Hight costs (approximately 5% of the total NHS budget in 2002 [Wanless, 2002]), and marked reductions in quality of life for the person affected, are associated with diabetic foot ulcers. Research suggests that supporting people with type 2 diabetes to carry out self-care for their condition improves health outcomes and quality of life (Department of Health [DH], 2005a; Tomkins and Collins, 2006). In practice, however, engaging people to carry out self-care is often a challenge for healthcare professionals, including podiatrists encouraging self-care of the diabetic foot.
Despite the emphasis on evidence-based practice within the NHS, as a profession podiatry is relatively new to the concept of integrating research evidence into practice (Vernon and Campbell, 2006). This article reviews the literature on the factors influencing the ability of people with diabetes to carry out self-care with the aim of helping podiatrists to incorporate research findings into their practice.
Literature review
Keywords for the review were determined (type 2 diabetes; self-care; podiatry; self-efficacy) and a key word tree was created. MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, PsycINFO, Applied Social Sciences Index and Abstracts, EMBASE and Google Scholar databases were searched. Search limiters were set to English and adults. Citations from some of the articles retrieved from the databases were followed up.
A total of 1693 papers were retrieved. Papers were excluded if they: (i) included comorbid conditions, (ii) related to acute care, (iii) related exclusively to type 1 diabetes (because it was considered that the urgency to maintain life in type 1 diabetes was a different motivational factor from that involved in the management of a chronic condition, such as type 2 diabetes), (iv) provided guidance on foot assessments, (v) validated research tools or measured the outcome of an intervention.
Of the 1693 papers retrieved, 112 were fully reviewed and themes related to patients and self-care in type 2 diabetes were identified.
Four themes emerged from the papers reviewed: self-efficacy and autonomous self-regulation; patient barriers to self-care; patient information and self-care; patient–clinician relationship. These themes, and their implications for podiatry practice, will now be examined.
What do we mean by self-care?
The DH (2005a; c) describes self-care as “the care taken by individuals towards their own health and wellbeing, this is extended to include care to children, family friends, neighbourhood and communities”.
Surveys around self-care tell us that people are requesting more information and support to help them manage their conditions (DH, 2005c). People rate support from clinicians highly as an enabler to achieve self-care (DH, 2005c). However, anecdotal evidence from podiatrists suggests that patients with type 2 diabetes prefer clinician-led care. Former advice on foot care placed an emphasis on routine clinic care may be responsible for this. Now that there is increasing evidence in support of people with diabetes undertaking self-care to improve health outcomes (DH 2005c), podiatrists wishing to encourage their patients to do this need to become skilled at effective communication and assessing the ability of patients to carry it out as advised. Furthermore, such advice needs to be tailored to the patients’ capability to self-care and their category of risk for foot problems.
“Self-efficacy” appears in literature as a concept associated with an individual’s ability to self-care (Sigurdardóttir, 2004). It is used as an important predictor of health outcomes in chronic disease management and is amenable to change (Walker et al, 2007). The concept of autonomous self-regulation refers to a person achieving self-control in self-care tasks, which involves self-direction and self-discipline. To achieve this, Sigurdardóttir (2004) observed that flexible self-care should be achieved, which is dependent on knowledge, physical skills and emotional control to fit it in with their lifestyle and enable them to maintain good diabetes control. Clinician feedback, through appraisal and support for the adjustments made (according to self-care performance) is important in assisting people with diabetes to achieve autonomous self-regulation (Walker et al, 2007).
The research papers reviewed here measured self-care by examining adherence to specific self-care behaviours, such as diet, exercise, blood glucose monitoring and foot care, alongside suggested strategies for improving adherence (Glasgow et al, 2001; Hearnshaw and Lindenmeyer, 2005). Successful measures of self-care have been judged clinically through blood pressure monitoring, an absence of the biochemical complications of diabetes, good glycaemic control, lipid profiles within specified clinical ranges, microalbuminuria monitoring and quality-of-life measures (Glasgow et al, 2001; Hearnshaw and Lindenmeyer, 2005).
While these are useful, movement away from medical measures towards psychological and social models of self-care can give a richer understanding of how self-care fits into people’s lives (Simmons, 2001). These models can suggest patterns that indicate which people are more likely or less likely to self-care. Patients who fail to engage in self-care may do so because they face a number of barriers, and these barriers require examination.
Patient barriers to self-care
People with diabetes need to undertake a variety of self-care practices and integrate them into their lifestyles to avoid complications, thus requiring them to become experts in juggling the priorities of their different self-care practices as their disease-state changes (Rubin, 2001; Whittemore et al, 2002; Bayliss et al, 2003; Sigurdardóttir, 2004; Hearnshaw and Lindenmeyer, 2005). People with diabetes can become overwhelmed by this, which itself can act as a barrier to effective self-care, improved physical health and quality of life (Rubin, 2001). Podiatrists should be empathetic to this fact when suggesting additional self-care regimens.
Research has identified barriers to self-care. These can be divided into psychological, psychosocial, educational and internal and external physical categories (Simmons, 2001). Internal barriers may relate to a lack of information and the beliefs a person may hold concerning a specific health problem and its treatment. These can be mediated by external factors such as strong and supportive interpersonal relationships, contact with role-models coping with the condition, and appropriate clinical care (Clark, 2003).
Age, time since diagnosis, gender, educational attainment and wider health issues appear to impact on self-care behaviours:
- Older people are generally perceived to be more adherent to self-care than young people (Morrongiello and Gottlieb, 2000; Aljasem et al, 2001; Clark, 2003). However, in podiatry, self-care in older people with diabetes can be compromised by obesity and retinopathy, limiting the ability of some to reach and see their feet (Neil, 2002).
- The longer the duration of diabetes, the less likely people are to feel competent to self-care, because of the influence of competing comorbidities and the fear of doing something wrong (Bayliss et al, 2003; Thoolen et al, 2006).
- In terms of gender, in the studies considered, men with diabetes generally received more social and dietary support from partners than women. Women, who often have stronger social networks, sometimes received more conflicting information as a result of this (Whittemore et al, 2005). In addition, difficulty in adhering to exercise was reported, yet higher levels of other physical activity were declared (Whittemore et al, 2005). Hjelm et al (2002) found that women were more likely to seek professional help and preventive care, whereas men commonly presented with acute foot problems.
- Research has also found that those who have higher levels of educational attainment are more likely to self-care (Walker et al, 2007).
- Poor physical health (e.g. eye disease, neuropathy, nephropathy, macrovascular disease, physical limitations) was found to impact negatively on self-care (Bayliss et al, 2003; Chambers et al, 2006; Walker et al 2007). These conditions can limit or remove an individual’s independence and force reliance on family, friends and healthcare services (Bayliss et al, 2003; Chambers et al, 2006; Walker et al, 2007).
- Patients experiencing low mood or depression can show apathy and lack the desire to self-care, while mental illness compromises the ability to self-care (Bonds et al, 2004; Peyrot et al, 2004; Chambers et al, 2006; Walker et al, 2007).
Patient information and self-care
Providing education for people with diabetes that will aid them in overcoming barriers to self-care is important in encouraging effective self-care. Some researchers have suggested that podiatrists should think more creatively about how to do this (Brown et al, 2002; Sigurdardóttir, 2004; Garrett et al, 2005).
Didactic methods of delivering information have been criticised as ineffective because they position patients as passive learners (Garrett et al, 2005). Group education interventions that use a collaborative format, where people actively participate in the learning process through small group discussions, role-playing and interactive techniques, may be more successful in achieving behavioural change, especially if they address underlying attitudes and motivations rather than just knowledge about diabetes (Garrett et al, 2005). Interventions based on behavioural theories have been found to promote self-efficacy and behavioural change among people with diabetes (Cooper et al, 2003; Garrett et al, 2005; Steed et al, 2005; Ko et al, 2007).
However, not all people with diabetes wish to be empowered to engage in self-care (Jahng et al, 2005; Schneider et al, 2006; Cegala et al, 2007). In some instances, increasing a person’s knowledge of their medical condition can make them less inclined to engage in self-care as they fear attempting to manage something they do not fully understand, especially if it is explained in biomedical language (Gillibrand and Flynn, 2001; Parry et al, 2006). Moreover, those who are seriously ill have been reported as having a preference for a more passive role and are reassured by a paternalistic approach on the part of the clinician (Martin et al, 2003; Jahng et al, 2005) Both of these factors mean that, in certain circumstances, people with diabetes increase their dependence on clinicians (Gillibrand and Flynn, 2001; Parry et al, 2006). However, these findings contrast with those of Chambers et al (2006) who found that the more severe a health problem the more motivated individuals are to engage in self-care.
A range of reasons for non-attendance at education sessions for diabetes, such as not having time, trouble reading, stress and transportation difficulties have been reported (Graziani et al, 1999). Other reasons include low perceived seriousness of the disease, no perceived benefits and denial or fear of what was to be learned (Graziani et al, 1999; Rhee et al, 2005). Those with higher HbA1c levels were more likely to have lower educational attainment (Rhee et al, 2005).
Despite barriers to education, awareness of alternative sources of information on diabetes management needs to be improved (Persell et al, 2004). Such information is available from the internet, NHS Direct, Diabetes UK, local pharmacists, The Expert Patient Programme, support networks through local PCTs and assistive technologies (DH, 2005b; c); Chambers et al, 2006; Walker et al, 2007). Chambers et al (2006) recommended that clinicians acknowledge and promote these as supportive health resources for the people they treat. However, clinicians should advise patients on sourcing credible and valid alternative information to support their self-care practices.
Clinical practice: Aiming for concordance not compliance
It is reported that some podiatrists blame the person receiving treatment for non-compliance when attempts to encourage self-care fail (Lutfey, 2004; Smith et al, 2006; Walker et al, 2007). However, there may be reasons for non-compliance that podiatrists need to reflect on.
Smith et al (2006) maintain that, in the initial consultation, people’s keenness to listen to their podiatrist is overridden by their anxiety at not knowing what to expect from the consultation. Parkin and Skinner’s (2003) examination of an outpatient setting found only 45% congruency of recall for decisions made between clinician and patient post-consultation. Additionally, Skinner (2004) noted that one quarter of the instances of inaccurate information recall were due to the use of complex medical terms during the consultation.
Chatterjee (2006) argued that gaps between clinicians’ desired outcomes and those achieved suggest a need to look beyond the clinical issue and seek to bring concordance to the consultation. Concordance implies a shared understanding between clinician and patient about treatment and management (Walker et al, 2007), and this may in part be promoted by training in consultation skills for both those giving and receiving treatment (Skinner, 2004; Smith et al, 2006).
Concordance may also be achieved by clinicians supporting people with diabetes in developing general self-management skills for the effective management of their condition (Skinner, 2004). The ability of clinicians to encourage self-care, or the extent to which providers elicit and acknowledge patients’ perspectives, support patient initiatives, offer choice about treatment options and provide relevant information, while minimising pressure or control, is known as “autonomy support” (Walker et al, 2007). This has been associated with patient motivation and increased competence (Williams et al, 2005).
Research suggests that to promote concordance in self-care there is a need to identify an individual’s “stage of change” – his or her readiness to undertake specific self-care activities (Koenigsberg et al, 2004; Chambers et al, 2006; Tomkins and Collins, 2006). Clinicians are encouraged to explore personalised barriers to self-care, adopting patient-centred consultation styles, and to advise on one or two specified behaviour changes at a time so that the goals set are considered achievable (Bayliss et al, 2003; Koenigsberg et al, 2004; Nagelkerk et al, 2006). Problem-solving strategies are advocated as an effective way to overcome barriers to change and to optimise self-care (Whittemore, 2000; Tomkins and Collins, 2006).
Implications for podiatry practice
Self-care in the management of the diabetic foot is a cause for debate among some clinicians. This literature review suggests that the degree of self-care promoted should reflect a patient’s capability and risk status. While promoting effective self-care may be a daunting undertaking for the podiatrist with an already busy clinical schedule, there are training resources and publications available to help (Rollnick et al, 1999; World Health Organization, 2003; Chambers et al, 2006; Tomkins and Collins, 2006; DH, 2008; The Health Foundation, 2008).
This review has highlighted issues for consideration and ways that people with diabetes might be supported to engage in self-care activities. In particular, the authors suggest that:
- People with diabetes could be assessed using patient-centred consultation styles to identify their ability and stage of preparation to undertake self-care.
- Acknowledging people’s characteristics, perspectives and potential barriers to engaging in self-care, and setting appropriate targets in conjunction with them, is preferable to the expectationof compliance.
- Encouraging self-efficacy and self-regulation must be an ongoing activity supported by feedback from, and reflection by, podiatrists.
Optimal foot regimens are paramount to people with diabetes in reducing progression to foot ulceration, and clinicians supporting people to develop good self-care practices can play a central role.
