Enhancing foot care education and support strategies in adults with type 2 diabetes

ABSTRACT

Background:

People with diabetes are susceptible to serious and disabling foot complications, which increase their morbidity and mortality rates. Examining the perspectives of people with diabetes on their foot care routines could help elucidate their beliefs and offer practical ways to prevent foot problems.

Purpose:

We explored the perspectives of adults with diabetes on their foot care practices to identify and enhance foot care education and support strategies.

Methodology:

Using the Zoom platform, 29 adults with diabetes completed a 3-month telehealth educational program, during which interviews were conducted. This article reports the results of thematic content analysis of the qualitative data. Coded participant statements were organized into categories and reexamined to identify emergent themes.

Results:

Analysis of participants' perceptions revealed four main themes of influences that facilitated and/or hindered their foot care practices. Foot care behaviors were facilitated by patients' personal knowledge of others with diabetes-related foot consequences (theme 1). Foot care practices were hindered by the emotional impact of living with diabetes (theme 2), and the physical, social, and lifestyle limitations associated with foot care (theme 3). Finally, patients noted that interactions with family could be either a facilitator or hindrance to their foot care routines (theme 4).

Conclusions:

These findings highlight multiple patient-centered factors related to personal, physical, psychosocial, and cultural influences that affect foot care behaviors.

Implications:

An understanding of how patients manage diabetes-related foot care can help nurse practitioners enhance foot care education and support strategies in this population.

Up to 26.1 million new diabetes-associated foot ulcer cases are diagnosed each year worldwide (Oliver & Mutluoglu, 2023). Although diabetes can lead to life-threatening and serious complications, including foot ulcers, osteomyelitis of the foot, and even amputations (Edmonds et al., 2021), the chance of developing an ulcer is considerably decreased if the patient is instructed in proper foot care, consistently performs foot self-examination, and routinely has their feet inspected by a clinician (Oliver & Mutluoglu, 2023). In addition to all the recommended diabetes management guidelines, patients' participation in foot self-care practices may be affected by the increased physical and psychosocial stressors of having a chronic illness. Given the possibility of stressors brought on by daily diabetes management, understanding the factors that may affect foot care is an important aspect of their wellbeing.

Patients with diabetes can experience a loss of protective sensation without being aware of the nerve changes, thereby increasing their risk of developing foot ulcerations (Edmonds et al., 2021). Between 19% and 34% of people with diabetes develop a foot ulcer, and 50–60% of ulcers progress to infection. Of those moderate or severe foot infections, 20% result in amputations of the lower extremities (Edmonds et al., 2021). In patients who develop foot ulcers, the 5-year mortality rate is >50% (Deogon et al., 2020), and the 3-year mortality rate may rise to 70% following amputation due to a foot ulcer (Stern et al., 2017). However, early identification of foot problems can reduce diabetes-related foot complications as well as morbidity and mortality. Because individuals may not seek care until foot complications arise (Costa et al., 2022), the best primary prevention strategy is a regular foot self-care routine. Thus, regular foot screening and assessment may have a substantial positive impact on patients' well-being and health outcomes.

A recent study evaluating the knowledge and practice of foot care revealed that the level of familiarity with various aspects of foot care, including inspection, cleaning, and protection, was poor among people with type 2 diabetes (Kassab et al., 2022). In addition, patients were often unaware of their risk of foot complications, had low adherence to foot care, and experienced an increased risk of lower-extremity amputations (Ahmad et al., 2018; Sibbald & Ayello, 2018; Walton et al., 2021). Although previous studies have examined the management of diabetes-related foot complications, patients' perspectives on foot care practices remain unclear. Examining the perspectives of people with diabetes on their foot care routines could help elucidate their beliefs and offer practical ways to develop foot care training programs that prevent foot complications from diabetes. Thus, the primary aim of this article was to investigate the perceptions of foot care behaviors by adults with type 2 diabetes who are participating in a telehealth-delivered foot care program.

Methods

Study design

We conducted a descriptive qualitative study nested within a pre–post feasibility study design evaluating a 3-month telehealth-delivered educational program on diabetes foot care (Ju et al., 2023). The parent study investigated the feasibility of providing a theory-based diabetes education, specifically emphasizing preventive foot care practices, to people with type 2 diabetes mellitus using synchronous telehealth technology (Ju et al., 2023). Enrollment, assessment, and program completion rates were obtained to determine the feasibility of the telehealth initiative (Ju et al., 2023). At baseline, 1.5 months, and 3 months, the Telehealth Usability Questionnaire (Parmanto et al., 2016), Diabetes Knowledge Scale (D'Eramo-Melkus et al., 1992), Summary of Diabetes Self-Care Activities (Toobert et al., 2000), and Diabetes Foot Self-Care Behavior Scale (Chin & Huang, 2013) were used to examine telehealth usability, diabetes knowledge, self-care practices, and foot care behaviors, respectively (Ju et al., 2023). Each participant had synchronous telehealth videoconferences with the nurse practitioner once a month for 3 months (Ju et al., 2023). Diabetes foot education, guided by the Integrated Theory of Health Behavior Change, was provided to each participant (Ju et al., 2023). The importance of foot care was highlighted, with a focus on key concepts, such as thorough examination of the feet, regular maintenance of toenails, proper caring of the feet, and appropriate selection of footwear (Ju et al., 2023). The feasibility study descriptively analyzed changes over 3 months in participants' diabetes knowledge, self-regulation, and foot care practices (Ju et al., 2023). The study was approved by the Institutional Review Board.

Patients participating in the feasibility study were informed about the semistructured qualitative interviews that would occur during their final telehealth session before they consented to participate in the feasibility education program. Having provided informed consent, they were aware of the upcoming interviews and willingly agreed to participate in the interviews during their last telehealth visit. We used a descriptive, interpretive, qualitative design with semistructured interview questions (Table 1). Interviews were conducted with participants during the final visit of the 3-month educational program, which allowed them to have a common understanding of evidence-based foot care and to be comfortable to speak about their foot care. As time permitted in the final visit, participants were asked to share their attitudes, beliefs, and practices of foot care. Owing to participants' individual schedules, some participants were not able to respond to all the questions. This article focuses on the thematic content analysis of the qualitative interview data. The COnsolidated criteria for REporting Qualitative research (COREQ) guidelines were used in reporting these qualitative data (Tong et al., 2007).

Table 1.

Interview guide

What has it been like living with diabetes?

What have you been told about caring for your feet?  What instructions were you given about how to care for your feet?  What do doctors or nurses ask you about your foot care?

On a scale of 1–10 with 1 = not important and 10 = very important, how important is caring for your feet?  If important, what makes it important? If not important, why is it not important?

What do you think about having your feet examined? What are your personal views on foot care?  Some people we talked to are shy about having others look or touch their feet. How do you feel about it?

Tell me your diabetes foot care routine. How do you care for your feet at home?  If checking feet daily, what are you looking for?  If paying attention to footwear, what types of shoes are you wearing?  What types of shoes do you wear in the summer? Inside and outside of homes?  How do you care for your toenails? If nail care, how often do you perform the task?

What problems do you have with performing foot care? How supportive are your friends and family?  If none, many people report having back pain that limits their ability to bend over to check their feet. Do you experience any back problems that may interfere with your daily activities?  Some people have trouble visualizing their feet. Can you see your feet? If not, has anyone helped you check your feet or done it for you?

Doctors and nurse practitioners often have limited time to spend with patients during a visit. What kind of information would like to have regarding your diabetes foot care?  Would you like more information about…  How to check your feet, what to look for specifically?  How do you care for your feet if they are dry or cracked?  Where to moisturize?

Setting and participants

Institutional Review Board–approved research flyers were given to the two medical clinics that serve people who reside in the southwest area of Houston. The medical providers in the two clinics assisted with recruitment of eligible participants and provided interested individuals with the contact information of the principal investigator (PI). To determine whether they qualify for participation, patients who were interested then reached out to the principal investigator through the phone. Individuals were eligible if they were 18–64 years old, had a diagnosis of type 2 diabetes mellitus, spoke English, had internet access, and had no history of leg or foot ulcers or amputations (Ju et al., 2023). On confirming the individual's eligibility, the primary investigator provided a comprehensive description of the study and obtained informed consent from every participant, either in person or electronically through Research Electronic Data Capture (REDCap), a secure electronic data application (Harris et al., 2019).

Data collection

After informed consent was obtained, we collected demographic information using REDCap (Harris et al., 2019), and individual virtual educational sessions were scheduled through Zoom. Semistructured interviews were conducted during the final telehealth visit. The research team consisted of the PI, a DNP-prepared family nurse practitioner with 10 years of clinical experience in treating adults with diabetes mellitus, a PhD-prepared nurse researcher with qualitative experience, a physician, an adult-gerontology nurse practitioner, and a PhD associate dean of research. There was no patient–provider relationship with the participants of the study. The interview sessions were conducted using a semistructured interview guide consisting of open-ended questions to encourage participants to freely express their experiences of foot care, perceptions of foot care behaviors, and ways of managing the care of their feet (Table 1). The PI verified the meaning of participant comments during the interviews to promote the credibility of interpreting the meaning of participant comments. Several participants invited their significant others to join them during the educational sessions and interviews whose agreement and support added credibility to the participant comments. Only comments from the patients were included as data in the transcriptions. The virtual sessions were audio recorded and transcribed. The PI verified the transcripts against the recordings to ensure the accuracy of the content.

Data analysis

A descriptive analysis of the participants' demographic variables was performed. Using Braun and Clark's 6-step process (Braun & Clarke, 2006), a thematic content analysis of the transcripts was conducted. First, audio recordings were listened to several times by the PI to verify and become familiar with the content of the transcripts. Second, two analyzing authors (H.J. and M.O.) each read the interview transcripts multiple times to identify shared meanings and generate codes. Third, regular meetings between the analyzing authors discussed the emerging meaning derived from the interviews by organizing related codes. Fourth, coded data were extracted and organized into categories using a Microsoft Excel spreadsheet (Microsoft Corporation, 2023) to promote consistency and relevance of the meaning. Fifth, categories of codes were organized into themes focused on the primary goal of describing participants' perceptions of foot care. Finally, themes were reviewed, and exemplars chosen by coauthors to highlight the meaning of the findings to readers in the final report. Trustworthiness of the analysis is evaluated through credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). Credibility was assured by having two researchers meet and discuss their analysis of data reaching consensus, verifying meaning with participants throughout the course of the interviews, and promoting relationship between the lead researcher and participants over the three occasions they met for the training and interview. Transferability of the meaning can be seen in the exemplars. The interviewing researcher assured dependability of the interpretation and avoidance of bias by tracking reflexive thoughts through memos and discussing in conversation with coauthor who is a qualitative researcher. Confirmability of the research results was obtained through agreement of coauthors not involved in analysis. Data saturation was achieved as the analyzing authors identified thematic comments from the participants and no new ideas or themes emerged.

Results

A subgroup of 29 individuals from the parent study participated in the qualitative interviews (Ju et al., 2023). Table 2 shows the characteristics of the 29 participants. Due to participant time constraints, some individuals were not able to respond to all the questions. The participants were largely male (18/29, 62%), married/cohabiting (22/29, 76%), racial/ethnic minorities (17/29, 59%), college educated (13/29, 45%), and 51 years old on average. Diabetes duration ranged from less than 1 year (7/29, 24%) to more than 10 years (6/29, 21%).

Table 2.

Participant characteristics

Characteristics	Participants, n (%)
Age (years)
30–39	5 (17)
40–49	4 (14)
50–59	16 (55)
60+	4 (14)
Sex
Male	18 (62)
Female	11 (38)
Marital status
Single	4 (14)
Married/cohabiting	22 (76)
Divorced	3 (10)
Educational attainment
Less than high school	3 (10.3)
High school	1 (3.4)
Some college	9 (31.0)
Associate degree	3 (10.3)
Bachelor's degree	10 (34.5)
Master's degree	2 (6.9)
Doctoral degree	1 (3.4)
Race/ethnicity
White	12 (41)
African American	8 (28)
Hispanic	8 (28)
Asian	1 (3)
Diabetes duration
Less than 1 year	7 (24)
1–5 years	7 (24)
6–10 years	9 (31)
More than 10 years	6 (21)

Analysis of participants' perceptions revealed four main themes of influences that facilitated and/or hindered their foot care practices. Foot care behaviors were facilitated by patients' personal knowledge of others with diabetes-related foot consequences (theme 1). Foot care practices were hindered by the emotional impact of living with diabetes (theme 2), and the physical, social, and lifestyle limitations associated with foot care (theme 3). Finally, patients noted that interactions with family members could be either a facilitator or hindrance to their foot care routines (theme 4). Each of these themes is described in subsequent sections with exemplars from patient interviews.

Personal knowledge of others with diabetes-related foot consequences

Several participants reported being more involved in foot care when recalling someone they knew who had experienced diabetes-related foot complications. Seeing the consequences of diabetes raised their awareness of similar foot consequences that could occur and motivated them to engage in their own foot care practices. Patients who had not personally seen diabetes-related foot complications were less likely to be engaged in routine foot care until they received education about the potential consequences. This participant recalled her brother's complications with diabetes,

I had a brother that had his toe removed. Then his leg [was] removed, and he passed away. Diabetes runs in my family. I have a friend that his toes are amputated. He is doing ok, but you never know. I constantly check my feet and toes and make sure they [are] dry in between. I am very paranoid about my feet now. (Participant 19)

Emotional impact of living with diabetes

A striking revelation from participants was the emotional impact of living with diabetes. For some patients, the diagnosis of diabetes created emotional distress, which persisted for years and affected their care decisions. This participant described how his emotional distress related to diabetes endures and affects his life and his interactions with other people,

I am really ashamed that I have diabetes. I can never talk to anybody that I have this thing. I am so ashamed of myself. I am so ashamed to tell people that. I used to hide my medication. I take my medication—hide it. I used to hide to take it. I don't want anyone to know because I am ashamed. I really hate it. Sometimes I want to buy things for diabetes—like when I go to Walgreens or anywhere, I would just see if somebody is looking at me. I am so ashamed. I really hate this disease. I don't know why I have this kind of thing. I really hate it. I don't want to be associated with anybody that has it. I don't like people to know that I have it. (Participant 2)

Several participants also expressed shyness and embarrassment when asked how they would feel having their feet examined by a health care provider. Participants mentioned that personal foot characteristics, such as foot appearance, toenail conditions, and foot injuries, may influence their inclination to have their feet examined. This participant displayed a nervous laughter and revealed that despite years of discomfort from the calluses on his feet, he had never shown his feet to a health care provider due to embarrassment,

I have to shave the calluses in order to walk. They get so painful I can't walk until I use the thing to shave it off. I have the calluses for years. No one has seen my feet except for my wife. It is embarrassing to show my feet to other people. (Participant 20)

Physical, social, and lifestyle limitations associated with foot care

In addition to the emotional impact of living with diabetes, participants described a range of physical, social, and lifestyle limitations associated with foot care. Physical limitations included participants' inability to adequately view or bend over to visualize their feet due to a large waist circumference or musculoskeletal pain. These two participants shared the physical barriers that prevented them from doing foot care,

I'm working on trying to lose weight so I can be able to start checking my feet down there. I have gained so much weight. I really can't reach down there. I have to have one of those things—brushes—that I use to wash my feet with soap. (Participant 25)

You know, I went and broke my knee like 2 years back. I started getting pedicures. And because I couldn't lean over to trim my toenail. But I try to take good care of my feet. The other day I had an ingrown toenail, and I didn't notice it until, you know, it was bleeding a little bit. (Participant 27)

Other participants also shared a variety of social and cultural norms that affected their choices of both indoor and outdoor footwear. Habits and comfort were mentioned as reasons for going barefoot even after learning about the increased risk for foot injury associated with walking without proper shoes. These two participants described the challenges of changing their habits of going barefoot,

I know I shouldn't have been. Me being me, I did it anyway. I was walking around barefoot out of the lake house the other weekend. I know I'm not supposed to. I did for a little bit. Mostly walking from the water up to the picnic table. It's habit. I'm out there a lot of times. I walk around barefoot when I'm out there. (Participant 17)

I was pretty bad in the past about walking outside without shoes on and stuff, so I've gotten better. I do have a pair of shoes right next to the door, so if I do walk outside, especially to meet my son at the bus stop or to walk to the bus, I do put my shoes on. (Participant 4)

In addition, cultural barriers can complicate a routine of wearing shoes when it is not the norm. This Asian participant shared his views to not wear outdoor shoes inside his home, It's hard [to wear shoes inside] in the summer, especially in the Asian culture. (Participant 27)

Participants also described mixed feelings toward certain lifestyle practices, such as going to a spa or nail salon. Although some participants reported going to a spa or nail salon regularly, others avoided pedicures and questioned the tools and practices used by nail technicians. Some participants noted that comorbid conditions such as gout, rheumatoid arthritis, and hammertoes further complicated their foot care behaviors.

Usually about every, I'm going to say every 4 months or so, I'll go get a pedicure, but that's more just so I can sit in the chair and have them trim my toenails and clean them up and rub on my legs and make them feel good. I would love to get pedicures once a month. Probably not a good idea for me to do it that often. It's really a waste of money for me. I think what complicates it and confuses me more is I have gout, too. (Participant 12)

I have problems with my feet [because] I have RA. I soak in the tub a lot. I am funny about my feet…I won't even let people give me a pedicure. I don't like the blades and things you don't know, you know what I mean. So, what I do is go to Sally's Beauty, and I get the little thing that you do your own feet so you don't have to have people do it for you. (Participant 3)

When individuals have additional health issues that affect their feet, participants expressed uncertainty about the appropriate foot care practices. Peripheral neuropathy, rheumatoid arthritis, cancer, foot deformity, gout, and other conditions can affect a person's lifestyle choices, foot care practices, and overall health status.

Interactions with family members

In this group of patients with diabetes, family members had both facilitating and hindering influences on their adoption of foot self-care activities. Some participants shared positive support from family members, such as assisting with foot inspections, especially if they had physical limitations. One participant described his dependence on his wife for foot care:

My wife mainly is the one checking my feet because she is able to get down there closer and all that. My wife looks at them constantly. She will look and tell me when my feet are really dry. My wife also got me about wearing sandals outside or putting something on my foot, so I don't stand on anything hot and damage my feet. (Participant 14)

Although some participants identified their partners as their main caregivers in diabetes management, others had not shared their diabetes diagnosis with their children and extended families. Some reported that they found discussing their diabetes diagnosis with others, at times even family members, challenging. These individuals were concerned about causing anxiety and psychological distress for their family members.

I haven't told my son that I have diabetes. My son is 16 and he doesn't know. Because both my dad and his grandmother also died of diabetes complications, so he has two grandparents he's lost. So I think that would be very challenging for him to understand that I've got it too. I haven't figured out how to tell him yet. (Participant 26)

Misconceptions regarding diabetes diagnosis, foot self-care, and treatment were challenges that several participants experienced within their families. A few reported perceived criticism and lack of physical and emotional support from their relatives. One participant lived alone and could only reach his foot with a brush. The participant felt that being alone further escalated his stressors, especially during the COVID-19 pandemic. He continues to experience COVID-19–related symptoms after being hospitalized for 2 weeks due to COVID-19. One participant did not feel comfortable discussing diabetes with her husband because he did not understand and was critical of her:

My husband's drilling me. I know what I need to do. I don't need him to tell me and make me feel bad, you know. So it's a good thing that the doctor—you and I—speak or we talk about it because it's not something you're going to want to say in front of everybody else, but when they do, they are twice as hard on you. (Participant 4)

For some people, talking to family members about foot care and diabetes was unpleasant, and they prefer to only discuss the topics with health care professionals. Family interactions can vary widely and affect how individuals manage diabetes self-care.

Discussion

This study strengthened our understanding of the perspectives of adults with type 2 diabetes regarding foot care and the factors influencing their foot care behaviors. The results reveal that the urgency of participants' foot care practices was affected by having personal knowledge of others with diabetes-related foot consequences, emotional impact of living with diabetes, limitations associated with foot care, and the interactions with family members on self-care management.

Participants stated that being aware of someone who experienced foot complications contributed to their adoption of foot care behaviors. Studies have shown that health behaviors can be facilitated by public awareness through education (Fathnezhad-Kazemi & Hajian, 2019), and behavior may be modified by using storytelling to translate knowledge (Wieland et al., 2017). Participants noted that they have become more conscious of foot care behaviors as a result of stories from family or friends about foot problems due to diabetes. Because of the known cases of foot complications, participants may have felt more susceptible to developing similar foot problems. Concerns about developing foot complications were the top reasons for learning and performing foot care. This observation is consistent with the results of previous studies on the limited knowledge of foot care and the concern of developing serious foot complications in people with diabetes (Costa et al., 2022; Owolabi & Chu, 2022; Sari et al., 2022).

The participants were also uncertain about the rationale for foot care and reported confusion about appropriate footwear and the suitability of pedicures and foot massages. A previous study noted some people misinterpreted foot care as symptom-based management and only cared for their feet after they started to experience symptoms (Owolabi & Chu, 2022). In addition, many individuals reported having blisters on their feet after wearing inappropriate socks or ill-fitting shoes. Some participants mentioned getting monthly pedicures and foot massages rather than inspecting their feet daily. Others reported that comorbid conditions, such as gout, rheumatoid arthritis, and foot deformities, further complicated their foot care practices. The inadequate understanding of the rationale for foot care behaviors may increase the risks of foot injuries, complications, and poor outcomes among this population.

Because of the chronic nature of diabetes and the necessity of daily self-management, participants reported feeling more supported when family members and other caregivers encouraged their foot care behaviors. Peer assistance and family support behaviors have been found to be associated with foot care adherence (Ghasemi et al., 2021; Kandel et al., 2022). Social and family support can play important roles in the well-being of adults with diabetes, and creating programs that involve family members and other supportive individuals may be essential to enhancing health and self-care behaviors in these patients (Baig et al., 2015). Informing family members and social support systems regarding the chronic condition of diabetes, validating their experiences as supporters, and teaching them stress-relieving activities are important in future educational programs (Baig et al., 2015).

In contrast to the family support mentioned by participants, a lack of comfort talking about diabetes with family and perceived criticism from them were also reported. Participants noted that without family support, they internalize their diabetes-related feelings and may face more difficulties with foot care. This finding is consistent with a previous study in which participants' families were unaware of foot care practices and did not encourage them to take care of their feet (Sari et al., 2022). This assessment shows the need for further research into teaching family members of people with diabetes about foot care and urging them to encourage their loved ones in performing daily foot practices (Sari et al., 2022). Ongoing support from family members and other caregivers may be beneficial for people with diabetes. Thus, collaboration with family members and support people in family-centered diabetes foot care programs should be developed for future research.

Furthermore, individuals with diabetes may experience additional challenges with foot care due to existing health concerns and other stressors. Some individuals reported feeling uneasy about having their foot examined by providers when they have discolored toenails, foot deformities, and other foot problems. Others mentioned that physical limitations such as back pain, knee pain, and a large waist circumference impeded their ability to bend down and view their feet. In addition to handling life and family responsibilities, they worried about not managing diabetes properly and not adhering to the recommended treatment guidelines. A recent study found that one predictor of foot self-care practice is diabetes distress (Sari et al., 2022). In the literature, diabetes distress is characterized by patient concerns about the management, psychological burden, and social support associated with the condition (Kurnia et al., 2017). Implementing a program to increase participants' awareness of foot care practice, provide participants with social support, and to lessen patients' diabetes distress may increase foot care practices in this population.

Strengths and limitations

Our participants recruited from two large medical clinics because part of the foot care educational program may not specifically reflect the demographics and views of all people with diabetes. Nevertheless, our study offers a unique perspective on these patients' perceptions and experiences with foot care practices. The discussions with the participants were conducted during the 3-month educational program after they developed rapport with the PI, which supports the credibility of the study findings (Nowell et al., 2017). Because the participants were enrolled in the foot care education program, they may already have had an interest in learning about foot care. However, we do not have data on people who were not seeking diabetes foot care knowledge. There was a broad range among participants in the length of time living with diabetes from less than 1 year to more than 10 years. We did not stratify the analysis data based on this timing. Thus, the relationship between foot care behaviors and the timing of diabetes diagnosis was not explored.

Implications for practice

To improve the awareness of potential serious foot complications in this population, nurse practitioners should take every opportunity to ask their patients with diabetes about their foot care practices, social support, and other stressors. Diabetes-related distress affected some participants' self-care practices. Collaboration with licensed counselors and performing mental health assessments may be helpful in enhancing diabetes self-management in the primary care setting. A routine foot examination by a health care professional based on risk factors for patients with diabetes should be scheduled to ensure that patients are not experiencing foot problems and to emphasize the importance of daily foot care and early intervention for foot symptoms. Patients who live alone and have difficulty caring for their feet independently may require more frequent foot care assessments by their health care provider. Those at high risk of foot complications should be referred to podiatry for close monitoring (Song & Chambers, 2023).

Conclusion

These findings highlight multiple patient-centered factors related to personal, physical, psychosocial, and cultural influences that affect foot care behaviors. These factors revealed limitations in their ability and capacity for independent foot care. By having an awareness of the factors influencing patients' foot care, clinicians can develop education and support strategies for this population. Nurse practitioners play a critical role in improving patients' diabetes health outcomes by asking them about their foot care practices, performing routine foot examinations, and ensuring that foot problems are treated promptly and effectively. Future research should examine the use of patient-centered foot care interventions and the associations between psychological well-being and foot care behaviors to improve the health outcomes of people with diabetes.

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