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  • 1.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics.
    Methodological considerations of investigating adherence to using offloading devices among people with diabetes2018In: Patient Preference and Adherence, ISSN 1177-889X, E-ISSN 1177-889X, Vol. 12, p. 1767-1775Article in journal (Refereed)
    Abstract [en]

    Foot ulcers are a diabetic complication associated with significant morbidity, mortality, and amputation risk. Offloading devices prevent and heal foot ulcers, but adherence to using these devices is low. The reasons for nonadherence are unclear, and study results are difficult to compare due to methodological heterogeneity. This paper explores aspects of investigating adherence to using offloading devices among people with diabetes and provides recommendations for future studies, focusing on study designs, definitions of adherence, measurement methods, and conceptual frameworks. Most studies use a cross-sectional observational study design, limiting the potential to establish the temporal sequence between predictors and adherence, rule out confounding factors, and establish causality. Studies defining adherence as the length of time the device is worn have often used self-report to measure adherence, which may be unreliable. Studies using activity monitors to measure adherence have defined adherence as the number of steps taken with the device, which excludes weight-bearing activities where no steps are taken. Conceptual frameworks are not made explicit in the current quantitative research. It is concluded that future studies should use a longitudinal design with observational studies to identify patient groups prone to nonadherence and factors that influence adherence and experimental studies to evaluate interventions to improve adherence, focusing on these patient groups and factors. Furthermore, adherence should be defined in terms of relative adherence to using offloading devices during all weight-bearing activities, and objective measurement of adherence ( using accelerometers and temperature monitors) should be used whenever possible. Clearly defined conceptual frameworks should guide the choice of factors to include in the study and the analysis of their interactions. By implementing these recommendations, research could provide a stronger evidence base in the future, supporting interventions to increase adherence and thereby improve outcomes for people with diabetic foot complications.

  • 2.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden; University Health Care Research Center, Region Örebro County, Örebro, Sweden.
    Lundqvist, Lars-Olov
    Örebro University, School of Law, Psychology and Social Work. University Health Care Research Center, Region Örebro County, Örebro, Sweden.
    Adherence to wearing therapeutic shoes among people with diabetes: a systematic review and reflections2016In: Patient Preference and Adherence, ISSN 1177-889X, E-ISSN 1177-889X, Vol. 10, p. 1521-1528Article, review/survey (Refereed)
    Abstract [en]

    Introduction: Therapeutic shoes are prescribed to prevent diabetic foot ulcers, but adherence to wearing the shoes is often poor.

    Aim: The aim of this study was to review the literature on factors that are associated with adherence to wearing therapeutic shoes and construct a model of adherence to aid future research and development in the field.

    Methods: We conducted a systematic search in PubMed, CINAHL, and PsycINFO for quantitative studies on factors associated with adherence to wearing therapeutic shoes among people with diabetes.

    Results: Six studies were included in the review. The studies focused mainly on patient-, therapy-, and condition-related adherence factors. There is some evidence (three to five studies) that sex, diabetes duration, and ulcer history are not associated with adherence. The evidence for or against the other factors was weak (only one or two studies) or conflicting.

    Conclusion: There is no conclusive evidence for using any factor to predict adherence to wearing therapeutic shoes, but there is some evidence against using certain factors for predicting adherence. Future studies should include a broader range of factors, including health system and social/economic factors, and they should investigate perceived costs and benefits of wearing therapeutic shoes in comparison with other shoes or no shoes. A seesaw model is presented illustrating the complex phenomenon of adherence. Further research is needed to identify factors associated with adherence to wearing therapeutic shoes, to enable the development of interventions to improve adherence and thereby reduce ulceration rates among people with diabetic foot complications.

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