Introduction
For a person with diabetes, the lifetime incidence rate of a diabetic foot ulcer (DFU) is between 19% and 34%, with a yearly incidence rate of 2%, and are the leading cause of non-traumatic lower extremity amputations.1 This is of more striking significance when contextualized by the fact that there is a 45%–57% risk of death within 5 years of a diabetes-related amputation.2 3 It has even been suggested that preventing DFU development is the way to reduce diabetes-associated mortality.4 Accordingly, ever-increasing importance is given to strategies aimed at preventing the development of DFUs—so much so that the James Lind Alliance in partnership with the National Institute for Health and Care Research identified this as one of the top 10 foot health research priorities in the UK.5 Likewise, a Delphi study of key stakeholders in Australia identified that education to improve self-care practices was one of the key priorities for future research to improve diabetes-related foot health and disease.6 With appropriate disease management and effective self-care behaviors, many complications, including DFUs, are deemed to be entirely avoidable.1 3 7 8 While the role of the HCP in helping patients to effectively manage their diabetes remains a crucial aspect of diabetes care, the International Working Group on the Diabetic Foot has cited good foot self-care behaviors as a key approach to prevent the development of DFUs.1 Despite this, a large integrative review identified that HCPs frequently report that foot self-care behaviors are not undertaken consistently enough by people with diabetes.9 Given the harms and costs associated with diabetic foot disease, all approaches that may help to reduce the incidence and prevalence of this require urgent investigation—not least efficacious and cost-effective measures such as appropriate foot self-care behaviors.
Self-care has been defined as the actions an individual takes in managing the symptoms associated with a chronic condition through physical activity and other lifestyle changes.10 In diabetes, self-care is a well-established facet of achieving optimal disease management and clinical outcomes because most of the day-to-day care and management of the disease is handled by patients and/or their families.11 The American Association of Diabetes Educators12 identified seven essential self-care behaviors in diabetes which predict good outcomes, viz.: healthy eating; being physically active; monitoring blood sugar; compliance with medications; good problem-solving skills; healthy coping skills and risk-reduction behaviors (which includes reducing risk of foot ulceration via good foot care). All of these behaviors positively correlate with good glycemic control, reduction of complications and improvement in quality of life.11 13–15 Although patients need to be the ones to act, support from healthcare professionals (HCPs) on what to change and encouragement to maintain changes has been shown to increase confidence and facilitate sustained self-care behaviors.16
Optimal foot self-care behaviors include: daily washing and drying of the feet; daily visual foot examinations; application of skin moisturizer; avoiding walking bare-footed (even within the home); ensuring that bathing water is not too hot; attending regular professional foot care and following professional advice in relation to foot care behaviors.17–21 Despite self-care being widely considered to be the most cost-effective way of managing diabetes and delaying or preventing of the development of associated complications, it is often found lacking in people with diabetes and is sometimes also underappreciated by HCPs.22 Evidence indicates that foot self-care behaviors, specifically, remain underused in the prevention of DFUs.9 11 17 23–25 Mogre et al26 undertook the only large systematic review to date that included adherence to foot self-care behaviors within a range of self-care practices in diabetes. Their review of 72 studies included 10 that specifically looked at foot self-care behaviors in a pooled population of over 1600: 40% of people with diabetes undertook regular foot inspections and just 10% met the criteria of having ‘good’ foot self-care practices. In comparison, adherence rates of 58% for diet; 71% for medication taking and 41% for exercise behaviors were reported. While this review was limited to low-income and middle-income countries, the findings were largely consistent with the literature on foot self-care behaviors in many different countries—including high-income ones.17 23–25 27
It appears that adherence to recommended self-care is limited at best, and that this is a multidimensional phenomenon involving social, economic, patient-related, health system-related and condition-related factors.28 In particular, the complex interplay between the known contributory factors of socioeconomic status; patient knowledge; patient education; patient beliefs; social support; HCP-patient interactions and health service experiences is where there is a need for further understanding.29–34 Additionally, studies that have identified issues of confusion and trust between patients and their HCPs in relation to foot self-care,32 have not explored areas of consensus and tension that may exist and whether they may contribute toward any perceived barriers and facilitators to foot self-care in diabetes. Therefore, this study sought to explore patient and HCP perspectives on barriers and facilitators toward patient foot self-care behaviors in adults with diabetes currently at low risk of developing a DFU. This demographic is an important one to assess as in the context of diabetes, low-risk populations tend to become high-risk in time and the establishing of good self-care behaviors are more effective if employed earlier in the disease progression.9 17