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Journal Club - 23rd February 2023

2 Mar 2023 11:56 AM | Anonymous

Article Title:

Reasons for (non-)adherence to self-care in people with a diabetic foot ulcer

Jaap J van Netten, Leonard Seng, Peter A Lazzarini, Jason Warnock, Bernd Ploderer


Wound Repair & Regeneration: official publication of the Wound Healing Society and the European Tissue Repair Society 2019,

Issue/Page No:


Discussion Date:      23 /    2  /    2023  

Study objective, hypothesis and question?

Qualitative, hypothesis generating study exploring.

Interview style performed


Rationale and relevance of the question?

(Why was the study done?)

DFU self-care lack of evidence, explore intervention self-care activities to

Respect self-care and no foot ulcers. But in this space limited.

Relevant area of research, majority of care is seen outside of the clinical setting. Time factor, limiting impact. Most of the work is done outside of the clinical setting for the patient. What goals patients have and identifying barriers is essential

Self-care with risk of ulceration vs those with active ulcerations would be different.

Relevance of this topic/question to FH Podiatrists?

(Is it urgent or essential reading for a podiatrist working in an acute hospital?


Essential for any podiatrist to consider with patient presenting with HRF wound. Enlightening, exploring the issues with the patient around integrating offloading into their day. Valued part of the treatment. Limitations with available offloading (cumbersome, knee to ankle height offloading), environmental and life style barriers to wear devices.  Short changing people with delivering in-effective education, aligning patient goals with therapeutic goals. Limitations with time in clinic, not necessarily seeing patient often enough to enforce the importance of therapeutic goals. What is their understanding of the therapeutic goals? Often patient confusion, not necessarily aware of the objectives of care.

Patient understanding of information supplied, what we communicate is essential, this may be interpreted differently. Motivation of the patient in this article was key to adherence

No indigenous or immigrant community included, barriers and issues maybe different or similar to general population?

Relevance is identified, duration of working in HRF and noting that education is important and how it is interpreted by the patients.

What methodological approach (design, analysis, etc.) has been used?

(RCT, Case control, case study series, meta analysis etc.)


A qualitative study using face-to-face semi-structured interviews, using the framework approach.

A 40-item, semi-structured interview guide was developed. The systematic nature of the framework approach allowed for the interview guide to be structured to align with the various aspects and factors of diabetic foot ulcer self-care.

Interview guide was piloted with two persons not included in the study, to ensure validity and feasibility.

5 key threads to that approach – interview

Familiarisation, Thematic framework identification, indexing, charting, mapping and interpreting data.

WHO adherence dimensions (social and economic factors; therapy-related factors; patient-related factors; health-system related factors; condition-related factors

Bias with study design,

-interview was completed after the appointment.

-not clear if patients were questioned by same person.

Missing methods information

Themes and interpretations were discussed

Smart phone use - may exclude some relevant participants.

What were the results of the study? (What did the investigators find?)


Multi-dimensional factors that contribute to non-adherence.

Nothing new, that self-care is not well done.  Didn’t look at the communication or education provided by the practitioner.

Patient explored the adherence at home only. Many factors, in education.

Research location (South East Queensland) may not have full relevance to the general population.

Further research proposing possible solutions to these issues with self-care rather than providing a reflective element to the study conclusion.

Strengths & weaknesses of this study? Are the results valid? Look at study design, appropriateness of the method(s), population and sample size, appropriate study conduct, data gathering, subject followup, influences of bias, methods of analysis, discussion, currentness and comprehensiveness of the listed references


  • Small sample size
  • More type 1 participants
  • No indigenous or immigrant participants
  • Testing hypothesis rather than finding new research
  • Did not encapsulate the whole population or cohort of DFU
  • Applicable to those with neuropathy only
  • Small sample
  • Possible bias – patient going from HRF appt to interview straight away. Re-discussion of results in the interview -.
  • Interview environment could have influence
  • Smart phone use, population younger, possibly wealthier, intellectually more advanced, cognition, higher socioeconomic group?? Tech savvy.
  • No formal assessment of health literacy – known for patients with DFU early dementia.
  • Dialysis patients have poor retention of information post dialysis with education – multiple research sources
  • Not generalisable limitations with population sample -potential for future research.
  • Not fresh minds participants from another study, possible bias with potential convenience.
  • Those that participate in research tend to be more engaged, likely to be more likely to follow education. Possible bias, higher health literacy.
  • Gaps in methods not discussed but clarification with Jaap the investigators were different to the clinicians.
  • Chronicity of the wounds would be interesting to explore, may influenced patient perception.
  • Those wearing TCC vs removable devices answers would be different from interview.


  • WHO framework identified – part of the theme of the paper and 5 point framework. Qualitative commentary is still valid. Points to think in own practice.
  • Learning points: new app for qualitative data app (www.saturateapp.com)

Do the conclusions follow logically from the design and results?

Yes, null hypothesis that difficulty in self care was going to be an issue. It reaffirms what we know, how do we address this in practice.

Apply this study to a wider cohort – difficulty in the qualitative design

Not assuming patients have any knowledge – care needs to be explicitly explained, clinical environment and time can influence effectiveness.

How do the results relate to current practice and how might they influence future practice? (What does the answer mean anyway? So what? Who cares?)

What we confirm and all believe and know, there are barriers and themes that need to be addressed with education and self-care.

Teaching and communication – we don’t recognise or research well, how well do we communicate to our patients?

Clinicians often assume that they communicate consistently with a valid and reliable outcome.

NESB/. Indigenous population and other populations can be impacted when the message does not get across. Repetition isn’t always effective communication. Patient can reach a point of saturation.

Outcomes from communication – need to be explored and the styles of communication/education used clinically.


Jaap comments

Qualitative study and question around possible bias environment and when clients were interviewed?

-Researchers were interviewers, early research career person and a non podiatric / no DFU experience colleague.

Japp not one of the interviewers

Qualitative research you will always have an element of bias with questioning.  Early career researcher, structure was useful and controlling research design.  Actively caring for the patient may influence patient.

Stranger may open up more.

Possible bias controlled and other variable with relatively structured approach to interview questions, researcher early in research career.

-Interview was completed in clinic room? Would it have made a difference, time, space between appointment?

Environment was considered with study design – patient home vs clinical space.  Awareness of influence on question outcomes.

Awareness that participants were happy to identify barriers to self-care. Jaap didn’t feel this influenced the conclusions from the study. Current study is not generalisable, but still adds to the research pool.

Future research opportunity different population sample, further focus on themes already identified from WHO framework and current study conclusions.  Negative patient may seek opportunity to complain to an outside researcher, could influence conclusions in qualitative research

Interview vs focus group – structured interview slightly better, where focus groups the researcher has to manage patient interaction and note where conversation may go.  Interaction was missed with patients which is prevalent in focus group.  Questions were used during current study with ‘other patients have experienced X…..” await outcome from participant.

Where do we go from here?

Does this open up for further research to be conducted here?

Clinical day and time can influence outcomes and education delivered.

The invisible balls that patients are constantly juggling with their health care. How do we incorporate education and self-care focus into our practice.  Not more checklists, already heavy administrative burden with a questionnaire or check list, more of an awareness and working more collaboratively. Difficult.

Interactions with people assumptions that you carry – insightful and people’s motivation. Aligning patient goals with therapeutic goals vs therapeutic goals aligning with patient goals. Holistic care. Staged approach to include more therapeutic care goals at each appointment.

Sample size small

  • Not generalisable
  • Use of mobile technology, higher intellect
  • Restricted sample size to control variables for early career researcher.
  • With a general population – different themes, already 5 barriers noted with WHO.  Would not have made a huge difference on the conclusions reached with the current study
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