Exploring patient and healthcare-professional perspectives on the barriers and facilitators to foot self-care behaviours in diabetes

Abstract

Background: Diabetes incidence and prevalence continues to grow and the chronic impacts of it can, amongst other things, lead to severe foot problems including ulceration and subsequent serious infection. Indeed, one in three people with diabetes will develop vascular impairment to the feet and more than one in ten will develop a diabetic foot ulcer [DFU]. DFUs contribute significantly to morbidity and mortality associated with diabetes and are extremely costly to health services. Accordingly, renewed efforts to reduce the development of DFUs are one of a number of public health focuses to try and reduce this burden. It is well established that good, effective foot self-care behaviours can be an important, low-cost approach to reducing the likelihood of DFU development – however, this appears to be an under-utilised measure and reasons for this remain unclear. This qualitative study sought to explore the perspectives of patients and healthcare professionals [HCPs] on barriers and/or facilitators to foot self-care behaviours in diabetes. In addition, it sought to identify if there may be any areas of consensus and/or tension between patient and HCP perspectives and whether or not they may contribute to any perceived barriers and/or facilitators towards foot self-care behaviours.

Methods: This was a sequential, qualitative study that used a hermeneutic phenomenological approach. There were three phases to this study. The first phase was in-depth, semi-structured patient interviews to gain patients’ perspectives on barriers and facilitators to foot self-care behaviours in diabetes. In the second phase HCPs underwent in-depth, semi-structured interviews on their perspectives on barriers and facilitators to foot self-care behaviours in diabetes as well as the findings from the phase I (patient) interviews. The HCPs interviewed in this phase included Podiatrists, Diabetes Nurses, Foot Health Practitioners (FHPs) and General Practitioners (GPs). In the third phase patient interview groups were presented with the findings from the phase I (patient) and phase II (HCP) interviews to try and identify any areas of consensus and tension between HCP and patient perspectives.

Analysis: Phases I and II were analysed using Interpretative Phenomenological Analysis (IPA). The third phase was analysed using simple thematic analysis. The IPA analyses allowed for detailed consideration of patient and HCP perspectives, respectively. The separate analyses for phases I and II provided stand-alone conclusions to be drawn from patient and HCP participants. This approach also allowed for deep analysis of areas of consensus and tension between patient and HCP perspectives on barriers and facilitators to foot self-care practices in diabetes. The use of thematic analysis from the patient group interviews added further trustworthiness by way triangulation of the findings and conclusions from the study as patients were provided the opportunity to reflect and comment upon the findings from phases I and II, respectively.

Findings: The findings from this study indicate that patients feel that they need to be suitably motivated and enabled to undertake good foot self-care behaviours. Furthermore, it appears that this motivation needs to be internally generated from patients’ lived experiences aligning with the information they receive from their HCPs for it to result in them initiating and sustaining foot self-care behaviours. HCPs, however, appear to focus upon patient knowledge as a major reason why patients may not undertake good foot self-care behaviour and assume that this is intertwined with a lack of motivation on the part of the patient. Accordingly, HCPs appear to have a proclivity towards stark health messaging to motivate patients towards foot self-care behaviour even though both patients and HCPs indicated that stark health messaging was not consistently effective as communication strategy. Non-foot specialist HCPs also expressed that they have some insecurity around their foot health knowledge and this appears to result in them not routinely steering patients towards conversations about foot health. The clearest areas of consensus in perspective between HCPs and patients included concerns over consequences of diabetes complications; the importance of patient education and frustrations around aspects of health service delivery. Meanwhile, the most notable areas of tension include mixed messaging from HCPs around the roles and responsibilities of foot health and who patients should initially see following the development of a foot problem.

Conclusions: This study has identified possible reasons why patients are often not getting timely access to the best care and advice when it comes to their foot health in diabetes. One of the strongest reasons for that appears to be that patients may not be being steered towards foot health conversations by their HCPs and that this may be the result of non-foot-specialist HCPs feeling insecure about their foot health knowledge. In addition, this study exposes some nuance around HCP proclivity towards often ineffective stark health messaging as a common tactic to develop motivation in patients. Finally, mixed messaging from HCPs around foot health responsibilities; patients sometimes lacking faith in HCP knowledge and disagreement between patients and HCPs as to who foot problems should initially be presented to may result in patients losing trust in HCPs and them not getting timely access to specialist care. Further research is needed to understand how approaches to policy and interventions may address these challenges.

Date of Award	2 Nov 2022
Original language	English
Awarding Institution	University of Bath
Supervisor	Fiona Gillison (Supervisor) & Mairghread Ellis (Supervisor)