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Who Cares About Foot Care? Barriers and Enablers of Foot Self-care Practices Among Non-Institutionalized Older Adults Diagnosed With Diabetes: An Integrative Review Lisa Matricciani and Sara Jones The Diabetes Educator published online 5 December 2014 DOI: 10.1177/0145721714560441 The online version of this article can be found at: http://tde.sagepub.com/content/early/2014/12/04/0145721714560441
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The Diabetes Educator OnlineFirst, published on December 5, 2014 as doi:10.1177/0145721714560441
TDEXXX10.1177/0145721714560441Barriers and Enablers of Foot Self-care in Older Adults Matricciani and Jones
Barriers and Enablers of Foot Self-care in Older Adults 1
Who Cares About Foot Care? Barriers and Enablers of Foot Self-care Practices Among Non-Institutionalized Older Adults Diagnosed With Diabetes An Integrative Review Purpose
Lisa Matricciani, BPod(Hons), BNurs Sara Jones, MSc, BA, Dip App Sci (Pod), PhD
Appropriate and timely foot self-care practices may prevent diabetes-related foot complications. However, selfcare practices are often neglected, particularly by older adults. The purpose of this study was to conduct an integrative, systematic literature review of the psychosocial barriers and enablers of foot self-care practices among older adults diagnosed with diabetes.
From the Sansom Institute, Division of Health Sciences, University of South Australia, Adelaide, Australia (Ms Matricciani, Dr Jones). Correspondence to Ms Lisa Matricciani, School of Health Sciences, University of South Australia, Adelaide SA 5001, Australia (matla005@ mymail.unisa.edu.au). Acknowledgments: Nancy Mastrogiacomo and Rebecca Munt for offering suggestions for this manuscript.
Methods An integrative, systematic literature review and a deductive thematic analysis was conducted to determine psychosocial barriers and enablers of foot self-care practices among older adults.
DOI: 10.1177/0145721714560441 © 2014 The Author(s)
Results A total of 130 different studies were retrieved from the search strategy. From these, 9 studies were identified and included for review. Physical ability, perceived importance, patient knowledge, provision of education, social integration, risk status, and patient-provider communication were identified as key barriers and enablers of foot self-care. Participants at high risk of foot complications were found to perceive themselves at greater risk of complications, receive more education, and engage in better overall foot self-care practices compared to those at low risk of foot complications. Matricciani and Jones Downloaded from tde.sagepub.com at TEXAS SOUTHERN UNIVERSITY on December 7, 2014
The Diabetes EDUCATOR 2
Conclusion Foot self-care practices appear underutilized as primary prevention measures by older adults and are instead adopted only once complications have already occurred. Likewise, facilitators of foot self-care practices, such as education, appear to be reserved for individuals who have already developed foot complications. Health care professionals such as diabetes educators, podiatrists, and general practitioners may play an important role in the prevention of foot complications among older adults by recognizing, referring, and providing early education to older adults.
Introduction Diabetes is the world’s fastest growing chronic condition, affecting over 300 million people worldwide, with estimates expected to approximately double by the year 2035.1 The risk of diabetes increases with age, and as such, older adults have the highest prevalence of diabetes.2-4 The proportion of older adults diagnosed with diabetes is projected to rise in line with the anticipated increase in population age.5 Such trends are concerning given that older adults experience significantly more diabetes-related health complications and health care costs than their younger counterparts.3 Foot complications are among the most serious, costly, and disabling consequences of diabetes and predominantly affect older adults.6,7 Older adults have a 2-fold increased risk of developing a foot ulcer and have the highest rate of major lower limb amputations secondary to diabetes.8,9 Foot ulcers are challenging to treat. Even with intensive and timely treatment, involving costly and time-consuming wound dressing changes, many foot ulcers do not heal, recur, and/or progress to amputation.10 This often leads to depression and reduced quality of life.11-13 Primary prevention strategies, such as maintaining target glycemic control and engaging in daily foot selfcare practices, are important diabetes self-management goals.14,15 Adequate glycemic control may delay the onset and progression of risk factors (ie, peripheral vascular disease, peripheral neuropathy, infection, and foot deformity) attributed to the development of foot complications. Foot self-care practices, such as inspecting feet daily, receiving professional foot care and assessments, keeping feet clean and dry, protecting feet from temperature extremes, and wearing appropriate footwear, minimizes the risk of foot complications.15,16 These self-care
practices are strongly encouraged by diabetes health authorities.17,18 Despite such recommendations, foot self-care practices are largely neglected. Cross-sectional studies reveal that a low proportion of people diagnosed with diabetes engage in preventive foot self-care practices, such as inspecting feet daily, while a high proportion undertake potentially harmful practices, such as walking barefoot.19,20 Consistent with these findings, a large population-based study reported only 20% of all people diagnosed with diabetes inspected their feet daily.21 Inadequate knowledge is often attributed as the reason why people with diabetes do not undertake foot self-care practices.22 As such, it is generally accepted that further education will equate to better knowledge, self-care practices, and an overall reduction in foot complications. However, education as a means of knowledge provision alone is not a strong predictor of preventive diabetes selfmanagement behaviors.22 Rather, education must be individualized, tailored to the unique needs, abilities, values, attitudes, and beliefs of the recipient, and address psychosocial factors underpinning self-care and careseeking behaviors to be successful.22,23 This is particularly relevant to older adults who are likely to experience age-related issues such as reduced mobility, limited social support, increased comorbidities, and cognitive decline, which may affect their ability to undertake foot self-care practices. To date, the psychosocial dimensions of foot self-care have not been extensively explored, and there has yet to be a comprehensive study that examines psychosocial barriers and enablers of foot self-care practices among older adults diagnosed with diabetes. If foot self-care practices are to continue to be advocated by health care professionals and encouraged as a primary prevention measure, then it is critical to gain an understanding of the psychosocial determinants of foot self-care, particularly among older adults, who are at greatest risk of foot complications. Therefore, the aim of this study is to systematically review the literature and answer the question, what are the psychosocial barriers and enablers of foot self-care practices among non-institutionalized older adults diagnosed with diabetes?
Methods A systematic literature search was conducted to identify all studies that examined psychosocial barriers and
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Barriers and Enablers of Foot Self-care in Older Adults 3
enablers of foot self-care practices among non-institutionalized older adults diagnosed with diabetes. The primary outcome measure was “foot self-care practices,” defined as practices undertaken by the individual in an effort to minimize their risk of diabetes-related foot complications. The primary predictor variables were “psychosocial barriers and/or enablers of foot self-care,” defined as attitudes, values, beliefs, thoughts, experiences, behaviors, and/or contextual elements that impede or promote foot self-care practices. Socioeconomic and cultural determinants of foot self-care practices were not explored in this study. Criteria for Inclusion and Exclusion
Any study that identified psychosocial barriers and/or enablers of foot self-care practices among non-institutionalized older adults diagnosed with type 1 or type 2 diabetes was considered for review. An “older adult” was defined according to the United Nations definition as any individual aged 60 years and older.24 Thus, only studies with a mean sample age of 60 years and older were included for review. In cases where the mean sample age was not reported but the number of participants per age range was reported (ie, 10 participants aged 50-60 years, 25 participants aged 60-70 years, etc.), the study was included only if the majority of participants were in the age categories 60 years and older. Both qualitative and quantitative studies were considered. Only full-text studies, published in English, since the year 2000 were accepted for inclusion for review. Studies that assessed people with and without diabetes but did not stratify findings according to diabetes status were excluded. Systematic Search Strategy
A systematic search strategy was employed to identify studies for review. Four electronic databases (Scopus, EbscoHost, Embase, Pubmed) were searched using the search terms: (Geriatric or elderly or older or aged care) and (diabet*) and (foot or feet or foot care) and (perception or beliefs or attitude* or knowledge or barrier or enabler or behav*). Date and English language limits were set. A preliminary search determined the scope and relevance of candidate databases. All abstracts were screened for inclusion criteria. Potentially eligible papers were read in full, and only relevant papers were kept for review. In cases where only an abstract was available, the
Table 1
NHMRC Hierarchy of evidence18 Level of Evidence I II III-1 III-2 III-3 IV
Study Design A systematic review of level II studies A randomized controlled trial A pseudorandomized controlled trial A comparative study with concurrent controls A comparative study without concurrent controls Case series with either posttest or pretest/posttest outcomes
study’s authors were contacted and an interlibrary loan request was made for the full-text copy of the article. If a full-text copy of the article was unavailable, the study was excluded. Reference lists of included studies were then reviewed to identify additional eligible articles. The final search was carried out on December 11, 2013. Evaluation of Studies Included for Review
All studies included in this review were read and reviewed for content extraction and appraised for their level of evidence using the NHMRC hierarchy of evidence scale (Table 1).25 Quantitative studies were appraised for their methodological quality using the STROBE (Strength of Reporting OBsevational studies in Epidemiology) checklist/tool.26 The STROBE statement provides a checklist that facilitates the critical appraisal and interpretation of observational studies. The checklist consists of 32 items regarding the article’s title, abstract, introduction, methods, results, and discussion sections as well as funding. Eighteen items are common to cohort studies, case-control studies, and cross-sectional studies, and 4 are specific to each of the 3 study designs. Given that quantitative studies included for review were a mix of cross-sectional and cohort observational studies, and there is no established instrument for quantitative observational studies, the STROBE checklist was utilized as it is suited to both types of observational studies.27 Qualitative studies were appraised for their methodological quality using the CASP (Critical Appraisal Skills Programme) checklist/tool for qualitative studies.28 The
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Scopus 80
EbscoHost 64
Pubmed 17
did not meet the inclusion criteria, and an additional 2 studies were identified by pearling study reference lists.35,39
Embase 93
Study Characteristics 254
124 Duplicates
130 123 Did not meet inclusion criteria 7
2 Pearling reference list
Total 9
Figure 1. Systematic search flow chart.
CASP checklist consists of 10 items that facilitates the systematic appraisal of reporting in qualitative studies. Specifically, the checklist allows assessment of whether the results are valid, clearly stated, and useful. The CASP appraisal tool has been used previously in systematic reviews to critically appraise qualitative studies.29,30 Analysis and Synthesis of Studies Included for Review
A deductive thematic analysis, as described by Braun and Clarke,31 was employed in this study. Specifically, all studies included for review were read and re-read in full, and key findings relating to the psychosocial barriers and enablers of foot care were recorded and summarized.
Results Search Results
The systematic search identified 9 different studies for inclusion in the review.21,32-39 As shown in Figure 1, of the 130 different studies identified, 123 were excluded as they
Table 2 presents a summary of the 9 studies included for review. With the exception of 1 qualitative study, all were quantitative observational studies. Most studies were conducted in the US (56%) and the UK (22%), followed by Australia (11%) and Germany (11%). Participants were mostly “younger older adults,” with an overall median sample age of 67 years, with diabetes for a median duration of 15.3 years. With the exception of 2 studies,35,38 there were an approximately equal number of males and females reported within each of the studies. Only 4 studies reported the type of diabetes experienced by participants. Of these, 2 studies21,39 exclusively examined participants with type 2 diabetes, while the other 2 studies37,38 examined participants with both type 1 and type 2 diabetes. The latter 2 studies did not stratify findings according to diabetes type. Critical appraisal scores of quantitative studies varied between 15 and 20 (out of 22). Overall, most studies failed to report sources of bias and how the study size was calculated. Most studies acknowledged the study strength as being the first to explore the research question proposed, while key identified weaknesses related to generalizability of results and the inherent limitation of a cross-sectional study design. Although most studies had a reasonably large sample size, the validity of self-report outcome measures had not been established in most. Further, it is important to note that measures of foot self-care varied across the studies and direct comparisons between studies cannot be made. For example, some studies defined foot self-care as inspecting feet daily while others defined foot self-care as “keeping feet clean” or created a composite measure consisting of multiple foot self-care practices. Key Findings
A summary of the key findings of all studies included for review are presented in Table 3. Overall, physical ability, perceived importance, knowledge, education, social integration, risk status, and patient-provider communication were identified as key barriers and enablers of foot self-care. Although the role of self-efficacy was explored by Perrin et al,38 the correlation was not strong enough to suggest self-efficacy beliefs predict actual foot care practices.
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Germany 2004
USA 1998
USA 2000-2001
USA 2009-2010 UK 1998
Australia 2001-2007
USA 2001-2002
USA 2002
Schmidtet al (2008)
Harwell et al (2001)
Olson et al (2009)
Arcury et al (2012) Pollock et al (2004)
Perrin et al (2009)
Bell et al (2005)
Heisler et al (2007) Lone et al (2008)
UK NR
Country, Year
Study
Descriptive Study Summary
Table 2
Cross-section Random IV 20/22 Qualitative N/A Purposive 6/10
Random
Cross-section IV 17/22
18
1588
688
96
365
Random
Convenient
563
717
537
269
n
Stratified
Random
Random
Convenient
Sampling
Cross-section IV 18/22
Cross-section IV 18/22 Cross-section IV 15/22
Cross-section IV 18/22
Cohort study III-2 18/22
Cross-section IV 16/22
Design, NHMRC, CAT
64
69.0 (8.7)
74.1 (5.4)
64.5 (10.7)
62.3 (NR)
NR
67
75.3 (8.0)
62.2 (12.4)
Age
50
54
49.4
24
NR
61.8
4
57
41.2
% Female
100
NR
100
90
NR
NR
NR
NR
62.4
% Type 2 Diabetes
6.5
11.8 (10.3)
12.4 (10.98)
15.89 (11.54)
NR
NR
NR
15.3 (11.3)
20.36 (11.12)
Duration
0
NR
NR
100
63.9
NR
100
30.73
43.3
% High Risk
Multiple dimensions of foot self-care examined, including professional care, inspection, cleaning, footwear, skin and nail care, first aid, walking barefoot Composite measure of inspection, cleaning, footwear, moisturizing, protection, skin and nail care, first aid, walking barefoot Summary of Diabetes Self-Care Activities scale; composite measure of foot self-care practices, including inspection, cleaning, footwear, soaking feet Frequency of checking feet for cuts and sores Multiple dimensions of foot self-care as expressed by participants in interview process, including inspection, cleaning, footwear, moisturizing, avoiding temperature extremes, callus debridement, nail care, first aid
The Frankfurter Catalogue of Foot Self-Care (FSCS) questionnaire; assessed 3 domains of foot self-care (professional assistance, personal self-care, footwear) as a composite and individual measures Frequency of checking feet for cuts and sores, receiving professional care, wearing protective shoes Multiple domains of foot self-care examined, including inspection, cleaning, footwear, moisturizing, avoiding temperature extremes, callus debridement, nail care, first aid Foot inspection
Foot Self-care (outcome measure)
The Diabetes EDUCATOR 6
Table 3
Summary of Study Findings Study
Key Findings
Schmidt et al (2008)
Physical mobility Foot self-care and footwear self-care were not associated with physical mobility. Patients with physical limitations were significantly more likely to receive professional foot care assistance (P < .001). Risk status High-risk patients received significantly more professional foot care assistance (P < .001) and had significantly better overall foot self-care practices compared with low-risk patients. No significant difference between risk status and foot self-care (P = .992) and footwear self-care (P = .327). Risk status did not significantly influence self-control of the feet, shoes, and socks. Education High-risk patients participated in more education programs than low-risk patients (P = .006). Participants who attended more than 3 education sessions had better foot self-care than those who did not attend any education (P = .009) or those who only attended 1 session (P = .034). Older and newly diagnosed were less likely to attend education (P value not reported). Education was not associated with professional foot care assistance (P = .522). Risk status People who were classified high risk of complications were more likely to have their feet professionally examined (P < .05), wear protective shoes (P < .05), perceive themselves at risk of complications (P < .05). Perceived risk The main reason reported by participants who did not examine their feet regularly was that they did not think it was important (60%), of whom, 79.08% were low risk of complications. Of the participants at high risk of complications, 73.93% perceived themselves at low risk of complications, and only 59% engaged in protective foot self-care practice of checking their feet daily. Physical limitations Participant-reported barriers of foot self-care (checking feet for cuts and sores) included not thinking it was important (60%), other reasons/didn’t know (30%), vision or physical limitation (9%), and didn’t know how (1%). Physical ability Participant-identified barriers included physical limitation (38%), visual impairments (19%), lack of knowledge (10%), lack of skill (10%), cost (9%), and not thinking it was important (7%). Knowledge Most participants did not feel that they “knew enough” about various foot care practices (60%). Participants felt that they “knew enough” about checking feet regularly (50%), keeping feet clean (70%), and wearing shoes all the time (57%). Few participants who reported “knowing enough” about various foot self-care practices did not actually engage in self-care practice. Social integration Measures of social integration significantly associated with better self-foot care, included having more children (P < .01). Measures of social integration significantly associated with more provider foot examinations included having larger secondary social networks (measured as the frequency of personal and telephone contacts) (P < .05) and having more children (P < .05). Risk status High-risk patients had better foot self-care (P values not reported) and better (but not significantly different, P = .21) foot care knowledge than low-risk patients. More high-risk participants (85.6%) received foot care advice than low-risk participants (77.1%). Knowledge No significant difference between knowledge and age (P = .162).
Harwell et al (2001)
Olson et al (2009)
Arcury et al (2012)
Pollock et al (2004)
(continued)
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Table 3 (continued) Study
Perrin et al (2009)
Bell et al (2005)
Heisler et al (2007)
Lone et al (2008)
Key Findings Participants who had previously received advice or information had better knowledge (P = .001). Education Most foot care advice came from podiatrists and diabetes clinics followed by general practice. Patients who received education were more likely to undertake foot examinations (P = .001). Physical limitations Participant-reported foot self-care barriers included mobility (13%), nail pathology (9%), time constraints (3%), visual impairment (2%), and being unaware of the practice (2%). Confidence in performing foot self-care behaviors Small positive correlation between Foot Care Confidence Scale scores and preventive foot-care behavior (r = 0.2; P = .05). No correlation between Foot Care Confidence Scale scores and potentially damaging behaviors (r = −0.05; P = .61). Foot Care Confidence Scale scores did not differ for those with and without a history of foot pathology (P = .95). Risk status Participants with a history foot pathology were more likely to engage in preventive behaviors (P = .02) and less likely to engage in potentially damaging behaviors (P < .001) compared to participants without a history foot pathology (ie, lower risk). Only the latter was statistically significant. Education Foot care was significantly better for people who attended a diabetes education class (P = .0668), who received information on how to care for their feet (P < .0001) and who had been shown how to care for their feet compared to those who had not (P < .0001). Physical limitations Physical functioning was not associated with foot self-care. Patient-provider communication Patients who rated their diabetes health care provider as providing adequate information were significantly more likely to engage in the foot self-care practice of checking their feet for sores and cuts (P < .001). Patients who reported participatory decision making with their diabetes health care provider were significantly more likely to engage in the foot self-care practice of checking their feet for sores and cuts (P < .001). Knowledge Participants were unaware of what a foot ulcer is, the cause, and how ulcers are treated. Participants had inadequate knowledge and misunderstandings of foot complications, including not knowing the link between glycemic control and foot complications, foot ulcers are easily healed, only people with poor foot hygiene get foot ulcers, amputations were purely the result of poor circulation, and believed neurological symptoms were the result of poor circulation. Inadequate knowledge led to dangerous foot self-care practice. For example, the belief that foot cuts and sores would easily heal resulted in many not seeking prompt medical assistance; the belief that foot complications were the result of poor circulation resulted in participants buying larger than required shoes and open shoes to promote circulation (however, for people with neuropathy, such footwear increases the risk of blisters and does not protect against trauma). Walking barefoot was also believed helpful as it was thought to “promote blood flow.” Education Participants felt foot care was often pushed aside for other topics of diabetes. Participants were often alerted to foot complications by hearing about other people’s foot problems. Patient-provider communication Patients reported difficulty communicating with health care provider and were often left feeling confused and deciding to not follow advice and rely on what they considered common sense. Participants reported not receiving adequate explanations, not understanding what was advised, perceived foot care was often the neglected component of education, and that their provider was disinterested. Regular foot checks by a podiatrist offered participants with reassurance, but only half had access to this service.
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Physical Ability
Education
Five studies identified physical ability as a barrier to foot self-care. Physical and visual limitations were reported as the main barriers of foot self-care by 57% of participants in the study by Olson and colleagues,35 while only 15% and 8% of participants reported physical limitations as a barrier of foot self-care in studies by Pollock et al36 and Harwell et al,33 respectively. Physical limitations were not associated with actual foot self-care behaviors in studies by Bell and colleagues21 and Schmidt et al.37 Restricted mobility was associated with more professional foot care in the study of Schmidt et al.37
Education was also associated with better foot selfcare practices.21,36,37 Although none of the studies examined education content or mode of delivery, Pollock et al36 revealed most foot care advice and education came from podiatrists and diabetes clinics and to a lesser extent, general practice. In contrast, Bell and colleagues21 found better self-care among those who had visited a doctor or podiatrist in the past year, although the latter association was not significant. Participants identified at high risk of foot complications received more education and/or advice than those at low risk of complications36,37 while older and newly diagnosed participants were less likely to receive education.37,39 Consistent with these findings, Lone et al39 reported most participants felt that foot care education was “pushed aside” when first diagnosed with diabetes to make way for other education topics.
Perceived Importance of Foot Self-care
Three studies identified perceived importance to be a barrier of foot self-care practices. Harwell et al33 identified 60% of participants reported they did not engage in foot self-care practices because they did not perceive such practices to be important. Of these participants, 79% were identified at low risk of foot complications. In contrast, only 2% and 7% of participants reported foot selfcare unimportant in studies by Pollock et al36 and Olson et al,35 respectively. Participants in these latter 2 studies were mostly at high risk of foot complications (63% and 100%, respectively), which may explain the discrepancy observed between studies. Knowledge
Inadequate knowledge was reported a barrier of foot self-care by 20% of participants in the study by Olson and colleagues35 and by 2% of participants in studies by Harwell et al33 and Pollock et al.36 Reports of adequate knowledge, however, did not appear to translate to actual foot self-care behaviors. Olson et al35 identified that many participants who reported “knowing enough” about specific foot self-care practices did not actually engage in the advised practice. Given findings varied according to ethnicity, the authors suggested the discrepancy may be explained by cultural factors. However, the discrepancy may also in part be explained by Lone and colleagues’39 study findings, which revealed inadequate and inaccurate foot care knowledge predicted self-care behaviors. Specifically, participants were engaging in practices they believed to “know enough” about and that they thought to be helpful but were in fact potentially harmful and not in line with medical recommendations.
Social Support
Two studies identified that elements of social integration were important enablers of foot self-care. Arcury et al32 identified having more children was significantly associated with better foot self-care while having larger secondary social networks (measured as the frequency of personal and telephone contacts) and speaking to relatives over the phone each week were significantly associated with professional foot assessments. Consistent with this study’s findings, Lone et al39 reported that many participants obtained diabetes-related foot care information through communication with family member, friends, and neighbors. Risk Status
Four studies reported better foot self-care practices by participants identified at high risk of foot complications compared with those at low risk of foot complications.33,36-38 High-risk participants were more likely to receive education and have professional foot assessments compared to low-risk participants.33,36-38 High-risk participants were also more likely to identify themselves as being high risk of foot complications. However, a significant proportion (74%) of high-risk participants considered themselves to be at low risk of complications.33 Patient-Provider Communication
Patient-provider communication was identified an important predictor of foot self-care practices in
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2 studies. Heisler and colleagues34 identified both the provision of adequate information and communication that facilitated participatory decision making were significantly associated with positive foot self-care behaviors. In contrast, Lone et al39 reported negative experiences resulted in many participants feeling confused and less likely to engage in self-care behaviors.
Discussion This is the first study to systematically review the literature to determine psychosocial barriers and enablers of foot self-care practices among non-institutionalized older adults diagnosed with diabetes. A total of 9 different studies were identified and included for review, from which physical ability, perceived importance, knowledge, education, social integration, risk status, and patient-provider communication were identified as important determinants of foot self-care practices. Identified barriers and enablers appeared independent and interrelated determinants of foot self-care, particularly with regards to risk status. Specifically, participants at high risk of foot complications were found to perceive themselves at greater risk of complications, receive more education, and engage in better overall foot self-care practices compared to those at low risk of foot complications. Given that perceived risk and education were independently associated with better foot self-care, it is likely that these factors mediated the observed association between risk status and foot self-care. The findings of this review are consistent with previous studies, which recognize health perceptions as important determinants of diabetes self-management behaviors.40,41 Such findings are in line with the Health Belief Model, a theoretical framework, that identifies perceived severity, susceptibility, benefits, costs, and cues to action as important dimensions for behavioral changes.42,43 While it is perhaps not surprising that those at high risk of foot complications perceived foot self-care practices more important than those at low risk of complications and engaged in better self-care, it remains unclear as to whether existing complications inherent of a highrisk status altered perceptions or whether a high-risk status prompted greater opportunities for education and professional assessments, thereby enhancing perceived importance. Thus, further research is needed to better understand the determinants of foot self-care perceptions and how such perceptions are associated with actual foot
self-care behaviors. Such an understanding may provide important insight into primary prevention strategies. This review also identified better foot self-care among those who received education. Education is thought to modify behaviors by empowering and motivating individuals to actively participate in self-care practices and is a recognized measure of primary prevention.14 However, education appeared reserved for those at high risk of foot complications. This finding is consistent with previous studies that report low-risk patients receive very little information about foot complications, while those with an established foot lesion are more likely to receive education.44-46 Such findings are concerning given that inadequate and inaccurate knowledge were found to facilitate potentially harmful behaviors, thereby suggesting a lack of education is a missed opportunities for prevention. Thus, there is arguably a need to ensure early education and assessment of foot care knowledge among older adults diagnosed with diabetes. Such an understanding may facilitate the prevention of potentially harmful practices that lead to foot ulceration and amputation. Patient-provider communication and social networks were also identified as enablers of foot self-care. Counter to previous investigations, which suggest older adults tend to express less desire to engage in participatory medical decision making, this review identified participatory communication styles an important enabler of foot self-care.47 It is possible that participatory communication styles facilitated achievable advice, suited to the individual’s physical abilities. For example, instructing an individual to “inspect their feet daily” is unlikely to be followed if the individual is unable to physically do so. Alternatively, participatory communication might identify this barrier and facilitate suggestions such as seeking help from a spouse or use of a mirror, which would be an achievable goal. Social networks were also an important enabler for positive foot self-care behaviors. However, it is possible that a lack of professional education and relying solely on family/friend/neighbor-derived education may, in part, contribute to misunderstandings leading to harmful behaviors. Thus, it is important that older adults are actively involved in foot self-care education and that foot self-care educational messages are predominantly delivered by health care professionals. Given the positive effect of communicating with family/friend/neighbor, it may be of benefit for such individuals to also attend education sessions.
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Table 4
Recommendations for Health Care Providers Physical ability, perceived importance, knowledge, education, social integration, risk status and patient-provider communication were identified as important determinants of foot self-care among older adults. This review provides important insight for health care providers providing foot self-care education to older adults. Specifically, the health care provider may find it effective to: - Identify the perceived importance placed on foot self-care and explain the rational and significance of preventive foot self-care practices. - Determine the patient’s knowledge of diabetes-related foot complications and foot self-care practices and provide appropriate education. - Clarify any misunderstandings that may lead to potentially harmful behaviors. - Identify whether the patient has received diabetes-related foot care education. Attempt to understand whether they enjoyed the session, learned new information, or had any questions. - Encourage social networking, as social integration facilitates foot self-care. Specifically, encourage spouses, family, or friends to attend education and for the individual to join support groups. - Identify the patient’s risk status and examine whether the patient understands their risk status and that they have received the appropriate referrals (eg, to podiatry). - Ensure communication is participatory and that the patient is engaged with the decision-making process. - Understand that patients may have beliefs relating to foot self-care that is somewhat different to medical advice, which may inadvertently lead to potentially harmful self-care practices. Efforts to understand these beliefs may facilitate positive behavior-modifying education
Strengths and Limitations
This is the first integrative, systematic literature review to examine psychosocial barriers and enablers of foot self-care among non-institutionalized older adults diagnosed with diabetes. As such, this review provides important insight into an important issue largely unexplored. However, several limitations need be addressed. Specifically, only full-text studies written in English since the year 2000 were included for review, which were then reviewed by only 1 reviewer. Furthermore, given that most of studies examined “younger older adults,” the results of this review may not accurately reflect “older adults.” The reported limitations of each of the studies included for review also need to be considered, of particular note, failure to report sources of bias. Given the apparent scarcity of evidence examining psychosocial barriers and enablers of foot self-care practices among non-institutionalized older adults diagnosed with diabetes, further research in this area in needed. Specifically, efforts are needed to better understand differences that exist according to risk status and diabetes type using validated outcome measures. Such investigations may provide important insight into the prevention of
foot complications. Future studies may also benefit from a mixed-method approach to quantify observed associations to gain the in-depth insight that only qualitative studies can achieve. However, until such research is conducted, the available literature tends to suggest health care providers need to consider physical ability, perceived importance, knowledge, education, social integration, risk status, and patient-provider communication when delivering foot self-care education to older adults. Table 4 summarizes the inferred recommendations from this study for health care providers delivering foot self-care education.
Conclusion This integrative review provides insight into the unique psychosocial barriers and enablers of foot selfcare among non-institutionalized older adults diagnosed with diabetes. Collectively, studies included for review suggest individuals who perceive foot care important, are at high risk of foot complications, have positive patientprovider communication experiences and strong social networks, and who have received education are more likely to engage in foot self-care practices. The issue of concern is that those who are identified as lower risk (or
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Barriers and Enablers of Foot Self-care in Older Adults 11
who identify themselves as such) are less likely to undertake self-care practices, thus potentially predisposing themselves to future complications. The challenge in future studies is to identify means and methods to facilitate an increase in the awareness of the importance of self-care, both among this patient group and among their health care providers.
Implications for Educators This review identifies psychosocial barriers and enablers of foot self-care practices among older, noninstitutionalized, adults diagnosed with diabetes. Physical ability, perceived importance, patient knowledge, provision of education, social integration, risk status, and patient-provider communication were identified barriers and enablers of foot self-care. Participants at high risk of foot complications were found to perceive themselves at greater risk of complications, receive more education, and engage in better overall foot self-care practices compared to those at low risk of foot complications. In understanding potential barrier and enablers of foot self-care practices, educators may be equipped to provide more effective education. Further, as this review highlights, there is a need for enhanced education among low-risk patients in an effort to prevent the development of potential future complications. References 1. International Diabetes Federation 2013. Managing Older People With Type 2 Diabetes: Global Guideline. http://www.idf.org/sites/ default/files/IDF-Guideline-for-older-people-T2D.pdf. Accessed January 15, 2013. 2. Selvin E, Coresh J, Brancati FL. The burden and treatment of diabetes in elderly individuals in the US. Diabetes Care. 2006;29(11):2415-2419. 3. Kirkman MS, Briscoe V, Clark N, et al. Diabetes in older adults. Diabetes Care. 2012;35(12):2650-2664. 4. Wild S, Roglic G, Green A, et al. Global prevalence of diabetes estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27(5):1047-1053. 5. Cheng Y, Imperatore G, Geiss L, et al. Secular changes in the agespecific prevalence of diabetes among US adults: 1988–2010. Diabetes Care. 2013;36(9):2690-2696. 6. Pataky Z, Vischer U. Diabetic foot disease in the elderly. Diabetes Metab. 2007;33(1):56-65. 7. Stockl K, Vanderplas A, Tafesse E, et al. Costs of lower-extremity ulcers among patients with diabetes. Diabetes Care. 2004;27(9):2129-2134. 8. Deshpande A, Harris-Hayes M, Schootman M. Epidemiology of diabetes and diabetes-related complications. Phys Ther. 2008;88(11):1254-1264.
9. Li Y, Burrows N, Gregg E, et al. Declining rates of hospitalization for nontraumatic lower-extremity amputation in the diabetic population aged 40 years or older: U.S., 1988-2008. Diabetes Care. 2012;35(1):235-273. 10. Dorresteijn J, Kriegsman D, Assendelft W, et al. Patient education for preventing diabetic foot ulceration. Cochrane Database Systematic Reviews. 2012;CD001488. 11. Nabuurs-Franssen M, Huijberts M, Nieuwenhuijzen Kruseman A, et al. Health-related quality of life of diabetic foot ulcer patients and their caregivers. Diabetologia. 2005;48(9):1906-1910. 12. Robbins J, Strauss G, Aron D, et al. Mortality rates and diabetic foot ulcers: is it time to communicate mortality risk to patients with diabetic foot ulceration? J Am Podiatr Med Assoc. 2008;98(6):489-493. 13. Vileikyte L. Diabetic foot ulcers: a quality of life issue. Diabetes Metab Res. 2001;17(4):246-249. 14. Bakker K, Apelqvist J, Schaper N. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res. 2012;28(1):225-231. 15. Nalini S, Armstrong D, Lipsky B. Preventing foot ulcers in patients with diabetes. JAMA. 2005;3(2):217-228. 16. Calle-Pascual A, Durán A, Benedí A, et al. Reduction in foot ulcer incidence: relation to compliance with a prophylactic foot care program. Diabetes Care. 2001;24(2):405-407. 17. Diabetes Australia. Diabetes and Your Feet. 2013. https://www. diabetesaustralia.com.au/en/Living-with-Diabetes/Mind–Body/ Diabetes–Your-Feet/#Caring%20for%20Your%20Feet. Accessed January 15, 2013. 18. National Health and Medical Research Council. National Evidence-Based Guideline: Prevention, Identification and Management of Foot Complications in Diabetes. 2011. https:// www.nhmrc.gov.au/guidelines/publications/di21. Accessed February 7, 2013. 19. Gulliford M, Mahabir D. Diabetic foot disease and foot care in a Caribbean community. Diabetes Res Clin Pract. 2002;56(1): 35-40. 20. Khamseh M, Vatankhah N, Baradaran H. Knowledge and practice of foot care in Iranian people with type 2 diabetes. Int Wound J. 2007;4(4):298-302. 21. Bell R, Arcury T, Snively B, et al. Diabetes foot self-care practices in a rural, triethnic population. Diabetes Educ. 2005;31(1): 75-83. 22. Harvey J, Lawson V. The importance of health belief models in determining self-care behaviour in diabetes. Diabet Med. 2009;26(1):5-13. 23. Funnell M, Brown T, Childs B, et al. National standards for diabetes self-management education. Diabetes Care. 2012;35(1): 101-108. 24. World Health Organisation. Health Statistics and Health Information Systems. 2014. http://www.who.int/healthinfo/survey/ageingdefnolder/en/. Accessed January 15, 2013. 25. National Health and Medical Research Council. NHMRC Additional Levels of Evidence and Grades for Recommendations for Developers of Guidelines. http://www.nhmrc.gov.au/_files_ nhmrc/file/guidelines/stage_2_consultation_levels_and_grades. pdf. 2009. Accessed February 10, 2013. 26. Von Elm E, Altman D, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. PLoS Med. 2007;4(10):867-872.
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27. Mallen C, Peat G, Croft P. Quality assessment of observational studies is not commonplace in systematic reviews. J Clin Epidemiol. 2006;59(1):765-769. 28. Critical Appraisal Skills Programme. 2013, CASP Checklists. http://www.casp-uk.net/. 2013. Accessed February 5, 2014, available at. 29. Bridges J, Flatley M, Meyer J. Older people’s and relatives experiences in acute care settings: Systematic review and synthesis of qualitative studies. Int J Nurs Stud. 2010;47(1):89-107. 30. Lakshman R, Ogilvie D, Ong K. Mothers’ experiences of bottlefeeding: a systematic review of qualitative and quantitative studies. Arch Dis Child. 2009;94(8):596-601. 31. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. 32. Arcury T, Grzywacz J, Ip E, et al. Social integration and diabetes management among rural older adults. J Aging Health. 2012;24(6):899-922. 33. Harwell T, Helgerson S, Gohdes D, et al. Foot care practices, services and perceptions of risk among Medicare beneficiaries with diabetes at high and low risk for future foot complications. Foot Ankle Int. 2001;22(9):734-738. 34. Heisler M, Cole I, Weir D, et al. Does physician communication influence older patients’ diabetes self-management and glycemic control? Results from the Health and Retirement Study (HRS). J Gerontol A Biol Sci Med Sci. 2007;62(12):1435-1442. 35. Olson J, Hogan M, Pogach L, et al. Foot care education and selfmanagement behaviors in diverse veterans with diabetes. Patient Prefer Adherence. 2009;3(45):45-50. 36. Pollock R, Unwin N, Connolly V. Knowledge and practice of foot care in people with diabetes. Diabetes Res Clin Pract. 2004;64(2):117-122. 37. Schmidt S, Mayer H, Panfil E. Diabetes foot self-care practices in the German population. J Clin Nurs. 2008;17(21):2920-2926.
38. Perrin B, Swerissen H, Payne C. The association between footcare self-efficacy beliefs and actual foot-care behaviour in people with peripheral neuropathy: a cross-sectional study. J Foot Ankle Res. 2009;2(3):1-8. 39. Lone G, Vedhara K, Searle A, et al. Patients’ perspectives on foot complications in type 2 diabetes: a qualitative study. Br J Gen Pract. 2008;58(553):555-563. 40. Shreck E, Gonzalez J, Cohen H, et al. Risk perception and selfmanagement in urban, diverse adults with type 2 diabetes: the improving diabetes outcomes study. Int J Behav Med. 2013;21(1):88-98. 41. Yuniarti K, Dewi C, Ningrum R, et al. Illness perception, stress, religiosity, depression, social support, and self-management of diabetes in Indonesia. Int J Res Stud Psych. 2012;2(1):25-41. 42. Becker M, Janz N. The health belief model applied to understanding diabetes regimen compliance. Diabetes Educ. 1985;11(1): 41-47. 43. Cerkoney K, Hart L. The relationship between the health belief model and compliance of persons with diabetes mellitus. Diabetes Care. 1980;3(5):594-598. 44. De Berardis G, Pellegrini F, Franciosi M, et al. Are type 2 diabetic patients offered adequate foot care? The role of physician and patient characteristics. J Diabetes Complications. 2005;19(6):319327. 45. McInnes A, Jeffcoate W, Vileikyte L, et al. Foot care education in patients with diabetes at low risk of complications: a consensus statement. Diabet Med. 2011;28(2):162-167. 46. Ortegon M, Redekop W, Niessen L. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care. 2004;27(4):901-907. 47. Belcher V, Fried T, Agostini J, et al. Views of older adults on patient participation in medication-related decision making. J Gen Med. 2006;21(1):298-303.
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Who Cares About Foot Care? Barriers and Enablers of Foot Self-care Practices Among Non-Institutionalized Older Adults Diagnosed With Diabetes: An Integrative Review Lisa Matricciani and Sara Jones The Diabetes Educator published online 5 December 2014 DOI: 10.1177/0145721714560441 The online version of this article can be found at: http://tde.sagepub.com/content/early/2014/12/04/0145721714560441
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The Diabetes Educator OnlineFirst, published on December 5, 2014 as doi:10.1177/0145721714560441
TDEXXX10.1177/0145721714560441Barriers and Enablers of Foot Self-care in Older Adults Matricciani and Jones
Barriers and Enablers of Foot Self-care in Older Adults 1
Who Cares About Foot Care? Barriers and Enablers of Foot Self-care Practices Among Non-Institutionalized Older Adults Diagnosed With Diabetes An Integrative Review Purpose
Lisa Matricciani, BPod(Hons), BNurs Sara Jones, MSc, BA, Dip App Sci (Pod), PhD
Appropriate and timely foot self-care practices may prevent diabetes-related foot complications. However, selfcare practices are often neglected, particularly by older adults. The purpose of this study was to conduct an integrative, systematic literature review of the psychosocial barriers and enablers of foot self-care practices among older adults diagnosed with diabetes.
From the Sansom Institute, Division of Health Sciences, University of South Australia, Adelaide, Australia (Ms Matricciani, Dr Jones). Correspondence to Ms Lisa Matricciani, School of Health Sciences, University of South Australia, Adelaide SA 5001, Australia (matla005@ mymail.unisa.edu.au). Acknowledgments: Nancy Mastrogiacomo and Rebecca Munt for offering suggestions for this manuscript.
Methods An integrative, systematic literature review and a deductive thematic analysis was conducted to determine psychosocial barriers and enablers of foot self-care practices among older adults.
DOI: 10.1177/0145721714560441 © 2014 The Author(s)
Results A total of 130 different studies were retrieved from the search strategy. From these, 9 studies were identified and included for review. Physical ability, perceived importance, patient knowledge, provision of education, social integration, risk status, and patient-provider communication were identified as key barriers and enablers of foot self-care. Participants at high risk of foot complications were found to perceive themselves at greater risk of complications, receive more education, and engage in better overall foot self-care practices compared to those at low risk of foot complications. Matricciani and Jones Downloaded from tde.sagepub.com at TEXAS SOUTHERN UNIVERSITY on December 7, 2014
The Diabetes EDUCATOR 2
Conclusion Foot self-care practices appear underutilized as primary prevention measures by older adults and are instead adopted only once complications have already occurred. Likewise, facilitators of foot self-care practices, such as education, appear to be reserved for individuals who have already developed foot complications. Health care professionals such as diabetes educators, podiatrists, and general practitioners may play an important role in the prevention of foot complications among older adults by recognizing, referring, and providing early education to older adults.
Introduction Diabetes is the world’s fastest growing chronic condition, affecting over 300 million people worldwide, with estimates expected to approximately double by the year 2035.1 The risk of diabetes increases with age, and as such, older adults have the highest prevalence of diabetes.2-4 The proportion of older adults diagnosed with diabetes is projected to rise in line with the anticipated increase in population age.5 Such trends are concerning given that older adults experience significantly more diabetes-related health complications and health care costs than their younger counterparts.3 Foot complications are among the most serious, costly, and disabling consequences of diabetes and predominantly affect older adults.6,7 Older adults have a 2-fold increased risk of developing a foot ulcer and have the highest rate of major lower limb amputations secondary to diabetes.8,9 Foot ulcers are challenging to treat. Even with intensive and timely treatment, involving costly and time-consuming wound dressing changes, many foot ulcers do not heal, recur, and/or progress to amputation.10 This often leads to depression and reduced quality of life.11-13 Primary prevention strategies, such as maintaining target glycemic control and engaging in daily foot selfcare practices, are important diabetes self-management goals.14,15 Adequate glycemic control may delay the onset and progression of risk factors (ie, peripheral vascular disease, peripheral neuropathy, infection, and foot deformity) attributed to the development of foot complications. Foot self-care practices, such as inspecting feet daily, receiving professional foot care and assessments, keeping feet clean and dry, protecting feet from temperature extremes, and wearing appropriate footwear, minimizes the risk of foot complications.15,16 These self-care
practices are strongly encouraged by diabetes health authorities.17,18 Despite such recommendations, foot self-care practices are largely neglected. Cross-sectional studies reveal that a low proportion of people diagnosed with diabetes engage in preventive foot self-care practices, such as inspecting feet daily, while a high proportion undertake potentially harmful practices, such as walking barefoot.19,20 Consistent with these findings, a large population-based study reported only 20% of all people diagnosed with diabetes inspected their feet daily.21 Inadequate knowledge is often attributed as the reason why people with diabetes do not undertake foot self-care practices.22 As such, it is generally accepted that further education will equate to better knowledge, self-care practices, and an overall reduction in foot complications. However, education as a means of knowledge provision alone is not a strong predictor of preventive diabetes selfmanagement behaviors.22 Rather, education must be individualized, tailored to the unique needs, abilities, values, attitudes, and beliefs of the recipient, and address psychosocial factors underpinning self-care and careseeking behaviors to be successful.22,23 This is particularly relevant to older adults who are likely to experience age-related issues such as reduced mobility, limited social support, increased comorbidities, and cognitive decline, which may affect their ability to undertake foot self-care practices. To date, the psychosocial dimensions of foot self-care have not been extensively explored, and there has yet to be a comprehensive study that examines psychosocial barriers and enablers of foot self-care practices among older adults diagnosed with diabetes. If foot self-care practices are to continue to be advocated by health care professionals and encouraged as a primary prevention measure, then it is critical to gain an understanding of the psychosocial determinants of foot self-care, particularly among older adults, who are at greatest risk of foot complications. Therefore, the aim of this study is to systematically review the literature and answer the question, what are the psychosocial barriers and enablers of foot self-care practices among non-institutionalized older adults diagnosed with diabetes?
Methods A systematic literature search was conducted to identify all studies that examined psychosocial barriers and
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Barriers and Enablers of Foot Self-care in Older Adults 3
enablers of foot self-care practices among non-institutionalized older adults diagnosed with diabetes. The primary outcome measure was “foot self-care practices,” defined as practices undertaken by the individual in an effort to minimize their risk of diabetes-related foot complications. The primary predictor variables were “psychosocial barriers and/or enablers of foot self-care,” defined as attitudes, values, beliefs, thoughts, experiences, behaviors, and/or contextual elements that impede or promote foot self-care practices. Socioeconomic and cultural determinants of foot self-care practices were not explored in this study. Criteria for Inclusion and Exclusion
Any study that identified psychosocial barriers and/or enablers of foot self-care practices among non-institutionalized older adults diagnosed with type 1 or type 2 diabetes was considered for review. An “older adult” was defined according to the United Nations definition as any individual aged 60 years and older.24 Thus, only studies with a mean sample age of 60 years and older were included for review. In cases where the mean sample age was not reported but the number of participants per age range was reported (ie, 10 participants aged 50-60 years, 25 participants aged 60-70 years, etc.), the study was included only if the majority of participants were in the age categories 60 years and older. Both qualitative and quantitative studies were considered. Only full-text studies, published in English, since the year 2000 were accepted for inclusion for review. Studies that assessed people with and without diabetes but did not stratify findings according to diabetes status were excluded. Systematic Search Strategy
A systematic search strategy was employed to identify studies for review. Four electronic databases (Scopus, EbscoHost, Embase, Pubmed) were searched using the search terms: (Geriatric or elderly or older or aged care) and (diabet*) and (foot or feet or foot care) and (perception or beliefs or attitude* or knowledge or barrier or enabler or behav*). Date and English language limits were set. A preliminary search determined the scope and relevance of candidate databases. All abstracts were screened for inclusion criteria. Potentially eligible papers were read in full, and only relevant papers were kept for review. In cases where only an abstract was available, the
Table 1
NHMRC Hierarchy of evidence18 Level of Evidence I II III-1 III-2 III-3 IV
Study Design A systematic review of level II studies A randomized controlled trial A pseudorandomized controlled trial A comparative study with concurrent controls A comparative study without concurrent controls Case series with either posttest or pretest/posttest outcomes
study’s authors were contacted and an interlibrary loan request was made for the full-text copy of the article. If a full-text copy of the article was unavailable, the study was excluded. Reference lists of included studies were then reviewed to identify additional eligible articles. The final search was carried out on December 11, 2013. Evaluation of Studies Included for Review
All studies included in this review were read and reviewed for content extraction and appraised for their level of evidence using the NHMRC hierarchy of evidence scale (Table 1).25 Quantitative studies were appraised for their methodological quality using the STROBE (Strength of Reporting OBsevational studies in Epidemiology) checklist/tool.26 The STROBE statement provides a checklist that facilitates the critical appraisal and interpretation of observational studies. The checklist consists of 32 items regarding the article’s title, abstract, introduction, methods, results, and discussion sections as well as funding. Eighteen items are common to cohort studies, case-control studies, and cross-sectional studies, and 4 are specific to each of the 3 study designs. Given that quantitative studies included for review were a mix of cross-sectional and cohort observational studies, and there is no established instrument for quantitative observational studies, the STROBE checklist was utilized as it is suited to both types of observational studies.27 Qualitative studies were appraised for their methodological quality using the CASP (Critical Appraisal Skills Programme) checklist/tool for qualitative studies.28 The
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Scopus 80
EbscoHost 64
Pubmed 17
did not meet the inclusion criteria, and an additional 2 studies were identified by pearling study reference lists.35,39
Embase 93
Study Characteristics 254
124 Duplicates
130 123 Did not meet inclusion criteria 7
2 Pearling reference list
Total 9
Figure 1. Systematic search flow chart.
CASP checklist consists of 10 items that facilitates the systematic appraisal of reporting in qualitative studies. Specifically, the checklist allows assessment of whether the results are valid, clearly stated, and useful. The CASP appraisal tool has been used previously in systematic reviews to critically appraise qualitative studies.29,30 Analysis and Synthesis of Studies Included for Review
A deductive thematic analysis, as described by Braun and Clarke,31 was employed in this study. Specifically, all studies included for review were read and re-read in full, and key findings relating to the psychosocial barriers and enablers of foot care were recorded and summarized.
Results Search Results
The systematic search identified 9 different studies for inclusion in the review.21,32-39 As shown in Figure 1, of the 130 different studies identified, 123 were excluded as they
Table 2 presents a summary of the 9 studies included for review. With the exception of 1 qualitative study, all were quantitative observational studies. Most studies were conducted in the US (56%) and the UK (22%), followed by Australia (11%) and Germany (11%). Participants were mostly “younger older adults,” with an overall median sample age of 67 years, with diabetes for a median duration of 15.3 years. With the exception of 2 studies,35,38 there were an approximately equal number of males and females reported within each of the studies. Only 4 studies reported the type of diabetes experienced by participants. Of these, 2 studies21,39 exclusively examined participants with type 2 diabetes, while the other 2 studies37,38 examined participants with both type 1 and type 2 diabetes. The latter 2 studies did not stratify findings according to diabetes type. Critical appraisal scores of quantitative studies varied between 15 and 20 (out of 22). Overall, most studies failed to report sources of bias and how the study size was calculated. Most studies acknowledged the study strength as being the first to explore the research question proposed, while key identified weaknesses related to generalizability of results and the inherent limitation of a cross-sectional study design. Although most studies had a reasonably large sample size, the validity of self-report outcome measures had not been established in most. Further, it is important to note that measures of foot self-care varied across the studies and direct comparisons between studies cannot be made. For example, some studies defined foot self-care as inspecting feet daily while others defined foot self-care as “keeping feet clean” or created a composite measure consisting of multiple foot self-care practices. Key Findings
A summary of the key findings of all studies included for review are presented in Table 3. Overall, physical ability, perceived importance, knowledge, education, social integration, risk status, and patient-provider communication were identified as key barriers and enablers of foot self-care. Although the role of self-efficacy was explored by Perrin et al,38 the correlation was not strong enough to suggest self-efficacy beliefs predict actual foot care practices.
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Germany 2004
USA 1998
USA 2000-2001
USA 2009-2010 UK 1998
Australia 2001-2007
USA 2001-2002
USA 2002
Schmidtet al (2008)
Harwell et al (2001)
Olson et al (2009)
Arcury et al (2012) Pollock et al (2004)
Perrin et al (2009)
Bell et al (2005)
Heisler et al (2007) Lone et al (2008)
UK NR
Country, Year
Study
Descriptive Study Summary
Table 2
Cross-section Random IV 20/22 Qualitative N/A Purposive 6/10
Random
Cross-section IV 17/22
18
1588
688
96
365
Random
Convenient
563
717
537
269
n
Stratified
Random
Random
Convenient
Sampling
Cross-section IV 18/22
Cross-section IV 18/22 Cross-section IV 15/22
Cross-section IV 18/22
Cohort study III-2 18/22
Cross-section IV 16/22
Design, NHMRC, CAT
64
69.0 (8.7)
74.1 (5.4)
64.5 (10.7)
62.3 (NR)
NR
67
75.3 (8.0)
62.2 (12.4)
Age
50
54
49.4
24
NR
61.8
4
57
41.2
% Female
100
NR
100
90
NR
NR
NR
NR
62.4
% Type 2 Diabetes
6.5
11.8 (10.3)
12.4 (10.98)
15.89 (11.54)
NR
NR
NR
15.3 (11.3)
20.36 (11.12)
Duration
0
NR
NR
100
63.9
NR
100
30.73
43.3
% High Risk
Multiple dimensions of foot self-care examined, including professional care, inspection, cleaning, footwear, skin and nail care, first aid, walking barefoot Composite measure of inspection, cleaning, footwear, moisturizing, protection, skin and nail care, first aid, walking barefoot Summary of Diabetes Self-Care Activities scale; composite measure of foot self-care practices, including inspection, cleaning, footwear, soaking feet Frequency of checking feet for cuts and sores Multiple dimensions of foot self-care as expressed by participants in interview process, including inspection, cleaning, footwear, moisturizing, avoiding temperature extremes, callus debridement, nail care, first aid
The Frankfurter Catalogue of Foot Self-Care (FSCS) questionnaire; assessed 3 domains of foot self-care (professional assistance, personal self-care, footwear) as a composite and individual measures Frequency of checking feet for cuts and sores, receiving professional care, wearing protective shoes Multiple domains of foot self-care examined, including inspection, cleaning, footwear, moisturizing, avoiding temperature extremes, callus debridement, nail care, first aid Foot inspection
Foot Self-care (outcome measure)
The Diabetes EDUCATOR 6
Table 3
Summary of Study Findings Study
Key Findings
Schmidt et al (2008)
Physical mobility Foot self-care and footwear self-care were not associated with physical mobility. Patients with physical limitations were significantly more likely to receive professional foot care assistance (P < .001). Risk status High-risk patients received significantly more professional foot care assistance (P < .001) and had significantly better overall foot self-care practices compared with low-risk patients. No significant difference between risk status and foot self-care (P = .992) and footwear self-care (P = .327). Risk status did not significantly influence self-control of the feet, shoes, and socks. Education High-risk patients participated in more education programs than low-risk patients (P = .006). Participants who attended more than 3 education sessions had better foot self-care than those who did not attend any education (P = .009) or those who only attended 1 session (P = .034). Older and newly diagnosed were less likely to attend education (P value not reported). Education was not associated with professional foot care assistance (P = .522). Risk status People who were classified high risk of complications were more likely to have their feet professionally examined (P < .05), wear protective shoes (P < .05), perceive themselves at risk of complications (P < .05). Perceived risk The main reason reported by participants who did not examine their feet regularly was that they did not think it was important (60%), of whom, 79.08% were low risk of complications. Of the participants at high risk of complications, 73.93% perceived themselves at low risk of complications, and only 59% engaged in protective foot self-care practice of checking their feet daily. Physical limitations Participant-reported barriers of foot self-care (checking feet for cuts and sores) included not thinking it was important (60%), other reasons/didn’t know (30%), vision or physical limitation (9%), and didn’t know how (1%). Physical ability Participant-identified barriers included physical limitation (38%), visual impairments (19%), lack of knowledge (10%), lack of skill (10%), cost (9%), and not thinking it was important (7%). Knowledge Most participants did not feel that they “knew enough” about various foot care practices (60%). Participants felt that they “knew enough” about checking feet regularly (50%), keeping feet clean (70%), and wearing shoes all the time (57%). Few participants who reported “knowing enough” about various foot self-care practices did not actually engage in self-care practice. Social integration Measures of social integration significantly associated with better self-foot care, included having more children (P < .01). Measures of social integration significantly associated with more provider foot examinations included having larger secondary social networks (measured as the frequency of personal and telephone contacts) (P < .05) and having more children (P < .05). Risk status High-risk patients had better foot self-care (P values not reported) and better (but not significantly different, P = .21) foot care knowledge than low-risk patients. More high-risk participants (85.6%) received foot care advice than low-risk participants (77.1%). Knowledge No significant difference between knowledge and age (P = .162).
Harwell et al (2001)
Olson et al (2009)
Arcury et al (2012)
Pollock et al (2004)
(continued)
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Table 3 (continued) Study
Perrin et al (2009)
Bell et al (2005)
Heisler et al (2007)
Lone et al (2008)
Key Findings Participants who had previously received advice or information had better knowledge (P = .001). Education Most foot care advice came from podiatrists and diabetes clinics followed by general practice. Patients who received education were more likely to undertake foot examinations (P = .001). Physical limitations Participant-reported foot self-care barriers included mobility (13%), nail pathology (9%), time constraints (3%), visual impairment (2%), and being unaware of the practice (2%). Confidence in performing foot self-care behaviors Small positive correlation between Foot Care Confidence Scale scores and preventive foot-care behavior (r = 0.2; P = .05). No correlation between Foot Care Confidence Scale scores and potentially damaging behaviors (r = −0.05; P = .61). Foot Care Confidence Scale scores did not differ for those with and without a history of foot pathology (P = .95). Risk status Participants with a history foot pathology were more likely to engage in preventive behaviors (P = .02) and less likely to engage in potentially damaging behaviors (P < .001) compared to participants without a history foot pathology (ie, lower risk). Only the latter was statistically significant. Education Foot care was significantly better for people who attended a diabetes education class (P = .0668), who received information on how to care for their feet (P < .0001) and who had been shown how to care for their feet compared to those who had not (P < .0001). Physical limitations Physical functioning was not associated with foot self-care. Patient-provider communication Patients who rated their diabetes health care provider as providing adequate information were significantly more likely to engage in the foot self-care practice of checking their feet for sores and cuts (P < .001). Patients who reported participatory decision making with their diabetes health care provider were significantly more likely to engage in the foot self-care practice of checking their feet for sores and cuts (P < .001). Knowledge Participants were unaware of what a foot ulcer is, the cause, and how ulcers are treated. Participants had inadequate knowledge and misunderstandings of foot complications, including not knowing the link between glycemic control and foot complications, foot ulcers are easily healed, only people with poor foot hygiene get foot ulcers, amputations were purely the result of poor circulation, and believed neurological symptoms were the result of poor circulation. Inadequate knowledge led to dangerous foot self-care practice. For example, the belief that foot cuts and sores would easily heal resulted in many not seeking prompt medical assistance; the belief that foot complications were the result of poor circulation resulted in participants buying larger than required shoes and open shoes to promote circulation (however, for people with neuropathy, such footwear increases the risk of blisters and does not protect against trauma). Walking barefoot was also believed helpful as it was thought to “promote blood flow.” Education Participants felt foot care was often pushed aside for other topics of diabetes. Participants were often alerted to foot complications by hearing about other people’s foot problems. Patient-provider communication Patients reported difficulty communicating with health care provider and were often left feeling confused and deciding to not follow advice and rely on what they considered common sense. Participants reported not receiving adequate explanations, not understanding what was advised, perceived foot care was often the neglected component of education, and that their provider was disinterested. Regular foot checks by a podiatrist offered participants with reassurance, but only half had access to this service.
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Physical Ability
Education
Five studies identified physical ability as a barrier to foot self-care. Physical and visual limitations were reported as the main barriers of foot self-care by 57% of participants in the study by Olson and colleagues,35 while only 15% and 8% of participants reported physical limitations as a barrier of foot self-care in studies by Pollock et al36 and Harwell et al,33 respectively. Physical limitations were not associated with actual foot self-care behaviors in studies by Bell and colleagues21 and Schmidt et al.37 Restricted mobility was associated with more professional foot care in the study of Schmidt et al.37
Education was also associated with better foot selfcare practices.21,36,37 Although none of the studies examined education content or mode of delivery, Pollock et al36 revealed most foot care advice and education came from podiatrists and diabetes clinics and to a lesser extent, general practice. In contrast, Bell and colleagues21 found better self-care among those who had visited a doctor or podiatrist in the past year, although the latter association was not significant. Participants identified at high risk of foot complications received more education and/or advice than those at low risk of complications36,37 while older and newly diagnosed participants were less likely to receive education.37,39 Consistent with these findings, Lone et al39 reported most participants felt that foot care education was “pushed aside” when first diagnosed with diabetes to make way for other education topics.
Perceived Importance of Foot Self-care
Three studies identified perceived importance to be a barrier of foot self-care practices. Harwell et al33 identified 60% of participants reported they did not engage in foot self-care practices because they did not perceive such practices to be important. Of these participants, 79% were identified at low risk of foot complications. In contrast, only 2% and 7% of participants reported foot selfcare unimportant in studies by Pollock et al36 and Olson et al,35 respectively. Participants in these latter 2 studies were mostly at high risk of foot complications (63% and 100%, respectively), which may explain the discrepancy observed between studies. Knowledge
Inadequate knowledge was reported a barrier of foot self-care by 20% of participants in the study by Olson and colleagues35 and by 2% of participants in studies by Harwell et al33 and Pollock et al.36 Reports of adequate knowledge, however, did not appear to translate to actual foot self-care behaviors. Olson et al35 identified that many participants who reported “knowing enough” about specific foot self-care practices did not actually engage in the advised practice. Given findings varied according to ethnicity, the authors suggested the discrepancy may be explained by cultural factors. However, the discrepancy may also in part be explained by Lone and colleagues’39 study findings, which revealed inadequate and inaccurate foot care knowledge predicted self-care behaviors. Specifically, participants were engaging in practices they believed to “know enough” about and that they thought to be helpful but were in fact potentially harmful and not in line with medical recommendations.
Social Support
Two studies identified that elements of social integration were important enablers of foot self-care. Arcury et al32 identified having more children was significantly associated with better foot self-care while having larger secondary social networks (measured as the frequency of personal and telephone contacts) and speaking to relatives over the phone each week were significantly associated with professional foot assessments. Consistent with this study’s findings, Lone et al39 reported that many participants obtained diabetes-related foot care information through communication with family member, friends, and neighbors. Risk Status
Four studies reported better foot self-care practices by participants identified at high risk of foot complications compared with those at low risk of foot complications.33,36-38 High-risk participants were more likely to receive education and have professional foot assessments compared to low-risk participants.33,36-38 High-risk participants were also more likely to identify themselves as being high risk of foot complications. However, a significant proportion (74%) of high-risk participants considered themselves to be at low risk of complications.33 Patient-Provider Communication
Patient-provider communication was identified an important predictor of foot self-care practices in
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2 studies. Heisler and colleagues34 identified both the provision of adequate information and communication that facilitated participatory decision making were significantly associated with positive foot self-care behaviors. In contrast, Lone et al39 reported negative experiences resulted in many participants feeling confused and less likely to engage in self-care behaviors.
Discussion This is the first study to systematically review the literature to determine psychosocial barriers and enablers of foot self-care practices among non-institutionalized older adults diagnosed with diabetes. A total of 9 different studies were identified and included for review, from which physical ability, perceived importance, knowledge, education, social integration, risk status, and patient-provider communication were identified as important determinants of foot self-care practices. Identified barriers and enablers appeared independent and interrelated determinants of foot self-care, particularly with regards to risk status. Specifically, participants at high risk of foot complications were found to perceive themselves at greater risk of complications, receive more education, and engage in better overall foot self-care practices compared to those at low risk of foot complications. Given that perceived risk and education were independently associated with better foot self-care, it is likely that these factors mediated the observed association between risk status and foot self-care. The findings of this review are consistent with previous studies, which recognize health perceptions as important determinants of diabetes self-management behaviors.40,41 Such findings are in line with the Health Belief Model, a theoretical framework, that identifies perceived severity, susceptibility, benefits, costs, and cues to action as important dimensions for behavioral changes.42,43 While it is perhaps not surprising that those at high risk of foot complications perceived foot self-care practices more important than those at low risk of complications and engaged in better self-care, it remains unclear as to whether existing complications inherent of a highrisk status altered perceptions or whether a high-risk status prompted greater opportunities for education and professional assessments, thereby enhancing perceived importance. Thus, further research is needed to better understand the determinants of foot self-care perceptions and how such perceptions are associated with actual foot
self-care behaviors. Such an understanding may provide important insight into primary prevention strategies. This review also identified better foot self-care among those who received education. Education is thought to modify behaviors by empowering and motivating individuals to actively participate in self-care practices and is a recognized measure of primary prevention.14 However, education appeared reserved for those at high risk of foot complications. This finding is consistent with previous studies that report low-risk patients receive very little information about foot complications, while those with an established foot lesion are more likely to receive education.44-46 Such findings are concerning given that inadequate and inaccurate knowledge were found to facilitate potentially harmful behaviors, thereby suggesting a lack of education is a missed opportunities for prevention. Thus, there is arguably a need to ensure early education and assessment of foot care knowledge among older adults diagnosed with diabetes. Such an understanding may facilitate the prevention of potentially harmful practices that lead to foot ulceration and amputation. Patient-provider communication and social networks were also identified as enablers of foot self-care. Counter to previous investigations, which suggest older adults tend to express less desire to engage in participatory medical decision making, this review identified participatory communication styles an important enabler of foot self-care.47 It is possible that participatory communication styles facilitated achievable advice, suited to the individual’s physical abilities. For example, instructing an individual to “inspect their feet daily” is unlikely to be followed if the individual is unable to physically do so. Alternatively, participatory communication might identify this barrier and facilitate suggestions such as seeking help from a spouse or use of a mirror, which would be an achievable goal. Social networks were also an important enabler for positive foot self-care behaviors. However, it is possible that a lack of professional education and relying solely on family/friend/neighbor-derived education may, in part, contribute to misunderstandings leading to harmful behaviors. Thus, it is important that older adults are actively involved in foot self-care education and that foot self-care educational messages are predominantly delivered by health care professionals. Given the positive effect of communicating with family/friend/neighbor, it may be of benefit for such individuals to also attend education sessions.
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Table 4
Recommendations for Health Care Providers Physical ability, perceived importance, knowledge, education, social integration, risk status and patient-provider communication were identified as important determinants of foot self-care among older adults. This review provides important insight for health care providers providing foot self-care education to older adults. Specifically, the health care provider may find it effective to: - Identify the perceived importance placed on foot self-care and explain the rational and significance of preventive foot self-care practices. - Determine the patient’s knowledge of diabetes-related foot complications and foot self-care practices and provide appropriate education. - Clarify any misunderstandings that may lead to potentially harmful behaviors. - Identify whether the patient has received diabetes-related foot care education. Attempt to understand whether they enjoyed the session, learned new information, or had any questions. - Encourage social networking, as social integration facilitates foot self-care. Specifically, encourage spouses, family, or friends to attend education and for the individual to join support groups. - Identify the patient’s risk status and examine whether the patient understands their risk status and that they have received the appropriate referrals (eg, to podiatry). - Ensure communication is participatory and that the patient is engaged with the decision-making process. - Understand that patients may have beliefs relating to foot self-care that is somewhat different to medical advice, which may inadvertently lead to potentially harmful self-care practices. Efforts to understand these beliefs may facilitate positive behavior-modifying education
Strengths and Limitations
This is the first integrative, systematic literature review to examine psychosocial barriers and enablers of foot self-care among non-institutionalized older adults diagnosed with diabetes. As such, this review provides important insight into an important issue largely unexplored. However, several limitations need be addressed. Specifically, only full-text studies written in English since the year 2000 were included for review, which were then reviewed by only 1 reviewer. Furthermore, given that most of studies examined “younger older adults,” the results of this review may not accurately reflect “older adults.” The reported limitations of each of the studies included for review also need to be considered, of particular note, failure to report sources of bias. Given the apparent scarcity of evidence examining psychosocial barriers and enablers of foot self-care practices among non-institutionalized older adults diagnosed with diabetes, further research in this area in needed. Specifically, efforts are needed to better understand differences that exist according to risk status and diabetes type using validated outcome measures. Such investigations may provide important insight into the prevention of
foot complications. Future studies may also benefit from a mixed-method approach to quantify observed associations to gain the in-depth insight that only qualitative studies can achieve. However, until such research is conducted, the available literature tends to suggest health care providers need to consider physical ability, perceived importance, knowledge, education, social integration, risk status, and patient-provider communication when delivering foot self-care education to older adults. Table 4 summarizes the inferred recommendations from this study for health care providers delivering foot self-care education.
Conclusion This integrative review provides insight into the unique psychosocial barriers and enablers of foot selfcare among non-institutionalized older adults diagnosed with diabetes. Collectively, studies included for review suggest individuals who perceive foot care important, are at high risk of foot complications, have positive patientprovider communication experiences and strong social networks, and who have received education are more likely to engage in foot self-care practices. The issue of concern is that those who are identified as lower risk (or
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who identify themselves as such) are less likely to undertake self-care practices, thus potentially predisposing themselves to future complications. The challenge in future studies is to identify means and methods to facilitate an increase in the awareness of the importance of self-care, both among this patient group and among their health care providers.
Implications for Educators This review identifies psychosocial barriers and enablers of foot self-care practices among older, noninstitutionalized, adults diagnosed with diabetes. Physical ability, perceived importance, patient knowledge, provision of education, social integration, risk status, and patient-provider communication were identified barriers and enablers of foot self-care. Participants at high risk of foot complications were found to perceive themselves at greater risk of complications, receive more education, and engage in better overall foot self-care practices compared to those at low risk of foot complications. In understanding potential barrier and enablers of foot self-care practices, educators may be equipped to provide more effective education. Further, as this review highlights, there is a need for enhanced education among low-risk patients in an effort to prevent the development of potential future complications. References 1. International Diabetes Federation 2013. Managing Older People With Type 2 Diabetes: Global Guideline. http://www.idf.org/sites/ default/files/IDF-Guideline-for-older-people-T2D.pdf. Accessed January 15, 2013. 2. Selvin E, Coresh J, Brancati FL. The burden and treatment of diabetes in elderly individuals in the US. Diabetes Care. 2006;29(11):2415-2419. 3. Kirkman MS, Briscoe V, Clark N, et al. Diabetes in older adults. Diabetes Care. 2012;35(12):2650-2664. 4. Wild S, Roglic G, Green A, et al. Global prevalence of diabetes estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27(5):1047-1053. 5. Cheng Y, Imperatore G, Geiss L, et al. Secular changes in the agespecific prevalence of diabetes among US adults: 1988–2010. Diabetes Care. 2013;36(9):2690-2696. 6. Pataky Z, Vischer U. Diabetic foot disease in the elderly. Diabetes Metab. 2007;33(1):56-65. 7. Stockl K, Vanderplas A, Tafesse E, et al. Costs of lower-extremity ulcers among patients with diabetes. Diabetes Care. 2004;27(9):2129-2134. 8. Deshpande A, Harris-Hayes M, Schootman M. Epidemiology of diabetes and diabetes-related complications. Phys Ther. 2008;88(11):1254-1264.
9. Li Y, Burrows N, Gregg E, et al. Declining rates of hospitalization for nontraumatic lower-extremity amputation in the diabetic population aged 40 years or older: U.S., 1988-2008. Diabetes Care. 2012;35(1):235-273. 10. Dorresteijn J, Kriegsman D, Assendelft W, et al. Patient education for preventing diabetic foot ulceration. Cochrane Database Systematic Reviews. 2012;CD001488. 11. Nabuurs-Franssen M, Huijberts M, Nieuwenhuijzen Kruseman A, et al. Health-related quality of life of diabetic foot ulcer patients and their caregivers. Diabetologia. 2005;48(9):1906-1910. 12. Robbins J, Strauss G, Aron D, et al. Mortality rates and diabetic foot ulcers: is it time to communicate mortality risk to patients with diabetic foot ulceration? J Am Podiatr Med Assoc. 2008;98(6):489-493. 13. Vileikyte L. Diabetic foot ulcers: a quality of life issue. Diabetes Metab Res. 2001;17(4):246-249. 14. Bakker K, Apelqvist J, Schaper N. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res. 2012;28(1):225-231. 15. Nalini S, Armstrong D, Lipsky B. Preventing foot ulcers in patients with diabetes. JAMA. 2005;3(2):217-228. 16. Calle-Pascual A, Durán A, Benedí A, et al. Reduction in foot ulcer incidence: relation to compliance with a prophylactic foot care program. Diabetes Care. 2001;24(2):405-407. 17. Diabetes Australia. Diabetes and Your Feet. 2013. https://www. diabetesaustralia.com.au/en/Living-with-Diabetes/Mind–Body/ Diabetes–Your-Feet/#Caring%20for%20Your%20Feet. Accessed January 15, 2013. 18. National Health and Medical Research Council. National Evidence-Based Guideline: Prevention, Identification and Management of Foot Complications in Diabetes. 2011. https:// www.nhmrc.gov.au/guidelines/publications/di21. Accessed February 7, 2013. 19. Gulliford M, Mahabir D. Diabetic foot disease and foot care in a Caribbean community. Diabetes Res Clin Pract. 2002;56(1): 35-40. 20. Khamseh M, Vatankhah N, Baradaran H. Knowledge and practice of foot care in Iranian people with type 2 diabetes. Int Wound J. 2007;4(4):298-302. 21. Bell R, Arcury T, Snively B, et al. Diabetes foot self-care practices in a rural, triethnic population. Diabetes Educ. 2005;31(1): 75-83. 22. Harvey J, Lawson V. The importance of health belief models in determining self-care behaviour in diabetes. Diabet Med. 2009;26(1):5-13. 23. Funnell M, Brown T, Childs B, et al. National standards for diabetes self-management education. Diabetes Care. 2012;35(1): 101-108. 24. World Health Organisation. Health Statistics and Health Information Systems. 2014. http://www.who.int/healthinfo/survey/ageingdefnolder/en/. Accessed January 15, 2013. 25. National Health and Medical Research Council. NHMRC Additional Levels of Evidence and Grades for Recommendations for Developers of Guidelines. http://www.nhmrc.gov.au/_files_ nhmrc/file/guidelines/stage_2_consultation_levels_and_grades. pdf. 2009. Accessed February 10, 2013. 26. Von Elm E, Altman D, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. PLoS Med. 2007;4(10):867-872.
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27. Mallen C, Peat G, Croft P. Quality assessment of observational studies is not commonplace in systematic reviews. J Clin Epidemiol. 2006;59(1):765-769. 28. Critical Appraisal Skills Programme. 2013, CASP Checklists. http://www.casp-uk.net/. 2013. Accessed February 5, 2014, available at. 29. Bridges J, Flatley M, Meyer J. Older people’s and relatives experiences in acute care settings: Systematic review and synthesis of qualitative studies. Int J Nurs Stud. 2010;47(1):89-107. 30. Lakshman R, Ogilvie D, Ong K. Mothers’ experiences of bottlefeeding: a systematic review of qualitative and quantitative studies. Arch Dis Child. 2009;94(8):596-601. 31. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. 32. Arcury T, Grzywacz J, Ip E, et al. Social integration and diabetes management among rural older adults. J Aging Health. 2012;24(6):899-922. 33. Harwell T, Helgerson S, Gohdes D, et al. Foot care practices, services and perceptions of risk among Medicare beneficiaries with diabetes at high and low risk for future foot complications. Foot Ankle Int. 2001;22(9):734-738. 34. Heisler M, Cole I, Weir D, et al. Does physician communication influence older patients’ diabetes self-management and glycemic control? Results from the Health and Retirement Study (HRS). J Gerontol A Biol Sci Med Sci. 2007;62(12):1435-1442. 35. Olson J, Hogan M, Pogach L, et al. Foot care education and selfmanagement behaviors in diverse veterans with diabetes. Patient Prefer Adherence. 2009;3(45):45-50. 36. Pollock R, Unwin N, Connolly V. Knowledge and practice of foot care in people with diabetes. Diabetes Res Clin Pract. 2004;64(2):117-122. 37. Schmidt S, Mayer H, Panfil E. Diabetes foot self-care practices in the German population. J Clin Nurs. 2008;17(21):2920-2926.
38. Perrin B, Swerissen H, Payne C. The association between footcare self-efficacy beliefs and actual foot-care behaviour in people with peripheral neuropathy: a cross-sectional study. J Foot Ankle Res. 2009;2(3):1-8. 39. Lone G, Vedhara K, Searle A, et al. Patients’ perspectives on foot complications in type 2 diabetes: a qualitative study. Br J Gen Pract. 2008;58(553):555-563. 40. Shreck E, Gonzalez J, Cohen H, et al. Risk perception and selfmanagement in urban, diverse adults with type 2 diabetes: the improving diabetes outcomes study. Int J Behav Med. 2013;21(1):88-98. 41. Yuniarti K, Dewi C, Ningrum R, et al. Illness perception, stress, religiosity, depression, social support, and self-management of diabetes in Indonesia. Int J Res Stud Psych. 2012;2(1):25-41. 42. Becker M, Janz N. The health belief model applied to understanding diabetes regimen compliance. Diabetes Educ. 1985;11(1): 41-47. 43. Cerkoney K, Hart L. The relationship between the health belief model and compliance of persons with diabetes mellitus. Diabetes Care. 1980;3(5):594-598. 44. De Berardis G, Pellegrini F, Franciosi M, et al. Are type 2 diabetic patients offered adequate foot care? The role of physician and patient characteristics. J Diabetes Complications. 2005;19(6):319327. 45. McInnes A, Jeffcoate W, Vileikyte L, et al. Foot care education in patients with diabetes at low risk of complications: a consensus statement. Diabet Med. 2011;28(2):162-167. 46. Ortegon M, Redekop W, Niessen L. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care. 2004;27(4):901-907. 47. Belcher V, Fried T, Agostini J, et al. Views of older adults on patient participation in medication-related decision making. J Gen Med. 2006;21(1):298-303.
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