Digital echoes of disease: Infodemiological analysis of diabetic foot search behavior in Ecuador

Digital echoes of disease: Infodemiological analysis of diabetic foot search behavior in Ecuador | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Digital echoes of disease: Infodemiological analysis of diabetic foot search behavior in Ecuador Juan Roca-Pogo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8662717/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Diabetic foot disease (DFD) is a severe complication of diabetes with high morbidity. Ecuador has significant diabetes prevalence, yet epidemiological data on DFD remains scarce. Infodemiology, using search query data, offers a novel approach to gauge public health interest where conventional surveillance is limited. This study aimed to characterize online search behavior for DFD in Ecuador and its global context. Methods A longitudinal, descriptive infodemiological study was conducted using Google Trends Search Volume Index (SVI) data from January 2015 to July 2025. We analyzed monthly SVI for "diabetic foot" in Ecuador, global trends, and comparative interest across five non-communicable diseases (NCDs). Related top and rising search queries were examined. Statistical analysis included descriptive statistics, time-series comparison, and Spearman's correlation. Results Ecuadorian SVI for DFD showed a volatile upward trend (ρ = 0.6503, p < 0.001), peaking at 100 in February 2023, frequently exceeding global values. Globally, Latin American nations exhibited the highest search interest, with Ecuador ranking 8th (SVI = 64). However, comparative national analysis revealed DFD search interest (mean = 2.18 SD = 0.13) was an order of magnitude lower than for cancer or hypertension. Query analysis showed predominant use of basic Spanish terminology ("pie diabetico", SVI = 100), alongside searches for symptoms, treatment, and clinical classifications, but also frequent misspellings. Conclusion Despite a high diabetes burden, Ecuador demonstrates disproportionately low public digital engagement with DFD information compared to other NCDs, suggesting significant awareness gaps. The alignment with global trends and specific query patterns indicates a maturing but incomplete public understanding of DFD severity. These findings underscore the utility of infodemiology in resource-limited settings and highlight an urgent need for targeted, literacy-appropriate health communication strategies to improve DFD awareness and prevention in Ecuador. Medical Informatics Diabetic foot Infodemiology Google Trends Public health surveillance Figures Figure 1 Figure 2 Introduction Diabetic foot disease (DFD) refers to the variety of pathological conditions that might affect the feet in patients with diabetes ( 1 , 2 ). It is a severe manifestation of diabetes mellitus, characterized by tissue destruction, ulceration, or infection in the presence of neuropathy and/or peripheral arterial disease. Foot-related complications, encompassing infections, ulcerations, and gangrene, represent a leading cause of hospitalization among individuals with diabetes ( 2 ). This condition serves as a critical prognostic indicator for lower extremity amputations and mortality, with studies reporting five-year mortality rates approaching 50% following the development of diabetic foot ulcers ( 1 ). National epidemiological data reveal a diabetes prevalence of 5.53% in Ecuador, with higher rates observed among women (6.17%) compared to men (4.57%). Significant risk factors include age over 45 years (OR = 18.18), overweight/obesity (OR = 2.81), family history of diabetes (OR = 2.99), and hypertension (OR = 3.02). Population-level risk stratification using FINDRISK demonstrates that 17.4% of Ecuadorians fall into the high-risk category, while 38.4% and 44.2% exhibit moderate and low risk, respectively ( 3 ). Infodemiology has emerged as a novel approach to assess population-level health concerns through digital search behavior analysis, particularly valuable in settings lacking comprehensive epidemiological data ( 4 , 5 ). The present research addresses a critical knowledge gap by employing Google Trends to examine diabetic foot-related searches in Ecuador, where formal epidemiological data on this complication remains scarce. This study aims to characterize online search behavior and public interest regarding diabetic foot in the Ecuadorian population, while exploring its implications for the country's healthcare system and public health strategies. Methodology This study employed a primarily descriptive design based on the analysis of monthly search volumes for the term "diabetic foot" using the Google Trends online platform ( https://trends.google.com/trends/ ). Google Trends topic-based queries consolidate multilingual search volumes into a single conceptual data set ( 4 ). Data were collected for the period spanning January 1, 2015, to July 31, 2025, with the Republic of Ecuador selected as the geographical region of interest. Search Volume Index (SVI) data for the term "diabetic foot" was generated and interpreted for the specified period, along with associated related queries. The SVI represents a normalized value on a scale of 0 to 100, reflecting the relative monthly search volume proportional to the total searches conducted within a specific time interval. It is important to note that this index does not represent the absolute number of searches performed during the period ( 4 ). The global trend for the term "diabetic foot" was included in the analysis to contextualize the search behavior observed in Ecuador within worldwide search dynamics for this clinical condition. A longitudinal analysis was conducted utilizing Google Trends data from January 2015 to July 2025 to analyze Search Volume Index (SVI) patterns for five high prevalent non-communicable diseases in Ecuador ( 6 ). Monthly SVI data were systematically retrieved these five conditions: Hypertension, Diabetic foot, Cancer, Cardiovascular disease, and Stroke, all geographically restricted to Ecuador. Furthermore, the study analyzed both top-related queries and rising-related queries. The former category comprises terms most frequently searched by users who also searched for "diabetic foot" during the analyzed period, while the latter refers to terms that experienced the most significant percentage growth in frequency during the same timeframe. Top queries are expressed in SVI values, whereas rising queries are reported as percentage increase. The dataset underwent comprehensive statistical analysis, including calculation of descriptive statistics (mean, median, standard deviation, range) for each condition and comparative analysis across diseases to identify temporal patterns and relative public engagement levels. Time-series analysis was employed to identify significant fluctuations and peak interest periods, with particular attention to the COVID-19 pandemic period (2020–2021) to assess potential pandemic-related effects on search behavior. All analyses were performed using standardized SVI metrics (relative scale 0-100) to ensure comparability across search terms and time periods ( 4 ). Statistical analysis A non-parametric statistical analysis using the Spearman rank correlation coefficient was conducted to evaluate the correlation between the variability in Ecuadorian and worldwide SVI (Surgical Volume Index) data. The analysis was performed using Google Sheets as a spreadsheet and data analysis tool. Results Figure 1 illustrates the longitudinal trends in Search Volume Index for "diabetic foot" in Ecuador compared to worldwide patterns from January 2015 to July 2025. The Ecuadorian data demonstrate substantial volatility with several pronounced peaks, most notably reaching the maximum SVI of 100 in February 2023, followed by secondary surges in July 2022 (SVI = 97) and November 2019 (SVI = 95). The global trend exhibits a more gradual upward trajectory, achieving its peak SVI of 100 in May 2025. Both datasets show synchronized patterns of interest fluctuation, particularly evident during the 2020–2021 pandemic period where both experienced temporary declines followed by accelerated growth phases. The Ecuadorian SVI frequently exceeded global values during peak engagement periods, suggesting periods of intensified regional concern relative to worldwide search behavior. The post-2020 period is characterized by increased volatility and generally elevated search interest in both datasets, indicating growing global attention to diabetic foot complications over the study period. A Spearman correlation coefficient of 0.6503 shows a moderate-to-strong positive association, indicating that Google search trends for 'diabetic foot' in Ecuador significantly synchronize with global patterns. The global Search Volume Index (SVI) analysis for "diabetic foot" reveals marked regional variations, with Latin American countries exhibiting the highest search interest. Nicaragua demonstrated the highest SVI (100), followed by Mexico (95) and El Salvador (94) as shown in shown in Table 1 . Ecuador ranked eighth (SVI 64), showing moderate but notable interest compared to regional neighbors such as Colombia (SVI 30) and Peru (SVI 61). In contrast, high-income nations, including the U.S., U.K., and Western European countries, displayed substantially lower search volumes (SVI ≤ 13). Spearman's correlation analysis revealed a strong positive association (ρ = 0.6503, p < 0.001) between worldwide and Ecuador-specific Search Volume Index trends for diabetic foot, indicating that Ecuadorian search patterns significantly reflect global interest fluctuations in this complication. Analysis of Google Trends SVI data for Ecuador (2015–2025) reveals significant variations in public interest across major NCDs. Cancer maintained consistently high search volumes (peak SVI = 100), while diabetic foot showed persistently low engagement (SVI = 2–3) as shown in Fig. 2 . Hypertension exhibited the most pronounced fluctuation, with a pandemic-related surge to SVI = 55 in April 2020. Cardiovascular diseases and stroke demonstrated gradual increases post-2020, reaching SVI = 14 and SVI = 21 respectively. Notably, diabetic foot search volumes remained an order of magnitude lower than those for cancer throughout the study period. The analysis of search queries related to diabetic foot in Ecuador demonstrates distinct information-seeking patterns. The term "pie diabetico" showed the highest search volume (SVI = 100), followed by linguistic variations ("pie de diabetico" SVI = 38; "pie diabético" SVI = 15) as detailed in Table 2 . Rising queries predominantly focused on clinical aspects, including infection ("pie diabético infectado"), symptoms ("síntomas de pie diabético"), and treatment ("cómo curar un pie diabético"). Technical terminology related to classification systems ("Wagner," "Texas," "CIE 10") and formal documentation searches ("pie diabético pdf") were notably present. The dataset also revealed common misspellings ("pie diavetico") and related terms ("podologo," "hiperglucemia") in user queries. Table 3 reveal the analysis of Google Trends SVI data for five major non-communicable diseases in Ecuador revealed significant differences in public search patterns. Hypertension showed the greatest variability (range 16–55, SD = 1.59), peaking during the COVID-19 pandemic (SVI = 55, April 2020). Cancer maintained the highest overall search interest (median SVI = 59, maximum SVI = 100). Cardiovascular diseases and stroke exhibited moderate but stable search volumes (medians SVI = 7 and 13 respectively). Diabetic foot demonstrated consistently low engagement (range 1–3, mean = 2.18 ± 0.13), with search volumes substantially lower than other conditions examined. Discussion The observed volatility in search interest, particularly the post-2020 surge in SVI variance, likely signifies a complex interplay of heightened public health awareness, potential seasonal fluctuations in diabetic foot complications, and increased media coverage of diabetes-related risks. This pattern of amplified digital health-seeking behavior during and after the COVID-19 pandemic aligns with global infodemiological studies, suggesting that healthcare system disruptions and heightened population-wide health consciousness may have collectively driven more volatile and intensive information-seeking practices regarding diabetic foot complications ( 7 , 8 ). However, the lack of a consistent seasonal pattern suggests that external factors, such as policy changes or digital health information dissemination, may play a significant role. Future studies should investigate correlations between these search trends and clinical epidemiological data to determine whether rising SVI corresponds to actual increases in diabetic foot incidence or improved public health literacy. Additionally, examining the impact of social media and news coverage on search behavior could clarify the drivers behind these digital engagement patterns. The pronounced concentration of search interest in Latin American nations potentially reflects regional disparities in diabetes mellitus burden, limitations in healthcare accessibility, and varying implementation of public health initiatives targeting pedal complications. Ecuador's intermediate ranking suggests the influence of distinct sociodemographic and healthcare delivery factors that differentiate its infodemiological profile from both higher and lower-search intensity neighbors. The comparatively minimal search volumes observed in high-income countries may indicate more effective preventive care pathways mitigating public concern or fundamentally different health communication ecosystems. This latter observation presents a compelling contradiction to existing literature which typically attributes limited digital health engagement in developing nations to infrastructural barriers and socioeconomic constraints, suggesting instead that high perceived disease burden may override these limitations in specific clinical contexts ( 7 ). Further research should explore whether these digital patterns correlate with clinical epidemiology, healthcare infrastructure, or cultural perceptions of diabetes-related complications in these regions. Understanding these dynamics could inform targeted public health interventions to address diabetic foot awareness and prevention as shown in previous works ( 9 ). The minimal public engagement with diabetic foot-related searches contrasts sharply with Ecuador's high diabetes prevalence and the condition's clinical significance as a major complication. This disparity suggests potential gaps in patient education or public health communication regarding diabetes-related foot care. Elevated search volumes for cancer and hypertension suggest effective awareness campaigns, yet contrast with documented declines in oncology-related queries observed in other regions during the initial pandemic wave ( 10 ). The findings highlight a critical need for targeted health communication strategies to improve recognition of diabetic foot risks, particularly given its preventable nature and substantial impact on quality of life. Future research should investigate whether this digital engagement pattern correlates with clinical outcomes or healthcare utilization patterns for diabetic foot complications in Ecuador. The analysis of search query semantics provides valuable insights into the evolving public understanding of diabetic foot disease in Ecuador. The predominance of foundational terminology searches, concurrent with rising interest in specific clinical manifestations such as infection and symptomatology, suggests a developing public awareness of the condition's severity and potential complications. This pattern of information-seeking behavior, where foundational knowledge precedes more complex clinical inquiries, aligns with established infodemiological models for diabetes-related complications, which similarly document that population-level search interest in specific sequelae like diabetic foot often emerges subsequent to, and at lower volumes than, general diabetes-related queries, yet demonstrates a distinct and growing trajectory as public health literacy matures ( 11 ). The presence of technical classification systems in searches may indicate either healthcare professional engagement or patients seeking advanced information, potentially reflecting gaps in primary care communication. The observed misspellings and related metabolic terms underscore fundamental challenges in health literacy that could hinder effective prevention and self-care. These findings suggest a need for multilingual, literacy-appropriate educational campaigns that address both basic awareness and clinical management of diabetic foot, while also improving the accessibility of reliable health information for Ecuador's diverse population. The minimal public engagement with diabetic foot-related, in comparison with other chronic NCDs searches presents a paradox in a country with significant diabetes prevalence. This finding may reflect either insufficient public awareness campaigns about this serious complication or potentially successful preventive care reducing information needs. The stark contrast with more volatile search patterns for hypertension and consistently high cancer-related queries suggests differing levels of public concern and media attention across disease categories. The results particularly emphasize the need to evaluate whether current diabetes education programs adequately address foot care complications. This study is subject to several important limitations that should be considered when interpreting the findings. First, the analysis inherently excludes segments of the Ecuadorian population without internet access or who do not utilize digital resources for health information, a significant consideration given that national data indicate only 66% of households had internet access and 77.2% of individuals used internet as of July 2024, with notable disparities in smartphone ownership (57.7%) and digital illiteracy (5.4%) ( 12 ). Second, the exclusive reliance on Google Trends data means search behaviors occurring on alternative search engines, social media platforms, or dedicated health websites, where substantial health information exchange occurs, remain unaccounted for in our analysis. Third, the study cannot control confounding variables that influence search behavior patterns, including educational attainment, digital literacy levels, linguistic variations, or cultural differences in health information-seeking behaviors. Finally, the aggregated nature of Google Trends data prevents granular analysis of specific search terms within the "diabetic foot" category, limiting our ability to discern nuanced variations in search intent or content focus as described by other authors ( 13 ). This study offers significant methodological strengths through its innovative application of infodemiology to assess public health engagement with diabetic foot in Ecuador. The analysis successfully identifies critical patterns in search behavior that reveal both population-level awareness gaps and specific educational needs, demonstrated through the co-occurrence of technical terminology searches (suggesting healthcare professional engagement) alongside basic term queries and misspellings indicating patient knowledge deficits. The longitudinal design captures important temporal trends, including post-2020 volatility increases potentially reflecting pandemic-related healthcare disruptions, while comparative analyses with both other non-communicable diseases and regional patterns provide valuable context for interpreting Ecuador's distinct digital engagement landscape. These findings establish a robust foundation for developing targeted health communication strategies and provide a replicable framework for monitoring public health priorities in resource-limited settings where traditional epidemiological data remain scarce. Conclusions This infodemiological study, leveraging Google Trends data in a setting with limited formal epidemiological records, reveals critical insights into Ecuador's public engagement with diabetic foot-related information. The findings demonstrate concerning disparities between the country's high diabetes prevalence and low search volumes for diabetic foot complications, suggesting either significant awareness gaps or potential shortcomings in current prevention strategies. The analysis highlights the need for targeted, literacy-appropriate health communication campaigns and improved integration of foot care education into diabetes management programs. Particularly striking is the contrast between stable diabetic foot searches and volatile patterns for other NCDs, underscoring the condition's under-prioritization in public health discourse despite its clinical severity and prevalence in the country. These digital behavior patterns serve as valuable indicators for shaping future public health interventions, emphasizing the importance of infodemiology as a complementary tool for health policy development in resource-limited settings. The study establishes a foundation for ongoing monitoring of diabetic foot awareness while calling for coordinated efforts to bridge the gap between digital engagement patterns and clinical prevention needs in Ecuador's diabetes care landscape. Declarations Ethics Informed consent was not required for this study as it utilized publicly available, aggregated data without direct human involvement. Acknowledgments During the preparation of this work, the author used different Large Language Models in order to refine the clarity and flow of the text. References Soonarane YK, Kirk M, Khandaker G, Varrall R (2025) Epidemiology and healthcare access inequities in diabetic foot disease: A retrospective study in Central Queensland, Australia. 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Available from: https://www.ecuadorencifras.gob.ec/tecnologias-de-la-informacion-y-comunicacion-tic/ Rovetta A Google trends in infodemiology: Methodological steps to avoid irreproducible results and invalid conclusions. Int J Med Inform [Internet]. 2024 Oct 1 [cited 2025 Nov 16];190. Available from: https://pubmed.ncbi.nlm.nih.gov/39043059/ Tables Tables are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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07:06:54","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":49048,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8662717/v1/a8b67c52be60d43ac4de11a3.html"},{"id":100856644,"identity":"23af6301-837b-444d-9ec3-f358d4550b5e","added_by":"auto","created_at":"2026-01-22 07:06:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":463881,"visible":true,"origin":"","legend":"\u003cp\u003eComparative Longitudinal Trends in Search Volume Index for \"Diabetic Foot\": Ecuador versus Worldwide Data (January 2015 - July 2025)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8662717/v1/fe2afde7ccba5ea67967c528.png"},{"id":100859313,"identity":"daef3cb2-6f4e-4020-a247-5d80f31d6088","added_by":"auto","created_at":"2026-01-22 07:26:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":329961,"visible":true,"origin":"","legend":"\u003cp\u003eComparative Search Volume Index Trends for Major Non-Communicable Diseases in Ecuador (2015-2025)\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8662717/v1/e1f5e8d9443715a6f2f33041.png"},{"id":101207510,"identity":"8a93b0c7-f262-41dd-b39b-eb866f5e6907","added_by":"auto","created_at":"2026-01-27 10:05:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":857366,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8662717/v1/f4b48f10-4984-47dd-8afd-64be9ff5f86d.pdf"},{"id":100949539,"identity":"a27da8f5-a122-4993-9869-cf57249a2fdf","added_by":"auto","created_at":"2026-01-23 07:04:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":32276,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8662717/v1/de1e6efe772b4c61beb7e6c7.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eDigital echoes of disease: Infodemiological analysis of diabetic foot search behavior in Ecuador\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetic foot disease (DFD) refers to the variety of pathological conditions that might affect the feet in patients with diabetes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It is a severe manifestation of diabetes mellitus, characterized by tissue destruction, ulceration, or infection in the presence of neuropathy and/or peripheral arterial disease. Foot-related complications, encompassing infections, ulcerations, and gangrene, represent a leading cause of hospitalization among individuals with diabetes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This condition serves as a critical prognostic indicator for lower extremity amputations and mortality, with studies reporting five-year mortality rates approaching 50% following the development of diabetic foot ulcers (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNational epidemiological data reveal a diabetes prevalence of 5.53% in Ecuador, with higher rates observed among women (6.17%) compared to men (4.57%). Significant risk factors include age over 45 years (OR = 18.18), overweight/obesity (OR = 2.81), family history of diabetes (OR = 2.99), and hypertension (OR = 3.02). Population-level risk stratification using FINDRISK demonstrates that 17.4% of Ecuadorians fall into the high-risk category, while 38.4% and 44.2% exhibit moderate and low risk, respectively (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInfodemiology has emerged as a novel approach to assess population-level health concerns through digital search behavior analysis, particularly valuable in settings lacking comprehensive epidemiological data (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The present research addresses a critical knowledge gap by employing Google Trends to examine diabetic foot-related searches in Ecuador, where formal epidemiological data on this complication remains scarce. This study aims to characterize online search behavior and public interest regarding diabetic foot in the Ecuadorian population, while exploring its implications for the country's healthcare system and public health strategies.\u003c/p\u003e "},{"header":"Methodology","content":"\u003cp\u003eThis study employed a primarily descriptive design based on the analysis of monthly search volumes for the term \"diabetic foot\" using the Google Trends online platform (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://trends.google.com/trends/\u003c/span\u003e\u003cspan address=\"https://trends.google.com/trends/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Google Trends topic-based queries consolidate multilingual search volumes into a single conceptual data set (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Data were collected for the period spanning January 1, 2015, to July 31, 2025, with the Republic of Ecuador selected as the geographical region of interest.\u003c/p\u003e\u003cp\u003eSearch Volume Index (SVI) data for the term \"diabetic foot\" was generated and interpreted for the specified period, along with associated related queries. The SVI represents a normalized value on a scale of 0 to 100, reflecting the relative monthly search volume proportional to the total searches conducted within a specific time interval. It is important to note that this index does not represent the absolute number of searches performed during the period (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe global trend for the term \"diabetic foot\" was included in the analysis to contextualize the search behavior observed in Ecuador within worldwide search dynamics for this clinical condition.\u003c/p\u003e\u003cp\u003eA longitudinal analysis was conducted utilizing Google Trends data from January 2015 to July 2025 to analyze Search Volume Index (SVI) patterns for five high prevalent non-communicable diseases in Ecuador (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Monthly SVI data were systematically retrieved these five conditions: Hypertension, Diabetic foot, Cancer, Cardiovascular disease, and Stroke, all geographically restricted to Ecuador.\u003c/p\u003e\u003cp\u003eFurthermore, the study analyzed both top-related queries and rising-related queries. The former category comprises terms most frequently searched by users who also searched for \"diabetic foot\" during the analyzed period, while the latter refers to terms that experienced the most significant percentage growth in frequency during the same timeframe. Top queries are expressed in SVI values, whereas rising queries are reported as percentage increase.\u003c/p\u003e\u003cp\u003eThe dataset underwent comprehensive statistical analysis, including calculation of descriptive statistics (mean, median, standard deviation, range) for each condition and comparative analysis across diseases to identify temporal patterns and relative public engagement levels. Time-series analysis was employed to identify significant fluctuations and peak interest periods, with particular attention to the COVID-19 pandemic period (2020–2021) to assess potential pandemic-related effects on search behavior. All analyses were performed using standardized SVI metrics (relative scale 0-100) to ensure comparability across search terms and time periods (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eA non-parametric statistical analysis using the Spearman rank correlation coefficient was conducted to evaluate the correlation between the variability in Ecuadorian and worldwide SVI (Surgical Volume Index) data. The analysis was performed using Google Sheets as a spreadsheet and data analysis tool.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the longitudinal trends in Search Volume Index for \u0026quot;diabetic foot\u0026quot; in Ecuador compared to worldwide patterns from January 2015 to July 2025. The Ecuadorian data demonstrate substantial volatility with several pronounced peaks, most notably reaching the maximum SVI of 100 in February 2023, followed by secondary surges in July 2022 (SVI\u0026thinsp;=\u0026thinsp;97) and November 2019 (SVI\u0026thinsp;=\u0026thinsp;95). The global trend exhibits a more gradual upward trajectory, achieving its peak SVI of 100 in May 2025. Both datasets show synchronized patterns of interest fluctuation, particularly evident during the 2020\u0026ndash;2021 pandemic period where both experienced temporary declines followed by accelerated growth phases. The Ecuadorian SVI frequently exceeded global values during peak engagement periods, suggesting periods of intensified regional concern relative to worldwide search behavior. The post-2020 period is characterized by increased volatility and generally elevated search interest in both datasets, indicating growing global attention to diabetic foot complications over the study period.\u003c/p\u003e\n\u003cp\u003eA Spearman correlation coefficient of 0.6503 shows a moderate-to-strong positive association, indicating that Google search trends for \u0026apos;diabetic foot\u0026apos; in Ecuador significantly synchronize with global patterns.\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eThe global Search Volume Index (SVI) analysis for \u0026quot;diabetic foot\u0026quot; reveals marked regional variations, with Latin American countries exhibiting the highest search interest. Nicaragua demonstrated the highest SVI (100), followed by Mexico (95) and El Salvador (94) as shown in shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Ecuador ranked eighth (SVI 64), showing moderate but notable interest compared to regional neighbors such as Colombia (SVI 30) and Peru (SVI 61). In contrast, high-income nations, including the U.S., U.K., and Western European countries, displayed substantially lower search volumes (SVI\u0026thinsp;\u0026le;\u0026thinsp;13).\u003c/p\u003e\n\u003cp\u003eSpearman\u0026apos;s correlation analysis revealed a strong positive association (\u0026rho;\u0026thinsp;=\u0026thinsp;0.6503, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between worldwide and Ecuador-specific Search Volume Index trends for diabetic foot, indicating that Ecuadorian search patterns significantly reflect global interest fluctuations in this complication.\u003c/p\u003e\n\u003cp\u003eAnalysis of Google Trends SVI data for Ecuador (2015\u0026ndash;2025) reveals significant variations in public interest across major NCDs. Cancer maintained consistently high search volumes (peak SVI\u0026thinsp;=\u0026thinsp;100), while diabetic foot showed persistently low engagement (SVI\u0026thinsp;=\u0026thinsp;2\u0026ndash;3) as shown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Hypertension exhibited the most pronounced fluctuation, with a pandemic-related surge to SVI\u0026thinsp;=\u0026thinsp;55 in April 2020. Cardiovascular diseases and stroke demonstrated gradual increases post-2020, reaching SVI\u0026thinsp;=\u0026thinsp;14 and SVI\u0026thinsp;=\u0026thinsp;21 respectively. Notably, diabetic foot search volumes remained an order of magnitude lower than those for cancer throughout the study period.\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eThe analysis of search queries related to diabetic foot in Ecuador demonstrates distinct information-seeking patterns. The term \u0026quot;pie diabetico\u0026quot; showed the highest search volume (SVI\u0026thinsp;=\u0026thinsp;100), followed by linguistic variations (\u0026quot;pie de diabetico\u0026quot; SVI\u0026thinsp;=\u0026thinsp;38; \u0026quot;pie diab\u0026eacute;tico\u0026quot; SVI\u0026thinsp;=\u0026thinsp;15) as detailed in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Rising queries predominantly focused on clinical aspects, including infection (\u0026quot;pie diab\u0026eacute;tico infectado\u0026quot;), symptoms (\u0026quot;s\u0026iacute;ntomas de pie diab\u0026eacute;tico\u0026quot;), and treatment (\u0026quot;c\u0026oacute;mo curar un pie diab\u0026eacute;tico\u0026quot;). Technical terminology related to classification systems (\u0026quot;Wagner,\u0026quot; \u0026quot;Texas,\u0026quot; \u0026quot;CIE 10\u0026quot;) and formal documentation searches (\u0026quot;pie diab\u0026eacute;tico pdf\u0026quot;) were notably present. The dataset also revealed common misspellings (\u0026quot;pie diavetico\u0026quot;) and related terms (\u0026quot;podologo,\u0026quot; \u0026quot;hiperglucemia\u0026quot;) in user queries.\u003c/p\u003e\n\n\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e reveal the analysis of Google Trends SVI data for five major non-communicable diseases in Ecuador revealed significant differences in public search patterns. Hypertension showed the greatest variability (range 16\u0026ndash;55, SD\u0026thinsp;=\u0026thinsp;1.59), peaking during the COVID-19 pandemic (SVI\u0026thinsp;=\u0026thinsp;55, April 2020). Cancer maintained the highest overall search interest (median SVI\u0026thinsp;=\u0026thinsp;59, maximum SVI\u0026thinsp;=\u0026thinsp;100). Cardiovascular diseases and stroke exhibited moderate but stable search volumes (medians SVI\u0026thinsp;=\u0026thinsp;7 and 13 respectively). Diabetic foot demonstrated consistently low engagement (range 1\u0026ndash;3, mean\u0026thinsp;=\u0026thinsp;2.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13), with search volumes substantially lower than other conditions examined.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe observed volatility in search interest, particularly the post-2020 surge in SVI variance, likely signifies a complex interplay of heightened public health awareness, potential seasonal fluctuations in diabetic foot complications, and increased media coverage of diabetes-related risks. This pattern of amplified digital health-seeking behavior during and after the COVID-19 pandemic aligns with global infodemiological studies, suggesting that healthcare system disruptions and heightened population-wide health consciousness may have collectively driven more volatile and intensive information-seeking practices regarding diabetic foot complications (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, the lack of a consistent seasonal pattern suggests that external factors, such as policy changes or digital health information dissemination, may play a significant role. Future studies should investigate correlations between these search trends and clinical epidemiological data to determine whether rising SVI corresponds to actual increases in diabetic foot incidence or improved public health literacy. Additionally, examining the impact of social media and news coverage on search behavior could clarify the drivers behind these digital engagement patterns.\u003c/p\u003e \u003cp\u003eThe pronounced concentration of search interest in Latin American nations potentially reflects regional disparities in diabetes mellitus burden, limitations in healthcare accessibility, and varying implementation of public health initiatives targeting pedal complications. Ecuador's intermediate ranking suggests the influence of distinct sociodemographic and healthcare delivery factors that differentiate its infodemiological profile from both higher and lower-search intensity neighbors. The comparatively minimal search volumes observed in high-income countries may indicate more effective preventive care pathways mitigating public concern or fundamentally different health communication ecosystems. This latter observation presents a compelling contradiction to existing literature which typically attributes limited digital health engagement in developing nations to infrastructural barriers and socioeconomic constraints, suggesting instead that high perceived disease burden may override these limitations in specific clinical contexts (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurther research should explore whether these digital patterns correlate with clinical epidemiology, healthcare infrastructure, or cultural perceptions of diabetes-related complications in these regions. Understanding these dynamics could inform targeted public health interventions to address diabetic foot awareness and prevention as shown in previous works (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe minimal public engagement with diabetic foot-related searches contrasts sharply with Ecuador's high diabetes prevalence and the condition's clinical significance as a major complication. This disparity suggests potential gaps in patient education or public health communication regarding diabetes-related foot care. Elevated search volumes for cancer and hypertension suggest effective awareness campaigns, yet contrast with documented declines in oncology-related queries observed in other regions during the initial pandemic wave (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The findings highlight a critical need for targeted health communication strategies to improve recognition of diabetic foot risks, particularly given its preventable nature and substantial impact on quality of life. Future research should investigate whether this digital engagement pattern correlates with clinical outcomes or healthcare utilization patterns for diabetic foot complications in Ecuador.\u003c/p\u003e \u003cp\u003eThe analysis of search query semantics provides valuable insights into the evolving public understanding of diabetic foot disease in Ecuador. The predominance of foundational terminology searches, concurrent with rising interest in specific clinical manifestations such as infection and symptomatology, suggests a developing public awareness of the condition's severity and potential complications. This pattern of information-seeking behavior, where foundational knowledge precedes more complex clinical inquiries, aligns with established infodemiological models for diabetes-related complications, which similarly document that population-level search interest in specific sequelae like diabetic foot often emerges subsequent to, and at lower volumes than, general diabetes-related queries, yet demonstrates a distinct and growing trajectory as public health literacy matures (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The presence of technical classification systems in searches may indicate either healthcare professional engagement or patients seeking advanced information, potentially reflecting gaps in primary care communication. The observed misspellings and related metabolic terms underscore fundamental challenges in health literacy that could hinder effective prevention and self-care. These findings suggest a need for multilingual, literacy-appropriate educational campaigns that address both basic awareness and clinical management of diabetic foot, while also improving the accessibility of reliable health information for Ecuador's diverse population.\u003c/p\u003e \u003cp\u003eThe minimal public engagement with diabetic foot-related, in comparison with other chronic NCDs searches presents a paradox in a country with significant diabetes prevalence. This finding may reflect either insufficient public awareness campaigns about this serious complication or potentially successful preventive care reducing information needs. The stark contrast with more volatile search patterns for hypertension and consistently high cancer-related queries suggests differing levels of public concern and media attention across disease categories. The results particularly emphasize the need to evaluate whether current diabetes education programs adequately address foot care complications.\u003c/p\u003e \u003cp\u003eThis study is subject to several important limitations that should be considered when interpreting the findings. First, the analysis inherently excludes segments of the Ecuadorian population without internet access or who do not utilize digital resources for health information, a significant consideration given that national data indicate only 66% of households had internet access and 77.2% of individuals used internet as of July 2024, with notable disparities in smartphone ownership (57.7%) and digital illiteracy (5.4%) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Second, the exclusive reliance on Google Trends data means search behaviors occurring on alternative search engines, social media platforms, or dedicated health websites, where substantial health information exchange occurs, remain unaccounted for in our analysis. Third, the study cannot control confounding variables that influence search behavior patterns, including educational attainment, digital literacy levels, linguistic variations, or cultural differences in health information-seeking behaviors. Finally, the aggregated nature of Google Trends data prevents granular analysis of specific search terms within the \"diabetic foot\" category, limiting our ability to discern nuanced variations in search intent or content focus as described by other authors (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study offers significant methodological strengths through its innovative application of infodemiology to assess public health engagement with diabetic foot in Ecuador. The analysis successfully identifies critical patterns in search behavior that reveal both population-level awareness gaps and specific educational needs, demonstrated through the co-occurrence of technical terminology searches (suggesting healthcare professional engagement) alongside basic term queries and misspellings indicating patient knowledge deficits. The longitudinal design captures important temporal trends, including post-2020 volatility increases potentially reflecting pandemic-related healthcare disruptions, while comparative analyses with both other non-communicable diseases and regional patterns provide valuable context for interpreting Ecuador's distinct digital engagement landscape. These findings establish a robust foundation for developing targeted health communication strategies and provide a replicable framework for monitoring public health priorities in resource-limited settings where traditional epidemiological data remain scarce.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis infodemiological study, leveraging Google Trends data in a setting with limited formal epidemiological records, reveals critical insights into Ecuador's public engagement with diabetic foot-related information. The findings demonstrate concerning disparities between the country's high diabetes prevalence and low search volumes for diabetic foot complications, suggesting either significant awareness gaps or potential shortcomings in current prevention strategies. The analysis highlights the need for targeted, literacy-appropriate health communication campaigns and improved integration of foot care education into diabetes management programs. Particularly striking is the contrast between stable diabetic foot searches and volatile patterns for other NCDs, underscoring the condition's under-prioritization in public health discourse despite its clinical severity and prevalence in the country. These digital behavior patterns serve as valuable indicators for shaping future public health interventions, emphasizing the importance of infodemiology as a complementary tool for health policy development in resource-limited settings. The study establishes a foundation for ongoing monitoring of diabetic foot awareness while calling for coordinated efforts to bridge the gap between digital engagement patterns and clinical prevention needs in Ecuador's diabetes care landscape.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eEthics\u003c/h2\u003e\n\u003cp\u003eInformed consent was not required for this study as it utilized publicly available, aggregated data without direct human involvement.\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eDuring the preparation of this work, the author used different Large Language Models in order to refine the clarity and flow of the text.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSoonarane YK, Kirk M, Khandaker G, Varrall R (2025) Epidemiology and healthcare access inequities in diabetic foot disease: A retrospective study in Central Queensland, Australia. BMJ Open [Internet]. Jul 28 [cited 2025 Aug 15];15(7). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/40730390/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/40730390/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoulton AJM, Whitehouse RW (2023) The Diabetic Foot. Endotext [Internet] [Internet]. Jul 28 [cited 2025 Aug 15]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK409609/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK409609/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCasa de la Diabetes Primera Encuesta Nacional de la Prevalencia de la Diabetes y factores asociados [Internet]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/28694479/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/28694479/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFelix C, Lopez-Flecher M, Vega M, Andrango K, Andrango S, Parise-Vasco JM et al Self-Reported Prevalence of Chronic Non-Communicable Diseases Concerning Socioeconomic and Educational Factors: Analysis of the PURE-Ecuador Cohort. Glob Heart [Internet]. 2025 [cited 2025 Aug 3];20(1):29. 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J Glob Health. ;10(1)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSnyder A, Jang S, Nazari IS, Som A, Flores EJ, Succi MD et al (2021) Google search volume trends for cancer screening terms during the COVID-19 pandemic. J Med Screen 28(2):210\u0026ndash;212\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRasheed R, Sivaprasad S Google trends as a surrogate marker of public awareness of diabetic retinopathy. Eye (Basingstoke) [Internet]. 2020 Jun 1 [cited 2025 Aug 21];34(6):1010\u0026ndash;2. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/32286499/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/32286499/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstituto Nacional de Estad\u0026iacute;stica y Censos del Ecuador. INEC (2025) [cited 2025 Aug 19]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/39043059/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/39043059/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Diabetic foot, Infodemiology, Google Trends, Public health surveillance","lastPublishedDoi":"10.21203/rs.3.rs-8662717/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8662717/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDiabetic foot disease (DFD) is a severe complication of diabetes with high morbidity. Ecuador has significant diabetes prevalence, yet epidemiological data on DFD remains scarce. Infodemiology, using search query data, offers a novel approach to gauge public health interest where conventional surveillance is limited. This study aimed to characterize online search behavior for DFD in Ecuador and its global context.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA longitudinal, descriptive infodemiological study was conducted using Google Trends Search Volume Index (SVI) data from January 2015 to July 2025. We analyzed monthly SVI for \"diabetic foot\" in Ecuador, global trends, and comparative interest across five non-communicable diseases (NCDs). Related top and rising search queries were examined. Statistical analysis included descriptive statistics, time-series comparison, and Spearman's correlation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEcuadorian SVI for DFD showed a volatile upward trend (ρ\u0026thinsp;=\u0026thinsp;0.6503, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), peaking at 100 in February 2023, frequently exceeding global values. Globally, Latin American nations exhibited the highest search interest, with Ecuador ranking 8th (SVI\u0026thinsp;=\u0026thinsp;64). However, comparative national analysis revealed DFD search interest (mean\u0026thinsp;=\u0026thinsp;2.18 SD\u0026thinsp;=\u0026thinsp;0.13) was an order of magnitude lower than for cancer or hypertension. Query analysis showed predominant use of basic Spanish terminology (\"pie diabetico\", SVI\u0026thinsp;=\u0026thinsp;100), alongside searches for symptoms, treatment, and clinical classifications, but also frequent misspellings.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDespite a high diabetes burden, Ecuador demonstrates disproportionately low public digital engagement with DFD information compared to other NCDs, suggesting significant awareness gaps. The alignment with global trends and specific query patterns indicates a maturing but incomplete public understanding of DFD severity. These findings underscore the utility of infodemiology in resource-limited settings and highlight an urgent need for targeted, literacy-appropriate health communication strategies to improve DFD awareness and prevention in Ecuador.\u003c/p\u003e","manuscriptTitle":"Digital echoes of disease: Infodemiological analysis of diabetic foot search behavior in Ecuador","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 07:06:49","doi":"10.21203/rs.3.rs-8662717/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab753e81-4b88-4df8-8dea-11dfa6bac13c","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61533783,"name":"Medical Informatics"}],"tags":[],"updatedAt":"2026-01-26T15:25:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 07:06:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8662717","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8662717","identity":"rs-8662717","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}