practice
Complications related to diabetic foot
ulcer and associated social vulnerability
factors at a referral centre in Brazil
Objective: To analyse the prevalence and associated social
vulnerability factors of complications related to diabetic foot ulcer
(DFU) among individuals followed up in a public care centre in Brazil.
Method: This is a cross-sectional study carried out with individuals
followed up at the diabetic foot service of the State Referral Center
for Diabetes and Endocrinology Assistance (CEDEBA) between
December 2019 and October 2020, during the COVID-19 pandemic.
Descriptive analysis and comparison of the prevalence of
complications related to DFU were carried out. The factors
associated with the outcome variables were verified by hierarchical
logistic regression analysis.
Results: Among the 253 participants in this study, 30.4% had an
active ulcer, 57.1% had a previous ulcer and 45.1% had an
Journal of
amputation. Lower limb ulcers were positively associated with male
sex (prevalence ratio (PR): 1.22 (1.04–1.43)) and negatively
associated with age >60 years (PR: 0.71 (0.61–0.83)), screening for
diabetes  ●  diabetic foot  ● epidemiology ●  prevention and control  ●  public health  ● ulcer ● vulnerability ● wound ●
wound care  ●  wound dressing  ●  wound healing
Wound Care
D
iabetic foot (DF) is a life-threatening,
chronic complication of diabetes. The
incidence has been increasing due to an
increase in worldwide diabetes prevalence
and prolongation of life expectancy of
people living with the disease.1,2 The increase in general
life expectancy increases the likelihood of developing
chronic diseases such as diabetes. The increase in life
expectancy of people living with diabetes increases the
probability of developing chronic complications of the
disease. It is caused by lesions in the deep tissues
associated with neurological disorders and peripheral
vascular disease in the lower limbs that can generate a
spectrum of manifestation, such as foot insensitivity,
claudication, deformities and Charcot foot. According
to the International Work Group on the Diabetic Foot
(IWGDF),3 it is a clinical syndrome characterised by the
existence of infection, ulceration and/or destruction of
Monique Magnavita Borba da Fonseca Cerqueira,1 Master in Public Health*;
Helena Maria Silveira Fraga Maia,1 Doctor in Public Health; Magno Conceição das
Mercês,1 Doctor in Health Sciences; Marcio Santos da Natividade,2 Doctor in Public
Health; Onsli dos Santos Almeida,1 Nurse; Eduardo Fernandes Santana,1 Master in
Public Health; Beatriz Andrade Mafra Oliveira,1 Medical Student; Marcelo Araújo,3
Doctor in Medicine
*Corresponding author email: mmcerqueira@uneb.br
1  Department of Life Sciences, State University of Bahia, Brazil.  2  Collective Health
Institute, Federal University of Bahia, Brazil.  3  Health Department, Santa Cruz State
University, Brazil.
2 JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022
diabetic foot (PR: 0.79 (0.67–0.92)) and the use of public transport to
access CEDEBA (PR: 0.82 (0.71–0.96)). On the other hand,
amputations were positively associated with male sex (PR: 1.61
(1.23–2.11)) and not working (PR: 3.83 (1.48–9.95)) and negatively
associated with age >60 years (PR: 0.57 (0.45–0.74)) and the use of
public transport to access CEDEBA (PR: 0.63 (0.49–0.81)).
Conclusion: The prevalence of complications was higher than in
previous studies, and associated with sociodemographic and clinical
characteristics. Further research should be encouraged to investigate
the role that determinants of health play in the course of the disease,
contributing to the construction of strategies that incorporate
formulations developed in the social and economic spheres to
broaden the impact of health actions on the prevention of major
diabetic foot complications.
Declaration of interest: The authors have no conflicts of interest
to declare.
 
deep tissues associated with neurological abnormalities
and varying degrees of peripheral vascular disease in the
lower limb.4
The condition includes changes of different origins,
the common outcome of which is the appearance of
diabetic foot ulcers (DFU). DFU can favour the invasion
of bacteria due to the loss of skin integrity, facilitating
the development of infections, which are a precipitating
factor for 60–90% of amputations.5–7
The treatment of DFU is challenging due to its
multifactorial aetiology. The risk of recurrence of an
ulcer is high even when it is healed, being estimated at
30–40% in the first five years,8 and the associated
mortality can reach up to 45% in five years.9 Thus, it is
understood that the prevention of DFU should be the
mainstay of care programmes aimed at reducing
amputation rates among people living with diabetes.10
Although efforts to build knowledge about DF have
resulted in the elaboration and wide dissemination of
prevention and treatment protocols, data have shown
that the number of amputations continues to increase.10
This may be related to the fact that epidemiology has
focused on the risk measurement of factors associated
© 2022 MA Healthcare Ltd
with individual lifestyle and exposure in an attempt to
explain the aetiology of DF, with little consideration of
environmental, behavioural and programmatic
influences on the disease.11,12
The distribution of risk factors for non-communicable
 practice

diseases (NCDs) is socially determined and, although Method

the causal relationship between an individual’s
socioeconomic position and diabetes is not yet fully
understood, the origin of the disease lies in complex
processes that interact with each other, involving the
lack of access to information about healthy foods,
physical activity, health services, and occupational and
economic opportunities.11,13 As reported in India, it has
been observed that DFU is usually a consequence of the
association between inadequate hygiene, use of
inappropriate shoes and delay in accessing health
services.14
In Brazil, there are no records of studies addressing
the association between prevalence and contexts that
produce vulnerability for the development of DFU and
amputations. In the northeast region of the country, for
instance, where social determinants of health play an
important role in the pathophysiology of the disease,
this suggests a gap in the knowledge about susceptibility
to this condition. Therefore, this study aims to analyse
the prevalence and associated factors of complications
related to DFU, among individuals followed up in a
This was a cross-sectional study with individuals
followed up at the DF service of the State Referral Center
for Diabetes and Endocrinology Assistance (CEDEBA),
specialised in multidisciplinary care for people with
diabetes, including endocrinologists, vascular surgeons,
physiotherapists, nurses, psychologists and social
workers. All patients were referred from primary
healthcare (PHC) and fulfilled the following criteria for
follow-up:
● Diagnosed with diabetes
● Showing neuropathic or arterial changes secondary to
the disease
● With or without presence of current or past ulcer,
osteoarticular deformities and/or DF-related
amputations.
People diagnosed with type 2 diabetes, >18 years of
age, with or without injuries and/or amputations in the
lower limbs related to diabetes, living in Salvador,
Bahia, Brazil, and who consented to sign the Free and
Informed Consent Form (FICF) were consecutively
included in the study. People with cognitive and/or

Journal of
secondary care centre, in the public services of the state language deficits that precluded the interviews, or living
of Bahia, located in northeast of Brazil, in order to outside the state capital, where CEDEBA is located, were
contribute to the debate on the subject. excluded from the study. (The addresses of people living

Fig 1. Hierarchical logistic regression model of factors associated with complications related to diabetic foot (DF)

Wound Care
Level 1 Level 2 Level 3 Level 4

Sociodemographic Environmental Clinical Communication Diabetic foot

characteristics characteristics characteristics processes injuries

- Age - Piped water - Diabetes duration - Understands

- Sex - Sanitary/sewage - Therapeutic everything in
- Skin colour/ - Rubbish collection adherence the service
ethnicity - Transport - Consultation at - Understands
- Marital status primary healthcare the terms
- Inhabitants - Health education - Asks when
and home to prevent in doubt
- Schooling diabetic foot - Has already left
- Screening of with doubts about
- Occupation
diabetic foot your disease
- Income
- Has already left
- Religion with doubts about
medications
- Feels well cared for
- Thinks the doctor
has made mistakes
- Feels responsible
for treatment
- Stopped seeking
help for fear
- Stopped seeking
help for not
knowing how to
say what was felt
© 2022 MA Healthcare Ltd

- The doctor
explained diabetes
complications

JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022 3

 practice
elsewhere were georeferenced with the intention of
identifying the distance people walked to the service,
and this variable was part of another study).
Primary data were collected with investigation forms
and clinical evaluation of the feet, and secondary data
were collected through a search of the patients’ medical
records. Initially, data collection took place from
December 2019 to March 2020 by the main author,
using a structured questionnaire. Face-to-face interviews
and care activities carried out by CEDEBA were
suspended from April 2020 due to the COVID-19
pandemic. Given this context and considering the
existence of secondary data recorded in medical records
by the main investigator, who is the doctor responsible
for the clinic where the research population was
selected, the interviews were resumed from August 2020
through telephone contact with individuals who had a
previous appointment for face-to-face consultation and
who accepted this type of interview, without prejudice
to the quality of the investigation. The physical
examination data were collected through the medical
records of the last performed consultation.
Journal of
Sociodemographic variables consisted of age and sex,
with age being categorised as <60 years or ≥60 years, the
age which defines people of older age according to the
Brazilian Institute of Geography and Statistics.15 Skin
colour was self-declared and classified according to the
Brazilian Institute of Geography and Statistics (IBGE),
but it was classified into white and non-white for
Wound Care
analysis purposes. Marital status was defined according
to the existence or absence of partners. The number of
residents in the household was categorised between
living alone or not living alone. Schooling was defined
according to the number of years of study, categorised
as <8 years and ≥8  years. Occupational activity was
classified into salaried work, retirement, unable to work
and without receiving benefits due to illness, or out of
the workforce, as defined by the IBGE. The categories
working and not working were considered for the
analysis. Individual income was categorised as ≤1 or >1
times minimum wage (R$1045.00). Religion was
determined according to how the faith was processed
by the individual, and categorised between those who
followed a religion and those who did not. The
questions about access to public services investigated
the existence of piped water, sanitary sewage and
rubbish collection at home, in addition to the use of
means of transport to access CEDEBA. All variables
related to sanitation were categorised as present or
absent, and the transport was classified as public, which
included the use of buses or the Metro, and private,
including own or family car, taxi and rides using
transportation applications.
The clinical data consisted of recording the diabetes
treatment time in years, which was categorised as
≤10  years or >10 years. This cutoff point was defined
because, according to Riaz et al.,16 most of the patients
with a DFU had diabetes for >10 years with poor
glycaemic control. Therapeutic adherence was classified
4 JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022
according to the four-item Morisky–Green scale,
namely:
1. Do you sometimes have problems remembering to
take your medication?
2. Do you sometimes forget to take your medication?
3. When you are feeling better, do you stop taking the
medication?
4. Sometimes, if you feel worse when taking the
medication, do you stop taking it?
The individuals were classified as non-adherent if
they answered positively to any of the questions. The
access to medical consultations at PHC in the last year
was judged by the number of times a year, being
stratified as: not attending or rarely attending; once or
twice; and three or more times. The last two categories
were condensed as regulars and the first defined non-
regulars for the analysis. Finally, the access to DF
prevention activities at PHC in the last year was
investigated by asking whether there was participation
of individuals in health education activities and
screening by examining the feet.
The following variables were used with regard to
adequate health communication: the patient
understands what is said in the service; understands the
terms used by health professionals; asks when in doubt;
has already left with doubts about the health situation;
has already left with doubts about how to use the
medications; feels well cared for by health professionals;
feels responsible for the treatment to be performed;
reported that some medical professional has made
mistakes; stopped seeking help from a health professional
because they do not know how to say what they have
felt; stopped seeking help from a health professional
because they were afraid of what they felt; and reported
that some medical professional has already explained in
detail the bad consequences of untreated diabetes. All
these variables were categorised as ‘yes’ or ‘no’.
The dependent variables or outcomes—current ulcer
and/or history of previous ulcer and amputation—were
determined by the clinical evaluation of the feet and/or
searching the medical records.
The collected data were tabulated in Microsoft Excel
for Windows (Microsoft Corp., US) and analyses were
conducted in the statistical package Stata 15 (supplied
by the Public Health Laboratory of the University of the
State of Bahia, Brazil), where corrections and
inconsistencies were eliminated. The descriptive
analysis identified the general and specific characteristics
of the studied population, and allowed the comparison
of the prevalence of related complications of DF
according to the characteristics found in the
investigations. Bivariate analyses were performed to
identify the set of variables most associated with the
outcomes considering the value of Pearson’s Chi‑squared
© 2022 MA Healthcare Ltd
test (χ2) or Fisher’s exact test. The magnitude of the
association under investigation was estimated by
calculating the prevalence ratios (PR), adopting the 95%
confidence interval (CI). A multivariate analysis was
performed according to the hierarchical model defined

a priori (Fig  1), using the value of p≤0.20 and the
theoretical consistency of association with the outcomes
as screening criteria for inclusion of the independent
variable. All socioeconomic variables were included in
the first block (level 1), even those not significant in the
bivariate analysis. The significant variables in this
analysis were conserved in the model and entered into
the adjustment of the next block, that is, the
environmental variables (level 2), which were
introduced into the model simultaneously, regardless of
changes in the value of the statistical significance of the
level 1 variables that were already in the model. The
same procedure was used for the following blocks (levels
3 and 4), i.e., clinical and communication variables,
respectively. The variables associated with the outcome
with a level of p≤0.17 were maintained in the partial
hierarchical models, but only those that showed a
significant association with the outcome, with a value
of p≤0.05, remained in the final model.
Ethical approval
The research project was approved by Committee on
Journal of
Publication Ethics at Plataforma Brasil under CAAE nº
23209119.7.0000.0057. All patients invited to
participate in the study signed the FICF.
Results
Of the 285 individuals approached, 259 signed the FICF
(15 refused to participate in the research, seven were
Wound Care
excluded for living in another city and four were
excluded for being patients with type 1 diabetes).
Among the questionnaires, six were excluded by
duplicate collection. Thus, 253 individuals living with
diabetes took part in this study. Sociodemographic and
environmental characteristics are described in Table 1.
Statistically significant differences in the proportion
of DFUs and amputations were observed between the
age groups, with the youngest individuals presenting
with a higher prevalence (85.9% and 58.7%,
respectively) when compared with older individuals
(59.6% and 37.3%, respectively; p<0.001 and p=0.001,
respectively). Regarding sex, men had a higher
occurrence of DFU (78.3%) and amputations (56.7%)
than women (60.9 and 34.6%, respectively; p=0.003
and p<0.0019, respectively). A higher proportion of
people with DFUs was also found among individuals
without religion (88.0%) compared with those who had
religion (67.4%; p=0.034). Regarding the means of
transport used to access CEDEBA, users of private
transport had a higher prevalence of DFUs and
amputations (75.9% and 53.7%, respectively) than
users of public transport (64.1% and 38.6%, respectively;
p=0.045 and p=0.017, respectively). No differences in
proportion were observed between DFUs and
© 2022 MA Healthcare Ltd
amputations, and other sociodemographic variables or
related to access to public services.
Table 2 shows data on the prevalence of injuries
related to DF according to clinical characteristics relative
to diabetes care activities, prevention of DF and
JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022
practice
communication. Most of the interviewees (71.2%)
already had some complication related to DF at the time
of the research and, among them, 30.4% had an active
ulcer, 57.1% had had a previous ulcer, and 45.1% had
undergone an amputation. Among amputees, 72.8%
had undergone a minor amputation, defined as those
below the ankle, and 27.2% a major amputation,
defined as those above the ankle. A higher proportion
of people with DFU was observed among individuals
with up to 10 years of illness (80.0%) than those with a
longer time of diabetes diagnosis (65.0%; p=0.021).
Regarding variables related to access to DF prevention
activities in PHC in the last year, a higher prevalence of
DFUs and amputations was observed among individuals
who participated in the screening at PHC in the last
year (86.3% and 58.8%, respectively) than individuals
who did not have their feet examined (69.4% and
41.6%, respectively; p=0.003 and 0.027, respectively).
The variable communication showed a higher
proportion of patients with DFU among users who said
they had already left a consultation with doubts about
their health situation (79.4%) than those who denied it
(65.8%; p=0.043) and among those who said they had
stopped seeking help due to fear of what they were
feeling (84.4%) compared with those who opposed this
behaviour (67.0%; p=0.046). A higher proportion of
amputations was also identified among individuals who
believed that a doctor had made a mistake with them
(55.4%) than those who do not believe in this possibility
(40.8%; p=0.033).
Tables 3 and 4 show the bivariate and multiple
analyses of the four variable levels regarding the
associations between complications of DF, and
sociodemographic and clinical characteristics, as well as
those related to access to public services and DF
prevention activities at PHC and communication of the
studied population. The multiple regression model
adjusted for the characteristics included in level 1
revealed that the variables age and sex remained
associated with DFU (prevalence ratio (PR): 0.69, 95% CI:
0.60–0.81; PR: 1.29, 95% CI: 1.09–1.52, respectively)
while following a religion lost its strength of association
with DFU after the adjustment (PR: 1.20, 95% CI: 0.95–
1.51). With regard to amputation, age, sex and
occupation maintained the strength of association after
the adjustment (PR: 0.63, 95% CI: 0.49–0.83; PR: 1.64,
95% CI: 1.24–2.17; PR:  3.32, 95%  CI: 1.30–8.44,
respectively). No variable was associated with the
outcomes at level 2. The block of variables at level 3
showed an association between DFU and diabetes
duration (PR: 0.81, 95% CI: 0.69–0.95). Screening for DF
(PR: 0.75, 95% CI: 0.65–0.87; PR: 0.71, 95% CI: 0.53–
0.94, respectively) is associated with both outcomes after
multiple regression. On the other hand, ‘access to health
education practices’ lost strength of association with
DFU after adjustment (PR: 1.09, 95% CI 0.85–1.40). The
block of variables at level 4 showed an association
between DFU and the variables ‘leaving with doubts
about the health situation’ and ‘not seeking help for fear
5
 practice

Table 1. Sociodemographic characteristics and those related to access to public services of individuals
living with type 2 diabetes followed up at the CEDEBA diabetic foot clinic, Salvador, Bahia, Brazil,
2019–2020 (n=253)
Variable n (%) Prevalence of p-value Prevalence of p-value
DFU, n (%) amputation, n (%)

Sociodemographic

Age, years

<60 92 (36.4) 79 (85.9) 54 (58.7)

≥60 161 (63.6) 96 (59.6) <0.001 60 (37.3) 0.001

Sex

Female 133 (52.6) 81 (60.9) 46 (34.6)

Male 120 (47.4) 94 (78.3) 0.003 68 (56.7) <0.001

Skin colour/ethnicity*

White 19 (7.5) 12 (63.2) 9 (47.4)

Non-white 233 (92.5) 163 (69.9) 0.536 105 (45.1) 0.846

Marital status*

With partner 131 (52.0) 90 (68.7) 62 (47.3)

Journal of
Without partner 121 (48.0) 85 (70.2) 0.790 52 (43.0) 0.488

Lives alone*

No 216 (85.7) 149 (69.0) 97 (44.9)

Yes 36 (14.3) 26 (72.2) 0.696 17 (47.2) 0.796

Schooling*, years

Wound Care
<8 127 (50.4) 87 (68.5) 0.744 51 (40.2) 0.102

≥8 125 (49.6) 88 (70.4) 63 (50.4)

Occupation*

Salaried 18 (7.1) 12 (66.7) 4 (22.2)

No work due to illness 32 (12.7) 29 (90.6) 0.087† 22 (68.8) 0.001

Retired 169 (67.1) 117 (69.2) 0.823 79 (46.7) 0.046

Out of the workforce 33 (13.1) 17 (51.5) 0.298 9 (27.3) 0.966†

Income (compared to minimum wage)*

≤1× 148 (58.7) 107 (72.3) 0.241 64 (43.2) 0.448

>1× 104 (41.3) 68 (65.4) 50 (48.1)

Religion

Catholic/Protestant/other 227 (90.1) 153 (67.4) 101 (44.5)

No religion 25 (9.9) 22 (88.0) 0.034 13 (52.0) 0.474

Access to public services

Piped water*

Yes 247 (98.0) 171 (69.2) 113 (45.7)

No 5 (2.0) 4 (80.0) >0.999† 1 (20.0) 0.501†

© 2022 MA Healthcare Ltd

Sanitary sewage*

Yes 236 (93.6) 165 (69.9) 107 (45.3)

No 16 (6.4) 10 (62.5) 0.712† 7 (43.7) 0.902

6 JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022


Table 1. Sociodemographic characteristics and those related to access to public services of individuals
living with type 2 diabetes followed up at the CEDEBA diabetic foot clinic, Salvador, Bahia, Brazil,
2019–2020 (n=253) (continued)
Variable n (%)
Access to public services (continued)
Garbage collection*
Yes 108 (42.9)
No 144 (57.1)
Means of transport (to access CEDEBA)
Private 108 (42.7)
Public 145 (57.3)
DFU—diabetic foot ulcer; *252 observations; †Fisher’s exact test
of asking’ (PR: 1.21, 95% CI: 1.03–1.42; PR: 1.26, 95% CI:
1.06–1.50, respectively). Moreover, thinking that a
doctor was wrong was associated with the outcome of
Journal of
amputation (PR: 1.36, 95% CI: 1.04–1.78). The variable
‘leaving with doubts about the health situation’ lost
strength of association with DFU after regression.
Table 5 shows the final hierarchical multivariate
logistic regression model. The variables considered
associated with the occurrence of DFU, adjusted for
diabetes duration and therapeutic adherence (and
Wound Care
although not statistically significant in our study,
having a strong association with the outcome according
to the literature), showed higher exposure among men
(PR: 1.22; 95% CI: 1.04–1.43) and lower exposure
among individuals aged 60 years or over (PR: 0.71;
95%  CI: 0.61–0.83), those who have access to public
transport to CEDEBA (PR: 0.82; 95% CI: 0.71–0.96) and
those who underwent screening tests (PR: 0.79; 95% CI:
0.67–0.92). The variables considered associated with
amputation outcome, adjusted for diabetes duration
and therapeutic adherence, showed higher exposure
among men (PR:  1.61; 95% CI: 1.23–2.11) and not
working (PR:  3.83; 95% CI: 1.48–9.95) and lower
exposure among individuals aged 60 years and over (PR:
0.56; 95% CI: 0.44–0.73) and who have access to public
transport for CEDEBA (PR: 0.65; 95% CI: 0.50–0.83).
Discussion
In the present study, a high prevalence of complications
related to DF was found among the interviewees. Parisi
et al.17 worked with 1055 participants selected in
Brazilian diabetes treatment centres and observed a
prevalence of 18.6% of active ulcer, 25.3% of history of
previous ulcer and 13.7% of amputation, which are
values much lower than those found in this study. This
© 2022 MA Healthcare Ltd
high prevalence may be related to the fact that the
participants were selected at a referral centre to which
cases with advanced neuropathic and circulatory
changes are referred, requiring a specialised evaluation.
Globally, it is estimated that the prevalence of DFU is
JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022
practice
Prevalence of p-value Prevalence of p-value
DFU, n (%) amputation, n (%)
72 (66.7) 46 (42.6)
103 (71.5) 0.407 68 (47.2) 0.465
82 (75.9) 58 (53.7)
93 (64.1) 0.045 56 (38.6) 0.017
around 6%, with the main risk factors being older age,
longer diabetes duration, hypertension, diabetic
retinopathy, smoking, chronic kidney disease and
peripheral arterial disease.2,18 Although Zhang et al.1
corroborate the information that older individuals are
more likely to develop a DFU, a negative association was
identified in the present study between being >60 years
old and developing complications related to DF. It
shows a trend of higher involvement of complications
that generate functional limitation in a young and
economically active population. In this sense, Coffey et
al.19 suggest that most individuals with a DFU do not
have information or have limited knowledge about the
mechanisms by which diabetes acts in the
pathophysiology of injuries. Even among those who
have an adequate level of knowledge, there are barriers
to the implementation of a self-care routine related to
the difficulties of a busy daily life, especially among the
youngest patients, which impacts on the adherence to
prevention and treatment practices. It is important to
highlight that foot self-care was particularly impactful
during the COVID-19 pandemic, when access to health
infrastructure may have been limited.20,21
Santos et al.22 observed the occurrence of a high
number of amputation surgeries in young people living
with diabetes, estimating that, in addition to potential
years of life lost, amputation in this population
determined years lived with disability. It suggests that
the limitations imposed by the ageing process will be
added to an irreversible physical disability, which
generates a high disease burden. Moreover, Hanashiro
et al.23 demonstrated that people with amputation are
impacted from a socioeconomic perspective after the
occurrence of the disability due to being unable to work
and falling income, requiring social security and
assistance protection, as return-to-work activities are
infrequent, despite rehabilitation.
According to Silva et al.,24 Brazil has a shortage of
specific measures aimed at preventing and controlling
diabetes and, more specifically, DF, suggesting that PHC
7
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Table 2. Clinical characteristics related to access to public services and diabetic foot (DF) prevention
activities at primary healthcare (PHC) and communication with individuals living with type 2 diabetes
followed up at the CEDEBA diabetic foot clinic, Salvador, Bahia, Brazil 2019–2020 (n=253)
Variable n (%) Prevalence of p-value Prevalence of p-value
DFU, n (%) amputation, n (%)

Clinic

Diabetes duration (in years)*

≤10 70 (27.7) 56 (80.0) 36 (51.4)

>10 183 (72.3) 119 (65.0) 0.021 78 (42.6) 0.208

Therapeutic adherence by the Morisky–Green test

Yes 86 (34.0) 56 (65.1) 41 (47.7)

No 167 (66.0) 119 (71.3) 0.316 73 (43.7) 0.549

Access to primary health care (PHC) in number of times a year

Rarely or not attending 150 (59.3) 102 (68.0) 0.627 65 (43.3) 0.505

≥1 103 (40.7) 73 (70.9) 49 (45.6)

Access to diabetic foot prevention activities at PHC in the last year

Journal of
Health education

Yes 75 (29.6) 57 (76.0) 36 (48.0)

No 178 (70.4) 118 (66.3) 0.127 78 (43.8) 0.542

Screening

Yes 51 (20.2) 44 (86.3) 30 (58.8)

Wound Care
No 202 (79.8) 131 (64.9) 0.003 84 (41.6) 0.027

Adequate health communication

Understands everything in the service

Yes 202 (79.8) 142 (70.3) 96 (47.5)

No 51 (20.2) 33 (64.7) 0.439 18 (35.3) 0.117

Understands the terms

Yes 160 (63.2) 108 (67.5) 70 (43.7)

No 93 (36.8) 67 (72.0) 0.451 44 (47.3) 0.583

Asks when in doubt

Yes 215(85.0) 145 (67.4) 94 (43.7)

No 38 (15.0) 30 (78.9) 0.157 20 (52.6) 0.309

Has already left with doubts about your disease

No 190 (75.1) 125 (65.8) 84 (44.2)

Yes 63 (24.9) 50 (79.4) 0.043 30 (47.6) 0.637

Has already left with doubts about medications

No 203 (80.2) 139 (68.5) 88 (43.3)

Yes 50 (19.8) 36 (72.0) 0.628 26 (52.0) 0.271

© 2022 MA Healthcare Ltd

Feels well cared for by health professionals

Yes 200 (79.1) 134 (67.0) 85 (42.5)

No 53 (20.9) 41 (77.4) 0.146 29 (54.7) 0.112

8 JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022

 practice

Table 2. Clinical characteristics related to access to public services and diabetic foot (DF) prevention
activities at primary healthcare (PHC) and communication with individuals living with type 2 diabetes
followed up at the CEDEBA diabetic foot clinic, Salvador, Bahia, Brazil 2019–2020 (n=253) (continued)
Variable n (%) Prevalence of p-value Prevalence of p-value
DFU, n (%) amputation, n (%)

Adequate health communication (continued)

Thinks that the doctor has made mistakes

No 179 (70.7) 118 (65.9) 73 (40.8)

Yes 74 (29.3) 57 (77.03) 0.082 41 (55.4) 0.033

Feels responsible for the treatment

Yes 235 (92.9) 162 (68.9) 104 (44.3)

No 18 (7.1) 13 (72.2) 0.771 10 (55.6) 0.353

Stopped seeking help for fear

No 221 (87.3) 148 (67.0) 97 (43.9)

Yes 32 (12.7) 27 (84.4) 0.046 17 (53.1) 0.326

Stopped seeking help for not knowing how to say what has felt

Journal of
No 225 (88.9) 154 (68.4) 98 (43.6)

Yes 28 (11.1) 21 (75.0) 0.479 16 (57.1) 0.173

The doctor explained about diabetes complicationsn

Yes 224 (88.9) 154 (68.8) 102 (45.5)

No 28 (11.1) 20 (71.4) 0.772 12 (42.9) 0.788

Wound Care
DFU—diabetic foot ulcer; *252 observations

should be the setting for these actions, with the
implementation of strategies based on the best scientific
evidence. Considering that screening, stratification and
regular clinical follow-up of people at risk have been
measures with a stronger level of evidence in the
prevention and control of complications related to DF,
it is indisputable that health surveillance actions
implemented at the most basic healthcare level have
the potential to control the epidemiological situation,
and may directly impact the human, social and financial
costs of the disease.
The large percentage of people who do not use PHC
as a gateway to the health system was notable in this
study, although no statistically significant associations
were found. From the user’s perspective, part of this
behaviour can be explained by the perception of
excessive bureaucratisation of actions in primary care,
which makes them seek, as a priority, solutions to their
health problems in the emergency units or at the
secondary level.25 However, it is possible that, under the
influence of the medical hegemonic model, users have
a culture of seeking specialised services and procedures.26
© 2022 MA Healthcare Ltd
lack of primary prevention practices. There is no doubt
that DFU and DF-related amputations are conditions
which can be treated in PHC, given that the main
protocols for disease management place the population
screening of individuals together with education
programmes for self-care and strict metabolic control as
priority recommendations.5,6
Regarding sex, being a man was strongly associated
with the development of ulcers and amputations. This
information is in line with most studies previously
published worldwide and can be explained by several
social and behavioural factors.27 It is assumed that male
individuals have a higher level of activity, and are often
home providers, which imposes a higher burden on the
feet. This fact, associated with a lower trend for
therapeutic adherence, contributes to the increased
chance of developing foot injuries.17 A study conducted
with 1515 people living with diabetes in the south of
Brazil showed that the prevalence of self-care deficit
with the feet was significantly higher among men, as
well as a less healthy behaviour in relation to diet.28 It
can be partially explained by the idea that men are

Additionally, there was a low level of access of the
interviewed individuals to health education and
screening actions aimed at DF prevention, and those
who had access to these activities already had
complications such as DFU or amputation, showing the
socialised to be strong and independent, making the act
of seeking care something that threatens their virility.29
The fact is that, regardless of the origin of these
behaviours, it is necessary to reposition prevention
strategies and health promotion, as well as forms of

JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022 9

 practice

Table 3. Association between diabetic foot ulcer (DFU) and amputation, and sociodemographic and clinical
characteristics, as well as those related to access to public services and diabetic foot (DF) prevention activities at
primary healthcare (PHC) and communication of individuals living with type 2 diabetes followed up at the CEDEBA
diabetic foot clinic, Salvador, Bahia, Brazil 2019–2020 (n=253)
DFU Amputation
Variable Crude PR Adjusted PR* p-value Crude PR Adjusted PR* p-value
(95% CI) (95% CI) (95% CI) (95% CI)
Level 1: Sociodemographic characteristcs
Age
<60 1.00 1.00 1.00 1.00
≥60 0.69 (0.60–0.81) 0.72 (0.62–0.84) <0.001 0.63 (0.49–0.83) 0.63 (0.48–0.81) 0.001
Sex
Female 1.00 1.00 1.00 1.00
Male 1.29 (1.09–1.52) 1.22 (1.04–1.43) 0.013 1.64 (1.24–2.17) 1.60 (1.22–2.09) <0.001
Skin colour/ethnicity
White 1.00 1.00
Non-white 1.11 (0.78–1.58) – 0.95 (0.58–1.56) –
Marital status
With partner 1.00 1.00
Without partner 1.02 (0.87–1.20) – 0.91 (0.69–1.19) –

Journal of
Lives alone
No 1.00 1.00
Yes 1.05 (0.84–1.31) – 1.05 (0.72–1.53) –
Schooling
<8 years 0.97 (0.83–1.15) – 0.80 (0.61–1.05) 0.86 (0.66–1.13) 0.279
≥8 years 1.00 1.00 1.00

Wound Care
Occupation
Working 1.00 1.00 1.00
Not working 1.05 (0.75–1.46) – 2.12 (0.88–5.07) 3.32 (1.30–8.44) <0.001
Income (minimum wages)
≤1 1.11 (0.93–1.31) – 0.90 (0.69–1.18) –
>1 1.00 1.00
Religion
Catholic/Protestant/other 1.00 1.00
No religion 1.31 (1.10–1.55) 1.20 (0.95–1.51) 0.152 1.17 (0.78–1.75) –
Level 2: Environmental characteristics: Access to public services
Piped water
Yes 1.00 1.00
No 1.16 (0.74–1.81) – 0.44 (0.08–2.54) –
Sanitary/sewage
Yes 1.00 1.00
No 0.89 (0.61–1.32) – 0.96 (0.54–1.71) –
Rubbish collection
Yes 1.00 1.00
No 1.07 (0.91–1.27) – 1.11 (0.84–1.46) –
Transport (to access CEDEBA)
Private (car or taxi) 1.00 1.00 1.00 1.00
© 2022 MA Healthcare Ltd

Public (bus and/or Metro) 0.84 (0.72–0.99) 0.84 (0.72–0.99) 0.045 0.72 (0.55–0.94) 0.72 (0.55–0.94) 0.017

Level 3: Clinical characteristics: diabetes duration (in years)

≤10 1.00 1.00 1.00 1.00

≤10 0.81 (0.69–0.95) 0.84 (0.71–0.98) 0.032 0.83 (0.62–1.10) 0.85 (0.64–1.13) 0.279

10 JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022

 practice

Table 3. Association between diabetic foot ulcer (DFU) and amputation, and sociodemographic and clinical
characteristics, as well as those related to access to public services and diabetic foot (DF) prevention activities at
primary healthcare (PHC) and communication of individuals living with type 2 diabetes followed up at the CEDEBA
diabetic foot clinic, Salvador, Bahia, Brazil 2019–2020 (n=253) (continued)
DFU Amputation
Variable Crude PR Adjusted PR* p-value Crude PR Adjusted PR* p-value
(95% CI) (95% CI) (95% CI) (95% CI)
Therapeutic adherence by the Morisky–Green test
Yes 1.00
No 1.09 (0.91–1.31) 1.08 (0.90–1.28) 0.403 0.92 (0.69–1.21) 0.91 (0.69–1.19) 0.485
Access to primary health care (PHC) in number of times a year
Rarely or not attending 0.96 (0.81–1.13) – 0.91 (0.69–1.20) –
≥1 1.00 1.0
Health education to prevent DF
Yes 1.00
No 0.87 (0.74–1.03) 1.09 (0.85–1.40) 0.481 0.91 (0.68–1.22) –
Screening of DF
Yes 1.00
No 0.75 (0.65–0.87) 0.73 (0.62–0.87) 0.001 0.71 (0.53–0.94) 0.72 (0.54–0.96) 0.035
Level 4: Communication
Understands everything in the service

Journal of
Yes 1.00
No 0.92 (0.74–1.15) – 0.74 (0.50–1.11) 0.70 (0.46–1.05) 0.049
Understands the terms
Yes 1.00
No 1.07 (0.90–1.26) – 1.08 (0.82–1.43) –
Asks when in doubt

Wound Care
Yes 1.00
No 1.17 (0.97–1.41) 1.19 (0.99–1.42) 0.080 1.20 (0.86–1.69) –
Has already left with doubts about the health situation
No 1.00
Yes 1.21 (1.03–1.42) 1.13 (0.94–1.35) 0.218 1.08 (0.79–1.46) –
Has already left with doubts about medications
No 1.00
Yes 1.05 (0.86-1.28) – 1.20 (0.88–1.63) –
Feels well cared for by health professionals
Yes 1.00
No 1.15 (0.97–1.38) 1.07 (0.87–1.32) 0.509 1.29 (0.96–1.73) –
Thinks that the doctor has made mistakes
No 1.00
Yes 1.17 (0.99–1.38) 1.12 (0.94–1.33) 0.222 1.36 (1.04–1.78) 1.41 (1.08–1.84) 0.017
Feels responsible for the treatment
Yes 1.00
No 1.05 (0.78–1.41) – 1.25 (0.81–1.94) –
Stopped seeking help for fear
No 1.00
Yes 1.26 (1.06–1.50) 1.22 (1.01–1.48) 0.057 1.21 (0.85–1.73) –
Stopped seeking help for not knowing how to say what has felt
No 1.00
Yes 1.10 (0.87–1.38) – 1.31 (0.92–1.87) –
© 2022 MA Healthcare Ltd

The doctor explained about diabetes complications

Yes 1.00
No 1.04 (0.81–1.33) – 0.94 (0.60–1.48) –
*Logistic regression with correction for PR was used separately and processed hierarchically with each outcome; CI—confidence interval; PR—prevalence ratio

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 practice

Table 4. Multivariate regression model of factors associated with the development of diabetic foot ulcer (DFU)
among individuals living with type 2 diabetes followed up at the CEDEBA diabetic foot clinic, Salvador, Bahia, Brazil
2019–2020 (n=253)
Variable Model A Model B Model C Model D Final model**
(Block 1) (Blocks 1 and 2) (Blocks 1, 2 and 3) (Blocks 1, 2, p-value <0.05
PR (95% CI) PR (95% CI) PR (95% CI) 3 and 4)
PR (95% CI)

Level 1: Sociodemographic characteristcs

Age*

<60 1.00 1.00 1.00 1.00 1.00

≥60 0.72 (0.62–0.84) 0.71 (0.61–0.82) 0.73 (0.63–0.85) 0.73 (0.63–0.85) 0.71 (0.61–0.83)

Sex*

Female 1.00 1.00 1.00 1.00 1.00

Male 1.22 (1.04–1.43) 1.23 (1.05–1.43) 1.19 (1.02–1.39) 1.21 (1.03–1.41) 1.22 (1.04–1.43)

Religion*

Catholic/Protestant/others 1.00 1.00 1.00 1.00

No religion 1.20 (0.95–1.51) 1.20 (0.95–1.50) 1.22 (0.98–1.51) 1.23 (0.99–1.51) –

Journal of
Level 2: Environmental characteristics

Transport (to access CEDEBA)*

Private 1.00 1.00 1.00 1.00

Public 0.81 (0.70–0.95) 0.83 (0.71–0.96) 0.84 (0.72–0.98) 0.82 (0.71–0.96)

Level 3: Clinical characteristics

Wound Care
Diabetes duration (years)

≤10

>10 1.00 1.00

Therapeutic adherence by the Morisky–Green test

Yes 0.93 (0.78–1.10) 0.96 (0.80–1.16) Adjustment

No 1.00 1.00

Screening* 1.09 (0.92–1.29) 1.07 (0.91–1.26) Adjustment

Yes 1.00 1.00 1.00

No 0.79 (0.68–0.92) 0.79 (0.68–0.92) 0.79 (0.67–0.92)

Level 4: Communication

Asks when in doubt*

Yes 1.00

No 1.16 (0.98–1.39) –

Stopped seeking help for fear

No 1.00

Yes 1.16 (0.94–1.43) –

Model adjustment analyses

AIC 289.4264 284.4282 281.5009 281.7031 282.8243

© 2022 MA Healthcare Ltd

ROC curve 0.69 0.73 0.76 0.76 0.75

VIF 2.68
*252 observations; **Permanence of variables statistically associated with outcomes at a significance level of 5% (p-value ≤0.05), evaluated from the AIC, ROC curve and VIF;
AIC—Akaike Information Criterion; CI—confidence interval; PR—prevalence ratio; ROC—receiver operating characteristic; VIF—variance inflation factor

12 JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022

 practice

Table 5. Multivariate regression model of factors associated with the development of amputation among individuals
living with type 2 diabetes followed up at the CEDEBA diabetic foot clinic, Salvador, Bahia, Brazil 2019–2020 (n=253)
Variable Model E (Block 1) Model F Model G Model H Final Model 1
PR (95% CI) (Blocks 1 and 2) (Blocks 1, 2 and 3) (Blocks 1, 2, 3 & 4) PR (95% CI)
PR (95% CI) PR (95% CI) PR (95% CI)

Level 1: Sociodemographic characteristcs

Age*

<60 1.00 1.00 1.00 1.00 1.00

≥60 0.61 (0.47–0.78) 0.57 (0.45–0.73) 0.57 (0.44–0.73) 0.59 (0.46–0.77) 0.57 (0.45–0.74)

Sex*

Female 1.00 1.00 1.00 1.00 1.00

Male 1.60 (1.22–2.10) 1.62 (1.24–2.11) 1.58 (1.20–2.07) 1.59 (1.21–2.08) 1.61 (1.23–2.11)

Occupation*

Working 1.00 1.00 1.00 1.00 1.00

Not working 3.19 (1.27–8.04) 3.83 (1.48–9.90) 3.62 (1.41–9.30) 4.02 (1.56–10.36) 4.11 (1.57–10.75)

Level 2: Environmental characteristics

Journal of
Transport (to acess CEDEBA)*

Private 1.00 1.00 1.00 1.00

Public 0.65 (0.50–0.83) 0.66 (0.51–0.85) 0.63 (0.49–0.82) 0.63 (0.49–0.81)

Level 3: Clinical characteristics

Diabetes duration (years)

Wound Care
≤10 1.00 1.00 1.00

>10 1.04 (0.78–1.40) 1.03 (0.77–1.37) 1.03 (0.77–1.37)

Therapeutic adherence by the Morisky–Green test

Yes 1.00 1.00 1.00

No 0.93 (0.72–1.22) 0.97 (0.74–1.28) 0.99 (0.75–1.30)

Screening

Yes 1.00

No 0.81 (0.61–1.08) – –

Level 4: Communication

Understands everything in the service*

Yes 1.00 1.00

No 0.70 (0.47–1.03) 0.72 (0.49–1.06)

Thinks that the doctor has made mistakes

No 1.00

Yes 1.19 (0.91–1.56)

Model adjustment analyses

AIC 323.1903 313.8631 317.7495 316.7376 316.28

© 2022 MA Healthcare Ltd

ROC curve 0.70 0.72 0.73 0.74 0.73

VIF

AIC—Akaike Information Criterion; CI—confidence interval; PR—prevalence ratio; ROC—receiver operating characteristic; VIF—variance inflation factor

JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022 13

 practice
intervention by health professionals, to consider
cultural specificities and attitudes conditioned by sex.
Although the use of public transport has shown a
negative association with the development of the
outcomes under study, the degree of functional
limitation determined by DF complications likely
influences the choice of the type of transport used by
people, considering the low accessibility of public
transport. Therefore, the use of private transport to
access CEDEBA is probably a consequence of the
existence of injuries that reduce the functional capacity
of individuals.
Limitations
The use of different approaches to obtain data, in
person and by telephone, can be considered a limitation
of the study. However, the objective data of the foot
evaluation were collected from medical records prepared
by the main researcher, who used the same methodology
already used in the clinical evaluations of individuals.
Moreover, the study involved a limited and
homogeneous number of participants, which limited
Journal of
the drawing of conclusions with strong evidence
capable of confirming the existence of an association
between certain demographic, socioeconomic and
programmatic characteristics, and the development of
complications related to DF. However, the results
presented so far are promising, as they have the
potential to contribute to the identification of
Wound Care
conditions of vulnerability of the population under
study. The analysis of the factors associated with DF
from the point of view of vulnerability has the potential
to offer subsidies for the construction of health practices
that incorporate, in addition to biomedical and
epidemiological knowledge, formulations developed in
References
1 Zhang P, Lu J, Jing Y et al. Global epidemiology of diabetic foot
ulceration: a systematic review and meta-analysis. Ann Med 2017;
49(2):106–116. https://doi.org/10.1080/07853890.2016.1231932
2 Rastogi A, Goyal G, Kesavan R et al. Long term outcomes after incident
diabetic foot ulcer: multicenter large cohort prospective study (EDI-FOCUS
investigators) epidemiology of diabetic foot complications study. Diabetes
Res Clin Pract 2020; 162:108113. https://doi.org/10.1016/j.
diabres.2020.108113
3 International Diabetes Federation. IDF Diabetes Atlas, 9th edition. 2019.
https://diabetesatlas.org/atlas/ninth-edition (accessed 4 October 2022)
4 Schaper NC, Apelqvist J, Bakker K. The international consensus and
practical guidelines on the management and prevention of the diabetic
foot. Curr Diab Rep 2003; 3(6):475–479. https://doi.org/10.1007/
s11892-003-0010-4
5 Armstrong DG, Lavery LA, Harkless LB. Treatment-based classification
system for assessment and care of diabetic feet. J Am Podiatr Med Assoc
1996; 86(7):311–316. https://doi.org/10.7547/87507315-86-7-311
6 Lavery LA, Armstrong DG, Vela SA et al. Practical criteria for screening
patients at high risk for diabetic foot ulceration. Arch Intern Med 1998;
158(2):157–162. https://doi.org/10.1001/archinte.158.2.157
7 Bowling FL, Rashid ST, Boulton AJM. Preventing and treating foot
complications associated with diabetes mellitus. Nat Rev Endocrinol 2015;
11(10):606–616. https://doi.org/10.1038/nrendo.2015.130
8 van Netten JJ, Price PE, Lavery LA et al. Prevention of foot ulcers in the
at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev
2016; 32(Suppl 1):84–98. https://doi.org/10.1002/dmrr.2701
14
the social spheres to broaden understanding about the
health needs of the target population.
Conclusions
The results of this investigation suggest that the
prevalence of DFUs and lower limb amputations in the
studied population is high, and that these complications
are associated with: sociodemographic characteristics
such as age, sex and occupation; environmental
characteristics such as the use of public transport to
access the CEDEBA; and characteristics related to access
to DF screening programmes. However, the impact of
these factors on the causality network of DF can be
minimised through the development of health
promotion, prevention and assistance activities that
consider, in addition to the clinical characteristics of
individuals, conditions that produce vulnerability.
The analysis of the factors associated with DFU from
this perspective has the potential to contribute to the
construction of strategies that incorporate, in addition
to biomedical and epidemiological knowledge,
formulations developed in the social and human
spheres to broaden the understanding about the health
needs of the target population. In this sense, new
studies with greater analytical power should be
encouraged to investigate the role that
sociodemographic, economic, environmental and
programmatic characteristics have on the development
of DF injuries to increase understanding of interference,
entanglement and significance of these factors on the
course of the disease.  JWC
Acknowledgements
The authors would like to thank the CEDEBA patients for their contribution
to this research.
9 Armstrong DG, Wrobel J, Robbins JM. Guest editorial: are diabetes-
related wounds and amputations worse than cancer? Int Wound J 2007;
4(4):286–287. https://doi.org/10.1111/j.1742-481X.2007.00392.x
10 Hingorani A, LaMuraglia GM, Henke P et al. The management of
diabetic foot: a clinical practice guideline by the Society for Vascular
Surgery in collaboration with the American Podiatric Medical Association
and the Society for Vascular Medicine. J Vasc Surg 2016; 63(2 Suppl):3S–
21S. https://doi.org/10.1016/j.jvs.2015.10.003
11 Duncan BB, Chor D, Aquino EML et al. [Chronic non-communicable
diseases in Brazil: priorities for disease management and research] [In
Portuguese]. Rev Saúde Pública 2012; 46(suppl 1):126–134. https://doi.
org/10.1590/S0034-89102012000700017
12 do Carmo ME, Guizardi FL. [The concept of vulnerability and its
meanings for public policies in health and social welfare] [In Portuguese].
Cad Saúde Pública 2018; 34(3). https://doi.
org/10.1590/0102-311X00101417
13 Agardh E, Allebeck P, Hallqvist J et al. Type 2 diabetes incidence and
socio-economic position: a systematic review and meta-analysis. Int J
Epidemiol 2011; 40(3):804–818. https://doi.org/10.1093/ije/dyr029
© 2022 MA Healthcare Ltd
14 Rastogi A, Bhansali A. Diabetic foot infection: an indian scenario.
J Foot Ankle Surg (Asia-Pacific) 2016; 3(2):71–79. https://doi.org/10.5005/
jp-journals-10040-1052
15 Instituto Brasileiro de Geografia e Estatística. [Sociodemographic and
Health Indicators in Brazil] [In Portuguese]. 2009. https://tinyurl.com/
mryz374d (accessed 4 October 2022)
16 Riaz M, Miyan Z, Zaidi SI et al. Characteristics of a large cohort of
JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022

patients with diabetes having at-risk feet and outcomes in patients with
foot ulceration referred to a tertiary care diabetes unit. Int Wound J 2016;
13(5):594–599. https://doi.org/10.1111/iwj.12289
17 Parisi MCR, Moura Neto A, Menezes FH et al. Baseline characteristics
and risk factors for ulcer, amputation and severe neuropathy in diabetic
foot at risk: the BRAZUPA study. Diabetol Metab Syndr 2016; 8(1):25.
https://doi.org/10.1186/s13098-016-0126-8
18 Chaudhary S, Bhansali A, Rastogi A. Mortality in Asian Indians with
Charcot’s neuroarthropathy: a nested cohort prospective study.
Acta Diabetol 2019; 56(12):1259–1264. https://doi.org/10.1007/
s00592-019-01376-9
19 Coffey L, Mahon C, Gallagher P. Perceptions and experiences of
diabetic foot ulceration and foot care in people with diabetes: a qualitative
meta-synthesis. Int Wound J 2019; 16(1):183–210. https://doi.org/10.1111/
iwj.13010
20 Gupta SK, Lakshmi PV, Kaur M, Rastogi A. Role of self-care in
COVID-19 pandemic for people living with comorbidities of diabetes and
hypertension. J Family Med Prim Care 2020; 9(11):5495–5501. https://doi.
org/10.4103/jfmpc.jfmpc_1684_20
21 Jude E, Rastogi A. COVID-19 pandemic and life style modification for
people with diabetes. Open Diabetes J 2021. https://tinyurl.com/42ftzkb8
(accessed 17 October 2022)
22 dos Santos KP, da Luz SC, Mochizuki L, d’Orsi E. [Burden of disease
from lower limb amputations attributable to diabetes mellitus in Santa
Catarina State, Brazil, 2008–2013] [In Portuguese]. Cad Saúde Pública
2018; 34(1). https://tinyurl.com/yc8dntpf (accessed 4 October 2022)
23 Hanashiro R, Correia VD, Sugawara AT. [Social inclusion in the labour
market of amputees in the process of rehabilitation] [In Portuguese].
Acta Fisiátrica 2018; 25(3). https://tinyurl.com/fshtw2ub (accessed 4
October 2022)
Journal of
24 Silva FM, Viana MCA, Barreto JOM et al. [Evidence brief for health
policy-making: prevention and control of diabetic foot in primary health
care] [In Portuguese]. BIS 2019; 20(2). https://doi.org/10.52753/bis.2019.
Wound Care
© 2022 MA Healthcare Ltd
JOURNAL OF WOUND CARE  VOL 31, NO 11, NOVEMBER 2022
practice
Reflective questions
● What paths should knowledge production take to contribute
to a reduction in the number of amputations related to
diabetic foot (DF)?
● How can health professionals act at the level of micropolicy
to minimise the vulnerability of these patients?
● How should healthcare systems be organised to mitigate
age- and gender-related risk in the case of DF?
v20.34481
25 Campos RT, Ferrer AL, da Gama CA et al. [Assesment of quality of
access in primary care in a large Brazilian city in the perspective of user]
[In Portuguese]. Saúde Em Debate 2014; 38(special). https://doi.
org/10.5935/0103-1104.2014S019
26 Spedo SM, da Silva Pinto, Tanaka OY. [The difficult access to
secondary health care services: São Paulo city case study, Brazil] [In
Portuguese]. Physis 2010; 20(3). https://doi.org/10.1590/
S0103-73312010000300014
27 Harding JL, Pavkov ME, Magliano DJ et al. Global trends in diabetes
complications: a review of current evidence. Diabetologia 2019;
62(1):3–16. https://doi.org/10.1007/s00125-018-4711-2
28 Rossaneis MA, Haddad M do CFL, Mathias TA de F, Marcon SS.
Differences in foot self-care and lifestyle between men and women with
diabetes mellitus. Rev Lat Am Enfermagem 2016; 24:e2761. https://doi.
org/10.1590/1518-8345.1203.2761
29 Botton A, Cúnico SD, Strey MN. [Gender differences in the access to
health services: necesssary problematization] [In Portuguese]. Mudanças
2017; 25(1):67–72
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