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11 Psychological and Behavioural Issues in Diabetic Foot Ulceration Loretta Vileikyte
Foot ulceration in persons with diabetes is an increasing problem worldwide,1 with over 80% of amputations preceded by foot ulcers,2 and there is little evidence of reduction in amputation rates.3 There is a need to better understand both the psychosocial factors involved in the development of diabetic foot ulcers and the ways by which foot ulceration influences an individual’s functioning.
There has been a steady increase in publications in this field over the past 5 years.
The present chapter summarises the key findings from recently conducted and ongoing studies into how patients adapt to diabetic foot ulceration, by focusing on two areas: the role of psychological factors in guiding adherence to preventive foot self-care and foot ulcer treatment; and the impact of diabetic foot ulceration on an individual’s emotional state and quality of life (QoL).
The chapter opens with an overview of the earlier educational and behavioural studies in this area, highlighting the limitations of previous research, which include a paucity of studies, poor methodological quality of many reports and the lack of a theory-driven, patient-centred ap- proach when studying adherence to foot self-care.
Subsequently, it introduces a novel approach to the study of psychological factors influencing adherence behaviours and demonstrates how patients’ lay beliefs about foot complications combine with medical information and foot ulcer experience in shaping adherence to foot self-care.
Next, studies linking diabetic foot ulceration to depressive symptoms are reviewed.
Finally, by comparing and contrasting the generic (non-specific to foot ulceration) approach to QoL assessment with patient-centred, foot-problem-focused investigations, it describes the ways by which foot ulceration impacts an individual’s functioning and QoL.
REVIEW OF EDUCATIONAL/BEHAVIOURAL STUDIES OF FOOT ULCER PREVENTION Three systematic reviews of educational and behavioural studies have been conducted to eval- uate the role of patient’s foot care education in the prevention of foot ulceration.4−6 The
The Foot in Diabetes, 4th Edition. Edited by Andrew J.M. Boulton, Peter R. Cavanagh and Gerry Rayman. C 2006 John Wiley & Sons, Ltd. ISBN: 0-470-01504-7
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EDUCATIONAL/BEHAVIOURAL STUDIES OF FOOT ULCER PREVENTION 133
reviews were unanimous in their main conclusion: due to the poor methodological quality of the studies, the available evidence is ‘generally unsatisfactory’, ‘inconclusive’ or ‘needs confirmation’.
For example, the results of the eight randomised controlled trials (RCTs),7−14 selected for the most recent review by Valk et al.,6 though conflicting, suggest that although education seems to have a short-term positive effect on foot care knowledge and behaviours, whether it can prevent foot ulceration and amputations remains uncertain.
Most of these studies were insufficiently powered to detect clinically important effects of patient educa- tion on the hard end points (foot ulceration and amputation) and had inadequate follow-up to assess the potential for prevention of foot complications.
Moreover, the eligibility cri- teria with regard to risk for foot ulceration were described adequately in only one of the RCTs,10 and monitoring of adherence to the intervention and outcomes was largely unac- ceptable (only three studies assessed both adherence to foot care and ulceration/amputation rates).9,13,14 One of the most commonly cited studies conducted by Litzelman et al.13 introduced a system of reminders and assessed the effect of this intervention on the prevalence of risk factors for lower extremity amputation in type 2 diabetic subjects.
This 12-month intervention was multifaceted and aimed at both the patient and the health care provider.
Patients received foot care education and entered into a behavioural contract for foot self-care, which was reinforced through telephone and postcard reminders.
In addition, the folders for intervention patients had special identifiers that prompted health care providers to (1) ask that patients remove their footwear; (2) perform foot examinations; (3) provide foot care education; and (4) refer to specialist care (podiatric, vascular and/or orthopaedic) when appropriate.
This important study demonstrated that foot self-care and professional foot care matter in reducing foot ulcer rates.
Patients receiving the intervention were more likely to report appropriate foot self-care behaviours than were control patients, and were less likely to have serious foot lesions.
However, it is unknown whether these behaviours were retained or faded out after the intervention ended.
It is conceivable that the behavioural change might not have been sustained, as it was not intrapersonally generated, i.e. it was not determined by an individual’s understanding and beliefs about foot complications; rather, it was imposed by researchers.
The other commonly cited study by Malone et al.10 randomised diabetic patients present- ing with severe foot complications (foot infection, ulceration or prior amputation) into those receiving basic foot care education and those with no education.
A brief 1-h education session consisted of fear-inducing communication (review of slides depicting infected diabetic feet and amputated diabetic limbs) and a provision of a simple set of instructions for patients re- garding foot self-care.
After 2 years follow-up, the ulceration and amputation rates were three times lower in the intervention than in the control group.
This study included only patients who had already experienced severe foot complications and it is, therefore, not clear whether the behavioural change took place in response to the intervention or whether it was the devel- opment of a foot ulcer that impacted foot self-care, as it is known that foot ulcer experience is predictive of better foot self-care.15 Thus, while education may well be more effective in this group, generalisation to patients who have never experienced diabetic foot complications remains questionable.
Importantly, all the aforementioned trials were designed to provide patients with an action plan, i.e. a list of preventive foot self-care behaviours, and/or enhancement of their behavioural skills, and none of the studies attempted to understand the psychological factors that might be implicated in patients’ foot care routine.
This, at least in part, could explain why the behavioural change was short lived11,14 or not achieved.9,12