Evaluating Foot Care Knowledge, Attitudes and Practices Among Diabetics in Dubai’s Primary Health Care Sector

Abstract

Background/Objectives: This cross-sectional study examined factors associated with diabetic foot complications and identified areas for targeted interventions. Methods: Participants were selected from Dubai Health Authority (DHA) primary health care centers (PHCCs) and divided into two groups: those with diabetic foot complications (DFC) and those without (non-DFC). Data were collected through demographic surveys and a structured questionnaire assessing knowledge, attitudes, and practices (KAP) related to foot care. Results: A significant age disparity was observed within the study population, with 70.6% of individuals in the DFC group being over 60 years. In contrast, only 41.8% of the non-DFC group fell within the same age range, underscoring the potential role of age as a critical risk factor. Analysis of KAP towards diabetic foot care did not reveal any notable differences when stratified by sex, employment status, or overall educational attainment. However, a higher proportion of individuals within the DFC group reported having received no formal education. Furthermore, participation in foot care education programmes was significantly correlated with enhanced knowledge (p < 0.001) and improved practices (p = 0.013). Overall, individuals within the DFC group exhibited significantly poorer self-care practices regarding foot health (p < 0.001). Conclusions: This finding indicates a pressing need for targeted educational interventions aimed at improving outcomes and reducing complications among patients with diabetes.

1. Introduction

Diabetes Mellitus represents a widespread and chronic metabolic disorder characterised by prolonged elevations in blood glucose levels, which affects a significant proportion of the global population [1]. The diabetic foot disease is one of the most severe complications associated with this condition, which is predominantly linked to peripheral arterial disease and diabetic peripheral neuropathy [1]. These conditions adversely affect the quality of life for patients and impose considerable medical, economic, and social burdens on healthcare systems internationally [2,3]. In the United Arab Emirates (UAE), healthcare expenditures related to diabetes were estimated to be approximately $6 billion in 2010, the highest in the region at that time [3]. With a national prevalence of diabetes surpassing 12.3%, the incidence of diabetic foot complications is on the rise [2,4]. Furthermore, individuals with diabetes are at an elevated risk of limb amputation, with global estimates suggesting that one amputation related to diabetes occurs every half a minute [5]. Notably, up to 85% of such amputations may be preventable through comprehensive care strategies, including regular foot assessments, proper foot hygiene, and guidance on appropriate footwear [5,6,7].

Extensive research has highlighted the importance of early detection and thorough patient evaluations in preventing diabetic foot complications [7,8]. Effective self-care practices, such as maintaining good glycaemic control, adhering to prescribed medications, employing healthy coping strategies, and implementing preventive foot care, are vital in managing and mitigating the risk of complications [9]. Moreover, involving patients in the decision-making processes related to their personal care plans has enhanced treatment adherence and improved clinical outcomes [10].

To gain insights into the perspectives and behaviours of patients, KAP studies are frequently employed to evaluate the management of Non-Communicable Diseases (NCDs), including diabetes [11,12]. This cross-sectional study aims to investigate the relationship between foot care-related KAP and the incidence of diabetic foot complications among patients attending PHCCs in Dubai. By assessing KAP within this population, the research seeks to identify existing knowledge gaps and behavioural patterns that can inform targeted interventions and educational strategies to enhance foot care and reduce the rates of complications.

2. Methods

2.1. Study Design, Ethical Considerations, and Data Collection Methods

This study adopted a cross-sectional, prospective case–control design to compare two groups of individuals diagnosed with diabetes: the case group are those presenting with diabetic foot complications (DFC), and the control group are those without such complications (non-DFC). Throughout the research process, ethical standards were rigorously maintained. Informed consent was acquired from all participants after their receipt of comprehensive written information regarding the study. Confidentiality was preserved through anonymisation procedures and secure data handling protocols, with all data stored on password-protected systems. Ethical approval was obtained from both the Research Ethics Committee at Queen Margaret University (QMU) in the United Kingdom and the Institutional Review Board at Mohammed Bin Rashid University (MBRU IRB) in the United Arab Emirates prior to the initiation of the study.

The study’s participants comprised individuals diagnosed with diabetes who are currently receiving care at the NCDs clinics operated by the DHA. Inclusive criteria included adults aged 18 years and over, who had a confirmed diagnosis of diabetes and provided informed consent by selecting the ‘Yes’ option on an online consent form. Individuals who were unable to provide informed consent were excluded from the study. Data collection was conducted by trained diabetes educators, who collected responses during the participants’ routine clinic visits. Prior to participation, individuals were informed about the study through a Participant Information Sheet (PIS), and the administration of the survey was carried out by research assistants. On average, the completion of the questionnaire took between 15 and 20 min. Participants’ responses were subsequently entered into a secure database protected by password access.

Data collection utilized a demographic questionnaire and a KAP questionnaire specifically designed to assess diabetic foot care. During the data entry process, participants’ Medical Record Numbers (MRNs) were linked to anonymized study identification numbers to ensure confidentiality. Following data collection, the MRNs were permanently deleted to further protect participant anonymity. All collected data were securely stored in an electronic, shared folder that was accessible solely to the principal investigator and designated members of the research team. To maintain data integrity, duplicate entries were systematically prevented through established verification protocols.

The demographic questionnaire comprised 21 items, the majority of which were derived from the participants’ medical records. One item, pertaining to attendance at a diabetic foot care program, was self-reported by participants. To safeguard participant privacy, sensitive information, including data related to alcohol use and religious affiliation, was obtained from medical records rather than through direct inquiry.

The KAP questionnaire, as originally devised by Hanley et al. [13], was adapted for the purposes of this investigation. Initially formulated in English, the instrument was subsequently translated into Arabic to enhance understanding among local participants. The questionnaire comprised ten inquiries related to knowledge, eight items pertaining to practices, and five questions addressing attitudes. The responses were in the form of yes/no or agree/disagree.

The primary objective of this study was to compare demographic characteristics and KAP scores between the groups classified as DFC and non-DFC. Through this comparative analysis, the study sought to identify potential risk factors associated with the onset of diabetic foot complications. Statistical significance was evaluated through the utilisation of p-values.

2.2. Statistical Analysis

Data were analysed using IBM SPSS Statistics software (version 2020) [14]. Survey responses were coded into variables for statistical processing. Descriptive and inferential statistics were employed, including the Chi-square test, Mann–Whitney U test, and Kruskal–Wallis H test, depending on the variable type and distribution. Statistical significance was established at a p-value < 0.05.

3. Results

A total of 268 individuals with diabetes participated in the study, divided into two groups: those with diabetic foot complications (DFC, n = 17) and those without (non-DFC, n = 251) (Table S1).

In terms of demographic characteristics, the DFC group included a significantly higher proportion of individuals aged over 60 years (70.6%) compared to the non-DFC group (41.8%), suggesting a strong association between advancing age and the development of diabetic foot complications. Regarding glycemic control, 94.1% of participants in the DFC group had blood glucose levels exceeding 111 mg/dL, compared to 78.1% in the non-DFC group. Moreover, the DFC group exhibited significantly higher HbA1c levels (p = 0.017), indicating poorer long-term glucose regulation. A longer duration of diabetes was also more prevalent in the DFC group, with a greater proportion of individuals having lived with the disease for over 30 years.

Medication use also differed significantly between the two groups. Insulin use was more frequent among individuals in the DFC group (p = 0.001), and they also reported higher use of herbal therapies (p = 0.003). Despite these clinical differences, no statistically significant variation was observed in self-reported adherence to diabetes management protocols (p = 0.104), indicating that perceived adherence may not fully explain the presence of foot complications.

Table 1. The mean KAP Scores Across Different Demographic Groups.

Variable	K.score 1.306 + 0.259 Mean Rank	p-Value	A.score 1.088 + 0.142 Mean Rank	p-Value	P.score 1.531 + 0.255 Mean Rank	p-Value
Age
<60 yrs.	128.60	0.153	138.36	0.261	134.30	0.961
>60 yrs.	142.12		129.51		134.76
Gender
Male	133.67		129.34		137.25
Female	135.58	0.840	141.15	0.134	130.95	0.504
Education
Never attended school	148.69	0.142	152.37	0.044	138.36	0.234
Up to high school	136.61		132.88		125.30
College and over	123.94		126.05		142.69
Occupation Status
Employed	126.59	0.179	127.42	0.149	125.03	0.106
unemployment	139.52		138.99		140.50
Education Program on DM Foot Care
Attended once	134.25	0.063	142.05	<0.001	147.07	0.013
Attended few times	120.86		103.28		139.56
Never attended	148.60		157.19		114.57

presents the mean scores for knowledge, attitude, and practice (KAP) across various demographic groups. While there were no statistically significant differences in KAP scores based on age or gender, education level showed a notable impact, particularly on attitude scores. Participants who had never attended school had higher attitude scores (mean rank = 152.37, p = 0.044) than those with higher education levels. Employment status did not significantly affect KAP scores.

Regarding educational interventions, those who had attended diabetes foot care education programs exhibited significantly better attitudes (p < 0.001) and practices (p = 0.013), highlighting the positive impact of structured education on diabetic foot care behaviors (Table 1).

Table 2. Comparison of Diabetic Foot Care KAP Among Participants With and Without Foot Complications.

Group	DFC (n = 17), Mean Rank	Non-DFC (n = 251), Mean Rank	Mann-Whiteny U	p-Value
Variables
Knowledge	128.97 (2192.5)	134.87 (33,853.5)	2039.5	0.759
Attitude	112.18 (1907.0)	136.01 (34,139.0)	1754.0	0.137
Practices	75.24 (1279.0)	138.51 (34,767.0)	1126.0	<0.001

compares KAP scores between participants with and without foot complications. While no significant differences were observed in knowledge (p = 0.759) or attitude (p = 0.137) scores between the DFC and non-DFC groups, practice scores were significantly lower in the DFC group (p < 0.001). This indicates that although participants may possess adequate knowledge and a positive attitude, these do not always translate into effective self-care behaviors, particularly among those already affected by foot complications.

4. Discussion

The findings of this study highlight important demographic and clinical factors associated with diabetic foot complications, with significant differences in age, glycemic control, and diabetes duration between the two groups of participants, DFC and non-DFC.

The DFC group included a significantly higher proportion of individuals aged over 60 years (70.6%) compared to 41.8% in the non-DFC group. This indicates that advancing age plays a critical role in the development of diabetic foot complications, aligning with existing research that identifies older age as a key risk factor for these complications [15,16]. These findings emphasize the need for targeted interventions for this vulnerable demographic.

Regarding blood glucose levels, the results revealed that 94.1% of individuals in the DFC group had levels exceeding 111 mg/dL, compared to 78.1% in the non-DFC group The DFC group also had significantly higher HbA1c levels (p = 0.017), which agrees with previous studies linking poor glycemic control with the onset of diabetic foot complications [4,17]. The longer duration of diabetes in the DFC group (with many participants living with the condition for over 30 years) also aligns with studies by Pavithra et al. [18] and Deribe et al. [19], which indicate that prolonged hyperglycemia significantly increases the risk of developing foot complications.

The higher use of insulin (p = 0.001) in the DFC group could imply more intensive diabetes management among individuals with foot complications. This suggests that insulin therapy, when combined with effective education, can improve diabetes-related complications. On the contrary, the increased use of herbal therapies (p = 0.003) in the DFC group may indicate attempts to manage complications through alternative treatments, indicating cultural preferences or perceived effectiveness of such therapies.

Despite self-reports of adherence to diabetes management protocols showing no significant difference between the two groups (p = 0.104), it is important to note the potential for social desirability bias. Participants in the DFC group may have over-reported adherence, aiming to comply with perceived health expectations, a common issue in self-reported data [20]. This discrepancy suggests that while individuals may claim adherence, the actual effectiveness of their diabetes management, particularly in terms of foot care, may not be sufficient to prevent complications.

The results also indicate that education level influenced attitudes toward foot care. Participants who had never attended school showed higher attitude scores compared to those with higher education (p = 0.044), which contradicts previous research such as that by Huimin et al. [21], which found no significant impact of education on self-care practices. However, the results of this study revealed that lower education levels might correlate with better foot care practices in some contexts, potentially due to cultural or life experience factors. Participants with lower education levels also demonstrated stronger knowledge about foot care, possibly acquired through lived experience over time [22,23].

Educational interventions showed significant effects on both attitudes and practices. Participants who attended foot care education programs demonstrated better scores in both areas (attitude p < 0.001, practice p = 0.013). This result shows the critical role of ongoing education in addressing gaps between knowledge and actual foot care behaviors, which supports the findings of Mehmood et al. [24] and Shamim et al. [25]. Also, Rao Li et al. [26] reported that continuous diabetes education is essential to improving self-care behaviors and preventing complications, especially for individuals with long-term diabetes.

Despite similar levels of knowledge between the two groups, knowledge alone did not prevent the occurrence of foot complications. This supports the idea that gaps in communication between healthcare providers and patients may contribute to suboptimal practices, even when participants are knowledgeable about foot care [22,27]. While 99.6% of participants expressed confidence in managing their diabetes, the slightly lower attitude scores in the DFC group indicate that improving attitudes towards foot care remains an important area for intervention.

A remarkable difference between the groups was observed in practice scores. The DFC group scored significantly lower (p < 0.001) than the non-DFC group. This could be interpreted as that; although participants may have knowledge and positive attitudes, barriers such as limited resources, psychological challenges, and lack of adequate follow-up care may prevent them from engaging in effective foot care practices. Furthermore, regarding the decision-making process, it was noted that 45.5% of participants in the DFC group chose to manage injuries independently. This finding underscores the need for further investigation to clarify the reasons underlying these choices.

The volunteers who administered the questionnaire received prior training; nevertheless, the variations in their interviewing approaches may have influenced the consistency and reliability of the responses. Also, translating the questionnaire into Arabic may have affected the accuracy of the collected data. Moreover, the unequal distribution of participants between the groups with and without diabetic foot complications was a limitation.

5. Conclusions

This study reveals several factors that require further attention and targeted intervention. The impact of age, long-term blood glucose control, and educational background on diabetic foot care shows the need for integrated and holistic approaches. Effective prevention and management of diabetic foot complications depend on continuous patient education, enhanced communication between healthcare professionals and patients, and addressing the gap between knowledge and actual practice through specifically designed interventions. The insights gained from this research enrich the current understanding of diabetic foot care and pave the way for future developments in diabetes management strategies.