Barriers to diabetic foot care in a developing country with a high incidence of diabetes related amputations: an exploratory qualitative interview study

Cornelia Guell, Nigel Unwin

Diabetes related foot disease is a major cause of morbidity and mortality in people with diabetes. This is despite the fact that interventions to reduce the burden of diabetic foot disease are estimated to be highly cost effective, even cost saving in both developed and developing countries. This exploratory qualitative study was undertaken in a developing country known to have a very high rate of diabetes related amputations. The aim of the study was to explore barriers to foot care from the perspectives of health care professionals and patients, with a view to informing further work to develop effective interventions. Semi-structured interviews, each of 30 to 60 minutes, were conducted with a purposive sample of 20 individuals (11 health carers and 9 patients with diabetes). Participants were asked how diabetic foot care was experienced and practised, and about knowledge and attitudes relevant to care. Health carers were also asked how they negotiated issues of priority setting within the available resources. Interviews were recorded, transcribed and underwent thematic analysis. Three broad categories of potential barriers to diabetic foot care were identified. First, health carers reported that they and their patients tended to prioritise glycaemic control and that this often eclipsed foot care. Second, health carers described resistance to changing professional roles, particularly within the context of limited resources. Newly assigned foot screening and care duties did not fit in easily with their main work schedule. The overall effect of this was to lead to increased referrals to already overstretched, and difficult to access, podiatrists. Finally, patients reported a health care system with significant reliance on 'self-care' ability, including the need for time and expertise to negotiate access to scarce professional foot care appointments. The findings from this exploratory study provide insight on broad barriers to diabetic foot care within a developing country setting. The three areas identified deserve further investigation to determine their impact on the delivery of diabetic foot care and the implications for designing effective interventions.