European Journal of Cardiovascular Medicine

Diabetes is a chronic condition characterized by elevated blood glucose levels due to either inadequate insulin production or the body's resistance to insulin, with type 2 diabetes being the most prevalent, particularly in adults¹. In 2019, there were about 77 million cases in India, and this number is expected to reach 135 million by 2045¹.

Diabetes is associated with various complications, including damage to the heart, kidneys, and nerves, but one of the most severe and common complications is diabetic foot². Diabetic foot, resulting from poor circulation, neuropathy, and infection, can lead to foot ulcers, which affect around 25% of diabetic patients, with 85% of lower-limb amputations being preventable if detected early. Each year, about 45,000 lower limb amputations occur in India due to diabetic foot³. Prevention strategies such as early identification and timely interventions are critical in reducing morbidity and improving patients' quality of life⁴.

In rural and developing areas, where access to healthcare is limited, educating family members and primary caregivers on diabetic foot prevention and care becomes all the more vital.

Aims and Objectives

1. To estimate the knowledge level and attitude about diabetic foot among primary care givers of diabetic patients.
2. To determine the association of knowledge and attitude about diabetic foot with socio-demographic factors.

Study type: A mixed method research of combined cross-sectional survey and qualitative research.

Study setting: Out patients department and in- patients wards of Medicine & surgery departments, in the selected tertiary care hospital.

Study population: Primary care givers accompanying diabetes patients in the selected tertiary care hospital.

Study duration: Five months. August 2023 to December 2023.

Sampling Procedure: Simple random sampling, using lottery method (Quantitative data)

Inclusion criteria: Participants aged 18 years and above, involved in diabetes patient care of family member and willing to participate in the study.

Exclusion criteria: Known case of diabetes mellitus.

Sample size: The sample size was estimated using n = (N) (Zα/2)^{2 /} (Zα/2)² + (4) (N) (e) ² formula, when population size is known i.e., total population of the selected district from the census 2011⁽⁷⁾ is 1082636. Where (Zα/2) = 1.96 at 95% Confidence interval, N = population size =1082636, e= 0.05.  We got the sample size as 384 and considering non response rate as 5% = 19. Sample size was calculated to be 384+19 = 403

Method of data collection

The study participants were interviewed individually using a pre-designed and semi-structured questionnaire. After obtaining written informed consent signed by the participant, the purpose of the study was explained to them. A mixed-methods approach was employed, combining a cross-sectional survey with qualitative research. A survey was conducted using a questionnaire and focus group discussions with primary caregivers of diabetic foot patients to explore their perspectives on diabetes, its complications (such as diabetic foot), and prevention strategies. The questionnaire was divided into three sections. The first section focused on the socio-demographic characteristics of the participants, including age, gender, educational background, occupation, socio-economic status, religion, and their relationship to the diabetic patient.

The second section focussed on assessing their knowledge about risk factors of diabetic foot, foot examinations and treatment. Scoring was assigned using a two-point scale: Zero for incorrect or "don't know" responses, and one for correct answers. The third section focused on participant’s attitude towards diabetic foot and its prevention, with questions addressing perceived susceptibility to diabetic foot, prevention strategies, and the importance of such measures. Scoring was given using a five-point Likert scale: One = strongly disagree, Two = disagree, Three = neutral, Four = agree, Five = strongly agree.

The number of participants were six to eight. The focus group discussion was carried out until thematic saturation was reached. A focus group discussion was conducted in the outpatient departments of selected tertiary care hospitals. The discussion centred on participants' awareness and attitudes towards diabetic foot complications, including its causes, risk factors, importance of foot examinations, available diagnostic investigations, and the recommended frequency of these exams. Additionally, the discussion addressed treatment adherence, common medication side effects, home care practices, the harmful effects of smoking and alcohol, and the significance of maintaining a diabetic diet and regular physical activity. The discussion was recorded using a digital voice recorder, and notes were taken. The recorded information was transcribed and translated into English.

Statistical Analysis:

Data was entered in MS Office Excel 2007 and after coding it was further processed and analysed using Open Epi info statistical software version 7.0. Data was expressed as percentages and proportions for qualitative data and mean and standard deviations for quantitative data. Chi square test was used for assessing the association among the study variables. A “p” value of <0.05 was considered as statistically significant.

Table 1: Socio-demographic factors of the study participants

In our study, participants' ages ranged from 18 to over 78 years. The largest group, 122 participants (30.3%), was aged between 28 and 37 years, and the majority, 235 participants (58.3%), were females. Most participants, 298 (73.9%), were married. In terms of education, a significant proportion were illiterate (96 participants, 23.8%), while another 96 (23.8%) had completed up to high school. A majority, 141 participants (35%), were housewives. Regarding socio-economic status, most participants (168, or 41.7%) belonged to Class III.

Table 2a: Information regarding Knowledge of primary care givers about Diabetic foot

The study revealed that, out of 403 participants, 188(46.7%) rightly answered that diabetic patients needs to check their footwear for tears and other objects regularly. Most participants, 169 (41.9%), indicated that normal temperature water should be used to wash the feet, while 75 (18.6%) correctly stated that lukewarm water is preferred. Only 157 (39%) participants correctly identified that diabetic patients should wear woollen socks. When asked about foot care frequency, the majority, 137 (34%), answered that diabetic patients should wash their feet once a day, followed by 94 (23.3%) who suggested twice a day or more.

Information regarding Knowledge of primary care givers about Diabetic foot revealed that majority had good knowledge about the factors such as diabetics will have reduced blood in their feet (53.8%), diabetics are likely to develop reduced sensation in their feet (60.5%), delayed wound healing among diabetics (59.8%), reduced sensation in feet due to minor injuries (54.8%), treatment adherence will reduce complications (87.3%), regular exercising can prevent diabetic foot (59.3%) & first noticeable signs are burning sensation , tingling & pain (53.1%) while majority (50.1%) were not aware about the prevention of diabetic foot with the use of talcum powder in  keeping the interdigital spaces dry.

Table 2b: Information regarding Knowledge of primary care givers about Diabetic foot

Table 3: Information regarding Attitude of primary care givers about Diabetic foot

Table 4: Association of Knowledge score of study participants with socio demographic details

Table 5: Association of attitude score of study participants with socio demographic details

Age (82.63), Gender (27.09), Educational status (34.18) and Socio-economic status (77.44) was found to be positively associated with the attitude of study participants towards diabetic foot. (p=0.000)

The Focus group discussion comprising of six to eight participants in each group was conducted to gather insights into their experiences with diabetes care, the challenges they face, and the support they expect from family and the community. When discussing foot care among diabetic patients, participants were asked how often footwear should be inspected. While the majority responded with “sometimes,” a smaller number said “regularly.” One female participant emphasized that footwear should be checked every time before wearing. Our study found that 46.7% of respondents believed diabetic patients should inspect their footwear regularly. We also assessed their awareness of early signs of diabetic foot, such as a burning sensation in the feet. Most participants recognized this symptom, attributing their knowledge to advice from treating doctors or information provided while accompanying relatives to medical appointments. In our study around 53.1% of the participants were aware of this sign. When asked about the ideal material for socks for diabetic patients, many suggested materials that allow air circulation, though they were unfamiliar with the recommendation of woollen socks. Whereas 39% participants in our study were familiar with this information. Participants expressed concerns about the financial burden of managing diabetes. In our study 7.9% strongly agreed that they found it as a burden. They highlighted the high costs of treating complications and regular diagnostic tests as significant challenges. Some also mentioned the need to take time off work to accompany family members for routine check-ups, which added to their difficulties.

Overall, the participants displayed a good understanding of diabetes management and maintained a positive attitude toward the disease. Many acknowledged the importance of exercise in preventing diabetes. In this particular study 10.9% knew how sedentary lifestyle contributes to diabetes. However, a small subset, particularly from lower socioeconomic backgrounds or with limited education, demonstrated minimal awareness of proper foot care practices.

The findings of this study shed light on the knowledge and attitudes of primary caregivers towards the prevention of diabetic foot syndrome in a rural tertiary care hospital. The

majority of participants were in the age group of 28-37, but in the study by Adeyemi TM et.al⁹, majority were in the age group of 55.65 years, and in another study Chellan G et.al⁸ the mean age was 59.9. This could be because in the Urban population it’s normally the spouse who are the primary care givers but in rural population it’s mostly the offspring. In the present study conducted in a rural hospital, Majority were females 235 (58.3), whereas in Chellan G et.al⁸   majority were males (67.5) & in Adeyemi TM et.al⁹, females (12) were a majority. This could mainly be due to the fact that women take the responsibility of taking care of the ones in illness. In this current study most of the primary care givers were married (298), similar results were found in Adeyemi TM et.al⁹ (15), but in Hanley G et.al¹⁰ most of them were single (60%). This could be due to fact that marriages are more common in India.. In our study most of them completed their education till high school (96), followed by illiterates (96). In the study done by Adeyemi TM et.al⁹ majority attained secondary education (10), similar to the study Hanley G et.al¹⁰ where secondary education was the most (87.1). This is because in rural India literacy rates are much lower.

The distribution of Socio-economic status in this study showed majority of participants belonging to class III 168 (41.7%) followed by class II 126 (31.3) whereas in the study conducted by Adeyemi TM et.al⁹ the monthly income was 2000-15000USD. In the study conducted by Alharbi MO et.al¹¹ the monthly was 5000-10000 Saudi Riyal. This could be because most of the primary care givers are farmers or daily wage workers, hence belong to lower socio economic class.

In our study 217 (53.8%) had good knowledge that diabetics are likely to develop reduced blood flow in their feet, similar to the study conducted by Alharbi MO et.al¹¹ 146 (56.2%) had good knowledge too and in the study done by Hanley G et.al¹⁰, 127 (60.5%) had bad knowledge. This is because of the health education programs conducted in the rural set ups. In our study 244 (60.5%) people were aware that diabetic people have reduced sensation in their foot, similarly in studies conducted by Hanley G et.al¹⁰ 81 (38.6%) and Alharbi MO et.al¹¹ 239 (92%) had good knowledge about the same. In current study, 221 (54.8%) were aware that they had to look after their feet as they cannot feel minor injuries, in Alharbi MO et.al¹¹ majority demonstrated adequate knowledge, in Hanley G et.al,¹⁰171 (81.4%) aware, and in Alharbi MO et.al¹¹ 199 (76.5%) had good knowledge. In this present study 188 (46.7%) felt that it is necessary to check the inside of the foot wear for any wear and tears and in a study by Alharbi MO et.al¹¹ 159 (61.2%) felt the same. In the current study 195(48.4%) felt that smoking increases the chance of developing diabetic foot ulcers whereas Tuha A et al,¹² study reveals that 182 (52.9%) people felt smoking affects the progression of diabetes and in Alharbi MO et.al¹¹ study about 124 (47.7%) had no knowledge that smoking reduces the blood flow to the feet hence causing diabetic foot. In the current study, majority, 241 (59.8%) were aware of delayed wound healing in Diabetic patients and similar findings were seen in study by Tuha A et al,¹² where majority, 235 (68.3%) had knowledge about delayed wound healing in patients with diabetes. In this study 200 (49.6%) think that walking bare foot outside the house is a risk factor for diabetic foot, in another study by Alharbi MO et.al¹¹ 106 (40.8%)  prefer walking bare foot as they are unaware that it is a risk factor for diabetic foot ulcers.

In this Current study about 73(18.9%) participants feel diabetic foot care as a burden and this could be mainly because of the financial expenditure during the regular check-ups and also the time spent towards taking special care of their feet. Only 160 (39.7%) of primary care givers feel confident about taking care of diabetic patient and this may be due to lack of knowledge and proper guidance in the rural population. In this study 135 (33.5%) participants expressed about not having the time to frequently check their relatives for the early signs of diabetic foot, whereas 161 (40%) had time, and 107 (26.6%) had a neutral opinion. This is because most of the Primary care givers were house wives who could take time to check their relative’s feet for early signs of diabetic foot. About 318 (78.9%) have positive attitude towards sedentary lifestyle contributing to diabetic foot. This could be due to constant awareness spread by the health care workers.

In this study 58% of participants had good knowledge which can be attributed to the health awareness and health education programs conducted by the ASHA and healthcare workers in the rural regions. In this study, 86.1% of primary caregivers have a positive attitude, largely due to the strong sense of compassion and responsibility within close families when it comes to caring for loved ones during illness in the rural areas.

The findings of this study shed light on the knowledge and attitudes of primary caregivers towards the prevention of diabetic foot syndrome in a rural tertiary care hospital. The results revealed varying levels of knowledge among primary caregivers regarding the risk factors associated with diabetic foot syndrome. While a significant proportion of participants correctly identified key risk factors such as the likelihood of developing foot ulcers, reduced blood flow, and sensation in diabetic patients' feet. These findings underscore the importance of targeted educational interventions aimed at improving knowledge about diabetic foot syndrome among primary caregivers. In this study only about 58% of the primary care givers had good knowledge about the complications of diabetes mellitus such as diabetic foot, risk factors leading to development of diabetic foot and the preventive measures. Which suggests that another 42% of primary giver’s knowledge is poor, hence there is need to increase awareness programs through information, education and communication at village level using ASHA's and ANM’s (PHCO) plays important role in improving knowledge among primary care givers.

Also display of predesigned health education videos related to diabetes mellitus and its complications such as diabetic foot, risk factors leading to the development of diabetic foot and the preventive measures which can be at household level should be displayed in the patient waiting area's in all the health care facilities.

Focus group discussions by the field staff in the community will improve the knowledge about such health conditions and individuals get an opportunity to clear their myths.

Most of the participants felt the treatment for diabetes related complications such as Diabetic foot is a burden. Hence policy makers should provide the drugs and high end investigation either free of cost or at a concession rate for the people with low socioeconomic class.

The attitude of the primary care givers in this study was very good, around 86.1% people had good attitude.

1. World Health Organization. Available from: https://www.who.int/health-topics/diabetes#tab=tab_1 .Last Accessed on 11^th March 2023.
2. Jia H, Wang X, Cheng J. Knowledge, attitudes, and practices associated with diabetic foot prevention among rural adults with diabetes in North China. Frontiers in Public Health. 2022 May 20;10:876105.
3. Diabetic association federation. Available from: https://diabetesatlas.org/idfawp/resource-files/2021/11/ (Last Accessed on 13^th April 2023)
4. Taksande BA, Thote M, Jajoo UN. Knowledge, attitude, and practice of foot care in patients with diabetes at central rural India. Journal of family medicine and primary care.
5. Vibha SP, Kulkarni MM, Kirthinath Ballala AB, Kamath A, Maiya GA. Community based study to assess the prevalence of diabetic foot syndrome and associated risk factors among people with diabetes mellitus. BMC endocrine disorders. 2018 Dec; 18(1):1-9.
6. Kaya Z, Karaca A. Evaluation of nurses’ knowledge levels of diabetic foot care management. Nursing research and practice. 2018 Jul 2; 2018.
7. Ramanagara district census population 2011-2023 . Available from : https://www.census2011.co.in/census/district/265-ramanagara.html Last accessed on 19^th January 2023.
8. Chellan G, Srikumar S, Varma AK, Mangalanandan TS, Sundaram KR, Jayakumar RV, Bal A, Kumar H. Foot care practice–The key to prevent diabetic foot ulcers in India. The Foot. 2012 Dec 1;22(4):298-302.
9. Adeyemi TM, Olatunji TL, Adetunji AE, Rehal S. Knowledge, practice and attitude towards foot ulcers and foot care among adults living with diabetes in Tobago: A qualitative study. International Journal of Environmental Research and Public Health. 2021 Jul 29;18(15):8021.
10. Hanley G, Chiou PY, Liu CY, Chen HM, Pfeiffer S. Foot care knowledge, attitudes and practices among patients with diabetic foot and amputation in St. Kitts and Nevis. International Wound Journal. 2020 Oct;17(5):1142-52.
11. Alharbi MO, Sulaiman AA. Foot care knowledge, attitude and practices of diabetic patients: A survey in Diabetes health care facility. Journal of Family Medicine and Primary Care. 2022 Jul 1;11(7):3816-23.
12. Tuha A, Getie Faris A, Andualem A, Ahmed Mohammed S. Knowledge and practice on diabetic foot self-care and associated factors among diabetic patients at Dessie referral hospital, northeast Ethiopia: mixed method. Diabetes, Metabolic Syndrome and Obesity. 2021 Mar 17:1203-14.