Abstract
Purpose
Foot care behaviours are considered the first line of defense against diabetic foot complications. In general, preventive behaviours are determined by multiple personal, social and psychological factors. The aim of this study was to assess foot care behaviours and their relation to protection motivation theory among a sample of adults with diabetes in Egypt.
Methods
A self-administered questionnaire was used to collect data about foot care practices and protection motivation theory among a random sample of 300 adults with diabetes attending primary health care units in Egypt.
Results
The results demonstrated that the foot care behaviours were inadequate amongst the sample(mean 5.13 ± 1.92 out of 11). Three constructs of protection motivation theory predicted the behaviours, namely: self-efficacy (p = 0.015), perceived seriousness (p = 0.013) and intention to adhere to foot care (p = 0.021). On the other hand, intention to adhere to foot care was correlated with higher levels of self-efficacy and perceived seriousness, and to lower levels of perceived barriers.
Conclusion
There was a low level of foot self-care amongst the sample. Health education programs reinforcing the intention to adhere to foot care behaviours can improve foot care practices among people with diabetes through increasing self-efficacy and perceived seriousness and reducing perceived barriers.
Keywords: Diabetic foot, Foot care, Protection motivation theory, Intention
Introduction
Diabetes is one of the main non-communicable chronic diseases in Egypt with a prevalence of 15.1% among adults in 2017 [1]. Diabetic foot is a common complication of diabetes [2] that affects the person’s quality of life [3] and represents a high burden on health services [1]. Asaad-khalil et al. (2015) reported that 29.3% of adults with diabetes in Egypt had sensory neuropathy, 11% had peripheral vascular disease, 8.7% had active foot ulceration, 6.1% had past history of foot ulceration and 4.4% had a history of amputation [1]. A wide range of literature has highlighted the importance of foot care practices as the first line of defense against diabetic foot complications [4, 5]. Foot self-care includes examining feet regularly, keeping them clean and dry, wearing suitable shoes and avoiding walking bare feet or exposing the feet to extremes of temperatures [6].
Protection motivation theory was applied to a wide range of health behaviours to assess their determinants and predict the intention to adhere to preventive and therapeutic practices [7]. Protection motivation theory suggests that a person performs a health behaviour, or has the intention to perform a behaviour, according to two cognitive appraisal processes; threat appraisal (perceived severity and susceptibility of the condition) and coping appraisal (perceived efficacy of the behaviour, perceived barriers to the behaviour and perceived self-efficacy to perform the action) [8].Protection motivation theory was used among persons with diabetes to predict physical activity [9, 10], adherence to treatment [13]and compliance with prevention behaviours in gestational diabetes [11].
The aim of this study was to assess the foot care behaviours and their relation to protection motivation theory among a sample of adults with diabetes in Egypt.
Methods
Study design and participants
A cross sectional design was used to collect data from a random sample of persons with diabetes attending primary health care units in Damanhour city, Al-Behaira governorate, Egypt between June and August 2019. One health care unit was chosen at random from each of the five main districts of the city.
Considering the prevalence of diabetes in Egypt to be 15.1% in 2017 [1] and a total population of 250,000 in Damanhour city [12] with a confidence interval of 95%, the total sample size was calculated to be 197 persons at least.
Instrument
After a literature review [7, 9–11, 13–17], a self-administered questionnaire was constructed to collect data about foot care behaviours and the constructs of protective motivation theory. To refine the questionnaire, the researcher conducted 4 focus groups among 20 persons with diabetes chosen at random from primary health care units (5 on each group). Participants in the focus groups were not included in the main study.
The refined version of the questionnaire was evaluated for face validity by two professors of public health and it was tested for reliability using the test –retest method. Cronbach’s Alpha equals 0.90 for foot care practices, 0.87 for perceived severity, 0.82 for perceived barriers, 0.82 for perceived susceptibility, 0.78 for self-efficacy and 0.75 for intention.
The final version of the questionnaire consisted of 3 sections:
The first section collected social and medical data of the participants: age, gender, educational level, diabetic feet problems as well as duration and type of diabetes.
The second section evaluated the foot care practices of the participants according to the foot care guidelines of American Diabetes Association [6]. The participants responded by “yes” or “no” to each of the 11 items. Appropriate behaviour was scored (1) and inappropriate behaviour was scored (0) with a maximum total of 11.
The third section evaluated the constructs of the protection motivation theory: Perceived susceptibility to foot complications (4items), perceived severity of foot complications (3items), perceived barriers to foot care behaviours (7 items), perceived efficacy of foot care behaviours (3 items) and intentions to perform foot care practices in the next 6 months (4 items). All items were assessed using a 5-points Likert scale, ranging from strongly agree to strongly disagree. Self-efficacy was assessed using the questionnaire developed by Perrin& Snow [14] which contains 12 items on a Likert scale ranging from “strongly confident”(=5) to” strongly not confident” (=1).
Ethical approval
The study was approved by the Ethical Committee, High Institute of Public Health, Alexandria University.
Statistical analysis
Data were analysed using SPSS version 22.0 (IBM Corporation, Armonk, NY, USA). Quantitative data were presented as mean ± S.D. and categorical data were presented as percentage. Student’s t test and one-way analysis of variance (ANOVA) were used to compare means. Pearson’s correlation coefficient was applied to find the strength of association between quantitative data. Multiple regression analysis was performed to find the predictors of total foot care behaviours.
Results
A total of 300 adults with diabetes participated in the study. The majority of the sample were men (60.6%), above 60 years old (59.4%) and had a university degree (53.0%). Duration of the disease was between 5to 10 years among (43.3%) of the participants and (89.3%) suffered from type 2 diabetes. There was a significant difference in foot care behaviours in relation to educational level, where participants with university degrees had the highest mean (5.94 ± 1.60) and persons with elementary/middle school education had the lowest mean (3.00 ± 1.41), P ≤ 0.05 (Table 1).
Table 1.
Foot care behaviours among adults with diabetes in relation to social and medical characteristics
| Number (%) | Total of foot care behaviors (Mean ± S.D) | P value | |
|---|---|---|---|
| Gender | |||
| Men | 182(60.6%) | 5.07 ± 2.21 | 0.853 |
| Women | 118(39.3%) | 5.20 ± 1.65 | |
| Age | |||
| Less than 40 years | 36(12.0%) | 4.33 ± 0.577 | 0.922 |
| 40–60 years | 86(28.6%) | 5.73 ± 1.67 | |
| Above 60 years | 178(59.4%) | 4.88 ± 2.18 | |
| Education | |||
| Elementary/middle school | 29(9.6%) | 3.00 ± 1.41 | 0.016* |
| High school/diploma | 112(37.4%) | 4.27 ± 1.90 | |
| University degree or above | 159(53.0%) | 5.94 ± 1.60 | |
| Duration of disease | |||
| Less than 5 years | 104(34.7%) | 5.57 ± 1.86 | 0.252 |
| 5–10 years | 130(43.3%) | 5.02 ± 1.68 | |
| More than 10 years | 66(22.0%) | 4.00 ± 2.28 | |
| Type of diabetes | |||
| Type 1 | 32(10.7%) | 5.67 ± 2.08 | 0.622 |
| Type2 | 268(89.3%) | 5.07 ± 1.94 | |
| Total | 300(100%) | 5.13 ± 1.92 | |
*p ≤ 0.05
Most of our sample washed their feet everyday (93.3%), did not put their feet in hot water (89.0%), wore comfortable shoes (85.6%) and checked their feet everyday (73.3%). On the other hand, a small proportion of the participants checked inside their shoes (9.6%), applied moisturizer on their feet (10.6%) and never walked barefoot (21.0%). (Table 2).
Table 2.
Details of foot care behaviours among adults with diabetes
| Foot care practice | Number | Percent |
|---|---|---|
| Keep blood glucose within normal | 99 | 33.0% |
| Check feet every day | 220 | 73.3% |
| Wash feet everyday | 280 | 93.3% |
| Dry feet after washing them | 160 | 53.3% |
| Dry between toes after washing feet | 70 | 23.3% |
| Apply moisturizing to keep feet skin soft | 32 | 10.6% |
| Trim toenails straight across | 210 | 70.0% |
| Never walk barefoot | 63 | 21.0% |
| Wear comfortable shoes that fit well | 257 | 85.6% |
| Check inside shoes before wearing them. | 29 | 9.6% |
| Do not put feet in hot water. Water bottles, heating pads, or electric blankets | 267 | 89.0% |
Foot care behaviours had a significant positive correlation with perceived susceptibility (p ≤ 0.05), perceived seriousness (p ≤ 0.01), self-efficacy (p ≤ 0.01) and intention (p ≤ 0.05) while they had a significant negative correlation with perceived barriers (p ≤ 0.01). On the other hand, intention to practice foot care was positively correlated with perceived seriousness (p ≤ 0.01) and self-efficacy (p ≤ 0.05), and negatively correlated to perceived barriers (p ≤ 0.01) (Table 3).
Table 3.
Correlation between foot care behaviours and protective motivation theory
| Perceived susceptibility | Perceived seriousness | Perceived efficacy | Perceived barriers | Self efficacy | Intention | |
|---|---|---|---|---|---|---|
| Perceived susceptibility | 1 | |||||
| Perceived seriousness | 0.212 | 1 | ||||
| Perceived benefits | 0.062 | 0.200 | 1 | |||
| Perceived barriers | 0.269 | −0.589 | −0.386* | 1 | ||
| Self efficacy | −0.426* | 0.217 | 0.340 | −0.842** | 1 | |
| Intention | −0.257 | 0.607** | 0.282 | −0.750** | 0.880** | 1 |
| Foot care behaviors | 0.452* | 0.609** | 0.243 | −0.784** | 0.865** | 0.804** |
*≤0.05
**≤0.01
A significant regression equation was found F (11, 18) =10.349, p < 0.000, with an R2 of 0.863. Three factors were statistically significant and positively affected the foot care behaviours. Self-efficacy (β = 0.620, t = 2.685, p = 0.015) was the strongest contributor to behaviours, followed by perceived seriousness (β = 0.522, t = 2.755, p = 0.013) then intention (β = 0.388, t = 0.890, p = 0.021) Table 4.
Table 4.
Multiple regression predicting foot care behaviours
| Factor | B | β | t | significant |
|---|---|---|---|---|
| Education | 0.522 ± 0.411 | 0.135 | 1.271 | 0.220 |
| Perceived susceptibility | 0.029 ± 0.064 | 0.050 | 0.447 | 0.660 |
| Perceived seriousness | 0.163 ± 0.059 | 0.522 | 2.755 | 0.013* |
| Perceived barriers | −0.040 ± 0.101 | −0.074 | −0. 395 | 0.698 |
| Self efficacy | 3.913 ± 1.457 | 0.620 | 2.685 | 0.015* |
| Intention | 0.106 ± 0.119 | 0.388 | 0.890 | 0.021* |
*≤0.05
Discussion
Lack of, or inadequate foot care is considered a risk factor of foot ulceration and amputation among persons with diabetes [18]. Therefore, tailoring education programs based on persons’ perceptions and motives to improve foot self management can reduce the risk of foot problems [19].
The results of our study show that foot care behaviours were poor amongst our sample (mean score 5.13 ± 1.92out of 11.0). This finding is consistent with several studies from developing countries reporting poor to moderate foot care practices among people with diabetes [20, 21].
It is to be noted that the majority of people with diabetes in the current study washed and inspected their feet daily as a ritual of Muslim prayer but only half of them dried their feet after washing and less than a quarter dried between the toes. Although (21.0%) of the participants confirmed that they never walked barefoot, and (85.6%) of them stated they wore comfortable shoes, the researcher noticed that the majority of the sample wore open shoes and sandals that did not protect their feet.
Educational level was the only social factor associated with foot care practices. Higher educational level is usually associated with better knowledge and more appropriate health behaviours [13]. In opposition to other studies, our research found no significant difference in foot care according to gender, type or duration of diabetes [22, 23]. This lack of association may indicate a widespread poor awareness of foot care among the sample regardless of social discrepancies.
Regarding the effect of threat appraisal on foot care practices, perceived severity was a predictor of foot care behaviours while perceived susceptibility had only a direct correlation with them. In contradiction, Jones et al. concluded in their meta- analysis that perceived susceptibility is a more powerful predictor than perceived severity across a wide range of health behaviours [17]. Moreover, the relation between perceived severity and preventive behaviours among persons with diabetes was inconsistent in different studies. Similar to our research, Tan (2004) reported a positive relation between perceived severity and complication prevention behaviours [13]. On the contrary, Gillibrand and Stevenson (2006) found an inverse relation between perceived severity of complications and self-care practices [15]. Other studies found that perceived severity did not influence health behaviours or intentions among persons with diabetes [16, 24].
Regarding coping appraisal, there was a negative correlation between perceived barriers and practices of foot care. In the same line, other studies demonstrated an inverse relation between perceived barriers and self foot examination [25], foot check up by physicians [16] and regular checkup of diabetes complications [26]. Furthermore, self-efficacy was a predictor of foot care in our study. Self-efficacy was a strong predictor of preventive behaviours in gestational diabetes [13], daily foot examination [27] and physical activity in type 1 and 2 diabetes [9].
Previous research reported that coping appraisal was more powerful than threat appraisal in determining health behaviours among persons with diabetes [9, 10]. In opposition, our results showed that self-efficacy and perceived severity had the same power in predicting foot care behaviours (t = 2.685, p = 0.015 & t = 2.755, p = 0.013 respectively) [7, 9, 17]. In addition, there was no significant relation between perceived efficacy and foot care behaviours. It is to be concluded that coping appraisal was not more influential in predicting health behaviours among our sample.
Similar to previous research among people with diabetes, intention was a predictor of health behaviours [7, 9]. However, intention was a less powerful predictor than self-efficacy and perceived barriers (t = 0.890). Jacob (2013) explained that intention may not always predict ongoing health behaviours due to personal or social factors that hinder executing the actions [11].
Conclusion
The results of our study showed that foot care practices were inadequate among our sample. Higher levels of foot self-care were directly related to intention, self-efficacy and perceived seriousness of diabetic foot complications. Educational programs based on the constructs of protection motivation theory can improve the level of foot care behaviours among persons with diabetes.
Limitations of the study
The present study has several limitations. Firstly, the study depends on self-reporting of behaviours which may be biased by social acceptability. Secondly, the study was based on a cross-sectional design which limits our ability to discover the cause-effect relationship between foot care behaviours and constructs of protection motivation theory.
Acknowledgments
The author would like to thank all the staff of Damanhour directorate of health as well as the people with diabetes who were willing to give their time to participate in the study.
Funding
The research was funded by the author.
Compliance with ethical standards
Conflict of interest
The author declares no conflict of interest.
Ethical approval
The study was approved by the Ethical Committee, High Institute of Public Health, Alexandria University.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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