Journal of foot and ankle research · 2026
Discomfort Avoidance and Desire for Normality Are Decision-Making Drivers of Footwear Choice in Underserved Communities at Risk of Diabetic Foot Ulcer.
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Anil Krithika, Sharma Neeraj, Patel Sonal, Bailey Jess, Smith Catherine, Abey Sally, Allcock Kayce, Collings Richard, Paton Joanne
Аннотация
BACKGROUND: Diabetes-related foot ulceration (DFU) is a serious complication that can lead to lower limb amputation or death. Custom-made footwear is a key preventative strategy, yet adherence to use is often low. The factors influencing decision-making for footwear use remain unclear, particularly among underserved groups such as people from low socioeconomic and South Asian backgrounds. This study aimed to identify the psychological mechanisms underlying footwear choice and adherence in people with diabetes from low socioeconomic and South Asian populations.
METHODS: This study used a qualitative approach conducted in two parts. Part 1 explored footwear-related experiences using one-to-one interviews informed by the COM-B model (which states that there are 3 components to Behaviour: Capability, Opportunity, Motivation). Findings from Part 1 informed Part 2, a 'think aloud' qualitative study examining reasoning strategies behind footwear choices. Participants were adults living with diabetes at moderate to high risk of foot ulceration, with or without prior foot ulcers or experience of therapeutic footwear. Those with active foot ulceration were excluded. Interview data were analysed using thematic analysis.
RESULTS: Eleven UK-based participants completed Part 1 (7 male, 4 female; median age 64; South Asian = 7; low socioeconomic status = 6). Seventeen themes were identified and categorised within the COM-B framework to inform Part 2. Fourteen participants completed Part 2 (10 male, 5 female; median age 67; South Asian = 5; low socioeconomic status = 8). Two key reasoning mechanisms emerged: (1) Discomfort Avoidance Prioritised Over Clinical Advice, reflecting a tendency to prioritise comfort over medical recommendations, and (2) Desire for Normality, describing a preference for familiar or 'normal' footwear.
CONCLUSION: Footwear decision-making among people living with diabetes seems to be informed by reasoning based on discomfort avoidance and normalcy. These findings highlight the need for a person-centred approach to footwear advice that may bridge the gap between footwear adherence and patients' reasoning mechanisms. These mechanisms must be confirmed in a replication study or in an appropriately large quantitative study.
METHODS: This study used a qualitative approach conducted in two parts. Part 1 explored footwear-related experiences using one-to-one interviews informed by the COM-B model (which states that there are 3 components to Behaviour: Capability, Opportunity, Motivation). Findings from Part 1 informed Part 2, a 'think aloud' qualitative study examining reasoning strategies behind footwear choices. Participants were adults living with diabetes at moderate to high risk of foot ulceration, with or without prior foot ulcers or experience of therapeutic footwear. Those with active foot ulceration were excluded. Interview data were analysed using thematic analysis.
RESULTS: Eleven UK-based participants completed Part 1 (7 male, 4 female; median age 64; South Asian = 7; low socioeconomic status = 6). Seventeen themes were identified and categorised within the COM-B framework to inform Part 2. Fourteen participants completed Part 2 (10 male, 5 female; median age 67; South Asian = 5; low socioeconomic status = 8). Two key reasoning mechanisms emerged: (1) Discomfort Avoidance Prioritised Over Clinical Advice, reflecting a tendency to prioritise comfort over medical recommendations, and (2) Desire for Normality, describing a preference for familiar or 'normal' footwear.
CONCLUSION: Footwear decision-making among people living with diabetes seems to be informed by reasoning based on discomfort avoidance and normalcy. These findings highlight the need for a person-centred approach to footwear advice that may bridge the gap between footwear adherence and patients' reasoning mechanisms. These mechanisms must be confirmed in a replication study or in an appropriately large quantitative study.