Overcoming barriers to self-management: The person-centred diabetes foot behavioural agreement

"I Never Thought They Would Ever Take Off My Toes": A Qualitative Illness Trajectory Study in People With Diabetic Foot Syndrome

Diabetic foot syndrome (DFS) can be prevented, but due to various obstacles preventive measures can only be implemented inadequately. Person-centred care forms the foundation for effective support measures. However, the current lack of a longitudinal perspective on patients' Illness trajectory hinders the development and provision of tailored support. The aim was to describe the illness trajectory experienced by patients with DFS. To investigate the research question we used a qualitative design based on the 'Interpretive Description' and conducted a purposive sample of individual interviews in a university hospital's wound outpatient department. Data were analysed according to Braun and Clark's reflexive thematic analysis using the illness trajectory model as a theoretical framework. We included 12 patients with diabetic foot ulcers and recorded wound duration, number of ulceration recurrences and rate of amputation. We identified six illness trajectory-relevant phases: (1) silent or non-apparent diabetes mellitus (DM); (2) occurrence of the first wound: present DFS; (3) needing inpatient treatment; (4) from a mosquito emerges an elephant; (5) being in outpatient treatment and experiencing wound-free periods and (6) the occurrence of recurrences. Participants stated both self-management and care coordination behaviours regarding their treatment. However, due to knowledge gaps, misunderstandings or a desire for 'normalcy' and independence from the healthcare system as they juggled multiple comorbidity-related responsibilities, they often acted contrary to behavioural recommendations. 'Silent diabetes' is not always prioritised in disease management.

Family Impacts of Diabetic Extremity Wound Caregiving: A Qualitative Multiple Case Study Report

More than three million people in the United States are treated for diabetic extremity wounds every year, with numerous physical, financial, and psychosocial impacts not only to patients but also their families who care for them. This study examined the experiences of families who care for adult members with a diabetic extremity wound. A qualitative multiple case study was conducted with four family cases recruited from an urban academic medical center in the Southeastern United States, with data collection consisting of individual interviews, demographic survey instruments, and family caregiving genogram construction. Individual- and cross-case synthesis was completed using reflexive thematic analysis. Themes related to impacts on family functioning, the caregiving experience, and formal health care utilization were identified. These findings provide insight into the experiences of families living with diabetic extremity wounds, as well as clinical and research directions for the future.

Development and acceptability of a culturally competent skills and knowledge assessment tool for patients with diabetes mellitus

Background

Patients newly diagnosed with type 2 diabetes mellitus (DM) and newly prescribed insulin need to learn essential self-care and management skills quickly. To optimize teaching, clinicians need to assess a patient's basic understanding of DM and their skills. While DM patient assessments exist, this study reports the development of an assessment of patient DM management skills and knowledge, using feedback from DM clinicians, patients, and caregivers.

Research Design and Methods

A systematic search of Pubmed/Medline and Scopus (1980-2017) of DM knowledge assessments was performed. Twenty-four studies were identified. Content from the existing assessments was adapted to create a 12 item DM-Skills Knowledge Assessment (SKA) to assess a patient's DM management skills and knowledge. To assess cultural humility, modified cognitive interviews were conducted in individual user sessions and semi-structured focus groups. Audio-transcripts of the interviews/focus groups were independently coded, and codes were grouped into key themes. Participant demographic characteristics were assessed.

Results

Five focus groups and eleven key informant interviews were conducted, including 10 DM clinicians, 12 patients/caregivers, and 15 laypersons. All 10 clinicians reported that the DM-SKA addresses the key domains of DM education deemed to be of highest importance during the transition from hospital to home and that their patients would be willing to complete the assessment. More than half of the patient/caregiver/layperson participants self-reported race/ethnicity other than non-Hispanic white and performed similarly to non-Hispanic white participants in understanding each item, willingness to complete the DM-SKA, and perception that family or community members would be willing to complete the DM-SKA. The DM-SKA has a baseline Flesch reading score of 81.3, indicating low complexity language.

Conclusion

DM clinicians agreed that the DM-SKA assesses all essential DM management skills. For patients/caregivers, it has acceptable literacy, cognitive validity, and culturally acceptable for racial/ethnic minority populations in the study, including elderly persons.

Fatalism as a Mediator of the Association Between Family Resilience and Self-Management Among Patients with Chronic Wounds in China

Purpose

The purpose of this study was to examine how fatalism acts as a mediator in the correlation between family resilience and self-management among patients with chronic wounds in China.

Participants and Methods

This study used a cross-sectional research design. A total of 269 adult patients (18-94 years old) with chronic wounds residing in Wuxi, China participated in this study. Participants completed the Chinese version of the Walsh Family Resilience Questionnaire, 16-item Chinese version of the Fatalism Scale, and Self-Management Scale of Chronic Wound Patients. We conducted correlation and mediation analyses using SPSS 27.0 and PROCESS 4.0.

Results

The results indicated family resilience was a significant positive predictor of self-management (β = 0.7101, p < 0.0001), and the pathway between family resilience and self-management was partially mediated by fatalism (Effect = 0.1432, 95% confidence interval [0.0625, 0.2341]).

Conclusion

The results indicated that incorporating spiritual interventions into future person-centered self-management programs could align with the motivation of patients with chronic wounds and their families, and reduce the negative impact of fatalism on health outcomes.

Health literacy education programmes developed for qualified health professionals: a scoping review

OBJECTIVES

Both literature and policy have identified the need for health literacy education for qualified health professionals. This study aimed to identify and map health literacy competencies and health literacy related communication skills educational interventions for qualified health professionals. The research questions included: Of the qualified health professional education interventions identified, which are focused on diabetes care? What health literacy competencies and health literacy related communication skills are integrated into each programme? What are the characteristics of each education programme? What were the barriers and facilitators to implementation? What methods are used to evaluate intervention effectiveness, if any?

DESIGN

Scoping review, informed by the Joanna Briggs Institute guidelines.

DATA SOURCES

The following databases: OVID; CINAHL; Cochrane; EMBASE; ERIC: PsycInfo; RIAN; Pro-Quest; UpToDate were searched.

ELIGIBILITY CRITERIA

Articles were included if the education programme focused on qualified health professionals, in all clinical settings, treating adult patient populations, of all study types.

DATA EXTRACTION AND SYNTHESIS

Two authors independently screened titles, abstracts and full text articles that met the inclusion criteria. The third author mediated any discrepancies. The data were extracted and charted in table format.

RESULTS

In total, 53 articles were identified. One article referred to diabetes care. Twenty-six addressed health literacy education, and 27 addressed health literacy related communication. Thirty-five reported using didactic and experiential methods. The majority of studies did not report barriers (N=45) or facilitators (N=52) to implementation of knowledge and skills into practice. Forty-nine studies evaluated the reported education programmes using outcome measures.

CONCLUSIONS

This review mapped existing education programmes regarding health literacy and health literacy related communication skills, where programme characteristics were identified to inform future intervention development. An evident gap was identified regarding qualified health professional education in health literacy, specifically in diabetes care.

Informal Family Caregiving of Patients with Diabetic Extremity Wounds: An Integrative Review

Annually, 26 million people worldwide develop diabetic extremity wounds, adversely impacting the lives of patients and their family caregivers, who provide vital health assistance to these patients. This integrative review synthesized scientific literature of informal caregiving experiences for patients with diabetic extremity wounds. Five databases were searched for relevant English-language quantitative or qualitative research; ten studies were included in the final analysis. The caregiving experience included disrupted routines, frustration, guilt, poor health care communication, helplessness, and anxiety. Increased caregiver burden and decreased quality of life were associated with higher patient amputation level, worsening wound appearance and patient pain, poor health care communication, lack of social support and/or caregiving help, and lack of caregiver employment outside the home. Future research opportunities include further exploration of caregiver tasks and priorities, caregiving experiences in settings lacking family support structures and equitable health system access, and relationships between the caregiver experience and patient health system utilization.

Factors Associated with Healing Outcomes in Primary Care Patients with Diabetic Foot Ulcers: A Retrospective Study in a Multiethnic Sample

OBJECTIVE

To identify and determine patient- and ulcer-related factors associated with healing outcomes within 3 months for patients with diabetic foot ulcer (DFU) in a multiethnic primary care sample.

METHODS

Retrospective data were collected over 3 months from 520 primary care patients with a DFU between April 1, 2016 and March 31, 2017. Multivariable prevalence ratios (PRs) were calculated using Poisson regression to find associations between patient- and ulcer-related factors and healing outcomes.

RESULTS

Most patients were male (66%) and Chinese (49.8%) and had a diabetes mellitus duration longer than 5 years (81.8%). Toe ulcers (64%) were most common. Healing occurred for 33.9% of participants; 19.1% and 1.5% underwent minor and major amputation, respectively. Wound sizes between 1 and 10 cm2 (PR, 0.61; 95% confidence interval [CI], 0.46-0.76; P < .001) and over 10 cm2 (PR, 0.55; 95% CI, 0.33-0.76; P = .003), ulcer duration 6 months or longer (PR, 0.36; 95% CI, 0.19-0.53; P < .001), ischemic ulcers (PR, 0.54; 95% CI, 0.22-0.86; P = .044), and neuroischemic ulcers (PR, 0.73; 95% CI, 0.53-0.93; P = .027) were negatively associated with healing outcomes. Women were more likely to experience healing (PR, 1.18; 95% CI, 0.91-1.45; P = .157).

CONCLUSIONS

Ulcer healing varied by sex and was affected by wound size, wound duration, and ischemic etiology, regardless of ethnicity. Prompt attention to these risk factors may reduce healing time. Further studies are warranted to elucidate the mechanism underlying sex differences in association with DFU healing.

"When nothing happens, nobody is afraid!" beliefs and perceptions around self-care and health-seeking behaviours: Voices of patients living with diabetic lower extremity amputation in primary care

Self-management and self-care are the cornerstone of diabetes care and an essential part of successfully preventing or delaying diabetes complications. Yet, despite being armed with the required information and guidance for self-management, self-care and adherence to foot self-care recommendations and compliance to medication among patients with diabetic foot ulcer and diabetic lower extremity amputations remain low and suboptimal. This study reveals in-depth account of nine such patients' beliefs and perceptions around their illness, their self-care, and their health-seeking behaviours. Patients living with diabetic lower extremity amputation displayed profound lack of knowledge of self-care of diabetes and foot and passive health-related behaviours. The overarching sense that "when nothing happens, nobody is afraid," points to a lack of motivation in taking charge of one's own health, whether this is with reference to treatment or care adherence, following recommended self-care advice, or seeking timely treatment. The Health Beliefs Model provides the theoretical framework for probing into the factors for the participants' suboptimal self-care and passive health-seeking behaviours. Two themes emerged from data analysis: profound knowledge deficit and passive health-related behaviours. The beliefs and perceptions around self-care and health-seeking behaviours for patients with lower extremity amputation are interpreted as the "ignorant self" with passive health-seeking behaviours. Patients with diabetes and diabetic foot diseases may benefit from personalized education, motivational interviewing, and family support.

Information about foot care provided to people with diabetes with or without their partners: Impact on recommended foot care behavior

BACKGROUND

Many people with diabetes will develop foot ulcers. To reduce risk, it is recommended that the feet are protected against harm and checked daily. Spouses can help people with diabetes care for their feet.

METHODS

A randomized parallel arm design compared information sheets given to participants with diabetes and their spouses (dyad group; n = 64) to an information sheet given only to participants with diabetes (individual group; n = 69). The self-reported number of days that the participant with diabetes' feet were (1) checked for problems and (2) protected against problems occurring (by the person with diabetes and/or the spouse) were summed for the week after receiving the information sheet. ANCOVAs tested the effects of group.

RESULTS

Frequency of foot detection behavior (Participant + Spouse) was significantly higher in the dyad group compared with the individual group. This was not the case for foot protection behavior (Participant + Spouse). Findings revealed greater levels of spousal support (for both protection and detection behavior) in the dyad group compared to the individual group.

CONCLUSIONS

Clinical recommendations and advice on foot care delivered both to people with diabetes and their spouses can encourage greater foot care than if delivered to the patient alone.

Social representations on diabetic foot: contributions to PHC in the Brazilian Northeast

This study aimed to identify the structuring elements guiding the establishment of the social representations of diabetic foot among people with diabetes mellitus. This qualitative study is based on the Social Representations Theory and was conducted in a capital of the Brazilian Northeast. The free word association test and a roadmap were used to characterize the sociodemographic and clinical profile to collect data. The analysis was performed using openEVOC software. The constituent elements of the diabetic foot's social representation "cure" and "really bad", revealing that living with a diabetic foot is challenging, but there is hope for a cure, which is a driving force in the daily search for care. The "prevention" element emerged in the representational field, denoting a more critical view and a capacity to transform the identified core elements. We found that the representational structure is based on subjective, valuating, and attitudinal contents. This knowledge can contribute to the design of interventions in the provision of care and diabetic foot screening in PHC services.

Barriers to management of diabetes foot ulcer: Experiential note from a setting with free medical services

The imperative need for behavioral agreement to overcome barriers of self-management of diabetes foot complication was recently articulated. A few journals have done parallel publications, which thereby stresses the significance of the issue. This article is to add to the "Overcoming barriers to self-management: the person-centred diabetes foot behavioural agreement". It presents experiential note with four tabulated cases of clients who have access to free state-of-the-art medical service; and non-adherence as a barrier to self-management is not due to affordances. It is to draw attention to the deliberately non-adherent patients where behavioral agreement process should be really driven by the client as in the real context of person-centered therapy.

Barriers to Self-Management of Type 2 Diabetes During COVID-19 Medical Isolation: A Qualitative Study

PURPOSE

Diabetes self-management behaviors are necessary to obtain optimum glycemic control, reduce the risk of complications, and improve health outcomes. The COVID-19 pandemic imposes an additional struggle for self-management by diabetes patients. Although previous studies have reported socio-demographic, behavioral, psychological, and cultural barriers to diabetes self-management, little is known about perceived barriers to diabetes self-management among patients during isolation following their recovery from COVID-19. The purpose of this study was to explore perceived barriers among type 2 diabetes patients during isolation following their recovery from COVID-19.

PATIENTS AND METHODS

A qualitative, exploratory, and descriptive research design was utilized. Semi-structured telephonic interviews were conducted with 12 patients with diabetes who had been discharged from one COVID-19 designated hospital and underwent isolation in the designated facilities in Wuhan City, Hubei Province, China. Data were analyzed using Colaizzi's seven steps.

RESULTS

Barriers to diabetes self-management identified by patients with diabetes during isolation were categorized into five major themes: inadequate knowledge and behavioral beliefs, shortage of resources, suffering from health problems, negative emotions, and lack of support.

CONCLUSION

Perceived barriers to diabetes self-management described by diabetes patients indicated a lack of environmental resources and support strategies to meet their needs. Efforts to remove barriers are important in assisting patients with diabetes to improve their quality of life and health outcomes.