Diabetic Foot Care Behaviors: A Literature Review
Titis Kurniawan1,2*, Imas Rafiyah1,2, Ardia Putra1,3, Yanuar Primanda1,4
1Master student, Master of Nursing Science (International Program), Faculty of Nursing, Prince of Songkla University, P.O. Box 9, Khor Hong, Hatyai, Songkhla, 90112, Thailand
2 Lecturer of Faculty of Nursing, Universitas Padjadjaran, Jl. Raya Bandung-Sumedang Km 21, Jatinangor, West-Java, 45363, Indonesia
3 Lecturer of Nursing Science Program, Medical Faculty, Syiah Kuala University, Gedung Petronas, Jl. Tgk. Tanoeh Abee, Darussalam, Banda Aceh, 23111, Indonesia
4 Lecturer of Nursing Science Program, Faculty of Medicine and Health Science, Muhammadiyah University of Yogyakarta, Jl. Lingkar Barat, Tamantirto, Kasihan, Bantul, Yogyakarta, 55183, Indonesia
*Corresponding author, E-mail: titiz_kazep@yahoo.com
Abstract—Diabetic foot care behaviors are one of essential component of diabetic foot ulcer prevention. It facilitates early detection of foot abnormalities and allows early treatment that produce bigger opportunity for better outcomes.
However, many of diabetic patients were not perform this practice properly. The aims of this review are to describe the diabetic foot care behaviors components, contributing factors, assessment, and diabetic foot care behaviors improvement program. A relevant literature searched from databases: PubMed, CINAHL, the Cochrane and ProQuest Medical Library, and Science Direct were conducted. It was found that diabetic foot care behaviors basically consist of simple activities that predict had significant benefits in preventing diabetic foot ulceration.
Foot care behaviors influenced by several factors including patients’
age, gender, knowledge, foot care education experiences, foot care education and foot examination that conducted by healthcare providers, and resources availability.
With regard to the important of foot care behaviors in preventing diabetic foot ulceration, it was recommended for healthcare providers to regularly assess patients’
foot care knowledge and behaviors and apply the certain strategies to improve patients’ foot care knowledge and behaviors properly.
Keywords-component;
diabetic foot care, foot ulcer, foot ulcer prevention.
I. INTRODUCTION
Diabetic foot ulcer (DFU) is the commonest diabetic complications. It affects almost 15% to 25% of
diabetic patients [1]. In the other hand, diabetic foot ulcer treatment is challenging, costly, time consuming [2,3,4], and often requires foot amputation [5]. It was reported that almost 32%
of diabetic patient with foot ulcer ended up with such types of foot
amputation [6].
Depressingly, evidences showed that diabetes related foot amputation is closely related to physical disability, depression, financial burdens, poor quality of life, and high mortality [4,7,8]. Thus, DFU prevention is very important.
Additionally, once diabetes peripheral neuropathy (DPN) is developed, diabetes patients’ feet are easily developing foot ulceration.
Some of the patients’ daily activities, such as walking bare foot, footwear, and trimming toenails are impending causes of foot ulcer. However, since the patients unable to sense the pain caused by injuries, foot ulcer become insensible injury and most of patients just know the ulcer after it developed such degree of infection [9]. These situations emphasize that daily foot inspection is very important. Daily foot inspection allows patient early detect any foot abnormalities that eventually provides large opportunity to prevent foot ulceration. It was noted that patients who performed proper foot care had significantly lower risk of foot ulceration than those who did not [10,11].
Unfortunately, previous studies showed that many diabetic patients did not perform it properly [11,
12, 13]. The objectives of this review are to outline the diabetic foot care behaviors components, contributing factors, assessment, and diabetic foot care behaviors improvement program.
II. METHOD
The
http://lib.med.psu.ac.th/lib medeng/ was used as the main channel to search related journals, articles, and other comprehensive reports from the classic nursing and health-related databases such as PubMed, Cumulative Index to Nursing and Allied Health (CINAHL), the Cochrane Library, and Science Direct. The numbers of keywords were used to obtain those articles including diabetic foot care, foot ulcer, foot care practice, and foot ulcer prevention.
III. DIABETICFOOTCARE BEHAVIORSCOMPONENTS
Diabetic foot care behaviors simply defined as the daily activities to assess or examine foot conditions and apply some recommended actions to maintain and improve foot conditions or minimize the risk based on the assessment findings [15].
Generally, it consists of foot assessment and foot care.
A. Foot Assessment This activity is purposed to identify the major causes of foot ulceration including foot peripheral neuropathy, vascular problem, and foot pressure. There were some recommended points in the foot assessment as followed [15, 16]:
1). Foot skin assessment. These
activities include skin color, dryness, thickness, fissures, or cracking. To ensure all part of foot were assessed properly, the diabetic patients suggested using mirror.
2). Peripheral neuropathy assessment.
This assessment is including thermal sensation, pain sensation, numbness, or autonomic damage.
3). Vascular
impairment assessment.
This assessment including assessing warm skin, distended vein and foot pulses.
4). Foot posture and shape assessment.
Activities including investigating of claw toes, metatarsal heads, or Charcot joint.
5). Callus and blister assessment. This assessment focused on the plantar pressured point including the site, size, and the appearance of callus or blister.
6). Infection or inflammation assessment.
It especially aimed to identify the between toes area and the moist part of each foot.
7). Assessment of
ulceration. This
assessment includes assessment of the foot ulcer site, appearance, size, infection signs, and exudation.
B. Foot Care
This activity
consists of any
recommended actions to maintain foot conditions and/or minimize foot ulcer risk factors. Those recommended foot care activities were include as follows [17,18,19]:
1). Foot hygiene.
The foot should be kept in clean, dry, and soft.
Patients are suggested to wash the foot daily by using mild soap and pour (warm not hot) water and soft washcloth. Avoid soaking feet more than 4 minutes and drying all parts the foot including between toes area gently by using soft and clean towel, especially between areas. To keep skin foot
moist, apply a
moisturizing lotion after washing.
2). Selecting and wearing fitted footwear. It was suggested to use proper cushion footwear, athletic shoes, footwear with laces, velcro, or buckles, and avoiding pointed-toe, open-toe shoes, high heels, sandals, and un-breathable and inelastic materials.
3). Toenails
trimming and care. This foot care action only suggested for the patients who able to reach and cut the toe nails properly.
Cutting the toenails carefully using proper nail cutter/nail clipper, following to the shape of the toes, avoid cut the nails too close to the skin of toenails bed, and avoid cutting down the corners or skin at the end of toenails (see Figure 1). In addition, it is suggested to perform nail cutting after soaking feet (after a bath or shower). When find toenails are ingrown, thickened, or infected, it should be treated and trimmed by a healthcare professional.
4). Avoiding extreme temperatures. Check the
temperature of
water/shower before used.
However, because patients mostly experience loss- sensation because of neuropathy, they may be unaware of thermal injury.
If possible, put water thermometer in the bathroom to ensure that the water is in the proper/tolerable
temperature.
5). Attending on the
regular health
professional foot examination. During the regular check up, patient is suggested to promptly report foot problems to the healthcare professional such as infection, ulcer, cuts that do not heal, and other abnormal findings that they find during daily assessment (redness, drainage, swelling, pain or dark discoloration). Also suggested for patients to ask any advises from nurses or primary care providers when superficial cuts, scratches, and blisters that do not heal in three days. The attending comprehensive foot examination frequencies will different for each patient depends on their risk factors severity.
Patients’ risk factors classification and scoring is as followed [16]:
TABLE I. RISK CLASSIFICATION
BASED ON THE COMPREHENSIVE
FOOT EXAMINATION
Risk Category
Definition Recommended 0 No LOPS,
no PAD, no deformity
Patient education including advice on appropriate footwear
1 LOPS+
deformity
Consider prescriptive or accommodative footwear
Consider prophylactic surgery if deformity is
not able to be safely accommodated in shoes. Continue patient education.
2 PAD +
LOPS
Consider prescriptive or accommodative footwear.
Consider vascular consultation for combined follow-up.
3 History of ulcer or amputation
Same as category 1.
Consider vascular consultation for combined follow-up if PAD present.
Abbreviations: PAD = peripheral artery diseases and LOPS = loss of protective sensation. Source:
Boulton et al. (2008).
IV. DIABETIC FOOT CARE
BEHAVIORS
CONTRIBUTING FACTORS
A. Patients’ Knowledge and Foot Care Education.
In one study stated that one of the barriers of performing foot care properly is patients’
lack of knowledge [20,21].
Inherent, the evidences mostly suggested that educational program improve patients’
knowledge and foot behaviors [22, 23]. In addition, it was noted that repeated exposure to the educational program improved patients’
adherence to perform proper foot care. Diabetic patients who participated in more than three education programs practiced had significantly better self foot care than patients who had no or only one training program [13, 24]
B. Patients’
Characteristic
One study
showed that man was more confident in their ability to manage their diabetes, reported fewer lapse in foot care, reported higher quality of life, and overall better treatment
satisfaction [25]. The other patients’ characteristics that significantly associated with greater basic foot care were younger age, African- American background, higher education, more severe foot neuropathy, and having experience of foot ulcer [13]. Another study noted that there were significant different of foot care behaviors and understanding between American Indian/Pacific Islanders, Asians, and African Americans [21].
C. Complication of Diabetes Mellitus
Complication of diabetes mellitus influence patients’ foot care behaviors in negative and positive direction.
Negatively, DM
complication may develop any physical disabilities that reduce patients’
capacity to perform foot care practice properly. In one study identified that some barriers of performing foot care practice were included vision problem, joint problem, and excess weight [21]. In contrast, complication also may improve patient awareness to perform foot care more properly in order to
minimize the
complications that already developed [24].
D. Foot Care Education
and Foot
Examination from Healthcare Providers
In the study identified that patients who received foot care education and their feet had been examined by healthcare providers were more likely to check their feet regularly [26].
E. Resources Availability
It was identified that lack of foot care equipments such as mirror, foot-stool, and nail cutter would inhibit patients to perform self-foot care properly [13]. Without those equipments may hinder them to perform some foot care techniques properly.
Based on all of those findings, it can be generalized that patients’
foot care behaviors are influenced by three major factors, namely: patients’
related factors, health care providers’ related factors, and resources availability related factors.
V. DIABETIC FOOT CARE BEHAVIORS ASSESSMENT
Patients’ self- report (questionnaire) on perceived foot care behaviors were generally used in the previous studies to measure the outcome of patients’ foot
care behaviors.
Observational method was also used in combination with patients’ self-report in evaluating foot care
behaviors [27],
unfortunately there was no clearly explanation regarding this technique.
The published
questionnaires had been developed to evaluate foot care behaviors were including Nottingham Assessment of Functional Foot-care Questionnaire (NAFF), DisFoKa-32, and summery of diabetes self- care activity (SDSCA).
A. Nottingham Assessment of Functional Foot- care Questionnaire (NAFF)
This instrument was developed by Lincoln and colleagues in 2007 and primarily consisted of 51-item [28]. It was
implemented with 100 diabetic patients and 61 healthy volunteers in out- patients department. The internal consistency was 0.46 and 0.39 in people with diabetes and in healthy volunteers, respectively. From this, 28 items were found significant differences between each group. The instrument was then revised into 29 items and consists of foot assessment (2 questions), foot wear (13 questions), foot hygiene (3 questions), prevent foot injury (7 questions), toenails, callus/corn care (2
questions), and
wound/ulcer care (2 questions). The internal consistency was 0.53 and there was a significant correlation (γ = 0.83; p <
0.001) and no significant difference (p = 0.85) between scores in the test- retest study. However, since this instrument developed and utilized in European countries, utilization in other regions is therefore needed to be modified to fit with context and culture.
B. DisFoKaPS-32 Questionnaire
This
questionnaire was developed by Khamseh and colleagues in 2007 based on foot care
principle, their
experiences as healthcare providers, and the recommendations from the American College of Foot and Ankle Surgeons and the British Diabetes Association [29]. It was originally developed in Persian Language version and consisted of 16 questions on knowledge and 16 items of foot care behaviors. Foot care practice section comprised
foot self-examination (4 questions), foot wear (3 questions), toenails care (2 questions), and foot hygiene (7 questions). The content validity was approved by five physicians and one nurse and tried-out with diabetic patients. However, there was no report regarding reliability test of this questionnaire.
C. Summary of Diabetes Self-Care Activities (SDSCA)
Questionnaire The SDSCA is a brief self-report questionnaire to assess diabetes self-management including: general diet, specific diet, exercise, blood-glucose testing, foot care, and smoking [30]. In addition, Toobert and colleagues reported the high internal consistency- reliability of the 5 categories of this tool (γ = 0.47) with an exceptional of the specific diet test- retest correlations were at moderate level (γ = 0.40).
Furthermore, SDSCA questionnaire was a brief, reliable, and valid self- report measure of diabetes self-management
(included foot care practice) and suggested to use both for research and clinical practice. The limitation of this instrument might be detected at the few items of foot care behaviors questions that consisted of two questions regarding patient’s practice in checking their foot and inspecting inside part of footwear. So, it might be not represent the whole picture of diabetic foot
care behaviors
components.
Regarding the components measured, NAFF and DisFoKaPS-32
seem more comprehensive than SDSCA. In addition, NAFF and DisFoKaPS-32 have some similarities including used foot inspection, foot hygiene, footwear, preventing foot injuries,
toenails/callus/corn care and moisturizing foot skin to measure foot care behaviors. However, since the NAFF developed in European country, the measurement items may not fit to measure foot care behaviors in non-European
countries.
VI. DIABETIC FOOT CARE BEHAVIORS IMPROVEMENT PROGRAM
According to the evidences from the previous studies, there were 10 studies (5 RCTs, 2 quasi experiments studies, and 3 systematic reviews) evaluated the effectiveness of diabetic foot care program in improving foot care behaviors and preventing foot ulcer. Even though there were some limitations regarding the methodological issues, all evidences suggested that educational program that combined with follow up, consultation, and providing printed material were effectively improved patients’ foot care knowledge and behaviors.
Accordingly, the
systematic reviews reported that trials in this arena considerably improved patients’ foot care knowledge and behaviors however most of those studies had lower internal validity and high risk of bias [23, 31,32].
Regarding the follow up strategies used, most of those studies utilized telephone call, card reminder, home visit,
and face-to-face followed up as schedule at clinic/
outpatient department during regular check up.
Regarding the phone call follow up, some other studies reported that phone call intervention for giving health education and/or follow-up effectively improved patients’
behaviors [33, 34, 35].
In the educational strategies, most of the previous studies provided diabetic foot care programs as an individual (face-to-face) or a group that combined with demonstration, discussion, providing leaflet/booklet,
providing other
motivational sessions, or providing consultation or couching. The efficacy of using individual and group diabetic foot care program showed that group approach was more effective than individual approach [36]. In other
study noted that
effectiveness of group
approach (4-8
patient/group) was equally effective in improving the outcomes and may allow other benefits regarding time and cost [38].
There were
several measured
outcomes evaluated in the previous studies. Those outcomes were ulcer/
diabetic foot
problem/amputation, patients’ foot care knowledge, and patients’
foot care behaviors. Those studies revealed that all of the diabetic foot care programs improved patients’ foot care knowledge and behaviors [27, 22, 36, 38-41], enhanced patients’ self efficacy [38], improved patients’ perceptions of barrier, benefit, severity, threat, and susceptibility
of foot care [27], and improved patients’ self- management behaviors [36,40]. However, effect of diabetic foot care programs on patients’
mood and quality of life were not found [27]. Also, did not reach statistical significant in term of diabetic foot care program on reducing foot ulcer or incidences, particularly in high risk patients [27, 39].
VII. CONCLUSION
Overall, foot care behaviors are one of the important components of foot ulcer prevention.
Unfortunately, the evidences suggested that many diabetic patients did not perform foot care practice properly. It was also identified that diabetic foot care behaviors were influenced by many factors, such as patients’ knowledge, foot care education experience, DM complications, foot care education and
examination from
healthcare providers, and resources availability.
Fortunately, most of those factors were modifiable and several foot care improvement programs showed effectively improved patients foot care knowledge and behaviors. Generally, the program provided was combination of interactive educational session with others strategies including follow-up phone call, booklet, motivation and counseling strategies.
Even though the previous
evidences showed
effectively improved patients’ foot care knowledge and behaviors, almost of those studies were conducted in the western countries.
Therefore, the program and measurement used
may not produce similar effect when it was applied in the countries with different characteristic/
cultural background.
VIII. RECOMMENDATION
Based on
evidences outlined, it is suggested for every healthcare provider who treats diabetic patients to regularly assess patients’
current foot care knowledge and behaviors and apply certain improvement program/
strategy to enhance patient foot care knowledge and behaviors in order to prevent diabetic foot ulceration.
ACKNOWLEDGMENT
I would like to thank to the Directorate of Higher Education, Ministry of National Education of Republic of Indonesia for giving me scholarship to continue my study in Faculty of Nursing, Prince of Songkla University, Thailand.
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