Diabetic Foot Care Behaviors: A Literature Review

Titis Kurniawan1,2*, Imas Rafiyah1,2, Ardia Putra1,3, Yanuar Primanda1,4

1
Master student, Master of Nursing Science (International Program), Faculty of Nursing, Prince of Songkla University,
P.O. Box 9, Khor Hong, Hatyai, Songkhla, 90112, Thailand
2
Lecturer of Faculty of Nursing, Universitas Padjadjaran, Jl. Raya Bandung-Sumedang Km 21, Jatinangor, West-Java,
45363, Indonesia
3
Lecturer of Nursing Science Program, Medical Faculty, Syiah Kuala University, Gedung Petronas, Jl. Tgk. Tanoeh
Abee, Darussalam, Banda Aceh, 23111, Indonesia
4
Lecturer of Nursing Science Program, Faculty of Medicine and Health Science, Muhammadiyah University of
Yogyakarta, Jl. Lingkar Barat, Tamantirto, Kasihan, Bantul, Yogyakarta, 55183, Indonesia
*Corresponding author, E-mail: titiz_kazep@yahoo.com
 Abstract—Diabetic foot care behaviors are one of
essential component of diabetic foot ulcer prevention. It
facilitates early detection of foot abnormalities and allows
early treatment that produce bigger opportunity for better
outcomes. However, many of diabetic patients were not
perform this practice properly. The aims of this review are
to describe the diabetic foot care behaviors components,
contributing factors, assessment, and diabetic foot care
behaviors improvement program. A relevant literature
searched from databases: PubMed, CINAHL, the Cochrane
and ProQuest Medical Library, and Science Direct were
conducted. It was found that diabetic foot care behaviors
basically consist of simple activities that predict had
significant benefits in preventing diabetic foot ulceration.
Foot care behaviors influenced by several factors including
patients’ age, gender, knowledge, foot care education
experiences, foot care education and foot examination that
conducted by healthcare providers, and resources
availability. With regard to the important of foot care
behaviors in preventing diabetic foot ulceration, it was
recommended for healthcare providers to regularly assess
patients’ foot care knowledge and behaviors and apply the
certain strategies to improve patients’ foot care knowledge
and behaviors properly.
Keywords-component; diabetic foot care, foot ulcer, foot
ulcer prevention.
I. INTRODUCTION
Diabetic foot ulcer (DFU) is the commonest
diabetic complications. It affects almost 15% to 25% of
diabetic patients [1]. In the other hand, diabetic foot ulcer
treatment is challenging, costly, time consuming [2,3,4],
and often requires foot amputation [5]. It was reported
that almost 32% of diabetic patient with foot ulcer ended
up with such types of foot amputation [6]. Depressingly,
evidences showed that diabetes related foot amputation is
closely related to physical disability, depression, financial
burdens, poor quality of life, and high mortality [4,7,8].
Thus, DFU prevention is very important.
Additionally, once diabetes peripheral
neuropathy (DPN) is developed, diabetes patients’ feet are
easily developing foot ulceration. Some of the patients’
daily activities, such as walking bare foot, footwear, and
trimming toenails are impending causes of foot ulcer.
However, since the patients unable to sense the pain
caused by injuries, foot ulcer become insensible injury
and most of patients just know the ulcer after it developed
such degree of infection [9]. These situations emphasize
that daily foot inspection is very important. Daily foot
inspection allows patient early detect any foot
abnormalities that eventually provides large opportunity
to prevent foot ulceration. It was noted that patients who
performed proper foot care had significantly lower risk of
foot ulceration than those who did not [10,11].
Unfortunately, previous studies showed that many
diabetic patients did not perform it properly [11, 12, 13].
The objectives of this review are to outline the diabetic
foot care behaviors components, contributing factors,
assessment, and diabetic foot care behaviors improvement
program.
II. METHOD
The http://lib.med.psu.ac.th/libmedeng/ was used
as the main channel to search related journals, articles,
and other comprehensive reports from the classic nursing
and health-related databases such as PubMed, Cumulative
Index to Nursing and Allied Health (CINAHL), the
Cochrane Library, and Science Direct. The numbers of
keywords were used to obtain those articles including
diabetic foot care, foot ulcer, foot care practice, and foot
ulcer prevention.
III. DIABETIC FOOT CARE BEHAVIORS COMPONENTS
Diabetic foot care behaviors simply defined as
the daily activities to assess or examine foot conditions
and apply some recommended actions to maintain and
improve foot conditions or minimize the risk based on the
assessment findings [15]. Generally, it consists of foot
assessment and foot care.
A. Foot Assessment
This activity is purposed to identify the major
causes of foot ulceration including foot peripheral
neuropathy, vascular problem, and foot pressure. There
were some recommended points in the foot assessment as
followed [15, 16]:
1). Foot skin assessment. These activities include
skin color, dryness, thickness, fissures, or cracking. To
ensure all part of foot were assessed properly, the diabetic
patients suggested using mirror.
2). Peripheral neuropathy assessment. This
assessment is including thermal sensation, pain sensation,
numbness, or autonomic damage.
3). Vascular impairment assessment. This
assessment including assessing warm skin, distended vein
and foot pulses.
4). Foot posture and shape assessment. Activities
including investigating of claw toes, metatarsal heads, or
Charcot joint.
5). Callus and blister assessment. This assessment
focused on the plantar pressured point including the site,
size, and the appearance of callus or blister.
6). Infection or inflammation assessment. It
especially aimed to identify the between toes area and the
moist part of each foot.
7). Assessment of ulceration. This assessment
includes assessment of the foot ulcer site, appearance,
size, infection signs, and exudation.
B. Foot Care
This activity consists of any recommended
actions to maintain foot conditions and/or minimize foot
ulcer risk factors. Those recommended foot care activities
were include as follows [17,18,19]:
1). Foot hygiene. The foot should be kept in clean,
dry, and soft. Patients are suggested to wash the foot daily
by using mild soap and pour (warm not hot) water and
soft washcloth. Avoid soaking feet more than 4 minutes
and drying all parts the foot including between toes area
gently by using soft and clean towel, especially between
areas. To keep skin foot moist, apply a moisturizing lotion
after washing.
2). Selecting and wearing fitted footwear. It was
suggested to use proper cushion footwear, athletic shoes,
footwear with laces, velcro, or buckles, and avoiding
pointed-toe, open-toe shoes, high heels, sandals, and un-
breathable and inelastic materials.
3). Toenails trimming and care. This foot care
action only suggested for the patients who able to reach
and cut the toe nails properly. Cutting the toenails
carefully using proper nail cutter/nail clipper, following to
the shape of the toes, avoid cut the nails too close to the
skin of toenails bed, and avoid cutting down the corners or
skin at the end of toenails (see Figure 1). In addition, it is
suggested to perform nail cutting after soaking feet (after
a bath or shower). When find toenails are ingrown,
thickened, or infected, it should be treated and trimmed by
a healthcare professional.
4). Avoiding extreme temperatures. Check the
temperature of water/shower before used. However,
because patients mostly experience loss-sensation because
of neuropathy, they may be unaware of thermal injury. If
possible, put water thermometer in the bathroom to ensure
that the water is in the proper/tolerable temperature.
5). Attending on the regular health professional foot
examination. During the regular check up, patient is
suggested to promptly report foot problems to the
healthcare professional such as infection, ulcer, cuts that
do not heal, and other abnormal findings that they find
during daily assessment (redness, drainage, swelling, pain
or dark discoloration). Also suggested for patients to ask
any advises from nurses or primary care providers when
superficial cuts, scratches, and blisters that do not heal in
three days. The attending comprehensive foot examination
frequencies will different for each patient depends on their
risk factors severity. Patients’ risk factors classification
and scoring is as followed [16]:
TABLE I. RISK CLASSIFICATION BASED ON THE COMPREHENSIVE FOOT
EXAMINATION
Risk Definition Recommended Suggested
Category Treatment follow-up
0 No LOPS, Patient education Annually (by
no PAD, no including advice on generalist
deformity appropriate footwear and/or
specialist)
1 LOPS+  Consider prescriptive Every 3-6
deformity or accommodative months (by
footwear generalist
 Consider prophylactic and/or
surgery if deformity is specialist)
not able to be safely
accommodated in
shoes. Continue
patient education.
2 PAD +  Consider prescriptive Every 2–3
LOPS or accommodative months (by
footwear. specialist)
 Consider vascular
consultation for
combined follow-up.
3 History of  Same as category 1. Every 1–2
ulcer or  Consider vascular months (by
amputation consultation for specialist)
combined follow-up if
PAD present.
Abbreviations: PAD = peripheral artery diseases and LOPS = loss of
protective sensation. Source: Boulton et al. (2008).
IV. DIABETIC FOOT CARE BEHAVIORS CONTRIBUTING
FACTORS
A. Patients’ Knowledge and Foot Care Education.
In one study stated that one of the barriers of
performing foot care properly is patients’ lack of
knowledge [20,21]. Inherent, the evidences mostly
suggested that educational program improve patients’
knowledge and foot behaviors [22, 23]. In addition, it was
noted that repeated exposure to the educational program
improved patients’ adherence to perform proper foot care.
Diabetic patients who participated in more than three
education programs practiced had significantly better self
foot care than patients who had no or only one training
program [13, 24]
B. Patients’ Characteristic
One study showed that man was more confident
in their ability to manage their diabetes, reported fewer
lapse in foot care, reported higher quality of life, and
overall better treatment satisfaction [25]. The other
patients’ characteristics that significantly associated with
greater basic foot care were younger age, African-
American background, higher education, more severe foot
neuropathy, and having experience of foot ulcer [13].
Another study noted that there were significant different
of foot care behaviors and understanding between
American Indian/Pacific Islanders, Asians, and African
Americans [21].
C. Complication of Diabetes Mellitus
Complication of diabetes mellitus influence
patients’ foot care behaviors in negative and positive
direction. Negatively, DM complication may develop any
physical disabilities that reduce patients’ capacity to
perform foot care practice properly. In one study
identified that some barriers of performing foot care
practice were included vision problem, joint problem, and
excess weight [21]. In contrast, complication also may
improve patient awareness to perform foot care more
properly in order to minimize the complications that
already developed [24].
D. Foot Care Education and Foot Examination from
Healthcare Providers
 In the study identified that patients who received
foot care education and their feet had been examined by
healthcare providers were more likely to check their feet
regularly [26].
E. Resources Availability
It was identified that lack of foot care
equipments such as mirror, foot-stool, and nail cutter
would inhibit patients to perform self-foot care properly
[13]. Without those equipments may hinder them to
perform some foot care techniques properly.
Based on all of those findings, it can be
generalized that patients’ foot care behaviors are
influenced by three major factors, namely: patients’
related factors, health care providers’ related factors, and
resources availability related factors.
V. DIABETIC FOOT CARE BEHAVIORS ASSESSMENT
Patients’ self-report (questionnaire) on perceived
foot care behaviors were generally used in the previous
studies to measure the outcome of patients’ foot care
behaviors. Observational method was also used in
combination with patients’ self-report in evaluating foot
care behaviors [27], unfortunately there was no clearly
explanation regarding this technique. The published
questionnaires had been developed to evaluate foot care
behaviors were including Nottingham Assessment of
Functional Foot-care Questionnaire (NAFF), DisFoKa-32,
and summery of diabetes self-care activity (SDSCA).
A. Nottingham Assessment of Functional Foot-care
Questionnaire (NAFF)
This instrument was developed by Lincoln and
colleagues in 2007 and primarily consisted of 51-item
[28]. It was implemented with 100 diabetic patients and
61 healthy volunteers in out-patients department. The
internal consistency was 0.46 and 0.39 in people with
diabetes and in healthy volunteers, respectively. From
this, 28 items were found significant differences between
each group. The instrument was then revised into 29 items
and consists of foot assessment (2 questions), foot wear
(13 questions), foot hygiene (3 questions), prevent foot
injury (7 questions), toenails, callus/corn care (2
questions), and wound/ulcer care (2 questions). The
internal consistency was 0.53 and there was a significant
correlation (γ = 0.83; p < 0.001) and no significant
difference (p = 0.85) between scores in the test-retest
study. However, since this instrument developed and
utilized in European countries, utilization in other regions
is therefore needed to be modified to fit with context and
culture.
B. DisFoKaPS-32 Questionnaire
This questionnaire was developed by Khamseh
and colleagues in 2007 based on foot care principle, their
experiences as healthcare providers, and the
recommendations from the American College of Foot and
Ankle Surgeons and the British Diabetes Association [29].
It was originally developed in Persian Language version
and consisted of 16 questions on knowledge and 16 items
of foot care behaviors. Foot care practice section
comprised foot self-examination (4 questions), foot wear
(3 questions), toenails care (2 questions), and foot hygiene
(7 questions). The content validity was approved by five
physicians and one nurse and tried-out with diabetic
patients. However, there was no report regarding
reliability test of this questionnaire.
C. Summary of Diabetes Self-Care Activities (SDSCA)
Questionnaire
The SDSCA is a brief self-report questionnaire to
assess diabetes self-management including: general diet,
specific diet, exercise, blood-glucose testing, foot care,
and smoking [30]. In addition, Toobert and colleagues
reported the high internal consistency-reliability of the 5
categories of this tool (γ = 0.47) with an exceptional of the
specific diet test-retest correlations were at moderate level
(γ = 0.40). Furthermore, SDSCA questionnaire was a
brief, reliable, and valid self-report measure of diabetes
self-management (included foot care practice) and
suggested to use both for research and clinical practice.
The limitation of this instrument might be detected at the
few items of foot care behaviors questions that consisted
of two questions regarding patient’s practice in checking
their foot and inspecting inside part of footwear. So, it
might be not represent the whole picture of diabetic foot
care behaviors components.
Regarding the components measured, NAFF and
DisFoKaPS-32 seem more comprehensive than SDSCA.
In addition, NAFF and DisFoKaPS-32 have some
similarities including used foot inspection, foot hygiene,
footwear, preventing foot injuries, toenails/callus/corn
care and moisturizing foot skin to measure foot care
behaviors. However, since the NAFF developed in
European country, the measurement items may not fit to
measure foot care behaviors in non-European countries.
VI. DIABETIC FOOT CARE BEHAVIORS IMPROVEMENT
PROGRAM
According to the evidences from the previous
studies, there were 10 studies (5 RCTs, 2 quasi
experiments studies, and 3 systematic reviews) evaluated
the effectiveness of diabetic foot care program in
improving foot care behaviors and preventing foot ulcer.
Even though there were some limitations regarding the
methodological issues, all evidences suggested that
educational program that combined with follow up,
consultation, and providing printed material were
effectively improved patients’ foot care knowledge and
behaviors. Accordingly, the systematic reviews reported
that trials in this arena considerably improved patients’
foot care knowledge and behaviors however most of those
studies had lower internal validity and high risk of bias
[23, 31,32].
Regarding the follow up strategies used, most of
those studies utilized telephone call, card reminder, home
visit, and face-to-face followed up as schedule at clinic/
outpatient department during regular check up. Regarding
the phone call follow up, some other studies reported that
phone call intervention for giving health education and/or
follow-up effectively improved patients’ behaviors [33,
34, 35].
In the educational strategies, most of the
previous studies provided diabetic foot care programs as
an individual (face-to-face) or a group that combined with
demonstration, discussion, providing leaflet/booklet,
providing other motivational sessions, or providing
consultation or couching. The efficacy of using individual
and group diabetic foot care program showed that group
approach was more effective than individual approach
[36]. In other study noted that effectiveness of group
approach (4-8 patient/group) was equally effective in
improving the outcomes and may allow other benefits
regarding time and cost [38].
There were several measured outcomes evaluated
in the previous studies. Those outcomes were ulcer/
diabetic foot problem/amputation, patients’ foot care
knowledge, and patients’ foot care behaviors. Those
studies revealed that all of the diabetic foot care programs
improved patients’ foot care knowledge and behaviors
[27, 22, 36, 38-41], enhanced patients’ self efficacy [38],
improved patients’ perceptions of barrier, benefit,
severity, threat, and susceptibility of foot care [27], and
improved patients’ self-management behaviors [36,40].
However, effect of diabetic foot care programs on
patients’ mood and quality of life were not found [27].
Also, did not reach statistical significant in term of
diabetic foot care program on reducing foot ulcer or
incidences, particularly in high risk patients [27, 39].
VII. CONCLUSION
Overall, foot care behaviors are one of the
important components of foot ulcer prevention.
Unfortunately, the evidences suggested that many diabetic
patients did not perform foot care practice properly. It was
also identified that diabetic foot care behaviors were
influenced by many factors, such as patients’ knowledge,
foot care education experience, DM complications, foot
care education and examination from healthcare
providers, and resources availability. Fortunately, most of
those factors were modifiable and several foot care
improvement programs showed effectively improved
patients foot care knowledge and behaviors. Generally,
the program provided was combination of interactive
educational session with others strategies including
follow-up phone call, booklet, motivation and counseling
strategies. Even though the previous evidences showed
effectively improved patients’ foot care knowledge and
behaviors, almost of those studies were conducted in the
western countries. Therefore, the program and
measurement used may not produce similar effect when it
was applied in the countries with different characteristic/
cultural background.
VIII. RECOMMENDATION
Based on evidences outlined, it is suggested for
every healthcare provider who treats diabetic patients to
regularly assess patients’ current foot care knowledge and
behaviors and apply certain improvement program/
strategy to enhance patient foot care knowledge and
behaviors in order to prevent diabetic foot ulceration.
ACKNOWLEDGMENT
I would like to thank to the Directorate of Higher
Education, Ministry of National Education of Republic of
Indonesia for giving me scholarship to continue my study
in Faculty of Nursing, Prince of Songkla University,
Thailand.
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