secure the supplies and care they needed for optimal DFU management. For example, a participant explained: “They want me to get diabetic shoes and the orthotic but at the time I didn’t have Medicaid … and with the deductible, they wanted $1,000 for the pair of shoes and the orthotic and I couldn’t afford it.” (45-year-old White female, Medicaid).

Interpersonal Level of Influence

Patient–clinician relationships.

Participants reported a wide array of levels of satisfaction with their medical providers, from long-standing personal and medically supportive relationships to negative experiences of not being listened to or being bounced from provider to provider. A predominant theme involved fragmented relationships with healthcare providers due to multiple factors including patients’ changes in residence, transitions in insurance status, providers leaving the area or switching practices, providers’ medical and holiday leave, and the COVID-19 pandemic. Given the complexity of managing their diabetes and related complications, these interruptions to patient-clinician relationships posed considerable barriers to effective disease management.

In addition, participants mentioned challenges in making timely appointments, and in getting time with their primary care physicians after major clinical events such as hospitalizations. One patient explained: “I had a lot of problems getting in contact with that doctor (primary care doctor). And after, I think it was the first four months after the amputation, and I just kept on trying to contact her… and I would try to call her, and she never returned my calls.” (47-year-old Hispanic male, history of multiple DFUs, foot infection, and toe amputation).

Similar challenges existed around establishing trusting relationships with the nurses that conducted home wound care following DFUs and amputations. This was due in large part to turnover in nursing staff or the rotation of nurses who conducted their home visits. A participant explained: “They [the companies] make a big deal about bringing the nurse in and have them trained on me and then two weeks later, I get a new nurse and redo it.” (45-year-old White female, underwent more than 20 procedures for DFUs).

Lastly, participants reported that the COVID-19 pandemic further intensified this lack of provider continuity due to limited in-person visits. For example, one participant described his struggles to connect with a new endocrinologist during the pandemic, stating: “I see him once and a current situation came up, so I haven’t been able to see him since then. [Due to the pandemic] it has been phone interviews, so, I haven’t really developed any significant rapport with my current endocrinologist.” (41-year-old White male, history of recurrent DFUs and toe amputations).

Community Level of Influence

Availability of services.

Participants commonly reported struggles with getting the medical equipment needed to prevent and manage their DFUs in a timely fashion, including offloading braces, dressing supplies, and therapeutic shoes and insoles. A few noted that the wound supplies provided by the hospital, clinic, or home healthcare companies ran out before their wounds had healed. One participant described maintaining medical supplies as his biggest challenge, saying: “The nurses themselves have been wonderful but their companies have been mainly touch-and-go with maintaining the supplies being delivered at an appropriate time” (41-year-old White male, Medicaid). Despite having prescriptions from physicians and insurance coverage, many participants also faced long waits for securing specialized diabetic shoes from medical supply companies, resulting in delayed or interrupted care. One participant described: "The insoles that I went in for, that they prescribed for me, it took me a long time to get them. Probably like three months after … and then when I got them, they, they were very flimsy, they didn’t last. It took me awhile to get another pair, a better design of the ones that they had” (47-year-old Hispanic male, self-employed, commercial health insurance).

Participants living in rural areas outside of Tucson cited additional challenges in managing their DFUs due to the time, expense, and distance involved in securing the elaborate routines of specialist appointments, routines, medications, and wound care necessary to effectively manage their DFUs. One participant described: “It was a difficulty because I am on the reservation and sometimes the medical things that I would need, like I said, insulin, the IV antibiotics, they wouldn't be able to come out here and do it. If I had lived in a city, then the people would come and get it done.” (38-year-old Native male, Medicare, rural Arizona).

Societal Level of Influence

Quality of care.

Many participants noted insufficient preventative foot care and education prior to DFU onset. Some reported that they did not learn about ulcer prevention until they developed DFUs. For example, one participant stated: “I don’t really remember (doctors) saying anything on ways to prevent other ulcers.” (38-year-old Native male, Medicaid and Indian Health Services). Some participants similarly reported that they did not receive routine foot examinations prior to developing their first DFU, even though they had regularly scheduled primary care appointments. One explained: “Well, early on they didn’t look at my feet. Before I got the ulcer, they didn’t look at them. They would just instruct me to check my blood sugar. But then after the ulcer and when they cut off my toe, that’s when they started to check my feet.” (67-year-old Hispanic male, commercial insurance).

Other barriers presented themselves while seeking adequate medical care for their new ulcers. Participants initially sought care from a variety of different venues— primary care doctors, podiatrists, specialists, emergency rooms, and urgent care clinics— as determined by how serious they interpreted their foot problems and insurance status and access issues. Some participants had the experience of being sent to multiple facilities in search of appropriate care, and those living in rural areas faced travel to different cities or towns. For example, a participant recalled that: “I went to the ER down here in XXX (a community hospital) and that was Friday (was discharged home) and then I saw my doctor on Monday and he sent me to XXX (a tertiary hospital) in Tucson.” (41-year-old White male, history of multiple DFUs and two toe amputations).

Many respondents experienced initial misdiagnoses and delays in receiving care. This included a few participants who presented for diabetic foot complications to acute care facilities, such as urgent care clincs and emergency rooms, and were sent home without an appropriate diagnosis, treatment, and follow-up. One woman recalled her frustrating journey that led to amputation:

‘I called my doctor…. She told me I want you to see an infectious disease doctor and have them put you on an IV antibiotic …. So, I get to the infectious disease doctor, and he says, ‘I’m not going to put you on antibiotic, it isn’t infected.’ So, that’s how I ended up with an amputation because he did not put me on any antibiotic. So, I went into the hospital, and they assigned me an infectious disease doctor and she came in, I’ll never forget this, and she started talking to me like I was stupid, and she goes, ‘You know you’re diabetic, you should’ve gone to a doctor right away ...’ And I said, ‘… hold on a second here, I am a very intelligent person and yes, I did, I went to my own doctor who made an appointment for me to see an infectious disease doctor.” (71-year-old White female, history of multiple DFUs and toe amputations)

Over the past two decades, substantial advances in diabetes therapy have greatly extended health and reduced morbidity. However, as evidenced in this article, significant obstacles to effective DFU treatment and management remain at multiple levels of the healthcare system. Some of these obstacles can be mitigated with more thoughtful education and alignment of access points to receive adequate health care. In this context we offer observations from our study to help address these deficits, particularly as they relate to decreasing notable health disparities.

An important individual level barrier is deficits in health literacy surrounding appropriate terminology to describe diabetic foot complications and how to make informed medical decisions about when to seek medical intervention [ 25 ]. Our findings suggest that a more aggressive and tailored education approach that guides patients to act quickly in seeking medical care and for rapid wound examination is warranted. Part of this education needs to emphasize that diabetes increases the infection and amputation risks of these seemingly “minor” foot injuries. Burdensome expenses related to DFU care posed a second individual level barrier, suggesting the need for continued advocacy for full coverage of DFU care among safety net insurance providers [ 26 , 27 ].

On the interpersonal level, our data illustrate that disruptions to the patient-clinician relationship damages rapport with patients and hinders optimal DFU care. Study participants frequently reported difficulties in accessing appropriate health care providers and disruptions to the patient-physician relationship due to the turnover of providers, changes to region and insurance status, and other factors. This gap calls for developing solutions to address medical provider shortages and to “fill in” health care assessment in a timely manner. One potential approach is to expand the use of trained community health workers who can help triage persons with differing levels of foot ulcers to available health care providers who work outside of the patient’s known environment [ 28 , 29 ].

On the community level, despite having appropriate prescriptions and insurance coverage, participants described significant challenges receiving medical equipment, which was often perceived to be due to shortcomings at the medical supply companies. Since most persons with diabetes see their pharmacist more frequently than any other member of their health care team, developing collaborations between pharmacies, providers, or healthcare system in which pharmacists take on the role of providing medical equipment such as wound care supplies or diabetic shoes, may be an effective approach. Pharmacist supported diabetes care has been shown to be well received by minority patients and to result in improved diabetes outcomes [ 30 , 31 ].

Finally, on the societal level, there is a need to improve preventive care for DFUs on the primary care physician level, a crucial strategy for limb salvage. The American Diabetes Association recommends that all patients with diabetes have their feet inspected at each doctor visit and have a comprehensive foot evaluation at least annually to identify risk factors for DFUs [ 32 ]. Greater focus needs to be placed on educating medical providers and patients, and on the importance of preventive foot care including self-foot inspection, foot examination by a medical professional, and the use of appropriate footwear. In addition, given that sample participants commonly reported receiving misdiagnoses and delays after seeking medical care for DFUs, a standardized protocol and care pathway for when, where, and how patients should seek initial DFU care and how the DFUs should be treated are imperative. Because delays occur both before and after seeking care, a focus must be made to educate both patients and providers about the standard protocol [ 33 ].

There are limitations to this study which should be considered when interpreting the results. Given the relatively modest sample size, we were not able to analyze the data for gender or age effects or by duration of diabetes. Nonetheless, this hard to reach patient sample representing a diverse population did offer very similar stories about the experiences and health disparities they faced in dealing with DFUs.

Diabetic foot ulceration remains a common and life-altering disease complication and one that disproportionately burdens people of racial and ethnic minority status, low socio-economic status, low insurance coverage, and those residing in rural areas. Our study examined the lived experience of a sample of persons with diabetes that face significant barriers at all levels of the healthcare system. Their stories highlight the importance of selecting multiple points of entry to make significant improvements in peoples’ health literacy, relationships with providers, and access to quality and effective medical care, services, and medical supplies. Moreover, this approach should creatively incorporate multiple possible modes of service delivery, including the integration of community health workers and pharmacists. While there are considerable challenges to achieving this goal, concerted efforts are needed to reduce DFUs’ devastating effects on mortality and morbidity and the inequitable burden of poorly managed diabetes foot care among highly affected populations.

Availability of data and materials

The de-identified qualitative data that support the findings of this study are available from corresponding author upon reasonable request.

Armstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers and Their Recurrence. N Engl J Med. 2017;376(24):2367–75.

Article   Google Scholar  

Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217–28.

Article   CAS   Google Scholar  

Hoffstad O, Mitra N, Walsh J, Margolis DJ. Diabetes, lower-extremity amputation, and death. Diabetes Care. 2015;38(10):1852–7.

Walsh JW, Hoffstad OJ, Sullivan MO, Margolis DJ. Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom. Diabet Med. 2016;33(11):1493–8.

Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes. Diabetes Care. 1998;21(12):2161–77.

Ratliff HT, Shibuya N, Jupiter DC. Minor vs. major leg amputation in adults with diabetes: Six-month readmissions, reamputations, and complications. J Diabetes Complications. 2021;35(5):107886.

Rice JB, Desai U, Cummings AK, Birnbaum HG, Skornicki M, Parsons NB. Burden of diabetic foot ulcers for medicare and private insurers. Diabetes Care. 2014;37(3):651–8.

Tan TW, Armstrong DG, Concha-Moore KC, et al. Association between race/ethnicity and the risk of amputation of lower extremities among medicare beneficiaries with diabetic foot ulcers and diabetic foot infections. BMJ Open Diabetes Res Care. 2020;8(1):e001328.

Tan TW, Shih CD, Concha-Moore KC, et al. Disparities in outcomes of patients admitted with diabetic foot infections. PLoS One. 2019;14(2):e0211481.

Margolis DJ, Malay DS, Hoffstad OJ, et al. Incidence of diabetic foot ulcer and lower extremity amputation among Medicare beneficiaries, 2006 to 2008: Data Points #2. In: Data Points Publication Series. Rockville (MD) 2011.

Skrepnek GH, Mills JL, Armstrong DG. A Diabetic Emergency One Million Feet Long: Disparities and Burdens of Illness among Diabetic Foot Ulcer Cases within Emergency Departments in the United States, 2006–2010. PLoS One. 2015;10(8):e0134914.

Arya S, Binney Z, Khakharia A, et al. Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease. J Am Heart Assoc. 2018;7(2):e007425.

Eslami MH, Zayaruzny M, Fitzgerald GA. The adverse effects of race, insurance status, and low income on the rate of amputation in patients presenting with lower extremity ischemia. J Vasc Surg. 2007;45(1):55–9.

Lefebvre KM, Chevan J. The persistence of gender and racial disparities in vascular lower extremity amputation: an examination of HCUP-NIS data (2002–2011). Vasc Med. 2015;20(1):51–9.

Lefebvre KM, Lavery LA. Disparities in amputations in minorities. Clin Orthop Relat Res. 2011;469(7):1941–50.

Lefebvre KM, Metraux S. Disparities in level of amputation among minorities: implications for improved preventative care. J Natl Med Assoc. 2009;101(7):649–55.

PubMed   Google Scholar  

Skrepnek GH, Mills JL, Lavery LA, Armstrong DG. Health Care Service and Outcomes Among an Estimated 6.7 Million Ambulatory Care Diabetic Foot Cases in the U.S. Diabetes Care. 2017;40(7):936–42.

Isa D, Pace D. Is ethnicity an appropriate measure of health care marginalization? A systematic review and meta-analysis of the outcomes of diabetic foot ulceration in Aboriginal populations. Can J Surg. 2021;64(5):E476–83.

Carr D, Kappagoda M, Boseman L, Cloud LK, Croom B. Advancing Diabetes-Related Equity Through Diabetes Self-Management Education and Training: Existing Coverage Requirements and Considerations for Increased Participation. J Public Health Manag Pract. 2020;26 Suppl 2, Advancing Legal Epidemiology:S37-S44.

Sutherland BL, Pecanac K, Bartels CM, Brennan MB. Expect delays: poor connections between rural and urban health systems challenge multidisciplinary care for rural Americans with diabetic foot ulcers. J Foot Ankle Res. 2020;13(1):32.

Stevens CD, Schriger DL, Raffetto B, Davis AC, Zingmond D, Roby DH. Geographic clustering of diabetic lower-extremity amputations in low-income regions of California. Health Aff (Millwood). 2014;33(8):1383–90.

NIMHD Research Framework. National Institute on Minority Helath and Health Disparities Web site. https://www.nimhd.nih.gov/about/overview/research-framework/ . Published 2017. Accessed 22 Jan 2022.

Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health. 2015;42(5):533–44.

Alvidrez J, Castille D, Laude-Sharp M, Rosario A, Tabor D. The National Institute on Minority Health and Health Disparities Research Framework. Am J Public Health. 2019;109(S1):S16–20.

Crocker RT, T-W. Palmer, KNB. Marrero, DG. . The Patient’s Perspective of Diabetic Foot Ulceration: A Phenomenological Exploration of Causes, Detection, and Care-Seeking. J Adv Nurs. 2022;78(8):2482–94. 

Fayfman M, Schechter MC, Amobi CN, et al. Barriers to diabetic foot care in a disadvantaged population: a qualitative assessment. J Diabetes Complications. 2020;34(12):107688.

Schaper NC, Apelqvist J, Bakker K. Reducing lower leg amputations in diabetes: a challenge for patients, healthcare providers and the healthcare system. Diabetologia. 2012;55(7):1869–72.

Collinsworth AW, Vulimiri M, Schmidt KL, Snead CA. Effectiveness of a community health worker-led diabetes self-management education program and implications for CHW involvement in care coordination strategies. Diabetes Educ. 2013;39(6):792–9.

Rosenthal EL, Wiggins N, Ingram M, Mayfield-Johnson S, De Zapien JG. Community health workers then and now: an overview of national studies aimed at defining the field. J Ambul Care Manage. 2011;34(3):247–59.

Smith M. Pharmacists’ role in improving diabetes medication management. J Diabetes Sci Technol. 2009;3(1):175–9.

Nabulsi NA, Yan CH, Tilton JJ, Gerber BS, Sharp LK. Clinical pharmacists in diabetes management: What do minority patients with uncontrolled diabetes have to say? J Am Pharm Assoc (2003). 2020;60(5):708–15.

American Diabetes A. 10 Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018;41(Suppl 1):S105–18.

Sanders AP, Stoeldraaijers LG, Pero MW, Hermkes PJ, Carolina RC, Elders PJ. Patient and professional delay in the referral trajectory of patients with diabetic foot ulcers. Diabetes Res Clin Pract. 2013;102(2):105–11.

Download references

Acknowledgements

Our team acknowledge the participants of the study.

The project is supported by a National Institute of Diabetes and Kidney Disease K23 Mentored Patient-Oriented Research Career Development Award (1K23DK122126) and a Society of Vascular Surgery Foundation Mentored Research Career Development Award Program (T-W.T) and a National Institute of Diabetes and Kidney Disease R01 (1R01124789) Award (D.G.A).

Author information

Authors and affiliations.

Southwestern Academic Limb Salvage Alliance (SALSA), Los Angeles, Tucson, USA

Tze-Woei Tan & David G. Armstrong

Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Ste 4300, Los Angeles, CA, 90033, USA

Center for Health Disparities Research (CHDR), University of Arizona Health Sciences, Tucson, AZ, USA

Rebecca M. Crocker, Kelly N. B. Palmer & David G. Marrero

University of Arizona College of Medicine, Tucson, AZ, USA

Chris Gomez

You can also search for this author in PubMed   Google Scholar

Contributions

Tze-Woei Tan: Conceptualization, Methology, Validation, Formal Analysis, Writing – Original Draft, Writing – Review & Editing, Supervision, Project Administration, Funding Acquisition. Rebecca M. Crocker: Conceptualization, Methology, Validation, Formal Analysis, Writing – Original Draft, Writing – Review & Editing. Kelly N.B. Palmer: Conceptualization, Methology, Validation, Formal Analysis, Writing – Review & Editing. Chris Gomez: Methology, Validation, Formal Analysis, Writing – Original Draft, Writing – Review & Editing. David G. Armstrong: Conceptualization, Methology, Writing – Review & Editing. David G. Marrero: Conceptualization, Methology, Validation, Formal Analysis, Writing – Original Draft, Writing – Review & Editing. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Tze-Woei Tan .

Ethics declarations

Ethics approval and consent to participate.

The University of Arizona Institutional Review Board approved the study in July 2019 (Protocol Number 1906749805). All participants provided written informed consent prior to participation.

Consent for publication

Not applicable.

Competing interests

The authors haves no related conflicts of interest to declare.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Tan, TW., Crocker, R.M., Palmer, K.N.B. et al. A qualitative study of barriers to care-seeking for diabetic foot ulceration across multiple levels of the healthcare system. J Foot Ankle Res 15 , 56 (2022). https://doi.org/10.1186/s13047-022-00561-4

Download citation

Received : 24 May 2022

Accepted : 22 July 2022

Published : 06 August 2022

DOI : https://doi.org/10.1186/s13047-022-00561-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Diabetic foot complications
• Foot ulceration
• Barriers in assessing medical care
• Health care system barriers
• Qualitative

Journal of Foot and Ankle Research

ISSN: 1757-1146

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

• Research article
• Open access
• Published: 20 March 2020

Diabetic foot care: knowledge and practice

• Aydin Pourkazemi 1 ,
• Atefeh Ghanbari   ORCID: orcid.org/0000-0002-7949-5717 2 ,
• Monireh Khojamli 1 ,
• Heydarali Balo 1 ,
• Hossein Hemmati 1 ,
• Zakiyeh Jafaryparvar 1 &
• Behrang Motamed 3  

BMC Endocrine Disorders volume  20 , Article number:  40 ( 2020 ) Cite this article

35k Accesses

50 Citations

1 Altmetric

Metrics details

Diabetic foot ulcers (DFUs) are common problems in diabetes. One of the most important factors affecting the quality of diabetes care is knowledge and practice. The current study aimed at determining the knowledge and practice of patients with diabetes regarding the prevention and care of DFUs.

The current analytical, cross sectional study was conducted in Guilan Province (north of Iran) on 375 patients registered in the medical records as type 2 diabetes mellitus. Demographic characteristics, knowledge, and practice of participants were recorded in a questionnaire during face-to-face interviews conducted by the researcher. Descriptive and inferential statistics were performed using SPSS version18.

The mean score of knowledge was 8.63 ± 2.5 out of 15, indicating that the majority of participants had a poor knowledge (84.8%). The mean practice score was 7.6 ± 2.5 out of 15, indicating that a half of them had poor performance (49.6%). There was a significant and direct correlation between knowledge and practice. Knowledge level, place of residence, marital status, and history of admission due to diabetic foot were predictors of practice score.

Conclusions

According to the low level of knowledge and practice in patients with diabetes regarding the prevention and care of DFUs, and considering the significant relationship of some demographics of patients with knowledge and practice scores, a targeted educational program is needed to promote knowledge of patients with diabetes.

Peer Review reports

What is already known about this subject?

Diabetes accounted for 1.3 million deaths (2.4% of all death). The prevalence of diabetes varies among countries in Eastern Mediterranean Region (EMR).

Prevalence of diabetes mellitus in Iran ranged 20 to 30% in different provinces with higher frequency among females from 1990 to 2013.

Among people living with diabetes mellitus, 20% are at risk for foot ulceration as a result of neuropathy.

Diabetic foot ulcers (DFUs) are one of most common diabetes complications with 0–4% prevalence.

Good knowledge and practice regarding DFU reduces the risk of diabetic foot complications and ultimately amputation.

What are the new findings?

- In the current study, 84.8% of the participants had poor knowledge and only 8.8% had good practice. There was a direct and significant correlation between knowledge and practice.

The lowest knowledge scores belonged to the use of talcum powder or other powders and not using lotions between the toes.

The strongest variables related to practice were knowledge, place of residence, marital status, and history of admission due to diabetic foot, indicating that these four variables were the predictors of practice score.

How might this impact on clinical practice in the foreseeable future?

Patients’ knowledge about foot ulcer prevention should be promoted based on guidelines both in community and hospitals.

Adherence to guidelines prevents DFU; targeted interventions directed toward patients/health care providers can lead to reduced DFU complications.

Diabetes mellitus is a group of common metabolic disease characterized by hyperglycemia. Due to multiple and prolonged complications, diabetes affects almost all systems of the body [ 1 ]. Diabetes caused 1.3 million deaths (2.4% of all death) and 56 million disability adjusted life years (DALYs) in 2013. The diabetes DALY rate increased from 589.9 per 100,000 in 1990 to 883.5 per 100,000 populations in 2013. Total DALYs from diabetes increased by 148.6% during 1990–2013; population growth accounted for a 62.9% increase, and aging and increase in age-specific DALY rates accounted for 31.8 and 53.9%, respectively [ 2 ]. The prevalence of diabetes varies among countries in EMR. In Saudi Arabia, the prevalence of diabetes was reported 13.4% Saudis aged 15 years or older [ 3 ] and in Pakistan 12.1% for males and 9.8% for females aged ≥25 years [ 2 ]. A systematic review on the prevalence of type 2 diabetes in Iran showed a range of 3 to 20% in different provinces [ 4 ].

Of people living with diabetes, 20% are at high risk of foot ulceration as a result of neuropathy [ 5 ]. Diabetic foot ulcers (DFU S ) comprise 12–15% of total estimated cost of diabetes in the developed countries, increasing to 40% in the developing countries [ 6 ]. DFUs are one of the most common diabetes complications with 4 to 10% prevalence in the affected population [ 7 ]. The overall incidence of DFU is 5.8–6.0% in some particular diabetic in the U. S, while it is 2.1–2.2% in smaller populations in Europe [ 8 ]. Treating foot ulcers can be expensive and it is evident that about 49–85% of all DFU S can be prevented by raising awareness and taking proper measures [ 7 ]..

Among the complications of diabetes, DFU S affects the patient’s quality of life in case of amputation. However, it is possible to prevent amputation using educational and care strategies [ 9 ]. Data show that 25% of patients with diabetes develop a foot ulcer in their lifetime and that the cost of treating a DFU S is more than twice that of any other chronic ulcer [ 10 ]. Diabetic foot amputation remains an unpleasant impact on patients’ life more than other complications [ 11 , 12 ]. Delays in referral of serious foot problems are of particular concern [ 5 ]. Ndosi et al., reported that 15.1% of patients died within the year of presentation, the ulcer had healed in 45.5%, but recurred in (9.6%). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06) [ 13 ].

Understanding the level of knowledge and practice in patients with diabetes is important in planning for the better control of diabetes and its complications. A study by Ahmad and Ahmad on 124 patients with diabetes in North India reported that 60.5 and 79.0% got lower scores in knowledge and practice toward diabetes, respectively [ 14 ]. Jackson IL et al., reported that 79.5% of patients with diabetes in Nigeria had more than 70% of overall knowledge about self-care [ 15 ]. The results of a study in Malaysia showed that the most patients (58%) had poor knowledge and 61.8% of them had poor practice of foot care [ 16 ].

Among diabetes complications, the foot ulcers are considered as the most preventable ones. Risk factors of DFU S are correlated with poor practices and knowledge. Good knowledge and practice toward diabetic foot care reduces the risk of diabetic foot complications and ultimately amputation [ 7 ]. According to American Diabetes Association, annual assessments of knowledge, skills and behaviors are necessary for patients with diabetes [ 15 ].. The current study was conducted to assess patients’ knowledge and practice toward diabetic foot care. No similar study is conducted in Rasht City (the capital of Guilan Province, Northern Iran) thus far; therefore, the present study aimed at evaluating the level of practice and knowledge toward foot care in patients with type 2 diabetes mellitus. Health system can prevent DFU and amputation by applying a strategy to raise knowledge in patients.

Study design and subjects

The current analytical, cross sectional study was conducted at a clinic in Razi Hospital, affiliated to Guilan University of Medical Sciences, which is the only endocrine disease referral center across the province. Data were gathered from May to July 2017 and the subjects were selected by consecutive sampling. To Diagnostic and classify the patients, the American Diabetic Association, the diagnostic criteria were utilized [ 17 ]. Patients with diabetes receive care, education, treatment, and other services at this center. The center also delivers healthcare services to outpatients and inpatients, as well as routine training. The research project was approved by the Deputy of Research, Guilan University of Medical Sciences. Participation in the study was voluntarily and the subjects were informed about their right to withdraw from the study at any stage. The participant’s privacy was respected, and data were kept confidential and utilized for study purposes only. Participants were asked to read and sign an informed consent form. Inclusion criteria were: receiving the diagnosis of type 2 diabetes mellitus, age 18 years or above, taking anti-diabetic medications for at least 1 month prior to the study, having clinical records at the center, and willing to participate in the study. The exclusion criteria were: critically ill patients with diabetes, pregnant or newly diagnosed (less than 1 month) patients, receiving any other treatment or therapy, and having major psychiatric problems. A structured datasheet was used to collect demographic and clinical information of the patients using paper-based and digital records archives. Some information was also collected by a medical student through face-to-face interviews. A paper-based questionnaire was distributed among both outpatients and inpatients. Wagner DFU classification system was used to classify the patients based on ulcers. In this hospital, we assessed peripheral neuropathy, retinopathy and peripheral vascular disease (PVD), respectively by using monofilament testing, optometrist or ophthalmologist reports and the clinical diagnosis documented by the surgeon or, if available, images taken through arterial Doppler or angiography. Macro vascular disease was defined as any macro vascular complications other than PVD including prior myocardial infarction, angioplasty, coronary artery bypass grafting, ischemic heart disease, or stroke [ 18 ].

In the current study, having one or two more complications was considered a positive condition. The sample size was determined 375 considering 95% confidence interval with d = 0.05 and P  = 0.58. A total of 375 out of 395 distributed questionnaires were completed and returned; the response rate was 94.4%.

A three-section questionnaire was used in the current study. First section included demographic characteristics such as age, gender, and duration of diabetes mellitus, place of residence, occupation, and level of education, marital status, and body mass index. Second part consisted of 15 questions about knowledge scored based on nominal (yes/no/I don’t know) scale, and third part with 15 questions focusing on practice was scored based on “yes/no” scale. The questionnaire was used to measure the level of knowledge and practice of subjects toward diabetic foot care. Patients’ demographic data were collected to analyze factors associated with knowledge and practice toward diabetic foot care. Each correct answer was given 1 point; however, wrong answers or choosing “I don’t know” option was given 0 point. The total score for each part ranged 0 to 15. Good or poor level of knowledge was determined based on the 75% of the maximum score of the questionnaire; therefore, the scores higher than 11.25 were considered good and those lower than 11.25 were considered poor. Examples of the questions included “Do you care about your diabetes?”; “Do you wash your feet every day?”; “Do you check the water temperature before using it?” and “Do you dry your feet after washing?”

The questionnaire was translated into the Persian language. Following the translations conducted by an Iranian professor of English literature, a native bilingual English speaker translated it back into English. Content validity was determined by gathering the views of 15 medical and nursing professionals after reviewing the questionnaire. Content validity ratio (CVR) and content validity index (CVI) of the questionnaire were assessed. Mean scores of CVI and CVR were higher than 0.80. Cronbach’s α coefficients were computed to evaluate reliability of knowledge and practice, which were 0.80 and 0.85, respectively.

Statistical analysis

After collecting data, descriptive statistics (frequency, mean, and standard deviation) were employed to summarize patients’ socio-demographic data and Chi-square test to investigate association between predictors (factors) and knowledge and practice level. In order to assess the differences between groups, the Wilcoxon, Mann-Whitney, and Kruskal-Willis tests were used for continuous variables. Factors related to knowledge and practice was estimated by multiple regressions. In this research, wrong answers and “I don’t know” merged as poor awareness. In order to assess the relationship between individual variables with knowledge and practice, we had to integrate these two items in order to have a better analysis. Variables with a P -value of < 0.1 were included in the multi-variate models. P -value < 0.05 was considered as the level of significance. All analyses were performed using SPSS version 18.

The mean (± SD) age of the 375 participants was 55.4 (±12.9) years, and 56.4% were female. Majority of patients had diabetes for less than 10 years (54.1%), were female (56.5%), urban residents (62.1%), illiterate or had elementary education (73.1%), did not have normal BMI (69.8%), and (10.6%) patients had 2 and more complications (Table  1 ). In terms of knowledge, only 57 participants (15.2%) had good knowledge, most of them (84.8%) had poor knowledge, and the mean score of patients’ knowledge was 8.63 ± 2.65. The highest percentage of correct answers was found with the knowledge about “The need for meeting or consulting a physician, if there were signs of wounding” (88.8%), followed by “Not walking without shoes” (83.5%) and “Washing and changing socks” (9.81%). The lowest knowledge was about “The use of talcum powder or other powders between the toes” (3.5%), followed by “Not using lotion between the toes” (22.24%), and “The proper method of trimming the toenails” (23.2%).

In terms of practice, only 33 patients (8.8%) had a good practice; most of them (91.2%) had a poor practice (Table  2 ), and the mean score of patients’ practice was 7.6 (± 2.5). The participants reported their best practice toward “Importance of diabetes control” (80.5%), followed by “Meeting or consulting a physician, in case of signs of DFU” (79.2%). The poorest practice was toward “The use of talcum powder between the toes” (2.7%), followed by “Proper method of trimming the toenails” (25.9%), and “Keeping the foot skin soft” (30.9%).

There was a direct and significant correlation between knowledge and practice ( P  < 0.0001, r < 0.8) (Fig.  1 ). There was a significant relationship between knowledge score and gender, duration of diabetes, occupation, level of education, place of residence, having DFU, hospital stay history, and amputation history.

Correlation Between Khowledge and Practice

The study results showed that patients with more than 10 years history of diabetes, history of DFU, history of hospital stay or experience of lower limb amputation due to DFU, female gender, and the ones with complications had higher knowledge ( P  < 0.05).

There was a significant correlation between practice score and gender, duration of diabetes, occupation, level of education, and place of residence (P < 0.05) (Table  3 ).

Also, based on multiple regression, the strongest variables related to practice were knowledge score ( P  < 0.0001), place of residence ( P  < 0.03), marital status ( P  = 0.008), and DFU ( P  = 0.02), indicating that these four variables were the predictors of foot care practices in the current study (Table  4 ).

In the current study, majority of patients with diabetes had lower levels of education. Studies report that level of knowledge depends on the level of education [ 14 , 19 ]. Understanding this variable is highly important in designing strategies to prevent diabetes.

In the current study, most patients had lower scores of knowledge and practice toward foot care, and the mean practice score was lower than the mean knowledge score, which was similar to the findings of Muhammad-Lutfi’s and Kim’s studies [ 16 , 20 ]. A study conducted on patients with diabetes in Western Nepal reported poor KAP (knowledge, attitude and practices) score; they indicated that the plausible factors could be lack of knowledge, lack of information, and literacy level of the studied population [ 21 ]. Another study on young Saudi females with diabetes also reported poor KAP scores [ 19 ]. Some studies reported that patients with diabetes had good level of knowledge about diabetes [ 7 , 16 , 22 , 23 ]. The differences in knowledge about foot care among patients with diabetes across the studies could be due to different trainings on diabetes care provided by the health care professionals in different settings [ 23 ] and also the literacy level of the studied subjects.

Several studies reported poor foot care practices among patients with diabetes. Kheir et al., reported poor practices toward regular inspection of feet among patients in Qatar [ 24 ]. Hamidah et al., from Malaysia observed that 28.4% of patients newly diagnosed with diabetes practiced good habits towards foot care [ 25 ]. Desalu et al., from Nigeria observed that only 10.2% of patients with diabetes had good foot care practices [ 26 ]. It was difficult to compare the results of the current study with those of other studies since the nature of the study populations and the applied measurements were different.

In the current study, there was a direct and significant correlation between knowledge and practice scores; therefore, with an increase in the knowledge score, the practice score also increased. Other studies also showed that patients who receive trainings on foot care checked their feet regularly [ 20 ]. Patients who are advised to take care of their feet and the ones whose feet are regularly checked by physicians have better practices toward foot care [ 27 ].

In the current study, the lowest knowledge scores were regarding the application of talcum powder or other powders and not using lotions between the toes, and the proper way of trimming the toenails; while the lowest practice scores were related to the application of talcum powder between the toes, the proper way of trimming the toenails; keeping the foot skin soft, and avoid dryness.

It should also be noted that due to wet climate in the North of Iran, use of lotion between the toes is not common. Nevertheless, it also needs training. Patients with diabetes need to keep between their toes dry using talcum powder and avoid the application of lotion since it is important as a hygienic measure for feet in preventing fungal infection [ 28 ]. Patients should also use skin moisturizers daily to keep the skin of their feet soft and should trim their toenails straight across (not rounded) to prevent damage to their toes [ 29 ].

In the current study, gender, duration of disease, occupation, place of residence, level of education, having DFU, and a history of hospitalization, amputation, and complication had significant relationships with knowledge. Also, gender, duration of disease, place of residence, occupation, and level of education had significant relationships with practice. It was found that knowledge level was higher in females, patients with a diabetes history of more than 10 years, and the ones underwent amputation due to DFU compared to the others; in addition, females, patients with a diabetes history of more than 10 years, and urban residents had better performance. The current study results showed that males were usually reluctant to disclose their health problems and seek professional care. Also, males presented greater deficit in self-care compared to females [ 30 ].

In the study by Muhammad-Lotfi, age, gender, level of education, and duration of diabetes had no significant relationship with knowledge and practice. This finding was in agreement with that of the current study [ 16 ], but another study indicated a significant relationship between the level of education and knowledge [ 31 ].

People with higher education are expected to be more likely to read and receive information about their illness and foot care and understand the information provided by medical staff in health care settings.

But in the current study, there was no significant relationship between the level of education and knowledge or practice, which could be due to the poor and inadequate resources of information about diabetes at the community level, since both educated and uneducated groups had inadequate information. It may also be due to the fact that in spite of possessing knowledge, due to the lack of time, heavy work load, and lack of adequate insurance coverage, patients could not take good care of their feet in practice, which requires more studies to root out the causes.

Nevertheless, the attitude of patients toward self-care in addition to sufficient knowledge was not studied in the current study. As observed in the present study, patients with a history of DFU or hospital stay, and even amputation and complication had higher knowledge level. It could be due to the fact that while completing the questionnaire, the current knowledge level of the subjects was questioned, which indicated that training medical centers can raise the level of knowledge in patients with DFU. In many Iranian state hospitals, diabetic training programs are not well organized, and the existing programs are weak. It is believed that knowledge about diabetes in the general population as well as patients with diabetes in Iran is not enough and there is a dire need for a good program for diabetes [ 32 ].

The collected data indicated that patients with diabetes had poor practice and knowledge about foot care. This is basically due to lack of proper communication between patients and medical team and inadequate education. Based on nurses’ opinion, recommendations and guidelines play an effective role in prevention, treatment, and reduction of complication among patients with DFU. Therefore, adaptation, implementation, and evaluation of the educational programs were recommended [ 33 ].

Thus, patients should be trained for foot ulcer prevention based on clinical practice guidelines for diabetes mellitus both in the community and hospitals. The results of the current study encouraged a positive outlook: A diabetes educator should give necessary advices to patients during every visit, in order to improve their perception about disease, diet, and lifestyle changes and help them control their glycemic level and overcome the complications of diabetes.

According to the principle of “prevention is better than cure” and considering the predictive factors in the current study including poor knowledge, urban residency, being single, and lack of DFU, more attention should be paid to patients possessing risk factors .

Knowledge and practice toward foot care were poor in most patients with diabetes. There was a significant relationship between some demographic characteristics of patients and knowledge and practice toward foot care. The level of knowledge, place of residence, marital status, and history of hospital stay due to DFU were the predictors of practice in patients with diabetes.

The strength of the current study was that it was the first, study to discuss this important issue in Guilan Province. The study also had some limitations; first, since the work had a cross sectional design, the direction of relationships and causal relationships cannot be determined. Second, the result of the study should be interpreted with caution, since they were obtained from a single center; a clinic-based study. Hospital-based studies cannot provide a true picture of knowledge and practice in the community. The current study sample did not represent the whole Iranian population consisting of several ethnicities. In this research, responses of the wrong answers and “I don’t know” have been grouped together, in order to achieve better analysis. Perhaps with increasing sample size, we could solve this problem in future studies.

Adequate knowledge and good practices are important to effectively control diabetes mellitus. Patients require continuous support of family members and community in order to modify their lifestyle and behaviors and make sustainable changes in order to better control their diabetes disease. Also, education about diabetes mellitus and its risk factors should be provided through mass media in order to effectively control it in the community.

Availability of data and materials

The datasets used and /or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Content validity index

Content validity ratio

Diabetic foot ulcers

Eastern Mediterranean Region

World health organization

Janmohammadi N, Moazzezi Z, Ghobadi P, et al. Evaluation of the risk factors of diabetic foot ulcer and its treatment in diabetic patients, Babol, North of Iran. Iranian J Endocrinol Metab. 2010;11(2):121–5. https://doi.org/10.1155/2018/7631659 .

Article   Google Scholar  

Moradi-Lakeh M, Forouzanfar MH, El Bcheraoui C, et al. High fasting plasma glucose, diabetes, and its risk factors in the eastern mediterranean region, 1990–2013: findings From the Global Burden of Disease Study 2013. Diabetes Care. 2017;40(1):22–9. https://doi.org/10.2337/dc16-1075 Epub 2016 Oct 26.

Article   PubMed   Google Scholar  

Bcheraoui C, Basulaiman M, Tuffaha M, et al. Status of the diabetes epidemic in the kingdom of Saudi Arabia, 2013. Int J Public Health. 2014;59:1011–21.

Haghdoost AA, Rezazadeh-Kermani M, Sadghirad B, Baradaran HR. Prevalence of type 2 diabetes in the Islamic Republic of Iran: systematic review and meta-analysis. East Mediterr Health J. 2009;15:591–9.

Article   CAS   Google Scholar  

Paisey R, Abbott A, Levenson R, et al. Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the south-west of England. Diabet Med. 2018;35(1):53–62. https://doi.org/10.1111/dme.13512 Epub 2017 Oct 11.

Article   CAS   PubMed   Google Scholar  

Solan YM, Kheir HM, Mahfouz MS, et al. Diabetic Foot Care: Knowledge and Practice. J Endocrinol Metab. 2017;6(6):172–7. https://doi.org/10.14740/jem388e .

Haq NU, Durrani P, Nasim A, et al. Assessment of Knowledge and Practice of Diabetes Mellitus Patients Regarding Foot Care in Tertiary Care Hospitals in Quetta, Pakistan. Specialty J Med Res Health Sci. 2017;2(4):35–43.

Google Scholar  

Jeffcoate WJ, Boyko EJ, Vileikyte L, et al. Current Challenges and Opportunities in the Prevention and Management of Diabetic Foot Ulcers. Diabetes Care. 2018;41:645–52. https://doi.org/10.2337/dc17-1836 .

Morey-Vargas OL, Smith SA. Be Smart: Strategies for foot care and prevention of foot complications in patients with diabetes. Prosthet Orthot Int. 2015;39(1):48–60.

Hurlow JL, Hamphreys GI, Bowling FL, et al. Diabetic foot infection: a critical complication. Int Wound J. 2018:1–8. https://doi.org/10.1177/0309364614535622 .

Clarke P, Gray A, Holman R. Estimating utility values for health states of type 2 diabetic patients using the EQ-5D (UKPDS 62). Med Decis Mak. 2002;22(4):340–9. https://doi.org/10.1177/0272989X0202200412 .

Laiteerapong N, Karter AJ, Liu JY, et al. Correlates of quality of life in older adults with diabetes. Diabetes Care. 2011;34(8):1749–53. https://doi.org/10.2337/dc10-2424 Epub 2011 Jun 2.

Article   PubMed   PubMed Central   Google Scholar  

Ndosi M, Wright-Hughes A, Brown S, et al. Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study. Diabet Med. 2018;35(1):78–88. https://doi.org/10.1111/dme.13537 Epub 2017 Nov 20.

Ahmad S, Ahmad MT. Assessment of knowledge, attitude and practice among diabetic patients attending a health care facility in North India. Indian J Basic Appl Med Res. 2015;4(3):501–9.

Jackson IL, Adibe MO, Okonta MJ, et al. Knowledge of self-care among type 2 diabetes patients in two states of Nigeria. Pharmacy Pract. 2014;12(3) PMID:25243026,PMCID:PMC4161403.

Muhammad-Lutfi A, Zaraihah M, Anuar-Ramdhan I. Knowledge and practice of diabetic foot care in an in-patient setting at a tertiary medical center. Malays Orthop J. 2014;8(3):22. https://doi.org/10.5704/MOJ.1411.005 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

American Diabetes Association. Classification and diagnosis of diabetes: standards of medical Care in Diabetes 2019. Diabetes Care. 2019;42(Suppl. 1):S13–28. https://doi.org/10.2337/dc19-S002 .

Jeyaraman K, Berhane T, Hamilton M, et al. Mortality in patients with diabetic foot ulcer: A retrospective study of 513 cases from a single Centre in the Northern Territory of Australia. BMC Endocr Disord. 2019;19:1. https://doi.org/10.1186/s12902-018-0327-2 .

Saadia Z, Rushdi S, Alsheha M, et al. A study of knowledge attitude and practices of Saudi women towards diabetes mellitus. A (KAP) study in Al-Qassim region. Internet J Health. 2010;11(2). https://doi.org/10.4236/jdm.2015.52014 .

Kim A, Hongsranagon P. Preventive behaviors regarding foot ulcers in diabetes type II patients at BMA health center no. 48, Bangkok, Thailand. J Health Res. 2008;22(suppl):21–8.

Gautam A, Bhatta DN, Aryal UR. Diabetes related health knowledge, attitude and practice among diabetic patients in Nepal. BMC Endocr Disord. 2015;15(1):25. https://doi.org/10.1186/s12902-015-0021-6 .

Saleh F, Mumu SJ, Ara F, et al. Knowledge and self-care practices regarding diabetes among newly diagnosed type 2 diabetics in Bangladesh: a cross-sectional study. BMC Public Health. 2012;12(1):1112. https://doi.org/10.1186/1471-2458-12-1112 .

Gul N. Knowledge, attitudes and practices of type 2 diabetic patients. J Ayub Med Coll Abbottabad. 2010;22(3):128–31 PMID: 22338437.

PubMed   Google Scholar  

Kheir N, Greer W, Yousif A, et al. Knowledge, attitude and practices of Qatari patients with type 2 diabetes mellitus. Int J Pharm Prac. 2011;19(3):185–91. https://doi.org/10.1111/j.2042-7174.2011.00118.x .

Hamidah H, Santhna L, Ruth RP, et al. Foot care strategy for the newly diagnosed DM Type 2 patients with low educational and socio-economic background: a step towards future. Clin Ter. 2012;163(6):473–8.

CAS   PubMed   Google Scholar  

Desalu O, Salawu F, Jimoh A, et al. Diabetic foot care: self-reported knowledge and practice among patients attending three tertiary hospital in Nigeria. Ghana Med J. 2011;45(2):60–5 PMID: 21857723.

Bell RA, Arcury TA, Snively BM, et al. Diabetes foot self-care practices in a rural, triethnic population. Diabetes Educ. 2005;31(1):75–83. https://doi.org/10.1177/0145721704272859 .

Aalami HB, Aalami HA, Siavashi B. Diabetic foot ulcer management review of literature. Iran J Surgery. 2009;16(4):1–7. https://doi.org/10.17795/jssc23312 .

Hasnain S, Sheikh NH. Knowledge and practices regarding foot care in diabetic patients visiting diabetic clinic in Jinnah hospital, Lahore. J Pak Med Assoc. 2009;59(10):687 PMID: 19813683.

Rossaneis MA, Haddad MD, Mathias T, et al. Differences in foot self-care and lifestyle between men and women with diabetes mellitus. Rev Lat Am Enfermagem. 2016;24:e2761. https://doi.org/10.1590/1518-8345.1203.2761 .

Chiwanga FS, Njelekela MA. Diabetic foot: prevalence, knowledge, and foot self-care practices among diabetic patients in Dar es Salaam, Tanzania–a cross-sectional study. J Foot Ankle Res. 2015;8(1):20. https://doi.org/10.1186/s13047-015-0080-y .

Delavari A, Alikhani S, Nili S, et al. Quality of care of diabetes mellitus type II patients in Iran. AIM . 2009;12(5):492–5 PMID: 19722773.

Ghanbari A, Rahmatpour P,Jafaraghaee et al .Quality assessment of Diabetic Foot ulcer clinical practice guildeline. J Evid Based Med .2018; 11(3):200–207. doi: https://doi.org/10.1111/jebm.12304 .

Download references

Acknowledgements

The authors wish to thank all the individuals who helped throughout the study, especially Razi Clinical Research Development Center.

The study was funded by the Deputy for Research; Guilan University of Medical Sciences. The funder had no role in the study design, data analysis and interpretation, and writing of the manuscript.

Author information

Authors and affiliations.

Razi Clinical Research Development unit, Guilan university of medical sciences, Rasht, Iran

Aydin Pourkazemi, Monireh Khojamli, Heydarali Balo, Hossein Hemmati & Zakiyeh Jafaryparvar

Social Determinants of Health Research center, nursing and midwifery school, Guilan University of medical sciences, Rasht, Iran

Atefeh Ghanbari

Department of internal medicine , Razi Hospital ,School of Medicine, Guilan university of Medical Sciences, Rasht, Iran

Behrang Motamed

You can also search for this author in PubMed   Google Scholar

Contributions

PA, KM, and GA: the study design; PA,KM and MB: data collection; PA, KM, GA, HH, and BH: data analysis; PA, GA, KM, BH, HH, MB and JZ: data interpretation and drafting of the manuscript. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Atefeh Ghanbari .

Ethics declarations

Ethics approval and consent to participate.

Written informed consent was obtained from participations and verbal consent from illiterate participants following a detailed explanation of the study objectives. The study was conducted in accordance with the ethical principles and its protocol was approved by the Ethics Committee of Guilan University of Medical Sciences (ethical code: IR.GUMS.REC.1396.8).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Pourkazemi, A., Ghanbari, A., Khojamli, M. et al. Diabetic foot care: knowledge and practice. BMC Endocr Disord 20 , 40 (2020). https://doi.org/10.1186/s12902-020-0512-y

Download citation

Received : 07 January 2019

Accepted : 25 February 2020

Published : 20 March 2020

DOI : https://doi.org/10.1186/s12902-020-0512-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Diabetic foot
• Diabetes mellitus

BMC Endocrine Disorders

ISSN: 1472-6823

• General enquiries: [email protected]

Diabetic Foot Self-Care Practices Among Adult Diabetic Patients: A Descriptive Cross-Sectional Study

Affiliations.

• 1 Department Hospital Pharmacy, Bako Primary Hospital, West Shewa, Oromia, Ethiopia.
• 2 Institute of Health, School of Pharmacy, Department of Pharmaceutics, Jimma University, Jimma, Oromia, Ethiopia.
• 3 Institute of Health, School of Pharmacy, Department of Clinical Pharmacy, Jimma University, Jimma, Oromia, Ethiopia.
• PMID: 33304103
• PMCID: PMC7723031
• DOI: 10.2147/DMSO.S285929

Background: Adequate foot care and regular foot examinations along with optimal glycemic control are effective strategies to prevent foot ulceration.

Aim: The aim of this study was to describe the patterns of foot self-care practice among diabetic patients attending an ambulatory clinic.

Methods: A descriptive cross-sectional study was conducted at the ambulatory clinic of Jimma Medical Center. A consecutive sampling technique was used. The data were analyzed by SPSS version 20 and descriptive statistics were used to describe the findings.

Results: A total of 370 diabetic patients (55.9% male and 68.4% type 2) were interviewed. The mean (±SD) age of the patients was 46.47±13.63 years. Over one-third (35.7%) of the patients had a previous history of foot ulcer. The majority of the patients self-inspect (92.5%) and wash (82.7%) 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: Jimma Medical Center; diabetes mellitus; foot self-care; practice.

© 2020 Hirpha et al.

Grants and funding

ORIGINAL RESEARCH article

Knowledge, attitudes, and practices associated with diabetic foot prevention among rural adults with diabetes in north china.

• 1 School of Public Health, Shanxi Medical University, Taiyuan, China
• 2 School of Management, Shanxi Medical University, Taiyuan, China

Background: The diabetic foot is a global threat to public health because it can result in infection and amputation, as well as cause the patient to experience considerable pain and incur financial costs. The condition of patients with diabetic foot in North China is distinguished by more severe local ulcers, a worse prognosis, and a longer duration of disease than that of patients with diabetic foot in the south. Through appropriate preventive measures, the diabetic foot can be effectively avoided. This study assesses the existing knowledge, attitudes and practices associated with diabetic foot prevention among adults with diabetes living in rural areas of North China.

Method: This cross-sectional survey included 1,080 rural adults from North China, cluster sampled 12 villages and surveyed diabetic patients without diabetic foot who participated in community diabetes management. The self-administered knowledge and attitude questionnaire and the Chinese version of the Nottingham Assessment of Functional Foot-care Questionnaire were used.

Result: Of the 1,080 subjects, 51.6% received moderate knowledge scores, 63.9% had a positive attitude and 71.4% received poor practice scores. In terms of knowledge, parameters of knowledge about foot examinations and treatment of foot problems showed the lowest scores. In terms of practice, in line with the results of the low knowledge score, parameters of the pursuit of medical treatment for foot problems and routine foot examinations were associated with the lowest scores. Multiple regression analysis revealed that participants who were current smokers (β: −0.049, 95% CI: −0.088 to −0.011) had lower knowledge scores than those who never smoke; participants who were current smokers (β: −0.818, 95% CI: −1.067 to −0.569) and past smokers (β: −0.299, 95% CI: −0.485 to −0.112) had lower attitude scores than those who had never smoked; participants who had higher knowledge scores (β: 1.964, 95% CI: 1.572–2.356) achieved higher scores on attitudes; women had better practice scores than men (β: 0.180, 95% CI: 0.122–0.239); patients with a long diabetes duration (6–10 years) had better practice scores than those who had a short diabetes duration (<2 years; β: 0.072, 95% CI: 0.012–0.131). Knowledge (β: 0.130, 95% CI: 0.001–0.258) and attitudes (β: 0.268, 95% CI: 0.249–0.287) were significantly associated with good practices.

Conclusions: Increasing knowledge regarding diabetic foot would help instill positive attitudes and cultivate better practices toward diabetic foot prevention. The results of this study may help guide future promotional resources to those groups most in need, which may help lower the incidence of diabetic foot among adults in North China.

Introduction

Diabetes is a metabolic disorder characterized by high blood glucose levels and is one of the most common chronic non-communicable diseases worldwide ( 1 ). According to the International Diabetes Federation Diabetes Atlas 10 th edition, an estimated 537 million people worldwide had diabetes in 2021, with that figure expected to rise to 643 million by 2030 ( 2 ). There are many patients with diabetes in China, and its prevalence rate has rapidly increased recently ( 3 ).

The prognosis of diabetes is perturbing due to long-term hyperglycemia leading to chronic damage and dysfunction of various tissues, especially the eyes, kidneys, heart, blood vessels and nerves ( 4 ). Diabetic foot is one of the most difficult complications to treat among all the complications of diabetes ( 5 ). Diabetic foot ulcers (DFU) are associated with high morbidity and mortality globally ( 6 ). A diabetic limb is amputated every 20 s according to estimates ( 7 ). In a Chinese tertiary hospital, the overall amputation rate among patients with diabetic foot ulcers was reported to be 21.5% ( 8 ), and mortality associated with lower extremity arterial diseases in patients with diabetes exceeded that associated with most cancers (except lung cancer, pancreatic cancer and others) ( 9 ). Furthermore, diabetic foot frequently necessitates extended hospitalization, which raises costs ( 10 ). As a result, the diabetic foot is regarded as one of the leading causes of disability and death in diabetes patients and a major public health issue imposing a significant socio-economic burden ( 7 ). Therefore, policymakers and academic researchers are focusing more on diabetic foot prevention.

Diabetic foot is preventable ( 11 ); early identification of and implementation of timely intervention against the risk factors of diabetic foot is critical for its prevention and treatment. In developed countries, growing evidence regarding diabetic foot treatment has revealed that relatively simple and low-cost interventions can reduce amputation rates by up to 85% ( 12 ). Peripheral neuropathy, peripheral vascular disease, abnormal plantar pressure, poor blood glucose control, and smoking are all risk factors for diabetic foot ulcers, and they all play a role in the disease's pathophysiology ( 13 ). Furthermore, studies have shown that age, gender, education level, lifestyle and socio-economic status are also important factors ( 14 ).

Previous research has also investigated the psychological factors of diabetic foot prevention. Palaya et al. ( 15 ) noted that self-efficacy influences diabetic patients' self-management behavior. Guo et al. ( 16 ) discovered that due to long-term disease treatment and management, patients may develop diabetes-related psychological distress such as depression and anxiety, including medical consultation-related distress, change-in-condition-related distress, and emotional burden-related distress, which can prevent patients from dealing with foot ulcer management and glycaemic control. Laopoulou et al. point out that the social support that patients receive from different sources can help them develop better self-management perseverance and help facilitate self-management practices ( 17 ). Over the last two decades, a large number of diabetic foot KAP studies have been conducted focused on identifying barriers to foot-care and improving foot care ( 18 – 20 ). Most studies agree that having more knowledge and positive attitudes toward diabetic foot care can help promote good diabetic foot-care practices ( 18 , 21 ). KAP-related studies can be used to improve patient foot care and to develop appropriate diabetic foot interventions.

Although there is an increasing number of studies on the diabetic foot, little is known about knowledge, attitudes and practices related to diabetic foot prevention among adults with diabetes living in rural areas of North China. Compared with those in southern China, patients with diabetic foot patients in North China were reported have a longer course of podiatry and a worse prognosis. Patients in the south are more affected by vascular and inflammatory factors, whereas those in the north are more affected by factors not only affected by hematology and vascular lesions but also restricted by economic conditions ( 22 ). Optimal foot-care practices may be the most cost-effective method for prevention or detecting diabetic foot complications, particularly in resource constrained areas ( 23 ). Furthermore, although studies have examined the impact of demographic variables on KAP of diabetic foot prevention, differences may exist between populations due to geographical, economic, and cultural factors. As a result, we need to understand the current status of KAP in diabetic foot prevention in patients with diabetes in rural North China, as well as the factors that influence them.

Understanding the current situation, identifying gaps, and improving policy require assessing the KAP for diabetic foot prevention among rural northerners. Therefore, the purpose of this study was to examine the knowledge on diabetic foot prevention, attitudes toward diabetic foot prevention, and foot-care practices among rural adults with diabetes in North China. We also aimed to identify the association between knowledge, attitudes and practices, and sociodemographic and clinical variables.

Materials and Methods

This cross-sectional study included rural adults with diabetes living in North China. Ethics approval was obtained from the Scientific Ethics Review Board of Shanxi Medical University (Code: 2021010). Participation in this study was voluntary, and informed consent was obtained from all participants.

Participants

We used the following Cochrane formula to determine the minimum sample size of this study:

where N = sample size, p = prevalence of diabetes in Chinese adults; q = 1 – p ; Z = standard normal deviation, usually set at 1.96, corresponding to the 95% confidence interval; and d = degree of accuracy desired, set at 0.02 in this study. Therefore, the minimum sample size calculated was 1,043. Assuming that 3% of the questionnaire answers would be incomplete, the sample size was finally determined to be 1,080.

All samples were selected using a multistage, stratified cluster sampling design (provinces, cities, or villages were selected as strata), and the clusters were selected from each strata. From October 2021 to January 2022, four cities were randomly selected in North China based on different geographical characteristics: Huaibei of Anhui Province, Baoding of Hebei Province, Liaoyang of Liaoning Province and Yantai of Shandong Province. Three villages were selected from each of the four cities. Participants were recruited based on the management records of each village. The inclusion criteria were patients with diabetes aged ≥18 years, living in rural areas of North China, clinically diagnosed with type 1 and type 2 diabetes for >6 months and with no foot ulcers. All diabetic patients in the selected villages who met the inclusion criteria and agreed to participate in the survey were included in the study. Patients who could not answer questions because of their mental state or showed severe clinical symptoms were excluded.

Questionnaires

The questionnaire comprises four sections. The first section is regarding the sociodemographic characteristics, including gender, age, marital status and education status, and clinical characteristics, including diabetes duration and smoking status, of the patients.

The second section comprises 11 questions regarding knowledge on diabetic foot prevention knowledge which was developed based on the researchers' knowledge and experience and published information ( 24 ). This section was designed to investigate the two dimensions of foot-care knowledge, i.e. risk factors of diabetic foot (five items) and foot examinations and treatment of foot problems (six items), using a two-point scale (0 = false and not sure, 1 = correct answer).

The third section of the questionnaire includes nine items to measure people's attitudes toward diabetic foot prevention. The questionnaire was designed to investigate three dimensions of foot-care attitudes, i.e. susceptibility to diabetic foot (two items), the importance of diabetic foot prevention (five items), and the initiatives related to diabetic foot prevention (two items), using a five-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree).

Finally, the fourth section of the questionnaire measures people's foot-related self-care practices. The Chinese version of the Nottingham Assessment of Functional Foot-care Questionnaire developed by Jing Li's team has been proven to be a valid and reliable method of assessing diabetic foot-care practices; therefore, it was used in this study ( 25 ). This questionnaire included 24 items, including five dimensions, such as daily foot examination (three items), foot cleaning (four items), foot protection (five items), choosing shoes and socks (nine items), and the behavior of seeking medical treatment for foot problems (three items). Among these, eight items follow reverse scoring. Additionally, the participants were asked to rate the frequency of performing the abovementioned practices on a four-point Likert scale, with higher scores indicating better foot self-care practices.

Statistical Analyses

Descriptive data are presented as means, standard deviations, and absolute frequencies and percentages depending on whether the variables were continuous or categorical. The sum score of each outcome was assessed based on Bloom's cut-off point ( 26 ). Knowledge was classified into the low level (<60%; 0–6 scores), moderate level (60–80%; 7–8 scores) and high level (>80%; 9–11 scores). Attitudes were classified into negative attitudes (<60%; 0–26 scores), neutral attitudes (60–80%; 27–36 scores) and positive attitudes (>80%; 37–45 scores). Practices were classified into the poor (<60%; 0–57 scores), moderate (60–80%; 58–76 scores), and good (>80%; 77–96 scores) levels. Pearson's correlation analysis was also used to determine the correlations between knowledge, attitudes and practices of diabetic foot prevention. Association of sociodemographic and clinical characteristics with knowledge, attitude, and practice was assessed using t -tests and analysis of variance (ANOVA). More specifically, t -test was used to assess the significant differences between two dependent variables. One-way ANOVA test was used to assess the significance of differences among three and more dependent variables. Multiple linear regression models were conducted to analyse predictor variables that were associated with the knowledge, attitude, and foot self-care practice scores. Variables that proved to be statistically significant in univariate analysis were further subjected to multiple linear regressions as well as the progressive incorporation of knowledge, and attitudes according to KAP theory. Specifically, gender and smoking status were entered as predictors in the regression model, with knowledge scores as the dependent variable. Gender, age, education status, diabetes duration, smoking status, and knowledge scores were entered as predictors in the regression model, with attitude scores as the dependent variable. Gender, duration of disease, smoking status, knowledge scores, and attitude scores were entered as predictors in the regression model, with practice scores as the dependent variable. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS; v.25).

Sociodemographic and Clinical Characteristics and Sources of Information on Diabetic Foot

A total of 1,080 participants completed the questionnaire; of these, 556 respondents (51.5%) were men, 595 (55.1%) were aged >60 years, and 866 (80.2%) were married. Regarding the education status, 648 (60%) of the 1,080 participants received primary school education or lower education and 176 (16.3) received a high school degree or higher education. More than one-third ( n = 435, 40.3%) of the respondents had diabetes that lasted >10 years and 109 (10.1%) were current smokers. The sociodemographic and clinical characteristics of the study population are shown in Table 1 .

Table 1 . Sociodemographic and clinical characteristics of the study population ( n = 1,080).

Knowledge, Attitudes and Practices of Diabetic Foot Prevention

Knowledge on diabetic foot prevention.

The highest possible score for all knowledge-related questions was 11. Based on the data of the 1,080 participants, the knowledge score ranged between 2 and 11 (mean ± standard deviation, 7.4 ± 1.5), indicating an overall knowledge level of 67.3%. Further, 63.5% participants scored low on knowledge on foot examinations and treatment of foot problems ( Table 2 ). The deficiencies are mainly reflected by the considerations that smoking is unimportant for preventing diabetic foot, that people with diabetes do not take long to heal from foot injuries and foot problems, and that scratching feet when the skin is dry; and that blisters and calluses can be treated by patients themselves.

Table 2 . Knowledge scores of diabetic foot prevention.

Attitudes Toward Diabetic Foot Prevention

Regarding attitudes, the highest possible score for all attitude-related questions was 45. Based on the data of the 1,080 participants, the attitude score ranged between 11 and 44 (mean ± standard deviation, 33.93 ± 9.0). It was observed that most participants (690, 63.9%) had a positive attitude. Among the three dimensions of attitude-related questions, the score for susceptibility to diabetic foot was the highest, that for the importance of diabetic foot prevention was lower, and that for the initiative of diabetic foot prevention was the lowest ( Table 3 ).

Table 3 . Attitude scores of diabetic foot prevention.

Practices of Foot Self-Care

Regarding practices of foot self-care, 771 (71.4%) participants scored poorly. Among the five dimensions of foot-care practice, the scores for the behavior of seeking medical treatment for foot problems was the lowest (40.4%) and that for daily foot examination was also low (42.3%), which was lower than the score rates for the other three dimensions ( Table 4 ).

Table 4 . Practice scores of diabetic foot prevention.

Univariate Analysis of Diabetic Foot Prevention Knowledge, Attitudes, and Foot-Care Practices

Univariate analysis revealed that the mean scores for knowledge were significantly different among participants based on their gender ( t -test, P < 0.05) and smoking status (ANOVA, P < 0.05). The mean attitude score was significantly different among participants based on their gender ( t -test, P < 0.05), age, education status, diabetes duration and smoking status (ANOVA, P < 0.05; Table 5 ). The mean practice scores were significantly different among participants based on their gender ( t -test, P < 0.05), diabetes duration, and smoking status (ANOVA, P < 0.05; Table 5 ).

Table 5 . Univariate analysis of diabetic foot prevention knowledge, attitudes, and foot self-care practices.

Correlation Between Knowledge, Attitudes, and Practices of Diabetic Foot Prevention

A correlation test indicated a direct and significant correlation between knowledge and attitudes ( P < 0.01, r = 0.309), knowledge and practices ( P < 0.01, r = 0.257), and attitudes and practices ( P < 0.01, r = 0.700).

Multiple Factors Analysis of Diabetic Foot Prevention Knowledge, Attitudes and Foot Self-Care Practices

As presented in Table 6 , the multivariable linear regression suggested that smoking status remained statistically significant in the final multivariable linear regression analysis ( F = 5.355, P = 0.001). The current smokers had lower knowledge scores than those who never smoked (β: −0.049, 95% CI: −0.088 to −0.011, P = 0.011).

Table 6 . Multiple linear regression results of knowledge, attitudes, and practices toward diabetic foot prevention.

Smoking status and knowledge showed statistically significant predictive capability for attitude scores. These two independent variables could explain 17.1% variation of attitude ( F = 21.234, P < 0.001). Specifically, the attitude scores of current smokers (β: −0.818, 95% CI: −1.067 to −0.569, P < 0.001) and past smokers (β: −0.299, 95% CI: −0.485 to −0.112, P = 0.002) were lower than those of never smokers. And knowledge positively affected attitude toward diabetic foot prevention (β: 1.964, 95% CI: 1.572–2.356, P < 0.001), the attitude score increases with the increase of knowledge score ( Table 6 ).

The results indicated that gender, diabetes duration, knowledge and attitude played a part in practice of foot care; these four independent variables could explain 54.7% variation of practice ( F = 164.038, P < 0.001). Specifically, women had better practice scores than men (β: 0.180, 95% CI: 0.122–0.239, P < 0.001). Patients with a long diabetes duration (6–10 years) had better practice scores than those with a short diabetes duration (<2 years; β: 0.072, 95% CI: 0.012–0.131, P = 0.018). Knowledge (β: 0.130, 95% CI: 0.001–0.258, P = 0.048) and attitudes (β: 0.268, 95% CI: 0.249–0.287, P < 0.001) positively affect practices ( Table 6 ).

Late complications of diabetes, especially diabetic foot, may lead to amputation, resulting in functional decline, increased economic burden on patients and a sharp decline in the patients' quality of life. Therefore, preventing diabetic foot is necessary. To the best of our knowledge, this is the first survey of its kind to be conducted in North China to determine the knowledge, attitudes, and foot-care practices regarding diabetic foot prevention among rural adults with diabetes. As measured by our survey, 23.3% of patients with diabetes have good knowledge on diabetic foot prevention and most have a positive attitude toward preventing diabetic foot. However, only 3% of patients with diabetes followed good diabetic foot prevention practices. The practice scores were lower than knowledge scores as revealed by the questionnaire, thus reflecting poor compliance with good self-care practices. Our results were comparable to those of other studies where the practice scores were always lower than knowledge scores ( 27 , 28 ).

Present Knowledge on Diabetic Foot Prevention

In our study, 56.1% of the participants had moderate and 25.1% had poor knowledge on diabetic foot. These results are in accordance with those of a previous study conducted in 144 hospitals across 31 Chinese provinces. Li et al. ( 29 ) reported that most patients with type 2 diabetes have a medium level of knowledge. Another study in Iran also reported similar results ( 30 ). Smoking is a significant risk factor for peripheral artery disease, which is directly related to the development of the diabetic foot; therefore, quitting smoking is crucial for preventing diabetic foot ( 31 ). Scratching of feet when the skin is dry may increase the risk of skin ulceration ( 32 ). Due to the influence of long-term hyperglycemia, oxidative stress, and various vascular and neurological complications, wound healing in patients with diabetes is usually delayed, resulting in chronic ulcers and diabetic foot. Notably, callus removal should be performed by professionally trained diabetic podiatrists as untimely treatment or improper management can lead to local or general infection, gangrene in serious cases, and even to amputation ( 33 ).

Present Attitudes Toward Diabetic Foot Prevention

The results of the present study demonstrated that the majority of the participants (63.9%) had a positive attitude toward prevention of diabetic foot. Analysis of the three dimensions of attitude indicated that most patients are well aware of their susceptibility of diabetic foot but pay little attention to its prevention, and lack motivation to take preventive measures. A possible reason for this may be that diabetic foot complications develop slowly, which leads patients to not realize the serious consequences in a short period of time, leading to them having a laidback attitude, patients think that they will not have diabetic foot or that complications will not occur in the near future, which subsequently leads to patients not taking measures to prevent diabetic foot.

Present Foot Self-Care Practices

The results of our study indicated that the foot self-care practices among the population of the rural areas in North China are concerning. Many patients treated corns, calluses and wounds on their own. This is consistent with the findings of studies conducted around the world ( 34 – 36 ). Patients chose to self-treat their foot problems, possibly due to a lack of foot-care knowledge or poor availability of medical facilities in rural areas.

The results of this study also indicated that daily foot examination behavior was poor. This is also in line with the results of other domestic ( 37 ) and international studies ( 34 ). Sun et al. ( 37 ) observed that some patients believe that asymptomatic feet do not require daily examination and, as a result, do not value the daily examination of feet and shoes before wearing them. Poor implementation of the daily examination dimension may be related to the patients' lack of knowledge on foot care for diabetic foot prevention. Furthermore, foot self-care necessitates long-term commitment, and checking feet and shoes every day can be repetitive and boring with no discernible effect in the short term.

Factors Influencing Foot-Care Knowledge, Attitudes and Practices

Our study examined the factors influencing the level of foot prevention knowledge, attitudes and practices among the participants. We found that current smokers had lower levels of knowledge and poor attitudes toward diabetic foot prevention than those who never smoked. According to Khamseh et al. ( 30 ), possible explanations for this include lower health literacy among smokers and reluctance to accept new information, making it more difficult for them to understand the complex disease mechanisms of the diabetic foot and the means of prevention offered; this makes them less motivated to take prevention measures ( 38 ). This could be a warning sign as smokers are more likely to develop foot complications such as ulcers and amputation in the future.

Our results revealed that rural women scored higher than men in terms of foot self-care practices related to diabetic foot prevention. Similar findings were also reported in studies conducted by Rossaneis et al. in Brazil. The difference observed may be attributed to the fact that men have lower levels of health literacy and concern for their health than women. Women pay more attention to the signs and symptoms of diseases, are more concerned about their body image, and have difficulty accepting the inability to walk properly and physical defects caused by diabetic foot, whereas men are often reluctant to admit their health problems and seek professional care ( 39 ). Another study on men's self-perceived health confirmed that most men did not seek medical care even after being diagnosed with a chronic disease owing to a lack of time during the working days, their schedules not coinciding with the working hours of health services, lack of severe symptoms, or because they faced more challenges in accessing medical services than women ( 40 ). As a result, women practiced better foot self-care than men. According to a meta-analysis, men with diabetic foot have roughly one and a half the amputation risk than women with diabetic foot ( 41 ). To tackle this, diabetic men should receive adequate health education.

The duration of diabetes influenced the mean practice scores; patients with a longer diabetes duration performed better in foot self-care practice. This is consistent with the findings of previous research ( 29 , 42 , 43 ). It is possible that patients having diabetes for a long duration were more likely to have repetitive educational sessions, which may favor their attitude and practice scores. However, patients having diabetes for a short duration may have less of an opportunity to receive foot self-care education. Therefore, individualized and systematic education should be developed and guidance should be provided according to disease duration to improve the self-care practice related to diabetic foot prevention in patients with diabetes.

Our study revealed that educational status had no impact on the foot self-care practice scores. Several studies found a significant association between education status and diabetic foot-care practice levels ( 18 , 44 ). This difference can be explained by the lack of adequate promotion of diabetic foot awareness in our study population. Both highly and poorly educated patients were inadequately informed about diabetic foot prevention.

Our results also indicated that knowledge positively affected attitudes and knowledge and attitudes positively affected practices. The better the patients' knowledge on foot care, the more positive was their attitudes toward preventing diabetic foot. Additionally, the more active measures that patients took to prevent diabetic feet, the better they cared for their feet. These results are consistent with previous studies ( 42 , 45 ). According to the KAP theory, the relationship between knowledge, attitudes and practices is progressive. Knowledge and information are the foundation for developing positive and correct beliefs and attitudes for changing health-related behavior.

Notably, the findings indicate that participants' diabetes knowledge did not translate into action to prevent foot problems. This implies that the intervention should shift from traditional education to critical education, i.e. the focus of education shifts from a purely knowledge-based domain to a concrete behaviors-based level. The mindsponge mechanism, which illustrates how a person can absorb new values and eject waning values conditionally based on contexts ( 46 ), suggests that specific individual characteristics and the interaction between the individual and the environment need to be considered when designing educational interventions ( 47 ). Specifically, when exposed to new information, people judge whether to keep it or discard it based on perceived value, the closer the information is to mindset, the more likely it is to be accepted. Accepted information becomes part of one's belief system and can influence subsequent decisions.

Health education aims to provide information to promote behavioral change to enhance health and quality of life. It is necessary to develop facilities for the patients to reinforce and maintain the desired behavior and to make the patients with diabetes willing participants in the educational process. This necessitates a collaborative effort between the hospital, health workers, health education teams, patients, and their families ( 48 , 49 ). When caring for diabetic patients, healthcare professionals should first assess their patients' knowledge and skills in diabetic foot care, particularly their ability to deal with foot problems daily. Moreover, health education teams target patients to provide them with the knowledge they need while assessing their willingness to use effective learning methods. Subsequently, a special foot clinic is recommended for hospitals and correct treatment methods are recommended for rural family doctors to increase the likelihood of patients with diabetes seeking medical help when they develop foot problems. These measures make it easier for patients with diabetes to seek medical help. Further, for patients to develop the habit of daily foot examinations, they are advised to organically integrate various care practices with their daily habits, which require the help and support of family members. As family members are a closely related group of patients with similar daily lifestyles, involving them in management helps reduce isolation and boredom as well as improve patients' self-care practices. To sum up, it is suggested that patients' diabetic foot-care practices be improved in the future through well-targeted knowledge education, increased motivation to prevent diabetic foot, facilitated medical visits, and an environment that encourages family foot care.

Limitations

Foot self-care practices were determined through a self-reported questionnaire, which may have response and recall biases. Prospective studies with larger sample sizes are warranted to explore the soci-cultural, clinical, and psychological factors that influence foot-care behavior, and further qualitative studies may be needed to explore additional influencing factors.

Conclusions

Patients with diabetes in rural areas of North China have poor diabetic foot prevention knowledge and foot-care behavior. We discovered that knowledge, attitude, gender, and duration of diabetes significantly influenced patients' practice of foot care. Considering the severity of the problem of diabetic foot in North China and the low level of knowledge and foot self-care practice, it is necessary to strengthen the education of diabetic foot prevention knowledge among adult patients in rural areas of North China. The findings of this study may help guide future promotional resources to those groups most in need, which may help reduce the occurrence of diabetic foot among adults in North China. Structured programs need to be planned to improve the knowledge, attitudes, and practices of diabetic foot prevention. Education should be differentiated by gender, diabetes duration, and smoking status.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Scientific Ethics Review Board of Shanxi Medical University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author Contributions

JC, HJ, and XW contributed to conception and design of the study. JC funded the study. HJ and XW participated in field study, organized the database, and performed the statistical analysis. HJ wrote the first draft of the manuscript. XW wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors gratefully acknowledge the active participation of all respondents.

1. Ramachandran S, Asokkumar K, Maheswari MU, Ravi TK, Dharman J. Investigation of antidiabetic, antihyperlipidemic, and in vivo antioxidant properties of Sphaeranthus indicus Linn in type 1 diabetic rats: an identification of possible biomarkers. Evid Based Complement Alternat Med. (2010) 2011:571721. doi: 10.1155/2011/571721

PubMed Abstract | CrossRef Full Text | Google Scholar

2. International Diabetes Federation. IDF Diabetes Atlas , 10th ed. Brussels (2021). Available online at: https://www.diabetesatlas.org (accessed January 10, 2022).

Google Scholar

3. Wang L, Peng W, Zhao Z, Zhang M, Shi Z, Song Z, et al. Prevalence and treatment of diabetes in China, 2013–2018. JAMA. (2021) 326:2498–506. doi: 10.1001/jama.2021.22208

4. Letta S, Aga F, Yadeta TA, Geda B, Dessie Y. Barriers to diabetes patients' self-care practices in eastern Ethiopia: a qualitative study from the health care providers perspective. Diabetes Metab Syndr Obes. (2021) 14:4335–49. doi: 10.2147/dmso.s335731

5. Dogruel H, Aydemir M, Balci MK. Management of diabetic foot ulcers and the challenging points: an endocrine view. World J Diabetes. (2022) 13:27–36. doi: 10.4239/wjd.v13.i1.27

6. Adeleye OO, Ugwu ET, Gezawa ID, Okpe I, Ezeani I, Enamino M. Predictors of intra-hospital mortality in patients with diabetic foot ulcers in Nigeria: data from the MEDFUN study. BMC Endocr Disord . (2020) 20:134. doi: 10.1186/s12902-020-00614-4

7. Bakker K, Apelqvist J, Lipsky BA, Van Netten JJ. The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus. DiabetesMetab Res Rev. (2016) 32(Suppl 1):2–6. doi: 10.1002/dmrr.2694

8. Li X, Xiao T, Wang Y, Gu H, Liu Z, Jiang Y, et al. Incidence, risk factors for amputation among patients with diabetic foot ulcer in a Chinese tertiary hospital. Diabetes Res Clin Pract. (2011) 93:26–30. doi: 10.1016/j.diabres.2011.03.014

9. Armstrong DG, Wrobel J, Robbins JM. Guest editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J. (2007) 4:286–7. doi: 10.1111/j.1742-481x.2007.00392.x

10. Skrepnek GH, Mills JLSr, Lavery LA. Armstrong DG. Health care service and outcomes among an estimated 67 million ambulatory care diabetic foot cases in the US. Diabetes Care. (2017) 40:936–42. doi: 10.2337/dc16-2189

11. Chaturvedi N, Stevens LK, Fuller JH, Lee ET, Lu M. Risk factors, ethnic differences and mortality associated with lower-extremity gangrene and amputation in diabetes. The WHO multinational study of vascular disease in diabetes. Diabetologia. (2001) 44:S65–71. doi: 10.1007/pl00002941

12. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. (2005) 293:217–28. doi: 10.1001/jama.293.2.217

13. Leal S, Johnson EL, Shubrook J, Butts A, Skolnik N. Standards of medical care in diabetes-2018 abridged for primary care providers. Clin Diabetes. (2018) 36:14–37. doi: 10.2337/cd17-0119

PubMed Abstract | CrossRef Full Text

14. Schmidt S, Mayer H, Panfil EM. Diabetes foot self-care practices in the German population. J Clin Nurs. (2008) 17:2920–6. doi: 10.1111/j.1365-2702.2008.02352.x

15. Palaya J, Pearson S, Nash T. Perception of social support in individuals living with a diabetic foot: a qualitative study. Diabetes Res Clin Pract. (2018) 146:267–77. doi: 10.1016/j.diabres.2018.10.016

16. Guo J, Wang H, Luo J, Guo Y, Xie Y, Lei B, et al. Factors influencing the effect of mindfulness-based interventions on diabetes distress: a meta-analysis. BMJ Open Diabetes Res Care. (2019) 7:e000757. doi: 10.1136/bmjdrc-2019-000757

17. Laopoulou F, Kelesi M, Fasoi G, Vasilopoulos G, Polikandrioti M. Perceived social support in individuals with diabetic foot ulcers: a cross-sectional survey. J Wound Ostomy Continence Nurs. (2020) 47:65–71. doi: 10.1097/won.0000000000000614

18. Chellan G, Srikumar S, Varma AK, Mangalanandan TS, Sundaram KR, Jayakumar RV, et al. Foot care practice - the key to prevent diabetic foot ulcers in India. Foot. (2012) 22:298–302. doi: 10.1016/j.foot.2012.08.007

19. Tuha A, Getie Faris A, Andualem A, Ahmed Mohammed S. Knowledge and practice on diabetic foot self-care and associated factors among diabetic patients at dessie referral hospital, northeast Ethiopia: mixed method. Diabetes Metab Syndr Obes. (2021) 14:1203–14. doi: 10.2147/dmso.S300275

20. Chiwanga FS, Njelekela MA. Diabetic foot: prevalence, knowledge, and foot self-care practices among diabetic patients in Dar es Salaam, Tanzania – a cross-sectional study. J Foot Ankle Res. (2015) 8:20. doi: 10.1186/s13047-015-0080-y

21. Rocha RM, Zanetti ML, dos Santos MA. Behavior and knowledge: basis for prevention of diabetic foot. Acta Paul Enferm. (2009) 22:17–23. doi: 10.1590/s0103-21002009000100003

22. Wang YZ, Wang AH, Zhao S, Li Q, Wang PH, Yan L, et al. Differences in risk factors of diabetic foot in the patients in South and North China. Natl Med J China. (2007) 87:1817–20. doi: 10.3760/j:issn:0376-2491.2007.26.007

23. Yilmaz Karadag F, Saltoglu N, Ak Ö, Çinar Aydin G, Senbayrak S, Erol S, et al. Foot self-care in diabetes mellitus: evaluation of patient awareness. Prim Care Diabetes. (2019) 13:515–20. doi: 10.1016/j.pcd.2019.06.003

24. Muhammad-Lutfi AR, Zaraihah MR, Anuar-Ramdhan IM. Knowledge and practice of diabetic foot care in an in-patient setting at a tertiary medical center. Malays Orthop J. (2014) 8:22–6. doi: 10.5704/moj.1411.005

25. Li J, Xing QL. Study on the reliability and validity of the Chinese version of the nottingham assessment of functional footcare. Chin J Pract Nurs. (2015) 6:450–3. doi: 10.3760/cma.j.issn.1672-7088.2015.06.021

CrossRef Full Text | Google Scholar

26. Bloom BS. Taxonomy Education . New York, NY: David McKay (1956).

27. Desalu OO, Salawu FK, Jimoh AK, Adekoya AO, Busari OA, Olokoba AB. Diabetic foot care: self reported knowledge and practice among patients attending three tertiary hospital in Nigeria. Ghana Med J. (2011) 45:60–5. doi: 10.4314/gmj.v45i2.68930

28. Pourkazemi A, Ghanbari A, Khojamli M, Balo H, Hemmati H, Jafaryparvar Z, et al. Diabetic foot care: knowledge and practice. BMC Endocr Disord . (2020) 20:40. doi: 10.1186/s12902-020-0512-y

29. Li R, Li Y, Guo XH, Lou QQ, Fang Z, Shen L, et al. The current status of foot self-care knowledge, behaviours, and analysis of influencing factors in patients with type 2 diabetes mellitus in China. Int J Nurs Sci. (2014) 1:266–71. doi: 10.1016/j.ijnss.2014.05.023

30. Khamseh ME, Vatankhah N, Baradaran HR. Knowledge and practice of foot care in Iranian people with type 2 diabetes. Int Wound J. (2007) 4:298–302. doi: 10.1111/j.1742-481x.2007.00381.x

31. Anderson JJ, Boone J, Hansen M, Spencer L, Fowler Z. A comparison of diabetic smokers and non-smokers who undergo lower extremity amputation: a retrospective review of 112 patients. Diabet Foot Ankle. (2012) 3:19178. doi: 10.3402/dfa.v3i0.19178

32. Aye M, Masson EA. Dermatological care of the diabetic foot. Am J Clin Dermatol . (2002) 3:463–74. doi: 10.2165/00128071-200203070-00003

33. Crawford F, Cezard G, Chappell FM, Murray GD, Price JF, Sheikh A, et al. A systematic review and individual patient data meta-analysis of prognostic factors for foot ulceration in people with diabetes: the international research collaboration for the prediction of diabetic foot ulcerations (PODUS). Health Technol Assess. (2015) 19:1–210. doi: 10.3310/hta19570

34. Bell RA, Arcury TA, Snively BM, Smith SL, Stafford JM, Dohanish R, et al. Diabetes foot self-care practices in a rural triethnic population. Diabetes Educ. (2005) 31:75–83. doi: 10.1177/0145721704272859

35. Makiling M, Smart H. Patient-centered health education intervention to empower preventive diabetic foot self-care. Adv Skin Wound Care . (2020) 33:360–5. doi: 10.1097/01.ASW.0000666896.46860.d7

36. Abbas ZG, Boulton AJM. Diabetic foot ulcer disease in African continent: ‘from clinical care to implementation’ - review of diabetic foot in last 60 years - 1960 to 2020. Diabetes Res Clin Pract. (2022) 183:109155. doi: 10.1016/j.diabres.2021.109155

37. Sun S, Zhao W, Dong Y, Li Z. Diabetes self-management status and influence factors analysis. Chin J Nurs. (2011) 46:229–33. doi: 10.3761/j.issn.0254-1769.2011.03.003

CrossRef Full Text

38. Liu K, Yuan HY, Shen SS, Liu J, Wang XY, Chen C, et al. Relationship between health literacy and health-related behaviors of enterprise employees. Chin J Industr Hyg Occup Dis. (2021) 39:193–7. doi: 10.3760/cma.j.cn121094-20200105-000011

39. Rossaneis MA, Haddad Mdo C, Mathias TA, Marcon SS. Differences in foot self-care and lifestyle between men and women with diabetes mellitus. Rev Lat Am Enferm. (2016) 24:e2761. doi: 10.1590/1518-8345.1203.2761

40. Laclé A, Valero-Juan LF. Diabetes-related lower-extremity amputation incidence and risk factors: a prospective seven-year study in Costa Rica. Pan Americ J Public Health. (2012) 32:192–8. doi: 10.1590/s1020-49892012000900004

41. Tang ZQ, Chen HL, Zhao FF. Gender differences of lower extremity amputation risk in patients with diabetic foot: a meta-analysis. Int J Low Extrem Wounds. (2014) 13:197–204. doi: 10.1177/1534734614545872

42. D'Souza MS, Ruppert SD, Parahoo K, Karkada SN, Amirtharaj A, Jacob D, et al. Foot care behaviors among adults with type 2 diabetes. Prim Care Diabetes. (2016) 10:442–51. doi: 10.1016/j.pcd.2016.04.002

43. Riaz M, Miyan Z, Zaidi SI, Alvi SFD, Fawwad A, Ahmadani MY, et al. Characteristics and outcomes of subjects with diabetic foot ulceration. Diabetes Care. (2012) 35:e63. doi: 10.2337/dc11-1906

44. Golightly YM, Hannan MT, Dufour AB, Jordan JM. Racial differences in foot disorders and foot type: the Johnston county osteoarthritis project. Arthritis Care Res. (2012) 64:1756–9. doi: 10.1002/acr.21752

45. Qasim M, Rashid MU, Islam H, Amjad D, Ehsan SB. Knowledge, attitude, and practice of diabetic patients regarding foot care: Experience from a single tertiary care outpatient clinic. Foot (Edinb) . (2021) 49:101843. doi: 10.1016/j.foot.2021.101843

46. Nguyen MH, Le TT, Nguyen HKT, Ho MT, Nguyen HTT, Vuong QH. Alice in suicideland: exploring the suicidal ideation mechanism through the sense of connectedness and help-seeking behaviors. Int J Intercult Relat. (2021) 18:3681. doi: 10.3390/ijerph18073681

47. Vuong QH, Napier NK. Acculturation and global mindsponge: an emerging market perspective. Int J Interculture Relations. (2015) 49:354–67. doi: 10.1016/j.Ijintrel.2015.06.003

48. Vuong QH, Le TT, La VP, Nguyen HTT, Ho MT, Van KQ, et al. Covid-19 vaccines production and societal immunization under the serendipity-mindsponge-3D knowledge management theory and conceptual framework. Humanit Soc Sci Commun. (2022) 9:22. doi: 10.1057/S41599-022-01034-6

49. Vuong QH. Information expensiveness perceived by Vietnamese patients with respect to healthcare provider's choice. Acta Inform Med. (2016) 24:360–3. doi: 10.5455/aim.2016.24.360-363

Keywords: knowledge, attitudes, practices, rural patients, diabetic foot

Citation: Jia H, Wang X and Cheng J (2022) Knowledge, Attitudes, and Practices Associated With Diabetic Foot Prevention Among Rural Adults With Diabetes in North China. Front. Public Health 10:876105. doi: 10.3389/fpubh.2022.876105

Received: 15 February 2022; Accepted: 14 April 2022; Published: 20 May 2022.

Reviewed by:

Copyright © 2022 Jia, Wang and Cheng. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Jingmin Cheng, chengjingmin@163.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.