Barriers and enablers to providing preventative and early intervention diabetes-related foot care: a qualitative study of primary care healthcare professionals’ perceptions
Leanne Mullan
A F , Karen Wynter A B C , Andrea Driscoll A B and Bodil Rasmussen A B C D E
+ Author Affiliations
- Author Affiliations
A Deakin University School of Nursing and Midwifery, 1 Gheringhap Street, Geelong, Vic. 3220, Australia.
B Centre for Quality and Patient Safety, Deakin University, 1 Gheringhap Street, Geelong, Vic. 3220, Australia.
C Western Health Partnership, 176 Furlong Road, St Albans, Burwood, Vic. 3021, Australia.
D Faculty of Health and Medical Sciences, Blegdamsvej 3B, 2200 Copenhagen, Denmark.
E Faculty of Health Sciences, University of Southern Denmark and Steno Diabetes Center, Campusvej 55, DK-5230 Odense M, Denmark.
F Corresponding author. Email: mulea@deakin.edu.au
Australian Journal of Primary Health 27(4) 319-327 https://doi.org/10.1071/PY20235
Submitted: 8 October 2020 Accepted: 4 February 2021 Published: 16 April 2021
Abstract
This study explored the perceived healthcare system and process barriers and enablers experienced by GPs and Credentialled Diabetes Educators (CDEs) in Australian primary care, in the delivery of preventative and early intervention foot care to people with diabetes. A qualitative design with inductive analysis approach was utilised and reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ). Semi-structured interviews were conducted with two GPs and 14 CDEs from rural, urban and metropolitan areas of Australia. Participants were from New South Wales, South Australia, Victoria, Western Australia, the Northern Territory and Queensland. Barriers to providing foot care constituted five broad themes: (1) lack of access to footcare specialists and services; (2) education and training insufficiencies; (3) human and physical resource limitations related to funding inadequacies; (4) poor care integration such as inadequate communication and feedback across services and disciplines, and ineffectual multidisciplinary care; and (5) deficient footcare processes and guidelines including ambiguous referral pathways. Enablers to foot care were found at opposing ends of the same spectra as the identified barriers or were related to engaging in mentorship programs and utilising standardised assessment tools. This is the first Australian study to obtain information from GPs and CDEs about the perceived barriers and enablers influencing preventative and early intervention diabetes-related foot care. Findings offer an opportunity for the development and translation of effective intervention strategies across health systems, policy, funding, curriculum and clinical practice, in order to improve outcomes for people with diabetes.
Keywords: primary health care, diabetic foot, diabetes, prevention, Australia, foot disease, general practitioner, nurse.
References
Allen ML, van der Does AMB, Gunst C (2016) Improving diabetic foot screening at a primary care clinic: a quality improvement project. African Journal of Primary Health Care & Family Medicine 8, a955| Improving diabetic foot screening at a primary care clinic: a quality improvement project.Crossref | GoogleScholarGoogle Scholar |
Alonso-Fernández M, Mediavilla-Bravo JJ, López-Simarro F, Comas-Samper JM, Carramiñana-Barrera F, Mancera-Romero J, de Santiago Nocito A (2014) Evaluation of diabetic foot screening in Primary Care. Endocrinología y Nutrición 61, 311–317.
| Evaluation of diabetic foot screening in Primary Care.Crossref | GoogleScholarGoogle Scholar | 24582291PubMed |
Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA (2020) Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. Journal of Foot and Ankle Research 13, 16
| Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer.Crossref | GoogleScholarGoogle Scholar | 32209136PubMed |
Australian Commission on Safety and Quality in Health Care (2015) Australian atlas of healthcare variation 2015: 6.8 diabetes-related lower limb amputation hospital admissions 18 years and over. (Australian Commission on Safety and Quality in Health Care: Sydney, NSW, Australia) Available at https://www.safetyandquality.gov.au/publications-and-resources/resource-library/australian-atlas-healthcare-variation-2015-chapter-68-diabetes-related-lower-limb-amputation-hospital-admissions-18-years-and-over [Verified 6 October 2020]
Australian Diabetes Educators Association (2020) What is credentialling? (Australian Diabetes Educators Association: Canberra, ACT, Australia) Available at https://www.adea.com.au/credentialling/what-is-credentialling/ [Verified 9 November 2020]
Begoray DL, Banister EM (2012) Reflexivity. In. ‘Encyclopedia of case study research’. (Eds AJ Mills, G Durepos, E Wiebe) pp. 788. (SAGE Publications: Thousand Oaks, CA, USA)
Bergin SM, Brand CA, Colman PG, Campbell DA (2009) An evaluation of community-based resources for management of diabetes-related foot disorders in an Australian population. Australian Health Review 33, 671–678.
| An evaluation of community-based resources for management of diabetes-related foot disorders in an Australian population.Crossref | GoogleScholarGoogle Scholar | 20166917PubMed |
Bergin SM, Alford JB, Allard BP, Gurr JM, Holland EL, Horsley MW, Kamp MC, Lazzarini PA, Nube VL, Sinha AK, Warnock JT, Wraight PR, (2012) A limb lost every 3 hours: can Australia reduce amputations in people with diabetes? The Medical Journal of Australia 197, 197–198.
| A limb lost every 3 hours: can Australia reduce amputations in people with diabetes?Crossref | GoogleScholarGoogle Scholar | 22900854PubMed |
Bower P, Wallace P, Ward E, Graffy J, Miller J, Delaney B, Kinmonth AL (2009) Improving recruitment to health research in primary care Family Practice 26, 391–397.
| Improving recruitment to health research in primary careCrossref | GoogleScholarGoogle Scholar | 19549623PubMed |
Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77–101.
| Using thematic analysis in psychology.Crossref | GoogleScholarGoogle Scholar |
Coffey L, Mahon C, Gallagher P (2019) Perceptions and experiences of diabetic foot ulceration and foot care in people with diabetes: a qualitative meta-synthesis. International Wound Journal 16, 183–210.
| Perceptions and experiences of diabetic foot ulceration and foot care in people with diabetes: a qualitative meta-synthesis.Crossref | GoogleScholarGoogle Scholar | 30393976PubMed |
Cohen J (1960) A coefficient of agreement for nominal scales. Educational and Psychological Measurement 20, 37–46.
| A coefficient of agreement for nominal scales.Crossref | GoogleScholarGoogle Scholar |
Commons RJ, Robinson CH, Gawler D, Davis JS, Price RN (2015) High burden of diabetic foot infections in the top end of Australia: An emerging health crisis (DEFINE study). Diabetes Research and Clinical Practice 110, 147–157.
| High burden of diabetic foot infections in the top end of Australia: An emerging health crisis (DEFINE study).Crossref | GoogleScholarGoogle Scholar | 26453263PubMed |
Commonwealth of Australia (2011) National Health & Medical Research Council (NHMRC) Guideline: National evidence-based guideline on prevention, identification and management of foot complications in diabetes. (Commonwealth of Australia: Canberra, ACT, Australia) Available at https://www.baker.edu.au/-/media/documents/impact/diabetes-foot-guidelines/baker-institute-foot-complications-full-guideline.pdf?la=en [Verified 13 October 2020]
Davies A (2014) How does Australian diabetic foot screening rate on an international stage? [Poster presentation]. Annual Scientific Meeting of the Australian Diabetes Society and the Australian Diabetes Educators Association, Australia, 27–29 August. Available at https://eprints.qut.edu.au/84294/
Department of Health (2019) Stronger rural health strategy – factsheets. (Department of Health: Canberra, ACT, Australia) Available at https://www1.health.gov.au/internet/main/publishing.nsf/Content/stronger-rural-health-strategy-factsheets
Formosa C, Chockalingam N, Gatt A (2019) Diabetes foot screenings: challenges and future strategies. The Foot 38, 8–11.
| Diabetes foot screenings: challenges and future strategies.Crossref | GoogleScholarGoogle Scholar | 30530012PubMed |
Guell C, Unwin N (2015) Barriers to diabetic foot care in a developing country with a high incidence of diabetes related amputations: an exploratory qualitative interview study. BMC Health Services Research 15, 377
| Barriers to diabetic foot care in a developing country with a high incidence of diabetes related amputations: an exploratory qualitative interview study.Crossref | GoogleScholarGoogle Scholar | 26369788PubMed |
Harrison-Blount M, Cullen M, Nester C, Williams A (2014) The assessment and management of diabetes related lower limb problems in India-an action research approach to integrating best practice. Journal of Foot and Ankle Research 7, 30
| The assessment and management of diabetes related lower limb problems in India-an action research approach to integrating best practice.Crossref | GoogleScholarGoogle Scholar | 24862010PubMed |
Hummers-Pradier E, Scheidt-Nave C, Martin H, Heinemann S, Kochen MM, Himmel W (2008) Simply no time? Barriers to GP’s participation in primary health care research. Family Practice 25, 105–112.
| Simply no time? Barriers to GP’s participation in primary health care research.Crossref | GoogleScholarGoogle Scholar | 18417465PubMed |
Krippendorf K (1980) ‘Content analysis: an introduction to its methodology.’ (Sage Publications Inc.: London)
Lazzarini PA, Pacella RE, Armstrong DG, van Netten JJ (2018) Diabetes-related lower-extremity complications are a leading cause of the global burden of disability. Diabetic Medicine 35, 1297–1299.
| Diabetes-related lower-extremity complications are a leading cause of the global burden of disability.Crossref | GoogleScholarGoogle Scholar |
Malterud K, Siersma VD, Guassora AD (2016) Sample size in qualitative interview studies: guided by information power. Qualitative Health Research 26, 1753–1760.
| Sample size in qualitative interview studies: guided by information power.Crossref | GoogleScholarGoogle Scholar | 26613970PubMed |
Mays N, Pope C (1995) Rigour and qualitative research. BMJ (Clinical Research Ed.) 311, 109–112.
| Rigour and qualitative research.Crossref | GoogleScholarGoogle Scholar |
Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A (2017) Diabetic foot. BMJ (Clinical Research Ed.) 359, j5064
| Diabetic foot.Crossref | GoogleScholarGoogle Scholar |
Mullan L, Driscoll A, Wynter K, Rasmussen B (2019) Barriers and enablers to delivering preventative and early intervention footcare to people with diabetes: a scoping review of healthcare professionals’ perceptions. Australian Journal of Primary Health 25, 517–525.
| Barriers and enablers to delivering preventative and early intervention footcare to people with diabetes: a scoping review of healthcare professionals’ perceptions.Crossref | GoogleScholarGoogle Scholar | 31718766PubMed |
Mullan L, Wynter K, Driscoll A, Rasmussen B (2020a) Preventative and early intervention diabetes-related footcare practices in primary care. Australian Journal of Primary Health 26, 161–172.
| Preventative and early intervention diabetes-related footcare practices in primary care.Crossref | GoogleScholarGoogle Scholar | 32061266PubMed |
Nickinson ATO, Bridgwood B, Houghton JSM, Nduwayo S, Pepper C, Payne T, Brown MT, Davies RSM, Sayers RD (2020) A systematic review investigating the identification, causes and outcomes of delays in the management of chronic limb-threatening ischaemia and diabetic foot ulcerations. Journal of Vascular Surgery 71, 669–681.e2.
| A systematic review investigating the identification, causes and outcomes of delays in the management of chronic limb-threatening ischaemia and diabetic foot ulcerations.Crossref | GoogleScholarGoogle Scholar | 31676182PubMed |
Norman PE, Schoen DE, Gurr JM, Kolybaba ML (2010) High rates of amputation among Indigenous people in Western Australia’. The Medical Journal of Australia 192, 421
| High rates of amputation among Indigenous people in Western Australia’.Crossref | GoogleScholarGoogle Scholar | 20367594PubMed |
O’Rourke S, Steffen C, Raulli A, Tulip F (2013) Diabetic major amputation in far north Queensland 1998–2008: what is the gap for Indigenous patients? The Australian Journal of Rural Health 21, 268–273.
| Diabetic major amputation in far north Queensland 1998–2008: what is the gap for Indigenous patients?Crossref | GoogleScholarGoogle Scholar | 24118149PubMed |
Pankhurst CJW, Edmonds ME (2018) Barriers to foot care in patients with diabetes as identified by healthcare professionals. Diabetic Medicine 35, 1072–1077.
| Barriers to foot care in patients with diabetes as identified by healthcare professionals.Crossref | GoogleScholarGoogle Scholar | 29696678PubMed |
Patel S, Cain R, Neailey K, Hooberman L (2017) Recruiting general practitioners in England to participate in qualitative research: challenges, strategies, and solutions. SAGE Research Methods, Cases Part 2. (SAGE Publications: London).
QSR International (2020) Nvivo 12 plus. (QSR International Pty Ltd: Melbourne, Vic., Australia) Available at https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home [Verified 6 October 2020]
Royal Australian College of General Practitioners (2019) General practice health of the nation 2019. (RACGP: Melbourne, Vic., Australia) Available at https://www.racgp.org.au/FSDEDEV/media/documents/Special%20events/Health-of-the-Nation-2019-Report.pdf [Verified 9 November 2020]
Sayampanathan AA, Cuttilan AN, Pearce CJ (2017) Barriers and enablers to proper diabetic foot care amongst community dwellers in an Asian population: a qualitative study. Annals of Translational Medicine 5, 254
| Barriers and enablers to proper diabetic foot care amongst community dwellers in an Asian population: a qualitative study.Crossref | GoogleScholarGoogle Scholar | 28706922PubMed |
Schaper NC, van Netten JJ, Spelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA (2019) IWGDF practical guidelines on the prevention and management of diabetic foot disease. (International Working Group on the Diabetic Foot (IWGDF: Amsterdam, The Netherlands) Available at https://iwgdfguidelines.org/wp-content/uploads/2019/05/IWGDF-Guidelines-2019.pdf
Services for Australian Rural and Remote Allied Health (SARRAH) (2020a) Health profile (SARRAH: Canberra, ACT, Australia) Available at https://sarrah.org.au/content/health-profile
Services for Australian Rural and Remote Allied Health (SARRAH) (2020b) Demography and population (SARRAH: Canberra, ACT, Australia) Available at https://sarrah.org.au/content/remote-and-rural-context
Stemler S (2000) An overview of content analysis. Practical Assessment, Research & Evaluation 7, 17
| An overview of content analysis.Crossref | GoogleScholarGoogle Scholar |
Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): A 32‐item checklist for interviews and focus groups. International Journal for Quality in Health Care 19, 349–357.
| Consolidated criteria for reporting qualitative research (COREQ): A 32‐item checklist for interviews and focus groups.Crossref | GoogleScholarGoogle Scholar | 17872937PubMed |
van Netten JJ, Lazzarini PA, Fitridge R, Kinnear E, Griffiths I, Malone M, Perrin BM, Prentice J, Sethi S, Wraight PR (2017) Australian diabetes-related foot disease strategy 2018–2022: the first step towards ending avoidable amputations within a generation – Wound Management CRC 2017. (Diabetic Foot Australia: Brisbane, Qld, Australia) Available at https://diabeticfootaustralia.org/wp-content/uploads/National-Strategy-to-end-avoidable-amputations-in-a-generation-final-1.pdf [Verified 6 October 2020]
Walker CA, Rahman A, Gipson-Jones TL, Harris CM (2019) Hospitalists’ needs assessment and perceived barriers in wound care management; a quality improvement project. Journal of Wound, Ostomy, and Continence Nursing 46, 98–105.
| Hospitalists’ needs assessment and perceived barriers in wound care management; a quality improvement project.Crossref | GoogleScholarGoogle Scholar | 30844867PubMed |
Whitlock E, Morcom J, Spurling G, Janamian T, Ryan S (2014) Wound care costs in general practice: a cross-sectional study. Australian Family Physician 43, 143–146.
