Abstract
Introduction: Footcare is an important component of wellbeing in older adults and the promotion of appropriate footcare interventions is imperative for health professionals working with this population. In this scoping review, we describe the health promotion models informing footcare interventions for older adults. The objectives were to (i) understand the context(s) where health promotion models have informed footcare interventions; (ii) identify the health promotion models informing interventions; and (iii) document the effectiveness of theoretically informed health promotion interventions for improving footcare in older adults. Methods: Footcare interventions developed using health promotion models worldwide and published in English before July 2023 were searched using MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar. Results: A total of 2,078 articles were identified, of which 31 were retrieved and assessed for eligibility. Eight articles met the eligibility criteria, with most interventions delivered in Asia (n = 5) and using self-efficacy theory as their theoretical framework (n = 6). Most of the studies included people with diabetes (n = 6) and outcomes were measured using foot health outcomes, knowledge of foot health, and footcare behaviors and self-efficacy. Conclusion: This scoping review has identified a range of footcare interventions, with evidence of promising outcomes on improving footcare in older adults. Approaches toward methods and dosage of intervention varied across the studies and more broadly, we identified that few studies report the health promotion model informing the design of intervention(s). Further research is required to ascertain which health promotion model, modality of promotion, and implementation approach are the most effective for improving footcare in older adults.
Introduction
Foot problems are common in older adults, with over 30% of those aged 65 years and older suffering from at least one foot problem [1]. Physiological changes affecting the circulatory, immune, and musculoskeletal systems all play a role in the development of these problems [1, 2] as do disease specific mechanisms. Despite the underlying cause, foot problems have been reported to cause pain [1], impaired balance [1, 2], increased risks of falls [3], and anxiety and depression [4] in older adults. Foot problems are often preventable and can be mitigated through practice of good footcare [5, 6] and access to podiatry services. Yet, older adults often face internal (e.g., physical ability, perceived importance, education level and knowledge) and external (e.g., communication between patient-provider, seasonal changes, finance) barriers to seeking and/or receiving footcare, and these underpin poorer health outcomes [7, 8]. Findings from a recent qualitative study identified that older adults benefitted from advice, education, and support to maintain appropriate footcare, yet evidence of the effectiveness of interventions are lacking [9], and there are many challenges to delivering preventative footcare interventions [10]. Effective health promotion strategies are fundamental to enhancing footcare and promoting interventions which target the factors influencing health behaviors.
Health promotion is multidimensional and seeks to enable people to take greater control of their health. Health promotion interventions are underpinned by models which provide a systematic framework for developing interventions relevant to desired outcomes [11] and those informed by a model, or their components, have been shown to be more effective than interventions without an underpinning model [12‒14]. Within the footcare literature, there is a breadth of approaches to footcare interventions, and these include education [15], motivational interviewing [16], and targeted care services delivered by professionals [17]. Yet, little is known about the health promotion models informing these interventions and how beneficial they are for improving footcare or foot health in older adults.
Accessible and personalized footcare services are important for older adults but many complex challenges impact the design and implementation of health promotion interventions. The aim of this scoping review was to describe health promotion models informing footcare interventions for older adults with foot problems. The objectives were to:
- (i)
understand the context(s) where health promotion models have informed footcare interventions;
- (ii)
identify the health promotion models informing interventions;
- (iii)
document the effectiveness of theoretically informed health promotion interventions for improving footcare in older adults.
Method
The scoping review adopts a systematic approach to evidence synthesis, inclusive of diverse study designs and sources. It supports the scoping of evidence on a topic where the research question is exploratory [18] and a breadth of evidence is to be captured. This scoping review was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for scoping reviews [19]. A protocol was developed a priori and agreed by the research team.
Our search strategy was developed in collaboration with two academic librarians (see full search strategy in online suppl. appendix 1; for all online suppl. material, see https://doi.org/10.1159/000538868), and this was developed based on the population (older adults with foot problems), concept (footcare intervention based on specific health promotion model), and context (all health-related settings) (see Table 1). The review included empirical and experimental studies reporting health promotion models for improving footcare in older adults aged ≥60 years of age, as per the definition of the United Nations [20]. The search was limited to articles published in English, without any restrictions on publication date.
Eligibility criteria for the scoping review based on the population, concept and context
| Term | Inclusion criteria | Exclusion criteria | Example search terms* |
|---|---|---|---|
| Population | ≥60 years of age regardless of health status; studies where mean age of participants ≥60 years of age or majority (over 50% of total included subjects) of study population ≥60 years of age | Any studies that target healthcare professionals solely and those with where age of subjects was below the age of 60 years | (Old* or “old* age*” or “old age” or “older adult*” or “older population”).mp |
| (Elder* or “elder population” or “elder age*”).mp | |||
| (Senior* or “senior citizen*” or “senior population”).mp | |||
| Concepts | Empirical and experimental studies reporting foot health or footcare promotion program that explicitly stated the health promotion model(s) that underpinned the program; interventions targeting other diseases but incorporate promotion of footcare as part of the program were also considered | Any foot health or footcare promotion program that did not reference a health promotion model as its underlying framework for development | (“Health Promotion Model” or “Health Promotion” or “Behavio?ral change*”).mp |
| (“Health Belief Model” or HBM or “Perceived Barriers” or “Perceived Benefits” or “Perceived Severity” or “Perceived Susceptibility” or “Self-efficacy”).mp | |||
| (“Transtheoretical Model of Change” or ‘Transtheoretical Model” or TTM or “Transtheoretical Model of Health Behavio?ral Change” or “Transtheoretical Model on Behavio?ral Changes” or “Behavio?ral Changes” or “Process of Behavio?ral Changes” or “Process* of Change*”).mp | |||
| Interventions that promote footcare and foot health and measured its effectiveness using at least one foot health-related outcome measure | Interventions that promote footcare and foot health and did not report its effectiveness with foot health-related outcome measure or did not report the outcome quantitatively | (feet or foot or footcare or “foot care” or “feet care” or “foot health” or “feet health”).mp | |
| Context | All health-related settings including community, clinical settings (hospitals, private clinics), and nursing and care homes |
| Term | Inclusion criteria | Exclusion criteria | Example search terms* |
|---|---|---|---|
| Population | ≥60 years of age regardless of health status; studies where mean age of participants ≥60 years of age or majority (over 50% of total included subjects) of study population ≥60 years of age | Any studies that target healthcare professionals solely and those with where age of subjects was below the age of 60 years | (Old* or “old* age*” or “old age” or “older adult*” or “older population”).mp |
| (Elder* or “elder population” or “elder age*”).mp | |||
| (Senior* or “senior citizen*” or “senior population”).mp | |||
| Concepts | Empirical and experimental studies reporting foot health or footcare promotion program that explicitly stated the health promotion model(s) that underpinned the program; interventions targeting other diseases but incorporate promotion of footcare as part of the program were also considered | Any foot health or footcare promotion program that did not reference a health promotion model as its underlying framework for development | (“Health Promotion Model” or “Health Promotion” or “Behavio?ral change*”).mp |
| (“Health Belief Model” or HBM or “Perceived Barriers” or “Perceived Benefits” or “Perceived Severity” or “Perceived Susceptibility” or “Self-efficacy”).mp | |||
| (“Transtheoretical Model of Change” or ‘Transtheoretical Model” or TTM or “Transtheoretical Model of Health Behavio?ral Change” or “Transtheoretical Model on Behavio?ral Changes” or “Behavio?ral Changes” or “Process of Behavio?ral Changes” or “Process* of Change*”).mp | |||
| Interventions that promote footcare and foot health and measured its effectiveness using at least one foot health-related outcome measure | Interventions that promote footcare and foot health and did not report its effectiveness with foot health-related outcome measure or did not report the outcome quantitatively | (feet or foot or footcare or “foot care” or “feet care” or “foot health” or “feet health”).mp | |
| Context | All health-related settings including community, clinical settings (hospitals, private clinics), and nursing and care homes |
*See online suppl. appendix 1 for full search strategy.
The search strategy was piloted within MEDLINE and further refined before being implemented across three databases (MEDLINE, Embase, and CINAHL) and the Cochrane Library. Google Scholar was also used to search grey literature. Reference lists of selected studies were also screened to capture any additional studies missed in the electronic database searches.
Selection of Evidence
A two-step screening method was adopted. Two members of the research team (Y.-T.W., and C.A.) were involved in independently screening the titles and abstracts against the eligibility criteria (level I screening). Once individual screening was completed, the two researchers met to discuss the results to ensure mutual agreement on eligibility for inclusion. Disagreement was resolved via discussion among the two researchers and further discrepancies settled with a third researcher (S.M.). Once title and abstract screening was completed, full text screening (level II) was undertaken independently by two researchers (Y.-T.W., and C.A.). This step completed with a discussion between the researchers to establish mutual agreement and to resolve any disagreement regarding inclusion and exclusion of studies. The reference lists of the selected studies were also screened once level II screening was completed to identify any eligible studies that were not captured in the electronic database searches. After searches were completed, citations were exported to Covidence for de-duplication and screening. All duplications were extracted prior to level I screening.
Data Extraction, Charting, and Synthesis
Data relevant to the research objectives were extracted and charted against a prespecified data extraction form adapted from the Joanna Briggs Institute (JBI) data extraction framework. Critical appraisal is not expected within a scoping review but, to address objective 3, we documented the effectiveness of interventions and used critical appraisal tools from the JBI to standardize the appraisal of the quality of studies. We used the 9-item checklist for quasi-experimental studies [21] and the 13-item checklist for randomized controlled trials [22]. The scores are reported but were not used to exclude any studies. The two researchers appraised all eligible papers individually and differences in scoring were resolved through discussion.
Results
Selection of Sources of Evidence
The identification and screening of sources of evidence are illustrated in Figure 1. In the identification phase, a total of 3,077 articles were identified (572 MEDLINE, 979 Embase, 532 CINAHL, 351 Cochrane Library, 643 Google Scholar). A total of 1,151 duplicates were removed via Covidence. In the title and abstract screening, 2,078 studies were screened, and 2,047 studies were deemed irrelevant based on the eligibility criteria, leaving 31 studies for full-text screening. Of the remaining 31 studies, 23 were excluded because they did not meet inclusion criteria for patient population (n = 7), outcome measure(s) (n = 6), health promotion model or theory (n = 7), English language (n = 2), or study design (i.e., systematic review) (n = 1). Reference list screening of included studies produced a further 152 studies to be included in title and abstract screening and they were all excluded with reference to the eligibility criteria.
Characteristics of Evidence
The characteristics of individual studies included in this review are presented in Table 2.
Study characteristics of the eight included studies
| Author (year) | Country (sample details) | Study aim | Sample size, gender, and age | Study design | Eligibility criteria |
|---|---|---|---|---|---|
| Alagamy et al. [23] (2019) | Egypt (older patients with diabetes that lived in nine geriatric homes in Al-Gharbiya governorate) | To assess the effect of nursing intervention based on self-efficacy theory on promotion of foot self-care and its acceptability among elderly people with DMII | N = 160, M: 92, F: 68, age range (mean): 62–87 (69.76) | Non-randomized experimental design (quasi-experiment) | Inclusion criteria: Normal protective sensation and lower extremities circulation, free of foot deformity/ulceration, no history of foot ulcer/amputation, ability to communicate, independent |
| Exclusion criteria: Any persons with abnormal findings | |||||
| Borges and Ostwald [24] (2008) | USA (adults with type 2 diabetes who predominantly resided in a Mexican American community) | To determine whether a 15-min culturally and linguistically appropriate intervention would improve foot self-care knowledge and behaviors in adult patients with DMII who presented for nonemergent care in ED | N = 167, M: 58, F: 109, mean age of nonparticipants (SD): 65 (11.5), mean age of participants (SD): 61.5 (11.4) | Pre and posttest, randomized, three-group design | Inclusion criteria: ≥40 years of age, resided within the county, diagnosed with type 2 diabetes, triaged as nonemergent, consented to home visit |
| Exclusion criteria: Triaged as emergent, has active foot ulceration/other foot pathology, inability to communicate verbally | |||||
| Chan [25] (2019) | Hong Kong (Adults with diabetes registered at podiatry departments of 2 local public hospitals) | To evaluate the effects of a program based on HBM on DMII patients by measuring DFC self-efficacy and self-care behaviors, and foot health perception | N = 288, M: 148, F: 140, age range (mean±SD): 39–92 (69.30±10.9) | Randomized controlled trial | Inclusion criteria: ≥18 years of age, ability to read Chinese/speak Cantonese, diagnosed with diabetes |
| Exclusion criteria: Any lower extremity amputation/any acute foot and/or ankle conditions that required urgent medical/podiatric review, old-aged home residents, those with serious cognitive impairments, any one of the hands is unable to touch feet that indicated impairment of self-care, any serious health conditions that would hinder DFC activities (e.g., end-stage renal failure on dialysis) | |||||
| Nguyen et al. [26] (2019) | Vietnam (People with type 2 diabetes) | To evaluate the effectiveness of a theory-based footcare education intervention program For people with diabetes at low risk of developing a foot ulcer | N = 119, M: 33, F: 86, mean age (SD): 62.22 (9.33) | Non-randomized experimental design (quasi-experiment) | Inclusion criteria: ≥2 months treatment and follow-up at the adult clinic of the center, ability to speak, read and understand Vietnamese, reachable by telephone, low risk of developing foot ulcer |
| Exclusion criteria: With cognitive impairment/serious comorbidities (e.g., stroke, dementia) | |||||
| O’Connor et al. [27] (2021) | United States of America (Non-diabetic older adults) | To determine the feasibility and preliminary efficacy of a footcare intervention on footcare knowledge, self-efficacy, behaviors, and foot pain in non-diabetic older adults | N = 32, M: 3, F: 19, age range (mean±SD): 65–88 (73.00±6.6) | Non-randomized experimental design (two-group experiment) | Inclusion criteria: ≥65 years of age, English-speaking, legally competent to provide informed consent, consented to participation |
| Exclusion criteria: Currently seeing any healthcare professionals for footcare, self-reported diabetes, non-traumatic amputation, legal blindness, demonstrated inability to reach their feet or see dots on their feet, and Mental Status Screener Score ≤2, absent pedal pulses, ingrown toenail(s), open foot ulcer(s) | |||||
| Savari et al. [28] (2023) | Iran (Non-diabetic older adults) | To assess the effects of educational programs based on the HBM and improve foot selfcare behavior in older adults in retirement centers | N = 120, M: 61, F: 59, mean age of experimental group (SD): 67.43 (7.3), mean age of control group (SD): 68.70 (17.2) | Non-randomized experimental design (quasi-experiment) | Inclusion criteria: Routine attendance at the retirement center, >60 years of age, ability to complete the survey, speak and read in Farsi, non-diabetic, access to a smartphone and the Internet 1–2 h per day, consented to participation |
| Exclusion criteria: Missing ≥1 educational session, unavailability to fill out posttest questionnaire | |||||
| Sharoni et al. [29] (2017) | Malaysia (Diabetic older adults living in a public long-term care institution) | To assess the feasibility, acceptability and potential impact of the self-efficacy education programme on improving foot self-care behaviors among older diabetic patients that stay in a public long-term care institution | N = 31, M: 14, F: 17, mean age (SD): 68.52 (4.23) | Non-randomized experimental design (quasi-experiment) | Inclusion criteria: ≥60 years of age, Malaysian, ability to communicate in Malay, independent in ADLs |
| Exclusion criteria: Diagnosed with cognitive impairment, psychosis, severe depression or blind, mute and deaf | |||||
| Sharoni et al. [30] (2018) | Malaysia (Diabetic older adults living in 3 elderly care facilities) | To evaluate the effectiveness of health education programs based on the self-efficacy theory on foot self-care behavior for older diabetic adults in elderly care facilities | N = 76, M: 54, F: 22, mean age (SD): 69.76 (7.51) | Randomized controlled trial | Inclusion criteria: Malaysian, ≥60 years of age, diagnosed with diabetes medically, present with/without diabetic foot problems, able to communicate in Malay, able to perform ADLs independently, have no major complications that would impede participation |
| Exclusion criteria: Diagnosed with cognitive function impairment and/or with depressive symptoms and/or with mental health conditions and presenting psychotic symptoms |
| Author (year) | Country (sample details) | Study aim | Sample size, gender, and age | Study design | Eligibility criteria |
|---|---|---|---|---|---|
| Alagamy et al. [23] (2019) | Egypt (older patients with diabetes that lived in nine geriatric homes in Al-Gharbiya governorate) | To assess the effect of nursing intervention based on self-efficacy theory on promotion of foot self-care and its acceptability among elderly people with DMII | N = 160, M: 92, F: 68, age range (mean): 62–87 (69.76) | Non-randomized experimental design (quasi-experiment) | Inclusion criteria: Normal protective sensation and lower extremities circulation, free of foot deformity/ulceration, no history of foot ulcer/amputation, ability to communicate, independent |
| Exclusion criteria: Any persons with abnormal findings | |||||
| Borges and Ostwald [24] (2008) | USA (adults with type 2 diabetes who predominantly resided in a Mexican American community) | To determine whether a 15-min culturally and linguistically appropriate intervention would improve foot self-care knowledge and behaviors in adult patients with DMII who presented for nonemergent care in ED | N = 167, M: 58, F: 109, mean age of nonparticipants (SD): 65 (11.5), mean age of participants (SD): 61.5 (11.4) | Pre and posttest, randomized, three-group design | Inclusion criteria: ≥40 years of age, resided within the county, diagnosed with type 2 diabetes, triaged as nonemergent, consented to home visit |
| Exclusion criteria: Triaged as emergent, has active foot ulceration/other foot pathology, inability to communicate verbally | |||||
| Chan [25] (2019) | Hong Kong (Adults with diabetes registered at podiatry departments of 2 local public hospitals) | To evaluate the effects of a program based on HBM on DMII patients by measuring DFC self-efficacy and self-care behaviors, and foot health perception | N = 288, M: 148, F: 140, age range (mean±SD): 39–92 (69.30±10.9) | Randomized controlled trial | Inclusion criteria: ≥18 years of age, ability to read Chinese/speak Cantonese, diagnosed with diabetes |
| Exclusion criteria: Any lower extremity amputation/any acute foot and/or ankle conditions that required urgent medical/podiatric review, old-aged home residents, those with serious cognitive impairments, any one of the hands is unable to touch feet that indicated impairment of self-care, any serious health conditions that would hinder DFC activities (e.g., end-stage renal failure on dialysis) | |||||
| Nguyen et al. [26] (2019) | Vietnam (People with type 2 diabetes) | To evaluate the effectiveness of a theory-based footcare education intervention program For people with diabetes at low risk of developing a foot ulcer | N = 119, M: 33, F: 86, mean age (SD): 62.22 (9.33) | Non-randomized experimental design (quasi-experiment) | Inclusion criteria: ≥2 months treatment and follow-up at the adult clinic of the center, ability to speak, read and understand Vietnamese, reachable by telephone, low risk of developing foot ulcer |
| Exclusion criteria: With cognitive impairment/serious comorbidities (e.g., stroke, dementia) | |||||
| O’Connor et al. [27] (2021) | United States of America (Non-diabetic older adults) | To determine the feasibility and preliminary efficacy of a footcare intervention on footcare knowledge, self-efficacy, behaviors, and foot pain in non-diabetic older adults | N = 32, M: 3, F: 19, age range (mean±SD): 65–88 (73.00±6.6) | Non-randomized experimental design (two-group experiment) | Inclusion criteria: ≥65 years of age, English-speaking, legally competent to provide informed consent, consented to participation |
| Exclusion criteria: Currently seeing any healthcare professionals for footcare, self-reported diabetes, non-traumatic amputation, legal blindness, demonstrated inability to reach their feet or see dots on their feet, and Mental Status Screener Score ≤2, absent pedal pulses, ingrown toenail(s), open foot ulcer(s) | |||||
| Savari et al. [28] (2023) | Iran (Non-diabetic older adults) | To assess the effects of educational programs based on the HBM and improve foot selfcare behavior in older adults in retirement centers | N = 120, M: 61, F: 59, mean age of experimental group (SD): 67.43 (7.3), mean age of control group (SD): 68.70 (17.2) | Non-randomized experimental design (quasi-experiment) | Inclusion criteria: Routine attendance at the retirement center, >60 years of age, ability to complete the survey, speak and read in Farsi, non-diabetic, access to a smartphone and the Internet 1–2 h per day, consented to participation |
| Exclusion criteria: Missing ≥1 educational session, unavailability to fill out posttest questionnaire | |||||
| Sharoni et al. [29] (2017) | Malaysia (Diabetic older adults living in a public long-term care institution) | To assess the feasibility, acceptability and potential impact of the self-efficacy education programme on improving foot self-care behaviors among older diabetic patients that stay in a public long-term care institution | N = 31, M: 14, F: 17, mean age (SD): 68.52 (4.23) | Non-randomized experimental design (quasi-experiment) | Inclusion criteria: ≥60 years of age, Malaysian, ability to communicate in Malay, independent in ADLs |
| Exclusion criteria: Diagnosed with cognitive impairment, psychosis, severe depression or blind, mute and deaf | |||||
| Sharoni et al. [30] (2018) | Malaysia (Diabetic older adults living in 3 elderly care facilities) | To evaluate the effectiveness of health education programs based on the self-efficacy theory on foot self-care behavior for older diabetic adults in elderly care facilities | N = 76, M: 54, F: 22, mean age (SD): 69.76 (7.51) | Randomized controlled trial | Inclusion criteria: Malaysian, ≥60 years of age, diagnosed with diabetes medically, present with/without diabetic foot problems, able to communicate in Malay, able to perform ADLs independently, have no major complications that would impede participation |
| Exclusion criteria: Diagnosed with cognitive function impairment and/or with depressive symptoms and/or with mental health conditions and presenting psychotic symptoms |
N, total participants; M, male participants; F, female participants; ADLs, Activities of Daily Living; DMII, type II diabetes mellitus; ED, emergency department; SD, standard deviation; HBM, health belief model; PRIOR, Person-centeRed; Health Belief Model guided dIabetic fOot caRe education; DFC, diabetic foot complications.
Participant Characteristics
Of the eight studies, the majority (n = 7) were published between 2017 and 2023. The studies were carried out in 6 different countries: Malaysia (n = 2), USA (n = 2), Hong Kong (n = 1), Egypt (n = 1), Vietnam (n = 1), and Iran (n = 1). Non-randomized (quasi)experimental study was the most adopted design (n = 5), followed by RCT (n = 2) and studies were conducted in geriatric homes [23], acute care facilities [24], podiatry department [25], community healthcare center [26], senior center [27], private retirement center [28], public long-term care institution [29], and public elderly care facilities [30]. Sample sizes ranged from 31 to 288 participants, with the mean age of participants ranging from 62.2 to 76.
Out of the eight studies, six [22‒26, 29, 30] included people with diabetes, while the remaining two studies only included older adults without diabetes [27, 28]. Comorbidities other than diabetes included hypertension [25‒27], hyperlipidemia [25], stroke [25, 27], cardiac disease [25, 27], retinopathy [25, 26], nephropathy [25, 26], and arthritis [27].
Health Promotion Model(s) and Interventions
Table 3 summarizes the intervention(s), health promotion model(s), and outcome(s) of the intervention. Self-efficacy theory (n = 6) was the most common health promotion model, with one also using constructs of self-efficacy theory along with social cognitive theory. Two studies based their intervention(s) on the health belief model.
Program overview by intervention characteristics, theory, outcomes, and quality assessment results
| Author (year) | Intervention | Health promotion model | Reported outcome and effect | Quality assessmentα | |
|---|---|---|---|---|---|
| measurement | intervention details | ||||
| Alagamy et al. [23] (2019) | Baseline, immediate post-intervention, 3-month post-intervention | Number of sessions: 5 sessions | Self-efficacy theory | Foot-related outcomes: KOFC* (range: 12–40, mean±SD: 38.95±6.73) | 9/9 |
| Method of intervention: group education (risk factors, symptoms, prevention of DFC, expectations of footcare, and promotion of foot self-care) | FCOE* (high self-confidence: 75.3%, moderate self-confidence: 4.7%, low self-confidence: 20.0%, p< 0.001) | ||||
| Goal-settings | DFSBS* (range: 6–11, mean±SD: 17.33±0.864, p< 0.001) | ||||
| Printed brochure on foot self-care | Diabetes outcomes: older diabetic structured interview schedule | ||||
| Footcare kit | Others: GSE scale* (high: 86.5%, medium: 3.5%, low: 10.0%; p < 0.001) the acceptability profile | ||||
| Individual footcare advice | |||||
| Delivery: supervisor nurse | |||||
| Borges and Ostwald [24] (2008) | Baseline, 1-month post-intervention | Number of sessions: 1 session | Social cognitive theory, self-efficacy theory | Foot-related outcomes: | 7/13 Bias related to selection and allocation: 2 unclear items (unclear if true randomization was used and if allocation to treatment group was concealed) |
| Foot self-care knowledge from DKQ-24 (N: 47, t value: −1.77, p = 0.08) | Bias related to administration of intervention/exposure: 2 unclear items (unclear if participants and persons who delivered treatments were blind to treatment assignment) | ||||
| Method of intervention: | Foot self-care observation guide* (N: 47, t value: −4.32, p< 0.01) | Bias related to assessment, detection and measurement of the outcome: 1 unclear item (unclear if outcome accessors were blind to treatment assignment) | |||
| Foot assessment | Diabetes outcomes: | Study design was not justified in main text and only methodology was described in the study | |||
| Group education (foot self-care) | Modified insulin management diabetes self-efficacy scale (MIMDSES) (N: 47, t value: −1.21, p= 0.23) | ||||
| Delivery: Researcher | Summary of diabetes self-care activities | ||||
| Others: | |||||
| Acculturation | |||||
| Chan [25] (2019) | Baseline, 12-week post-intervention | Number of sessions: 1 session +2 follow-up calls | Health belief model | Primary foot-related outcome: | 12/13 bias related to administration of intervention/exposure: 1 unfulfilled item (persons who delivered treatments were not blind to treatment assignments due to their healthcare background and knowledge) |
| FCCS* (mean (SD): 47.2 (6.8), β (95% CI): 3.8 (1.5, 6.0), p = 0.001) | |||||
| Method of intervention: | Secondary foot-related outcomes: | ||||
| Foot assessment | Diabetic foot care behavior assessment | ||||
| One-to-one education (DFU risks) | • Preventive* (mean (SD): 0.48 (0.10), β (95% CI): −0.05 (−0.07, −0.02), p = 0.001) | ||||
| Discussion on barriers | • Potentially damaging* (mean (SD): 0.88 (0.08), β (95% CI): 0.03 (0.01, 0.06) p = 0.02) | ||||
| Goal-settings | Podiatry health questionnaire | ||||
| Printed information booklet | • Summative score* (mean (SD): 8.6 (2.1), β (95% CI): −0.59 (−1.03, 0.01), p = 0.04) | ||||
| Diabetic footcare logbook | • VAS* (mean (SD): 15.2 (3.4), β (95% CI): 1.18 (0.04, 2.33), p = 0.04) | ||||
| Delivery: podiatrists | Hallux toenail cuticle to free edge index | ||||
| • Right* (mean (SD): 12.8 (2.1), β (95% CI): −0.75 (−1.40, −1.10), p = 0.02) | |||||
| • Left* (mean (SD): 13.1 (2.3), β (95% CI): −0.65 (−1.29, −0.01) p = 0.04) | |||||
| Hallux relative toenail thickness index | |||||
| • Right (mean (SD): 18.0 (2.0), β (95% CI): −0.44 (−0.88, 0.01), p = 0.06) | |||||
| • Left (mean (SD): 18.0 (1.9), β (95% CI): −0.31 (−0.71, 0.10), p = 0.14) | |||||
| Skin stiffness of plantar metatarsal area | |||||
| • Right plantar metatarsal area (mean (SD): 55.3 (13.5), β (95% CI): −0.30 (−3.88, 3.29), p = 0.87) | |||||
| • Left plantar metatarsal area (mean (SD): 56.8 (15.1), β (95% CI): −1.41 (−4.49, 1.67), p = 0.37) | |||||
| • Right calcaneal area (mean (SD): 56.7 (8.1), β (95% CI): −2.83 (5.20, −0.47), p = 0.19) | |||||
| • Left calcaneal area (mean (SD): 57.4 (7.4), β (95% CI): −1.51 (−3.71, 0.69), p = 0.18) | |||||
| Xerosis assessment | |||||
| • Right (mean (SD): 1.3 (1.2), β (95% CI): −0.18 (−0.55, 0.19), p = 0.35) | |||||
| • Left (mean (SD): 1.2 (1.2), β (95% CI): −0.23 (−0.61, 0.15), p = 0.24) | |||||
| Nguyen et al. [26] (2019) | Baseline, 1-month, 3-month, and 6-month post-intervention | Number of sessions: 1 session +3 follow-up calls | Self-Efficacy Theory | Foot-related outcomes: | 8/9 unfulfilled item: the participants included in comparisons were not receiving similar treatment/care, other than the exposure or intervention of interest due to differences in income and diabetes management between groups |
| FSCB | |||||
| Method of intervention: Group education (risks and management of DFU and foot problems, appropriate foot self-care) | • Preventive foot self-care behavior* (β (95% CI): 0.13 (0.07, 0.19), p < 0.001) | ||||
| • Potentially foot damaging behavior (β (95% CI): −0.005 (−0.05, 0.04), p = 0.82) | |||||
| Discussion on barriers | FCCS | ||||
| Goal-settings | FSKQ | ||||
| Footcare kit | Foot assessment form (only reported DCC results)* (aOR (95% CI): 0.045 (0.014, 0.141), p < 0.001) | ||||
| Printed foot educational materials | Toenail conditions and problems | ||||
| Delivery: Researcher | Diabetes outcome: | ||||
| Diabetes self-care activities (SDSCA) | |||||
| O’Connor et al. [27] (2021) | Baseline, 1-month, 4-month, and 7-month post-intervention | Number of sessions: 4 group sessions | Self-efficacy theory | Foot-related outcomes: | 8/9 unfulfilled item: the participants included in comparisons were not receiving similar treatment/care, other than the exposure or intervention of interest due to differences in medical history between groups |
| FSKQ (median: 10, mean: 9.7, SD: 1.0) | |||||
| Method of intervention: Group education (recommended foot care behaviors, choice of footwear, foot exercises) | FCCS (median: 58, mean: 56.9, SD: 3.4) | ||||
| NAFF (median: 59, mean: 56.1, SD: 8.9) | |||||
| Peer support | MFPDI (median: 2, mean: 6.8, SD: 9.7) | ||||
| Discussion on barriers | R-FHS (median: 3, mean: 2.7, SD: 2.0) | ||||
| Individual coaching and footcare advice | |||||
| Printed handout of footcare tips | |||||
| Footcare kit | |||||
| Delivery: researcher | |||||
| Savari et al. [28] (2023) | Baseline, 2-month post-intervention | Number of sessions: 2 group sessions +2 online sessions | Health belief model | Foot-related outcomes: | 9/9 |
| FSCB (mean±SD: −0.05±0.28, t value: 7.032, p < 0.001) | |||||
| Method of intervention: Group education (foot health knowledge, footcare behaviors, risks of foot problems) | Constructs of health belief model: | ||||
| Perceived susceptibility* (mean±SD: 0.23±1.09, t value: 8.087, p < 0.001) | |||||
| Discussion on barriers of footcare | Perceived severity (mean±SD: 0.22±1.71, t value: 2.024, p = 0.075) | ||||
| Delivery: unknown | Perceived benefits* (mean±SD: −0.48±0.83, t value: 7.131, p < 0.001) | ||||
| Perceived barriers (mean±SD: −0.03±0.25, t value: −1.87, p = 0.066) | |||||
| Perceived self-efficacy* (mean±SD: −0.15±1.43, t value: 4.186, p < 0.001) | |||||
| Cues to action* (mean±SD: −0.08±1.04, t value: 5.392, p < 0.001) | |||||
| Others: | |||||
| Observational checklist* (mean±SD: 0.08±0.33, t value: 6.903, p < 0.001) | |||||
| Sharoni et al. [29] (2017) | Baseline, 12-week post-intervention | Number of sessions: 1 session +4 weekly nurse visits +1 one-to-one discussion +4 biweekly nurse visits | Self-efficacy theory | Primary foot-related outcome: | 8/9 unfulfilled item: there was no control group, as it was a one-group pre-test, posttest experiment |
| DFSBS* (mean±SD: 68.00±6.23, Z: −4.86, p = 0.001) | |||||
| Method of intervention: Group education (risks and management of DFCs and foot self-care behaviors) | Secondary foot-related outcomes: | ||||
| KOFC* (mean±SD: 9.97±1.35, Z: −4.47, p = 0.001) | |||||
| Goal-settings | FCOE* (mean±SD: 25.97±3.43, Z: −4.79, p = 0.001) | ||||
| Discussion on barriers | FCSE* (mean±SD: 43.68±4.94, Z: −4.76, p = 0.001) | ||||
| Individual advice/feedback | Diabetes outcomes: | ||||
| Printed pamphlet on foot self-care | Fasting blood glucose* (mean±SD: 6.98±2.18, Z: −2.57, p = 0.010) | ||||
| Footcare kit | Others: | ||||
| Reminder checklist | Modified version of neuropathy and foot ulcer specific quality of life: physical symptoms* (mean±SD: 19.90±12.32, Z: −2.99, p = 0.003) | ||||
| Delivery: researcher | Psychological functioning (mean±SD: 27.58±6.72, Z: −0.31, p = 0.754) | ||||
| Sharoni et al. [30] (2018) | Baseline, 4-week, 12-week post-intervention | Number of sessions: 1 session +2 fieldwork visits +1 one-to-one discussion | Self-Efficacy Theory | Primary foot-related outcome: | 10/13 bias related to selection and allocation: 1 unfulfilled item (only randomization occurred at center level rather than individual level) |
| DFSBS* (mean±SE: 57.19±1.26, CA: 9.84 (1.79), 95% CI: 6.28–13.40, p < 0.01) | Bias related to administration of intervention/exposure: 2 unfulfilled items (patients were aware of treatment allocation after intervention was given and no blinding of those who delivered intervention) | ||||
| Method of intervention: Group education (risks and management of DFCs, foot self-care behaviors) | Secondary foot-related outcomes: | ||||
| KOFC* (mean±SE: 7.20±0.40, CA (SE): 1.88 (0.56), 95% CI: 0.76, 3.00, p < 0.01) | |||||
| Goal-settings | FCOE* (mean±SE: 23.33±0.48, CA(SE): 2.73 (0.68), 95% CI: 1.38, 4.07, p < 0.01) | ||||
| Discussion on barriers | FCSE* (mean±SE: 38.66±0.75, CA(SE): 4.40 (1.06), 95% CI: 2.29, 6.51, p < 0.01) | ||||
| Individual advice/feedback | Others: | ||||
| Printed pamphlets on foot self-care | QoL: physical symptoms (mean±SE: 28.56±1.87, CA(SE): −0.46 (2.65), 95% CI: −5.73, 4.82) | ||||
| Footcare kit | Psychological functioning (mean±SE: 29.75±2.49, CA: −0.12 (3.53), 95% CI: −7.15, 6.91) | ||||
| Reminder checklist | |||||
| Delivery: researcher (registered nurse) | |||||
| Author (year) | Intervention | Health promotion model | Reported outcome and effect | Quality assessmentα | |
|---|---|---|---|---|---|
| measurement | intervention details | ||||
| Alagamy et al. [23] (2019) | Baseline, immediate post-intervention, 3-month post-intervention | Number of sessions: 5 sessions | Self-efficacy theory | Foot-related outcomes: KOFC* (range: 12–40, mean±SD: 38.95±6.73) | 9/9 |
| Method of intervention: group education (risk factors, symptoms, prevention of DFC, expectations of footcare, and promotion of foot self-care) | FCOE* (high self-confidence: 75.3%, moderate self-confidence: 4.7%, low self-confidence: 20.0%, p< 0.001) | ||||
| Goal-settings | DFSBS* (range: 6–11, mean±SD: 17.33±0.864, p< 0.001) | ||||
| Printed brochure on foot self-care | Diabetes outcomes: older diabetic structured interview schedule | ||||
| Footcare kit | Others: GSE scale* (high: 86.5%, medium: 3.5%, low: 10.0%; p < 0.001) the acceptability profile | ||||
| Individual footcare advice | |||||
| Delivery: supervisor nurse | |||||
| Borges and Ostwald [24] (2008) | Baseline, 1-month post-intervention | Number of sessions: 1 session | Social cognitive theory, self-efficacy theory | Foot-related outcomes: | 7/13 Bias related to selection and allocation: 2 unclear items (unclear if true randomization was used and if allocation to treatment group was concealed) |
| Foot self-care knowledge from DKQ-24 (N: 47, t value: −1.77, p = 0.08) | Bias related to administration of intervention/exposure: 2 unclear items (unclear if participants and persons who delivered treatments were blind to treatment assignment) | ||||
| Method of intervention: | Foot self-care observation guide* (N: 47, t value: −4.32, p< 0.01) | Bias related to assessment, detection and measurement of the outcome: 1 unclear item (unclear if outcome accessors were blind to treatment assignment) | |||
| Foot assessment | Diabetes outcomes: | Study design was not justified in main text and only methodology was described in the study | |||
| Group education (foot self-care) | Modified insulin management diabetes self-efficacy scale (MIMDSES) (N: 47, t value: −1.21, p= 0.23) | ||||
| Delivery: Researcher | Summary of diabetes self-care activities | ||||
| Others: | |||||
| Acculturation | |||||
| Chan [25] (2019) | Baseline, 12-week post-intervention | Number of sessions: 1 session +2 follow-up calls | Health belief model | Primary foot-related outcome: | 12/13 bias related to administration of intervention/exposure: 1 unfulfilled item (persons who delivered treatments were not blind to treatment assignments due to their healthcare background and knowledge) |
| FCCS* (mean (SD): 47.2 (6.8), β (95% CI): 3.8 (1.5, 6.0), p = 0.001) | |||||
| Method of intervention: | Secondary foot-related outcomes: | ||||
| Foot assessment | Diabetic foot care behavior assessment | ||||
| One-to-one education (DFU risks) | • Preventive* (mean (SD): 0.48 (0.10), β (95% CI): −0.05 (−0.07, −0.02), p = 0.001) | ||||
| Discussion on barriers | • Potentially damaging* (mean (SD): 0.88 (0.08), β (95% CI): 0.03 (0.01, 0.06) p = 0.02) | ||||
| Goal-settings | Podiatry health questionnaire | ||||
| Printed information booklet | • Summative score* (mean (SD): 8.6 (2.1), β (95% CI): −0.59 (−1.03, 0.01), p = 0.04) | ||||
| Diabetic footcare logbook | • VAS* (mean (SD): 15.2 (3.4), β (95% CI): 1.18 (0.04, 2.33), p = 0.04) | ||||
| Delivery: podiatrists | Hallux toenail cuticle to free edge index | ||||
| • Right* (mean (SD): 12.8 (2.1), β (95% CI): −0.75 (−1.40, −1.10), p = 0.02) | |||||
| • Left* (mean (SD): 13.1 (2.3), β (95% CI): −0.65 (−1.29, −0.01) p = 0.04) | |||||
| Hallux relative toenail thickness index | |||||
| • Right (mean (SD): 18.0 (2.0), β (95% CI): −0.44 (−0.88, 0.01), p = 0.06) | |||||
| • Left (mean (SD): 18.0 (1.9), β (95% CI): −0.31 (−0.71, 0.10), p = 0.14) | |||||
| Skin stiffness of plantar metatarsal area | |||||
| • Right plantar metatarsal area (mean (SD): 55.3 (13.5), β (95% CI): −0.30 (−3.88, 3.29), p = 0.87) | |||||
| • Left plantar metatarsal area (mean (SD): 56.8 (15.1), β (95% CI): −1.41 (−4.49, 1.67), p = 0.37) | |||||
| • Right calcaneal area (mean (SD): 56.7 (8.1), β (95% CI): −2.83 (5.20, −0.47), p = 0.19) | |||||
| • Left calcaneal area (mean (SD): 57.4 (7.4), β (95% CI): −1.51 (−3.71, 0.69), p = 0.18) | |||||
| Xerosis assessment | |||||
| • Right (mean (SD): 1.3 (1.2), β (95% CI): −0.18 (−0.55, 0.19), p = 0.35) | |||||
| • Left (mean (SD): 1.2 (1.2), β (95% CI): −0.23 (−0.61, 0.15), p = 0.24) | |||||
| Nguyen et al. [26] (2019) | Baseline, 1-month, 3-month, and 6-month post-intervention | Number of sessions: 1 session +3 follow-up calls | Self-Efficacy Theory | Foot-related outcomes: | 8/9 unfulfilled item: the participants included in comparisons were not receiving similar treatment/care, other than the exposure or intervention of interest due to differences in income and diabetes management between groups |
| FSCB | |||||
| Method of intervention: Group education (risks and management of DFU and foot problems, appropriate foot self-care) | • Preventive foot self-care behavior* (β (95% CI): 0.13 (0.07, 0.19), p < 0.001) | ||||
| • Potentially foot damaging behavior (β (95% CI): −0.005 (−0.05, 0.04), p = 0.82) | |||||
| Discussion on barriers | FCCS | ||||
| Goal-settings | FSKQ | ||||
| Footcare kit | Foot assessment form (only reported DCC results)* (aOR (95% CI): 0.045 (0.014, 0.141), p < 0.001) | ||||
| Printed foot educational materials | Toenail conditions and problems | ||||
| Delivery: Researcher | Diabetes outcome: | ||||
| Diabetes self-care activities (SDSCA) | |||||
| O’Connor et al. [27] (2021) | Baseline, 1-month, 4-month, and 7-month post-intervention | Number of sessions: 4 group sessions | Self-efficacy theory | Foot-related outcomes: | 8/9 unfulfilled item: the participants included in comparisons were not receiving similar treatment/care, other than the exposure or intervention of interest due to differences in medical history between groups |
| FSKQ (median: 10, mean: 9.7, SD: 1.0) | |||||
| Method of intervention: Group education (recommended foot care behaviors, choice of footwear, foot exercises) | FCCS (median: 58, mean: 56.9, SD: 3.4) | ||||
| NAFF (median: 59, mean: 56.1, SD: 8.9) | |||||
| Peer support | MFPDI (median: 2, mean: 6.8, SD: 9.7) | ||||
| Discussion on barriers | R-FHS (median: 3, mean: 2.7, SD: 2.0) | ||||
| Individual coaching and footcare advice | |||||
| Printed handout of footcare tips | |||||
| Footcare kit | |||||
| Delivery: researcher | |||||
| Savari et al. [28] (2023) | Baseline, 2-month post-intervention | Number of sessions: 2 group sessions +2 online sessions | Health belief model | Foot-related outcomes: | 9/9 |
| FSCB (mean±SD: −0.05±0.28, t value: 7.032, p < 0.001) | |||||
| Method of intervention: Group education (foot health knowledge, footcare behaviors, risks of foot problems) | Constructs of health belief model: | ||||
| Perceived susceptibility* (mean±SD: 0.23±1.09, t value: 8.087, p < 0.001) | |||||
| Discussion on barriers of footcare | Perceived severity (mean±SD: 0.22±1.71, t value: 2.024, p = 0.075) | ||||
| Delivery: unknown | Perceived benefits* (mean±SD: −0.48±0.83, t value: 7.131, p < 0.001) | ||||
| Perceived barriers (mean±SD: −0.03±0.25, t value: −1.87, p = 0.066) | |||||
| Perceived self-efficacy* (mean±SD: −0.15±1.43, t value: 4.186, p < 0.001) | |||||
| Cues to action* (mean±SD: −0.08±1.04, t value: 5.392, p < 0.001) | |||||
| Others: | |||||
| Observational checklist* (mean±SD: 0.08±0.33, t value: 6.903, p < 0.001) | |||||
| Sharoni et al. [29] (2017) | Baseline, 12-week post-intervention | Number of sessions: 1 session +4 weekly nurse visits +1 one-to-one discussion +4 biweekly nurse visits | Self-efficacy theory | Primary foot-related outcome: | 8/9 unfulfilled item: there was no control group, as it was a one-group pre-test, posttest experiment |
| DFSBS* (mean±SD: 68.00±6.23, Z: −4.86, p = 0.001) | |||||
| Method of intervention: Group education (risks and management of DFCs and foot self-care behaviors) | Secondary foot-related outcomes: | ||||
| KOFC* (mean±SD: 9.97±1.35, Z: −4.47, p = 0.001) | |||||
| Goal-settings | FCOE* (mean±SD: 25.97±3.43, Z: −4.79, p = 0.001) | ||||
| Discussion on barriers | FCSE* (mean±SD: 43.68±4.94, Z: −4.76, p = 0.001) | ||||
| Individual advice/feedback | Diabetes outcomes: | ||||
| Printed pamphlet on foot self-care | Fasting blood glucose* (mean±SD: 6.98±2.18, Z: −2.57, p = 0.010) | ||||
| Footcare kit | Others: | ||||
| Reminder checklist | Modified version of neuropathy and foot ulcer specific quality of life: physical symptoms* (mean±SD: 19.90±12.32, Z: −2.99, p = 0.003) | ||||
| Delivery: researcher | Psychological functioning (mean±SD: 27.58±6.72, Z: −0.31, p = 0.754) | ||||
| Sharoni et al. [30] (2018) | Baseline, 4-week, 12-week post-intervention | Number of sessions: 1 session +2 fieldwork visits +1 one-to-one discussion | Self-Efficacy Theory | Primary foot-related outcome: | 10/13 bias related to selection and allocation: 1 unfulfilled item (only randomization occurred at center level rather than individual level) |
| DFSBS* (mean±SE: 57.19±1.26, CA: 9.84 (1.79), 95% CI: 6.28–13.40, p < 0.01) | Bias related to administration of intervention/exposure: 2 unfulfilled items (patients were aware of treatment allocation after intervention was given and no blinding of those who delivered intervention) | ||||
| Method of intervention: Group education (risks and management of DFCs, foot self-care behaviors) | Secondary foot-related outcomes: | ||||
| KOFC* (mean±SE: 7.20±0.40, CA (SE): 1.88 (0.56), 95% CI: 0.76, 3.00, p < 0.01) | |||||
| Goal-settings | FCOE* (mean±SE: 23.33±0.48, CA(SE): 2.73 (0.68), 95% CI: 1.38, 4.07, p < 0.01) | ||||
| Discussion on barriers | FCSE* (mean±SE: 38.66±0.75, CA(SE): 4.40 (1.06), 95% CI: 2.29, 6.51, p < 0.01) | ||||
| Individual advice/feedback | Others: | ||||
| Printed pamphlets on foot self-care | QoL: physical symptoms (mean±SE: 28.56±1.87, CA(SE): −0.46 (2.65), 95% CI: −5.73, 4.82) | ||||
| Footcare kit | Psychological functioning (mean±SE: 29.75±2.49, CA: −0.12 (3.53), 95% CI: −7.15, 6.91) | ||||
| Reminder checklist | |||||
| Delivery: researcher (registered nurse) | |||||
SD, standard deviation; N, frequency; β, beta coefficient: CI, confidence interval; DCC, dry skin, cracked skin and corns/callus; aOR, adjusted odds ratio; Z, standard score; SE, standard error; CA, comparison analysis (Bonferroni adjustment methods of comparison analysis); FCOE, footcare outcome expectation; QoL, quality of life; KOFC, knowledge of footcare; FCSE, footcare self-efficacy; DFSBS, diabetes foot self-care behavior scale; FSCB, foot self-care behavior; R-FHS, revised foot health score; MFPDI, Manchester foot pain and disability index; NAFF, Nottingham assessment of functional footcare; FCSS, footcare confidence scale; FSKQ, foot self-care knowledge questionnaire; GSE, general self-efficacy.
*Indicates statistically significant results. α Quality assessment was conducted using JBI critical appraisal tools: 9-item checklist for quasi-experimental studies and 13-item checklist for randomized controlled trials.
Approaches to the delivery of education varied across the studies; Chan [25] used one-to-one education delivered by podiatrists while most of the studies (n = 7) delivered education in group formats. The study by Sharoni et al. [29] adopted a hybrid of group and online education (via a messaging app). In these sessions, a broad spectrum of topics was covered, from risk and management of foot complications [23, 27, 28], information on diabetic foot problems and its management [21‒24, 27], recommended footcare behaviors [23‒30], and standard footcare [23‒30]. There were also several interventions used in the studies other than face-to-face education and this included discussion on barriers/obstacles of footcare (n = 7), printed booklets/brochure/pamphlets (n = 6), footcare kit (n = 5), facilitation of goal-settings (n = 5), individual advice/coaching/feedback on footcare (n = 4), and reminder checklist (n = 2).
Outcomes
There were multiple outcome measures used across the eight studies and these measured various dimensions of foot health outcomes, as well as other health outcomes. These are discussed according to the intended outcomes.
Foot Health Outcomes
Footcare promotion programs typically generated positive outcomes, as reported in Table 3. The effects of these interventions were classified into 3 categories: foot health outcomes, knowledge on foot health, footcare behaviors and self-efficacy.
Foot Health Outcomes. There were 6 different instruments used across the studies to measure foot health outcomes before and after the intervention(s): footcare outcome expectation (FCOE) (n = 3), foot conditions (hallux toenail cuticle to free edge index, hallux relative toenail thickness index, skin stiffness of plantar metatarsal area, xerosis assessment) (n = 1), podiatry health questionnaire (n = 1), foot assessment form (n = 1), Manchester foot pain and disability index (MFPDI) (n = 1), and the revised foot health score (R-FHS) (n = 1). Foot conditions used by Chan [25] were the only observer-reported outcome measure used, while the other 5 instruments were patient-reported outcomes. There were positive and statistically significant patient-reported outcomes regardless of study design, theoretical model, modality, and dosage of interventions among the six studies. Regardless of whether the delivery of intervention was in the form of five 20–30 min group sessions [23], single group education session and fieldwork visits [29, 30] or single group session with telephone follow-ups [26], they all showed significant improvements in FCOE within intervention groups; whereas four group sessions with individual coaching, peer support, and provision of footcare equipment also showed significant improvements in MFPDI and R-FHS that measured foot pain and foot health in the intervention group [27]. For the observer-reported outcomes reported in Chan’s [25] study, it was only the hallux toenail cuticle to free edge index which showed significant improvement.
Knowledge of Foot Health. A total of 3 measurement tools were used for assessing changes in knowledge of foot health in six studies: knowledge of footcare (KOFC) (n = 3), foot self-care knowledge questionnaire (FSKQ) (n = 2), and foot self-care knowledge from diabetes knowledge questionnaire (DKQ-24) (n = 1). Positive and significant changes in KOFC were observed in 3 interventions [23, 29, 30] where self-efficacy theory was adopted to inform footcare promotion programs which consisted of group education [23] and group sessions coupled with follow-up visits and one-to-one consultations [29, 30]. The adoption of self-efficacy theory in the group education sessions also showed significant improvement in the intervention conducted by O’Connor et al. [27] and measured by the FSKQ. In the study by Nguyen et al. [26], the results of FSKQ intervention were reported and adjusted along with all the other measurement tools for foot self-care behaviors and showed significant improvements in all three follow-up periods when compared to baseline. Footcare knowledge measured in Borges and Ostwald’s [24] study, which constituted of a 15-minute education session and follow-up home visit, showed no significant improvement in experimental group when compared to those in control.
Footcare Behaviors and Self-Efficacy. All eight studies reported changes in footcare behaviors and self-efficacy among participants. Different instruments were used across studies and included the foot care confidence scale (n = 3), foot self-care behavior (FSCB) (n = 2), footcare self-efficacy (n = 2), Nottingham assessment of functional footcare (NAFF) (n = 1), foot self-care observation guide (n = 1), diabetes foot self-care behavior scale (DFSBS) (n = 3), diabetic foot care behavior assessment (n = 1). Two of these instruments used were diabetes-specific and measured footcare behaviors and self-efficacy in patients with diabetes, in 4 different studies [23, 25, 29, 30]. DFSBS was the primary outcome in two of these studies [29, 30]. When being measured by FSCB, studies using group sessions that adopted self-efficacy theory [26] and health belief model [28] both produced significant improvements in intervention groups when compared to control groups. Another group-based education program using self-efficacy theory also produced significantly positive results in NAFF [27]. In the three studies that modeled their group education programs on self-efficacy theory, they all produced significantly positive results in DFSBS [23, 29, 30]. On the other hand, the one-to-one intervention based on health belief model [25] yielded positive and significant results in intervention group when measured with Diabetic Foot Care Behavior Assessment.
Sources of Evidence
The results from the quality appraisal are presented in Table 3. Of the 5 quasi-experimental studies, 2 studies attained all 9 reported items and 4 studies fulfilled 8 out of 9 reported items based on the checklist as participants in the control group received no treatments or intervention (i.e., not receiving similar treatment other than the intervention of interest). Of the 3 RCTs, 1 study fulfilled 12 out of 13 reported items as the healthcare professionals were not blinded to the treatment assignment [25]; whereas the other RCT fulfilled 10 out of 13 reported items based on the checked list, as there was no true randomization used, participants were not blinded to the treatment assignment, and those delivering the treatment were not blind to treatment assignment [30]. All the unfulfilled items in the RCTs were biases related to internal validity.
Discussion
This scoping review sought to describe health promotion models underpinning footcare interventions for older adults with foot problems and has identified eight studies, with the self-efficacy theory (used as a standalone theory extracted from social cognitive theory), social cognitive theory, and the health belief model used to inform footcare interventions. This review has identified that all included studies reported improved footcare behaviors and knowledge following interventions underpinned by a health promotion model. However, each study varied in the approach to intervention, context of delivery, dosage, measurement, and results.
Use of Health Promotion Models and Their Effectiveness
The social cognitive theory, self-efficacy theory, and health belief model were used to inform the development of health promotion interventions to improve footcare, similar to the use of behavioral theories in other work [12‒14, 31]. The social cognitive theory was proposed by Bandura (1986) and described the interactions between human behaviors, personal factors, and environmental influences and that human beings are
“self-organizing, proactive, self-reflecting and self-regulating” [32, 33].
This describes how people learn by observing others, and how they use cognitive processes to regulate their behavior. The health belief model
“addresses the individual’s perceptions of the threats posed by a health problem (susceptibility, severity), the benefits of avoiding the threat, and factors influencing the decision to act (barriers, cues to action, and self-efficacy)” [34].
The six constructs within this model are factors of health-related behaviors and can be used to explain and predict behaviors. Intended changes in constructs through footcare interventions can theoretically result in behavioral modification and thus improve foot health outcomes in older adults. Our review identified one study which reported on how each construct in the Health belief model affected the outcomes of an intervention [28]. Self-efficacy was used as a standalone construct/theory to inform footcare interventions. Self-efficacy refers to the confidence in one’s ability to act and overcome barriers [32, 34] and is influenced by perceived self-efficacy and outcome expectations [35].
Within the health promotion literature, the self-efficacy theory and health belief model have demonstrated positive outcomes in initiating desirable behavioral changes within different populations (e.g., hemodialysis patients, dentistry, heart failure patients) [36‒38]. Nonetheless, due to the heterogeneity in study designs, modalities of intervention, settings, participant characteristics, and foot-related outcome measures, it is difficult to determine whether there are any differences between the models when used to guide footcare interventions. Furthermore, all the studies reported in this review adopted at least two interventions, with group education being the most popular modality among others, such as foot assessment, printed education materials, goal-settings, discussion of barriers to footcare, and footcare equipment. One study [26] detailed how constructs of the health belief model were incorporated within the intervention and highlighted the need for studies to provide further details on how models and theories were informing interventions. This is important to determine whether the intervention produces better outcomes, or if it is a synergistic effect from the multicomponent interventions.
Across the literature, there was limited reporting of health promotion models, and this was a common reason for exclusion in full-text screening. While the underreporting of health promotion models within interventions is a challenge [31], it may also be attributed to the fact that programs were not developed with a specific health promotion model or behavioral theory. It is recommended that future footcare promotion interventions include reporting of the health promotion model (or the absence of it) to support the development of a theoretically robust evidence base.
Aging Population and Footcare Promotion Initiatives
Whilst all included studies comprised of participants with a mean age of 60 years or above, there was variation; three targeted adults of different age groups [24‒26] and six studies only included people with diabetes [23‒26, 29, 30]. There were 5 studies [24, 26‒29] that recorded statistically significant differences in participant characteristics (e.g., having a primary care provider, income, diabetes management by diet or insulin, history of hypertension, ethnicity) between intervention and control groups without consideration of the effects on the intervention.
The literature identified in this review was dominated by studies in people with diabetes but other comorbidities (e.g., hypertension, cardiac diseases, renal impairment) were reported, and reflected the growing prevalence of multi-morbidity in the older population [39]. However, none of the studies investigated whether (multi-)morbidities influenced the outcomes. Without further investigation on the potential effects of co-morbidities on the reported outcomes (e.g., stratifying disease-free older adults, those with diabetes only, and those with multimorbidities) more research is needed to compare the differences in outcomes.
All the interventions focused on the individual level and did not appear to address issues at family, community, policy, or structural level. It is recognized that health promotion programs beyond individual level may be perceived as more complicated, or out of scope for some agencies. Previous studies have shown promising results for community-based and societal-based interventions for health promotion in areas such as musculoskeletal health for the elderly [40] and adults with hypertension [39, 41] and suggest that new approaches to programs for older adults to improve footcare at a community or population level could be feasible.
There was no evidence of any of the studies considering the economic value of the interventions. The clinical impact of a health promotion programs should be evaluated alongside its economic value to inform decision making on whether the program is viable [42]. Cost and clinical effectiveness of footcare promotion initiatives for older adults need to be considered to ensure the quality, feasibility, and efficacy for improving foot health in older adults. This points to the need to conduct studies that look at both direct effectiveness of footcare interventions and their cost-benefit and/or cost-effectiveness to recognize the practicality of programs when implemented in real world scenarios.
There was a range of foot-related outcome measures used across the studies. All the theoretically informed promotion strategies yielded positive results when compared to control groups or conventional interventions without clear theoretical basis. There was a lack of consensus on the utilization of foot-related outcome measures to be used in the studies that investigate effectiveness of footcare promotion program, e.g., footcare self-efficacy is measured using both FCCS (n = 3) and FCSE (n = 2). In addition, further research on the validity and reliability of foot-related outcome measurements is recommended to standardize measurement tools used to evaluate foot-related outcomes.
The findings of this scoping review need to be considered against several limitations. We imposed language restrictions which may have introduced a publication bias. In addition, Google Scholar was the only platform we used to search for grey literature. We also acknowledge that the focus on models of health promotion (as opposed to the implementation or delivery of interventions) is likely to have resulted in the exclusion of studies. Data synthesis was challenging due to the heterogeneity of foot health outcome measures used in each study and whilst we did not impose any restrictions on health status of included subjects, most participants had diabetes, and this limits the generalizability of findings to the older adult population.
Whilst this review has uncovered several health promotion interventions, there is no standard approach to the methods and/or dosage of intervention, and further research is required to ascertain which footcare interventions, and implementation approach, are effective. There is also a need to enhance the development and reporting of theory-based interventions for improving footcare in older adults. It is recognized that footcare interventions need to be tailored to different settings and populations and greater recognition of the intrapersonal, interpersonal, and community level factors which may interact with interventions and influence foot-related outcomes is needed. Further work which explicitly draws upon (and reports) health behavior theories and adopts systematic approaches to developing, implementing and evaluating interventions is needed to address the growing burden of footcare problems in older adults.
Conclusion
The health promotion interventions identified in this review represented a broad spectrum of theoretically informed interventions delivered globally, and many demonstrated promising outcomes on improving footcare in older adults. Whilst this review identified that the self-efficacy theory and the health belief model were the most adopted, there were differences with the methods and dosage of intervention(s). As such, further research is required to ascertain which health promotion model, modality of promotion, and implementation approach are the most effective within footcare settings. The overall findings suggest that there is a need to understand more about the theoretical basis for health promotions interventions in older adults. Similarly, footcare promotion programs for different settings and subgroups in older populations, as well as how physiological, interpersonal, environmental, social, and political variables may interact with interventions and influence foot-related outcomes, are all important components that require further research.
Acknowledgments
We would like to thank Chimnedum Akwani for their contributions toward data screening and selection.
Statement of Ethics
An ethics statement is not applicable because this study is based exclusively on published literature.
Conflict of Interest Statement
We have no conflicts of interest to declare.
Funding Sources
This study was not supported by any sponsor or funder. The work was conducted in partial fulfilment of the MSc (preregistration) physiotherapy program for the first author (Y.-T.W.).
Author Contributions
S.M. conceived the idea, and S.M. and Y.-T.W. were both involved in the design of the study, and development of the study protocol and methods. Y.-T.W. conducted the data searching, analysis, extraction, and synthesis. Y.-T.W. and S.M. have written and edited the work and both have approved the submitted version.
Data Availability Statement
Our search strategies are included in this article. Further inquiries can be directed to the corresponding author.
References
