As the prevalence of LEAs in T2DM continues to increase, it is imperative to gain firsthand accounts of patient perspectives of risk factors for LEAs [2, 3]. Findings from this research suggest that there are a range of factors that seemingly confound a patient’s ability to manage their risk of LEAs. These factors extend beyond the biological and modifiable risk factors such as glycemic index, peripheral arterial disease, neuropathy and structural foot deformities and reflect the complexities that underpin what patients encounter in their everyday lives [6]. Therefore, a holistic approach which recognizes and caters to these complexities may be required in order to better manage the risks associated with LEAs.
Competing priorities
Competing priorities, including family care and finances, emerged as key themes that influenced participants’ perspectives on risk factors for LEAs. Competing priorities have been reported previously in a systematic review of support needs for patients with COPD, which identified finance, work, and housing as important priorties [21]. While caregiver burden has long been recognized as a phenomenon in the management of chronic disease and disability [22]. The results of the current study support previous acknowledgements the burden of caregiver roles of patients who suffer with chronic disease remains largely overlooked by health care professionals [23].
Competing priorities were particularly experienced by participants who had low social support. Participants described this as feelings of inevitability, helplessness, and ultimately inability to manage their diabetes or risk factors. Low social support from friends and family is an intangible factor [24] that can impact morbidity and mortality with the magnitude of the effect being similar to obesity, smoking, hypertension, and physical activity [25]. Our findings reflect studies that low social support networks are directly related to illness and mortality [24, 25].
Low financial resources similarly related to challenges accessing health care. Previous studies have reported that poor access to diabetes care increased the risk of LEAs [26]. In Australia, access to health care and medication is heavily subsidized by the government, however we found that low financial resources were still a barrier. Even where participants acknowledged they had access to health care, factors such as employment responsibilities impacted this. Reflecting Maslow’s hierarchy of needs that unless patients can meet their base needs such as physical and physiological safety for both themselves and their families, they may not be in a psychological position to prioritise other factors impacting their health such as accessing health care [21, 27].
Awareness
Another theme identified in this research was participants lack of awareness. Some participants were unaware of their risks, despite having had a previous LEA and a history of diabetes for more than 25 years. This is of concern, as a health care professional may assume that long duration of chronic diseases is associated with better awareness about risk factors. One possible explanation may be that patients are receiving health information that does not cater to their current understanding. This has been supported with previous literature, highlighting that unless information is contextualized it doesn’t have an impact, which will influence engagement in preventative practices [28,29,30]. Ausubel’s theory, which is based on the principle that the most important factor influencing learning is what the learner already knows [31], suggests a lack of awareness of risk factors for LEAs may be in part due to ineffective education strategies.
Awareness was also influenced by experiences with health care professionals, particularly issues with patient-provider communication. The findings from the current research reflect the notion that satisfaction with patient-provider communication may be associated with greater adherence to self-management practices [32]. In a meta-analysis, the non-adherence percentage was 19% higher in those patients who reported poor patient-provider communication [33]. This supports patient centered communication theories which focus on strategies that accommodate to patient’s communication styles, may lead to improved disease outcomes through increased awareness of risk factors for LEAs [34].
Of interest, even though 53% of participants had experienced several amputations, many downplayed the severity of their diabetes and risk of further LEAs. One possible explanation for this finding is that whilst T2DM is very common, mortality rates and complications are not as commonly discussed [1, 6]. Robbins and associates [1] demonstrates that a diagnosis of cancer is perceived as a more life-threatening diagnosis than diabetes. However, the five-year mortality rates for patients with LEAs are higher than breast and prostate cancer being 46.2-56.6% compared to 31.0% for all reported cancer [35]. This follows the transtheoretical model that the focus is not to intimidate patients to change but rather to engage self-motivation and alter patient perspectives on components such as risk factors to attain self-involvement [21].
Clinical relevance
Health care professionals may recognize risk as arising from the patients’ health status rather than in conjunction with other factors that influence risk [36]. This supports the medical model of health, where there is an optimal level of physiological functioning and below this level could be assumed as poor health [37]. Whereas the findings from the current study suggest that factors such as competing priorities may also need to be considered.
The World Health Organization (WHO) defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ [38]. Suggesting that health is multifactorial and a biopsychosocial approach is needed in clinical practice [37]. Such an approach has gained traction in recent times with the American Diabetes Association releasing a position statement on the psychosocial care of people with diabetes [39].
The findings of the current study support that a holistic approach, where intervention strategies recognize and cater to complexities such as individuals social roles and responsibilities and the need to meet basic physical and psychological needs, could improve clinical outcomes. By recognizing that patients' risk factors for a lower extremity amputation go beyond biological factors, clinicians could implement early referrals, prioritize goals, establish realistic expectations based on the patients' current priorities and alter management plans to ultimately prevent LEA’s.
The findings of the current study also provide support for the ongoing evaluation of individuals diabetes self-care competence [39]. Individual’s awareness of their condition might not always be considered as a risk factor for diabetic foot complications and hence may not be a focus for both the health professional and patient. International guidelines of the diabetic foot engourage ongoing education in a diabetic foot risk assessment, however, their current knowledge may not be assessed [8]. Assessing a patients' awareness and communication styles may allow for the adoption of strategies that enable the assimilation of learning into existing knowledge and understanding [31].
Our findings are consistent with a patient-centered approach to care, which acknowledges the importance of the patient-practitioner relationship and communication [40]. This approach aims to consider individuals psychosocial factors and surrounding social environment to develop a shared understanding of goals and barriers to treatment [40]. If clinicians consider incorporating strategies to address patients' communication needs across the continuum, including determining goals and barriers to care, effective care enviroments, and establishing the patients' needs to communicate, it may help improve both the patients and the practitioners awarness of that individuals risk factors for LEAs.
Limitations
As with any research, there are limitations that need to be acknowledged. Firstly, this research was a qualitative study, conducted within one tertiary hospital setting. While this may limit the transferability of the findings, they do provide first-hand perspectives of patients admitted for a LEA as a result of T2DM. Another limitation to conducting interviews within a hospital setting was interruptions during the interviews. Other health care professionals needed to provide patient care during the interview, however the interview was able to be paused and then resumed. Finally, while this research provides rich information from the patient perspective, it does not provide health care professionals perspective. Further research with this stakeholder group will add to the knowledge base in this field.
