Open access
Adherence to diabetic foot care
To cite: Sertsu A, Nigussie K,
Lami M, et al. Adherence
to diabetic foot care
recommendations and
associated factors among
people with diabetes in Eastern
Ethiopia: a multicentre cross-­
sectional study. BMJ Open
2023;13:e074360. doi:10.1136/
bmjopen-2023-074360
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Received 05 April 2023
Accepted 23 August 2023
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Correspondence to
Mr Addisu Sertsu;
​addis7373@​gmail.c​ om
recommendations and associated factors
among people with diabetes in Eastern
Ethiopia: a multicentre cross-­
sectional study
Addisu Sertsu ‍ ‍,1 Kabtamu Nigussie,1 Magarsa Lami,1 Deribe Bekele Dechasa,1
Lemesa Abdisa ‍ ‍,1 Addis Eyeberu ‍ ‍,1 Jerman Dereje,1 Aminu Mohammed ‍ ‍,2
Obsan Kassa Taffese,3 Tilahun Bete ‍ ‍,1 Damte Adugna,1 Abraham Negash ‍ ‍,1
Abel Tibebu Goshu ‍ ‍,4 Adera Debella,1 Shiferaw Letta1
ABSTRACT
Objective This study aimed to determine the level of
adherence to foot care recommendations and associated
factors among people with diabetes on follow-­up in public
hospitals in Eastern Ethiopia.
Setting An institutional-­based cross-­sectional study was
conducted in public hospitals found in Eastern Ethiopia
from 25 February to 25 March 2022.
Participants A total of 419 patients with chronic diabetes
who visited diabetic clinics in public hospitals in Eastern
Ethiopia for follow-­up were included.
Main outcome measure The level of adherence to
diabetic foot care recommendations and associated
factors.
Results The findings indicated that 44.3% (95% CI: 39.3,
49.0) of people with diabetes had inadequate adherence to
diabetic foot care recommendations. Age between 28–37
(adjusted OR (AOR)=1.10; 95% CI: 1.27, 5.63) and 38–47
years (AOR=2.19; 95% CI: 2.74, 8.89), rural residence
(AOR=1.71; 95% CI: 1.15, 2.57), absence of comorbidity
(AOR=2.22; 95% CI:1.34, 5.14), obesity (AOR=1.43;
95% CI: 1.10, 5.05) and inadequate foot care knowledge
(AOR=2.10; 95% CI: 1.52, 4.35) were factors significantly
associated with inadequate adherence to diabetic foot care
recommendations.
Conclusion More than two-­fifths of people with
diabetes had inadequate adherence to diabetic foot
care recommendations. Younger age, rural residence,
absence of comorbidity, obesity and inadequate foot care
knowledge were significantly associated with inadequate
adherence to diabetic foot care recommendations. It is
very essential to educate people with diabetes about the
importance of foot care recommendations in preventing
and delaying the risks of foot-­related problems and
complications.
INTRODUCTION
Approximately 19.4 million individuals on the
continent have diabetes in 2019, one of the
most prevalent non-­communicable diseases,
Sertsu A, et al. BMJ Open 2023;13:e074360. doi:10.1136/bmjopen-2023-074360
Original research
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STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ The study assured representativeness and general-
isability (a multicentre study was carried out at eight
public hospitals located in Eastern Ethiopia).
⇒ The accuracy of the data was improved by the use of
both primary and secondary data, as well as direct
measurements of specific variables, such as weight
and height.
⇒ A valid data collection tool (Nottingham Assessment
of Functional Foot Care), which has a high internal
consistency (α=0.84), was used.
⇒ The cross-­sectional nature of the study used makes
it difficult to draw causal inferences.
⇒ Social desirability biases could have been intro-
duced by the interviewing method.
and this number is predicted to double in
Africa after 10 years.1–3 Along with the rise
in diabetes prevalence, related complica-
tions are having a detrimental influence
on patients’ prognoses, overburdening the
healthcare system and destabilising the econ-
omies of the countries in the region.4 Many
African countries have recently incurred
enormous costs for the treatment of diabetes
and its consequences.5 6 Evidence suggested
that diabetic complications raised healthcare
costs in Ethiopia.7 Diabetes-­related foot ulcers
(DFUs) are the leading cause of morbidity,
hospitalisation and mortality among people
with diabetes.8
Several risk factors, including neuropathy,
peripheral vascular disease and inadequate
glycaemic control, contribute to the develop-
ment of DFUs.9 DFUs in Africa account for
13%,10 whereas it ranges from 12% to 32% in
Ethiopia.11 These figures are expected to rise
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as diabetes becomes more prevalent. DFUs that are not
properly treated can result in serious complications like
severe infections and amputations of the lower extremi-
ties.12 The likelihood of these complications is higher in
resource-­limited African countries.13 A prospective study
from Western Ethiopia showed that 3 out of every 10
patients with DFUs had lower extremity amputations.14 In
addition, those who have DFUs are more likely to pass
away than those without them.15
Patients frequently endure recurrence and reinfec-
tion even though early identified DFUs can be effectively
treated. Therefore, regular assessment, early detection
and timely management are beneficial in reversing
undesirable consequences.9 To avoid the development
of DFUs and significantly reduce the debilitating foot
complications that occur in people with diabetes, diabetic
foot self-­care is a crucial self-­care strategy that is both
efficient and affordable.16 The International Working
Group on the Diabetic Foot recommends that patients
should be advised to perform at least daily foot care to
check areas of irritation, redness, cuts, sores or blisters
on the foot surfaces and in between the toes.17 Diabetes
foot care recommendations include daily foot inspection
and washing, drying between the fingers, wearing prop-
erly fitting footwear, and avoiding soaking the feet and
barefoot walking.18
Several studies have revealed that the prevalence of
diabetes differs across Ethiopia.7 19 20 The literature that
is currently available indicated that Eastern Ethiopian
regions have a higher prevalence of diabetes than the
national estimates. Type 2 diabetes affects 14%, 9% and
7% of people in the Dire Dawa Administration, Somali
and the Harari regional states, respectively.19 There
are, however, few studies that primarily focus on overall
diabetic self-­management, and specifically on adherence
to diabetic foot care recommendations among individuals
with diabetes. Therefore, the purpose of this study was
to assess adherence to diabetes foot care recommenda-
tions and associated factors among people with diabetes
on follow-­up at public hospitals in Eastern Ethiopia, and
the study generate useful evidence that would improve
patient prognosis and design appropriate interventions
to lower the risks of developing DFUs.
MATERIALS AND METHODS
Study area, period and design
The study was carried out in selected public hospitals
in Eastern Ethiopia between 25 February and 25 March
2022. Of 15 existing public hospitals, 8 of them were
randomly chosen: Hiwot Fana Comprehensive Special-
ized Hospital, Jugol, Dilchora, Jigjiga, Chiro, Asebot,
Chelenko and Hirna Hospitals. Hiwot Fana Comprehen-
sive Specialized Hospital and Jugol Hospital are found
in the Harari regional state. Chiro, Asebot and Hirna
Hospitals are located in the West Hararge zone, while
Chelenko Hospital is located in the East Hararge zone of
the Oromia regional state. Dilchora and Jigjiga Hospitals
2 Sertsu A, et al. BMJ Open 2023;13:e074360. doi:10.1136/bmjopen-2023-074360
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are found in the Dire Dawa Administration and Somali
regional state, respectively.
Patient and public involvement
Patients or the general public were not engaged in the
planning, conduct, reporting or dissemination of our
study.
Study design and population
An institutional-­
based cross-­
sectional study design was
employed among 419 systematically selected people with
diabetes who had been on follow-­up for at least 6 months
from the selected hospitals in Eastern Ethiopia. All
people with diabetes who were on follow-­up at randomly
selected eight public hospitals of Eastern Ethiopia were
the source population, whereas all people with diabetes
who were on follow-­up during the study period were the
study population.
Inclusion and exclusion criteria
Included were all patients with diabetes who had been on
follow-­up for at least 6 months at randomly chosen public
hospitals. The study excluded people with diabetes who
were seriously ill during arrival and those who tested posi-
tive for COVID-­19.
Sample size determination and sampling technique
The sample size was determined using the single popu-
lation proportion formula and considering a propor-
tion of adherence to diabetic foot care recommendation
of 45.4%,21 a 95% CI and a 5% margin of error. After
adding a 10% non-­response rate, the final sample size
was 419. The sample was proportionally allocated to each
public hospital to select a representative sample from
each selected hospital. Following the retrieval of the
whole patient population that would have a follow-­up in
each hospital during the study period (N=1123, K=3), a
systematic random sampling procedure was used. The
K-­value was determined using the formula as follows:
K=1123/419=3. The study participants were selected for
interviews at intervals of three until the estimated sample
size was reached.
Measurement and data collection tools
Data were collected using a structured questionnaire
which was initially prepared in English, then translated
by language experts into the local languages of Afaan
Oromo and Amharic, and finally back into English. The
questionnaire includes data on sociodemographics, clin-
ical variables, disease and treatment details, behavioural
characteristics, knowledge of diabetic foot care and foot
care recommendations for patients with diabetes. Clin-
ical factors contained information about the presence
of comorbidity, foot complications and current treat-
ment of the patients. Eight questions with ‘yes’, ‘no’ and
‘I don’t know’ responses were used to assess the knowl-
edge of patients with diabetes regarding diabetic foot
care. Each ‘yes’ response was given a code of 1, while
‘no’ and ‘I don’t know’ responses were given a code of

0.22 Foot self-­care recommendation was assessed by using
a questionnaire adapted from a validated tool of the
Nottingham Assessment of Functional Foot Care revised
2015 (NAFFC).23 The tool was proven to be valid and reli-
able for assessing diabetic foot care behaviour.24 Only 16
of 19 questions that could be answered with ‘yes’ or ‘no’
responses were chosen to assess the diabetic foot care
recommendations adherence to fit the context. Values of
0 and 1 were assigned for incorrect and correct answers,
respectively. Then, the scores for each study participant
were computed and the mean was determined to catego-
rise the recommendation level as ‘adequate’ and ‘inade-
quate’ adherence. The mean recommendation score was
7.62±2.42, with the minimum and maximum values being
5 and 12 out of 16, respectively.
Except for height and weight, which were measured
using a stadiometer and weighing scales, data were
collected through in-­person interviews and by reviewing
their medical records. Body mass index (BMI) was calcu-
lated and categorised as normal weight if it fell between
18.5 and 24.9 kg/m2, overweight if it fell between 25.9 and
29.9 kg/m2 and obese if it is >30 kg/m2. The data were
collected by four diploma nurses under the supervision
of two BSc nurses.
Operational definition
Diabetic foot care recommendations are actions and activities
carried out by people with diabetes to take care of them-
selves to prevent foot-­ related problems and complica-
tions like inspecting their feet, daily washing and drying
between the fingers, wearing shoes that fit well, and
avoiding going barefoot and soaking their feet.25
Adequate adherence: participants who scored above the
mean on diabetes foot care recommendations-­ related
questions.
Inadequate adherence: participants who scored below the
mean on diabetes foot care recommendations-­ related
questions.
Glycaemic control was assessed by using fasting blood
glucose (FBG) level. To know the blood glucose level
of the people with diabetes, respective records were
reviewed to obtain their FBG levels during their last three
visits. According to the American Diabetic Association,
blood glucose control was considered good if the mean
of three consecutive FBG measurements falls within the
normal range of 70 and 130 mg/dL, and poor if the mean
of three FBG measurements is either above or below the
normal range.26
Comorbidity refers to an additional disease other than
diabetes.27
Neuropathy is the presence of at least one symptom from
the list of potential symptoms such as stabbing, shooting,
burning or electric shock-­like pain that may be worse at
night and disrupt sleep.28
Diabetes complication: by reviewing the patient’s medical
record, a patient with diabetes was deemed to have
diabetes complications if they had any of the following:
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retinopathy, nephropathy, neuropathy, myocardial infarc-
tion or stroke.29
Adequate knowledge of foot care: patients with diabetes
mellitus who score greater than or equal to the mean on
knowledge-­related questions about diabetes foot care.
Inadequate knowledge of foot care: patients with diabetes
mellitus who score less than the mean on knowledge-­
related questions about diabetes foot care.
Behavioural characteristics: behaviours related to the use
of alcohol, smoking and khat consumption within the last
3 months.
Data quality assurance and management
The research’s objectives, the sampling procedure, inter-
viewing techniques and general approaches to the study
participants were all thoroughly covered over a 2-­ day
training session for data collectors and supervisors. To
ensure the completeness, accuracy and consistency of the
data collection, a session was held on each day of the data
collection period. The necessary changes were made after
a pretest on 5% of the sample size. Principal investigators
and supervisors checked the accuracy of the anonymised
data every day. Cronbach’s α was calculated to determine
the internal reliability of diabetes foot care recommenda-
tions (α=0.82).
Statistical analysis
Data were cleaned, coded, entered and exported from
EpiData V.3.1 to SPSS V.22 for further analysis. The
outcome variable was coded as ‘1’ for adequate adher-
ence to the diabetic foot care recommendations and ‘0’
for inadequate adherence. A bivariate logistic regression
model was used to see the relationship between indepen-
dent factors and inadequate adherence to diabetes foot
care recommendations. A multivariable logistic regres-
sion analysis was conducted with a variable that had a p
value of less than 0.25 in the bivariate analysis. The model
fitness was determined using the Hosmer-­ Lemeshow
goodness-­ of-­
fit test (p=0.320). The independent vari-
ables’ multicollinearity was not evident in the variance
inflation factor. At a p value of 0.05, statistically significant
associations were defined by an adjusted OR (AOR) and
a 95% CI.
RESULTS
Sociodemographic characteristics
A total of 400 people with diabetes were included in the
study, yielding a response rate of 95.5%. After beginning
to take part in the study, 19 patients stopped the inter-
view. The participant’s mean age was 43.45±15.7 years.
Two hundred thirty (57%) of them were urban residents,
and more than half of the participants (56.5%) were male
(table 1).
Clinical and behavioural-related characteristics
Nearly two-­thirds of study participants (67.8%) had type 2
diabetes. The mean diabetes duration was 5.54±2.11 years.
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Table 1 Sociodemographic characteristics of patients with Table 2 Clinical characteristics among patients with DM
DM on follow-­up in public hospitals in Eastern Ethiopia, on follow-­up in public hospitals in Eastern Ethiopia, 2022
2022 (n=400) (n=400)
Age 18–27 25 6.2 Variable Category Frequency Percentage
28–37 76 19.0 Less than or
38–47 81 20.2 equal to 5
years 356 89.0
48–57 84 21.0
Greater than 5
58–67 61 15.3
Duration of DM years 44 11.0
>68 73 18.3 Family history Yes 62 15.5
Educational status No formal education 66 16.5 of DM No 338 84.5
Primary 56 14.0 Comorbidity Yes 90 22.5
Secondary 160 40.0 No 310 77.5
College and above 118 29.5 Type of Hypertension 40 44.4
Marital status Married 199 49.7 comorbidity Heart failure 36 40.0
Single 94 23.5 Asthma 10 11.1
Divorced 40 10.0 Others* 4 4.4
Widowed 67 16.8
Diabetic Yes 52 13.0
DM, diabetes mellitus. complications No 348 87.0
Types of Nephropathy 15 28.8
complications Neuropathy 22 42.3
Two hundred fifty-­five people with diabetes (63.75%) had
Retinopathy 12 23.0
poor glycaemic control. About 1 in 5 (18%), and 1 in 10
(9%) patients with diabetes were current smokers and Cardiovascular 3 5.7
alcohol drinkers, respectively. Nearly half (52%) of them disease
were current khat consumers (table 2). Foot ulcer Yes 44 11.0
No 356 89.0
Diabetes foot care knowledge
Treatment Only diet 34 8.5
The mean score for the study participants’ knowledge of
diabetic foot care was 4.22 (±2.01). Two hundred ninety-­ Oral anti-­ 100 25.0
diabetic agent
four (48.5%) of patients with diabetes had inadequate
knowledge of diabetic foot care, whereas about 206 Insulin 154 38.5
(51.5%) had adequate knowledge of diabetic foot care Combined 112 28
(table 3). (oral drugs and
insulin)
Diabetes foot care recommendation adherence Having Yes 192 48
Inadequate foot care recommendation adherence among information No 208 52
patients with diabetes was found to be 44.3% (95% CI: about diabetic
39.3%, 49.0%) in this study. More than two-­thirds (68% foot care
and 70.0%) walked around their home barefoot and BMI Normal 119 29.8
failed to dry their toes after washing their feet, respec- Overweight 129 32.2
tively, while the majority (84.5%) wear sandals (table 4).
Obese 152 38.0
Factors associated with inadequate adherence to diabetic foot *HIV/AIDS, skin infection, renal stone.
care recommendations BMI, body mass index; DM, diabetes mellitus.
In the bivariate logistic regression analysis, factors such
as age, educational level, residence, smoking, alcohol
intake, comorbidity, information regarding diabetic foot Patients between the ages of 28–37 and 38–47 years
care, khat consumption, obesity and awareness of foot were 1.10 times (AOR=1.10; 95% CI: 1.27, 5.63) and
problems were associated with inadequate adherence to 2.19 times (AOR=2.19; 95% CI: 2.74, 8.89), respectively,
diabetic foot care recommendations. However, the multi- more likely to have inadequate adherence to foot care
variate logistic regression indicated that age between recommendations than patients aged 60 years and older.
28–37 and 38–47 years old, rural residence, no comorbid- Inadequate adherence to diabetic foot care recommen-
ities, obesity and inadequate knowledge of diabetic foot dations was more common in rural patients with diabetes
care were all independently associated with inadequate than in urban patients with diabetes (AOR=1.71; 95% CI:
adherence to diabetic foot care recommendations. 1.15, 2.57). Inadequate adherence to diabetic foot care

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Table 3 Knowledge of diabetic foot care among patients with DM on follow-­up in public hospitals in Eastern Ethiopia, 2022
(n=400)
Variables Category Frequency Percentage
Patients with DM should take medications regularly Yes 214 53.5
No 186 46.5
Controlling blood sugar can reduce complications Yes 178 44.5
No 222 55.5
Patients with DM should look after their feet because wounds and infections Yes 190 47.5
may not heal quickly No 210 52.5
Patients with DM should look after their feet because they may get a foot ulcer Yes 250 62.5
No 250 62.5
Smoking affects DM progression Yes 180 45.0
No 220 55.0
Patients with DM should wash their feet every day Yes 167 41.8
No 233 58.2
Patients with DM should wash their feet using warm water, not hot water Yes 158 39.6
No 242 60.5
Patients with DM should wear socks and shoes at all times Yes 165 41.2
No 235 58.8
Overall knowledge Inadequate 194 48.5
Adequate 206 51.5
DM, diabetes mellitus.

recommendations was 2.22 times (AOR=2.22; 95% CI:
1.34, 5.14) more prevalent in patients without comor-
bidities than in patients with comorbidities. Compared
with patients with normal BMIs, patients with BMIs in the
obese category had a 1.43-­fold (AOR=1.43; 95% CI: 1.10,
5.05) higher likelihood of not following diabetic foot care
recommendations. Inadequate knowledge of diabetic
foot care increased the likelihood of not adhering to
recommendations for diabetic foot care by 2.10 times
(AOR=2.10; 95% CI: 1.52, 4.35) (table 5).
DISCUSSION
This study was done to assess diabetic foot care recom-
mendation adherence among patients with diabetes on
follow-­up in public hospitals in Eastern Ethiopia. Ages
28–37 and 38–47 years, rural residence, no comorbidity,
obesity and respondents having inadequate knowledge
of diabetic foot care were all associated with a higher
likelihood of inadequate adherence to diabetic foot care
recommendations.
In our study, 44.3% of respondents had inadequate
adherence to diabetic foot care recommendations. In
comparison with a Malaysian study, the results of this study
have lower findings.30 The discrepancy may be caused by
variations in the study population, study setting, sample
size, sampling technique, study duration and participant
ages. Our study included both patients with type 1 and
type 2 diabetes mellitus on follow-­up in public hospitals
in Eastern Ethiopia, unlike the Malaysian study, which
only included patients with type 2 diabetes mellitus at
follow-­up at four primary health clinics.30 Additionally,
data were collected from 450 respondents in Malaysia
using the universal sampling approach (non-­probability
method) over a year (December 2017–December 2018),
as opposed to 400 respondents in our study who were
collected using the systematic sampling method within
a single 1-­month period. In Malaysia, only 11 questions
were used to assess the diabetic foot care recommenda-
tions; however, we chose 16 questions that were pertinent
to our case.30 The differences in study findings could
be explained by these inconsistencies between the two
studies.
However, our findings were greater than the study
done in Pakistan’s Lahore Jinnah Hospital (32%).31 This
is probably caused by variations in sample size, sampling
strategy and research methodology. Only 150 respon-
dents were included in a study conducted in Pakistan
using convenience sampling (non-­ probability).32 The
lower proportion in the other study can be explained by
the participants’ relatively higher socioeconomic status,
which may have allowed them to have better knowledge
of diabetes and its effects through health education
and various media.22 Inadequate health literacy among
respondents regarding diabetic foot care and the high
proportion of illiterate participants (54%) in our study
may also contribute to our higher findings.

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Table 4 Diabetic foot care recommendation adherence among patients with DM on follow-­up in public hospitals in Eastern
Ethiopia, 2022 (n=400)
Variables Category Frequency Percentage
Do you examine or inspect your feet regularly? Yes 205 51.2
No 195 48.8
Do you wash your feet daily? Yes 265 66.2
No 135 33.8
Do you check your shoes before you put them on? Yes 199 49.8
No 201 50.2
Do you walk outside with bare feet? Yes 98 24.5
No 302 75.5
Do you carefully dry between toes after washing your feet? Yes 117 29.3
No 283 70.7
Do you moisturise your feet (put cream on) daily? Yes 176 44
No 224 56
Do you sit with your legs crossed? Yes 195 48.8
No 205 51.2
Do you wear sandals/slippers? Yes 338 84.5
No 62 15.5
Do you check the temperature of the water before soaking your feet? Yes 143 35.8
No 257 64.2
Do you wear shoes without socks? Yes 185 46.3
No 215 53.7
Do you put your feet near the fire? Yes 112 28
No 288 72
Do you put a dry dressing on a blister when you get one? Yes 128 32
No 272 68
Do you cut your toenails? Yes 326 81.5
No 74 18.5
Do you put a dry dressing on a graze, cut or burn when you get one? Yes 130 32.5
No 270 67.5
Do you check your shoes when you take them off? Yes 162 40.5
No 238 59.5
Do you walk around the house on bare feet? Yes 272 68
No 128 32
Overall diabetic foot care recommendation adherence Inadequate 177 44.3
Adequate 223 55.7
DM, diabetes mellitus.

In this study, patients with diabetes between the ages
of 28–37 and 38–47 years were less likely than patients
with diabetes over 60 years to follow recommendations
for proper diabetic foot care. This result is in line with
the research done in Northwest Ethiopia.22 Compared
with older people, young and middle-­aged adults may
have more societal and familial responsibilities and less
time for self-­care. They might also not feel the need to
check on their feet frequently if there are no evident or
impending injuries because of the disease’s effect on the
peripheral pain system.
Patients who did not follow diabetic foot care recom-
mendations were more likely to live in rural than urban
areas. This study was similar to that conducted in Bahir
Dar, Northern Ethiopia.21 In rural locations, patients with
diabetes may find it difficult to obtain information on
adequate foot care due to a lack of close medical facilities
and limited access to health information in general.

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Table 5 Factors associated with diabetic foot care (DFC) recommendation adherence among patients with DM on follow-­up
at public hospitals in Eastern Ethiopia, 2022 (n=400)
DFC recommendation
adherence
Variables Category Inadequate Adequate COR (95% CI) AOR (95% CI)
Age 18–27 13 12 1.55 (1.18, 10.29) 0.49 (0.53, 1.09)
28–37 12 64 2.44 (1.12, 4.23) 1.10 (1.27, 5.63)*
38–47 51 30 5.26 (1.12, 4.48) 2.19 (2.74, 8.89)†
48–57 66 18 0.27 (0.25, 1.04) 0.23 (0.26, 8.27)
58–67 5 56 0.13 (0.25, 0.71) 0.45 (0.56, 1.02)
>68 30 43 1 1
Educational status No formal education 36 30 3.68 (1.94, 6.98) 1.57 (0.80, 4.71)
Primary 29 27 3.30 (1.69, 5.45) 1.26 (0.75, 3.88)
Secondary 83 77 3.31 (1.96, 5.57) 1.30 (0.76, 2.95)
College and above 29 89 1 1
Residence Rural 94 76 2.19 (1.46, 3.28) 1.71 (1.15, 2.57)*
Urban 83 147 1 1
Having information Yes 98 94 1.70 (0.70, 2.92) 1.81 (0.80, 4.47)
regarding DFC No 79 129 1 1
Current smoker Yes 44 28 2.30 (1.37, 3.89) 0.76 (0.67, 2.53)
No 133 195 1 1
Khat chewers Yes 110 98 2.09 (2.46, 5.23) 1.52 (0.84, 4.85)
No 67 125 1 1
Current alcohol drinkers Yes 22 14 2.12 (1.05, 4.27) 0.85 (0.90, 3.32)
No 155 209 1 1
Comorbidity No 148 162 1.92 (2.32, 7.85) 2.22 (1.34, 5.14)†
Yes 29 61 1 1
BMI Obese 83 69 2.89 (1.22, 7.53) 1.43 (1.10, 5.05)*
Overweight 50 79 1.52 (1.32, 8.23) 0.61 (0.75, 2.43)
Normal 35 84 1 1
Knowledge of DFC Inadequate 105 89 2.20 (2.14, 6.73) 2.10 (1.52, 4.35)*
recommendation Adequate 72 134 1 1
Hosmer-­Lemeshow goodness-­of-­fit test was fitted.
*P<0.05
†P<0.001
AOR, adjusted OR; BMI, body mass index; COR, crude OR; DM, diabetes mellitus.

Patients without comorbidities were more likely than
those with comorbidities to have inadequate adherence
to diabetic foot care recommendations.22 The rationale
could be that individuals with comorbidities frequently
visit hospitals or other healthcare facilities, where they are
exposed to greater health education or awareness than
individuals without comorbidities. Doctors and other
healthcare professionals may suggest and urge patients to
increase their self-­care recommendations to prevent any
problems brought on by comorbidities.33
Compared with participants whose weight was within
the normal BMI range, participants in the obese BMI cate-
gory were more likely to not adhere to the recommenda-
tions for diabetic foot care. Our findings were supported
by a Malaysian study.30 Patients’ levels of compliance
with self-­care recommendations, such as diet and exer-
cise regimes, are substantially predicted by their BMI.
Because of the better body image, self-­esteem and general
emotional state, the likelihood of engaging in a partic-
ular self-­care activity may also have a favourable impact
on starting and maintaining the other activities.34 Overall,
the lack of exercise and sedentary lifestyles among obese
patients with diabetes lead to inadequate self-­care recom-
mendations in all areas. Obese individuals might live a
healthier lifestyle less consistently.35
Compared with those who have inadequate knowledge
of diabetic foot care, those who have adequate knowl-
edge were more likely to adhere to recommendations

Sertsu A, et al. BMJ Open 2023;13:e074360. doi:10.1136/bmjopen-2023-074360 7

 Open access
for diabetic foot care. This finding is consistent with the
Malaysian study.30 This may be explained by the fact that
more awareness will result in meticulous and attentive
observation of foot problems, which would lead respon-
dents to have better adherence to diabetic foot care
recommendations.
Strengths and limitations
The study assured representativeness and generalisability
(a multicentre study was carried out at eight public hospi-
tals located in Eastern Ethiopia). In addition, the accu-
racy of the data was improved by the use of both primary
and secondary data, as well as direct measurements of
specific variables, such as weight and height. Moreover,
a valid data collection tool (NAFFC), which has a high
internal consistency (α=0.84), was used. However, the
study has some limitations. The cross-­sectional nature of
the study used makes it difficult to draw causal inferences.
What is more, social desirability biases could have been
introduced by the interviewing method.
CONCLUSION
Two out of every five patients who visited follow-­ up
diabetic appointment clinics had inadequate adherence
to recommendations for diabetic foot care. Age between
28–37 and 38–47 years old, living in rural areas, not
having any comorbid conditions, obesity and inadequate
knowledge of diabetic foot care were factors found to be
independently associated with inadequate adherence to
diabetic foot care recommendations. More focus should
be put on long-­term patient education and adherence to
foot care recommendations at the primary care level to
ensure quality foot care. After washing their feet, patients
neglected to thoroughly self-­inspect and did not mois-
turise their dry skin. On top of that, they neglected to
wash their feet at least once a day. Therefore, clinicians
should inform patients with diabetes about diabetic foot
problems, the importance of good foot care practices
including foot self-­inspection and foot cleaning, and the
risks of wearing sandals or other open-­ toed footwear,
walking barefoot or wearing shoes without socks at every
follow-­up appointment.
Author affiliations
1
School of Nursing and Midwifery, College of Health and Medical Sciences,
Haramaya University, Harar, Ethiopia
2
School of Nursing and Midwifery, College of Medicine and Health Sciences, Dire
Dawa University, Dire Dawa, Ethiopia
3 in Africa: a systematic review of existing literature. Global Health
School of Public Health, College of Health and Medical Sciences, Haramaya
University, Harar, Ethiopia
4
School of Nursing and Midwifery, Asrat Woldeyes Health Science College, Debre
Berhan University, Debre Berhan, Ethiopia
Acknowledgements We would like to thank all of the people who took part in
the study, collected the data, worked at the hospitals that were chosen, and were
otherwise directly or indirectly involved in this study.
Contributors AS is the principal investigator and all co-­authors contributed
significantly to this work whether that in conception (AS, KN, ML, and AN), study
design, (LA, AE, JD, AM), execution (OT, DA, AN, ATG, AD and SL), methodology (KN,
ML, DD, LA, AE, JD, AM), acquisition of data analysis (AS, KN, DD, LA, JD, AM, AN,
8 Sertsu A, et al. BMJ Open 2023;13:e074360. doi:10.1136/bmjopen-2023-074360
BMJ Open: first published as 10.1136/bmjopen-2023-074360 on 4 October 2023. Downloaded from http://bmjopen.bmj.com/ on October 6, 2023 by guest. Protected by copyright.
ATG, AD and SL), writing original draft (AS, AN, KN, ATG, and SL), review and editing,
and interpretation (AS, KN, ML, LA, AM, AN, ATG, and SL). All authors participated in
drafting, revising or critically reviewing the article and agreed to be accountable for
all aspects of the work. All authors read and approved the final manuscript.
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.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Ethics approval The conduct of the study adhered to the Helsinki Declaration of
Medical Research Ethics.3630 The study was authorised by the Institutional Health
Research Ethics Review Committee of Haramaya University (reference number:
IHRERC/014/2022) and granted ethical clearance and permission. After the
approval, a formal letter of collaboration was given to the Chief Executive Officer
(CEO) of each chosen hospital. Then, permission was sought from the head of the
diabetes clinic unit. The significance and purpose of the study were explained
to the study participants, and they were also informed to keep their information
confidential. Data collection only began after receiving complete, fully informed,
voluntary, written and duly signed consent. The participants were given the
assurance that their names were not included, and obtained information was only
used for research purposes.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.
Open access 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: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
Addisu Sertsu http://orcid.org/0000-0003-3921-0518
Lemesa Abdisa http://orcid.org/0000-0002-6912-1025
Addis Eyeberu http://orcid.org/0000-0002-3147-3770
Aminu Mohammed http://orcid.org/0000-0002-5661-6037
Tilahun Bete http://orcid.org/0000-0003-4812-0784
Abraham Negash http://orcid.org/0000-0001-9406-1979
Abel Tibebu Goshu http://orcid.org/0000-0003-0818-4169
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