Diabetic Foot Care Behaviors: A Literature Review

Titis Kurniawan1,2*, Imas Rafiyah1,2, Ardia Putra1,3, Yanuar Primanda1,4

1
Master 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 color, dryness, thickness,
the diabetic foot care fissures, or cracking. To
behaviors components, ensure all part of foot were
contributing factors, assessed properly, the
assessment, and diabetic diabetic patients suggested
foot care behaviors using mirror.
improvement program. 2). Peripheral
neuropathy assessment.
II. METHOD This assessment is
The including thermal
http://lib.med.psu.ac.th/lib sensation, pain sensation,
medeng/ was used as the numbness, or autonomic
main channel to search damage.
related journals, articles,
3). Vascular
and other comprehensive
impairment assessment.
reports from the classic
This assessment including
nursing and health-related
assessing warm skin,
databases such as
distended vein and foot
PubMed, Cumulative
pulses.
Index to Nursing and
Allied Health (CINAHL), 4). Foot posture and
the Cochrane Library, and shape assessment.
Science Direct. The Activities including
numbers of keywords investigating of claw toes,
were used to obtain those metatarsal heads, or
articles including diabetic Charcot joint.
foot care, foot ulcer, foot
5). Callus and
care practice, and foot
blister assessment. This
ulcer prevention.
assessment focused on the
III. DIABETIC FOOT CARE plantar pressured point
BEHAVIORS COMPONENTS including the site, size,
and the appearance of
Diabetic foot care
callus or blister.
behaviors simply defined
as the daily activities to 6). Infection or
assess or examine foot inflammation assessment.
conditions and apply some It especially aimed to
recommended actions to identify the between toes
maintain and improve foot area and the moist part of
conditions or minimize the each foot.
risk based on the
7). Assessment of
assessment findings [15].
ulceration. This
Generally, it consists of
assessment includes
foot assessment and foot
assessment of the foot
care.
ulcer site, appearance,
A. Foot Assessment size, infection signs, and
This activity is exudation.
purposed to identify the B. Foot Care
major causes of foot
This activity
ulceration including foot
consists of any
peripheral neuropathy,
recommended actions to
vascular problem, and foot
maintain foot conditions
pressure. There were some
and/or minimize foot ulcer
recommended points in
risk factors. Those
the foot assessment as
recommended foot care
followed [15, 16]:
activities were include as
1). Foot skin follows [17,18,19]:
assessment. These
activities include skin
 1). Foot hygiene. not able to be safely
patients’ characteristics
accommodated in
The foot should be kept in that significantly
shoes. Continue
clean, dry, and soft. 4). Avoiding extreme patientassociated
education. with greater
Patients are suggested to temperatures. Check the basic foot care were
2 PAD +  Consider prescriptive
wash the foot daily by temperature of LOPS younger age, African-
or accommodative
using mild soap and pour water/shower before used. American
footwear. background,
(warm not hot) water and However, because patients higher
 Consider vasculareducation, more
soft washcloth. Avoid mostly experience loss- consultation
severefor foot neuropathy,
combined follow-up.
soaking feet more than 4 sensation because of and having experience of
minutes and drying all neuropathy, they may be 3 History of  Same foot
as category
ulcer1. [13]. Another
ulcer or  Consider vascular
parts the foot including unaware of thermal injury. study noted that there were
amputation consultation for
between toes area gently If possible, put water combined follow-updifferent
significant if of foot
by using soft and clean thermometer in the care
PAD present. behaviors and
towel, especially between bathroom to ensure that Abbreviations: PAD = peripheral
understanding between
areas. To keep skin foot the water is in the artery diseases and LOPS = loss American Indian/Pacific
moist, apply a proper/tolerable of protective sensation. Source: Islanders, Asians, and
moisturizing lotion after temperature. Boulton et al. (2008). African Americans [21].
washing.
5). Attending on the IV. DIABETIC FOOT CARE C. Complication of
2). Selecting and regular health BEHAVIORS Diabetes Mellitus
wearing fitted footwear. It professional foot CONTRIBUTING FACTORS Complication of
was suggested to use examination. During the diabetes mellitus influence
proper cushion footwear, regular check up, patient is A. Patients’ Knowledge
patients’ foot care
athletic shoes, footwear suggested to promptly and Foot Care Education.
behaviors in negative and
with laces, velcro, or report foot problems to the In one study positive direction.
buckles, and avoiding healthcare professional stated that one of the Negatively, DM
pointed-toe, open-toe such as infection, ulcer, barriers of performing foot complication may develop
shoes, high heels, sandals, cuts that do not heal, and care properly is patients’ any physical disabilities
and un-breathable and other abnormal findings lack of knowledge [20,21]. that reduce patients’
inelastic materials. that they find during daily Inherent, the evidences capacity to perform foot
assessment (redness, mostly suggested that care practice properly. In
3). Toenails
drainage, swelling, pain or educational program one study identified that
trimming and care. This
dark discoloration). Also improve patients’ some barriers of
foot care action only
suggested for patients to knowledge and foot performing foot care
suggested for the patients
ask any advises from behaviors [22, 23]. In practice were included
who able to reach and cut
nurses or primary care addition, it was noted that vision problem, joint
the toe nails properly.
providers when superficial repeated exposure to the problem, and excess
Cutting the toenails
cuts, scratches, and educational program weight [21]. In contrast,
carefully using proper nail
blisters that do not heal in improved patients’ complication also may
cutter/nail clipper,
three days. The attending adherence to perform improve patient awareness
following to the shape of
comprehensive foot proper foot care. Diabetic to perform foot care more
the toes, avoid cut the
examination frequencies patients who participated properly in order to
nails too close to the skin
will different for each in more than three minimize the
of toenails bed, and avoid
patient depends on their education programs complications that already
cutting down the corners
risk factors severity. practiced had significantly developed [24].
or skin at the end of
Patients’ risk factors better self foot care than
toenails (see Figure 1). In D. Foot Care Education
classification and scoring patients who had no or
addition, it is suggested to and Foot
is as followed [16]: only one training program
perform nail cutting after Examination from
[13, 24]
soaking feet (after a bath TABLE I. RISK CLASSIFICATION Healthcare Providers
or shower). When find BASED ON THE COMPREHENSIVE B. Patients’
FOOT EXAMINATION In the study
toenails are ingrown, Characteristic
Risk Definition Recommended identified that patients
thickened, or infected, it One study
Category who received foot care
should be treated and showed that man was
0 No LOPS, Patient education education and their feet
trimmed by a healthcare no PAD, no includingmore
advice confident
on in their had been examined by
professional. deformity appropriate footwear
ability to manage their healthcare providers were
diabetes, reported fewer more likely to check their
1 LOPS+  Consider prescriptive
lapse in foot care, reported
deformity or accommodative
feet regularly [26].
higher quality of life, and
footwear E. Resources
overall better treatment
 Consider prophylactic
surgerysatisfaction [25]. The other
if deformity is 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 efficacy [38], improved almost of those studies [3] W. J. Jeffcoate, and
utilized telephone call, patients’ perceptions of were conducted in the K. G. Harding,
card reminder, home visit, barrier, benefit, severity, western countries. “Diabetic foot ulcer,”
and face-to-face followed threat, and susceptibility Therefore, the program Lancet, vol. 361, pp.
up as schedule at clinic/ of foot care [27], and and measurement used 1545–1551, 2003.
outpatient department improved patients’ self- may not produce similar [4] G. Ragnarson-
during regular check up. management behaviors effect when it was applied Tennvall and J.
Regarding the phone call [36,40]. However, effect in the countries with Apelqvist, “Health-
follow up, some other of diabetic foot care different characteristic/ economic
studies reported that phone programs on patients’ cultural background. consequences of
call intervention for giving mood and quality of life diabetic foot
health education and/or were not found [27]. Also, VIII. RECOMMENDATION lesions,” Clinical
follow-up effectively did not reach statistical Based on Infectious Diseases.
improved patients’ significant in term of evidences outlined, it is Vol. 39 pp. S132–
behaviors [33, 34, 35]. diabetic foot care program suggested for every S139, 2004.
on reducing foot ulcer or healthcare provider who [5] Canadian Diabetes
In the educational
incidences, particularly in treats diabetic patients to Association [CDA],
strategies, most of the
high risk patients [27, 39]. regularly assess patients’ “Approached
previous studies provided
current foot care treatment of a patient
diabetic foot care VII. CONCLUSION knowledge and behaviors with diabetic ulcer,”
programs as an individual
Overall, foot care and apply certain Available at
(face-to-face) or a group
behaviors are one of the improvement program/ http://www.diabetes.
that combined with
important components of strategy to enhance patient ca/, 2005.
demonstration, discussion,
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evidences suggested that prevent diabetic foot “Common problems
motivational sessions, or
many diabetic patients did ulceration. in diabetic foot
providing consultation or
not perform foot care clinic,” Journal of
couching. The efficacy of ACKNOWLEDGMENT
practice properly. It was Medical Association
using individual and group
also identified that Thailand, vol. 7, pp.
diabetic foot care program I would like to
diabetic foot care 1097-1101, 2008.
showed that group thank to the Directorate of
behaviors were influenced Higher Education, [7] M. Abdelgadir, W.
approach was more
by many factors, such as Ministry of National Shebeika, M. Eltom,
effective than individual
patients’ knowledge, foot Education of Republic of C. Berne, and K.
approach [36]. In other
care education experience, Indonesia for giving me Wikblad, “Health
study noted that
DM complications, foot scholarship to continue my related Quality of
effectiveness of group
care education and study in Faculty of life and sense of
approach (4-8
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patient/group) was equally
healthcare providers, and University, Thailand. Sudanese diabetic
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