Knowledge and Practice of Foot Self-Care Among Diabetic Patients in National Guard Primary Care in Riyadh

Objective: This study aimed to evaluate the level of knowledge and practice of foot self-care in diabetic patients in Primary care at National Guard hospital, Riyadh, Saudi Arabia. Methods: This cross-sectional study was conducted among diabetic patients attending the three biggest primary healthcare centers of the National Guard Health Affairs in Riyadh, Saudi Arabia (ISKAN clinic, HCSC, and NGCSC). The patients were asked to fill a self-administrated questionnaire that investigated demographics, knowledge, inspection, and practice. Results: Among 390 diabetic patients, 74.1% had type 2 diabetes, 6.4% had foot ulcers, and 23.1% received training on diabetic care. The knowledge score was 10.86 ± 1.66, whereas practice score was 20.2 ± 3.5. The mean score of knowledge was significantly affected by education level ( p < 0.001), whereas the mean score of practice was significantly varied regarding gender ( p < 0.001), education level ( p -value = 0.001), occupation ( p < 0.001), duration of diabetes ( p -value = 0.001), and treatment ( p -value = 0.001). Conclusion: Diabetic patients in this study had a good level of knowledge regarding foot self-care, whereas the practice was acceptable but not optimum.


Introduction
Diabetes mellitus (DM) is a metabolic disorder of multiple etiology [1], characterized by hyperglycemia due to defects in insulin secretion, action, or both [2].The prevalence of DM in Saudi Arabia increased dramatically through the years due to the change in lifestyle.Saudi Arabia is on the seventh rank among the top 10 countries concerning the DM prevalence [3].It is estimated that almost seven million Saudi individuals are diabetic, and about three million are pre-diabetics [4].
Diabetes-associated complications increase the burden of the disease globally due to prolonged morbidity [5].Diabetic foot is one of the most common long-term complications of uncontrolled DM [6].Diabetic foot refers to different degrees of vascular and neurological abnormalities affecting the foot and the tendency toward deep foot tissue destruction, infection, and ulceration.It was assessed that roughly 15% or more than 150 million diabetic patients at a particular phase would develop foot ulcers, globally [4,7].The global prevalence of diabetic foot varies, and the average global prevalence is 6.4% [8].It was reported that the lifetime risk of developing diabetic foot ulcers among diabetic patients is almost 15% compared to non-diabetic patients [9].
The concept of self-care could be related to the practice of activities that individuals initiate and perform on their own behalf to maintain health, life, and well-being [10].Foot self-care practices such as hygiene practices, daily inspection, seeking professional treatment for wounds and ulcers, and shoe selection could reduce the risk of foot complications [11].
Proper awareness and knowledge about foot care are important defenses against diabetic foot problems [12].Knowledge and awareness about proper foot care reduce the rates of admissions, complications, and amputations [10,13].The knowledge about foot selfcare practices among patients with diabetes in Saudi Arabia is limited [11].Also, the correct practice of foot healthcare is necessary for reducing the incidence of foot complications and foot ulcers [14].
Managing the daily care of diabetes seems to be a challenging task for many patients; the ability of patients to be involved in the daily routine of diabetes self-care seems to be grounded in motivational, educational, and psychological factors [5].Therefore, this study was conducted to evaluate the level of knowledge and practice of foot self-care and its associated factors in diabetic patients attending the Primary care at National Guard Hospital, Riyadh, Saudi Arabia.

Subjects and Methods
This cross-sectional study was conducted among diabetic patients attending the three biggest primary healthcare centers of the National Guard Health Affairs in Riyadh, Saudi Arabia (ISKAN clinic, HCSC, and NGCSC).The study was conducted between December 2022 and March 2023, it included all diabetic patients aged older than 18 years old, regardless of their gender and type of management, whereas the exclusion criteria were nondiabetic patients, patients younger than 18 years old, and psychiatric patients.The patients were asked to fill in a self-administrated questionnaire.All questions were based on questionnaires from previous literature.The questions were sent to an experienced person for validation.The English version of the questionnaire was translated into Arabic language and then retranslated to English language to ensure the accuracy and meaningfulness of the item.The questionnaire was then revised and modified by a research team and then piloted on 15 participants who were excluded from the final study to ensure its validity and reliability.
The questionnaire consisted of 4 sections with a total number of 36 questions.The first section included 13 questions investigating the demographic data.The second section investigated the knowledge about foot care through seven questions.The third section investigated patients' inspection of feet/footwear, consistency of wearing footwear and caring for feet through seven questions.The fourth section investigated practice regarding clinical symptoms/conditions through nine questions.
The sample size calculation was 382, then it was increased to 390 to compensate for nonresponse or incomplete data.Data were entered and analyzed using a statistical package for the social sciences version 20 software.Analytical statistics were done using the chi-square test to assess differences between categorical variables, and means were compared using independent student t-test and analysis of variance.Statistical significance (p-value) was set at 0.05 or less.

Results
A total of 390 diabetic patients met the inclusion criteria and participated in the study.Males (50.3%) were slightly more dominant compared to females (49.7%).The mean age was 54.2 ± 12.8 years.The large majority were Saudi patients (98.5%), and the largest proportions had secondary education (34.9%), and were not working (49.2%) (Table 1).
Most of the patients had type 2 diabetes (74.1%), and the largest proportions reported 10 years and more as a duration for DM (42.1%), and 54.4% reported a value of HbA1C value less than 8. Also, the largest proportion of patients reported measuring blood sugar at 3-6 months (36.4%), and are on treatment of diet and oral diabetic medications (26.4%).The large majority reported no foot ulcer (93.6%), whereas more than one-half of patients reported chronic diseases (54.4%), and a few proportions reported receiving training on diabetic care (23.1%) (Table 2).
The largest proportions reported rarely or never of the following symptoms and complaints; suffering from peripheral nerve symptoms in the last month (38.5%), feeling a burning sensation in the feet (34.9%), feeling tingling in the feet (35.1%), feeling numbness (35.4%), and having white skin discoloration between toes 232(59.5%).More than one-half (62.4%), reported that they never check feet regularly when they visited the clinic.Also, more than one-half of patients didn't get a discussion about foot care in the clinic (55.4%) and didn't visit the emergency department for any diabetic foot problem (67.9%).Majority (89.2%) reported that they don't seek care at a diabetic foot clinic (Table 3).
The mean ± SD score of knowledge was assessed, and the mean score was 10.86 ± 1.6 (Table 4).
The mean score of knowledge did not vary between gender group (p-value = 0.1), nationality (p-value = 0.5), or occupation (p-value = 0.1), but the mean score of knowledge was significantly varied among different education levels (p ˂ 0.001) (Table 5).
The largest proportion of patients reported checking their feet once a day (44.4%),always drying between the toes (35.1%), and daily using moisturizing cream on the feet between the toes (40%).On the other hand, 35.1% reported that they never check their shoes before wearing them or walking around bare foot.The practice score was 20.2 ± 3.5 (Table 6).
The practice score was significantly affected by the duration of DM (p-value = 0.001) and treatment regimen (p-value = 0.001) (Table 8).

Discussion
This study was carried out to investigate the level of knowledge and practice of foot self-care among diabetic patients.The study was conducted on 390 diabetic patients, with a few proportions having foot ulcers (6.4%).In one Saudi study conducted on 250 patients attending Jazan diabetic center, it was found that the prevalence of diabetic foot was 55.2%, and 18% had a history of foot ulcer [15].
In the current study, a few proportions of patients reported feeling some symptoms always, including peripheral nerve symptoms (15.6%), burning sensation in the feet (23.1%), and numbness (12.1%).In a Saudi study from Riyadh, there were 42.1% suffered foot complications, where 35.5% had numbness, 4.3% had a history of healed ulcers, and 2.3% reported toe amputation [16].
The maximum score of knowledge was 13; the overall mean score of knowledge among the patients was 10.8, reflecting a good level of knowledge.However, the proportion of patients having good and poor levels of knowledge was not estimated.By assessing the factors affecting the score of knowledge, it was found that education was a significant factor, and those with a high level of education reported a high score of knowledge.
A study from Jazan reported the mean score of knowledge among diabetic patients, and it was 8.37 reflecting good knowledge.Additionally, those who had good knowledge represented 63.6%.The score of knowledge significantly varied between educational levels and gender [8].These findings were similar to the current study except for the variation of knowledge between genders, where no significant difference was found between the two genders in the current study.
Also, the mean score of knowledge was assessed among diabetic patients in a study from Aseer, where the overall score of knowledge was 11.01, which was a low score.Females significantly had higher knowledge score compared to males.Additionally, patients who had previous training or attended workshops on diabetic foot care had a significantly higher score in knowledge [17].These findings were in contrast to the current study, where knowledge level was good among current study patients, and gender had no significant impact on knowledge level.
Furthermore, the impact of training on diabetic care on the knowledge of patients was not investigated.
A study from Makkah conducted on 409 patients using a self-administrated questionnaire reported that the patients with type 2 DM represented the majority of patients (85.6%).Most of the patients (74.4%) had a poor level of knowledge regarding foot self-care, and only 4.2% had a good level of knowledge.A higher level of knowledge was associated with being employed and type II diabetes [5].
In agreement with the current study, type 2 DM patients represented most of the participants, and this reflects the higher prevalence of type 2 DM compared to type 1, and this might raise the concern regarding the lifestyle of the population.The spread of a sedentary lifestyle and the adoption of an unhealthy diet of high carbohydrates and fat content are driving an increase in the number of people with obesity-related type 2 diabetes [5].Additionally, a good level of knowledge with no impact of occupation was reported, and this is in contrast to the previous study [5].Furthermore, the correlation between knowledge and the type of DM was not investigated.
A study from Al Madinah city, Saudi Arabia included 363 diabetic patients revealed that 90.6% scored good knowledge, whereas 9.4% scored poor knowledge regarding foot care.The good score of knowledge was associated significantly with the occupation of participants and the duration of diabetes.On the other hand, gender and educational levels had no significant association with knowledge [18].In this study, the proportion of patients having good knowledge was not determined.However, in line with the current findings, gender and education levels had no significant association with the level of knowledge.Poor knowledge was reported among diabetic patients from Jeddah, where only 38% had good knowledge about diabetic foot care [2].One Saudi study demonstrated that the duration of diabetes, marital status, age, and gender had no significant association with knowledge, and 53.6% of patients had good knowledge of foot care [15].
A study from Kuwait reported that the overall mean score of knowledge of diabetic patients about foot selfcare was 12.7, with a maximum possible score of 16.These findings reflected that the majority of patients had good knowledge (79.3%).Being a university student revealed lower odds of having good knowledge, whereas being diagnosed with diabetes for a long duration of 10 years and above and having no additional comorbidities were predictors for higher odds of having good knowledge [19].In the current study, there was no university student who participated in the study; however, graduated participants showed a higher level of knowledge.On the other hand, the impact of diabetes duration on knowledge was not investigated in the current study.
Regarding practice investigation, there was an acceptable level of practice, but not a good level, where the mean score of the practice of patients was 20.2 out of the In contrast to the current findings, the mean score of practice, as reported in a study from Jazan, was 8.14, reflecting good care, and those who reported a good level of practice represented 55.3% participants.However, in agreement with the current findings, the scores of practice were significantly affected by educational levels and gender [8].In a study from Makkah, the practice of foot self-care among diabetic patients was poor among 63.3% patients.However, the study did not report the factors that affected the practice level [5].
A good level of practice was reported among 93.7% of diabetic patients from Al Madinah city, and this good score was associated with the education level of the patients, whereas no association was found regarding gender, age groups, occupation, or duration of diabetes [18].The study reported findings in contrast to the current study findings; the only agreement with the previous study was regarding the association between education level and the level of practice.A poor practice was found among diabetic patients from diabetic centers in Jeddah, where only 22% were following diabetic foot care practice [2].
In a study from Kuwait, the maximum score of practice was 87, whereas the overall mean score of practice among patients was 55.7, reflecting that most of the patients (61.3%) reported satisfactory practice.Higher odds of good practice were associated with diabetes duration of 5 to less than 10 years and being on a diet only [19].In the current study, diabetes duration of 2-4 years was associated with the highest score of practice.Also, the treatment, including diet plus oral diabetes medications and diet only, was associated with higher scores of practice.

Conclusion
There was a good level of knowledge among diabetic patients regarding foot self-care, whereas the practice was acceptable but not optimum.Additionally, a few proportions of the patients received training on diabetic care.Hence, the establishment of awareness campaigns and training programs to enhance the practice of diabetic patients' foot self-care.

Table 5 .
Knowledge score of the participants in association with different sociodemographic characteristics.

Table 7 .
Practice score according to sociodemographic of the participants (n = 390).

Table 8 .
Level of practice (self-care) according to the duration of diseases and treatment.