Knowledge, Attitude and Practice Regarding Risk of Diabetic Foot Among Diabetic Patients in Aseer Region, Saudi Arabia

Background Diabetic foot care is vital as it is preventable complication but dangerous even a small trauma can end with serious consequences. Diabetes may cause nerve damage that affects feet sensation. Diabetes may also reduce blood flow to the feet, making it harder to heal an injury or resist infection. Because of these problems, patients may lose notice of early foot abnormalities. Diabetic patients’ awareness regarding how to care for their feet plays a significant role in preventing these complications. Methods A correlation cross-sectional study was conducted targeting all diabetic patients aging 20 years or more. Online questionnaire was used for data collection. Questionnaire was uploaded online using social media platforms by the researchers and their relatives and friends. The questionnaire included patient personal data, patients’ knowledge regarding diabetic foot, attitude and practice regarding the risk of diabetic foot among diabetic patients. Results A total of 1,000 diabetic patients fulfilling the inclusion criteria completed the study questionnaire. Exact of 77.5% of the patients know that Diabetics can get gangrene in the foot, 74.9% know diabetics can develop ulcers in the foot, 66.7% reported that Diabetes can reduce blood flow to the feet of diabetic patients, 66.6% agreed that diabetic patients can suffer from a lack of sensation in the feet. Exact of 84.5% of the study participants agreed that Diabetics should check for any wounds on their feet daily, 78.7% agreed that Diabetics should visit a doctor when there is any infection or wound in the feet, 76.6% think that diabetic patients should wear specialized shoes to avoid diabetic foot according to the doctor's instructions. A total of 822 (82.2%) of the study patients wash their feet daily, and 295 (29.5%) usually wear cotton socks regularly and 39.6% sometimes wear the stock. Only 192 (19.2%) regularly walk barefoot and 41.7% sometimes do. Conclusion In conclusion, the current study results showed that nearly two out of each three diabetic patients were knowledgeable for diabetic foot and its care. High knowledge was associated with young age, high education and having family member with diabetes mellitus (DM). Also, patients had a good attitude towards diabetic foot care and the effect of diabetes on foot health with to some level accepted practice except for some issues.


Introduction
Diabetes mellitus (DM) is a worldwide public health problem. with chronic progressive metabolic disorder featured by hyperglycaemia, caused by either deficiency or resistance to the insulin hormone [1,2]. A diabetic foot is one of the diabetes complications caused due from peripheral arterial disease (PAD) with sensory neuropathy at diabetic patients' feet [3,4]. Diabetic foot is a long-lasting complication of diabetes with a high burden that affects diabetic patients' quality of life [5][6][7]. Presence of several characteristic diabetic foot pathologies such as infection, diabetic foot ulcer and neuropathic osteoarthropathy is called diabetic foot syndrome [8].
There are many risk factors of the diabetic foot include old age, duration of diabetes, and hypertension. Peripheral neuropathy associated with sensory loss and peripheral vascular disease-resulting ischemia are the leading risk factors causing foot ulcer and eventually foot amputation [9][10][11]. And diabetic foot ulcers are frequent and most disturbing preventable complications of patients with long-term uncontrolled diabetes mellitus [12]. Diabetic foot ulcer-associated morbidity and early mortality because of chronic complications of foot was recorded. [11,12]. The most reported sites of these ulcers are the areas of the foot that encounters frequent trauma and pressure sensations [13]. Most of the diabetic foot complications can be prohibited with alert foot care. It takes effort and time to build up good foot care habits, but self-care is essential [14,15].
Diabetic patients' awareness regarding how to care for their feet plays a significant role in preventing these complications with decreased social, medical, and economic burden of its consequences including foot ulcers and amputation. The current study aimed to assess the knowledge, attitudes, practices and risk factors influencing diabetic foot ulcers among diabetes patients in Aseer region, Southern of Saudi Arabia.

Methodology
A correlation cross-sectional study was conducted targeting all diabetic patients aging 20 years or more. Patients less than 20 years, Patient who is already having diabetic foot, amputated foot, or foot ulcers, and those who did not fill the study questionnaire were excluded. After having ethical approval, and due to the current environment due to COVID-19 pandemic, online questionnaire was used for data collection. All accessible adults in the general population were invited to fill the uploaded questionnaire consecutively till achieving the required sample size. The questionnaire was developed by researchers after intensive literature reviews and expert's consultation. Study questionnaire validity was assessed by a panel of three experts in diabetology with applying all confirmed modifications. Also, reliability and clarity were assessed using pilot of 30 diabetic patients who were excluded from the main study with α-Cronbach's of 0.74. The questionnaire included patient personal data, patients' knowledge regarding diabetic foot, attitude and practice regarding the risk of diabetic foot among diabetic patients. Questionnaire was uploaded online using social media platforms by the researchers and their relatives and friends.

Data analysis
After data were extracted, it was revised, coded, and fed to statistical software IBM SPSS version 22(SPSS, Inc. Chicago, IL). All statistical analysis was done using two-tailed tests. p-value less than 0.05 was statistically significant. For knowledge items, each correct answer was scored one point and the total summation of the discrete scores of the different items was calculated. A patient with a score less than 60% of the total score was considered to have poor awareness while good awareness was considered if he had a score of 60% of the total or more. Descriptive analysis based on frequency and percent distribution was done for all variables including participants' age, gender, education level, family history of diabetes. Also, participants' knowledge items regarding diabetic foot, attitude towards diabetic foot care, and patients practice towards their foot were displayed. Crosstabulation was used to assess the distribution of knowledge level according to participants' personal data and the distribution of patients practice according to their knowledge level. Relations were tested using Pearson chi-square test.
The study was approved by Regional Committee for Research Ethics, Directorate Health Affairs-Aseer Region with a study number of (REC-02-09-202). After the institutional review board (IRB) approval, the data was collected only by authorized members.

Results
A total of 1,000 diabetic patients fulfilling the inclusion criteria completed the study questionnaire. Patients ages ranged from 20 to 59 years old with a mean age of 42.6 ± 11.8 years old. Exact of 670 (67%) of the patients were males and 658 (65.8%) were married. As for educational level, 566 (56.6%) were university graduated and 238 (23.8%) had secondary level of education. Exact of 678 (67.8%) patients had family history of diabetes ( Table 1).

Discussion
The current study aimed to assess knowledge level of diabetic patients in Aseer region regarding diabetic foot and its care. Also, to identify their attitude towards diabetic foot care and their daily life practice regarding their foot care. Diabetic foot is one of the main complications of DM which diagnosed among nearly half of diabetic patients and causing about 80% of lower limb amputation [16,17]. Diabetic foot includes some type of neuropathy and angiopathy affecting mainly the foot ending with tissue damage, infection, and ulceration [9]. Poor diabetic control, long duration of uncontrolled diabetes, peripheral vasculopathy, older age, and poor awareness regarding diabetes generally and foot care particularly are the most known risk factors for diabetic foot [18].
In Saudi Arabia, diabetic foot ulcer is the leading cause of lower limb amputation, reference to the last few years, it caused lower limb amputation for 49.6% of cases [19] and it is predictable that this rate will show more increase next few years [20,21]. Diabetic foot in Saudi Arabia prevalent in 3.3% of diabetic patients; with 2.1% suffered foot ulcer and 1.1% had amputation [11]. Diabetic foot complications are preventable relative to all other diabetic complications [22,23]. Awareness of patients about foot care is vital to avoid diabetic foot consequences, and amputation [24]. Foot complications including foot ulcers are more frequent among diabetic patients with poor awareness of their foot care [25].
The current study showed that more than two-thirds of the diabetic patients were knowledgeable regarding diabetic foot and its care. The highest awareness was for diabetic foot consequences (ulcers and gangrene) and they were aware of the effect of diabetes on foot blood supply and neuropathy associated with lack of sensation. Knowledge level was significantly higher among young aged patients which may be due to their worry of diabetes-related complications which may affect their future life, highly educated patients who can read, explore and had related information by their own selves, and those with a family history of DM. Literature review showed high variety in estimated diabetic patients' knowledge and awareness regarding diabetic foot and its care. This high variety of estimated awareness levels may be attributed to many factors including the method of awareness assessment, difference in samples characteristics and even the medical care strategies applied for diabetic patients in each country regarding doctor visits or ability to catch service and information through telephone. Solan YM et al. [26] found that 53.6% of diabetic patients reported a good knowledge level regarding diabetic foot. Males were more complaint to foot drying by 65.2%, while females are applying more attention to softening of skin by 72.3%. In Tanzania, Chiwanga FS et al. [27] showed that the mean knowledge score for diabetic foot was 11.2 out of a total possible score of 23 (48.6%). Low scores were reported among patients with low education (8.3 ± 6.1), diabetes duration of < 5 years (10.2 ± 6.7) and not receiving advice on foot care (8.0 ± 6.1). Among the 404 patients, 48 % had received advice on foot care, and 27.5 % had their feet examined by a doctor at least once since their initial diagnosis. Foot selfcare was significantly higher in patients who had received advice on foot care and in those whose feet had been examined by a doctor at least once. Locally, in Saudi Arabia, Algshanen MA [28] reported that 55.1% of diabetic patients had high score for diabetic foot knowledge. About 69% had very low score 0-2 out of 6 in the assessment of previous education of diabetic foot. More than half of the participants (56.5%) had a score 6-10 out of 15 in the evaluation of practice with diabetic foot. Alhuqayl AA et al. [29] found that 53.3%, of diabetic patients had good knowledge about diabetic foot while low knowledge represented 46.7% among participants. The significant determinants for god knowledge level included patients gender (p < 0.001), education level (p = 0.001), DM type (p = 0.002), and suffering diabetic retinopathy (p = 0.009).
As for patients' attitude and practice, the current study showed that the vast majority of the study patients agreed that diabetics should check for any wounds on their feet daily, and that they should visit a doctor when there is any infection or wound in the feet. More than three-quarters of the patients think that diabetic patients should wear specialized shoes to avoid diabetic foot according to the doctor's instructions. Only 20.9% agreed that Diabetics should not make periodic visits to the diabetes clinic for the purpose of examination and 16.5% believe that I can treat myself if I have diabetes without consulting a doctor. As for practice, more than 80% of the study patients wash their feet daily, but about half of them wear cotton socks. About half of the patients may walk barefoot which is unsafe due to the higher risk of trauma. Checking foot when had any problem was the most reported behaviour (68.6%). Exact of 70.4% of the patients reported that they consult a physician when found any deformity (wound/ulcer) in their feet.

Conclusions
In conclusion, the current study results showed that nearly two out of each three diabetic patients were knowledgeable for diabetic foot and its care. High knowledge was associated with young age, high education and having family member with DM. Also, patients had a good attitude towards diabetic foot care and the effect of diabetes on foot health. Practice regarding patients' foot was satisfactory except for avoiding trauma leading causes including walking with bared feet and change shoes with damage only not periodically. Also, feet check frequency was not high among the patients. Diabetic patients need periodic health education programs and training for all disease-related complications including foot-related consequences.

Additional Information
Disclosures