Knowledge, attitudes, and practices of Footcare in Diabetic patients in Hammoud University Medical Center

doi:10.21203/rs.3.rs-4165910/v1

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Knowledge, attitudes, and practices of Footcare in Diabetic patients in Hammoud University Medical Center

https://doi.org/10.21203/rs.3.rs-4165910/v1

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Introduction and literature: Diabetes mellitus is a metabolic heterogeneous disease that requires long-term management and is accompanied by several complications. Diabetic foot is one of the important complications encountered by diabetes. it arises to multiple vascular and neurological complications that diabetes results in. Patients need to be advised and follow the physicians' instructions to maintain the best outcomes. our study aims to tackle the knowledge, attitudes, and practices of diabetics regarding diabetic foot care at Hamoud Unversity Medical Center.

Methods: a total of 108 patients in Hamoud University Medical Center were questioned after obtaining the hospital IRB approval. Results were entered and analyzed by Spss v23. quantitative data were analyzed as means and qualitative as frequencies and percentages. The scores were calculated into means, ANOVA, and t-tests were used to find correlations between scores and factors with significant p-values <0.05.

Results: The study included 108 participants of mean age was 60.14 ±15.3. The majority of participants are males 64.8% ( n=70), and 34.3% (n=37) are of university level. out of diabetic complications, most are hypertensive. Patients were found to have good knowledge responses, some were with positive attitudes, and all were with bad practices. As for correlations, no statistically significant result was found in the knowledge section. Several factors were found with a positive relation in the attitude section as level of education and type of occupation. Lastly, also positive correlations were found in practices between several factors as duration of diabetes, occupation, and marital status with p-values <0.05.

Conclusion: The study concludes that there is much more to learn and educate. Participants are aware of the dangers but do not follow proper health care services to prevent complications. Overall, the integration of both data sets reveals a multifaceted perspective among respondents, emphasizing the importance of tailored education, support, and interventions to promote adherence to foot care routines and optimize diabetes management outcomes.

Diabetic

Footcare

Ulcer

Lebanon

knowledge

Attitude

Practices

Diabetes mellitus and its complications

Diabetes mellitus is a metabolic heterogeneous disease characterized with episodes of hyperglycemia and glucose intolerance, due to deficiency in insulin or lack in insulin action or both (1). Diabetes is a chronic disease that requires continuous strict monitoring of the glycemic levels to prevent short term and long-term complications. Awareness and patient education about the importance of regular exercise, weight loss, healthy diet and controlling blood sugar plays an important role in preventing acute complications and reducing long term complications (2).Despite healthy lifestyle and precautious measures, the longer you have diabetes and the lower your control to glycemic level the higher the incidence to have complication. Diabetes can cause both acute and chronic complications (5). Acute complications might manifest as diabetic ketoacidosis DKA, and hyperglycemic hyperosmolar state HHS, and lactic acidosis. However, chronic complications are further subdivided into micro and macro vascular complications, with retinopathy, nephropathy and neuropathy representing micro vascular complications (3) and cardiac, cerebral and vascular representing macro vascular complications. The most encountered micro vascular complications are diabetic retinopathy and nephropathy, manifesting as visual impairment or even blindness and chronic kidney disease respectively(6). Additionally, peripheral neuropathy was highly prevalent complication in both type 1 diabetes (T1D) and type 2 diabetes (T2D), with a prevalence exceeding 50% in type 2 who are diabetic for more than 10 years (9)(4)(5)(6).

Foot ulcers in diabetic patients

As healthcare workers control outside consultation room is limited (7). Amongst the wide range of complications that accompany diabetes mellitus, diabetic foot infections stand out as one of the most challenging. Almost all patients with DM are at risk of developing diabetic foot infections with current studies showing that the prevalence of developing foot ulcers is 4–10%, the annual population based incidence is 1.0–4.1% and the lifetime incidence my reach as high as 25%(12). Infections in ulcerated feet in patients with DM pose a major cause for morbidity in those patients, in addition to discomfort, increased number of visits to health-care providers, wound care and antimicrobial therapy (13).

With infections being the most common cause (more than 50%), patients with DFIs frequently require minor or major amputations of the lower limbs ( 15–27%)(14).

Major amputations are associated with significant morbidity and mortality (ranging from 13 to 40% at 1 year to 39 to 80% at 5 years 2) in addition to psychological and financial consequences (15). It has been reported that nearly 70% of nontraumatic amputations were performed due to a diabetic foot(10). Diabetic foot ulcer is defined as any necrosis, gangrene, or full-thickness skin defect occurring distal to the ankle in a diabetic patient(3).Many reports showed that this problem is the most frequent cause of hospitalization for diabetic patients, representing up to 25% of all hospital admissions of diabetic patients.(10)

Knowledge, attitude, and practices about foot care in diabetic patients

Diabetic foot care is extremely important for patients and their health(10). They should be well educated about their disease and the complications caused. For instance diabetic patients should have received education about the sensation loss and decrease blood flow they will have with time(11). These patients should also be aware of checking their sole of the feet and any developing ulcer due to delayed wound healing(10). Many patients have deficit about the knowledge of these practices and that’s why it is very important to address these specific deficits in order to improve overall diabetic foot care.This point was revealed by Shamim et al.'s research in Alkharj, Saudi Arabia, which investigates the knowledge, attitudes, and practices regarding diabetic foot care among both Saudi and non-Saudi diabetic patients. The study provides valuable insights into the diverse population and their approach to foot care.It sheds light on the difference of approach to diabetic foot care in relation to different geographical and cultural context (19).

The Saudi study mentioned that > 70% of the participants are well educated about diabetic foot care and how to deal with it (10). It was also seen that in another study in Riyadh confirmed that Saudian’s have good knowledge about the topic (11). Questions like the blood flow to the feet, the awareness of developing ulcers, and the loss of sensation in diabetic patients were asked in both studies (10, 11). Another study done in Pakistan showed that nurses do educate patients about diabetic foot care for prevention rather than reaching ulcers and having to treat (16). Unlike rural parts of India where studies have found poor knowledge of diabetic foot care (17).

Even though researches found good knowledge about diabetes and its complication the attitudes and practices are still poor. Performing a good attitude and practice includes clinical visits to the doctor, proper medication use, and proper treatment of sores (10). Fortunately the source of knowledge in major studies was from physicians and nurses (10, 16, 17). Shaqran et al revealed that participants perform regular exercises, take their medications properly, and take advices from specialist which indicates good attitudes (10).

Practice levels in a study conducted by Alharbi et al. were average of 56% with performing good foot care as washing daily ,applying moisturizers, drying them, and inspecting shoes before wearing daily (18). Also, it was proven that those with longer duration of diabetes had better practices than those with shorter duration (10). That’s exactly why diabetic patient foot care practice is extremely and crucially important for limb preservation to avoid amputation and the loss that varies from toes till whole foot amputation which was proved by The study by Hanley et al. that focuses on diabetic foot care practices among patients with foot complications and amputation in St. Kitts and Nevis (15, 16, 17). No single study was found in Lebanon to address the issue and upon this the following research was conducted. Saudi Arabia was the main country to address foot care in diabetic patients and we have adopted their question to conduct ours. This research draws attention to the critical aspects of foot care in preventing severe complications.

Study design: a cross sectional study targeting diabetic patients in HUMC
Study place: Hamoud University Medical Center
Study population (inclusion criteria &exclusion criteria): All Diabetic patients admitted to HUMC
Study period: Surveying and data collection will start directly after the IRB approval. One year is the estimated time to complete this study.
Sampling (type &size): There will be no sampling carried out for the purpose of this study. Nevertheless, 108 diabetic patients are included. Participants are to be interviewed with no upper limit. The minimum sample size was calculated based on confidence level of 95%, margin of error of 5%, these measures were selected to ensure that enough power can be achieved to test different hypotheses through future further analysis of the results.
Data collection procedures and tools: All research participants will be approached by the investigators whereby the aims of the study will be explained and consenting will take place.

The investigators will interview diabetic patients with a questionnaire targeting the aim of the research. It will take 5–10 minutes only. Plan of data processing and analysis: Processing of data will include data entry that will be entered into a Microsoft Excel spreadsheet which will be designed specifically for this study resembling the paper forms (same order of questions…) to avoid data entry mistake. After that, data will be transferred into the Statistical Package of Social Science (IBM SPSS, version 23) which will be used for data cleaning, management, and analyses using built range checks with automatic error prompts. In addition, we will perform ascending/ descending order view of variables and descriptive histograms that will easily identify outliers. Descriptive analyses will be carried out by calculating the mean and standard deviation for continuous variables, and number and percent for categorical ones. Knowledge, attitudes, and practices are analyzed as mean scores and compared using ANOVA and t-tests with the provided factors.

The study included 108 participants of mean age was 60.14 ± 15.3. The majority of participants are males 64.8% ( n = 70), 34.3% (n = 37) are of university level, 27.8% (n = 30) are of high school level, and 11% (n = 12) are with no education level. Almost half of the participants 51.9% (n = 56) are employed and 66.7% (n = 72) are married. 75.9% (n = 82) of the participants are Lebanese and 56.5% (n = 61) are smokers. As for diabetic complications and other comorbidities, 78.7% (n = 85) are hypertensive, 31.5% (n = 34) are with renal disease, 58.3% (n = 63) are with dyslipidemia ,39.8% (n = 43) are with heart disease, and 23.1% (n = 25) suffer of retinopathy (Table 1).

Table 1

Participants' Demographics
Demographics		Mean	SD
Age		60.14	± 15.3
Age		Frequency (n)	Percentage %
Gender	Male	70	64.8%
Gender	Female	38	35.2%
Marital Status	Single	18	16.7%
	Married	72	66.7%
	Widowed	16	14.8%
	Divorced	2	1.9%
Education	No Education	12	11.1%
	Elementary	6	5.6%
	Middle School	13	12%
	High School	30	27.8%
	University	37	34.3%
	Higher Education	10	9.3%
Occupation	Student	5	4.6%
	Employed	56	51.9%
	Unemployed	29	26.9%
	Retired	18	16.7%
Nationality	Lebanese	82	75.9%
Nationality	Palestinian	26	24.1%
Smoker	Yes	61	56.5%
Smoker	No	47	43.5%
Hypertension	Yes	85	78.7%
Hypertension	No	23	21.3%
Renal Disease	Yes	34	31.5%
Renal Disease	No	74	68.5%
Dyslipidemia	Yes	63	58.3%
Dyslipidemia	No	45	41.7%
Heart Disease	Yes	43	39.8%
Heart Disease	No	65	60.2%
Retinopathy	Yes	25	23.1%
Retinopathy	No	83	76.9%

In Table 2, the majority of participants are with diabetes type 2 89.8% (n = 97). 68.5% (n = 74) had diabetes for more than 10 years and 37% (n = 40) were of uncontrolled Hba1c. The mean value of Hba1c was 7.7 ± 1.88. As for their medication 67.6% (n = 73) of the participants are on oral agents and only 4.6% (n = 5) are on diet only. 34.3% (n = 37) have current foot ulcers and 21.3% (n = 37) have reported multiple foot problems. 26.9% (n = 29) had amputation and 51.9% (n = 56) have received advice on diabetic foot care.

Table 2

diabetes and its complications
Diabetes and diabetic complications		Frequency(n)	Percentage %
Diabetes type	Type 1	11	10.2%
Diabetes type	Type2	97	89.8%
Duration of Diabetes	< 10 Years	34	31.5%
Duration of Diabetes	> 10 Years	74	68.5%
Last Reading of Hba1c	Controlled	31	28.7%
	Uncontrolled	40	37%
	Highly Uncontrolled	6	5.6%
	Unknown	31	28.7%
Diabetes Treatment	Oral Agent (s)15	73	67.6%
	Insulin	15	13.9%
	Oral Agents and Insulin	15	13.9%
	Diet	5	4.6%
Foot Complaints	None	56	51.9%
	Current Ulcer	37	34.3%
	Healed Ulcer	15	13.9%
Sensation problem in feet	None	37	34.3%
	Foot Pain at rest	17	15.7%
	Multiple Problems	23	21.3%
	Foor Pain during walking	10	9.3%
	Numbness	21	19.4%
Amputation	Yes	29	26.9%
Amputation	No	79	73.1%
Received advice on Diabetic foot	Yes	56	51.9%
Received advice on Diabetic foot	No	52	48.1%
Value of Hba1c		Mean	SD
Value of Hba1c		7.77	± 1.88

As for the knowledge section, participants answered 11 questions. 92.6% (n = 100) knew that diabetics develop foot ulcers, 92.6% (n = 100) knew that diabetics develop reduced blood flow in their feet, 97.2% (n = 105) knew that taking medications regularly reduces diabetic complications and 93.5% (n = 101) knew that it is important to examine foot ware for any tear or object ( Table3)

Table 3

Knowledge
Knowledge		Frequency (n)	Percentage %
Diabetics develops foot ulcers	Yes	100	92.6%
Diabetics develops foot ulcers	No	8	7.4%
Diabetics develops reduced blood flow in their feet	Yes	99	91.7%
Diabetics develops reduced blood flow in their feet	No	9	8.3%
Diabetics develops reduced sensation in their feet	Yes	100	92.6%
Diabetics develops reduced sensation in their feet	No	8	7.4%
Poor circulation develops from smoking	Yes	100	92.6%
Poor circulation develops from smoking	No	8	7.4%
Important to examine sole because diabetics develop poor sensation	Yes	101	93.5%
	No	7	6.5%
Wounds and infections do not heal quickly	Yes	103	95.4%
Wounds and infections do not heal quickly	No	5	4.6%
Taking medication regularly reduce DM complications	Yes	105	97.2%
Taking medication regularly reduce DM complications	No	3	2.8%
It is important to examine foot ware for any tear or object	Yes	101	93.5%
It is important to examine foot ware for any tear or object	No	7	6.5%
Foot gangrene is one complication of DM foot infection	Yes	101	93.5%
Foot gangrene is one complication of DM foot infection	No	7	6.5%
Do you think exercise will help reduce complications	Yes	96	88.9%
Do you think exercise will help reduce complications	No	12	11.1%
Uncontrolled diabetes leads to foot deformity	Yes	100	92.6%
Uncontrolled diabetes leads to foot deformity	No	8	7.4%

Table 4 demonstrates the attitude of participants for diabetic foot care. 58.3% (n = 63) said that they can take responsibility of daily examination of their feet and foot ware. 69.4% (n = 75) are able to live normal life with appropriate measures of diabetes and 68.5% (n = 74) can use special foot ware advised by foot-care specialist.

Table 4

Attitude
Attitude		Frequency (n)	Percentage %
Can you perform regular exercise and change your food habits to prevent further diabetic complications?	Yes	60	55.6%
	No	48	44.4%
Can you take the responsibility of daily examination of your feet and foot ware, as well as regular footcare specialist consultation?	Yes	63	58.3%
	No	45	41.7%
Can you use special foot ware adviced by foot-care specialist?	Yes	74	68.5%
	No	34	31.5%
Will you wear footwear indoors as advised by your foot-care specialist?	Yes	70	64.8%
	No	38	35.2%
Can you be able to live a normal life with appropriate measures for diabetes?	Yes	75	69.4%
	No	33	30.6%

Table 5 reveals the practices of diabetic foot care among the participants. Half of the participants claimed that they used comfortable, closed, and soft foot ware and examined their shoes before wearing them whereas the other half did not. Only 33.3% (n = 36) said that they continuously wear cotton socks, and 32.4% (n = 35) said that regularly visit physicians for foot checkups. 42.6% (n = 46) only claimed that they wash their feet and dry in between the toes daily and regularly. 55.6% (n = 60) of the participants regularly cut their toenails.

Table 5

Practices
Practices		Frequency (n)	Percentage %
Do you examine your feet daily ?	Yes	40	37%
Do you examine your feet daily ?	No	68	63%
Do you use comfortable, closed, and soft foot wear?	Yes	54	50%
Do you use comfortable, closed, and soft foot wear?	No	54	50%
Do you examine your shoes before wearing them?	Yes	54	50%
Do you examine your shoes before wearing them?	No	54	50%
Do you walk barefoot, outside?	Yes	34	31.5%
Do you walk barefoot, outside?	No	74	68.5%
Do you continuously wear cotton socks?	Yes	36	33.3%
Do you continuously wear cotton socks?	No	72	66.7%
Do you examine your feet for any marks resulting from shoes/socks?	Yes	54	50%
	No	54	50%
Do you change your socks daily ?	Yes	77	71.3%
Do you change your socks daily ?	No	31	28.7%
Do you daily wash your feet with warm water?	Yes	46	42.6%
Do you daily wash your feet with warm water?	No	62	57.4%
Do you carefully dry the cleft between toes after washing?	Yes	46	42.6%
Do you carefully dry the cleft between toes after washing?	No	62	57.4%
Do you apply moisturizer daily on your feet?	Yes	44	40.7%
Do you apply moisturizer daily on your feet?	No	64	59.3%
Do you cut your toenails regularly?	Yes	60	55.6%
Do you cut your toenails regularly?	No	48	44.4%
Do you regularly visit a physician for a foot check-up?	Yes	35	32.4%
Do you regularly visit a physician for a foot check-up?	No	73	67.6%
Do you regularly change foot-wear even without damage?	Yes	57	52.8%
Do you regularly change foot-wear even without damage?	No	51	47.2%

As for studying the relation between knowledge and different factors, Table 6 showed that none of the factors was significantly related to knowledge out of total score of 11. For example, the mean score of those between 18 and 49 was slightly higher than the other age group (score = 10.5/11) but p-value = 0.76. males and females were with almost equal mean score but p-value > 0.05. Also, it was shown that those with longer duration of diabetes scored higher than those with short term but with no significant value. In general, all mean values of the categories were higher than 9.

Table 6

Knowledge Correlated to different factors
	Knowledge Score Mean /11	P-Value
Age (Years)
18–49	10.5	0.764
50–64	10.07
> 64	10.26
Gender
Male	10.1	0.381
Female	10.5	0.381
Marital Status
Single	11	0.266
Married	9.94
Widowed	10.63
Divorced	11
Education
No Education	10.58	0.138
Elementary	10.33
Middle School	8.62
High School	10.43
University	10.59
Higher Education	10
Occupation
Student	11	0.498
Employed	10.35
Unemployed	10.31
Retired	9.55
Smoker
Yes	10.26	0.91
No	10.21	0.91
Diabetes type
Type 1	10.73	0.453
Type2	10.19	0.453
Duration of Diabetes
< 10 Years	9.74	0.115
> 10 Years	10.47	0.115
Last Reading of Hba1c
Controlled	10.48	0.201
Uncontrolled	9.65
Highly Uncontrolled	11
Unknown	10.61

As for the relation between attitude and variables, the results are demonstrated in Table 7. It was significantly proven with p-value < 0.001 that those of age group 18–49 were of best attitude (4.25/5). In addition, those who are single had the best attitude 4.05/5 with p-value < 0.05. Education, occupation, type of diabetes, and diabetes duration were statistically significant with p-values < 0.05. smoking, control of Hba1c, and gender was not statistically significant.

Table 7

atittude Correlated to different factors
	Attitude Score Mean /5	P-Value
Age (Years)
18–49	4.25	< 0.001
50–64	3.54
> 64	2.21
Gender
Male	3.17	0.969
Female	3.15	0.969
Marital Status
Single	4.05	0.016
Married	3.18
Widowed	2.25
Divorced	2
Education
No Education	1.83	0.01
Elementary	2.33
Middle School	2.69
High School	3.2
University	3.7
Higher Education	3.5
Occupation
Student	4.4	< 0.001
Employed	3.75
Unemployed	2.76
Retired	1.67
Smoker
Yes	3.34	0.228
No	2.94	0.228
Diabetes type
Type 1	4.18	0.04
Type2	3.05	0.04
Duration of Diabetes
< 10 Years	4	< 0.001
> 10 Years	2.78	< 0.001
Last Reading of Hba1c
Controlled	3.74	0.68
Uncontrolled	2.9
Highly Uncontrolled	2
Unknown	3.16

In Table 8, relations between practices of mean score out of 13 questions is shown. Gender did not differ in practices with both mean score like each other. Those single were more likely to perform proper practices than others with mean score 7.28/13 and p-value = 0.031. Those employed had the highest score 8 with statistically significant p- value < 0.05. finally, those with longer duration of diabetes > 10 years were statistically proven to perform better practices with a statistically proven p-value < 0.05.

Table 8

Practices correlated to different factors
	Practice Score Mean /13	P-Value
Age (Years)
18–49	6.46	0.244
50–64	6.15
> 64	5.35
Gender
Male	5.86	0.84
Female	5.97	0.84
Marital Status
Single	7.28	0.031
Married	5.8
Widowed	5.31
Divorced	2
Education
No Education	4.33	0.113
Elementary	4
Middle School	5.46
High School	6.2
University	6.43
Higher Education	6.6
Occupation
Student	8	0.039
Employed	6.39
Unemployed	5.07
Retired	5.11
Smoker
Yes	6.06	0.49
No	5.68	0.49
Diabetes type
Type 1	7.09	0.144
Type2	5.76	0.144
Duration of Diabetes
< 10 Years	6.94	0.009
> 10 Years	5.42	0.009
Last Reading of Hba1c
Controlled	6.35	0.508
Uncontrolled	5.48
Highly Uncontrolled	6.83
Unknown	5.8

This study’s aim is to assess and highlight the knowledge, attitudes and practices of foot care among diabetic patients in Hammoud University Medical Center, Lebanon.In contrast to other previous studies which demonstrated that patients with a higher level of education possess a greater understanding of diabetic foot care(11, 1, 2), the data from our study suggests that uneducated patients have similar knowledge of diabetic foot care in comparison to educated ones. Our study data also shows that single or divorced patients have greater knowledge than those who are married. This opposes to the idea of spousal support, in terms of nutrition, commitment, treatment and better coping with long term diseases, that comes with being married (3). patients who have had diabetes for > 10 showed more knowledge similarly to a study in Saudi Arabia (18). As mentioned in that study, this could be due to the patient’s long-term exposure to the disease which lead to more experience and better handling in term of diabetic foot care.

A significant majority of respondents (92.6%) recognize the high likelihood of diabetics developing foot ulcers, reduced blood flow, and reduced sensation in their feet, indicating a robust awareness of the significant risks associated with diabetes-related foot complications just like Alshammari et al.that found that a majority of diabetic patients recognized the risks associated with foot complication similar to the high awareness observed in our study (18). Additionally, while 97.2% believe that regular medication intake can reduce diabetes complications, there remains a need to address skepticism regarding exercise, with 88.9% acknowledging its potential benefits, and 11.1% expressing doubts.Moreover, the skepticism towards exercise reported in our data echoes findings by Taksande et al., indicating a common trend in addressing lifestyle modifications among diabetic individuals (17)

Respondents' willingness to engage in preventive measures and lifestyle modifications reflects a proactive stance towards self-care. Notably, 55.6% express confidence in their ability to incorporate regular exercise and dietary changes to prevent further diabetic complications. However, a significant portion (44.4%) appears uncertain or hesitant, suggesting potential barriers or misconceptions hindering adherence to lifestyle modifications.

Furthermore, a majority (58.3%) are willing to take responsibility for daily foot examinations, foot ware maintenance, and regular consultations with foot-care specialists,in contrast a notable proportion (41.7%) express hesitation or reluctance, indicating challenges in implementing consistent foot care routines. Nonetheless, the majority (68.5%) are open to using specialized foot ware recommended by foot-care specialists, demonstrating a willingness to embrace tailored interventions for diabetic foot management (20).In addition, only a minority (37%) report examining daily feet examination, indicating a potential gap in proactive foot care practices among a significant portion of the surveyed population. However, there appears to be a balanced approach to footwear hygiene and selection, with an equal split (50% each) of respondents reporting the use of comfortable, closed, and soft footwear, as well as examining their shoes before wearing them. Furthermore, a substantial majority (68.5%) refrain from walking barefoot outside, demonstrating an awareness of injury risks and the importance of foot protection. While there are varying levels of adherence to recommended foot hygiene practices, such as changing socks daily (71.3%) and regularly cutting toenails (55.6%), there are notable gaps in consistent foot washing with warm water (42.6%) and application of moisturizer (40.7%). Additionally, a minority (32.4%) report regularly visiting a physician for foot check-ups, suggesting room for improvement in accessing professional foot care services. However, there is evidence of proactive footwear maintenance among respondents, with a slight majority (52.8%) regularly changing footwear even without damage. In terms of foot care practices, our study highlights both strengths and areas for improvement, mirroring the findings of Hanley et al. and Pourkazemi et al.(21). While there is a notable willingness to use specialized footwear, consistent with Hanley et al., there are gaps in daily foot examinations and foot hygiene practices, consistent with Pourkazemi et al. (21). Additionally, the reluctance to regularly visit physicians for foot check-ups resonates with the findings of Desalu et al., suggesting a common challenge in accessing professional foot care services among diabetic patients (22).Overall, the data underscores the importance of promoting consistent foot care routines and access to professional foot care services among diabetic individuals to optimize foot health outcomes.

Regarding expectations of diabetes management, a significant majority (69.4%) believe they can lead a normal life with appropriate management measures, underscoring optimism and resilience in coping with the condition. However, a substantial minority (30.6%) express doubts, highlighting the need for comprehensive support and education to address concerns and facilitate effective self-management strategies.Overall, our data underscores the need for tailored education and support interventions, as emphasized by Al-Hariri et al., to promote adherence to foot care routines and optimize diabetes management outcomes (23).By addressing the barriers and misconceptions identified in our study, healthcare providers can enhance foot care practices among diabetic individuals, ultimately reducing the risk of complications and improving overall foot health.

37% of our participants stated that they inspect their feet on daily basis, however, a study done in India showed 71.4% of the diabetics were inspecting their feet daily (24). This may be due to lack of knowledge about proper foot hygiene.

Additionally, almost two-third of our participants did not walk barefoot outside, which is comparable to a study done in India were only 7% of the diabetics walk barefoot outside (24). So, diabetic patients’ education about the importance of good behaviors done in order to prevent any injury.

Regarding foot washing, 42.6% do wash their feet with warm water daily and less than the half do dry the cleft between the toes after washing, similar results are shown in a study done in India were less than half of the diabetics dry their feet between toeas after washing them (24). Educating people about the good foot hygiene will help decrease the infection due to lack of knowledge.

Nevertheless, our study showed that about half of our participants inspect their footwear before wearing them, which is comparable to results of previous studies done in China less than half of the patients do inspect their footwear before wearing them (25).

Students and employed patients in our study showed a significantly better attitude towards diabetic foot care than unemployed ones. Having a job typically leads to higher income and potentially exposure to information related to better diabetic foot care practices which could translate into a more positive and clear attitude towards managing diabetes and diabetic foot care (4).

Patients aged between 18–49 and patients with type 1 DM showed a remarkably better attitude towards DFC, this similarity between the 2 classes could be attributed to the fact that young patients most commonly develop DM Type 1.

It is found that patients who have had diabetes for > 10 years showed a significantly poorer attitude than those who have been ill for less than 10 years which opposes to the data in a study done in Saudi Arabia by Alshammari et al. where most of the patients who had a better attitude toward diabetic foot and diabetic foot care were patients who had long-standing diabetes of > 5 years (11).

The study concludes that there is much more to learn and educate. Participants are aware of the dangers but do not follow proper health care services to prevent complications. Further, and larger studies should be done over this health care issue to provide better outcomes. One of the limitations of our study was the single institution involvement nevertheless this is a central referral hospital with large number of admissions of various Lebanese population .Overall, the integration of both data sets reveals a multifaceted perspective among respondents, emphasizing the importance of tailored education, support, and interventions to promote adherence to foot care routines and optimize diabetes management outcomes.

Ethical Considerations: ethical considerations to all private data were taken by consenting patients to participate into the study. No identities were used in the study.

Availability of data and materials : N/A

Competing interests: no competing interests

Funding : N/A

Author’s contribution :

The PI will take the role of tutoring, advising, guiding and revising the investigators work. (10% of their time will be allocated for this study).
Others investigators will allocate 15% of their time toward this project.
All members of the research group will participate in the process of recruitment, data collection, processing and analysis.
Data comparison and drawing of conclusions are also expected from all members.

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No competing interests reported.

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Knowledge, attitudes, and practices of Footcare in Diabetic patients in Hammoud University Medical Center

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Abstract

Background

Diabetes mellitus and its complications

Foot ulcers in diabetic patients

Knowledge, attitude, and practices about foot care in diabetic patients

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