Using the search term diabetes mellitus in PubMed yielded 353 111 publications; adding diabetic foot ulcers reduced the number of articles to 6807, including foot care OR footcare into the search terms reduced the number of the articles to 506, and adding experiences or perceptions significantly reduced the numbers of articles to 5. Limiting the search to papers published in English brought the number of articles eligible for analysis to 4, and limiting the inclusion to studies conducted among adults resulted in 2 articles. This process was repeated in the other literature databases and yielded 12 studies that qualified for full text review; the final numbers were 2 from PubMed, 5 from CINAHL, 1 from Cochrane, and 4 from Google Scholar. Three (3) were excluded for not addressing foot care in persons with diabetes, leaving 9 peer-reviewed, qualitative research studies. Details of the initial search results and refined inclusions are presented in Figure 1. Characteristics of the included studies are outlined and summarized in Table 1, and outcomes from each study are reported in Table 3.
Design. The 9 full-text articles included 113 patients with diabetes (95 patients with DFUs or a history of DFUs and 18 with no DFUs): 4 were qualitative descriptive design,9,11,17,18 2 were descriptive phenomenology studies,19,20 1 used a grounded theory design,21 1 used an interpretive phenomenology,22 and 1 used an exploratory qualitative design.23 Analysis of the transparency of the reviewed studies according to SRQR showed 4 studies scored below 15, indicating a lack of transparency. Only 2 studies critically appraised the issue of trustworthiness.19,20 All other studies failed to report the issues of trustworthiness; thus, findings from these studies should be interpreted with caution.
Location. Study location varied; 4 studies were conducted in the United Kingdom, 1 in the US, and 1 each in South Africa, Jordan, Iran, and Barbados. All 9 studies sampled adults with diabetes; 3 also assessed provider perspectives.17 21,23
Participant characteristics. Clinically, participants included 18 individuals with diabetes and without foot ulceration9 and 95 individuals with diabetes who had open or healed ulcers12,13,15,16; 16 participants had undergone DFU-related amputations.18,19
Themes. The themes identified from all the studies included DFUs as a burden, poor knowledge and perception about foot self-care practices, nonadherence to foot care recommendations, and engaging in risky self-management practices. In general, participants’ perceptions of foot self-care differed from their providers and from the standard of care guideline recommendations.
DFUs as a burden. Findings indicate that patients with DFUs suffered depression, anxiety, and fear of re-ulceration, the threat of amputation, the slow healing process, taking medication, loss of independence, and lifestyle limitations,17,19 while others felt serious anger resulting from an inability to fulfill their social roles22 and emotional pain related to immobility and the fear of amputation.17 Some authors reported that participants felt hopeless and perceived a loss of social support in their struggle to prevent re-ulceration.18,19,21 Patients with healed DFUs often felt a lack of control to prevent re-ulceration due to their perception of foot care being frustrating and overwhelming.18
Poor knowledge and perception about foot self-care practices. Results also showed that some patients with diabetes did not practice foot self-care because of their perceptions and beliefs about foot self-care.19,22,23 For example, study participants often did not feel a need for foot self-care because they perceived foot self-care as less important compared to glycemic control, felt it was unnecessary, and did not understand why it is important to care for their own feet.21-23 Others lacked knowledge or information about foot self-care17,19,22 and/or misinterpreted foot self-care information from their providers.17,21,22 The studies reviewed also suggested that patients with diabetes have poor foot self-care knowledge and often do not pay attention to foot self-care education provided by the health care providers.9,19,21 For instance, some patients with diabetes and DFUs believed that podiatrists would heal their ulcers, making it unnecessary to take action for themselves.17 A substantial number of participants reported lack of knowledge of the necessity of foot self-care practices and what to do, and were, in part, responsible for their inability to practice foot self-care.17-19
Nonadherence to foot care recommendations. Findings indicated that patients were less likely to adhere to treatment recommendations that conflicted with their usual or preferred lifestyles.9,17,19,22 For example, despite agreeing that foot rest was one of the best remedies for foot ulceration, a few patients with DFUs were not able to rest their feet as recommended because they perceived it as uncomfortable.17 Additional reasons for not following foot care recommendations included not believing such care was necessary17,18 or not appreciating their feet could be injured.21,23 Similarly, some patients with DFUs believed that DFUs are a spiritual, and not a medical, problem.20 For instance, most participants in 1 study perceived DFUs as a spiritual problem mostly caused by witchcraft, ancestry, or God and not by lack of foot self-care.20
Engaging in risky self-management practices. Most patients in the reviewed studies based their foot treatment regimen on their personal health care beliefs; these included self-management practices such as rubbing their feet with olive oil, applying ointments on DFUs, inserting their feet in cold salted water,13 soaking feet in hot water,20 and/or wiping feet daily with surgical methylated spirit.11 Wiping the feet daily with surgical methylated spirits can cause skin dryness and predispose the skin of the feet to ulceration.11 None of these practices are included in the foot self-care guidelines recommended by the American Diabetes Association.5 Most patients in the reviewed studies sought self-management strategies with the goal of comfort, cure, and preventing DFUs, despite the fact that some practices inadvertently increased their risk of developing a foot ulcer.11,20,21
Discordance between patient and provider impressions and expectations on foot self-care. Three (3) studies compared patient and provider perspectives on recommended foot self-care practices, demonstrating that patients’ interpretations of foot care information were sometimes different from what was intended by providers.17,21,23 Both patients and podiatrists identified barriers to effective foot self-care. For example, some podiatrists reported that some patients with diabetes and foot ulcers irresponsibly neglected to care for their feet, often did not follow foot self-care recommendations, and should be blamed for their foot complications, given that they received training on foot self-care.17,21 On the other hand, some podiatrists acknowledged that the advice given to patients with DFUs is often difficult to follow and was believed to decrease adherence.17 An emphasis on tight glycemic control was reported to dominate the thinking both of health professionals and patients, deeming other aspects of diabetes care, including foot care, into less of a priority.23 Health care professionals also reported patient resistance to foot self-care, while patients blamed their providers for not providing access to quality foot care services.21,23 Patients also believed they had not received enough training and support from health care professionals who primarily blame the patient for the DFU, citing patients’ lack of knowledge, lack of attention to self-foot care education provided, and no adherence to foot self-care recommendation provided.17,21,23 For example, podiatrists in 1 study reported that although patients with DFUs agreed that foot rest was one of the best remedies for foot ulceration, few patients rested their feet as much as recommended.17 In this same study, patients with DFUs reported they expected their podiatrists to cure their DFUs and did not feel it was necessary to take actions for themselves.