ORCID
- Krithika Anil: 0000-0002-8027-1665
- Neeraj Sharma: 0000-0002-6160-0793
- Sally Abey: 0000-0002-9330-6564
- Kayce Allcock: 0009-0007-8623-6143
- Richard Collings: 0000-0002-7048-1386
- Joanne Paton: 0000-0002-8833-3226
Abstract
BackgroundDiabetes-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.MethodsThis 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.ResultsEleven 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.ConclusionFootwear 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.
DOI Link
Publication Date
2026-07-12
Publication Title
Journal of Foot and Ankle Research
Volume
19
Issue
3
ISSN
1757-1146
Acceptance Date
2026-07-02
Deposit Date
2026-07-16
Funding
This study was part of a larger project that was funded by the Great Foundations charity for £116,298.
Keywords
Diabetic foot, Decision making, Cognitive interview, Think-aloud method
Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Recommended Citation
Anil, K., Sharma, N., Patel, S., Bailey, J., Smith, C., Abey, S., Allcock, K., Collings, R., & Paton, J. (2026) 'Discomfort Avoidance and Desire for Normality Are Decision-Making Drivers of Footwear Choice in Underserved Communities at Risk of Diabetic Foot Ulcer', Journal of Foot and Ankle Research, 19(3). Available at: 10.1002/jfa2.70186
