knowledge, Attitude and Practice Regarding Foot Care Among Diabetic Patients Who Visited Health Centers In Khartoum State, Sudan, 2018

ALafraa Ahmed Mohammed Ahmed1; Elfatih M. MaliK2, MBBS, MD

1 Medical student, faculty of medicine, University of Khartoum, Sudan;
2 Assistant Professor, Sudan FETP Technical Advisor, Faculty of Medicine, University of Khartoum, Sudan.

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Correspondence to: ALafraa Ahmed Mohammed Ahmed, Faculty of medicine, University of Khartoum, Sudan.
Email: afraahmed41@gmail.com
Telephone: +249 998204849

Received: August 22, 2019
Revised: August 28, 2019
Accepted: August 29, 2019
Published online: September 24, 2019


AIM: Foot care received little attention from medical doctors who are concentrating on therapeutic and diagnostic measures more than education of patients and preventive aspects.The aim of this study was to assess knowledge, attitude and practice regarding foot care among Sudanese diabetic patients.

MATERIALS and METHODS: In this multi-central cross-sectional study, 270 diabetic patients interviewed using a questionnaire containing qualitative and quantitative aspects after taking verbal consent. Data has been analysed using SPSS software version 20.

RESULTS: Overall, 176 (65.2%) women and 94 (34.8%) men were included. The mean (SD) age in years was 57 (11.6). A total of 219 (81.1%) have educational level below university level. Those who have knowledge about foot care constitute 151 (55.9%) with different response to knowledge measures. The source of information was medical staff in 95 (63%) of patients. Regarding attitude, 257 patients (95.2%) were aware about foot care, and they considered it as a preventable method from foot complication. On the other hand, 158 patients (58.5%) have poor practice. There are highly significant association between educational level and knowledge (< 0.001), educational level and practice (0.012) and between knowledge and practice (0.001).

CONCLUSION: These results supported the view that education and trained health care providers have a role in increasing the awareness of diabetic patients about foot care.

Key words: Knowledge; Attitude; Practice; Diabetes; Foot care

© 2019 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Ahmed AAM, MaliK EM. knowledge, Attitude and Practice Regarding Foot Care Among Diabetic Patients Who Visited Health Centers In Khartoum State, Sudan, 2019. International Journal of Diabetes Research 2019; 2(1): 46-49 Available from: URL: http://www.ghrnet.org/index.php/ijhr/article/view/2668

Abbreviation: DM: Diabetes mellitus; DFU: Diabetic foot ulcer; KAP: knowledge, attitude and practice.


Diabetes mellitus (DM) is a metabolic disorder characterized by chronic hyperglycaemia[1]. Among the degenerative chronic diseases with high morbidity and mortality rates, DM especially type 2 (DM2), is becoming a global health issue. Every year, the incidence is increasing worldwide. If diabetic patients don’t control glucose level by treatment and routine visit to doctor, they will develop serious complications such as retinopathy, nephropathy, neuropathy, coronary artery disease, cerebrovascular disease and peripheral vascular disease[2]. Diabetic neuropathy includes mononeuropathies, polyneuropathies, plexopathies and radiculopathies. It receives special attention because it leads to diabetic foot ulcer (DFU)[3]. DM and its complications have negative impact on the quality of life, psychological wellbeing, social functioning, employment and cost of treatment[4].

In 2002, WHO defined DFU as an infection, ulceration, and/or destruction of deep tissues associated with neurological abnormalities and varying degrees of peripheral vascular disease in the lower limb. DM and DFU are common medical problem in Sudan. Lower limb amputation among inpatients with diabetic foot in Khartoum hospitals increased in last years. Recently, DFU accounted for 10.2% of all complications reported from private clinics in the Khartoum state. According to some studies, the prevalence of DFU among the population of rural Sudan is 3.9%. Although the magnitude of the DFU and its consequences (amputation) is high in Sudan, limited researches have been performed to investigate the role of multiple potential etiologic factors in this complication[5]. Foot ulcer should be managed by multidisciplinary team. Good patient’s education and self-care decrease amputation. A study from Pakistan highlighted the fact that a proper education and awareness program can change the attitude of the public regarding diabetes[6]. Although there are improvement in awareness of population about DM due to self-management education programmes for people with diabetes, still there is a gab between knowledge, attitude and practice[7].

Foot care is a key issue to prevent foot ulcer. When patients have adequate knowledge and information, their attitude will change and they will be able to do right practice in order to prevent foot ulcer. Practices regarding foot care are prepared meal plans, exercise, foot hygiene, toe and nail care, daily check and inspection of foot and leg[8,9].

Foot care received little attention from medical doctors who are concentrating on therapeutic and diagnostic measures more than education of patients and preventive aspects. The aim of this study was to assess knowledge, attitude and practice about foot care among Sudanese diabetic patients and association of education with knowledge and practice.

Methods and materials

This research is descriptive observational multi-centers cross-sectional study conduct at health centers in Khartoum, Sudan between October 2018 to December 2018. Both quantitative and qualitative methods were used in this study. A total of 270 diabetic patients from 9 health centres were enrolled in this study (30 patients from each center).

Data was collected through self‐administered and structured interview questionnaire covering socio-demographic characteristics, knowledge, source of knowledge, attitude and practice after taken verbal consent from participants.

Data was analyzed using IBM SPSS software version 20. Descriptive analysis performed for quantitative and qualitative measures and displayed as frequency and percentages in form of tables. Chi-square test was used to assess the association between the socio-demographic characteristics and level of knowledge, and practice, and between knowledge and practice.


Overall, 176 (65.2%) women and 94 (34.8%) men were included with a mean age of 57 years (SD = 11.6) and mean duration of diabetes of 10 years (SD = 7.4). Regarding educational level, 15.9% were illiterate and 18.9% were either graduate or post-graduate.

Further analysis showed Those who have knowledge about foot care constitute 151 (55.9%), different response to knowledge measures as shown in table 1. The source of information was medical staff (doctors, diabetic educators ora nutritionist) in 95 (63%) of patients, other source like: tradition, magazine, books, posters. the scoring of knowledge was categorized. in to yes (have knowledge) and no (haven’t knowledge), the frequency of patients with (yes) was 151 (55.1%) and (no). was 119 (44.9%).

Regarding attitude, 257 patients (95.2%) awarded about foot care, and 203 (79%) patients they considered foot care as a preventable method from foot complication (diabetic septic foot, infected wound, not healed wound…etc), other cause like: as part from personal hygiene (most), make me relax,as a disease.

Table 2 present responses of patients to measures of practice, The scoring of the practices of foot care is categorized into poor and good practice of foot care. The respondent will be categorized into poor practice of foot care if the correct number of question answered is between 0-5 out of 8 questions and good practice if 6-8 out of 8 questions. the frequency of patients with poor practice was 158 (58.5%) and good practice was 112 (41.5%).

Chi -square test in Table 3 and 4 present no association between gender and knowledge (p = 0.532), gender and practice (p = 0.797), on the other hand there are highly significant association between educational level and knowledge (p < 0.001), educational level and practice (p = 0.012) and between knowledge and practice (p = 0.001).

Table 1 Participants knowledge about various aspects of foot care (n=151).
Foot care aspects Frequency %
Regular inspection of their foot3422.5
Washing 8354.9
Moistening 8254.3
Nail cutting3019.9
Not bare foot2415.9
Wearing socks2214.6
Wearing diabetic shoes7851.7
Number who answer with yes  
% of those who respond out of 270 participants   
You need to write statement instead of one or 2 words  

Table 2 Participants practice related to foot care (n=270).
Foot care aspectsDescription Frequency %
Inspection Daily 20174.4
Every 2 days51.9
Not inspected5620.7
Washing More than one time/ day22698.5
One time per day31.1
Not washing regularly 10.4
Drying Yes 9735.9
No 13951.5
Sometimes 3412.6
moistening Yes18769.3
No 3011.1
Sometimes 5319.6
Nail cutting Yes26096.3
No 00
Sometimes 103.7
Bare foot Yes62.2
Sometimes 4215.6
wearing socks Yes5118.9
No 12445.9
Sometimes 9535.2
wearing diabetic shoes Yes 6524.1
No 16460.7
Sometimes 4115.1

Table 3 association between scio-demographic characteristics and knowledge.
Socio-demographic characteristics Knowledge about foot careChi-square test P-value
Yes No
Sex Male55390.0380.532
Female 9680  
Educational level Illiterate 1132  
Primary 4748  
Secondary 58230.3340
Graduate 2614  
Above graduate 92  

Table 4 association between scio-demographic characteristics and knowledge with practice.
Socio-demographic characteristics Practice about foot careChi-square test P-value
Good Poor
Sex Male38560.0160.797
Female 74102  
Educational level Illiterate 1231  
Primary 3164  
Secondary 43380.2180.012
Graduate 2020  
Above graduate 65  
Knowledge Yes 76750.2020.001
No 3683  


Socio-demographic results show that DM affect elderly, most of study participants are female, mean of duration of DM is 10 years as same in several study, most of study population below the level of university (81.1%), few of them are very educated (18.8%), most of uneducated patients are female similar to many studies. This result may be explained by the fact that female education is not allowed in our society, cultural and traditions, specially in rural area in Sudan and even educated female are not complete there education to university and stop in primary and secondary level because it married early or other causes determined by our cultural and tradition.

Regarding knowledge and response to it measures, Pakistan and Malaysian study show very good response what is surprising is that low response to knowledge measurement specially nails cutting, not walk barefoot, wear socks and inspection, not like this is different in these results maybe due to different socioeconomic and educational level in out country and other country, and the degree of effectiveness of our educational program to prevent diabetic foot and councilling from medical staff which concentrate in some measures not all measures mentioned above.

We add to this study attitude related to Foot care because most of studies concentrated on knowledge and practice. In Brazilian study show high percent of participants are performed physical examination (80%) because they want to prevent foot related complications and approximately the same in this study (79%), but make this results different that Brazilian study suggest that different in attitude related to inadequate knowledge from doctors that affect on attitude of patients toward Foot care, but we observe in this study main reason is our patients always heard about amputation almost form many sources,family,friends and social media not from medical staff which be main source of knowledge, this explain the different in percentage of knowledge, attitude and practice.

Response of patients to questions related to practice is high in most of questions except in drying, wear socks and diabetic shoes, a possible explanation for this might be that the most of practice is a part of our daily activity as Sudanese population, low response in drying due to there think that it dry by it self after few minutes after washing not as in guidelines of foot care in diabetic patients which recommended that drying feet after washing directly, also low response in wear socks and shoes because they feel uncomfortable when wear it. comparing of this result regarding response of practice with other study is high, in general several studies show that there are high response to practice like Pakistan and Indian study with few variation in percentage of response, contradiction to Malaysian study present that low response for practice of most of practice measurements comparing with response of knowledge of same study, this variations of response between practice and knowledge explain by lack of proper and fully counseling of medical staff to patients about knowledge & practice of foot care.

There are significant association between educational level and knowledge (< 0.001), and practice (0.012), also there are significant association between knowledge and practice (0.001), no significant association with sex, this results are similar to Nigerian and Pakistani studies determine the impact. and effect of education in knowledge and practice, contradiction to 2 Malaysian studies present there are not significant association between educational level and knowledge and practice because different background of education of participants which included in these studies.


These results supported the view that education and trained health care providers have a role in increasing the awareness of diabetic patients about foot care.Different in response to knowledge, attitude and practice due to impact of our society, tradition and culture.

The study offers some important insights into deficiency in educational programs and fully councilling from health care provides to diabetic patients to complications related to diabetes, that reflected on knowledge and practice of patients, and increase the gap between knowledge and practice


Training health care provider, nurse and doctors in council diabetic patients in complications related to diabetes, training diabetic educators and make works shops and courses in diabetic foot care, build special diabetic clinic in primary health center with trained diabetic educators to. Increase awareness of diabetic patients about multiple discipline in diabetes, spread of posters that talk about foot care.


Firstly I would like to extent my special Thank to my supervisor D. ELFATIH M MALIK for his continuous advice and support me in every single step in my research from the beginning to the end, also deep grateful to patients and health centers for their collaboration,respect and response, last but not at least, D.Elhami, A.Ahmed and my dear friends especially D.Alaa tawfig for their guidance, encouragement and support.


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