Knowledge and Practices of Foot Care and Associated Factors Among Patients With Diabetes in Vietnam: A Survey at a Single Center From 2021 to 2022 (2025)

2.1. Study Design: The Study Setting

This is a descriptive cross-sectional study, which was conducted at the outpatient and inpatient units of the department of endocrinology and metabolism of Cho Ray Hospital, the largest tertiary care center in Southern Vietnam. Most patients hospitalized at Cho Ray Hospital were transferred from their local hospital for the first time. By including patients from both sectors, we aimed to increase the representativeness of the studied population for the diabetic community of Southern Vietnam. Data were collected from 05/2021 to 06/2022.

2.2. Inclusion Criteria and Procedure

Patients aged 18–80 years who had been diagnosed with Type 1 diabetes for at least five years or with Type 2 diabetes, as defined by the American Diabetes Association criteria, and who were able to understand and respond to the questionnaire were eligible for inclusion. Exclusion criteria included a history of neurological or psychotic disorders, refusal to participate, or the presence of acute medical conditions that impeded the patient’s ability to complete the questionnaire.

Participants were recruited using a convenience sampling method from both inpatient and outpatient units of the department of endocrinology and metabolism at Cho Ray Hospital, with efforts made to ensure equal representation from each setting. Prior to data collection, the principal investigator conducted training sessions for the research physicians and nurses to ensure consistent understanding and administration of the questionnaire items across the research team.

2.3. Sample Size

The sample size was calculated with the assumption that the proportion of patients in our population having a good score of knowledge was 50%, and the standard error was 2.5%.

2.4. Tools and Materials

The content validity and the internal consistency of the Vietnamese version of Section D were previously validated by Nguyen et al. [12]. One item from the original version, “Have your feet measured when buying a new pair of shoes,” was removed due to limited applicability in the Vietnamese context. A culturally relevant item, “Gradually increase the wearing time when using new shoes,” was added in its place. Additional revisions included minor reordering and the rewording of two items for regional clarity. Specifically, Item 14 was modified from “Using heating pads to warm cold feet” to “Using heating pads or soaking your feet in warm water,” reflecting common practices in Southern Vietnam. Item 16 was adapted from “Treat corns/calluses with blades” to “Treat corns/calluses with blades/sharp objects,” acknowledging the use of scissors as reported by patients. All modifications were reviewed and approved by two local experts to ensure cultural appropriateness and content validity.

2.5. Ethical Consent

The study protocol obtained ethical approval number 1157/GCN-HĐĐĐ by the Ethics Board of Cho Ray Hospital on May 13, 2021. We strictly followed the ethical guidelines in conducting research studies on human subjects in the “Declaration of Helsinki.” Trained researchers interviewed the patients using an evaluated questionnaire after the patients were explained about the meaning and procedure of the study and had signed the consent form. Participation was voluntary. The privacy of participants has been kept confidential. All methods carried out in the study were performed in accordance with relevant guidelines and regulations.

2.6. Data Analysis

The data were analyzed with R Studio Version 2022.07.1. Numeric variables are displayed as the mean ± standard deviation (SD). Two means were compared using a t-test for normally distributed variables and a Mann–Whitney test for non-normal variables. Comparisons of more than two variables were performed using ANOVA for normally distributed variables and the Kruskal–Wallis test for abnormally distributed variables. Pairing analysis for categorical variables with more than two values was performed using the Tukey’s test. p < 0.05 was considered to be statistically significant.

Multivariable analysis for categorical variables was performed using ordinal logistic regression for the knowledge score and linear regression for the practice score. The Brant method was used to test for proportional odds assumptions. Multivariable analysis was performed on 392 patients after eliminating 11 unusual observations belonging to the category “Dispensary,” whose knowledge scores were unusually high, from the analysis.

3.1. General Characteristics of the Studied Population

The mean age of the studied population was 57.9 ± 11.56. Half (n = 202, 50.1%) were outpatients. Most of the patients (n = 209, 51.8%) were female. The mean duration of diabetes was 9.8 ± 7.7 years. Twenty-five patients had just been diagnosed with diabetes and had yet to receive any treatment (see Table 1).

3.2. Knowledge of Foot Self-Care of Diabetic Patients

The studied population’s average foot care knowledge score was 6.9 ± 2.11 out of 10. 52.9% of the patients had a good score (≥ 7.5), 24.1% of the patients had an intermediate score (5.0–7.5), and 23.1% of the patients had a bad score (< 5.0).

Most patients (74.7%–89.8%) understood protective foot care behaviors: observing feet daily, washing feet with lukewarm water and mild soap, checking the water temperature with hands before use, using soft towels to dry both feet after washing them, cutting straight across fingernails, not waking barefoot outdoors, looking inside shoes before use, not sitting with legs across, regularly going to see the doctors for diabetic foot, and the need to see doctors if patients have foot calluses.

The questions for which only 50%–70% of patients had correct answers were questions about eliminating foot corns/calluses using sharp objects, cutting fingernails down to the sides, the appearance of dry skin and foot calluses in diabetic patients, and the decreased sensation of foot in diabetic patients (51%–69.7%).

Questions for which only 30%–50% of patients had correct answers included 8, 11a, 14, 18c, 19a, and 19d. Only 44.7%–49.6% of patients had the correct answer for questions related to managing foot corns/calluses and the need to wear socks when putting on shoes. 39.5% of patients understood that dry and drought skin must be addressed. Only 37.7% of patients understood they should not walk barefoot indoors, even on regularly cleaned floors. Nearly one-third of patients (30.8%) understood they should not soak their feet in hot water. Only 6.2% of patients gave the correct answer for not applying moisturizer onto the whole foot’s skin (see Table 2).

3.3. Factors Associated With Foot Care Knowledge

Based on the univariate analysis (see Table 3), significant differences were observed in the mean foot care knowledge scores across various categories of the following independent variables: working area, educational level, engagement in searching for diabetes-related information, primary healthcare center responsible for patient care, and history of amputation. In contrast, no statistically significant differences in knowledge scores were identified among patients with multiple comorbidities or a history of soft tissue infections (see Table 3).

A total of 11 observations categorized under “Dispensary” were excluded from the multiple regression analysis due to their unusually high foot care knowledge scores, which appeared inconsistent with the expected profile of small medical centers primarily serving local populations. Following this adjustment, ordinal regression analysis was conducted on data from 392 patients. Three factors were significantly associated with higher levels of foot care knowledge: educational level, duration of diabetes, and history of amputation. Patients with higher levels of education were more likely to demonstrate greater knowledge. Each additional year of living with diabetes was associated with a 7% increase in the odds of being in a higher knowledge category. Furthermore, individuals with a history of amputation had 2.02 times greater odds of belonging to a higher knowledge group compared to those without such a history. The type of healthcare center where patients received primary care did not show a significant association with knowledge scores when controlling for other variables (see Table 4).

3.4. The Foot Care Practice Score of the Studied Population

The average foot care practice score among the study population was 0.51 ± 0.13, with a maximum possible score of 1. Approximately half of the participants reported engaging in key preventive behaviors such as inspecting their feet, washing them regularly, testing water temperature before use, and changing socks daily. Despite this, suboptimal practices remained common. Notably, 58.6% of patients reported walking barefoot indoors on a daily basis, and only 14.9% were aware of the need to apply moisturizer to dry skin. The majority (87%) frequently wore sandals or slip-on footwear, and 40% continued the harmful practice of soaking their feet in hot water. In addition, only 9.9% of participants reported taking appropriate precautions when using new footwear (see Table 5).

3.5. Factors Associated With Foot Care Practice

Univariate analysis (see Table 6) revealed significant differences in foot care practice scores across various subgroups, including working area, educational level, active engagement in seeking diabetes-related information, primary healthcare center, history of soft tissue infection, history of amputation, and number of comorbidities. In addition, foot care practice scores demonstrated a statistically significant positive correlation with the duration of diabetes (p < 0.0001).

A multivariate linear regression model was applied to data from 392 patients to identify factors associated with foot care practice scores. The model explained 45.5% of the variance in practice scores, with working area, active information-seeking behavior, highest educational level, and foot care knowledge emerging as contributing variables (see Table 7). However, the working area was not significantly associated with foot care practice. Similarly, patients with higher levels of education did not exhibit significantly better foot care practices compared to those without formal education. In contrast, patients who actively sought diabetes-related information had practice scores that were 0.04 points higher than those who did not. Furthermore, foot care knowledge was positively associated with practice: for each one-point increase in knowledge score, the practice score increased by 0.03 points (see Table 7).

4.1. Foot Care Knowledge and Associated Factors

Most patients demonstrated awareness of basic foot care practices, including daily foot inspection, washing with lukewarm water and mild soap, testing water temperature with their hands, drying feet with a soft towel, trimming toenails straight across, avoiding barefoot walking outdoors, checking inside shoes before use, avoiding leg crossing, regularly attending medical check-ups for diabetic foot care, and recognizing the need to consult a physician for foot calluses. However, correct responses sharply declined for questions addressing diabetes-specific foot care behaviors. These included not soaking feet in hot water, avoiding barefoot walking indoors, wearing socks when using shoes, and managing dry skin and foot calluses appropriately (see Table 2).

Soaking feet in hot water is a common practice among older individuals in Vietnam to relieve tingling sensations. However, this practice poses risks for patients with diabetic neuropathy. Only 30.8% of participants correctly identified this behavior as harmful. Likewise, only a small proportion of patients correctly responded to the question regarding the inappropriateness of applying moisturizer between the toes. This aligns with findings from previous studies [14, 15]. Although moisturizers are commonly recommended to prevent skin cracks and calluses in individuals with diabetes [8, 16], their use between the toes is discouraged due to increased moisture and the risk of fungal infections, especially in tropical climates such as Southern Vietnam. In this context, where hot and humid weather prevails year-round, applying moisturizer is not a widespread habit. Moreover, the knowledge not to apply creams between the toes reflects a more advanced understanding of foot care, which was lacking in most participants.

Ordinal regression analysis indicated that educational level, duration of diabetes, and history of amputation were significantly associated with higher knowledge scores. These findings are consistent with previous research linking foot care knowledge to educational attainment [17, 18] and duration of diabetes [19]. Higher education levels may support better memory and learning capacity [20], thereby facilitating greater understanding of diabetic self-care. In addition, patients living with diabetes for longer periods may have had more opportunities to encounter educational materials or advice on foot care. In contrast, neither the number of comorbidities nor a history of foot infections was significantly associated with knowledge scores.

4.2. The Foot Care Practice and Associated Factors

The mean foot care practice score observed in our study was comparable to that reported by Nguyen Thi Phuong Lan in a study conducted in Ho Chi Minh City 6 years prior [12]. However, differences in sample characteristics should be noted. In her study, 52.9% of participants had completed high school education, compared to 32.7% in our sample. In addition, 37.3% of her participants had received prior diabetes education, while only 5.7% of our participants reported the same. Considering the positive association between higher educational attainment and receipt of foot care education with improved foot care practices, demonstrated in multiple studies [15, 19, 21, 22], and the fact that both studies used the same evaluation tool, it may be speculated that foot care practice among Vietnamese patients with diabetes has improved modestly over time.

Our questionnaire assessed 17 behaviors, categorized into nine protective behaviors and eight harmful behaviors. While some protective practices, such as foot inspection, proper foot washing, water temperature testing, and checking inside shoes, were reported by over half of the participants, other key behaviors were less common. For instance, the use of moisturizers, gradual adaptation to new shoes, and trimming toenails straight across were practiced by fewer than 30% of respondents. These findings are consistent with previous studies reporting low adherence to moisturizer use [15, 23] and proper toenail trimming [23].

Conversely, harmful practices were still prevalent. A substantial proportion of participants reported walking barefoot indoors (58.6%), wearing sandals or slip-ons daily (87%), relying solely on the sensation of fit when buying new shoes (61.5%), and using heating pads or soaking their feet in hot water (40%). These behaviors mirror those observed in Sari’s study [15].

Multivariate linear regression analysis revealed that only active information-seeking behavior and foot care knowledge were significantly associated with foot care practice scores. Our findings contrast with several other studies that reported associations between foot care practice and diabetes duration [19, 23] and educational level [21]. In contexts where systemic diabetes education programs are consistently delivered through primary care, longer disease duration may lead to more opportunities for patient education, increased exposure to complications, and enhanced motivation to engage in preventive foot care behaviors. However, in Vietnam, structured educational interventions remain limited, particularly at the primary care level. As a result, the duration of diabetes may not translate into improved foot care knowledge or practice.

A similar explanation may apply to educational attainment. While higher education is often associated with better health literacy, it does not guarantee knowledge of specialized foot care unless patients have been exposed to relevant information. This interpretation aligns with findings from Woo’s integrative review [24], which identified foot care knowledge and education, not general education level, as predictors of foot care behaviors.

Our results support a linear relationship between knowledge and practice, echoing findings from Dhandapani and colleagues [18, 24]. These findings underscore that while increasing patient knowledge is critical for improving foot care behaviors, it must be complemented by broader educational interventions and healthcare system support.

This study has several limitations. First, as a cross-sectional design, it is subject to recall bias, particularly in self-reported practices. Second, the study was conducted at a single tertiary hospital in Southern Vietnam, which may limit the generalizability of findings. However, data were collected from both inpatient and outpatient settings within one of the region’s largest hospitals, making this a meaningful reference point for future research on diabetic foot care in Vietnam.