Adherence to diabetic foot care recommendations and associated factors among people with diabetes in Eastern Ethiopia: a multicentre cross-sectional study

Abstract

Objective

This study aimed to determine the level of adherence to foot care recommendations and associated factors among people with diabetes on follow-up in public hospitals in Eastern Ethiopia.

Setting

An institutional-based cross-sectional study was conducted in public hospitals found in Eastern Ethiopia from 25 February to 25 March 2022.

Participants

A total of 419 patients with chronic diabetes who visited diabetic clinics in public hospitals in Eastern Ethiopia for follow-up were included.

Main outcome measure

The level of adherence to diabetic foot care recommendations and associated factors.

Results

The findings indicated that 44.3% (95% CI: 39.3, 49.0) of people with diabetes had inadequate adherence to diabetic foot care recommendations. Age between 28–37 (adjusted OR (AOR)=1.10; 95% CI: 1.27, 5.63) and 38–47 years (AOR=2.19; 95% CI: 2.74, 8.89), rural residence (AOR=1.71; 95% CI: 1.15, 2.57), absence of comorbidity (AOR=2.22; 95% CI:1.34, 5.14), obesity (AOR=1.43; 95% CI: 1.10, 5.05) and inadequate foot care knowledge (AOR=2.10; 95% CI: 1.52, 4.35) were factors significantly associated with inadequate adherence to diabetic foot care recommendations.

Conclusion

More than two-fifths of people with diabetes had inadequate adherence to diabetic foot care recommendations. Younger age, rural residence, absence of comorbidity, obesity and inadequate foot care knowledge were significantly associated with inadequate adherence to diabetic foot care recommendations. It is very essential to educate people with diabetes about the importance of foot care recommendations in preventing and delaying the risks of foot-related problems and complications.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study assured representativeness and generalisability (a multicentre study was carried out at eight public hospitals located in Eastern Ethiopia).

• The accuracy of the data was improved by the use of both primary and secondary data, as well as direct measurements of specific variables, such as weight and height.

• A valid data collection tool (Nottingham Assessment of Functional Foot Care), which has a high internal consistency (α=0.84), was used.

• The cross-sectional nature of the study used makes it difficult to draw causal inferences.

• Social desirability biases could have been introduced by the interviewing method.

Introduction

Approximately 19.4 million individuals on the continent have diabetes in 2019, one of the most prevalent non-communicable diseases, and this number is predicted to double in Africa after 10 years.^1–3 Along with the rise in diabetes prevalence, related complications are having a detrimental influence on patients’ prognoses, overburdening the healthcare system and destabilising the economies of the countries in the region.⁴ Many African countries have recently incurred enormous costs for the treatment of diabetes and its consequences.^{5 6} Evidence suggested that diabetic complications raised healthcare costs in Ethiopia.⁷ Diabetes-related foot ulcers (DFUs) are the leading cause of morbidity, hospitalisation and mortality among people with diabetes.⁸

Several risk factors, including neuropathy, peripheral vascular disease and inadequate glycaemic control, contribute to the development of DFUs.⁹ DFUs in Africa account for 13%,¹⁰ whereas it ranges from 12% to 32% in Ethiopia.¹¹ These figures are expected to rise as diabetes becomes more prevalent. DFUs that are not properly treated can result in serious complications like severe infections and amputations of the lower extremities.¹² The likelihood of these complications is higher in resource-limited African countries.¹³ A prospective study from Western Ethiopia showed that 3 out of every 10 patients with DFUs had lower extremity amputations.¹⁴ In addition, those who have DFUs are more likely to pass away than those without them.¹⁵

Patients frequently endure recurrence and reinfection even though early identified DFUs can be effectively treated. Therefore, regular assessment, early detection and timely management are beneficial in reversing undesirable consequences.⁹ To avoid the development of DFUs and significantly reduce the debilitating foot complications that occur in people with diabetes, diabetic foot self-care is a crucial self-care strategy that is both efficient and affordable.¹⁶ The International Working Group on the Diabetic Foot recommends that patients should be advised to perform at least daily foot care to check areas of irritation, redness, cuts, sores or blisters on the foot surfaces and in between the toes.¹⁷ Diabetes foot care recommendations include daily foot inspection and washing, drying between the fingers, wearing properly fitting footwear, and avoiding soaking the feet and barefoot walking.¹⁸

Several studies have revealed that the prevalence of diabetes differs across Ethiopia.^{7 19 20} The literature that is currently available indicated that Eastern Ethiopian regions have a higher prevalence of diabetes than the national estimates. Type 2 diabetes affects 14%, 9% and 7% of people in the Dire Dawa Administration, Somali and the Harari regional states, respectively.¹⁹ There are, however, few studies that primarily focus on overall diabetic self-management, and specifically on adherence to diabetic foot care recommendations among individuals with diabetes. Therefore, the purpose of this study was to assess adherence to diabetes foot care recommendations and associated factors among people with diabetes on follow-up at public hospitals in Eastern Ethiopia, and the study generate useful evidence that would improve patient prognosis and design appropriate interventions to lower the risks of developing DFUs.

Materials and methods

Study area, period and design

The study was carried out in selected public hospitals in Eastern Ethiopia between 25 February and 25 March 2022. Of 15 existing public hospitals, 8 of them were randomly chosen: Hiwot Fana Comprehensive Specialized Hospital, Jugol, Dilchora, Jigjiga, Chiro, Asebot, Chelenko and Hirna Hospitals. Hiwot Fana Comprehensive Specialized Hospital and Jugol Hospital are found in the Harari regional state. Chiro, Asebot and Hirna Hospitals are located in the West Hararge zone, while Chelenko Hospital is located in the East Hararge zone of the Oromia regional state. Dilchora and Jigjiga Hospitals are found in the Dire Dawa Administration and Somali regional state, respectively.

Patient and public involvement

Patients or the general public were not engaged in the planning, conduct, reporting or dissemination of our study.

Study design and population

An institutional-based cross-sectional study design was employed among 419 systematically selected people with diabetes who had been on follow-up for at least 6 months from the selected hospitals in Eastern Ethiopia. All people with diabetes who were on follow-up at randomly selected eight public hospitals of Eastern Ethiopia were the source population, whereas all people with diabetes who were on follow-up during the study period were the study population.

Inclusion and exclusion criteria

Included were all patients with diabetes who had been on follow-up for at least 6 months at randomly chosen public hospitals. The study excluded people with diabetes who were seriously ill during arrival and those who tested positive for COVID-19.

Sample size determination and sampling technique

The sample size was determined using the single population proportion formula and considering a proportion of adherence to diabetic foot care recommendation of 45.4%,²¹ a 95% CI and a 5% margin of error. After adding a 10% non-response rate, the final sample size was 419. The sample was proportionally allocated to each public hospital to select a representative sample from each selected hospital. Following the retrieval of the whole patient population that would have a follow-up in each hospital during the study period (N=1123, K=3), a systematic random sampling procedure was used. The K-value was determined using the formula as follows: K=1123/419=3. The study participants were selected for interviews at intervals of three until the estimated sample size was reached.

Measurement and data collection tools

Data were collected using a structured questionnaire which was initially prepared in English, then translated by language experts into the local languages of Afaan Oromo and Amharic, and finally back into English. The questionnaire includes data on sociodemographics, clinical variables, disease and treatment details, behavioural characteristics, knowledge of diabetic foot care and foot care recommendations for patients with diabetes. Clinical factors contained information about the presence of comorbidity, foot complications and current treatment of the patients. Eight questions with ‘yes’, ‘no’ and ‘I don’t know’ responses were used to assess the knowledge of patients with diabetes regarding diabetic foot care. Each ‘yes’ response was given a code of 1, while ‘no’ and ‘I don’t know’ responses were given a code of 0.²² Foot self-care recommendation was assessed by using a questionnaire adapted from a validated tool of the Nottingham Assessment of Functional Foot Care revised 2015 (NAFFC).²³ The tool was proven to be valid and reliable for assessing diabetic foot care behaviour.²⁴ Only 16 of 19 questions that could be answered with ‘yes’ or ‘no’ responses were chosen to assess the diabetic foot care recommendations adherence to fit the context. Values of 0 and 1 were assigned for incorrect and correct answers, respectively. Then, the scores for each study participant were computed and the mean was determined to categorise the recommendation level as ‘adequate’ and ‘inadequate’ adherence. The mean recommendation score was 7.62±2.42, with the minimum and maximum values being 5 and 12 out of 16, respectively.

Except for height and weight, which were measured using a stadiometer and weighing scales, data were collected through in-person interviews and by reviewing their medical records. Body mass index (BMI) was calculated and categorised as normal weight if it fell between 18.5 and 24.9 kg/m², overweight if it fell between 25.9 and 29.9 kg/m² and obese if it is >30 kg/m². The data were collected by four diploma nurses under the supervision of two BSc nurses.

Operational definition

Diabetic foot care recommendations are actions and activities carried out by people with diabetes to take care of themselves to prevent foot-related problems and complications like inspecting their feet, daily washing and drying between the fingers, wearing shoes that fit well, and avoiding going barefoot and soaking their feet.²⁵

Adequate adherence: participants who scored above the mean on diabetes foot care recommendations-related questions.

Inadequate adherence: participants who scored below the mean on diabetes foot care recommendations-related questions.

Glycaemic control was assessed by using fasting blood glucose (FBG) level. To know the blood glucose level of the people with diabetes, respective records were reviewed to obtain their FBG levels during their last three visits. According to the American Diabetic Association, blood glucose control was considered good if the mean of three consecutive FBG measurements falls within the normal range of 70 and 130 mg/dL, and poor if the mean of three FBG measurements is either above or below the normal range.²⁶

Comorbidity refers to an additional disease other than diabetes.²⁷

Neuropathy is the presence of at least one symptom from the list of potential symptoms such as stabbing, shooting, burning or electric shock-like pain that may be worse at night and disrupt sleep.²⁸

Diabetes complication: by reviewing the patient’s medical record, a patient with diabetes was deemed to have diabetes complications if they had any of the following: retinopathy, nephropathy, neuropathy, myocardial infarction or stroke.²⁹

Adequate knowledge of foot care: patients with diabetes mellitus who score greater than or equal to the mean on knowledge-related questions about diabetes foot care.

Inadequate knowledge of foot care: patients with diabetes mellitus who score less than the mean on knowledge-related questions about diabetes foot care.

Behavioural characteristics: behaviours related to the use of alcohol, smoking and khat consumption within the last 3 months.

Data quality assurance and management

The research’s objectives, the sampling procedure, interviewing techniques and general approaches to the study participants were all thoroughly covered over a 2-day training session for data collectors and supervisors. To ensure the completeness, accuracy and consistency of the data collection, a session was held on each day of the data collection period. The necessary changes were made after a pretest on 5% of the sample size. Principal investigators and supervisors checked the accuracy of the anonymised data every day. Cronbach’s α was calculated to determine the internal reliability of diabetes foot care recommendations (α=0.82).

Statistical analysis

Data were cleaned, coded, entered and exported from EpiData V.3.1 to SPSS V.22 for further analysis. The outcome variable was coded as ‘1’ for adequate adherence to the diabetic foot care recommendations and ‘0’ for inadequate adherence. A bivariate logistic regression model was used to see the relationship between independent factors and inadequate adherence to diabetes foot care recommendations. A multivariable logistic regression analysis was conducted with a variable that had a p value of less than 0.25 in the bivariate analysis. The model fitness was determined using the Hosmer-Lemeshow goodness-of-fit test (p=0.320). The independent variables’ multicollinearity was not evident in the variance inflation factor. At a p value of 0.05, statistically significant associations were defined by an adjusted OR (AOR) and a 95% CI.

Results

Sociodemographic characteristics

A total of 400 people with diabetes were included in the study, yielding a response rate of 95.5%. After beginning to take part in the study, 19 patients stopped the interview. The participant’s mean age was 43.45±15.7 years. Two hundred thirty (57%) of them were urban residents, and more than half of the participants (56.5%) were male (table 1).

Table 1.

Sociodemographic characteristics of patients with DM on follow-up in public hospitals in Eastern Ethiopia, 2022 (n=400)

Age	18–27	25	6.2
	28–37	76	19.0
	38–47	81	20.2
	48–57	84	21.0
	58–67	61	15.3
	>68	73	18.3
Educational status	No formal education	66	16.5
	Primary	56	14.0
	Secondary	160	40.0
	College and above	118	29.5
Marital status	Married	199	49.7
	Single	94	23.5
	Divorced	40	10.0
	Widowed	67	16.8

DM, diabetes mellitus.

Clinical and behavioural-related characteristics

Nearly two-thirds of study participants (67.8%) had type 2 diabetes. The mean diabetes duration was 5.54±2.11 years. Two hundred fifty-five people with diabetes (63.75%) had poor glycaemic control. About 1 in 5 (18%), and 1 in 10 (9%) patients with diabetes were current smokers and alcohol drinkers, respectively. Nearly half (52%) of them were current khat consumers (table 2).

Table 2.

Clinical characteristics among patients with DM on follow-up in public hospitals in Eastern Ethiopia, 2022 (n=400)

Variable	Category	Frequency	Percentage
Duration of DM	Less than or equal to 5 years	356	89.0
	Greater than 5 years	44	11.0
Family history of DM	Yes	62	15.5
	No	338	84.5
Comorbidity	Yes	90	22.5
	No	310	77.5
Type of comorbidity	Hypertension	40	44.4
	Heart failure	36	40.0
	Asthma	10	11.1
	Others*	4	4.4
Diabetic complications	Yes	52	13.0
	No	348	87.0
Types of complications	Nephropathy	15	28.8
	Neuropathy	22	42.3
	Retinopathy	12	23.0
	Cardiovascular disease	3	5.7
Foot ulcer	Yes	44	11.0
	No	356	89.0
Treatment	Only diet	34	8.5
	Oral anti-diabetic agent	100	25.0
	Insulin	154	38.5
	Combined (oral drugs and insulin)	112	28
Having information about diabetic foot care	Yes	192	48
	No	208	52
BMI	Normal	119	29.8
	Overweight	129	32.2
	Obese	152	38.0

*HIV/AIDS, skin infection, renal stone.

BMI, body mass index; DM, diabetes mellitus.

Diabetes foot care knowledge

The mean score for the study participants’ knowledge of diabetic foot care was 4.22 (±2.01). Two hundred ninety-four (48.5%) of patients with diabetes had inadequate knowledge of diabetic foot care, whereas about 206 (51.5%) had adequate knowledge of diabetic foot care (table 3).

Table 3.

Knowledge of diabetic foot care among patients with DM on follow-up in public hospitals in Eastern Ethiopia, 2022 (n=400)

Variables	Category	Frequency	Percentage
Patients with DM should take medications regularly	Yes	214	53.5
	No	186	46.5
Controlling blood sugar can reduce complications	Yes	178	44.5
	No	222	55.5
Patients with DM should look after their feet because wounds and infections may not heal quickly	Yes	190	47.5
	No	210	52.5
Patients with DM should look after their feet because they may get a foot ulcer	Yes	250	62.5
	No	250	62.5
Smoking affects DM progression	Yes	180	45.0
	No	220	55.0
Patients with DM should wash their feet every day	Yes	167	41.8
	No	233	58.2
Patients with DM should wash their feet using warm water, not hot water	Yes	158	39.6
	No	242	60.5
Patients with DM should wear socks and shoes at all times	Yes	165	41.2
	No	235	58.8
Overall knowledge	Inadequate	194	48.5
	Adequate	206	51.5

DM, diabetes mellitus.

Diabetes foot care recommendation adherence

Inadequate foot care recommendation adherence among patients with diabetes was found to be 44.3% (95% CI: 39.3%, 49.0%) in this study. More than two-thirds (68% and 70.0%) walked around their home barefoot and failed to dry their toes after washing their feet, respectively, while the majority (84.5%) wear sandals (table 4).

Table 4.

Diabetic foot care recommendation adherence among patients with DM on follow-up in public hospitals in Eastern Ethiopia, 2022 (n=400)

Variables	Category	Frequency	Percentage
Do you examine or inspect your feet regularly?	Yes	205	51.2
	No	195	48.8
Do you wash your feet daily?	Yes	265	66.2
	No	135	33.8
Do you check your shoes before you put them on?	Yes	199	49.8
	No	201	50.2
Do you walk outside with bare feet?	Yes	98	24.5
	No	302	75.5
Do you carefully dry between toes after washing your feet?	Yes	117	29.3
	No	283	70.7
Do you moisturise your feet (put cream on) daily?	Yes	176	44
	No	224	56
Do you sit with your legs crossed?	Yes	195	48.8
	No	205	51.2
Do you wear sandals/slippers?	Yes	338	84.5
	No	62	15.5
Do you check the temperature of the water before soaking your feet?	Yes	143	35.8
	No	257	64.2
Do you wear shoes without socks?	Yes	185	46.3
	No	215	53.7
Do you put your feet near the fire?	Yes	112	28
	No	288	72
Do you put a dry dressing on a blister when you get one?	Yes	128	32
	No	272	68
Do you cut your toenails?	Yes	326	81.5
	No	74	18.5
Do you put a dry dressing on a graze, cut or burn when you get one?	Yes	130	32.5
	No	270	67.5
Do you check your shoes when you take them off?	Yes	162	40.5
	No	238	59.5
Do you walk around the house on bare feet?	Yes	272	68
	No	128	32
Overall diabetic foot care recommendation adherence	Inadequate	177	44.3
	Adequate	223	55.7

DM, diabetes mellitus.

Factors associated with inadequate adherence to diabetic foot care recommendations

In the bivariate logistic regression analysis, factors such as age, educational level, residence, smoking, alcohol intake, comorbidity, information regarding diabetic foot care, khat consumption, obesity and awareness of foot problems were associated with inadequate adherence to diabetic foot care recommendations. However, the multivariate logistic regression indicated that age between 28–37 and 38–47 years old, rural residence, no comorbidities, obesity and inadequate knowledge of diabetic foot care were all independently associated with inadequate adherence to diabetic foot care recommendations.

Patients between the ages of 28–37 and 38–47 years were 1.10 times (AOR=1.10; 95% CI: 1.27, 5.63) and 2.19 times (AOR=2.19; 95% CI: 2.74, 8.89), respectively, more likely to have inadequate adherence to foot care recommendations than patients aged 60 years and older. Inadequate adherence to diabetic foot care recommendations was more common in rural patients with diabetes than in urban patients with diabetes (AOR=1.71; 95% CI: 1.15, 2.57). Inadequate adherence to diabetic foot care recommendations was 2.22 times (AOR=2.22; 95% CI: 1.34, 5.14) more prevalent in patients without comorbidities than in patients with comorbidities. Compared with patients with normal BMIs, patients with BMIs in the obese category had a 1.43-fold (AOR=1.43; 95% CI: 1.10, 5.05) higher likelihood of not following diabetic foot care recommendations. Inadequate knowledge of diabetic foot care increased the likelihood of not adhering to recommendations for diabetic foot care by 2.10 times (AOR=2.10; 95% CI: 1.52, 4.35) (table 5).

Table 5.

Factors associated with diabetic foot care (DFC) recommendation adherence among patients with DM on follow-up at public hospitals in Eastern Ethiopia, 2022 (n=400)

Variables	Category	DFC recommendation adherence		COR (95% CI)	AOR (95% CI)
		Inadequate	Adequate
Age	18–27	13	12	1.55 (1.18, 10.29)	0.49 (0.53, 1.09)
	28–37	12	64	2.44 (1.12, 4.23)	1.10 (1.27, 5.63)*
	38–47	51	30	5.26 (1.12, 4.48)	2.19 (2.74, 8.89)†
	48–57	66	18	0.27 (0.25, 1.04)	0.23 (0.26, 8.27)
	58–67	5	56	0.13 (0.25, 0.71)	0.45 (0.56, 1.02)
	>68	30	43	1	1
Educational status	No formal education	36	30	3.68 (1.94, 6.98)	1.57 (0.80, 4.71)
	Primary	29	27	3.30 (1.69, 5.45)	1.26 (0.75, 3.88)
	Secondary	83	77	3.31 (1.96, 5.57)	1.30 (0.76, 2.95)
	College and above	29	89	1	1
Residence	Rural	94	76	2.19 (1.46, 3.28)	1.71 (1.15, 2.57)*
	Urban	83	147	1	1
Having information regarding DFC	Yes	98	94	1.70 (0.70, 2.92)	1.81 (0.80, 4.47)
	No	79	129	1	1
Current smoker	Yes	44	28	2.30 (1.37, 3.89)	0.76 (0.67, 2.53)
	No	133	195	1	1
Khat chewers	Yes	110	98	2.09 (2.46, 5.23)	1.52 (0.84, 4.85)
	No	67	125	1	1
Current alcohol drinkers	Yes	22	14	2.12 (1.05, 4.27)	0.85 (0.90, 3.32)
	No	155	209	1	1
Comorbidity	No	148	162	1.92 (2.32, 7.85)	2.22 (1.34, 5.14)†
	Yes	29	61	1	1
BMI	Obese	83	69	2.89 (1.22, 7.53)	1.43 (1.10, 5.05)*
	Overweight	50	79	1.52 (1.32, 8.23)	0.61 (0.75, 2.43)
	Normal	35	84	1	1
Knowledge of DFC recommendation	Inadequate	105	89	2.20 (2.14, 6.73)	2.10 (1.52, 4.35)*
	Adequate	72	134	1	1

Hosmer-Lemeshow goodness-of-fit test was fitted.

*P<0.05

†P<0.001

AOR, adjusted OR; BMI, body mass index; COR, crude OR; DM, diabetes mellitus.

Discussion

This study was done to assess diabetic foot care recommendation adherence among patients with diabetes on follow-up in public hospitals in Eastern Ethiopia. Ages 28–37 and 38–47 years, rural residence, no comorbidity, obesity and respondents having inadequate knowledge of diabetic foot care were all associated with a higher likelihood of inadequate adherence to diabetic foot care recommendations.

In our study, 44.3% of respondents had inadequate adherence to diabetic foot care recommendations. In comparison with a Malaysian study, the results of this study have lower findings.³⁰ The discrepancy may be caused by variations in the study population, study setting, sample size, sampling technique, study duration and participant ages. Our study included both patients with type 1 and type 2 diabetes mellitus on follow-up in public hospitals in Eastern Ethiopia, unlike the Malaysian study, which only included patients with type 2 diabetes mellitus at follow-up at four primary health clinics.³⁰ Additionally, data were collected from 450 respondents in Malaysia using the universal sampling approach (non-probability method) over a year (December 2017–December 2018), as opposed to 400 respondents in our study who were collected using the systematic sampling method within a single 1-month period. In Malaysia, only 11 questions were used to assess the diabetic foot care recommendations; however, we chose 16 questions that were pertinent to our case.³⁰ The differences in study findings could be explained by these inconsistencies between the two studies.

However, our findings were greater than the study done in Pakistan’s Lahore Jinnah Hospital (32%).³¹ This is probably caused by variations in sample size, sampling strategy and research methodology. Only 150 respondents were included in a study conducted in Pakistan using convenience sampling (non-probability).³² The lower proportion in the other study can be explained by the participants’ relatively higher socioeconomic status, which may have allowed them to have better knowledge of diabetes and its effects through health education and various media.²² Inadequate health literacy among respondents regarding diabetic foot care and the high proportion of illiterate participants (54%) in our study may also contribute to our higher findings.

In this study, patients with diabetes between the ages of 28–37 and 38–47 years were less likely than patients with diabetes over 60 years to follow recommendations for proper diabetic foot care. This result is in line with the research done in Northwest Ethiopia.²² Compared with older people, young and middle-aged adults may have more societal and familial responsibilities and less time for self-care. They might also not feel the need to check on their feet frequently if there are no evident or impending injuries because of the disease’s effect on the peripheral pain system.

Patients who did not follow diabetic foot care recommendations were more likely to live in rural than urban areas. This study was similar to that conducted in Bahir Dar, Northern Ethiopia.²¹ In rural locations, patients with diabetes may find it difficult to obtain information on adequate foot care due to a lack of close medical facilities and limited access to health information in general.

Patients without comorbidities were more likely than those with comorbidities to have inadequate adherence to diabetic foot care recommendations.²² The rationale could be that individuals with comorbidities frequently visit hospitals or other healthcare facilities, where they are exposed to greater health education or awareness than individuals without comorbidities. Doctors and other healthcare professionals may suggest and urge patients to increase their self-care recommendations to prevent any problems brought on by comorbidities.³³

Compared with participants whose weight was within the normal BMI range, participants in the obese BMI category were more likely to not adhere to the recommendations for diabetic foot care. Our findings were supported by a Malaysian study.³⁰ Patients’ levels of compliance with self-care recommendations, such as diet and exercise regimes, are substantially predicted by their BMI. Because of the better body image, self-esteem and general emotional state, the likelihood of engaging in a particular self-care activity may also have a favourable impact on starting and maintaining the other activities.³⁴ Overall, the lack of exercise and sedentary lifestyles among obese patients with diabetes lead to inadequate self-care recommendations in all areas. Obese individuals might live a healthier lifestyle less consistently.³⁵

Compared with those who have inadequate knowledge of diabetic foot care, those who have adequate knowledge were more likely to adhere to recommendations for diabetic foot care. This finding is consistent with the Malaysian study.³⁰ This may be explained by the fact that more awareness will result in meticulous and attentive observation of foot problems, which would lead respondents to have better adherence to diabetic foot care recommendations.

Strengths and limitations

The study assured representativeness and generalisability (a multicentre study was carried out at eight public hospitals located in Eastern Ethiopia). In addition, the accuracy of the data was improved by the use of both primary and secondary data, as well as direct measurements of specific variables, such as weight and height. Moreover, a valid data collection tool (NAFFC), which has a high internal consistency (α=0.84), was used. However, the study has some limitations. The cross-sectional nature of the study used makes it difficult to draw causal inferences. What is more, social desirability biases could have been introduced by the interviewing method.

Conclusion

Two out of every five patients who visited follow-up diabetic appointment clinics had inadequate adherence to recommendations for diabetic foot care. Age between 28–37 and 38–47 years old, living in rural areas, not having any comorbid conditions, obesity and inadequate knowledge of diabetic foot care were factors found to be independently associated with inadequate adherence to diabetic foot care recommendations. More focus should be put on long-term patient education and adherence to foot care recommendations at the primary care level to ensure quality foot care. After washing their feet, patients neglected to thoroughly self-inspect and did not moisturise their dry skin. On top of that, they neglected to wash their feet at least once a day. Therefore, clinicians should inform patients with diabetes about diabetic foot problems, the importance of good foot care practices including foot self-inspection and foot cleaning, and the risks of wearing sandals or other open-toed footwear, walking barefoot or wearing shoes without socks at every follow-up appointment.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Not required.

Ethics approval

The conduct of the study adhered to the Helsinki Declaration of Medical Research Ethics.³⁶ The study was authorised by the Institutional Health Research Ethics Review Committee of Haramaya University (reference number: IHRERC/014/2022) and granted ethical clearance and permission. After the approval, a formal letter of collaboration was given to the Chief Executive Officer (CEO) of each chosen hospital. Then, permission was sought from the head of the diabetes clinic unit. The significance and purpose of the study were explained to the study participants, and they were also informed to keep their information confidential. Data collection only began after receiving complete, fully informed, voluntary, written and duly signed consent. The participants were given the assurance that their names were not included, and obtained information was only used for research purposes.