European Journal of Cardiovascular Medicine

substantial global health challenge in the 21st century, accounting for over 74% of all deaths. They engender profound morbidity and mortality, resulting in substantial socioeconomic burden on healthcare systems and national economies.(1)

Diabetes mellitus, a major global public health concern, stands as one of the most rapidly escalating health emergencies of the 21st century. With 1 in 9 adults living with diabetes, over 4 in 10 remain unaware of their condition. Currently there are approximately 589 million diabetics worldwide, with over 4 in 5 residing in low- and middle-income countries. According to the International Diabetes Federation’s estimates, this prevalence is projected to double by 2050.(2) India has 74.2 million individuals living with diabetes, and this number is anticipated to reach 151.5 million by 2045 unless substantial preventive measures are implemented. Consequently, diabetes continues to be one of the leading contributors to this global burden.(3)

Foot-related complications, including peripheral neuropathy, foot ulcers, infections, and gangrene, significantly contribute to disability and hospitalization among individuals with diabetes. These complications frequently result in lower limb amputations.(4) Diabetes still remains a leading cause of non-traumatic amputation of lower limb globally, with individuals with diabetes experiencing a 15 times higher risk of such amputations compared to non-diabetics.(5) Studies indicate that every 30 seconds, a lower limb is lost worldwide due to diabetes, with up to 85% of diabetes-related lower limb amputations preceding foot ulcers. Many of these ulcers could have been prevented through proper self-care and timely medical intervention.(6) The incidence of foot ulcers among individuals with diabetes ranges from 8% to 17%,(7) affecting the health-related quality of life of over 25% of those affected.(8) Furthermore, more than half of individuals with diabetes become infected, necessitating hospitalization. A substantial portion of these infections leads to amputations, resulting in substantial economic burden for families and healthcare systems.(9) Individuals with a history of diabetic foot ulcers exhibit a 40% higher 10-year mortality rate compared to individuals with diabetes alone. Diabetic foot ulcers double the risk of death and heart attack while increasing the risk of stroke by 40%.(10) Despite these severe consequences, a significant number of patients, particularly in rural and resource-constrained settings, present late with advanced foot conditions due to factors such as inadequate awareness, lack of education on foot hygiene, sociocultural practices, and limited access to structured diabetic care services. (11)

The cornerstone of diabetic foot prevention lies in patient education and behavior modification. Knowledge, attitude, and practice (KAP) surveys provide valuable insights into patients’ understanding of foot care, their perception of risk, and their adherence to recommended practices. Such assessments are essential for identifying gaps in health literacy and developing targeted interventions aimed at reducing the incidence of foot ulcers and subsequent amputations. (12) Evidence suggests that while many diabetic patients may possess basic knowledge of foot care, this often does not translate into practice, indicating a critical knowledge-practice gap that warrants attention. (13)

In India, rural populations face unique challenges due to limited healthcare infrastructure, lower health literacy, and socio-cultural barriers, which compound the risk of poor diabetic outcomes. In this context, evaluating the knowledge, attitude and practices related to foot care among diabetic patients attending rural primary healthcare services becomes crucial for both clinical and public health planning.

This study was conducted to assess the knowledge, attitude, and practice regarding foot care among diabetic patients attending a rural health center in Chennai, their association with their socio demographic characteristics and to examine the knowledge practice gap among them.

This is an analytical cross-sectional study conducted at the Rural Health Centre in Chennai, Tamil Nadu. The study was carried out over a seven-month period from May to November 2019. The study included adults’ aged ≥30 years with a confirmed diagnosis of type 2 diabetes mellitus attending diabetic clinic at a rural health center in Chennai. Those who were able to understand and speak Tamil were included in the study. Patients with amputated lower limbs, cognitive impairment, and obvious disability that could impair the functions of the nervous system were excluded from the study.

Sample size was calculated based on a study done in a rural hospital in South India where good foot care practices was 67 %( 14). With a relative precision of 5% and a non-response rate of 10%, the sample size was calculated to be 832.

Data was collected by using a pretested, semi-structured questionnaire administered through face-to-face interview by systematic random sampling, after obtaining ethical clearance from the Institutional Ethics Committee. Written informed consent was obtained from all participants prior to data collection, ensuring confidentiality and the right to withdraw at any stage. The questionnaire included four sections namely socio-demographic profile, Knowledge on diabetic foot care, Attitude towards foot care and Practices related to foot care, prepared based on the ‘Nottingham assessment of functional foot care’ questionnaire,(15) recommendation of American College of Foot and Ankle Surgeons and Diabetes UK(16) and from similar studies and modified according to the local culture. The responses were scored, and cut-off levels were used to categorize knowledge, attitude, and practice as poor or good based on modified Bloom’s criteria. Knowledge score > 50% was considered adequate and practice score > 50% was considered to be good.

Data was entered into Microsoft Excel and analyzed using SPSS version 21. Descriptive statistics such as frequency, percentage, mean, and standard deviation were analyzed. Chi-square tests were applied to assess the association between KAP scores and demographic variables. A p-value of <0.05 was considered statistically significant.

A total of 832 diabetic patients attending a rural health center in Chennai were included in the study. The socio-demographic profile, knowledge, attitude, and practice (KAP) levels regarding diabetic foot care, as well as associations between KAP and demographic variables, are summarized below.

Socio-Demographic Characteristics:

All participants were above 30 years of age ranging from 34 years to 76 years with a mean age of 52.1 + 9.77 years. More than half of the participants (59.5%) were above 50 years. Females constituted 70% of the study population. Based on the modified BG Prasad socio-economic classification, most participants (41%) belonged to Class IV. (Table 1)

Nearly one third of the participants (29.5%) had diabetes for more than 10 years. Most of them adhered to treatment and follow up. Only 10% participants had history of foot ulcers.

Knowledge on Diabetic Foot Care:

Out of 832 participants, 452 (54.3%) [95% CI – 50.9% to 57.7%] demonstrated adequate knowledge regarding foot care. (Figure 1) While 88.1% were aware that diabetics must take regular medications to prevent complications, only 25.7% knew about the importance of foot care due to sensory loss. Notably, 83.8% and 85.2% recognized the need for daily foot and footwear inspection respectively, with only 9.5% having knowledge on the correct method of trimming toenails. (Table 2)

Among the study participants, 70% reported of getting information regarding foot care, with around half of them informed by health care professionals.

Attitude towards Foot Care:

More than half of the participants exhibited a positive attitude towards diabetic foot care. A large majority (88.6%) agreed that lifestyle changes were essential to prevent complications, and 83.8% supported the use of specialized footwear. However, only 57.1% endorsed the need for regular self-foot examination. (Table 3)

Foot Care Practices:

Among the 832 participants, only 345 participants (41.4%) [95% CI – 38% to 44.7%] followed good foot care practices. (Figure 2) Although 97.1% examined their feet daily and 93.8% washed them regularly, only 5.2% reported changing footwear regularly. Furthermore, 90% walked barefoot indoor, 68.6% outdoors and only 4.3% oiled their toes —practices associated with high risk of foot injury. (Table 4)

Association of knowledge and practice and socio demographic and clinical variables:

Crude odds ratios (ORs) were calculated to examine the association of foot care knowledge and practice with age, sex, and socioeconomic status (SES) and clinical factors like duration of diabetes and history of foot ulcers.

When analyzed by age group, older participants (51 years and above) had slightly higher odds of having adequate knowledge compared to younger participants (30–50 years) (OR = 1.16; 95% CI: 0.87–1.53). However, older participants had marginally lower odds of demonstrating adequate foot care practices (OR = 0.91; 95% CI: 0.68–1.20). Neither association reached statistical significance.

With respect to sex, male participants exhibited significantly higher odds of having adequate knowledge (OR = 1.42; 95% CI: 1.05–1.92; p=0.02) compared the females. They also had higher odds of adequate foot care practices (OR = 1.19; 95% CI: 0.89–1.61), however, this association was not statistically significant.

Participants from upper socioeconomic classes were more likely to demonstrate adequate knowledge (OR = 1.29; 95% CI: 0.99-1.71) and statistically significant better foot care practices (OR = 1.63; 95% CI: 1.23-2.16; p=0.0006) compared to those from lower classes.

Those living with diabetes for 10 years and beyond showed significant higher odds of having adequate knowledge (OR = 0.73; 95% CI: 0.54-0.99; p=0.04) compared to those with shorter duration of disease. They also had better practices (OR = 0.87; 95% CI: 0.64-1.20) compared to those who had the disease for less than 10 years. But this association was not statistically significant. These findings suggest that longer duration of illness alone may not ensure better foot care, emphasizing the need for sustained patient education.

Participants with a prior history of foot ulcers had statistically significant three times higher odds of possessing adequate knowledge (OR = 2.92; 95% CI: 1.73–4.92, p=0.0001), likely due to personal experience or prior counseling. However, this did not translate into better practices (OR = 0.60; 95% CI: 0.36 – 1.02), highlighting a persistent knowledge-practice gap, particularly among those at high risk. (Figure 3, Figure 4)

Relationship between knowledge adequacy and practice:

Table 5 highlights the relationship between the level of knowledge and the quality of foot care practices among the study participants. Participants with adequate knowledge were nearly four times more likely to engage in good foot care practices compared to those with inadequate knowledge, demonstrating a statistically significant association between knowledge and practice. (OR = 3.71; 95% CI: 2.75-4.99; p<0.0001). Thus, strongly indicating that better knowledge about foot care is positively associated with improved foot care behavior.

Table 1: Socio demographic characteristics of the participants (N=832):

Table 2: Knowledge regarding diabetic foot care (N=832)

Table 3: Attitude towards diabetic foot care (N=832)

Table 4: Foot care practices among participants (N=832)

Table 5: Relationship between knowledge adequacy and practice:

Diabetic foot complications, a disabling and common complication, remain a major public health issue, particularly in low- and middle-income countries where delayed diagnosis, suboptimal patient education, and limited healthcare access contribute to poor outcomes. The present study assessed the knowledge, attitude, and practice (KAP) regarding diabetic foot care among patients attending a rural health center in Chennai, revealing several gaps that require urgent attention.

Although more than half (54.3%) of the participants had adequate knowledge on foot care, only 41.4% demonstrated good foot care practices. This is lower than the proportion reported in a study done in similar settings in Southern India, which showed that, about 75% had good knowledge and 67% had good foot care practices (14). This demonstrates a significant knowledge–practice gap, which may be due to poor communication between the doctors and the patients, differences in healthcare access and literacy levels, and also lack of counseling by health care providers due to busy clinic schedule. The findings of the present study are similar to the studies done in UK (16), rural health centre in Thane district(17) and Lahore(18) . This highlights that awareness alone does not translate into behavior change unless accompanied by sustained motivation, access to care, and culturally appropriate education.

While a large proportion of participants knew that diabetes required regular medication (88.1%) and understood the importance of inspecting feet and footwear daily (83.8% and 85.2% respectively), less than 10% knew about the critical preventive measures, such as smoking cessation and nail trimming techniques. And only 25.7% recognized that sensory loss could lead to unnoticed injuries. These deficiencies mirror findings from studies in Nigeria, Iran, and Pakistan, where patients demonstrated broad awareness of diabetes but lacked in-depth knowledge of foot care measures(13,18).

Despite poor overall knowledge, most participants showed a favorable attitude towards foot care. More than 88% agreed that lifestyle changes are necessary to prevent complications and supported the use of special footwear. However, only 57.1% endorsed regular self-foot examination. This partial acceptance of recommended practices may reflect gaps in counseling or low perceived susceptibility to complications. Studies from Ethiopia, Nigeria and the UAE have similarly found a mismatch between patient attitudes and actual practices (12,13,19).

Practice-wise, while over 93% reported washing their feet daily and 97% claimed to inspect them, risky behaviors were widespread. Notably, 90% walked barefoot indoors, and 68.6% did so outdoors and only 5.2% reported changing their footwear regularly, reflecting the inadequate application of preventive behaviors that substantially increase the risk of foot injuries, ulcers, and eventual amputations, particularly in those with peripheral neuropathy. These findings are consistent with studies from Nigeria, Ethiopia, Karachi, Thane, Chandigarh and southern India, where improper footwear use and barefoot walking were commonly observed among diabetics (13,14,19-21), thus indicating that participants paid attention only to a few aspects of foot care. The habit of walking bare-foot is a dangerous approach, as diabetic neuropathy can increase plantar pressure making them more prone for developing foot ulcers.

Analysis of demographic factors revealed no statistically significant associations between KAP levels and age or duration of diabetes. However, some patterns were noteworthy. Older adults (≥50 years) had slightly higher knowledge but not better practices, suggesting that age-related experience may improve awareness but not necessarily translate into behavioral change. Males had higher odds of both knowledge and good practice (p=0.02), though females constituted the majority of the sample. Similar findings were observed in studies done in Nigeria and Ethiopia.(13,18). This is in contrary to the study conducted in Southern India(14). The poorer outcomes among women may stem from reduced access to information, sociocultural constraints, or limited autonomy in health decision-making, issues previously documented in Indian and global literature (18,21). Further exploration may be warranted to understand gender related barriers to healthcare.

Participants from upper socioeconomic strata demonstrated better knowledge and significantly higher odds of adequate foot care practices compared to those from lower strata. This aligns with previous studies highlighting the influence of socioeconomic status on health literacy, access to healthcare, and adherence to self-care behaviors in diabetes (22,23). Higher SES often enables greater access to education, healthcare services, and resources such as appropriate footwear, while individuals from lower SES backgrounds may face barriers such as limited health literacy, financial constraints, and competing life demands (24). These findings highlight the importance of targeted interventions to address health inequities by integrating foot care education into community outreach and public health programs aimed at socioeconomically disadvantaged populations.

One of the most important findings was the statistically significant association between a history of foot ulcers and adequate knowledge (OR = 2.92; p = 0.0001). However, this improved knowledge did not lead to better practices, indicating a persistent knowledge–practice gap even in high-risk individuals. This finding echoes the work of Pendsey et al, who observed that personal experience alone does not necessarily lead to behavior modification unless reinforced through structured counseling and follow-up (6).

Crucially, participants with adequate knowledge were significantly more likely to practice good foot care (OR = 3.71; 95% CI: 2.75–4.99, p < 0.0001), This finding is consistent with existing evidence suggesting that knowledge is a critical determinant of self-care in diabetes, including daily foot inspection, hygiene, and footwear use (13,14, 25). However, the presence of some participants with adequate knowledge but poor practices highlights the well-recognized knowledge–practice gap in foot care management. Factors such as motivation, persistent communication, perceived susceptibility, cultural norms, and access to care may mediate this gap (26). This suggests a pressing need for comprehensive, culturally sensitive, behaviorally focused health education interventions, delivered through individual and community-based strategies that go beyond knowledge to address the barriers to practice and promote long-term adherence.

The use of self-reported data in the study could have introduced social desirability bias, especially in reported practices such as foot washing and inspection. The excluson of urban diabetics limits the comparative analysis and the generalizability of the findings across diverse populations.

RECOMMENDATION:

This study shows that some areas of foot care knowledge and practices are deficient among the diabetics in the rural area and highlights the need for targeted interventions to bridge the knowledge-practice gap. Structured, culturally sensitive health education modules for diabetic patients and their families should be incorporated into routine diabetes management at primary care level, focusing on the importance of foot care, sensory loss, proper footwear, nail trimming techniques, early screening and prompt treatment of new lesions.

Community-based behavior change communication (BCC) campaigns through posters, leaflets, videos, and interactive group sessions can help reinforce preventive practices and discourage risky behaviors like walking barefoot indoors, not changing footwear, and ignoring minor foot injuries. Peer led support groups can be formed within the community to encourage adherence and provide positive role models for behavior change. Frontline Health Workers like ASHAs, ANMs, and PHC nurses should be trained to reinforce key foot care messages, perform basic screenings, and dispel misconceptions during patient interactions. Routine foot screening for neuropathy, annual foot examinations and early management of foot complications must be strengthened along with regular risk screening for closer follow up at the primary care level.

To ensure equitable access, protective footwear should be made available at subsidized rates, particularly for patients from lower socioeconomic backgrounds. Gender-specific approaches may be planned to address the barriers faced by women such as autonomy, access, and health literacy. Further, qualitative research can be done to explore patient perspectives and barriers to practice, to tailor future interventions.

This study highlights critical gaps in the knowledge and foot care practices among diabetics  in a rural area of Chennai. While over half of the participants had adequate knowledge, less than half followed appropriate foot care practices, reflecting a significant knowledge–practice gap. Factors such as gender, socioeconomic status, and prior history of foot ulcers were associated with knowledge and practices, but not consistently predictive of behavior change. This shows the urgent need for structured, culturally tailored, patient friendly educational intervention coupled with regular foot screening to reduce the risk of diabetic foot ulcer and amputations. Behaviour change communication should be disseminated widely in the community with the diabetics encouraged to get actively involved. Integrating foot care into routine diabetes management and empowering frontline health workers can play a pivotal role in preventing diabetic foot complications and reducing the risk of amputations.

1.       World Health Organization. Invisible numbers: the true extent of noncommunicable diseases and what to do about them. Geneva: WHO; 2022 [cited 2025 May 5]. Available from: https://apps.who.int/iris/rest/bitstreams/1466662/retrieve

2.       International Diabetes Federation. Diabetes facts & figures [Internet]. Brussels, Belgium: IDF; 2024 [cited 2025 May 13]. Available from: https://idf.org/about-diabetes/diabetes-facts-figures/

3.       International Diabetes Federation. IDF Diabetes Atlas, 11th ed. Brussels, Belgium: International Diabetes Federation, 2025. Available from: https://www.diabetesatlas.org.

4.       Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: A systematic review and meta-analysis. Ann Med. 2017;49(2):106–16. doi:10.1080/07853890.2016.123193

5.       Gupta S. Management of diabetic foot. Medicine Update. 2012;22. Available from: http://www.apiindia.org/pdf/medicine_update_2012/diabetology_10.pdf

6.       Pendsey S, Abbas ZG. The step-by-step program for reducing diabetic foot problems: A model for the developing world. Curr Diab Rep. 2008;7(6):425–8. doi:10.1007/s11892-007-0068-3

7.       Crawford F, Inkster M, Kleijnen J, Fahey T. Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis. QJM. 2007;100(2):65–86. doi:10.1093/qjmed/hcl140

8.       Goodridge D, Trepman E, Embil JM. Health-related quality of life in diabetic patients with foot ulcers: A literature review. J Wound Ostomy Continence Nurs. 2005;32(6):368–77. doi:10.1097/00152192-200511000-00010

9.       Margolis DJ, Malay DS, Hoffstad OJ, Leonard CE, MaCurdy T, Tan Y, et al. Economic burden of diabetic foot ulcers and amputations. 2011 [cited 2016 Mar 3]; Available from: http://www.ncbi.nlm.nih.gov/books/NBK65152/

10.    Diabetic foot ulcers double death rate: Study - Times of India [Internet]. [cited 2016 Mar 3]. Available from: http://timesofindia.indiatimes.com/city/ahmedabad/Diabetic-foot-ulcers-double-death-rate-Study/articleshow/25783943.cms

11.    Shahbazian H, Yazdanpanah L, Latifi SM. Risk assessment of patients with diabetes for foot ulcers according to risk classification consensus of international working group on diabetic foot (IWGDF). Pak J Med Sci. 2013;29(3):730–4. doi:10.12669/pjms.293.3061

12.    Al-Maskari F, El-Sadig M. Knowledge, attitude and practices of diabetic patients in the United Arab Emirates. PLoS One. 2007;2(9):e1285. doi:10.1371/journal.pone.0001285

13.    Desalu OO, Salawu FK, Jimoh AK, Adekoya AO, Busari OA, Agboola SM. Diabetic foot care: Self-reported knowledge and practice among patients attending three tertiary hospital in Nigeria. Ghana Med J. 2011;45(2):60–5.

14.    George H, Rakesh PS, Krishna M, Alex R, Abraham VJ, George K, et al. Foot care knowledge and practices and the prevalence of peripheral neuropathy among people with diabetes attending a secondary care rural hospital in southern India. J Family Med Prim Care. 2013;2(1):27–32. doi:10.4103/2249-4863.109946

15.    Lincoln N, Jeffcoate W, Ince P, Smith M, Radford K. Validation of a new measure of protective footcare behaviour: the Nottingham Assessment of Functional Footcare (NAFF). Pract Diabetes Int. 2007 May;24(4):207–11. doi:10.1002/pdi.1135

16.    Pollock RD, Unwin NC, Connolly V. Knowledge and practice of foot care in people with diabetes. Diabetes Res Clin Pract. 2004;64(2):117–22. doi:10.1016/j.diabres.2003.11.008

17.    Pitchai P, Joshi J. Knowledge and practice of foot care amongst diabetics in India: Comparison between urban and rural setting—a reality check. Int J Health Sci Res. 2015;5(4):181–9.

18.    Hasnain S, Sheikh NH. Knowledge and practices regarding foot care in diabetic patients visiting diabetic clinic in Jinnah Hospital, Lahore. J Pak Med Assoc. 2009;59(10):687-90.

19.    Seid A, Tsige Y. Knowledge, practice, and barriers of foot care among diabetic patients attending Felege Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia. Adv Nurs. 2015;2015:1–9. doi:10.1155/2015/934623

20.    Agha SA, Usman G, Agha MA, Anwer SH, Khalid R, Raza F, et al. Influence of socio-demographic factors on knowledge and practice of proper diabetic foot care. Khyber Med Univ J. 2014;6(1):24–8.

21.    Kaur K, Singh MM, Walia I. Knowledge and self-care practices of diabetics in a resettlement colony of Chandigarh. Indian J Med Sci. 1998;52(8):341-7.

22.    Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord. 2013;12:14. doi:10.1186/2251-6581-12-14

23.    Hussain S, Habib A, Singh A, Akhtar M, Najmi AK. Knowledge, attitude and practices among patients with diabetic foot ulcer. Diabetes Metab Syndr. 2017;11(Suppl 2):S576–S579. doi:10.1016/j.dsx.2017.03.035

24.    Kumar S, Goyal A, Dutta R. Foot care knowledge and practices among diabetic patients in rural India. Int J Community Med Public Health. 2018;5(3):1115–9. doi:10.18203/2394-6040.ijcmph20180775

25.    Boulton AJM, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719–24. doi:10.1016/S0140-6736(05)67698-2

26.    Rathur HM, Boulton AJM. The diabetic foot. Clin Dermatol. 2007;25(1):109–20. doi:10.1016/j.clindermatol.2006.09.007