Foot self-care knowledge, practices and associated factors among individuals diagnosed with diabetes attending clinics at base hospitals in Colombo, Sri Lanka: an analytical cross-sectional study - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. 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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Open . 2026 Apr 9;16(4):e108460. doi: 10.1136/bmjopen-2025-108460 Search in PMC Search in PubMed View in NLM Catalog Add to search Foot self-care knowledge, practices and associated factors among individuals diagnosed with diabetes attending clinics at base hospitals in Colombo, Sri Lanka: an analytical cross-sectional study Buddhinie Nisansala Jayaweerage Buddhinie Nisansala Jayaweerage 1 Faculty of Nursing, University of Colombo, Colombo, Sri Lanka Find articles by Buddhinie Nisansala Jayaweerage 1 , Manuri Hettiarachchi Manuri Hettiarachchi 1 Faculty of Nursing, University of Colombo, Colombo, Sri Lanka Find articles by Manuri Hettiarachchi 1 , Athukoralage Dona Kaveesha Athukoralage Dona Kaveesha 1 Faculty of Nursing, University of Colombo, Colombo, Sri Lanka Find articles by Athukoralage Dona Kaveesha 1 , Malith Ruwaranga Gamaralalalage Malith Ruwaranga Gamaralalalage 1 Faculty of Nursing, University of Colombo, Colombo, Sri Lanka Find articles by Malith Ruwaranga Gamaralalalage 1 , Sriskantharaja Sisudan Sriskantharaja Sisudan 1 Faculty of Nursing, University of Colombo, Colombo, Sri Lanka Find articles by Sriskantharaja Sisudan 1 , Peshila Mahanama Peshila Mahanama 1 Faculty of Nursing, University of Colombo, Colombo, Sri Lanka Find articles by Peshila Mahanama 1 , Chathuri Dilhani Malawi Arachchi Chathuri Dilhani Malawi Arachchi 1 Faculty of Nursing, University of Colombo, Colombo, Sri Lanka Find articles by Chathuri Dilhani Malawi Arachchi 1 , Thevapatham Kamshiga Thevapatham Kamshiga 1 Faculty of Nursing, University of Colombo, Colombo, Sri Lanka Find articles by Thevapatham Kamshiga 1 , Sandushani Kaushalya Sandushani Kaushalya 2 Department of Clinical Nursing, Faculty of Nursing, University of Colombo, Colombo, Sri Lanka Find articles by Sandushani Kaushalya 2 , Elango Shopijen Elango Shopijen 3 Department of Nursing, Faculty of Health Sciences, The Open University of Sri Lanka, Colombo, Sri Lanka Find articles by Elango Shopijen 3, ✉ , Gnanaselvam Kisokanth Gnanaselvam Kisokanth 2 Department of Clinical Nursing, Faculty of Nursing, University of Colombo, Colombo, Sri Lanka Find articles by Gnanaselvam Kisokanth 2 Author information Article notes Copyright and License information 1 Faculty of Nursing, University of Colombo, Colombo, Sri Lanka 2 Department of Clinical Nursing, Faculty of Nursing, University of Colombo, Colombo, Sri Lanka 3 Department of Nursing, Faculty of Health Sciences, The Open University of Sri Lanka, Colombo, Sri Lanka Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. None declared. ✉ Mr Elango Shopijen; [email protected] Received 2025 Jul 26; Accepted 2026 Mar 27; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13084796 PMID: 41956551 Abstract Abstract Background Diabetic foot is an infection, ulceration or destruction of the tissue of the foot of a person diagnosed with diabetes mellitus (DM). Diabetic foot ulcer (DFU) is a major and preventable complication of DM. Adequate knowledge and foot self-care practices are crucial to reduce the risk of DFU complications, particularly in resource-limited healthcare settings. Objective To assess the knowledge and practices related to foot self-care and associated factors among individuals diagnosed with diabetes attending diabetic clinics at all base hospitals in Colombo District, Sri Lanka. Method An analytical cross-sectional study was conducted among 423 individuals diagnosed with diabetes attending the diabetic clinic at all three base hospitals in Colombo district, from January 2023 to March 2024 (study period). Participants were selected by using a systematic random sampling. Data were collected using a validated and pre-tested interviewer-administered questionnaire. Descriptive and inferential analyses were performed using Statistical Packages for Social Sciences V.26 software. Associations were examined using χ 2 tests, independent sample t-tests and one-way ANOVA (Analysis of Variance), with a p value<0.05 considered statistically significant. Results The majority of the participants were females (71.2%). Among the participants, 33.8% of them had a poor level of knowledge regarding foot self-care. Knowledge level was significantly associated with the participants’ family history of diabetes and the hospital where they attended the clinic (p<0.05). Females had a significantly higher mean knowledge score (60.5±19.7) than males (55.4±23.7) (p=0.03), and participants attending District General Hospital Avissawella had the highest mean knowledge score (67.9±21.6) among other hospitals (p=0.01). Approximately 67.6% of them demonstrated satisfactory foot self-care practices. Practice level was significantly associated with the hospital where they attended the clinic and the type of medication used for DM (p<0.05). Conclusion Nearly one-third of participants demonstrated poor knowledge of foot self-care, despite over half exhibiting satisfactory foot-care practices. This gap highlights the need for targeted education to boost awareness and promote consistent foot care, which is a key step in preventing diabetic foot complications and improving long-term outcomes for individuals diagnosed with diabetes. Keywords: Knowledge; Diabetic foot; Diabetes Mellitus, Type 2; Delivery of Health Care, Integrated; Self Care STRENGTHS AND LIMITATIONS OF THIS STUDY. A large sample size across all base hospitals in Colombo District, Sri Lanka, improves internal validity. Systematic random sampling reduced selection bias. Use of a validated interviewer-administered questionnaire minimised missing data. Self-reported practices may be subject to social desirability bias. The cross-sectional design limits causal inference between associated factors and outcomes. Introduction Diabetes mellitus (DM) is characterised by elevated blood glucose levels and is one of the most common, yet manageable health problems faced by many countries worldwide. 1 The worldwide prevalence of DM is increasing significantly, with millions of people at risk of complications like diabetic foot ulcers. 1 2 Diabetic foot is one of the most common complications of DM. The International Working Group on the Diabetic Foot (IWGDF) Guideline defines diabetic foot as infection, ulceration or destruction of tissue of the foot of a person with currently or previously diagnosed DM, usually accompanied by diabetic neuropathy and/or Peripheral Artery Disease in the lower extremity. 3 The pooled worldwide prevalence of diabetic foot ulceration (DFU) was 6.3%, 4 and around 20% of people with DM worldwide had a significant risk of developing foot ulcers because of neurological conditions. 5 DFUs are among the most common diabetes consequences, representing nearly 12%–15% of the overall cost associated with diabetes and up to 40% in developing countries. Further, DFUs can be prevented by raising awareness and taking preventive measures. 6 Base hospitals often have fewer specialists, which can limit access to endocrinologists and diabetes educators. Patients may not receive comprehensive care and lack access to structured diabetes education programmes, which can impact their understanding of diabetes management, self-care and lifestyle modifications. Thus, the study aimed to assess the knowledge, practices and factors influencing foot self-care among individuals diagnosed with diabetes attending diabetic clinics at all base hospitals in Colombo District, Sri Lanka. The research study significantly helps to improve the understanding of the level of awareness and adherence to DFU preventive practices among individuals diagnosed with diabetes. Further, it could help to identify any gaps in misconceptions in diabetes foot care, the need for educational programmes, and ultimately reduce the risk of foot complications in individuals diagnosed with diabetes. Methodology Study design and setting An analytical cross-sectional study was conducted in the diabetic clinics of all base hospitals in the Colombo District, including Base Hospital Homagama (BHH), Colombo East Base Hospital (CEBH) in Mulleriyawa and District General Hospital Avissawella (DGHA). The data collection was conducted from January 2024 to mid-March 2024. Study population Both males and females with type 1 or type 2 DM who lived in the Colombo District for more than 6 months were included in the study. People who are unable to perform self-foot care due to comorbidities such as visual impairments, cognitive impairments and physical disabilities were excluded. Sample size and sampling procedure The sample size was calculated using Daniel’s sample size formula (z=1.96, p=50%, and d=0.05) (10), and a total of 423 participants were enrolled in the study. The sample size for each hospital was proportionally divided using the total number of registered individuals diagnosed with diabetes at clinics. Accordingly, 150 participants from BHH, 277 participants from CEBH and 46 participants from DGHA were enrolled in this study. A systematic random sampling technique was used to select the participants. The available daily clinic registers from each clinic were used as the sampling frame. Study instrument—development and validation A validated, pretested Interviewer-administered questionnaire (IAQ) was used to collect data from the participants (see online supplemental material 1 ). The IAQ was developed through an extensive review of the English-language literature on diabetic foot self-care knowledge, practices and associated factors conducted by the investigators. To ensure validity, face and content validity (judgemental) were performed by three field experts, including two consultant endocrinologists and a diabetic education nurse. The IAQ was presented to these experts for evaluation, and they were asked to provide feedback on several aspects, including relevance, clarity, representativeness, cultural appropriateness and comprehensiveness of each item. Based on the evaluation, the experts suggested several modifications, particularly regarding wording and cultural context. The investigators carefully incorporated these revisions to improve the clarity and applicability of the instrument. The questionnaire was pre-tested for acceptability, comprehension, ease of administration and to assess the clarity and suitability of the wording used at the Divisional Hospital, Padukka, among 30 participants who met the inclusion and exclusion criteria, in December 2023, after receiving the Ethics Review Committee (ERC) approval in November 2023. Necessary modifications were made to the questionnaire to improve the understandability and time efficiency. The questionnaire consisted of three sections: Section A, sociodemographic factors including age, gender, education level, occupation, monthly income, hospital attended, duration of diabetes, family history of diabetes and type of diabetic medication used. Section B consisted of questions to assess the knowledge related to diabetic foot self-care, including risk factors for DFU, features of nerve damage in feet, warning signs of diabetic wounds, steps of foot self-care, parts to give special attention, complications, symptoms of reduced blood circulation and considerations for buying new shoes. Section C, composed of questions to assess practices related to diabetic foot self-care, including daily foot self-care behaviours, such as foot hygiene, footwear habits, nail care, inspections for injuries or oedema, protection from heat and chemicals, frequency of foot check-ups and behaviours such as smoking, alcohol consumption and seeking medical advice for foot-related problems. Variables and measurement/operational definitions A score of ‘one’ was given for every correct answer, and a score of ‘zero’ was given for every wrong or no answer for the knowledge assessment. The total score was converted into percentages and interpreted as follows: good knowledge (76%–100%), adequate knowledge (50%–75%) and poor/inadequate knowledge (0%–49%). 7 8 Practice assessment related to foot self-care was assessed using a five-point Likert scale (one—never, two—rarely, three—sometimes, four—often, five—always). 7 The total score was converted into percentages and interpreted as follows: good practices (score>70%), satisfactory practices (50–70%) and poor practices (score<50%). 9 Data analysis The SPSS V.26 software was used for data analysis. Descriptive statistics were applied to obtain percentages and means with SD. An independent sample t-test was used to assess the association between mean knowledge and mean practice scores and gender and age categories. One-way ANOVA was used to compare the mean knowledge and practice scores across hospitals, marital status, level of education, occupation and monthly income. The χ 2 test was used to identify the factors associated with knowledge and practice towards foot self-care. A p value<0.05 was considered statistically significant in all tests. Results Demographic profiles of study participants The response rate was 100%. Nearly 91% of participants were between the ages of 50 years or older, and 71% were females. Nearly 39% of participants had an education level up to grades 6–10, and 64% were unemployed. Further, 35% of the participants had a monthly income of less than Rs 10 000. Among participants, 48.3% had a body mass index between 18.5 and 24.9 kg/m 2 . Most of the participants (98.6%) have a family history of DM. Almost all participants (98.6%) were taking antihyperglycaemic medications for DM. Knowledge and factors associated with foot self-care The majority of participants (93.4%) reported having received education about diabetic foot ulcers, with nearly 78% indicating that their primary source of information was nurses. Nearly 72% of the participants believed that cracked feet were the main risk factor for the DFU. In addition, numbness or tingling (81.6%), and blisters on the feet (79.0%), pain in the calf muscles while walking (51.1%) and a change in the temperature of the feet (32.4%) are also stated as warning signs of DFU. Further, nearly 88% of the participants stated that amputation of the affected feet is a common complication of DFU. Further, most participants (81%) indicated that suitable shoes should not have hard, rough edges and should feel comfortable inside, while 78.5% stated that it is important to choose shoes that fit well (See online supplemental table 1 ). The mean knowledge score regarding foot self-care was 59.00 (± 21.10), and only 22.5% of them had a good level of knowledge (76–100%). Knowledge level was significantly associated with the participants’ family history of DM and the hospital where they attended the clinic (p<0.05) (see online supplemental table 3 ). Females (60.5±19.7) had a significantly higher mean knowledge score than males (55.4±23.7) regarding diabetic foot care (p=0.03). In addition, participants attending the diabetic clinic at District General Hospital Awissawella (67.9±21.6) had significantly higher mean knowledge scores compared with those at Base Hospitals of Homagama (58.8±19.8) and Mulleriyawa (57.3±21.4) (p=0.01) (see online supplemental table 4 ). Practice and factors associated with foot self-care Nearly half of the participants (56%) reported that they frequently wash their feet, while 74% indicated that they wear shoes when going outside. Additionally, 30% of participants stated that they often dry their feet and between their toes after washing. Less than half (46%) reported that they never moisturise their feet by applying creams or oils. The majority (93.6%) also stated that they never wear diabetic shoes (see online supplemental table 2 ). The overall mean practice score was 64.76 (±8.53). Only 27.9% of participants demonstrated a good level of foot self-care practice, while nearly 68% scored at a satisfactory level. In addition, practice level was significantly associated with the hospital where they attended the clinic and the type of medication used for DM (p<0.05) (see online supplemental table 3 ). Statistically significant mean differences were observed between the practice score and the hospital they were attending, the clinic and the gender of the participants (p<0.05). Females had a significantly higher mean practice score (65.4±8.1) than males (63.2±9.4) regarding diabetic foot care practice (p=0.02). The participants who were attending the diabetic clinic at BHH (66.5±8.1) had significantly higher mean practice scores than Base hospitals of Mulleriyawa (63.6±8.4) and Awissawella (64.9±9.7) (p=0.01) (see online supplemental table 4 ). Discussions This study assessed knowledge and practices related to diabetic foot self-care and associated factors among people with diabetes attending all base hospitals in Colombo District, Sri Lanka. Only 22.5% of participants demonstrated a good level of knowledge regarding foot self-care. Knowledge levels were significantly associated with participants’ family history of diabetes and the hospital where they attended the clinic. Females had a significantly higher mean knowledge score compared with males, and participants attending the DGHA had the highest mean knowledge score among the surveyed hospitals. Approximately 27.9% of participants exhibited good foot self-care practices. Furthermore, practice levels were significantly associated with the hospital attended and the type of medication used for diabetes management. Knowledge level and factors related to foot care among participants The findings of this study indicate a commendable level of knowledge among participants regarding DFUs and their associated risk factors. Approximately 23% of participants demonstrated good knowledge of foot self-care, highlighting notable gaps in awareness despite regular clinic attendance. Similar levels of knowledge have been reported in a study conducted in Saudi Arabia. 10 However, contrasting findings were shown in a study conducted among Diabetic Patients at Aldaraga Centre, Gezira State, Sudan. 11 This underscores a substantial gap in awareness and understanding of diabetic foot care, which is particularly concerning given the high risk of complications such as DFUs associated with diabetes. Previous research has established that inadequate knowledge about foot care significantly contributes to the higher prevalence of DFUs, emphasising the urgent need for targeted educational interventions. 12 13 To address the significant gap in diabetic foot care knowledge, it is essential to develop and implement comprehensive policies that incorporate foot care education as a standard part of diabetes management protocols, supported by adequate resources and community awareness campaigns. The observed variations in knowledge levels across hospitals suggest that differences in available resources, educational programmes or care models implemented 14 at hospitals may be more effective in educating individuals diagnosed with diabetes about their foot care needs. Understanding the factors contributing to these discrepancies in knowledge is essential for enhancing educational initiatives across all healthcare settings. 15 Further, the gender difference in knowledge could be attributed to various factors, including differing health-seeking behaviours, social roles or access to information. Studies have shown similar findings, indicating that women are often more proactive in seeking health information and engaging in preventive health behaviours compared with men. 15 16 It is essential to establish standardised education policies, allocate resources to under-resourced facilities and develop gender-sensitive programmes. Additionally, all hospitals should implement consistent, culturally sensitive education protocols and train providers to deliver targeted counselling. Creating standardised educational materials, monitoring their effectiveness and designing gender-specific interventions at all hospitals will help promote equitable and effective foot care knowledge among diabetic patients. Additionally, a significant association between knowledge level on diabetic foot care and participants’ family history of diabetes was found. This can be explained by increased exposure to diabetes-related complications within affected families. Studies have shown that individuals with a family history of diabetes are more likely to have greater awareness and understanding of the disease and its management, including foot care, due to firsthand experiences and shared knowledge. 17 18 Witnessing family members’ struggles with diabetes complications can motivate individuals to seek information and adopt preventive behaviours, thereby enhancing their knowledge levels. 19 Practice level and factors related to foot self-care among participants Overall, only one-third of the participants demonstrated good practice regarding diabetic foot self-care. A similar finding was found in a study conducted at primary healthcare centres in Kuwait. 20 In contrast, a study from Pakistan showed a higher rate of good practice. 21 Despite this, two-thirds of participants had a satisfactory or lower level of practice, indicating that a significant proportion of individuals still need improvement in diabetic foot self-care. Limited awareness and knowledge about proper foot care, inadequate patient education and cultural beliefs could contribute to poor self-care behaviours. Additionally, barriers such as limited access to healthcare resources, time constraints and lack of motivation may hinder individuals from adopting recommended practices. It is essential to enhance patient education, train healthcare providers and raise community awareness. Increasing access to foot care services and integrating foot care into diabetes management guidelines are also important. Support programmes should motivate patients to adopt better habits, and regular monitoring can help evaluate progress. These combined efforts aim to reduce complications and improve overall patient outcomes. The level of diabetic foot care practice was significantly associated with the hospital where patients attended the clinic and the type of medication used for diabetes management. Similarly, a study conducted among patients admitted with diabetes at a medical college hospital in southern India found that higher practice scores were significantly linked to patients who were currently receiving insulin, with or without oral hypoglycaemic agents. 22 The variation in diabetic foot care practices across hospitals and medication types may be due to differences in healthcare quality and patient education. Policies should standardise foot care education, train healthcare providers, establish specialised clinics, promote regular follow-ups and integrate foot care into national guidelines. The study noted the reverse trend, where higher satisfactory practice levels are observed despite limited knowledge on foot self-care. This discrepancy may be attributed to the possibility that participants acquire practical foot-care habits through experiential learning or routine behaviours without a comprehensive understanding of the underlying principles. Cultural practices, peer influences or previous education might promote certain behaviours even if participants lack detailed knowledge. Additionally, some individuals may follow instructions from healthcare providers or caregivers without fully understanding the reasons behind specific practices, leading to satisfactory practices despite poor knowledge. This gap highlights the need for targeted educational interventions that not only promote proper foot-care behaviours but also ensure a thorough understanding to foster long-term adherence and prevent complications. The findings of this study have significant implications for diabetic foot care in Sri Lanka and other similar lower-middle-income countries. Implementing a structured, nurse-led health education programme at the clinical practice level, especially in primary and base hospitals, could enhance patients’ knowledge and self-care practices. Such an approach has the potential to improve overall foot care behaviours and reduce the risk of complications among individuals diagnosed with diabetes. There are several methodological limitations to consider when interpreting these findings. The cross-sectional design restricts the ability to establish causal relationships between knowledge, practices and associated factors. Additionally, data were self-reported, which may be subject to recall bias or social desirability bias. The study did not include clinical assessments of foot conditions, which could affect the accuracy of reported practices. Moreover, since the research was conducted in base hospitals within a single district, the results may not be generalisable to other healthcare settings. Despite these limitations, the use of a validated instrument and a large, representative sample enhances the overall reliability and robustness of the findings. Conclusion Despite a significant proportion of the participants demonstrating satisfactory practice levels, only a small proportion exhibited good knowledge, highlighting a gap between awareness and self-care behaviour. Knowledge levels were influenced by factors such as family history of diabetes and the healthcare setting, while practice levels were associated with the hospital attended and medication type. This discrepancy underscores the urgent need for targeted educational programmes to improve awareness and promote consistent foot care behaviours, which are essential for preventing diabetic foot complications and enhancing long-term health outcomes for people with diabetes. Supplementary material online supplemental file 1 bmjopen-16-4-s001.pdf (369.6KB, pdf) DOI: 10.1136/bmjopen-2025-108460 online supplemental file 2 bmjopen-16-4-s002.pdf (318.9KB, pdf) DOI: 10.1136/bmjopen-2025-108460 Acknowledgements The authors are obliged to thank all the participants who participated in this study, and for generously giving their time and sharing their experiences. We are grateful to the staff of the diabetic clinics at BHH, CEBH and DGHA for their cooperation and support during data collection. We also appreciate the assistance provided by the clinic nursing staff in facilitating participant recruitment and ensuring the smooth conduct of the study. Footnotes Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online ( https://doi.org/10.1136/bmjopen-2025-108460 ). Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent for publication: Not applicable. Ethics approval: This study involves human participants and was approved by the Ethics Review Committee, Faculty of Medicine, University of Colombo Protocol. The initial stages of the research process, including the literature review, proposal development, preparation of study instruments and the development of the information sheet, consent form and other ethics-related documents, commenced in January 2023. Subsequently, the study protocol and all relevant documents were submitted to the Ethics Review Committee, Faculty of Medicine, University of Colombo, Sri Lanka, and formal ethical approval was obtained on 16 November 2023 (Protocol No: EC-23−129/Date of approval: 16.11.2023). 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Supplementary Materials online supplemental file 1 bmjopen-16-4-s001.pdf (369.6KB, pdf) DOI: 10.1136/bmjopen-2025-108460 online supplemental file 2 bmjopen-16-4-s002.pdf (318.9KB, pdf) DOI: 10.1136/bmjopen-2025-108460 Data Availability Statement Data are available upon reasonable request. 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