Abstract
Background
Individuals living with diabetes mellitus (DM) are at an increased risk for multiple serious health complications including diabetic foot disease (DFD). Daily, DFD contributes to increased morbidity, mortality, increased hospitalization, limb amputation, and reduced quality of life. Prevention of DFD is a foundational component of diabetes management.
Purpose
The purpose of this study was to explore how individuals manage the care required to protect their feet from DM related foot complications.
Methods
This qualitative descriptive study utilized semi structured interviews to explore the perspectives of 23 participants on preventing foot care complications associated with DM. All data were analyzed using reflexive thematic analysis.
Results
Participants were challenged to consistently make health choices that were congruent with recommended DM self-management for the prevention of DFD. In addition, participants intuited multiple mixed messages from healthcare providers and workplaces that appeared to diminish their individual responsibility to self-manage their DM. Findings were organized under two main themes: a) Ineffective coping: Distancing self from disease b) Vacillating responsibility: Multiple mixed messages.
Conclusions
Nurses are in a unique position to provide the education and support needed to assist individuals in carrying out the many recommended self-care strategies to reduce the risk of DFD. Contextually, nurses must encourage consistent messaging among health care providers and workplaces to prioritize the health needs of individuals living with diabetes and to support the challenging work these individuals must navigate every day. It will take a concerted effort to reinforce the message that diabetes care is a priority for everyone.
Background and purpose
Worldwide, diabetes mellitus (DM) is one of the leading public health emergencies of the twenty-first century (International Diabetes Federation [IDF], 2019). In the literature exploring the global burden of diabetes, the IDF estimates that worldwide the number of adults living with diabetes will climb from some 451 million or 8.4% in 2017 to 693 million or 9.9% by 2045. In addition to this startling prediction, the IDF estimates that nearly half of all individuals living with diabetes are unaware of their condition (Cho et al., 2018). In Canada, 10% of the population live with diagnosed Type 1 or Type 2 DM, and potentially another 4% with undiagnosed DM (Diabetes Canada, 2022). The prevalence of diagnosed DM in Canada is predicted to increase to over five million Canadians or 12.1% of the population over the next 10 years (Diabetes Canada, 2022).
Individuals living with DM are at an increased risk for multiple serious health complications and premature death (Houlden, 2018). One prevalent and severe complication contributing to increased morbidity, mortality, increased hospitalization, and reduced quality of life is diabetic foot disease (DFD) (Bus et al., 2020; Cho et al., 2018; Houlden, 2018; Jupiter et al., 2016; Schaper et al., 2020). The International Working Group on the Diabetic Foot (IWGDF, 2019) defines diabetic foot disease (DFD) as an “infection, ulceration or destruction of tissues of the foot associated with neuropathy and/or peripheral artery disease in the lower extremity of a person with (a history of) diabetes mellitus” (van Netten et al., 2019, p. 2). Individuals living with DM are 20 times more likely than the general population to be hospitalized for a non- traumatic lower limb amputation (Diabetes Canada, 2022). According to the IDF (2019) a diabetic foot ulcer claims the limb of an individual living with diabetes every 30 s. Overwhelmingly, diabetic foot disease imposes a great burden on individuals, families, health care services, and society (Schaper et al., 2020).
Prevention of DFD is a foundational component of diabetes management. In a position statement, Diabetes Canada (2021) estimates that up to 85% of amputations are preventable with diabetes management, education, preventative foot care, and regular screening. Significantly, the onus of managing the care requirements of DM and decreasing the risk of serious complications such as DFD fall heavily on the individual living with DM. Diabetes is a complex, multifaceted disease touching all elements of an individual's life. To improve blood glucose levels, to achieve and maintain a healthy weight, to manage mental health, and to delay or prevent the complications of diabetes; individuals are tasked with adopting diabetes-specific nutrition and physical activity recommendations, to stop smoking, and to comply with medication regime (American Diabetes Association, 2021). In addition to these general lifestyle recommendations, to prevent diabetic related foot complications, individuals must assume an active and empowered role in their foot care and footwear decisions. Individuals are instructed to maintain excellent foot hygiene and care, to perform a daily foot care examination, to have their footwear professionally fitted, and to consult professionals for questions, concerns, and annual foot screening (Botros et al., 2017, 2020).
Individuals who are consistent in adhering to good self-care recommendations can improve their quality of life, experience better health, and reduce their risk of serious complications associated with DM such as DFD. Multiple studies suggest that individuals living with diabetes struggle daily to adhere to DM self care recommendations (Beattie et al., 2014; Bus et al., 2020; Ogunlana et al., 2021; Pourkazemi et al., 2020; Rouyard et al., 2017). Additional research is needed to learn more about how individuals navigate the many recommended self care strategies associated with the management of DM to reduce the risk of DFD. The purpose of this study was to explore how individuals living with DM in the community setting manage the care required to protect their feet from DM related foot complications.
Methods and procedures
Design and sample
This qualitative descriptive study (Sandelowski, 2000, 2010) explored individual's perspectives on preventing foot care complications associated with DM.
Individuals living with Type 1 and Type 2 DM were invited to describe their activities related to DM self-management in relation to foot care and footwear choices while living and working with diabetes mellitus. We utilized this approach as it gives individuals an opportunity to share their journey. Our sample consisted of 23 individuals living with DM in one Eastern Canadian province. Participants resided in smaller communities of 475 to 6000 population. Participants were in close driving proximity (15–45 min) to larger health care centres and services. To include a wide representation of individuals, we invited male and female adults of different ages. We sought to collect rich, thick data that reflected the perspectives of persons living with this complex disease (Braun & Clarke, 2013; Creswell, 2014; Salmons, 2015).
Data collection
Cape Breton University Research Ethics Board approval was obtained. Data collection included semi-structured, in-person interviews. To recruit participants, posters were distributed in the community (library, pharmacies, senior centres). Individuals wishing to participate in the study contacted the Research Assistant to sign the consent form and to set up an appointment. Interviews were conducted in the community at times and locations most convenient for the participant. Interviews lasted between 40 to 60 min on average. Interviews were recorded and all data were transcribed for analysis. Data collection continued until new data did not yield new information.
Data analysis
All data (N = 23) were analyzed using reflexive thematic analysis [TA] (Braun & Clarke, 2013, 2019, 2020). We used QSR International's 2011 NVivo 11 qualitative software to sort and code data. Braun and Clarke (2013) describe TA as a method for systematically identifying and organizing patterns of meaning or themes across a data set. Articulating one's philosophical assumptions underpinning one's iteration of TA is an important element of reflexive TA (Braun & Clarke, 2019, 2020, 2022). In this study we employed a constructivist reflexive approach that assumes the relativism of multiple social realities influenced by context and recognizes the co-creation of knowledge through reflexivity between the researcher and the participants (Guba & Lincoln, 2005).
The researchers had no preconceptions about the themes generated from the data, so as not to bias the interpretation of the results. Consistent with thematic analysis each transcribed recording was analyzed as it was completed. Following the TA procedures outlined by Braun and Clarke (2013, 2019, 2020), we familiarized ourselves with the data. We met regularly to discuss the findings and generated initial codes by highlighting and applying codes to analytically significant fragments of data. As well, we examined the most significant or frequently occurring initial codes to find, review, and define common themes relating to how adults living with diabetes make choices about caring for their feet. In conclusion, we produced an analytic narrative.
Results
Participants in this study included 23 participants (13 females, 10 males) living with DM from 13 months to 49 years. Participants ranged between 24–85 years (average: 56.5). Two males and four females lived with Type 1 DM, and eight males and four females lived with Type 2 DM. Consistent with the homogeneous cultural makeup of individuals in this area of Eastern Canada, 22 participants identified as white and one as Indigenous.
Results for TA suggest that participants were challenged to consistently make health choices that were congruent with recommended DM self-management for the prevention of DFD. In addition, participants described multiple mixed messages from, workplaces, and healthcare providers that appeared to diminish their individual responsibility to self-manage their DM. Many of the self-care choices, practices, and coping strategies described by participants portrayed an attempt to balance the desire to carry on with normal activities while implementing the self-care requirements of living with DM. This balancing act increased their risk for developing diabetic foot care complications. Findings were organized under two main themes: 1) Ineffective coping: Distancing self from disease and 2) Vacillating responsibility: Multiple mixed messages.
Ineffective coping: distancing self from the disease
Participants were aware that foot complications including wounds, ulcers, and amputations were potential complications of diabetes. Through their language and their choices, they appeared to be attempting to distance themselves from the disease and its potential complications as a way of coping and trying to stay positive. Unfortunately, some of these coping mechanisms increased the potential for diabetic foot complications. Participants distancing practices were subsumed under three subthemes: (a) Disconnecting: Don’t go looking for a problem, (b) Predestined: It runs in my family, and (c) Personification: My sugars creep up.
Disconnecting: don’t go looking for a problem
Participants in this study stressed that caring for their feet was often not a priority. Although they were aware of potential foot complications, if they felt well, they did not engage in preventative foot assessments. One 63-year-old man, when asked about checking his blood sugar commented, “I work, and I work, and I feel fine, and I don’t even look at it.” Regarding checking feet daily another man in his sixties stated, “as long as you are feeling ok you don’t really worry about it, you don’t go looking for a problem, right?” Similarly, a female in her sixties noted “at the end of the day, you don’t feel sick, so you’re not going to do anything… it's like when you have the flu, you feel sick, you do something”. Referring to routinely checking her blood sugars or her feet this participant acknowledged that she doesn’t do this stating, “Basically that's what it boils down to, and you are not going to do anything until it slaps you in the face”. Another creatively expressive participant, a male in his forties, suggested that it was difficult to stay motivated to control his diabetes and that every now and then it would be good to get “a kick in the pants to keep you going, to make sure that, hey, you can stop taking sugar in your coffee”.
Predestined: it runs in my family
Many participants expressed a sense that they could not escape developing diabetes as “it ran in the family”. This thinking did not spur participants to take steps to ward off this possibility. It appeared to have the opposite effect of giving individuals permission to not take responsibility because it would happen, nevertheless. One participant in his sixties described himself as “coming from a diabetic background” he related that his grandmother, aunts, and uncles were all diabetics. He was pleased that because of this, when he was diagnosed, he “knew everything” about the disease. Another female in her fifties acknowledged that diabetes was quite prevalent on her father's side of the family, she stated inevitably, “so it's been passed down.” Because of this each time she visited her doctor she would always ask to be tested for diabetes. She noted: When I would go to the doctor, I would say to him, test me because diabetes is in my family. I don’t have heart disease, I don’t have cancer, but the diabetes thing just runs rampant. And no matter what we seem to do, we just can’t seem to avoid it. It just kind of happens.
Similarly, another participant stated that most of his family were diabetics. He spoke of the disease process in a casual manner commenting that some of his family members including his brother and sister were “on a diabetic diet, my sister takes three or four needles, my brother is just on the pills, Metformin, and the rest of them don’t care. “He added, “it runs in my family.” Another participant, a female in her fifties whose grandmother had a toe amputated for a diabetes related wound was not confident that her actions could protect her from the same fate. Worrying about her ability to cut her toenails properly, she noted that she often gets ingrown toenails. She stated, “I always get ingrown toenails and I am just always worried about that, especially my big toe because that is what happened to my grandmother… then my grandmother had her toe amputated.”
Personification: my sugars creep up
The language that many participants used to discuss their experience with diabetes and caring for their feet was interjected with figures of speech that personified or gave human like qualities to the diabetic disease process. These expressions appeared to depict an understanding of a disease process that was not in their control, a process that had a life of its own. One female in her sixties in discussing the relationship between diabetes and foot care expressed, “Yes, as your sugars creep up then you are at risk for numb feet.” The expression distances the participant from the responsibility of controlling her blood sugars because sugars have a life of their own with an ability to creep up. Another female in her fifties expressed a similar sentiment. She acknowledged that a skin injury to a foot would heal better if one kept their “sugar levels” in “good balance” then added “but as soon as your sugar starts flying up your feet won’t heal.” Participants tended to use distancing language when referring to their blood sugars. For instance, one participant described being fearful about developing nerve damage to her feet because “sometimes my blood sugars are not well controlled.” The participant does not indicate that her actions control blood sugar but that someone or thing else is responsible.
Vacillating responsibility: multiple mixed messages
Participants in this study appeared challenged in assuming the recommended self-care strategies required to manage their DM and to protect their feet from DM complications. Participant's reluctance to assume responsibility for their care appeared to be related to the inconsistent messaging that they intuit on multiple levels. Many participants were not convinced that intensive adherence to DM self-care recommendations for the prevention of foot complications was important because in their experience the disease was not given this type of priority by their health care providers or their workplace. The disease appeared to take on an invisible quality – out of sight, out of mind. Participant's comments relating to vacillating responsibility were subsumed under three subthemes: a) Reactive care: If you have any problems with your feet, let me know b) Invisible disease: lack of support and c) Assuming responsibility: Uncertainty of proper diabetic foot care practices.
Reactive care: if you have any problems with your feet, let me know
In their routine interactions with their physicians some participants indicated that their diabetic management and the prevention of potential foot related complications was given low priority. Some participants claimed to have physicians who did not conduct regular foot checks and who did not discuss the importance of diabetes related foot care. In referring to her doctor, one participant in her twenties stated that she seldom talked to her doctor about diabetes. She claimed, “I don’t talk to my family doctor about my diabetes because I just don’t find that she uhm…ever acts like she has time for me.” This participant trusted the advice of the diabetic nurse educator even though she did not see her frequently. Another participant in her sixties explained that her doctor had done a filament test on her feet one time that she could remember. When questioned further about this, she stated, “my doctor did that to me when I was first diagnosed… gosh, that's probably 10–15 years ago.” Some physicians did not appear to prioritize routine assessment of their patients with diabetes for potential complications. In referring to her doctor, a woman in her sixties with a long history of DM stated, “I see him twice a month, and like I said, he always says if you have any problems with your feet let me know.” Similarly, another participant stated that her doctor did not assess her feet but encouraged her “if you see any change in your feet or anything that doesn't look right you come back over and see us.”
Assuming responsibility: uncertainty of proper diabetic foot care practices
The lack of discourse and attention to DM and diabetic foot management by health care providers appeared to put participants at greater risk because they did not appear to understand the correct methods to care for their feet to decrease the risk of DFD. Many participants described a variety of foot care practices that appeared to indicate uncertainty related to proper care of feet for individuals living with diabetes. There appeared to be some knowledge of a connection between diabetes and foot care issues although it was seldom articulated clearly. When asked directly about the connection between diabetes and potential foot complications, one participant in his sixties stated, “Well, it, um, if you have diabetes, your diet, if it's not under control…then it can affect your blood circulation, and cause problems.” Overall, there was a vague understanding that living with diabetes potentially increased the risk for foot complications. A female in her seventies noted, “You have to take care of your feet, because if not you can get infections or whatever, you could have amputations or whatever.” Despite this general awareness by participants, most participants did not engage in regular systematic assessment of their feet. Many participants appeared to be guessing at what the proper care was. One female participant in her twenties expressed uncertainty related to foot care: I’m honestly not even sure what I’m supposed to do. I know I’m supposed to check, and I’m saying moisturize but I feel like your feet aren’t supposed to be too wet? So, then I’m not even sure if that's right?
Participants noted that they had difficulty assessing the soles of their feet and sometimes they had to ask someone else to look. They did not appear aware of the use of a mirror for this important task. One male in his forties commented: I do my own self inspections every now and again, especially if I feel something out of the ordinary, or something seems amiss, or I think there might be a cut or something on my foot. But I do have joint problems… Luckily, I do have a partner who … would look that up for me. That is only the bottom of my feet obviously because that is the hardest part to see. I am not quite as flexible as I once was.
Similarly, another male in his sixties remarked “The only thing as I am getting older is I find it is hard to get the feet up, you know, and see the bottom or whatever and with eyes as well as you age.”
Many participants stated the main care for their feet was to keep them clean and to use a moisturizer. When asked where they go for information regarding diabetes care and foot care almost all participants stated they would use google to search for information. Their search activity was not formalized. When asked if there were particular sites that they visited, the most common response was similar to a female in her twenties who stated, “No, I don’t have any site that I am loyal to, I just google it…and use whatever comes up.”
Invisible disease: no recognition
Participant's facility to assume responsibility for the self-management of their DM was further downplayed and potentially compromised by the perceived lack of priority the disease was given in the workplace. Some participants described experiencing a lack of support within their workplaces to assist them in maintaining good health and preventing complications from diabetes. One male in his fifties explained that one of the most difficult factors about having diabetes was the fact that diabetes is an invisible disease. He described having to park a long distance from his workplace entrance and requesting a closer parking spot. He explained to his employer that if he had a close parking spot, “I could keep my sugar checkers, my medicines and keep my privacy and personal without getting in…you know, all the stuff at work.” His employer insisted he needed a handicapped parking sticker from his doctor, which he was provided. Having to display this sticker on his vehicle bothered this participant because no one could see from his appearance that he had a disability.
Furthermore, when referring to his diabetes, he stated “But this is the ignorance, because people don’t see it. It is an invisible disease.” More concerning were the participants who described their work environment as a place that hindered their ability to protect and maintain their health. One participant stated that his company didn’t give time for lunch, and this interfered with the employees’ ability to regulate their insulin dosage. He stated, “they don’t put us on lunch at all, they don’t care.” Another woman in her fifties who worked at a fish processing plant stated that the boots she had to wear increased her risk for ingrown toenails “I have to get home quickly, and I get them off quickly because they do hurt, and they do drive my nails in further.” Another participant who worked shift work stated the long shifts interfered with her ability to remember to take her evening medication. When working a 12-h day shift she noted, “I take most of my pills in the morning, my Metformin. I always forget my dinner pill, always forget my dinner.”
Discussion
The findings of this qualitative descriptive study reveal that a combination of individual and contextual factors converge, which may increase the risk for individuals living with diabetes of developing diabetic foot disease. Building on previous findings (Beattie et al., 2014; Newton et al., 2015; Pourkazemi et al., 2020), participants in this study appeared to strive for a balance between the seriousness and complexity of living with a chronic illness like DM with its potential complications, and the desire to not be overly burdened by this responsibility. Many participants expressed thoughts and actions that aided their ability to cope with the [dis]-ease of living with a chronic illness. To this extent, some coping mechanisms described by participants permitted them to distance themselves from the potential seriousness of the complications of DM including the risks associated with developing DFD. A number of the ineffective strategies employed by individuals were further reinforced and amplified by the multiple mixed messages some participants interpreted from their health care provider and their workplaces.
Distancing and coping
To counterbalance the extra burden of health care responsibility imposed by living with a chronic illness with multiple potential health complications including DFD some participants described coping strategies that appeared to distance themselves from the responsibilities of the disease self-management. This distancing initially presented itself in the manner some participants slightly normalized DM. The high prevalence of diabetes in general populations may be one of the factors that potentiates this normalization. Mendenhall et al. (2016) refer to a ‘discursive normalization’ of diabetes that arises from frequent and open conversations regarding the increasing universality of diabetes. The normalizing discourse may enhance individuals to moderate the seriousness of the disease (Mendenhall et al.). Normalizing diabetes was more pronounced in individuals who had family members living with the disease, participants described themselves as not being able to protect themselves from developing diabetes or from developing potential foot ulcerations as it “ran in the family” or this had happened to other family members. Similar to other findings (Beattie et al., 2014; Zhu et al., 2021), contrary to spurring individuals to take health measures to potentially reduce the risk of developing DFD, participants accepted that foot complications may be a part of their future health profile. This is noteworthy in that individuals who focus on the genetic component of DM and DFD may be less confident and less compliant towards the multiple interventions including diet, activity, medication, screening, and prompt medical attention to foot tissue injuries that may reduce these risks (Botros et al., 2020, Embil et al., 2018).
Individual factors
On an individual level, participants appeared to have some degree of knowledge that foot injury could lead to serious complications for individuals living with diabetes. There was also a consensus that self-managing DM in general was one way to prevent diabetes related complications such as DFD. Even with this general understanding, many participants in discussing their role in self-managing DM appeared to downplay the importance of daily, diabetic foot self-care, and the need to pay particular attention to their feet and footwear. This was particularly evident when participants were feeling well. The sense of “don’t go looking for a problem” was an expression used by some participants. When participants felt well, they seldom engaged in recommended preventative foot assessments placing them at greater risk for DFD (Embil et al., 2018; Stevens et al., 2022). This lessening of self-care practices in the presence of awareness of the potential complications of DFD may be an attempt to create balance and live as normally as possible. In a former study, Beattie et al. (2014) noted that individuals engaged in a type of strategic adherence, making a trade-off between living a normal life and following recommended foot care practices.
Of note in this study were the words and phrases some participants used to describe their experience of self-managing DM. Their descriptions conjured an image of a disease that appeared separate from them. Participant's use of language appeared to personify or give human like qualities to the diabetic disease process, suggesting the disease was not in their control, that it had a life of its own. Subtlety in this use of language, participants appeared to shift responsibility for diabetic foot care regimes away from themselves and toward the disease, for example “my blood sugars creep up” and “my sugars fly up”. These expressions depict an understanding of a disease process that was not in their control thereby further permitting individuals to slightly distance themselves from the illness and its daily self-care requirements. Martino et al. (2020) suggest that personification may be a defense strategy used to decrease emotional suffering related to the burden of managing the care requirements of DM. This type of distancing is concerning in that these individuals may perceive their risk for complications such as DFD as low leading them to be less likely to follow recommended self-care practices and to potentially delay seeking medical attention for foot complications (Bus et al., 2020; Ogunlana et al., 2021; Rouyard et al., 2017).
Contextual factors
Contextually, in this study many participants appeared to intuit messages from their health care providers and in their workplaces that reinforced their notion that DM and DFD self-management was not consistently prioritized. As observed in previous studies (Chithambo & Forbes, 2015; Embil et al., 2018; Evans et al., 2022) some participants noted that routine visits to physician's offices did not include having their feet assessed or being questioned or educated regarding the importance of maintaining the multiple self-care recommendations for the prevention of DFD. Many participants described being uncertain of the correct methods to care for their feet to decrease the risk of DFD and some stated that their physicians left it up to the individual to contact them if they had “a problem with their feet”. This sparsity of discourse and attention to DM and diabetic foot management by health care providers may play a role in client's neglecting to prioritize and carry out recommended foot practices. The importance of clear two-way communication and consistent messaging by health care providers to meet and support the individual needs identified by clients to prevent DFD has been highlighted in the literature (Coffey et al., 2019; Evans et al., 2022; Stevens et al., 2022).
Outside of the health care environment, in their workplaces, participants interpreted multiple messages that DM and the prevention of DFD was not prioritized as a serious health concern. One participant described how diabetes was an “invisible disease” and thus no special attention was given to the health care needs of individuals living and working with diabetes. Earlier, Ruston et al. (2013) noted that in the absence of employer or manager support, individuals managed their DM in a way that minimized the visibility of DM and of any disruption to work. Other study participants described not being afforded time to eat meals or time to take their medication during working hours. One female participant stated that the boots she had to wear increased her risk for ingrown toenails. These findings support and add nuance to previous findings, which report that the self-management of diabetes was detrimentally impacted by working conditions where individuals experience poor job control, shift work, heavy workloads and a lack of understanding by fellow workers and employers regarding the specific needs for diabetes self-care. (Loerbroks et al., 2018; McCarthy et al., 2021; Ruston et al., 2013). This perceived lack of recognition further inhibited participants in our study from requesting or implementing measures to follow prescribed health regimes. Inadequate support and recognition of the needs of individuals working with DM places individuals at higher risk for poor diabetic control and the potential for DFD (Benefits Canada, 2021; Diabetes Canada, 2022; Loerbroks et al., 2018; Ruston et al., 2013). Support for workplaces to promote employment environments consistent with optimal employee self-management of diabetes are available (Benefits Canada, 2021; Canadian Centre for occupational Health and Safety, 2019; Diabetes Canada, 2023). In our study participants did not describe awareness of these supports.
Implications for nursing and future research
This qualitative descriptive study was successful in giving a space and a place for participants living with diabetes to express their concerns and their challenges related to maintaining the self-care responsibilities of managing DM and the prevention of DFD. Participants need credible education, and they need health-care providers and workplaces to be part of their trusted care circle. Nurses are in a unique position to provide the education and support needed to assist individuals living with DM to find the balance they appear to seek. Stevens et al. (2022) discuss the importance of building rapport with patients, exploring their readiness to manage DM and foot health, and reinforcing positive behaviours with patients and their support persons. Nurses can do this in the multiple settings where they encounter individuals living with diabetes, such as hospitals, homes, community centres, clinics, and workplaces. Additional research is needed to identify effective strategies that encourage consistent messaging at multiple levels to prioritize the health needs of individuals living with diabetes and to support the challenging work these individuals must manage every day.
Limitations of the study
The findings of this study were drawn from a relatively homogeneous group of participants residing in Eastern Canada and therefore may not be generalizable to the experiences of all individuals living and working with DM. Similar studies with larger groups of participants living with diabetes, with or without foot complications, would help establish a broader view and greater understanding of participant's adherence to self-care practices to prevent DFD.
Conclusion
Overall, individuals living with DM in this study were challenged to carry out the many recommended self-care strategies associated with the management of DM to reduce the risk of DFD. Participants appeared to strive for balance in their life, daily weighing the persistent complex needs of self-managing DM and the desire to not be overly burdened by this responsibility. To create this balance, some participants described coping mechanisms that permitted them to distance themselves from the potential complications of DM including DFD. Some of the ineffective strategies employed by individuals appeared to be further reinforced by mixed messages intuited from health care providers and in their workplaces. Participants reported that some health care providers did not consistently address the importance of foot care and that many workplaces were not conducive to participants carrying out the self-management requirements of DM. Consequently, a concerted effort is needed to reinforce the message that diabetes care is a priority for everyone. In this way, we may help to reduce another limb lost to DFD.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Cape Breton University, (grant number Research, Innovation, Scholarship, and Exploration).
