Abstract
Introduction: Diabetic foot care involves measures and practices aimed at maintaining foot health in individuals with diabetes and reducing the risk of severe, life-threatening complications. It is essential for diabetic patients to have the knowledge, attitudes, and skills necessary to enhance proper foot care, which can lead to better health outcomes and an improved quality of life.
Methods: This cross-sectional study utilized data from a sample of 647 diabetic patients residing in the Al-Qassim region of the Kingdom of Saudi Arabia. Participants completed self-administered online questionnaires, ensuring their anonymity.
Results: An overwhelming majority (604, 93.4%) of the patients had a positive attitude towards diabetic foot care, compared to only 43 (6.6%) with a poor attitude. Patients’ age and duration of diabetes were significantly associated with their attitudes towards foot care (p=0.011*; p=0.005*), with those having a family history of diabetes showing a significantly more positive attitude towards diabetic foot care. Furthermore, nearly three-quarters (480, 74.2%) of diabetic patients had good knowledge about foot care, while about one-quarter (167, 25.8%) had poor knowledge. There was no statistically significant association between knowledge regarding diabetic foot care and patients' socio-demographic attributes.
Conclusion: The study revealed a high percentage of surveyed patients with good knowledge and a positive attitude towards diabetic foot care. However, significant gaps in diabetic education were evident, as a substantial proportion of patients had not received formal education on the subject. This highlights the need for educational programs aimed at improving both knowledge and attitudes, as well as promoting good routine practices by consistently reminding patients about health practices and the risks associated with diabetes-related complications.
Keywords: al-qassim, attitude, diabetic patients, foot care, knowledge, practices, saudi arabia
Introduction
Diabetes mellitus (DM) is a very common chronic disease. In 2010, the global prevalence of adults aged 20-79 years was estimated to be 6.4%, or roughly 285 million adults. By 2030, it is expected to rise to 7.7% or roughly 439 million adults [1,2]. Globally, DM is a public health concern as a long-term, progressive metabolic disease characterized by hyperglycemia, which is brought on by an inability to metabolize insulin or by resistance to it [3-5]. According to data from the World Health Organization (WHO), Saudi Arabia has the second-highest diabetes prevalence in the Middle East and the seventh-highest worldwide [6].
Every day, more and more diabetic patients experience complications related to their feet and lower limbs; globally, this affects between 50 and 60 million people [7]. One of the complications of diabetes that results from peripheral arterial disease (PAD) is diabetic foot, which is characterized by sensory neuropathy in the feet of diabetic patients [8,9]. Men are more likely than women to develop diabetic foot complications, and type 2 diabetics are more likely than type 1 diabetics to do so [10]. With an annual foot ulceration rate of roughly 2%, lower-middle-income economies are more likely than high-income ones to experience foot ulcerations [7,11]. Complications from diabetic feet are a major cause of morbidity, low quality of life, and early death [7,12]. The main risk factors for diabetic foot disease are uncontrolled hyperglycemia, the length of diabetes, peripheral artery disease, peripheral neuropathy, foot deformity, recurrent minor traumas, and infections [7,13-17]. Furthermore, less than one-third of practitioners recognize the signs of diabetic peripheral neuropathy. Unusually high morbidity and mortality are caused by the misdiagnosis that follows [18].
Maintaining adequate care of the feet has always been crucial to reducing the risk of diabetic foot problems and their consequences. With appropriate foot care practices, such as routine foot washing and drying, routine foot assessments, proper nail care, and appropriate footwear, diabetic foot and its complications can be avoided or identified early. Patients should take self-foot care seriously and incorporate it into their daily routine [7,19].
To the best of our knowledge, no research has been done to assess diabetic patients' awareness of diabetic foot care in Al-Qassim province, Saudi Arabia. Nevertheless, some studies have been conducted in Saudi Arabia to determine diabetic patients' awareness of diabetic foot care. Therefore, this study aims to assess the attitudes and knowledge of diabetic patients in the province of Al-Qassim regarding diabetic foot care.
Objectives
The study aims to assess the attitudes and knowledge of diabetic patients in the province of Al-Qassim regarding diabetic foot care.
Materials and methods
Study design
This study employed a descriptive, questionnaire-based, cross-sectional design. The research was conducted online among individuals residing in the Al-Qassim region of Saudi Arabia. The study duration extended from May 2024 to October 2024.
Study population
The target population comprised individuals residing in the region, as per the latest statistics from the General Authority for Statistics in Saudi Arabia, which reported a population of 1,488,285 [20].
Sample size
The sample size was determined using the Raosoft Sample Size Calculator [21], with a margin of error of 5% and a confidence level of 95%. Based on these parameters, the estimated sample size was 377 participants. A convenience sampling technique was utilized to recruit participants.
Inclusion and exclusion criteria
The inclusion and exclusion criteria for participant eligibility are summarized in Table 1.
Table 1. Inclusion and Exclusion Criteria.
| Criteria | Details |
| Inclusion Criteria | Anyone in the Al-Qassim region of Saudi Arabia aged above 18 |
| Anyone known to have type 1 or type 2 diabetes, whether Saudi or non-Saudi | |
| Exclusion Criteria | Anyone who has not accepted to participate |
Data collection
Data were collected using an online, self-administered questionnaire distributed via Google Forms (Appendix 1). The questionnaire was disseminated across multiple social media platforms, including WhatsApp, Twitter, and Instagram. Prior to participation, individuals were required to provide electronic informed consent. The research team ensured the accessibility of the questionnaire and provided assistance to participants as needed.
Data management and analysis plan
All participants who agreed to participate were provided with an informed consent form. The online questionnaire was designed to prevent incomplete submissions by requiring responses to all items. Upon collection, the data were reviewed to ensure completeness and accuracy. Responses were exported to Microsoft Excel (Redmond, WA, USA) for encoding and confidentiality maintenance. No personally identifiable information, such as names or contact details, was collected. The data were securely stored with password protection, accessible only to the research team. For statistical analysis, the data were transferred to SPSS (IBM Corp., Armonk, NY, USA). Continuous variables, such as age, were reported as mean ± standard deviation, while categorical variables, such as gender, were described using frequencies and percentages. The chi-square test was employed to compare categorical variables, with a p-value of less than 0.05 considered statistically significant.
Ethical considerations
Ethical considerations were rigorously adhered to throughout the study. Participant confidentiality and data privacy were prioritized, and no identifying information was collected. Ethical approval for the study was obtained from the ethical committee of Qassim University's medical college (approval number: CL-20240516-11).
Knowledge classification
To assess participants' knowledge about foot care, 12 key questions were included in the questionnaire. Each correct or appropriate response indicating accurate knowledge was awarded one point, while incorrect or "unsure" responses received zero points, resulting in a maximum possible score of 12. Based on the total score, participants were classified into two categories: those who scored 8 or more points (≥66.7%) were considered to have good knowledge, while those who scored 7 or fewer points (<66.7%) were categorized as having poor knowledge.
Results
Table 2 shows that a total of 647 diabetic patients completed the questionnaires. Among them, more than half (356, 55.0%) were male, and nearly one-third (194, 30.0%) were aged between 18 and 29 years. The vast majority of participants were Saudis (607, 93.8%), with a notable proportion being married (399, 61.7%). Most had attained a university education or higher (478, 73.9%). In terms of employment, nearly one-third (209, 32.3%) were government sector employees, and about one-quarter (164, 25.3%) reported a monthly income of over 15,000 riyals. Additionally, a significant number of patients had a family history of diabetes (406, 62.8%), while a considerable proportion (245, 37.9%) reported having fewer than two clinical visits per year.
Table 2. Socio-demographic data of the participants (N=647).
Socio-demographic information presented in frequencies (n) and proportion (%)
| Variables | Category | Frequency and percentage n (%) |
| Sex | Female | 291 (45.0%) |
| Male | 356 (55.0%) | |
| Age in years | Under 18 years | 17 (2.6%) |
| 18-29 | 194 (30.0%) | |
| 30-39 | 101 (15.6%) | |
| 40-49 | 142 (21.9%) | |
| 50-59 | 118 (18.2%) | |
| 60 years and above | 75 (11.6%) | |
| Nationality | Saudi | 607 (93.8%) |
| Non-Saudi | 40 (6.2%) | |
| Marital status | Single | 223 (34.5%) |
| Married | 399 (61.7%) | |
| Divorced | 12 (1.9%) | |
| Widow | 13 (2.0%) | |
| Education level | Intermediate education | 29 (4.5%) |
| Primary education and below | 14 (2.2%) | |
| Secondary education | 126 (19.5%) | |
| University education or higher | 478 (73.9%) | |
| Profession | Government sector employee | 209 (32.3%) |
| Private sector employee | 95 (14.7%) | |
| Retired | 116 (17.9%) | |
| Student | 132 (20.4%) | |
| Unemployed | 95 (14.7%) | |
| Monthly income in Riyals | Less than 5000 riyals | 240 (37.1%) |
| 5000-10000 riyals | 132 (20.4%) | |
| 10000-15000 riyals | 111 (17.2%) | |
| More than 15000 riyals | 164 (25.3%) | |
| Duration of diabetes in years | Less than a year | 27 (4.2%) |
| 1-5 years | 65 (10.0%) | |
| 6-10 years | 52 (8.0%) | |
| More than 10 years | 97 (15.0%) | |
| Family history | 406 (62.8%) | |
| Number of clinic visits per year | Less than two visits | 245 (37.9%) |
| 2-4 visits | 229 (35.4%) | |
| 5-7 visits | 102 (15.8%) | |
| More than 7 visits | 71 (11.0%) |
Table 3 shows the patients’ knowledge regarding diabetic foot health. The overwhelming majority of patients (590, 91.2%) were aware that diabetics are more likely to develop gangrene in the foot. Additionally, 577 patients (91.2%) recognized that regular foot care can prevent many diabetic foot problems, and 575 patients (88.9%) understood that diabetics may lose sensation in their feet. Furthermore, 574 patients (88.7%) knew that loss of sensation can make diabetics more vulnerable to foot ulcers.
Table 3. Knowledge measurement.
Knowledge attributes presented in frequencies (n) and proportion (%)
| Attributes | Categories | n (%) |
| Diabetics may experience reduced blood flow to their feet | Strongly agree | 345 (53.3%) |
| I agree | 211 (32.6%) | |
| Neutral | 47 (7.3%) | |
| I do not agree | 39 (6.0%) | |
| Strongly disagree | 5 (0.8%) | |
| Am aware that diabetics may lose sensation in their feet | Strongly agree | 373 (57.7%) |
| I agree | 202 (31.2%) | |
| Neutral | 39 (6.0%) | |
| I do not agree | 27 (4.2%) | |
| Strongly disagree | 6 (0.9%) | |
| I understand that diabetes can get foot ulcers | Strongly agree | 401 (62.0%) |
| I agree | 194 (30.0%) | |
| Neutral | 29 (4.5%) | |
| I do not agree | 18 (2.8%) | |
| Strongly disagree | 5 (0.8%) | |
| Diabetics are more likely to develop gangrene in the foot | Strongly agree | 430 (66.5%) |
| I agree | 160 (24.7%) | |
| Neutral | 37 (5.7%) | |
| I do not agree | 15 (2.3%) | |
| Strongly disagree | 5 (0.8%) | |
| Loss of sensation in the feet can make diabetics vulnerable to foot ulcers | Strongly agree | 381 (58.9%) |
| I agree | 193 (29.8%) | |
| Neutral | 41 (6.3%) | |
| I do not agree | 28 (4.3%) | |
| Strongly disagree | 4 (0.6%) | |
| Am aware that decreased blood flow to the feet can make diabetics prone to foot ulcers | Strongly agree | 377 (58.3%) |
| I agree | 193 (29.8%) | |
| Neutral | 47 (7.3%) | |
| I do not agree | 25 (3.9%) | |
| Strongly disagree | 5 (0.8%) | |
| I know that diabetes can cause changes in the shape of the foot | Strongly agree | 323 (49.9%) |
| I agree | 178 (27.5%) | |
| Neutral | 82 (12.7%) | |
| I do not agree | 47 (7.3%) | |
| Strongly disagree | 17 (2.6%) | |
| I understand that high blood sugar levels can damage the blood vessels in the feet | Strongly agree | 355 (54.9%) |
| I agree | 204 (31.5%) | |
| Neutral | 56 (8.7%) | |
| I do not agree | 24 (3.7%) | |
| Strongly disagree | 8 (1.2%) | |
| I know the signs of diabetic foot infection | Strongly agree | 237 (36.6%) |
| I agree | 156 (24.1%) | |
| Neutral | 133 (20.6%) | |
| I do not agree | 91 (14.1%) | |
| Strongly disagree | 30 (4.6%) | |
| I understand the importance of wearing proper shoes for people with diabetes | Strongly agree | 360 (55.6%) |
| I agree | 198 (30.6%) | |
| Neutral | 52 (8.0%) | |
| I do not agree | 28 (4.3%) | |
| Strongly disagree | 9 (1.4%) | |
| I know that smoking can increase foot complications in diabetics | Strongly agree | 345 (53.3%) |
| I agree | 174 (26.9%) | |
| Neutral | 76 (11.7%) | |
| I do not agree | 41 (6.3%) | |
| Strongly disagree | 11 (1.7%) | |
| I know that regular foot care can prevent many diabetic foot problems | Strongly agree | 405 (62.6%) |
| I agree | 172 (26.6%) | |
| Neutral | 40 (6.2%) | |
| I do not agree | 23 (3.6%) | |
| Strongly disagree | 7 (1.1%) |
Table 4 presents the results of the patients’ attitudes toward diabetic foot care. The vast majority of patients (615, 95.1%) recognized nutrition as an important factor in controlling blood sugar levels. Most participants agreed that exercise helps maintain diabetic foot health (566, 87.5%) and that regular visit to a podiatrist are necessary for diabetics (550, 85.0%). Additionally, 534 patients (82.5%) expressed a willingness to use special shoes to protect their feet. Interestingly, nearly half of the patients (327, 50.5%) had received education about diabetic foot care from a healthcare provider.
Table 4. Attitude measurement.
Attitude measurement attributes presented in frequencies (n) and proportion (%)
| Attributes | Categories | n (%) |
| Nutrition is an important factor in controlling blood sugar levels | Yes | 615 (95.1%) |
| No | 13 (2.0%) | |
| Maybe | 19 (2.9%) | |
| Am willing to use special shoes to protect my feet | Yes | 534 (82.5%) |
| No | 35 (5.4%) | |
| Maybe | 78 (12.1%) | |
| I think regular visits to a podiatrist are necessary for diabetics | Yes | 550 (85.0%) |
| No | 29 (4.5%) | |
| Maybe | 68 (10.5%) | |
| I believe exercise helps maintain diabetic foot health | Yes | 566 (87.5%) |
| No | 28 (4.3%) | |
| Maybe | 53 (8.2%) | |
| I have received education about diabetic foot care from a health care provider | Yes | 327 (50.5%) |
| No | 231 (35.7%) | |
| Maybe | 89 (13.8%) |
Table 5 illustrates the patients’ practices regarding diabetic foot care. Among the 188 patients with sores or wounds (29.1%), more than half (108, 57.4%) sought medical attention for treatment. Most patients reported washing their feet daily (562, 86.9%) and cutting their nails straight across while filing the edges (502, 77.6%), regardless of whether they had diabetes. Furthermore, a considerable proportion refrained from using harsh chemicals or over-the-counter treatments on their feet without consulting a doctor (443, 68.5%). Surprisingly, less than half of the patients reported wearing socks designed specifically for people with diabetes (197, 30.4%), while only 204 (31.5%) of them self-inspected their feet daily.
Table 5. Practice measurement.
Practice measurement presented in frequencies (n) and proportion (%)
| Attributes | Categories | n (%) |
| Have you ever had sores or wounds on your feet? | Yes | 188 (29.1%) |
| No | 459 (70.9%) | |
| If yes, in the question above, how did you deal with them? | I treated it myself | 80 (42.6%) |
| I sought medical attention | 108 (57.4%) | |
| I check my feet daily, whether I have diabetes or not | Yes | 278 (43.0%) |
| No | 214 (33.1%) | |
| Sometimes | 155 (24.0%) | |
| I wash my feet daily, whether I have diabetes or not | Yes | 562 (86.9%) |
| No | 42 (6.5%) | |
| Sometimes | 43 (6.6%) | |
| I dry my feet between toes after washing, whether I have diabetes of not | Yes | 344 (53.2%) |
| No | 181 (28.0%) | |
| Sometimes | 122 (18.9%) | |
| I use lotion/moisturizer on my feet, whether I have diabetes or not | Yes | 334 (51.6%) |
| No | 169 (26.1%) | |
| Sometimes | 144 (22.3%) | |
| I avoid walking barefoot, whether I have diabetes or not | Yes | 424 (65.5%) |
| No | 128 (19.8%) | |
| Sometimes | 95 (14.7%) | |
| I check my shoes before wearing them, whether I have diabetes or not | Yes | 329 (50.9%) |
| No | 203 (31.4%) | |
| Sometimes | 115 (17.8%) | |
| I protect my feet and keep them away from high and low temperatures, whether I have diabetes of not | Yes | 420 (64.9%) |
| No | 128 (19.8%) | |
| Sometimes | 99 (15.3%) | |
| I cut my nails straight across and file the edges, whether I have diabetes or not | Yes | 502 (77.6%) |
| No | 73 (11.3%) | |
| Sometimes | 72 (11.1%) | |
| I wear socks designed specifically for people with diabetes, whether I have diabetes or not | Yes | 197 (30.4%) |
| No | 359 (55.5%) | |
| Sometimes | 91 (14.1%) | |
| I use a mirror to check the soles of my feet if I have difficult seeing them, whether I have diabetes or not | Yes | 204 (31.5%) |
| No | 358 (55.3%) | |
| Sometimes | 85 (13.1%) | |
| I avoid using heating pads or hot water bottles on my feet, whether I have diabetes or not | Yes | 315 (48.7%) |
| No | 254 (39.3%) | |
| Sometimes | 78 (12.1%) | |
| I refrain from using harsh chemicals or over-the-counter treatment on my feet without consulting a doctor | Yes | 443 (68.5%) |
| No | 155 (24.0%) | |
| Sometimes | 49 (7.6%) | |
| I monitor my blood sugar levels regularly | Yes | 376 (58.1%) |
| No | 166 (25.7%) | |
| Sometimes | 105 (16.2%) | |
| I do exercise regularly to help control your blood sugar levels | Yes | 325 (50.2%) |
| No | 151 (23.3%) | |
| Sometimes | 171 (26.4%) |
Table 6 shows the patients’ knowledge measurement levels based on the questions provided in the questionnaire. The knowledge measurement consisted of 12 questions categorized into five subscales: strongly agree, I agree, neutral, I do not agree and strongly disagree. The response options were as follows: 5=strongly agree; 4=I agree; 3=neutral; 2=I do not agree; 1=strongly agree. The highest score any participant could get was 60, and the lowest score any respondent could get was 12. Data was converted to composite scores. The scoring system was categorized as follows: Good knowledge (48-60) and poor knowledge (12-47). Data was then analyzed to find out the levels of knowledge among the diabetic patients.
Table 6. Association between socio-demographic data and the patients’ level of knowledge regarding diabetic foot care .
* Significant at p<0.05 level.
| Socio-demographic variables | Knowledge level | Cramer’ V, DF | P-value | ||
| Poor | Good | ||||
| Sex | Female | 80 (27.5%) | 211 (72.5%) | 0.035, 1 | 0.377 |
| Male | 87 (24.4%) | 269 (75.6%) | |||
| Age in years | Under 18 years | 6 (35.3%) | 11 (64.7%) | 0.113, 5 | 0.140 |
| 18-29 | 56 (28.9%) | 138 (71.1%) | |||
| 30-39 | 33 (32.7%) | 68 (67.3%) | |||
| 40-49 | 27 (19.0%) | 115 (81.0%) | |||
| 50-59 | 28 (23.7%) | 90 (76.3%) | |||
| 60 years and above | 17 (22.7%) | 58 (77.3%) | |||
| Nationality | Saudi | 160 (26.4%) | 447 (73.6%) | 0.049, 1 | 0.215 |
| Non-Saudi | 7 (17.5%) | 33 (82.5%) | |||
| Marital status | Single | 62 (27.8%) | 161 (72.2%) | 0.095, 3 | 0.120 |
| Married | 100 (25.1%) | 299 (74.9%) | |||
| Divorced | 0 (0.0%) | 12 (100.0%) | |||
| Widow | 5 (38.5%) | 8 (61.5%) | |||
| Education level | Intermediate education | 4 (13.8%) | 25 (86.2%) | 0.092, 3 | 0.138 |
| Primary education and below | 6 (42.9%) | 8 (57.1%) | |||
| Secondary education | 28 (22.2%) | 98 (77.8%) | |||
| University education or higher | 129 (27.0%) | 349 (73.0%) | |||
| Profession | Government sector employee | 40 (19.1%) | 169 (80.9%) | 0.109, 4 | 0.105 |
| Private sector employee | 27 (28.4%) | 68 (71.6%) | |||
| Retired | 32 (27.6%) | 84 (72.4%) | |||
| Student | 38 (28.8%) | 94 (71.2%) | |||
| Unemployed | 30 (31.6%) | 65 (68.4%) | |||
| Monthly income in Riyals | Less than 5000 riyals | 68 (28.3%) | 172 (71.7%) | 0.064, 3 | 0.444 |
| 5000-10000 riyals | 36 (27.3%) | 96 (72.7%) | |||
| 10000-15000 riyals | 28 (25.2%) | 83 (74.8%) | |||
| More than 15000 riyal | 35 (21.3%) | 129 (78.7%) | |||
| Duration of diabetes in years | Less than a year | 10 (37.0%) | 17 (63.0%) | 0.109, 4 | 0.105 |
| 1-5 years | 24 (36.9%) | 41 (63.1%) | |||
| 6-10 years | 13 (25.0%) | 39 (75.0%) | |||
| More than 10 years | 20 (20.6%) | 77 (79.4%) | |||
| Family history | 100 (24.6%) | 306 (75.4%) | |||
| Number of clinic visits per year | Less than two visits | 68 (27.8%) | 177 (72.2%) | 0.050, 3 | 0.661 |
| 2-4 visits | 60 (26.2%) | 169 (73.8%) | |||
| 5-7 visits | 24 (23.5%) | 78 (76.5%) | |||
| More than 7 visits | 15 (21.1%) | 56 (78.9%) | |||
Table 6 presents the association between patients’ socio-demographic data and their levels of knowledge regarding diabetic foot care. The study revealed that nearly three-quarters (480, 74.2%) of the diabetic patients had good knowledge, while about one-quarter (167, 25.8%) of them had poor knowledge regarding diabetic foot care. The study found no significant association between patients’ knowledge levels about diabetic foot care and the social demographic variables (p>0.005).
Table 7 presents the association between patients’ socio-demographic data and their levels of attitude towards diabetic foot care. The study revealed that a significant majority (604, 93.4%) of the diabetic patients had a good attitude, while only 43 (6.6%) of them had a poor attitude towards diabetic foot care. Patients’ age and duration of diabetes were found to be significantly associated with their attitude towards diabetic foot care (p=0.011; 0.005*). However, there was no significant association between patients’ attitude towards diabetic foot care with other social demographic variables (p>0.005).
Table 7. Association between socio-demographic data and the patients’ attitude towards diabetic foot care .
* Significant at p<0.05 level.
| Socio-demographic variables | Attitude level | Cramer’ V, DF | P-value | ||
| Poor | Good | ||||
| Sex | Female | 16 (5.5%) | 275 (94.5%) | 0.042, 1 | 0.289 |
| Male | 27 (7.6%) | 329 (92.4%) | |||
| Age in years | Under 18 years | 4 (23.5%) | 13 (76.5%) | 0.151, 5 | 0.011* |
| 18-29 | 19 (9.8%) | 175 (90.2%) | |||
| 30-39 | 4 (4.0%) | 97 (96.0%) | |||
| 40-49 | 5 (3.5%) | 137 (96.5%) | |||
| 50-59 | 6 (5.1%) | 112 (94.9%) | |||
| 60 years and above | 5 (6.7%) | 70 (93.3%) | |||
| Nationality | Saudi | 39 (6.4%) | 568 (93.6%) | 0.035, 1 | 0.379 |
| Non-Saudi | 4 (10.0%) | 36 (90.0%) | |||
| Marital status | Single | 20 (9.0%) | 203 (91.0%) | 0.071, 3 | 0.355 |
| Married | 21 (5.3%) | 378 (94.7%) | |||
| Divorced | 1 (8.3%) | 11 (91.7%) | |||
| Widow | 1 (7.7%) | 12 (92.3%) | |||
| Education level | Intermediate education | 1 (3.4%) | 28 (96.6%) | 0.054, 3 | 0.601 |
| Primary education and below | 2 (14.3%) | 12 (85.7%) | |||
| Secondary education | 9 (7.1%) | 117 (92.9%) | |||
| University education or higher | 31 (6.5%) | 447 (93.5%) | |||
| Profession | Government sector employee | 11 (5.3%) | 198 (94.7%) | 0.087, 4 | 0.296 |
| Private sector employee | 6 (6.3%) | 89 (93.7%) | |||
| Retired | 8 (6.9%) | 108 (93.1%) | |||
| Student | 14 (10.6%) | 118 (89.4%) | |||
| Unemployed | 4 (4.2%) | 91 (95.8%) | |||
| Monthly income in Riyals | Less than 5000 riyals | 18 (7.5%) | 222 (92.5%) | 0.032, 3 | 0.882 |
| 5000-10000 riyals | 9 (6.8%) | 123 (93.2%) | |||
| 10000-15000 riyals | 7 (6.3%) | 104 (93.7%) | |||
| More than 15000 riyal | 9 (5.5%) | 155 (94.5%) | |||
| Duration of diabetes in years | Less than a year | 5 (18.5%) | 22 (81.5%) | 0.152, 4 | 0.005* |
| 1-5 years | 9 (13.8%) | 56 (86.2%) | |||
| 6-10 years | 4 (7.7%) | 48 (92.3%) | |||
| More than 10 years | 7 (7.2%) | 90 (92.8%) | |||
| Family history | 18 (4.4%) | 388 (95.6%) | |||
| Number of clinic visits per year | Less than two visits | 17 (6.9%) | 228 (93.1%) | 0.015, 3 | 0.985 |
| 2-4 visits | 15 (6.6%) | 214 (93.4%) | |||
| 5-7 visits | 6 (5.9%) | 96 (94.1%) | |||
| More than 7 visits | 5 (7.0%) | 66 (93.0%) | |||
Discussion
Given the high incidence rate of diabetes in Saudi Arabia, there is a knowledge gap among diabetic patients regarding foot care, which increases the risk of serious complications. Understanding patients’ attitudes and knowledge may help tailor treatment strategies to enhance foot care behaviors, prevent complications, and improve patients’ quality of life and overall health outcomes [22]. This study aimed to assess the attitude and knowledge of diabetic patients in the province of Al-Qassim regarding diabetic foot care.
The study revealed that nearly three-quarters (480, 74.2%) of diabetic patients had good knowledge about foot care, while about one-quarter (167, 25.8%) had poor knowledge. The level of knowledge in our study was significantly higher than in other studies conducted in Saudi Arabia, where Solan et al. [23] reported good knowledge in only 53.6% of patients, and Al-Aboudi et al. [24] reported 13.3%. This wide variation in the prevalence of knowledge observed across studies in Saudi Arabia may be attributed to differences in data collection methods and variations in sample sizes. Notably, the study found that the majority of patients (590, 91.2%) were aware that diabetics are more likely to develop gangrene in the foot and that regular foot care can prevent many diabetic foot problems (577, 91.2%).
Regarding the attitude, an overwhelming majority (604, 93.4%) of the patients had a positive attitude towards diabetic foot care, compared to only 43 (6.6%) with a poor attitude. It was observed that a significant majority of patients recognized the importance of nutrition in controlling blood sugar levels (615, 95.1%) and the role of exercise in maintaining diabetic foot health (566, 87.5%). Additionally, most patients expressed a willingness to use special shoes to protect their feet (534, 82.5%).
The study revealed that patients aged 18 years and older had a significantly better attitude towards diabetic foot care compared to those under 18 years (p = 0.011). This difference in attitude levels may be attributed to the greater experience older individuals have in managing diabetes, leading to increased awareness of the importance of foot care and the risks of potential complications [25]. Furthermore, patients with a family history of diabetes had a significantly better attitude towards diabetic foot care compared to those who had lived with the disease for a shorter duration (p = 0.005). These findings align with those of a study conducted by Shah et al., which reported that patients with a long-standing history of diabetes had a better attitude towards diabetic foot care [26]. Surprisingly, about 327 patients (50.5%) had received education about diabetic foot care from a healthcare provider, highlighting significant gaps in educational uptake, as nearly half (320, 49.5%) had not received formal education on this topic. This underscores the need for awareness programs to enhance patients' knowledge and motivate them to adopt a positive attitude towards diabetic foot care.
Regarding foot care practices, more than half of the patients (108, 57.4%) with sores or wounds sought medical attention, indicating adherence to proper health practices among a substantial proportion. However, most participants did not engage in good routine practices, as less than half (204, 31.5%) self-inspected their feet daily, and only about 197 (30.4%) wore socks specifically designed for people with diabetes. While these rates are higher compared to previous studies - where only 22.2% of participants in Goie and Naidoo [27] examined their feet and only 14% in Hasnain and Sheikh [28] reported good foot care practices - there is still a need to motivate healthcare practitioners to educate diabetic patients and consistently remind them about routine health practices and the risks of diabetes-related complications.
It is crucial to consider the limitations of the study while assessing the results. The cross-sectional design could only assess the relationship between the study attributes, but not their causalities. The study findings could be generalized to the entire Saudi Arabian population given that it was conducted in only one region, Al-Qassim. Furthermore, since the study relied on self-reported online survey data, biases related to recollection and social desirability may have compromised its reliability and accuracy.
Conclusions
The study revealed a high percentage of surveyed patients with good knowledge and a positive attitude towards diabetic foot care. However, significant gaps in diabetic education were evident, as a substantial proportion of patients had not received formal education on the subject. This highlights the need for educational programs aimed at improving both knowledge and attitudes, as well as promoting good routine practices by consistently reminding patients about health practices and the risks associated with diabetes-related complications.
Appendices
Appendix 1
Survey on Knowledge About Foot Care for Diabetic Patients in the Qassim Region
Consent to Participate
Do you agree to participate in this survey?
• Yes • No
Demographic and Residential Information
Do you reside in the Qassim region?
• Yes • No
Personal Information
Gender:
• Male
• Female
Age:
• Under 18 years
• 18-29 years
• 30-39 years
• 40-49 years
• 50-59 years
• 60 years and above
Nationality:
• Saudi
• Non-Saudi
Marital Status:
• Married
• Single
• Divorced
• Widowed
Education Level:
• Primary education or below
• Middle school education
• High school education
• University degree or higher
Occupation:
• Government sector employee
• Private sector employee
• Unemployed
• Retired
• Student
Monthly Income:
• Less than 5,000 SAR
• 5,000-10,000 SAR
• 10,000-15,000 SAR
• More than 15,000 SAR
Duration of Diabetes Diagnosis:
• Less than a year
• 1-5 years
• 6-10 years
• More than 10 years
• A close relative has diabetes
Number of Clinic Visits Per Year:
• Less than 2 visits
• 2-4 visits
• 5-7 visits
• More than 7 visits
Knowledge Assessment
Are you aware that diabetic patients may experience reduced blood flow to their feet?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Do you know that diabetic patients may lose sensation in their feet?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Do you understand that diabetic patients can develop foot ulcers?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Are you aware of the possibility of diabetic patients developing gangrene in their feet?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Do you know that loss of sensation in the feet can make diabetic patients more prone to foot ulcers?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Are you aware that reduced blood flow to the feet can make diabetic patients more prone to foot ulcers?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Do you know that diabetes can cause changes in foot shape?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Are you aware that high blood sugar levels can damage blood vessels in the feet?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Do you know the signs of diabetic foot infection?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Do you understand the importance of wearing appropriate footwear for diabetic patients?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Are you aware that smoking can worsen foot complications in diabetic patients?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Do you know that regular foot care can prevent many diabetic foot problems?
• Strongly agree • Agree • Neutral • Disagree • Strongly disagree
Attitude Assessment
Do you consider nutrition an important factor in controlling blood sugar levels?
• Yes
• No
• Maybe
Would you be willing to wear special footwear to protect your feet?
• Yes
• No
• Maybe
Do you think regular visits to a podiatrist are necessary for diabetic patients?
• Yes
• No
• Maybe
Do you believe that physical exercise helps maintain diabetic foot health?
• Yes
• No
• Maybe
Have you received education about diabetic foot care from a healthcare provider?
• Yes
• No
• Maybe
Have you ever had foot ulcers or wounds? How did you handle them?
• Yes, I sought medical care
• Yes, I treated them myself
• No
Foot Care Practices
Do you check your feet daily, whether you have diabetes or not?
• Yes • No • Sometimes
Do you wash your feet daily, whether you have diabetes or not?
• Yes • No • Sometimes
Do you dry your feet and between your toes after washing, whether you have diabetes or not?
• Yes • No • Sometimes
Do you use lotion/moisturizer on your feet, whether you have diabetes or not?
• Yes • No • Sometimes
Do you avoid walking barefoot, whether you have diabetes or not?
• Yes • No • Sometimes
Do you check your shoes before wearing them, whether you have diabetes or not?
• Yes • No • Sometimes
Do you protect your feet from extreme hot and cold temperatures, whether you have diabetes or not?
• Yes • No • Sometimes
Do you trim your nails straight across and file the edges, whether you have diabetes or not?
• Yes • No • Sometimes
Do you wear socks designed for diabetic patients, whether you have diabetes or not?
• Yes • No • Sometimes
Do you use a mirror to check the soles of your feet if you have trouble seeing them, whether you have diabetes or not?
• Yes • No • Sometimes
Do you avoid using heating pads or hot water bottles on your feet, whether you have diabetes or not?
• Yes • No • Sometimes
Do you refrain from using harsh chemicals or over-the-counter treatments on your feet without consulting a doctor?
• Yes • No • Sometimes
Do you monitor your blood sugar levels regularly?
• Yes • No • Sometimes
Do you engage in regular physical activity to help control your blood sugar levels?
• Yes • No • Sometimes
Disclosures
Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Qassim University Medical College Ethical Committee issued approval CL-20240516-11.
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Author Contributions
Concept and design: Saleh Hussain Alshaiban, Reem Alsalamah, Rayan A. Alsagri, Heba Mohammad, Lajeen Alnowaisser, Khalil N. Al-Shakhaly, Khaled Asiri
Acquisition, analysis, or interpretation of data: Saleh Hussain Alshaiban, Reem Alsalamah, Rayan A. Alsagri, Heba Mohammad, Lajeen Alnowaisser, Khalil N. Al-Shakhaly, Khaled Asiri
Drafting of the manuscript: Saleh Hussain Alshaiban, Reem Alsalamah, Rayan A. Alsagri, Heba Mohammad, Lajeen Alnowaisser, Khalil N. Al-Shakhaly, Khaled Asiri
Critical review of the manuscript for important intellectual content: Saleh Hussain Alshaiban, Reem Alsalamah, Rayan A. Alsagri, Heba Mohammad, Lajeen Alnowaisser, Khalil N. Al-Shakhaly, Khaled Asiri
Supervision: Saleh Hussain Alshaiban, Reem Alsalamah
References
- 1.Global estimates of the prevalence of diabetes for 2010 and 2030. Shaw JE, Sicree RA, Zimmet PZ. https://www.diabetesresearchclinicalpractice.com/article/S0168-8227(09)00432-X/fulltext. Diabetes Res Clin Pract. 2010;87:4–14. doi: 10.1016/j.diabres.2009.10.007. [DOI] [PubMed] [Google Scholar]
- 2.Attitude and knowledge about foot care among diabetic patients in Riyadh, Saudi Arabia. Alshammari ZJ, Alsaid LA, Parameaswari PJ, Alzahrani AA. J Family Med Prim Care. 2019;8:2089–2094. doi: 10.4103/jfmpc.jfmpc_248_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.General aspects of diabetes mellitus. Alam U, Asghar O, Azmi S, Malik RA. Handb Clin Neurol. 2014;126:211–222. doi: 10.1016/B978-0-444-53480-4.00015-1. [DOI] [PubMed] [Google Scholar]
- 4.Knowledge, attitude, and practice regarding diabetic foot care among Saudi and non-Saudi diabetic patients in Alkharj. Shamim M, Alhakbani MS, Alqahtani MS, Alharthi OS, Alhaqbani YJ. J Family Med Prim Care. 2021;10:859–864. doi: 10.4103/jfmpc.jfmpc_1681_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Knowledge, attitude and practice regarding risk of diabetic foot among diabetic patients in Aseer Region, Saudi Arabia. Al Amri AM, Shahrani IM, Almaker YA, Alshehri DM, Argabi MA, Alghamidi FA, Alqahtani YZ. Cureus. 2021;13:0. doi: 10.7759/cureus.18791. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Diabetes mellitus in Saudi Arabia: a review of the recent literature. Al Dawish MA, Robert AA, Braham R, Al Hayek AA, Al Saeed A, Ahmed RA, Al Sabaan FS. Curr Diabetes Rev. 2016;12:359–368. doi: 10.2174/1573399811666150724095130. [DOI] [PubMed] [Google Scholar]
- 7.Evaluation of knowledge, attitude, and practices of foot self-care among diabetic patients attending different diabetic clinics in Najran, Saudi Arabia. Alsareii S. King Khalid Univ J Health Sci. 2023;8:37–47. [Google Scholar]
- 8.Hoboken: John Wiley & Sons; 2006. The Foot in Diabetes. [Google Scholar]
- 9.Preventing foot ulcers in patients with diabetes. Singh N, Armstrong DG, Lipsky BA. JAMA. 2005;293:217–228. doi: 10.1001/jama.293.2.217. [DOI] [PubMed] [Google Scholar]
- 10.Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. https://www.tandfonline.com/doi/10.1080/07853890.2016.1231932?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed. Ann Med. 2017;49:106–116. doi: 10.1080/07853890.2016.1231932. [DOI] [PubMed] [Google Scholar]
- 11.Diabetic foot. Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A. BMJ. 2017;359:0. doi: 10.1136/bmj.j5064. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Barriers to diabetic foot care in a developing country with a high incidence of diabetes related amputations: an exploratory qualitative interview study. Guell C, Unwin N. https://pmc.ncbi.nlm.nih.gov/articles/PMC4570260/ BMC Health Serv Res. 2015;15:377. doi: 10.1186/s12913-015-1043-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Book review: Williams Textbook of Endocrinology. Vargatu I. Acta Endo (Buc) 2016;12:113. [Google Scholar]
- 14.Diabetes. [ May; 2024 ]. 2024. https://www.who.int/news-room/fact-sheets/detail/diabetes https://www.who.int/news-room/fact-sheets/detail/diabetes
- 15.Pathways to diabetic limb amputation. Basis for prevention. Pecoraro RE, Reiber GE, Burgess EM. Diabetes Care. 1990;13:513–521. doi: 10.2337/diacare.13.5.513. [DOI] [PubMed] [Google Scholar]
- 16.Diabetic heel ulcer in the Sudan: determinants of outcome. Bakheit HE, Mohamed MF, Mahadi SE, Widatalla AB, Shawer MA, Khamis AH, Ahmed ME. J Foot Ankle Surg. 2012;51:152–155. doi: 10.1053/j.jfas.2011.10.032. [DOI] [PubMed] [Google Scholar]
- 17.Characteristics predicting the outcome in individuals with diabetic foot ulcerations. Vella L, Formosa C. J Am Podiatr Med Assoc. 2017;107:180–191. doi: 10.7547/15-070. [DOI] [PubMed] [Google Scholar]
- 18.Acta Endocrinol (Buchar) Vol. 12. Philadelphia: Saunders; 2011. Williams Textbook of Endocrinology; p. 113. [Google Scholar]
- 19.Foot self-care in diabetes mellitus: evaluation of patient awareness. Yılmaz Karadağ F, Saltoğlu N, Ak Ö, et al. Prim Care Diabetes. 2019;13:515–520. doi: 10.1016/j.pcd.2019.06.003. [DOI] [PubMed] [Google Scholar]
- 20.General Authority for Statistics in Saudi Arabia. [ May; 2024 ]. 2024. https://www.stats.gov.sa/en/home https://www.stats.gov.sa/en/home
- 21.Sample size calculator. [ May; 2024 ]. 2024. http://www.raosoft.com/samplesize.html http://www.raosoft.com/samplesize.html
- 22.Diabetic foot awareness among diabetic patients in Saudi Arabia. Algshanen MA, Almuhanna MF, Almuhanna AM, et al. Egypt J Hospit Med. 2017;68:1289–1290. [Google Scholar]
- 23.Diabetic foot care: knowledge and practice. Solan Y, Kheir H, Mahfouz M, et al. https://jofem.org/index.php/jofem/article/view/396 J Endocrinol Metab. 2016;6:172–176. [Google Scholar]
- 24.Knowledge, attitudes, and quality of life of type 2 diabetes patients in Riyadh, Saudi Arabia. Al-Aboudi IS, Hassali MA, Shafie AA. J Pharm Bioallied Sci. 2016;8:195–202. doi: 10.4103/0975-7406.171683. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Knowledge, attitudes and practices regarding diabetes in the general population: a cross-sectional study from Pakistan. Gillani AH, Amirul Islam FM, Hayat K, et al. Int J Environ Res Public Health. 2018;15 doi: 10.3390/ijerph15091906. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Assessing the knowledge, attitudes and practice of type 2 diabetes among patients of Saurashtra region, Gujarat. Shah VN, Kamdar PK, Shah N. https://pmc.ncbi.nlm.nih.gov/articles/PMC2822215/ Int J Diabetes Dev Ctries. 2009;29:118–122. doi: 10.4103/0973-3930.54288. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Awareness of diabetic foot disease amongst patients with type 2 diabetes mellitus attending the chronic outpatients department at a regional hospital in Durban, South Africa. Goie TT, Naidoo M. Afr J Prim Health Care Fam Med. 2016;8:0–8. doi: 10.4102/phcfm.v8i1.1170. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Knowledge and practices regarding foot care in diabetic patients visiting diabetic clinic in Jinnah Hospital, Lahore. Hasnain S, Sheikh NH. https://pubmed.ncbi.nlm.nih.gov/19813683/ J Pak Med Assoc. 2009;59:687–690. [PubMed] [Google Scholar]