Illness beliefs predict self-care behaviours in patients with diabetic foot ulcers: A prospective study
Introduction
Diabetic foot ulcers are a common complication of diabetes, affecting up to 25% of people with the disease [1]. The costs to health services are considerable. In 2010–2011 the English health service spent £639–662 million on diabetic foot care alone: equivalent to £1 in every £150 of total spending [2]. The burden of ulceration is also significant for patients, with the rate of depressive disorder in people with ulceration reported to be as high as 32% [3].
The personal and societal costs of diabetic foot ulcers have led to initiatives, such as educational and other more complex interventions, which seek to reduce the incidence and burden of ulceration [4], [5]. The promotion of foot-related self-care behaviours is at the heart of most these approaches. Indeed, the central importance of self-care behaviours was echoed in a recent consensus statement issued by a multidisciplinary expert panel [6]. This panel advocated a range of behaviours for reducing foot complications such as ulceration, whilst also acknowledging that there is still very little evidence to support specific self-care practices.
This area of diabetes management is, however, thwarted by a lack of high quality evidence in two related areas. First, relatively little research has been undertaken into the factors which influence engagement with foot self-care. It is clear that patients often report limited knowledge and poor understanding of foot care practices [7], [8]. Unfortunately, such observations have led investigators to focus, almost exclusively, on knowledge as the precursor to behaviour; and in turn to educational interventions as a means of improving foot self-care behaviours and reducing ulcer risk [4]. We know, however, that knowledge alone is a poor determinant of behaviour [9]; and that educational interventions have, at best, only short-term effects on self-care behaviours and no discernible effect on clinical outcomes [4]. Thus, if we are to develop effective interventions to promote foot self-care behaviours we need to shift the focus away from knowledge and towards other modifiable predictors of behaviour.
Although relatively little research has been conducted into other modifiable determinants of foot-self-care behaviours, many published studies point towards patients’ beliefs as being potentially important determinants of foot-self-care practices [10], [11], [12]. The central role of patient beliefs in influencing outcomes in diabetes per se (e.g., glycaemic control, quality of life) is now well-documented [13], [14]. In contrast, their role in influencing foot-care behaviours has been limited to cross-sectional and/or qualitative studies which necessarily limit the potential to interrogate causal pathways [10], [11], [12].
A second limitation is that much of the work in this area has focussed on the self-care practices of patients at risk of ulceration, rather than those with an ulcer. In view of evidence that patients without ulcers often do not see the relevance of foot-self-care [15], it seems unlikely that findings from patients without ulcers can be readily generalised to those contending with active ulceration.
We describe here results from a prospective observational study which examined the relationship between patients’ illness beliefs and their self-reported foot care practices. The design of the study allowed us to examine the role of illness beliefs whilst controlling for the effects of ‘past behaviour’ i.e., foot-care at study entry; as this is known to be the most influential determinant of current and future behaviour: [16], [17]. Furthermore, we were also able to include in our model the effects of clinical and demographic variables which might be expected to influence engagement with self-care practices (i.e., age and ulcer severity as measured by ulcer size).
Section snippets
Patients
A convenience sample of patients with diabetes mellitus and a foot ulcer was recruited from outpatient podiatry clinics in secondary care. Patients were recruited into a longitudinal research programme examining psychological and behavioural aspects of diabetic foot ulceration. Ethics and relevant regulatory approvals were obtained from all hospital trusts from which patients were recruited and all participating patients provided written informed consent. The clinical team identified eligible
Illness beliefs
All participants completed the Brief Illness Perceptions Questionnaire (BIPQ) [18]. This instrument is derived from the highly influential self-regulatory model of illness [19] which asserts that patients form illness beliefs (also referred to as representations or cognitions) when contending with a health threat and that these beliefs play a central role in determining patients’ emotional and behavioural responses to their illness. Accordingly, illness beliefs can be expected to be influential
Participant characteristics
Table 2 summarises the clinical and demographic characteristics of all patients at baseline. This reveals that the mean age of patients was 61 years; the majority were male (n = 128); had a diagnosis of type 2 diabetes (n = 117); an average HbA1c of 8.7 (72 mmol/mol) and a mean ulcer size of 17.5 mm2. Descriptive data for the measures of illness beliefs and foot self-care behaviours are also presented in Table 2. The maximum score for each belief dimension is 10. Accordingly, our results indicate
Discussion
Foot self-care practices are assumed to be important determinants of ulcer outcomes [6]. The dominant focus of research in this field has been patients who are at risk of ulcers, but ulcer free; and also on knowledge as the primary determinant of these behaviours. However, it cannot be assumed that evidence from ulcer-free patients is generalisable to patients with ulcers. Furthermore, we know that knowledge is likely to be, at best, a necessary but not sufficient determinant of behaviour [9].
Conflicts of interest
The authors do not have any conflicts of interest to declare.
Acknowledgements
The authors also wish to acknowledge the clinical teams and patients at all participating centres for their unwavering support and cooperation; and other members of the research team who contributed to acquisition of data and data management. The present study was funded by a programme grant from the Medical Research Council, UK.
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