Determinants of Foot Care Adherence Among High-Risk Diabetic Populations: Insights From an Ethnic Minority Community Study in Southwest China

Abstract

Background:

Effective foot care is crucial for preventing diabetic foot ulcers (DFU). While previous studies have identified general determinants of foot care adherence, the unique challenges faced by ethnic minority communities in rural settings remain underexplored. This qualitative study aimed to explore determinants of foot care among individuals at high risk of DFU in an ethnic minority community in Southwest China.

Methods:

Twenty participants from 4 local communities were recruited, and data were collected through semi-structured interviews. Data from the interviews were analyzed using a thematic analysis approach.

Results:

Thematic analysis revealed 3 key themes: prioritization of personal health needs, historical cultural perception, and interaction within working and family contexts. Notably, misconceptions regarding the correlation between blood circulation and foot odor have diminished the perceived importance of foot care, while misunderstandings about food and nutrition indirectly impacted it. Foot hygiene practices are performed less consistently compared to handwashing in daily life.

Conclusions:

This study provides novel insights into the specific determinants of foot care adherence among high-risk diabetic populations in a rural, ethnic minority setting. The findings emphasize the need for culturally tailored interventions that address misconceptions, language barriers, and social dynamics to improve foot care practices and reduce the risk of DFU.

Keywords

diabetes foot care ulcer adherence China foot inspection hot foot baths

Introduction

Globally, diabetes mellitus (DM) is the seventh leading cause of death.¹ From 2015 to 2040, it was estimated that the incidence of T2DM has risen from 415 million to 642 million. In 2019, approximately 463 million adults (aged = 20-79 years) were living with diabetes. By 2045, the incidence will rise to 700 million.² In China, DM was the seventh leading non-communicable disease.^1,2 In 2019, the data showed that the number of people with diabetes in China was 116.4 million, followed by India (77 million) and the United States (31 million). In addition, this number was predicted to increase to 147.2 million by 2045.² Diabetes and diabetic complications have a broad impact on both patients themselves and various aspects of life, such as families, communities, the health care system, and even the country’s economies.^1,3 The global prevalence of diabetic foot complications varies between 3% in Oceania and 13% in North America, with a global average of 6.4%. Approximately 1% of people with diabetes will suffer from lower-limb amputation at some stage.⁴ In China, a study that encompassed participants from diverse geographic regions found that individuals with diabetes experienced an annual incidence of ulceration of approximately 8.1%, with a recurrence rate of approximately 31.6% within the first year. Furthermore, the amputation rate for patients afflicted with DFU was documented to be 5.1%.⁵

A person with diabetes who has loss of protective sensation or peripheral artery disease (The International Working Group on the Diabetic Foot [IWGDF] risk levels 1-3) should perform a daily self-inspection of the entire surface of both feet, which includes the following: redness, blisters, calluses, open sores (ulcers), swelling, dryness, nail thickness, length, tenderness, and foot skin temperature.⁶ Feet are recommended to be washed with water at a temperature lower than 37°C, without using any kind of heater to warm it.⁴ In accordance with the IWGDF 2023 Risk Stratification System,⁶ the risk of DFU is classified into 4 levels: very low (absence of loss of protective sensation [LOPS] and no Peripheral Artery Disease [PAD]), low (LOPS or PAD), moderate (LOPS + PAD, or LOPS + foot deformity, or PAD + foot deformity), and high (LOPS or PAD, along with 1 or more of the following: a history of foot ulcer, a lower-extremity amputation [minor or major], or end-stage renal disease). However, actual adherence to foot care has proven unsatisfactory. Commonly observed foot issues included edema, dry skin, thickened and discolored toenails, and hallux valgus. Particularly among the elderly, there were significant difficulties in adopting proper foot care practices and maintaining optimal foot health at home.⁷

Baise city is located near the border between China and Vietnam, characterized by mountainous terrain and picturesque rural landscapes. Owolabi found that people living with DM in rural areas had various misperceptions about diabetic foot care and the prevention of lower-limb amputation, which resulted in delays in foot care.⁸ The Baise region is home to many ethnic minorities and is characterized by cultural diversity. Health behaviors are generally influenced by cultural norms and customs. As Adhikari reported, in South Asia, sugar and sweets hold significant religious value in Hinduism, often presented as offerings to gods and goddesses. Declining such offerings as a guest was considered disrespectful and could impact the reciprocal relationship.⁹ Although many previous studies have identified determinants related to overall foot care,^10,11 few have exclusively focused on foot care in high-risk populations. Additionally, the marginalized geography of Baise city, near the border between China and Vietnam, means that perceptions of determinants related to these issues are poorly understood locally.

The WHO global reports on diabetes and complication prevention emphasize the significance of education and awareness on self-care to facilitate early detection and treatment of complications.¹² Relevant programs should tailor services to people’s needs, not just focus on diseases, and treat them as participants in care, not just beneficiaries. This helps ensure that people receive the right care at the right time.¹ The IWGDF guidelines on the prevention and management of diabetic foot disease also emphasize that structured education and intervention should be culturally appropriate and aligned with patients’ personal circumstances.⁶ Behavior change is determined by multiple interrelated dimensions, such as physical condition, social and cultural environment, and personal attributes.¹³ Effective diabetic foot care relies on changing individual preferences and beliefs, cultural background, and interpersonal relationships. It is important to explore determinants of foot care among individuals at high risk of DFU in the community to prevent DFU.

Materials and Methods

Design and Setting

This study utilized a qualitative semi-structured interview design¹⁴ because of its ability to broaden our understanding of people’s beliefs, experiences, and behaviors.¹⁵ This methodology is straightforward, providing researchers with the means to understand the experiences and viewpoints of participants. It aligns with the principles of naturalistic inquiry, which are essential for enhancing nursing practice and optimizing patient outcomes.¹⁶ Fieldwork was conducted by the researcher (WQZ), who, as an outsider, gained an insider’s view. This approach enhanced the understanding of how socio-cultural and physical environments impact health behaviors. The research was conducted in 4 local communities, selected for their similar geographical conditions and cultures. Baise city is located in the Guangxi Zhuang Autonomous Region, in the southwest of China. Its remote geographical characteristics and concentration of multiple ethnic groups resulted in a unique culture, social relations, and dialect, which could further contribute to changes in health behaviors among individuals with diabetes in the local area. In the past few years, the incidence of DFU increased from 10.3% in 2020 to 14.6% in 2022, with intermediate years showing increases of 12.2%, in the local area (statistics were obtained from a local hospital from January 1, 2020, to December 12, 2022).

Participants

To ensure a comprehensive and diverse range of determinants, this study selected twenty participants from local communities in accordance with the following inclusion criteria: (1) A diagnosis of T2DM, (2) identified as belonging to the DFU high-risk group according to the IWGDF 2023 Risk Stratification System (loss of protective sensation or peripheral artery disease, and at least one of the following: a history of foot ulcer, a lower-extremity amputation (minor or major), or end-stage renal disease),⁶ (3) Age over 18 years (the Mini-Mental State Examination [MMSE] was used to assess cognitive function, with a score of 24 or higher considered indicative of normal cognitive function in individuals aged 60 years or older), (4) Ability to communicate in China, and (5) Willingness to participate. We employed a purposive sampling strategy to intentionally identify and gather determinants from participants representing various age groups, ethnic backgrounds, genders, and disease durations, among other factors. Once a potential participant expressed interests, the researcher (WQZ) contacted the participant by phone to agree on the meeting time, location, and the duration of the in-depth interview. In addition, we ensured that informed consent was obtained from all study participants. Our reporting adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ), a 32-item checklist.

Data Collection

Data collection was conducted between June and December 2023. The interview team included the chief investigator (WQZ) and an assistant (JL), both nurse practitioners, who were trained in diabetic foot care in advance. To better prepare for and familiarize themselves with the procedure, the 2 primary interviewers (WQZ and JL) conducted a simulation interview. Before involving community staff, the lead researcher (WQZ) obtained consent from community leaders. Initially, the researcher (JL) called participants to confirm the details of the interview, including its location, time, and duration. Interviews were conducted on pre-assigned days (typically 2-3 days/week), with 2 to 3 participants scheduled per day to allow sufficient time for meaningful discussion and to avoid fatigue. Each interview lasted approximately 45 to 60 min and was recorded using both notes and digital audio. Upon arrival, participants were introduced by a familiar chief nurse, then escorted to a quiet, private room. After a brief explanation and demonstration, informed consent was obtained. The interview guide (Table 1) developed after reviewing the literature^1,6 was evaluated by 5 experts for content validity, with a validity coefficient of .85.¹⁷ Open-ended questions were used to explore determinants of foot care adherence, followed by probes. Data collection continued until saturation was reached and no new information emerged.¹⁸ Interviews were recorded using audio devices and notes. All records were stored in a password-protected box to maintain privacy. Participants received verbal appreciation at the end of each session.

Table 1.

Interview Guide.

How is your adherence to foot care?

1. What are your thoughts on foot care?

2. How often do you inspect your feet?

What are the barriers to foot care?

1. Do you find it difficult to perform foot care? (Could you tell me more about what makes it difficult for you? )

2. Are there any challenges you encounter with foot care? (If appropriate, could you share how your background, traditions, or community might influence how you care for your feet?)

3. What prevents you from consistently caring for your feet? (Would you say your community plays any role in how you manage your foot care?)

4. Are there any other reasons that hinder regular foot care? (Have you ever felt that your background or beliefs affected how you talked about foot care with healthcare providers?)

Data Analysis

The study began with a preliminary interview and data analysis involving a single participant. This initial phase allowed refinement of the interview process and data analysis techniques. Adjustments were made to elements such as the sequence of questioning and the inclusion of visualization tools, including mind maps, diagrams, and tables. After refining the methodology during the preliminary interview, the researcher conducted 4 additional interviews with participants, employing the same techniques. Thematic analysis involved an iterative process drawing from both inductive and deductive approaches.¹⁹ Initially, audio recordings were transcribed verbatim and cross-referenced with notes. The transcribed data were coded by 2 researchers (WQZ and JL) respectively based on their relevance to the research questions. Sub-themes emerged from the coded information, sharing close interpretive connections after discussion. For example, the sub-theme “conflict with working time” encompassed descriptions like “my work is to help handling the funeral at night” and “I have housework to do, and farm work too.” These sub-themes were reviewed for differences and similarities by two researchers (WQZ and XLM). After analyzing the sub-themes, main themes were constructed by emphasizing commonalities. For instance, the sub-themes “blood glucose concerns taking higher priority” and “misconception on health and illness” were combined into the overarching theme “prioritization of personal health needs.” The researchers documented the study’s findings, supported by quotes and detailed explanations. In case of disagreement, the researcher team collaborated to reach a consensus. Data analysis was conducted using NVivo 12 software (QSR International Pty Ltd.). The researcher (WQZ) returned to participants to confirm that the identified interview categories accurately reflected their thoughts and perspectives, addressing any discrepancies.

Trustworthiness

This qualitative inquiry adhered to the criteria proposed by Lincoln and Guba¹⁸ to prioritize research trustworthiness. To enhance the study’s credibility, a member-checking method was used. The collected data were carefully summarized, with participants involved in the review process. The study’s dependability was further supported through thorough auditing of all research processes and documents. To ensure confirmability, at least 2 researchers re-examined and reviewed the data, addressing any discrepancies. Additionally, a reflective journal was maintained after each interview to reduce researcher bias. A detailed description of the findings was provided to support transferability.

Results

Twenty participants, aged between 43 and 73 years, were enrolled in the study. The majority of participants were male (n = 14; 70%), and ethnicity was the most common (n = 10; 50%). The majority of participants had received an elementary school education (n = 12; 60%) and had a disease duration of 0 to 5 years (n = 12; 60%). About half of the participants identified as farmers (n = 12; 60%). Most participants earned a monthly income of between 1000 and 2000 CNY (n = 8; 40%; see Table 2).

Table 2.

Characteristics of Participants (n = 20).

Characteristics	Group	N	%
Age (years)	40-49	2	10
	50-59	6	30
	60-69	10	50
	>70	2	10
Gender	Female	6	30
Gender	Male	14	70
Ethnicity	Han	10	50
	Zhuang	8	40
	Yao	2	10
Education	Elementary school	12	60
	Junior high school	6	30
	Senior high school	2	10
Duration of disease (years)	0-5	12	60
	6-10	5	25
	>11	3	15
Occupation	Farmer	12	60
	Teacher	1	5
	Governmental employee	3	15
	Factory worker	2	10
	Retirement	2	10
Monthly Income in CNY (1 US dollar = 7.17 CNY)	2000 or lower	8	40
	2001-3000	6	30
	3001-4000	3	15
	4001 or above	3	15

The determinants of foot care adherence were categorized into 3 themes: prioritization of personal health needs, historical cultural perceptions, and interaction within working and family contexts.

Theme 1: Prioritization of Personal Health Needs

This theme, divided into 3 sub-themes, highlighted the importance of health issues, blood glucose control, and misconceptions about health have led to insufficient attention to foot care.

Sub-Theme 1: Various Health Issues Present Impediments to Accessing and Giving Precedence to Foot Care

In addition to their concerns about foot care, participants expressed ongoing worries related to a range of health issues, including back pain, shoulder discomfort, and hypertension, among others. The widespread nature of these health challenges, even in their everyday form, seemed to increase anxiety levels, which in turn hindered participants’ ability and willingness to prioritize foot care.

It is very difficult (care about foot), too many problems. I have hypertension, back pain, shoulder pain, too many sufferings. My hypertension is very high. I check blood pressure every day and I take medication. It is still very high. (Participant 4)

One participant noted the difficulty of checking for pre-ulcer symptoms on their feet due to severe cervical pain. The discomfort was further exacerbated by the need for frequent bending.

I have cervical problem. I feel painful when I bend to pick up things not even to say checking foot problem. It takes times right? (Participant 2)

Sub-Theme 2: Blood Glucose Concerns Taking Higher Priority

One participant expressed a heightened focus on blood glucose control, prioritizing it over all other health concerns. The individual regularly monitored blood glucose levels, dedicating significant time and energy to this task, which inadvertently led to neglecting the critical aspect of foot care.

I will try (check foot), but the foot problem is not the one I care the most. I care more about my blood glucose.” “Once the blood glucose goes up, I feel nervous. (Participant 7)

Each reading of the glycemic index on the monitor triggered a noticeable sense of stress. The immediate and direct perception of the numerical values provoked considerable anxiety, with even a slight increase intensifying the emotional response.

Of course the blood glucose, I check it every day. When the numbers turns up, I feel worried. When it is in normal, so I don’t need to worry too much about it, at least for a day (Participant 1)

Sub-Theme 3: Misconception on Health and Illness

Several participants relied on personal judgments to determine what they believed was beneficial or harmful to their foot health. For example, 1 participant thought that washing their feet in hot water could improve blood circulation and promote foot health. However, this practice increased the risk of scalding due to reduced skin sensitivity caused by diabetic microangiopathy.

I think hot water is good for blood circulation, for foot and for the whole body. And ginger can help to dispel cold too. (Participant 3)

Soaking feet in hot water was also seen as a possible solution to reduce foot odor, a belief shared by many participants. Additionally, 1 interviewee mentioned a family recommendation to use an electronic heater on their feet, a method intended to relieve discomfort caused by excessive sweating. These insights highlight the diverse and sometimes unconventional strategies people use to manage foot-related issues.

I am easy to get sweat, especially on the foot. And my son likes to play football. He used to soak foot like that, so that’s why he bought me a electronic heating barrel. . .Yes, I think soaking foot in hot water could decrease foot odor problem. (Participant 10)

Theme 2: Historical Cultural Perception

This theme highlighted the influence of local culture on health behaviors. Foot care adherence was significantly shaped by the cultural norms and customs of the local community.

Sub-Theme 1: Cultural Expectations and Embarrassment

Participants expressed feeling differently perceived in daily activities and interactions, which contributed to a sense of being seen as weaker or inferior. This perception, combined with the fear of interpersonal embarrassment, led some to hesitate when repeatedly caring for their feet during breaks in daily life or work. These feelings of discomfort highlighted the complex psycho-social challenges faced by individuals with diabetes, underscoring the broader impact of health conditions on their daily lives and social interactions.

I don’t know too much about how they think about me. But I may feel some embarrassments myself. You see if I have to check foot often when we are outside, it is not so good. They won’t say it, but you have to be careful about that yourself. (Participant 13)

One participant shared concerns about frequent foot care might make others associate her with unpleasant foot characteristics, such as scars, or deformities, which could lead to social rejection or judgment. This fear of judgment revealed the intricate relationship between personal health practices, societal perceptions, and the psychological burden of being perceived as “different,” influencing individuals’ behaviors and experiences.

Yes, but people may know it (Scars or deformities) differently. You have diabetes and you are different from others for sure. You check again and again which means there are something wrong there. (Participant 1)

Sub-Theme 2: Getting Used to Local Language

Some members of the local community, deeply rooted in their native language, faced challenges in fully understanding the nuanced advice given by healthcare providers. This linguistic barrier, representing both a cultural and communication divide, significantly impacted the effectiveness of behavior change initiatives.

Normally I speak local language at home. Sometimes I feel a little bit difficult to understand what the doctor say, especially when the doctor speak fast and use professional words. (Participant 6)

The pace of communication between healthcare providers and participants was crucial. The habitual use of the Zhuang dialect reflected the linguistic environment in which they lived and worked, surrounded by native speakers. This context underscored the need for healthcare professionals to tailor their communication strategies to the cultural and linguistic characteristics of the community they serve.

Sometimes, if the doctor speaks too fast, I could not totally understand. Speaking Zhuang dialect is no problem to me, I don’t use Mandarin that often, and I speak Zhuang dialect with relatives and friends when I am at home. And people working together in factory mostly are my fellow-villages, we speak the same language. (Participant 7)

Sub-Theme 3: Influence of Hygiene Norms and Visible Cleanliness

A participant highlighted a difference in hygiene practices, prioritizing handwashing over foot care. Handwashing was a regular habit after fieldwork, cooking, and housework, while foot care was less consistent, typically performed only when feet became visibly dirty after fieldwork. This suggests that foot hygiene may be driven more by perceived necessity than by routine, which could negatively impact foot health.

Not really, no. I only wash my feet when they get really dirty, like after working in the field. When I come back, there’s usually a lot to do, and by the time I finish everything, it’s already night. But I do wash my hands all the time—after field work, before cooking, and after doing housework. (Participant 8)

Honestly, I don’t really pay much attention to my feet. I wash them every now and then, usually only if they start to feel uncomfortable or after I’ve been out all day. But with my hands, I’m more careful—I wash them often, like after using public transportation, before eating, or when I get back home. It just feels more necessary, you know? (Participant 12)

Sub-Theme 4: Conflict Between Dietary Recommendations and Traditional Food Practices

Preparing elaborate meals for friends was viewed as a way to express hospitality. One participant, due to a misunderstanding about food and nutrition, struggled to adhere to a diabetic diet. This led to prolonged fluctuations in blood glucose levels, which in turn caused anxiety, eventually leading to the neglect of other aspects of diabetes care, including foot care.

Physician says that I cannot eat too much, especially greasy food and meat. So how can I get enough nutrition? You cannot say you don’t eat when friends prepare so well. Right?. . .Now I care the most is first my blood glucose, it goes up and down, never under control. . .I feel my life is ruined, I cannot do anything else, I feel exhausted. (Participant 4)

Theme 3: Interaction Within Working and Family Contexts

This category illustrates how competing work demands, limited support from distant children, and difficulty in forming habits collectively hinder consistent foot care. Despite receiving guidance, participants often struggled to integrate foot care into daily routines, reflecting a gap between knowledge and sustained practice.

Sub-Theme 1: Conflict With Working Time

Beyond health concerns, participants felt compelled to maintain their daily routines and activities. Rather than adjusting their habits to prioritize foot care, they continued with established practices. Especially during busy work periods, participants consistently prioritized professional responsibilities, often at the expense of essential health practices. This dual commitment reflected the complex balancing act individuals face, highlighting the challenge of integrating health priorities into their broader daily lives and responsibilities.

I think, it is a little bit waste of time. I have many things to do as you know, cooking, feeding chicken, ducks, and field work. . . . . . We just make a bit of money each year from these chickens and ducks. When I am in busy, I rarely pay attention to my foot. (Participant 1)

Maybe you don’t know too much about my work. My work is to help handling the funeral at night. The work is tiring and offers little pay. I have to work whole day from daytime to the next day morning. I don’t notice too much on my foot when I am busy. (Participant 9)

Participants shared that investing time in self-cultivation, such as growing their own vegetables, was seen as necessary to ensure a steady supply of fresh, healthy food. However, this focus on food production increased their workload, leaving them with limited time for regular foot care. As a result, the demands of daily responsibilities, including housework and farming, often took priority over foot care.

I have housework to do, and farm work too. I really don’t have time paying attention to the foot when I am busy in working. So I am sorry. . .I think that I plant vegetables myself, I can save money and I can make sure that I eat healthy food. (Participant 5)

Sub-Theme 2: Support Provided by Offspring in Care Giving

Many participants expressed frustration over the absence of their children nearby. The need to invest extra energy in household and fieldwork further compounded their difficulties. As a result, proper foot care often took a backseat as they focused on their work responsibilities.

They (children) rarely have time coming back to help me, even though it is on festival. If they are busy, they will not able to come back. (Participant 9)

At home, I plant trees and vegetables, and I raise chicken and ducks too. . . No, they (my children) both work in other place far away from here. . .They work in the factory, only have one day off every week. And they work overtime even in some festivals. (Participant 12)

Sub-Theme 3: Difficulty Perfoming Habits

Some participants reported receiving guidance on diabetic foot care during hospitalization or outpatient visits, but they struggled to establish a consistent routine. As a result, the long-term effectiveness of the advice remained uncertain. This revealed a gap between acquiring knowledge and applying it in practice, emphasizing the need for tailored strategies to promote sustainable foot care habits.

Like checking for redness, washing foot and so on, I think I can make it. The problem is that I don’t form a habit.”; “It is difficult to change habits and get used to the other one. It is different from marketing; you do it everyday. (Participant 6)

Discussion

In this study, we found that participants’ time and energy were often diverted toward addressing other physical health issues. This finding aligns with prior research that highlighted patients’ difficulties with daily foot inspections due to memory problems.²⁰ Vision impairments were also noted as a barrier, making it harder to detect early signs of ulcers.²¹ In some cases, splints on the feet obstructed the ability to perform foot inspections.²² It is essential to consider patients’ overall physical condition when offering tailored recommendations for foot care.²³ Additionally, participants in our study devoted considerable time to managing blood glucose levels, often prioritizing this over checking for pre-ulcer symptoms. As a result, foot care was often seen as secondary to more immediate concerns, such as monitoring glycemic levels.²⁴ For patients with T2DM, the primary tasks typically include managing diet, physical activity, and monitoring HbA1c levels.²⁵ In some cases, foot care recommendations were not provided by healthcare providers.²⁶ Education on diabetes care should place equal emphasis on the importance of foot care as well as well-established monitoring practices, such as glycemic control.²⁷ In our study, some participants believed that washing their feet with hot water could promote ulcer healing, which led them to downplay the importance of other foot care practices. Previous literature has also noted that some patients mistakenly believed that increased foot exercise, such as walking barefoot, could enhance blood circulation.²⁸ Additionally, the habit of wearing sandals was seen by some participants as a way to give their feet more space to stretch.²⁰ A study conducted in South Africa similarly reported that applying a hot water bottle to the feet in winter was believed to improve blood flow.²⁹ Our study also found that some participants thought soaking their feet in hot water helped relieve foot odor. This misconception diminished the perceived importance of regular foot care and, in turn, increased the risk of skin damage for individuals already at risk for diabetic foot ulcers (DFU). Conversely, a study on postharvest anthracnose treatment demonstrated that a combined carbonate salts and hot water method was effective in controlling incidence rates.³⁰ Another study on neuromuscular relaxation showed that immersion in 42℃ hot water was effective in reducing both maximal voluntary contraction and voluntary activation levels.³¹ However, in the context of diabetic foot care, it is crucial to dispel the misconception that increasing blood circulation through hot water immersion can prevent ulcers or alleviate foot odor.

Cultural diversity within the local area played a significant role in shaping foot care adherence. In our study, perceptions of discriminatory treatment arose from an unrealistic fear of infection, which often led to feelings of helplessness among individuals with diabetes when managing foot care. They reported experiencing unwanted attention and indifference in social interactions, particularly when foot care practices were involved. Patients frequently described the emotional toll of being reminded of previous ulcers, especially when trying to perform foot inspections in public.³² One U.S. study similarly reported that some patients feared rejection from loved ones after being diagnosed with T2DM³³ Participants in a U.K. study also expressed embarrassment when checking their feet in public, fearing judgment due to potential foot odor.¹⁰ Additionally, scars from previous ulcers were often perceived as unappealing, leading to further reluctance to engage in foot care practices in front of others.³⁴ These findings underscore the need to address societal perceptions and encourage positive attitudes toward diabetes and foot care in public spaces. The cultural significance of food was another factor influencing foot care adherence in our study. In Chinese culture, a plentiful meal is a symbol of happiness and hospitality, which often leads to overconsumption of food.³⁵ Similarly, in India, high sugar consumption is prevalent as part of cultural practices.³⁶ This cultural emphasis on food, combined with dietary instability, often resulted in fluctuating glycemic levels, which in turn undermined participants’ efforts to prioritize foot care. While this link to food was not initially recognized, meat was increasingly viewed as an essential part of the diet in our study. The stress and anxiety caused by concerns over inadequate nutrition without meat consumption led to difficulties in both dietary and blood glucose control, indirectly hindering foot care efforts. As evidenced in other studies, East Asians strongly associate meat with festive occasions and celebrations.³⁷ In Japan, for example, household meat consumption increased significantly since 2019, with much of the supply being imported.³⁸ This growing demand for meat, particularly beef, aligns with the local cultural association of “Wagyu” beef with luxury.³⁵ Education on health and nutrition balance is essential and should be included in diabetes care programs.³⁹ In addition, several participants, particularly those from rural areas, were accustomed to speaking the local Zhuang language, which hindered their understanding of foot inspection instructions. Although previous research has explored the relationship between language and health behavior, it has primarily focused on general diabetes care, rather than foot care specifically. For example, an Irish study reported that consultations with physicians were often insufficient, leading to poor comprehension of medical advice and a lack of understanding of self-care practices.⁴⁰ Poor health literacy was commonly linked to passive attitudes toward diabetes management, particularly in areas like diet and medication adherence.^41,42 Clear, understandable information and adequate interpretation during physician-patient communication were identified as essential to improving health outcomes.⁴³ In our study, participants’ limited understanding of foot care was often tied to cultural and linguistic factors, suggesting the importance of integrating language practices that are commonly understood within the community to improve foot care literacy. Lastly, participants in our study often reserved foot care for moments when their feet became visibly dirty or uncomfortable, highlighting a reactive approach to foot care. This finding aligns with the theme from an article exploring perception about feet, falls, and exercise, where participants metaphorically referred to their feet as “second-class citizens,” often neglecting foot care unless prompted by visible signs of discomfort or pain.⁴⁴ This shared tendency to overlook routine foot care emphasizes a need for enhanced health education to encourage the integration of foot care into daily hygiene practices.

We also identified that many participants faced a dilemma between adhering to foot care practices and maintaining their daily routines. This finding is consistent with an Australian study, which noted that foot inspections were often neglected because they conflicted with participants’ daily work schedules.²² The demands of their routines led to a lack of attention to foot care, which eventually resulted in delays in seeking medical intervention for foot issues.²¹ Interestingly, participants in our study also linked healthy food to the practice of “growing your own food,” which, although not previously acknowledged, added significant burdens in terms of fieldwork. As a result, time for regular foot examinations was diminished. This aligns with findings from a study on consumer behavior in Japan, which highlighted that domestic production, particularly of meat, was a key factor in ensuring food quality and influencing dietary habits.⁴⁵ Another report revealed that consumers actively sought health-related information to ensure the safety and quality of food, such as labels like “rice-fed pork.”⁴⁶ In this context, the belief in the benefits of self-planting could potentially support healthier eating habits, as long as it does not interfere with regular foot care practices in time management. Several sources of support were considered helpful in further sparing time for foot care for the patients, including church staff,⁴⁷ community members,³³ and even fellow patients with diabetes.⁴⁸ These findings underscore the potential benefits of a volunteer-based, collaborative intervention to support foot care practices. Additionally, we found that some participants had been living alone for extended periods, which made it difficult for them to manage foot care without family assistance.⁴⁹ Family members play a crucial role in building mutual trust and providing advice.⁷ Assistance from family and friends with both daily tasks and foot care was often reported as essential.⁴⁰ Given these findings, it is important to develop family-engaged strategies to facilitate foot care. In our study, the difficulty of consistently performing foot checks was also identified as a barrier to proper care. This finding echoes results from previous studies, which found that participants often struggled to maintain foot care routines after ulcers had healed,¹⁰ or when they did not have proactive support from clinicians.⁵⁰ Even those who adhered to healthcare providers’ recommendations expressed uncertainty about how long they could sustain these practices.⁴⁸ Strategies such as extending the duration of educational programs and incorporating monthly follow-up sessions have been shown to positively influence long-term foot care adherence.³⁹ The value of additional sessions to reinforce learning outcomes was strongly supported by participants in our study.⁴⁸ Several recommendations for improving foot care adherence were summarized and identified in our study (see Table 3).

Table 3.

Recommendation for Future Research.

1. Health education

(1) Adjustment in education contents

- Stress importance on both monitoring blood glucose and inspecting foot

- Without direct relevance between blood supply and the occurrence of ulcer or foot odor

- Knowledge on balanced nutrition and health

- Emphasis on regular foot care as part of daily hygiene

(2) Integrate various language in forms of education

(3) Integrate with periodic foot care training

2. Public advertising

(1) Eliminate panic toward diabetes clarifying no infectiousness

(2) Appeal to awareness and understanding toward foot care

3. Volunteer service

(1) Assist in daily living

(2) Alleviate work burdens

4. Family support

(1) Assist in daily work and living

(2) Participate with medical activities

Strengths and Limitations

This qualitative study provides valuable insights into the determinants of foot care adherence, offering evidence that can inform the development of more effective interventions and serve as a foundation for future research. However, certain limitations must be acknowledged. To enrich the data, future studies could incorporate a combination of in-depth individual interviews and focus group discussions. Focus groups, in particular, allow participants to build on each other’s responses, potentially generating ideas and insights that may not emerge in one-on-one interviews. Although the 4 villages in this study shared certain characteristics, complete uniformity in culture and the physical environment was difficult to achieve. Additionally, the study sample consisted of twenty participants, which may limit the generalizability of the findings. Future research could benefit from incorporating perspectives from a broader range of stakeholders, such as nurses, physicians, and podiatrists, to further enhance the depth and breadth of the inquiry.

Conclusions

This study identifies key determinants of foot care adherence among individuals at risk for diabetic foot ulcers (DFU) in an ethnic minority community in Southwest China. The findings highlight the interplay between personal health priorities, cultural perceptions, and social dynamics that influence foot care practices. By focusing on a rural, ethnic minority setting, this study provides novel insights into the specific challenges faced by this population, including misconceptions about foot care, language barriers, and traditional dietary customs. These findings emphasize the need for culturally tailored educational interventions that integrate foot care into daily hygiene practices and address both physical and psychological barriers. Future research should explore multi-disciplinary interventions and family engagement to improve foot care adherence and reduce the risk of DFU.

Footnotes

Acknowledgements

The authors would like to appreciate all participants for providing their support and suggestions to this research.

ORCID iD

Xinling Ma

Institutional Review Board Statement

Before involving community members, the lead researcher (WQZ) obtained consent from community leaders. Participants were informed of their right to withdraw at any time, and confidentiality was guaranteed with anonymous data collection. The study was approved by the institutional review board of the China health administration agency in the local district (1224/2024).

Consent to Pariticipate

Informed consent was obtained from all study participants.

Author Contributions

All authors contributed to the conception and design of the study. Participant recruitment was coordinated by WQZ, JL, YLG, and GRL. Material preparation was done by WQZ and YLG and reviewed by WQZ and JL. Data collection was conducted by WQZ and JL. Three authors, WQZ, JL, and XLM analyzed the data and prepared the initial draft of the manuscript. WQZ, JL, MJL, and SLL provided critical review of data draft. All authors read and approved the final manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Our study was generously supported by the “Research Foundation Capacity Improvement Project for Middle-aged and Young Teachers in Guangxi Universities” (Project No.: 2025KY0541). This funding was instrumental in facilitating various aspects of our research, including data collection, analysis, and community engagement. Including this acknowledgement aligns with academic best practices and ensures that our research is fully transparent and accountable.

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.

Data Availability Statement

Data collected for this study are available from the corresponding author (XLM) on reasonable request.

References

World Health Organization. Global reports on diabetes. 2016. Accessed November 8, 2024. https://www.who.int/diabetes/global-report/en/

International Diabetes Federation. IDF Diabetes Atlas 10th edition. 2021. Accessed October 14, 2024. https://diabetesatlas.org/atlas/tenth-edition/

Ramachandran

Wan-Ma

Snehalatha

Diabetes in Asia. Lancet. 2010;375(9712):408-418.

American Diabetes Association. Microvascular complications and foot care. Int Diabetes Care. 2015;38:S58-S266.

Jiang

Ran

Jia

. Epidemiology of type 2 diabetic foot problems and predictive factors for amputation in China. Int J Low Extrem Wounds. 2015;14(1):19-27. doi:10.1177/1534734614564867

Sicco

Isabel

CNS

Matilde

M-S

. IWGDF Guidelines on the prevention and management of diabetes-related foot disease. 2023. Accessed November 9, 2024. https://iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-Guidelines-2023.pdf

Stolt

Suhonen

Puukka

Viitanen

Voutilainen

Leino-Kilpi

Foot health and self-care activities of older people in home care. J Clin Nurs. 2012;21(21-22):3082-3095.

Owolabi

Chu

KM.

Knowledge, attitude and perception towards lower limb amputation amongst persons living with diabetes in rural South Africa: a qualitative study. Afr J Prim Health Care Fam Med. 2022;14(1):e1-e10.

Adhikari

Mishra

SR.

Culture and epidemiology of diabetes in South Asia. J Glob Health. 2019;9(2):020301.

10.

Beattie

Campbell

Vedhara

Whatever I do it’s a lost cause: the emotional and behavioral experiences of individuals who are ulcer free living with the threat of developing further diabetic foot ulcers: a qualitative interview study. Health Expect. 2014;17(3):429-439.

11.

Abu-Qamar

Wilson

Foot care within the Jordanian healthcare system: a qualitative inquiry of patient’s perspectives. Aust J Adv Nurs. 2011;29(1):28-36.

12.

World Health Organization. Diabetes country profiles. 2024. Accessed November 4, 2024. https://www.who.int/diabetes/country-profiles/en/

13.

Stokols

Translating social ecological theory into guidelines for community health promotion. Am J Health Promot. 1996;10(4):282-298.

14.

Streubert

Carpenter

DR.

Qualitative Research in Nursing: Advancing the Humanistic Imperative, 5th edn. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011.

15.

Pathak

Jena

Kalra

Qualitative research. Perspect Clin Res. 2013;4(3):192.

16.

Turale

A brief introduction to qualitative description: a research design worth using. Pacific Rim Int J Nurs Res. 2020;24(3):289-291.

17.

Polit

Beck

Owen

SV.

Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health. 2007;30(4):459-467.

18.

Lincoln

Guba

EG.

Qualitative Research Guideline Project. Sage Publication; 1985.

19.

Braun

Clarke

Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101.

20.

Gale

Vedhara

Searle

Kemple

Campbell

Patients’ perspectives on foot complications in type 2 diabetes: a qualitative study. Br J Gen Pract. 2008;58(553):555-563.

21.

Chithambo

Forbes

Exploring factors that contribute to delay in seeking help with diabetes related foot problems: a preliminary qualitative study using interpretative phenomenological analysis. Int Diabetes Nurs. 2015;12(1):20-26.

22.

Wong

Haswell-Elkins

Tamwoy

McDermott

d’Abbs

Perspectives on clinic attendance, medication and foot-care among people with diabetes in the Torres Strait Islands and northern peninsula area. Aust J Rural Health. 2005;13(3):172-177.

23.

Rehling

Bjørkman

Andersen

Ekholm

Molsted

Diabetes is associated with musculoskeletal pain, osteoarthritis, osteoporosis, and rheumatoid arthritis. J Diabetes Res. 2019;2019:6324348.

24.

Anders

Smith

Developing a resource for people with diabetes about preventing foot problems: research, audit and user insight. J Commun Healthcare. 2010;3(3-4):184-196.

25.

Guell

Unwin

Barriers to diabetic foot care in a developing country with a high incidence of diabetes related amputations: an exploratory qualitative interview study. BMC Health Serv Res. 2010;15:377.

26.

Hill

Dunlop

Determining the patient-perceived impact of foot health education for patients with diabetes mellitus. Diabetic Foot J. 2015;18(4):174-178.

27.

Divan

Greenfield

Morley

Weinstock

RS.

Perceived burdens and benefits associated with continuous glucose monitor use in type 1 diabetes across the lifespan. J Diabetes Sci Technol. 2022;16(1):88-96.

28.

Searle

Gale

Campbell

Reducing the burden of chronic wounds: prevention and management of the diabetic foot in the context of clinical guidelines. J Health Serv Res Policy. 2008;13 Suppl 3:82-91.

29.

Matwa

Chabeli

Muller

Levitt

NS.

Experiences and guidelines for foot care practices of patients with diabetes mellitus. Curationis. 2003;26(1):11-21.

30.

Getnet

Alemu

Tsedaley

Effect of combined application of carbonate salts and hot water treatment for the management of postharvest anthracnose (Colletotrichum gloeosporioides) of papaya. Food Sci Nutr. 2023;11(7):3811-3819.

31.

Rodrigues

Orssatto

LBR

Trajano

Wharton

Minett

GM.

Increases in muscle temperature by hot water improve muscle contractile function and reduce motor unit discharge rates. Scand J Med Sci Sports. 2023;33(5):754-765.

32.

Moreira

Sales

CA.

The nursing care towards individuals with diabetic foot: a phenomenological focus. Rev Esc Enferm USP. 2010;44(4):896-903.

33.

Foster

Lauver

LS.

When a diabetic foot ulcer results in amputation: a qualitative study of the lived experience of 15 patients. Ostomy Wound Manage. 2014;60(11):16-22.

34.

Aliasgharpour

Nayeri

ND.

The care process of diabetic foot ulcer patients: a qualitative study in Iran. J Diabetes Metab Disord. 2012;11(1):27.

35.

Nam

Lee

Meat products and consumption culture in the East. Meat Sci. 2010;86(1):95-102.

36.

Stone

Pound

Pancholi

Farooqi

Khunti

Empowering patients with diabetes: a qualitative primary care study focusing on South Asians in Leicester, UK. Fam Pract. 2005;22(6):647-652.

37.

Choi

Lee

KJ.

Ethnic differences in attitudes, beliefs, and patterns of meat consumption among American young women meat eaters. Nutr Res Pract. 2023;17(1):73-90.

38.

Zammit

Howden

Martin

Agricultural overview. Agric Commodities. 2020;10:1-7.

39.

Ferraro

Bargagli

Dietetic and lifestyle recommendations for stone formers. Arch Esp Urol. 2021;74(1):112-122.

40.

Delea

Buckley

Hanrahan

McGreal

Desmond

McHugh

Management of diabetic foot disease and amputation in the Irish health system: a qualitative study of patients’ attitudes and experiences with health services. BMC Health Serv Res. 2015;15:251.

41.

Kim

Song

Park

Utz

Patients’ experiences of diabetes self-management education according to health-literacy levels. Clin Nurs Res. 2020;29(5):285-292.

42.

Fransen

Beune

Baim-Lance

Bruessing

Essink-Bot

ML.

Diabetes self-management support for patients with low health literacy: perceptions of patients and providers. J Diabetes. 2015;7(3):418-425.

43.

Visscher

Steunenberg

Heerdink

Rademakers

Medication self-management support for people with diabetes and low health literacy: a needs assessment. PLoS ONE. 2020;15(4):e0232022.

44.

Conde

Hendry

Woodburn

Skelton

DA.

‘Feet are second class citizens’: exploring the perceptions of Scottish and Portuguese older adults about feet, falls and exercise- a qualitative study. J Foot Ankle Res. 2020;13(1):66.

45.

Wang

Huang

Yamano

, et al A comparative study of consumer behavior and preferences in relation to pork consumption in Japan and China. Nihon Chikusan Gakkaiho. 2019;90(4):327-335.

46.

Sasaki

Motoyama

Watanabe

Nakajima

Meat consumption and consumer attitudes in Japan: an overview

Meat Sci. 2022;192:108879.

47.

de Vera

. Perspectives on healing foot ulcers by Yaquis with diabetes. J Transcult Nurs. 2023;14(1):39-47.

48.

Vedhara

Beattie

Metcalfe

Development and preliminary evaluation of a psychosocial intervention for modifying psychosocial risk factors associated with foot re-ulceration in diabetes. Behav Res Ther. 2012;50(5):323-332.

49.

Abu-Qamar

Wilson

The lived experience of a foot burn injury from the perspective of seven Jordanians with diabetes: a hermeneutic phenomenological study. Int Wound J. 2012;9(1):33-43.

50.

Drovandi

Crowley

Alahakoon

Perceptions of Australians with diabetes-related foot disease on requirements for effective secondary prevention. Aust J Rural Health. 2023;31(4):690-703.