In the current study, majority of patients with diabetes had lower levels of education. Studies report that level of knowledge depends on the level of education [14, 19]. Understanding this variable is highly important in designing strategies to prevent diabetes.
In the current study, most patients had lower scores of knowledge and practice toward foot care, and the mean practice score was lower than the mean knowledge score, which was similar to the findings of Muhammad-Lutfi’s and Kim’s studies [16, 20]. A study conducted on patients with diabetes in Western Nepal reported poor KAP (knowledge, attitude and practices) score; they indicated that the plausible factors could be lack of knowledge, lack of information, and literacy level of the studied population . Another study on young Saudi females with diabetes also reported poor KAP scores . Some studies reported that patients with diabetes had good level of knowledge about diabetes [7, 16, 22, 23]. The differences in knowledge about foot care among patients with diabetes across the studies could be due to different trainings on diabetes care provided by the health care professionals in different settings  and also the literacy level of the studied subjects.
Several studies reported poor foot care practices among patients with diabetes. Kheir et al., reported poor practices toward regular inspection of feet among patients in Qatar . Hamidah et al., from Malaysia observed that 28.4% of patients newly diagnosed with diabetes practiced good habits towards foot care . Desalu et al., from Nigeria observed that only 10.2% of patients with diabetes had good foot care practices . It was difficult to compare the results of the current study with those of other studies since the nature of the study populations and the applied measurements were different.
In the current study, there was a direct and significant correlation between knowledge and practice scores; therefore, with an increase in the knowledge score, the practice score also increased. Other studies also showed that patients who receive trainings on foot care checked their feet regularly . Patients who are advised to take care of their feet and the ones whose feet are regularly checked by physicians have better practices toward foot care .
In the current study, the lowest knowledge scores were regarding the application of talcum powder or other powders and not using lotions between the toes, and the proper way of trimming the toenails; while the lowest practice scores were related to the application of talcum powder between the toes, the proper way of trimming the toenails; keeping the foot skin soft, and avoid dryness.
It should also be noted that due to wet climate in the North of Iran, use of lotion between the toes is not common. Nevertheless, it also needs training. Patients with diabetes need to keep between their toes dry using talcum powder and avoid the application of lotion since it is important as a hygienic measure for feet in preventing fungal infection . Patients should also use skin moisturizers daily to keep the skin of their feet soft and should trim their toenails straight across (not rounded) to prevent damage to their toes .
In the current study, gender, duration of disease, occupation, place of residence, level of education, having DFU, and a history of hospitalization, amputation, and complication had significant relationships with knowledge. Also, gender, duration of disease, place of residence, occupation, and level of education had significant relationships with practice. It was found that knowledge level was higher in females, patients with a diabetes history of more than 10 years, and the ones underwent amputation due to DFU compared to the others; in addition, females, patients with a diabetes history of more than 10 years, and urban residents had better performance. The current study results showed that males were usually reluctant to disclose their health problems and seek professional care. Also, males presented greater deficit in self-care compared to females .
In the study by Muhammad-Lotfi, age, gender, level of education, and duration of diabetes had no significant relationship with knowledge and practice. This finding was in agreement with that of the current study , but another study indicated a significant relationship between the level of education and knowledge .
People with higher education are expected to be more likely to read and receive information about their illness and foot care and understand the information provided by medical staff in health care settings.
But in the current study, there was no significant relationship between the level of education and knowledge or practice, which could be due to the poor and inadequate resources of information about diabetes at the community level, since both educated and uneducated groups had inadequate information. It may also be due to the fact that in spite of possessing knowledge, due to the lack of time, heavy work load, and lack of adequate insurance coverage, patients could not take good care of their feet in practice, which requires more studies to root out the causes.
Nevertheless, the attitude of patients toward self-care in addition to sufficient knowledge was not studied in the current study. As observed in the present study, patients with a history of DFU or hospital stay, and even amputation and complication had higher knowledge level. It could be due to the fact that while completing the questionnaire, the current knowledge level of the subjects was questioned, which indicated that training medical centers can raise the level of knowledge in patients with DFU. In many Iranian state hospitals, diabetic training programs are not well organized, and the existing programs are weak. It is believed that knowledge about diabetes in the general population as well as patients with diabetes in Iran is not enough and there is a dire need for a good program for diabetes .
The collected data indicated that patients with diabetes had poor practice and knowledge about foot care. This is basically due to lack of proper communication between patients and medical team and inadequate education. Based on nurses’ opinion, recommendations and guidelines play an effective role in prevention, treatment, and reduction of complication among patients with DFU. Therefore, adaptation, implementation, and evaluation of the educational programs were recommended .
Thus, patients should be trained for foot ulcer prevention based on clinical practice guidelines for diabetes mellitus both in the community and hospitals. The results of the current study encouraged a positive outlook: A diabetes educator should give necessary advices to patients during every visit, in order to improve their perception about disease, diet, and lifestyle changes and help them control their glycemic level and overcome the complications of diabetes.
According to the principle of “prevention is better than cure” and considering the predictive factors in the current study including poor knowledge, urban residency, being single, and lack of DFU, more attention should be paid to patients possessing risk factors .
Knowledge and practice toward foot care were poor in most patients with diabetes. There was a significant relationship between some demographic characteristics of patients and knowledge and practice toward foot care. The level of knowledge, place of residence, marital status, and history of hospital stay due to DFU were the predictors of practice in patients with diabetes.
The strength of the current study was that it was the first, study to discuss this important issue in Guilan Province. The study also had some limitations; first, since the work had a cross sectional design, the direction of relationships and causal relationships cannot be determined. Second, the result of the study should be interpreted with caution, since they were obtained from a single center; a clinic-based study. Hospital-based studies cannot provide a true picture of knowledge and practice in the community. The current study sample did not represent the whole Iranian population consisting of several ethnicities. In this research, responses of the wrong answers and “I don’t know” have been grouped together, in order to achieve better analysis. Perhaps with increasing sample size, we could solve this problem in future studies.