Socio-Cultural Aspects of Diabetic Foot: An Ethnographic Study and an Integrated Model Proposal

Abstract

Background: Diabetes mellitus (DM) is an ongoing and growing health problem worldwide, with a series of important complications such as diabetic foot that can significatively reduce the quality of life of affected patients. This study aims to explore the socio-cultural aspects of patients with diabetic foot, analyzing the following research question: “What are the socio-cultural aspects experienced by patients with diabetic foot?” Methods: A qualitative design using an ethnographic approach was applied to study the social and cultural aspects of Italian diabetic foot patients. Results: We included 20 key informants: 13 men and 7 women. Ages ranged from 54 to 71, with an average age of 61.2. The data analysis revealed five main themes: perceptions of diabetic foot, living with diabetic foot, impacts of culture and economic performance, barriers to health and diabetic foot, and home remedies and alternative medicine. Conclusions: This study provides a new perspective on the influence of cultural factors on the health of diabetic foot patients, showing various factors related to a lack of knowledge and training, fear, and acceptance of diabetic foot. This study also presents a new integrated model which will allow patients and practitioners to act on the various critical issues that emerged from our research.

1. Introduction

Diabetes mellitus (DM) is an ongoing and growing health problem worldwide [1]. There are two types of DM: type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM), based mainly on the absence of insulin (the former) or insulin resistance (the latter). T1DM is characterized by an early onset of the disease, with characteristics presenting in juveniles. T2DM is a member of a heterogeneous syndrome called metabolic syndrome or syndrome X. Although human biological factors may play a role, the occurrence and spread of T2DM is the result of sociocultural factors related to changes in the quality and quantity of energy (diet) consumed and the amount of food and energy expenditure (physical activity) of the patient [2]. For these reasons, diabetes and its various manifestations are a classic example of the relationship between society, culture, biomedicine, biology, and behavior [1]; this represents an interesting field of research for the social sciences.

Importantly, a combination of behavioral, demographic, biological, and social factors contribute to the development of the disease [3], presenting an interesting health phenomenon related to social science research. In fact, diabetic disease issues present a “biocultural laboratory” [1], where evolutionary and historical processes play an important role and provide a theoretical framework for empirical research [4].

In this regard, among the medical humanities, the history of medicine is most useful. In fact, the geneticist James V. Neel [5], in 1962, developed positive genetic thinking that opened the door to knowledge about the relationship between diabetes and socio-cultural factors. Those findings continue to have an impact on social studies, books, and papers.

Subsequently, Cinzia Eaton [6] published one of the first socio-anthropological literature reviews, in which she investigated the relationship between socio-cultural dimensions and diabetes. After the publication of that paper, a leading epidemiologist, Bennett [1], recognized the importance of cultural and social spheres in the manifestation and progression of diabetes.

Kue Young supported the interaction between environmental and genetic factors, explaining how the cause and distribution of diabetes reflect differences in social influences, genetic susceptibility, and the contribution of specific risk factors such as diet, obesity, and physical activity [7].

Moreover, Neel introduced a framework for establishing a set of assumptions, or more specifically, a set of interrelationships, that would form the basis for the biological, archaeological, and socio-cultural aspects of diabetes [8]. Thus, for Neel, the human body is a product of evolutionary processes, slow in duration and velocity, operating throughout a period that encounters changes in social and cultural processes [8].

DM has several important complications, such as diabetic retinopathy, nephropathy, and diabetic foot. Diabetic foot is a common long-term complication that includes ulceration of the skin of the foot. Its impact has important consequences in terms of morbidity and mortality. In diabetic foot conditions, the ulcered skin may also get infected by bacterial action, and in this condition, amputation is often needed to reduce the possibility of local or systemic infection [9]. For all these reasons, several related economic, physical, and social issues can affect the quality of life (QoL) of affected patients [10].

Considering the intersection of sociocultural aspects and diabetic foot, according to Costa et al. [11], the following variables should be considered:

(1)

Gender issues. Men are more likely to suffer from serious foot problems, but women with poorer attitudes toward medical shoes have worse health. Women’s problems should receive more attention from doctors; in addition, women need to be more proactive in protecting themselves. On the other hand, men are more likely to seek help for unexpected problems, and they are more pessimistic about the future.

(2)

Socioeconomic status. This is a variable that increases the incidence of lower-limb problems. For example, people who live in rural areas with a lower social status are 50% more likely to undergo lower-limb amputations.

(3)

QoL. This is a global indicator of health and well-being. Within this variable, changes in body image create QoL issues for diabetic patients. In fact, about 50% and 79% of diabetic patient types have a negative body image. This variable is very important for the social impact of diabetic foot, since the body image of diabetic patients is an important social element.

(4)

Social relation. Patients with diabetic foot are often lonely and have great difficulty communicating and sharing their disease experience with others. Weak social networks are associated with poorer health, which may, in turn, be associated with the risk of ulcer formation. This is a significant problem for people living with a diabetic patient, as it reduces social support. Social support is an important component of social capital and may be a preventive factor during stressful health-related experiences; it is necessary for the patient’s ability to accept the situation.

Furthermore, complications such as diabetic ulcers recall not only the aforementioned problem of body image but also a very interesting concept, namely, that of “social skin”, introduced by the social scientist Turner [12] and according to which “the surface of the body, as the common frontier of society, the social self, and the psycho-biological individual, becomes the symbolic stage upon which the drama of socialization is enacted, and bodily adornment (in all its culturally multifarious forms, from body-painting to clothing and from feather head-dresses to cosmetics) becomes the language through which it is expressed” ([12], p. 486). Probably, by using this concept, which has never been applied before to diabetic foot, it will also become clearer why these conditions that modify the skin have such a negative impact on the social and cultural level, since it is due to a real protective barrier from the outside world, namely, the social skin. In fact, the skin constitutes “one such cultural medium, perhaps the one most specialized in the shaping and communication of personal and social identity” ([12], p. 487]). Therefore, an ulcer negatively alters the process of transformation of the “skin from a mere ‘natural’ envelope of the physical body into a sort of social filter, able to contain within a social form the biological forces and libidinal energies that lie beneath” ([12], p. 488]).

Starting from all these premises, the research question of this study is: What are the socio-cultural aspects experienced by patients with diabetic foot?

2. Materials and Methods

2.1. Study Design

A qualitative design using an ethnographic approach was applied to study the social and cultural aspects of Italian diabetic foot patients. Ethnography allowed the present researcher to collect data on participants’ actual behavior, rather than reported behavior [13].

2.2. Settings and Sample

The study was carried out from January 2020 to December 2023 and involved some universities belonging to the Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, specifically, the Unit of Vascular Surgery at the Magna Graecia University of Catanzaro, and the Unit of Vascular Surgery at the “Federico II” University of Naples. All patients gave written informed consent. A purposive sampling method was used to recruit key informants based on their expected contribution to the study and their experience of diabetic foot, which they might help us better understand. Key informants were those who were most likely to have in-depth knowledge of and experience with diabetic foot. The specific criteria used to ensure diversity in the selected variables were as follows:

(1)

Age range 50–75, when diabetic foot issues are more present and when subjects are still socially, culturally, and economically active, avoiding the same age in more than 3 subjects.

(2)

Gender: as diabetic foot is more prevalent in men, the maximum number of included women should not exceed 40%.

(3)

Employment status: more than 70% of patients should be actively employed, to study the influence of diabetic foot on working life.

(4)

Socioeconomic status: each recruited subject must have a minimum income, equal to the minimum pension paid by the Istituto Nazionale Previdenza Sociale (INPS), the center of the Italian welfare state, that is, 6695.91 euros gross per year according to INPS regulatory provision nr. 147/2019 [14].

Eligible patients were selected by the researchers during their visit to the vascular surgery units included in the study. The study was explained to them, and they were asked if they agreed to participate. Those who agreed were given an appointment to meet in person.

2.3. Data Collection

Data were collected through interviews, observations, and written field notes. The interview process was based on Spradley’s [15] ethnographic interview model, allowing for the exploration of social and cultural aspects of diabetic foot patients. Interviews were conducted by the researcher, an experienced qualitative researcher. Before the interviews, participants were informed about the study. They were informed that participation was voluntary and that they had the right to withdraw at any time. At this point, participants were asked to complete a questionnaire in which demographic information such as age, gender, education level, and employment was collected.

A semi-structured interview guide was developed based on a literature review conducted by the research team. The interview guide included questions on demographic, social, cultural, and health aspects and was reviewed by diabetic foot experts. The questions were modified according to their recommendations and tested on 12 patients before being used in the study. Participants of the pilot study were not included in the main study. The interview guide was developed in Italian. We used descriptive questions [15] for the main topics of interest. In

Table 1. Example of descriptive questions that were included in the interview guide.

Topic	Example of Questions
Perception of diabetic foot	Could you describe how you perceived the diabetic foot in terms of concern, recognition, etc.? Could you describe the factors that lead to your wound?
Living with diabetic foot	Could you describe the impact of diabetic foot on your daily life? Could you describe how diabetic foot has impacted your independence in daily life?
Economic aspects of diabetic foot	Could you describe how diabetic foot has impacted your working life? Could you describe what the costs involved in managing diabetic foot were?
The role of the barriers to health	Could you describe what obstacles you have encountered in healthcare settings regarding diabetic foot? Could you describe your knowledge about the types of healthcare services specific to diabetic foot care?
Alternative medicine and home remedies	Could you describe if you have knowledge of and/or have applied home remedies for diabetic foot care? Could you describe if you have knowledge and/or if you have resorted to forms of alternative medicine?

, we report some examples of questions used.

Interviews were conducted in a specific place in the vascular surgery units and lasted 25 to 35 min. Saturation was reached with 20 patients when no new information or additional perspectives were observed in the themes through the addition of more participants [16], which was checked after each interview.

Observations were made during the visits to understand the social and cultural aspects of the participants related to diabetic foot. Of particular interest were perceptions of diabetic foot, economic aspects of diabetic foot, the role of barriers, and alternative medicine and home remedies. The researcher who conducted the interviews specializes in qualitative and ethnographic research and has lived and grown up within Italian culture and language, allowing him to immediately immerse himself in this field.

The researcher and the remaining members of the research team took field notes throughout the study period to record the environment, actions, thoughts, and feelings. Field notes, according to Creswell [17], are fundamental in ethnographic studies as they enhance the data and provide a rich context for analysis. Figure 1 shows the entire research process through three distinct, yet interrelated, ethnographic stages.

2.4. Data Analysis

The analysis was conducted with the NVivo 12 software and using inductive thematic analysis [18]. All transcripts were thoroughly read multiple times to ensure a thorough understanding; they were also reviewed using an inductive coding approach. The interviews with the participants continued until no new codes emerged. The inductive content analysis method was used to analyze the interviews. Content analysis is a systematic approach that can be used to comprehend large amounts of textual information through the encoding and classification of data. The data were coded according to the methods of Graneheim and Lundman [19]. Regular online meetings were held to reach consensus and to discuss emergent themes. After in-depth repeated readings, the researchers determined the codes, subthemes, and themes. The codes, subthemes, and themes were submitted to a consultant specializing in qualitative research, and their opinions were obtained.

Each transcript was compared with field notes to provide the researcher with additional context beyond the information written in the transcript. Concepts emerging from the data were coded and constantly compared, and themes and subthemes were developed [20]. The expert in qualitative research met with the other two authors to compare the identified codes and discuss similarities and differences. If differing opinions emerged, discussion continued until a consensus was reached on emerging themes or subtopics.

2.5. Trustworthiness

To ensure the reliability of the study, the following four criteria were considered throughout the study: credibility, conformability, dependability, and transferability [19]. Two researchers were experienced in qualitative research and working with patients with diabetes. The interviews were independently coded by researchers experienced in qualitative research who had read and analyzed the interviews in depth several times. The interviews with the participants continued until no new codes emerged. Qualitative interviews were terminated when no new codes emerged, that is, when data saturation was reached. In the last stage, two researchers compared the codes they obtained and reached a consensus on creating subthemes and then themes. Credibility was ensured by consulting a third-party expert to examine the themes, subthemes, and codes of the collected data. The researchers explained each stage of the research process in detail. The findings are presented in rich, in-depth descriptions. There were no hierarchical or social relationships between the researcher and the participants. The interviews were conducted by the same researcher and recorded using the same voice recorder. All research data, including the audio recordings and transcripts, were stored appropriately to ensure confirmability and allow for future verification of the findings. Dependability was ensured by documenting every analytical process used in the study for future audits. Transferability was ensured by appropriately presenting the explanations provided by the participants.

The researchers also used methodological triangulation, including in-depth interviews, participant observation, and field notes. To perform researcher triangulation, an experienced researcher and two other authors were involved in the analysis and interpretation of the data. To validate the results, data triangulation was carried out through several interviews. We also conducted peer debriefing, expert project review and discussion, and member checking, inviting participants to review, validate, and confirm the findings.

2.6. Ethical Aspects of the Study

The study was approved by the Institutional Review Board of the Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology (Approval number: ER.ALL.2018.62.A.). Before conducting the interviews, the purpose of the study was explained to the participants and written informed consent was obtained from each participant. Participants were assured that the information they received would be treated confidentially. Participants were also informed that they could end the interview at any time.

2.7. Reflexivity Statement

The authors were aware that when interviewing the key informants, they needed to try and remain neutral, setting aside their views and reactions and listening from the perspective of a researcher. Nevertheless, the authors acknowledge that it is difficult to be objective and to set aside their personal experience, thus taking an insider position.

In particular, the authors considered their prior assumptions and experience, awareness of social settings and the social ‘distance’ between the researcher and the research subject, fair dealing, awareness of wider social and political context, the role of the research team as collaborators in knowledge production, and the potential for psychological harm.

3. Results

The main characteristics of the key informants are shown in

Table 2. Demographic data of key informants.

Patient Number	Age	Gender	Education	Occupation Type	Income Level (Euros Gross per Year)	Diabetic Foot Duration	Amputation (Finger/Fingers or Foot)
1	61	Male	Secondary school	Carpenter	15,600	2 years	Finger (one)
2	62	Female	Secondary school	Employee	27,500	1 year	no
3	60	Male	Primary school	Construction worker	12,300	3 years	Fingers (two)
4	66	Male	Secondary school	Electrician	14,700	2 years	Part of the foot (transmetatarsal amputation)
5	58	Female	Secondary school	Housemaid	7500	2 years	No
6	59	Female	Primary school	Housewife	24,600 (husband’s income)	2 years	No
7	63	Male	Secondary school	Employee	25,300	3 years	Fingers (two)
8	68	Male	Secondary school	Retired	11,200	2 years	No
9	58	Male	Master’s degree	Teacher	29,600	1 year	No
10	55	Female	Secondary school	Shopkeeper	11,800	1 year	No
11	57	Female	Secondary school	Housewife	15,800 (husband’s income)	1 year	No
12	55	Male	Master’s degree	Manager	73,400	2 years	No
13	69	Male	Secondary school	Mechanic	11,400	2 years	No
14	71	Female	Primary school	Retired	9200	3 years	Fingers (two)
15	70	Male	Secondary school	Retired	8100	5 years	Foot
16	56	Male	Secondary school	Employee	21,200	1 year	No
17	58	Female	Master’s degree	Teacher	25,600	1 year	No
18	54	Male	Master’s degree	Lawyer	93,000	1 year	No
19	62	Male	Secondary school	Bartender	10,700	4 years	Part of the foot (transmetatarsal amputation)
20	61	Male	Secondary school	Farmer	12,500	4 years	Part of the foot (transmetatarsal amputation)

. We included 20 key informants, 13 men and 7 women. Ages ranged from 54 to 71 years old, with an average age of 61.2 years. Most of the key informants attended either primary or secondary school, and only 4 had a university degree. Regarding work activity, it appeared to be particularly varied.

The data analysis revealed 5 main themes and 14 subthemes. Figure 2 shows the hierarchy of the themes and subthemes.

Table 3. Prevalence of themes and subthemes.

Theme	Prevalence (n. of Patients)	Prevalence (%)	Subtheme	Prevalence (n. of Patients)	Prevalence (%)
Perceptions of diabetic foot	16/20	80%	Low awareness	10/16	62.5%
			Realization	6/16	37.5%
Living with diabetic foot	14/20	70%	A life turned upside down	7/14	50%
			Body changes	6/14	42.85%
			Emotional impacts	14/14	100%
Impacts of culture and economic performance	12/20	60%	Work, opportunities, and productivity	12/12	100%
			Direct and Indirect Costs Perceived	5/12	41.85%
Barriers to health and diabetic foot	9/20	45%	Lack of understanding of the perceived need for foot care	7/9	77.78%
			Misunderstandings about the role of foot care services	6/9	66.67%
			Very long waiting times	6/9	66.67%
			Poor service availability	5/9	55.56%
			Cultural beliefs regarding healthcare as a barrier	5/9	55.56%
Home Remedies and Alternative Medicine	6/20	30%	Home remedies and foot ulcers	5/6	83.33%
			Alternative medicine and foot ulcers	4/6	66.67%

shows the prevalence of specific themes and subthemes within the dataset.

3.1. Theme 1: Perceptions of Diabetic Foot

Sixteen patients showed recognition and concern about diabetic foot, including low awareness and understanding.

3.1.1. Low Awareness

Ten patients showed low awareness regarding diabetic foot. Six key informants reported experiencing foot problems; they only saw a small wound on their feet, but they did not take it seriously at first. Five of the informants did not know that foot wounds are related to diabetes, so they did not pay attention to the wounds. The key informants believed that foot problems are not serious enough to require medical attention. When doctors told them the condition is serious, they became aware of the need to treat their feet.

Being honest, I knew nothing about the diabetic foot issue. Culturally, we are used to hearing about diabetes as a disease with sweet urine… I never thought it could affect the feet of my foot. I discovered the first lesion by chance.

(Participant 2)

I found out I had problems related to diabetic foot by pure chance! I was at my family doctor and by chance, while I was wearing sandals that day, he noticed some lesions on my foot… His expression changed, he became serious and when he told me what was happening… well, I was scared…

(Participant 5)

Another interesting aspect concerns the reasons behind the low awareness of problems related to diabetic foot. First, a particular situation emerged among 8 key informants, namely, that the lack of attention toward foot lesions was linked to the fear of seeing one’s damaged skin and showing it at first to family members and then to health professionals.

Must I be honest? I noticed the first lesion on my foot, but I pretended it wasn’t there, or rather I hoped it would have gone away… I didn’t want to show my damaged skin too, diabetes itself has made me sick in the eyes of my family, among my friends, who would have suffered too much if they had shown me how sick I was. Unfortunately, this has caused a very significant worsening of the diabetic ulcer on my right foot.

(Participant 1)

Seeing the skin of my foot ulcerate made me fear that I would become even more “sick” so I pretended not to see it, I hid the ulcer for a long time by using stockings. Let’s face it, a person with lesions covered by dressings and plasters arouses interest and repulsion in anyone! And I did not want to suffer all that!

(Participant 8)

3.1.2. Realization

For 6 key informants, their realization was associated with their local beliefs, i.e., that if there is no pain, then it is not a pathological situation.

In my area they say, “Without pain there is no disease” and so since I didn’t feel any discomfort in my foot, I honestly didn’t give much importance to the appearance of lesions.

(Participant 10)

Let’s face it… we are accustomed since we were children to think that what hurts is the source of some symptom, what does not “scream from the body” does not scare anyone. How many times have we fallen and for a small scrape we were told, and we did the same as adults, “Come on, it will go away”? And, I have exactly repeated to myself, “Come on, it will go away”… And instead… having trusted this belief, is leading me to lose my foot!

(Participant 12)

3.2. Theme 2: Living with Diabetic Foot

Diabetic foot can negatively impact daily life. In fact, changes were recorded in the social, psychological, economic, and physical characteristics of 14 key informants.

3.2.1. A Life Turned Upside Down

One of the first changes in the life of a diabetic foot patient is related to gender roles in the family. Thirteen key informants were men, who felt their role as breadwinners was diminishing. If they suffer from diabetic foot, their motivation and ability to work or make a living will decrease, and their value and role in the family will decrease.

The first thing that changed when I was diagnosed with diabetes, which got worse with the appearance of diabetic foot, was the way my wife and daughter started treating me… It was devastating. I come from a generation that thinks that men should provide protection, maintenance, and support to the women of the house… Seeing my wife working two jobs to support our daughter in school and to cover part of the health expenses related to my health issues, humiliates me…

(Participant 3)

The worst thing since I have diabetic ulcers is seeing myself limited in my work activities! I was a man who went to the countryside, raised animals, thus, always on the move… Now my wife does all this, and I feel so helpless and sorry that I can no longer relieve her of the activities like in the past! I feel like a half man.

(Participant 20)

Another upheaval closely related to the previous one concerns the loss of autonomy in daily activities.

I lost part of my foot, and this has significantly reduced my autonomy… Even to go to the bathroom I have to ask for help… It’s terrible, you know? Towards activities that once seemed trivial to me, now I look at them with the eyes of someone who had extreme freedom that now is lost forever!

(Participant 4)

I used to clean the house every day, I loved seeing everything shiny and smelling nice… Now I have to wait for my daughter to be free to have a clean house… I’m grateful to her but depending on another person devastates me!

(Participant 14)

Another important issue identified concerned the social activities organized by loved ones of the key informants, who complained of a series of difficulties.

I can no longer leave the house because of my foot, and this has meant that I have not gone to my daughter’s house for several years because it is located on the fourth floor of a building without a lift, and I cannot climb the stairs… How many times have I pretended that I had the flu so as not to make her feel guilty about the various parties she has organized throughout this period…

(Participant 19)

A friend of mine, who really wanted to have me at her birthday parties, transformed her warehouse into a small living room, so being on the ground floor it is easy for me to go!

(Participant 6)

3.2.2. Body Changes

Six key informants highlighted the negative impact of the bodily changes caused by diabetic foot, not only due to the limitations of movement, but also due to the negative perception that others may have regarding these bodily changes, and in particular the different smells of their body.

Seeing an ulcer on your foot, that goes through part of the skin is something destabilizing… We were used, since we were little, to perceive the skin as a form of protective shield, and the feet as the solid base on which to move in the world… When all this is altered, I stopped even looking at it and looking at myself in the mirror… what I see disgusts me, let alone others!

(Participant 17)

My body has changed a lot… not only because I live a more sedentary lifestyle that has made me gain weight, but also because my smell has changed! Now I constantly smell of disinfectants… I used to love perfumes so much…

(Participant 7)

Another physical alteration described by 6 key informants was increased pain that disrupted their sleep, making them tired, conditions that further limited their daily life, making them more depressed.

Before all this, I was a person who slept just enough to face the day… Now my body is constantly a source of pain, especially at night, I have shooting pains in my foot, and this makes me even more slow and dejected… I feel that I will not have the life or the body I used to have!

(Participant 18)

I always feel tired and fatigued… I used to be a dynamic person, I never stood still, and how about now? My body looks like that of a ninety-year-old man!

(Participant 9)

One of the main thoughts from 6 key informants regarding bodily changes concerned amputation. The analyses revealed two types of attitudes towards amputation. Three informants showed fear and non-acceptance of amputation, while another 3 instead considered this intervention as a form of liberation or solution from both the unbearable smell and the pain.

I’m so scared of losing my foot… I’m afraid if that were to happen, I’d feel terrible… I’ve read about phantom limb syndrome, and I’m scared I’d go crazy… How would my life change? I wouldn’t be able to look at myself in the mirror anymore…

(Participant 19)

It is certainly a destructive intervention, but can I be honest? In order to no longer feel the vastness and the shame of the bad smell and above all the pain, I think that as an intervention it would free me… It would give me a new life, more difficult but certainly free from a source of so many annoyances!

(Participant 8)

3.2.3. Emotional Impacts

Diabetic foot can exacerbate negative emotions such as confusion, hopelessness, anxiety, depression, and depression. Fourteen of the key informants expressed the fear of losing their feet, with a consequent feeling of incompleteness.

I don’t feel as lucid as I used to… my mind wanders and worry often keeps me from paying attention to what’s around me… My constant thought? The possible amputation of my foot… I’m so afraid of seeing my life completely turned upside down… And these negative thoughts accompany every single moment of the day…

(Participant 16)

My emotions? They are totally negative; I have lost the desire for anything from food to sex… I do nothing but fear of finding new ulcers… I am constantly with a magnifying glass looking at my feet… I can’t think of anything else…

(Participant 11)

Due to the gradual restriction of daily activities, 9 key informants expressed feelings of worthlessness, subordination, and limited independence due to having to seek help from family and friends, situations that generated further negative emotions.

A few days ago, I dropped my newspaper on the floor… I tried in every way to pick it up but in the end, I just fell off the chair… The fact that my wife found me like that made me feel like a useless man with my dignity now in pieces!

(Participant 13)

Can I be honest? It’s so frustrating to have to depend on others! Sometimes I wish I had never woken up! A life chained to the house is not for me!

(Participant 15)

Diabetic foot causes key informants to feel isolated from their friends and family. They believe that the smell of infected ulcers harms their social interactions, generating feelings of shame and embarrassment in themselves and toward others.

One of the most horrible things about this problem is the bad smell that the foot gives off because of the ulcers… The stench is synonymous with dirt, with a person to be kept away… I who have always loved perfumes, am experiencing this situation catastrophically… I often think that friends and relatives feel disgusted towards me… in reality, I’m the first one to feel disgusted towards myself!

(Participant 20)

Does a disease like diabetes and especially diabetic foot cause loss of relationships? Well in my opinion yes! Patches, syringes, and especially bad smells are all factors that push people away… friends and in some ways relatives, but anyone including me, we don’t like things like that!

(Participant 8)

Without clear treatment, 14 key informants were uncertain about their future. However, they were motivated to take good care of their feet due to the consequences of the disease.

The relative slowness of healing of diabetic ulcers makes me fear the future, in fact, I always see it as uncertain and unstable… Even though I am trying to do everything to be compliant with the various treatments… But I often ask myself: will they be effective? Will I preserve my foot?

(Participant 17)

I have never been very “obedient” to medical prescriptions… But believe me with the diabetic foot problem yes… I am doing everything I can to follow in detail everything the doctor prescribed and recommended… But I admit that I am very afraid of how this ulcer will progress… I am afraid for the future…

(Participant 7)

3.3. Theme 3: Impacts of Culture and Economic Performance

From the interviews conducted with 12 key informants, a certain internalization of the culture linked to productivity and being high-performing emerged.

3.3.1. Work, Opportunities, and Productivity

According to 12 key informants, diabetic foot is associated with reduced working hours and productivity due to the need for visits to the hospital, medication, etc., thus reducing working hours.

Visits to the clinic, dressings, bookings, and then it starts all over again… All this time wasted in the hospital makes me reduce my working hours, the paperwork increases and my income decreases… In all this whirlwind, the taxes to pay, the mortgage, the daughter at university to support, etc. do not stop… The time of illness does not coincide with the speed that our society requires.

(Participant 19)

As soon as I was diagnosed with the ulcer, do you know what I thought? And now what do I do with my work? We are all obsessed with work because the expenses are so high when you have a family, that you don’t think about anything else… And then with a diabetic foot, how can I be independent at work? How can I keep up with my colleagues? These are questions that haunt me!

(Participant 2)

3.3.2. Direct and Indirect Perceived Costs

Furthermore, 5 key informants highlighted both the direct costs related to diabetic ulcer dressings not covered by the health system and other medical devices such as diabetic foot shoes, as well as the indirect costs, such as transportation, telephone bills, and lost working hours.

Although the national health system provides drugs for the treatment of diabetes, it does not guarantee the economic coverage of the cost of the dressings, which are quite high and guarantee a reduced number of shoes for diabetic feet and not adequate for any needs such as breaking them. This means that the diabetic foot for a patient like me, with low economic availability, is very difficult to manage!

(Participant 14)

Well, the diabetic foot complication is really difficult to manage… not only because of the dressings, etc. but also because I live far from the hospital and every time I have to go there, I have to spend a lot on transportation… not to mention the fact that I still have a landline and the long hours of waiting to book an appointment result in a very high cost on my phone bill!

(Participant 1)

3.4. Theme 4: Barriers to Health and Diabetic Foot

Another topic that emerged among key informants was healthcare barriers faced by diabetic foot sufferers.

3.4.1. Lack of Understanding of the Perceived Need for Foot Care

Seven key informants identified the first barrier as a lack of initial education by healthcare professionals regarding the possibility of developing foot complications or on when and how to access foot care services.

If at the beginning some healthcare professionals had explained to me in detail the complications of diabetes, and how disabling the diabetic foot was, I certainly would not have made so many mistakes such as uncomfortable shoes that caused the appearance of the first ulcer!

(Participant 3)

I had a lot of difficulty at the beginning understanding which clinics there were, the phone numbers to call, etc. because both the websites and the information provided by the healthcare professionals were unclear, confusing, and not easily found…

(Participant 18)

3.4.2. Misunderstandings About the Role of Foot Care Services

Six key informants described misunderstandings about the foot care services or their role as further barriers.

I didn’t immediately understand the real and concrete role of healthcare services related to diabetic foot… I didn’t even know that there was such a figure as podiatry, I was convinced it was a sort of beautician, and therefore I understood that it was a pedicure service, so initially, I thought it was not very useful as a treatment… Instead, I was wrong… There is not much clarity either on the internet or from healthcare professionals…

(Participant 5)

I knew absolutely nothing about the existence of specialized foot care services until I was directed to them after the first ulcers appeared on my foot.

(Participant 16)

3.4.3. Very Long Waiting Times

Six key informants on diabetic foot care at all levels, from primary care to vascular surgery and hospital care, described long waiting times; this may also be considered an important cause of worsening of diabetic complications.

I called to book an appointment for March 2022, and they booked and examined me only in July of the same year. Because of this delay, I used, maybe quite improperly I admit, the urgent care services, and emergency departments of various hospitals trying to shorten the waiting times… I was too worried… and the ulcer was getting worse quickly!

(Participant 10)

I firmly believe that the long waiting times to access the clinic contributed significantly to worsening my foot complications!

(Participant 15)

3.4.4. Poor Service Availability

Five key informants described the lack of availability of specialist services relatively close to their residences as a barrier.

Due to the lack of specialized services, I not only went to different clinics to seek foot care services but often had to go to the hospital, where they simply changed my dressing.

(Participant 4)

I was very upset when the podiatrist told me to go to his office more often because my nails were badly cut… But how can I go more often if I live very far away? There is no dedicated public transport, nor centers closer to my residence. In fact, for all these situations I have already lost my big toe!

(Participant 13)

3.4.5. Cultural Beliefs Regarding Healthcare as a Barrier

The culture of fear in a healthcare context emerged as a further barrier. Five key informants reported feeling intimidated by healthcare settings or being victims of medical malpractice, which pushed them to postpone treatment, with a consequent worsening of their diabetic foot.

I put it off as long as possible before going to the hospital for my foot… there are so many things said about hospital experiences on TV, in the newspapers, and especially by friends and relatives… and I was scared… I was very ashamed… and I waited a long time… maybe too long… in fact, I’ve already lost three toes!

(Participant 17)

I have always been afraid of hospitals, of medical instruments… Until I got sick with diabetes, and with my foot already in an advanced state of deterioration, I never wanted to go to the hospital… I thought about all the news of medical malpractice… and you know? I preferred to postpone rather than act… and today I bitterly regret it!

(Participant 2)

3.5. Theme 5: Home Remedies and Alternative Medicine

Another interesting theme that emerged from the analysis was that 6 key informants resorted to home remedies or alternative medicine to treat, especially in the initial phase, problems related to diabetic foot.

3.5.1. Home Remedies and Foot Ulcers

The use of home remedies, such as garlic, onion, honey, or cotton rags, is still very common in some rural areas in southern Italy; this also emerged from interviews with 5 key informants.

Especially at the beginning, I resorted to the famous “grandmother’s methods” and applied onion to the ulcer and then covered it with pieces of cotton cloth. My grandmother always said that onion had excellent effects on skin lesions and that cotton had the power to “dry” the wounds.

(Participant 6)

Well, I have used and continue to use both garlic and honey to try to soothe diabetic ulcers… the doctor says they have little efficacy, but I believe a lot in natural medicine, and I think that if used correctly it can integrate so-called “official” medicine.

(Participant 11)

3.5.2. Alternative Medicine and Foot Ulcers

Four key informants stated that they had turned to alternative treatments provided by homeopaths, acupuncturists, or chiropractors to relieve some of their diabetic foot problems.

I have always had a lot of faith in alternative treatments… in my family we have always had this passion, so much so that my niece is both a homeopath and an expert in acupuncture and so I also resorted to it for the treatment of my diabetic foot… and personally, I had excellent results!

(Participant 9)

I read on the internet about a chiropractor in Emilia Romagna, and during a visit to that region, I made an appointment, and I must say that I found myself very well. Some relatives of mine live in Emilia Romagna, and when I go and visit them, then I make also an appointment with the chiropractor. I found myself very well and I did not experience the anxiety of being in a health context…

(Participant 12)

4. Discussion

Our research is among the first that shows the socio-cultural aspects internalized in Italian patients with diabetic foot. The main themes to emerge from our research were perceptions of diabetic foot, living with diabetic foot, the impacts of reduced cultural and economic performance, barriers to health, and home remedies and alternative medicine.

Regarding the perception of the key informants relating to the diabetic foot, the results obtained are in line with those in the available literature. Key informants’ opinions about their lives matter. Therefore, it is important to understand the thoughts of the participants to encourage changes in their behavior and attitudes. Our research results show that the key informants had little knowledge about foot care. They did not know what diabetic foot looked like or how it occurs [21]. The subtheme “low awareness” is completely in line with the results obtained from the study conducted by Meriç et al. [22], in which, again with a qualitative approach, they studied a series of aspects related to diabetic foot ulcers. Key informants showed lack of awareness and understanding of diabetic foot problems that can lead to longer hospital stays and worse results. A lack of education and a lack of knowledge are the main reasons for delaying seeking health care [23]. Therefore, awareness and knowledge are important in the treatment and management of patients, as they should be made more aware of diabetic foot [24].

Diabetes disrupts patients’ lives from the moment it is diagnosed, because it requires a series of daily checks such as home blood sugar levels, self-administration of insulin, a low-carb diet, periodic checks, etc. [25]. The onset of the diabetic foot only further aggravates this disruption of daily life, as was revealed in our study. One of the most interesting changes detected concerned gender issues, in which men showed a greater negative perception of the impact of diabetic foot on their role in the family and in society. In this regard, our results are in line with those in the study of Zhu et al. [26], where it was pointed out that some of the men who participated in the conversation hoped that they would play a significant role in the family relationship, but significant changes occurred after the onset of diabetic foot. They often need the friendship and attention of their wife, but at the same time, they feel desperate and that they will be a burden to others [26].

Another type of problem described by key informants involved bodily changes that were described in a highly negative manner. Body change problems are one of the things that affect QoL and mental functioning, causing negative emotions and feelings about the body, as well as depression of self-esteem. It is well known that the way patients feel their bodies has a significant impact on their social, mental, and physical well-being, as well as on QoL [27].

Both from the key informants and from the literature, it is evident how the bad smell of the foot ulcers negatively impacts on daily life of patients [28,29]. Smell is one of the main factors influencing human cognition, behaviors, and relations. It is not only the biomedical dimension of the origin and implementation of human physical well-being, but also the cultural and social aspects that are deeply rooted and define the perception of the value systems, psychological attitudes, and social structures of a culture [30]. Therefore, the key informants internalized this complex nature of the smell and experienced firsthand what Rindisbacher observed, i.e., “that establish good and bad smells (are) an ancient classification underlying most socio-historically grounded categories “ ([31], p. 20). Thus, our findings are in line with the concept that “If a person smells ‘bad’, or deviates from the olfactory cultural norm, the odor may be a sign that there is something wrong with their physical, emotional or mental health. The odor is a natural sign of the self as both a physical and a moral being. The odor is a symbol of the self” ([32], p. 444).

The key informants in our research often faced social and psychological challenges; most of their core emotions were related to fear, uncertainty, anxiety, loneliness, guilt, sadness, and shame [33]. Other studies suggest that the smell of wounds isolates them from social life and makes them vulnerable to anxiety, stress, or depression [33,34]. Ulcers can cause shame or low self-esteem, increasing isolation from social interactions. This aspect is very important, because if the skin is the concrete boundary between oneself and the other, between the individual and society [12], ulceration determines a real form of non-voluntary openness to others, especially other “strangers,” such as health professionals, and this has highly negative psychosocial impacts. In fact, “the ‘social skin’ models the social boundary between the individual actor and other actors; but at a deeper level it models the internal, psychic diaphragm between the pre-social, libidinous energies of the individual and the ‘internalized others’’ ([12], p. 503). Thus, modifications of the social skin, such as a diabetic ulcer, in line with our results, mean that individuals identified as “sick” may create new social relationships [12] with their family members or healthcare professionals.

In our research, we studied the role of economic factors. In this regard, the cost of treating diabetic foot patients is higher than for diabetic patients without ulcers [35]. Diabetic foot patients have more diagnoses and longer hospital stays. In addition, diabetic foot patients face many unseen financial burdens due to, e.g., hospital stays, medication, and other life support costs, including transportation costs, dressings, and shoes costs [36]. Meanwhile, due to the limited mobility of these patients, their jobs or activities have stopped, making it more difficult to pay for their treatment. Another study [37] showed that diabetic foot patients have difficulty performing tasks that require physical strength and experience impatience and difficulty carrying out tasks that require mental processing, communication, and interpersonal interactions.

Another topic strongly felt by the key informants in this study concerned the specific barriers encountered in healthcare contexts. Our results are consistent with those of other studies suggesting that one of the most common barriers is a lack of knowledge regarding diabetic foot and the need for foot care [38,39,40]. A lack of understanding of this situation and how to handle it has led to there being little or no interest in finding a cure for this disease [41]. Health education and information, using new technologies such as telemedicine or related applications, may result in empowering patient awareness of health issues. Increasing patient participation in foot care services using technology has been successful in reducing amputation rates in diabetic patients [42,43]. Another barrier for key informants is waiting time. According to the current literature, there are long waiting times for diabetic foot care at all levels, including podiatry, primary care, vascular surgery, specialist wound care, and outpatient and inpatient care; this is considered to have a negative impact on the severity of foot diseases [44,45,46]. Another barrier cited by participants was the lack of access to foot care services, many of whom indicated high engagement with appointments. Due to a lack of foot care services in their respective areas, many patients had to travel to distant hospitals where there were additional medical staff [47]. The role of the culture of fear as a barrier to healthcare for the key informants is important. The fear of healthcare professionals is described by the term iatrophobia [48]. This is a major barrier, because the key informants did not ask for the information necessary for effective treatment or disease management and subsequently received less medical care [49]. The fear of healthcare professionals is potentially dangerous, and patients can avoid licensed experts and seek informal sources of healthcare [50]. This culture of fear is therefore a significant factor influencing treatment adherence, as a result of which diabetic foot patients may feel overwhelmed with ongoing foot self-care and abandon many activities, such as wearing recommended shoes [51,52,53].

The last theme regards the home remedies and alternative medicine used by key informants. Medicinal plants have been used by diabetics for many years [54]. The key informants in this study believed that combining medicinal plants with medicine would heal ulcers better. However, the combination of drugs and medicinal plants must be supported by specific research. Health professionals, during patient training, should ensure that the medicinal plants used have been properly tested for safety and efficacy [55].

Moreover, alternative medicine is a challenge for healthcare providers today, and its implementation is similar “to separate(ing) the pearls from the mud” [56]. The effectiveness of this discipline is becoming clearer due to the increasing rate of diabetes worldwide, the search by patients for better overall treatments, and the doubts among some patients about the power of modern medicine [57]. Distinguishing the effectiveness of complementary alternative medicine (CAM) treatments from ineffective treatments remains a difficult task which is further complicated by the lack of well-designed efficacy trials and testing for a large number of treatments [58]. However, to better work with patients, healthcare professionals need to consider a patient’s needs and the risk of using CAM and provide patients with reliable recommendations for CAM treatment. In addition, patients and healthcare providers need to be fully aware of the limitations of current treatments in alternative medicine [59].

4.1. Cultural Comparative Issues

Regarding the relationship between our results and those from other countries, it is important to note that few research articles by social scientists have analyzed the sociocultural aspects of diabetic foot, with most publications coming from healthcare researchers.

In Germany, according to Meyer-Heintze [60], education is crucial for the prevention of diabetic foot and the successful treatment of people with diabetes. The integrated activities of the purchaser, the medical review board, and all healthcare professionals can improve the quality of treatment and reduce costs.

Recent research in the UK [61] has specifically analyzed only psychological aspects and suggests that key elements of psychological interventions which have been considered successful in diabetes management have not yet been applied in diabetic foot risk management. For example, Crews et al. [62] highlighted in their research on US unloading, diabetic peripheral neuropathy, depression, pain, self-efficacy, and social support, beliefs and emotions specific to diabetic foot ulcer risk and the importance of exercise interventions in this population. In addition, recommendations are made for the implementation and study of physical activity interventions for people at risk of diabetic foot ulcers.

One study from the Czech Republic [63] showed results that contradict ours. In particular, the living standards of the registered diabetic foot patients enrolled were overwhelmingly poor. Contrary to our expectations, diabetic foot patients’ stress tolerance and mental health appeared to be good (except for patients with a history of major amputation), and there was no evidence of severe depression or related outcomes.

Another study from India [64] showed that diabetic patients have a very low QoL compared to their diabetic counterparts. Similarly, diabetic foot is associated with significantly lower QoL in terms of both physical and mental health. That study proposed to develop a patient education model for diabetic foot patients by focusing on various QoL domains that are negatively affected by the presence of foot ulcers.

Another study from Brazil [65] showed interesting results consistent with our methodology. According to the authors, diabetic foot is an object of social representation that shows how people construct, bind, and apply knowledge. This study supports the planning of interventions that influence the development of representations that generate positive health behaviors in terms of self-monitoring of the foot, which could be a tool to support the care of people with diabetes.

As in many other studies, a Turkish paper [66] analyzed only the psychological aspect of diabetic foot and tried to determine how this aspect affects the treatment and care of diabetic foot patients and offered access to specialized care.

This represents a brief overview aimed at illustrating how the study of the socio-cultural aspects of diabetic foot in general have always been analyzed in a sectoral manner considering only some variables, while in our study, we tried to include a large and varied number of inherent aspects regarding diabetic foot from the point of view of the patient’s experience, thus underlining the importance of an integrated and, at the same time, systemic vision of the social, economic, cultural, psychological, and health aspects all together.

4.2. Implication of the Study: A Proposal of a New and Integrative Model

In the era of translational and clinical research, it is essential to integrate advances in the social sciences (such as theory, evaluation, interventions, and health policy) into all aspects of diabetic foot care. The complex nature of diabetes in general, in which biomedical, social, cultural, and behavioral aspects intersect, requires a reconfiguration of care such that all these variables are integrated, since the current approach is based on a unidimensional and not very transversal vision, with negative consequences on the results. Focusing on biomedical interventions without integrating social sciences into clinical care greatly reduces the impact of biomedicine [67].

For these reasons, we developed a model (Figure 3) based on the concept of integration and aimed at suggesting how we could act on the various critical issues that emerged from our research.

The basic idea of this model is represented by the concept of integration, which can be defined as the link between biomedical aspects and social sciences, to improve clinical outcomes in terms of efficiency, effectiveness, and increasing satisfaction of patients with diabetic foot. Our integrated model includes measures to address gaps in the care pathway for patients receiving simultaneous healthcare and social support. Transdisciplinarity in the context of integrated care involves collaboration between health professionals and social workers to achieve a shared and unified understanding of patients’ needs globally, allowing for coordinated action and complementary roles. This aspect is achieved with the concrete involvement not only of traditional healthcare figures such as doctors, specialists, nurses, etc., but also social scientists such as sociologists, anthropologists, psychologists, etc., who are capable of grasping all those cultural, social, psychological, and unconscious aspects that escape from the biomedical dimension [68].

Another central element in our model is the idea of improving the care of people with diabetic foot through the establishment four levels of care. This distinction is important for several reasons [69]. First, establishing different levels of care creates a comprehensive system for assessing patients’ medical needs and directing care to specialists and providers as needed. Because each level of care comes with its services and responsibilities, providers at each level can customize care to optimize the patient experience while improving patient outcomes [70]. From the patients’ perspective, understanding the different levels of care is equally important. By understanding the care delivered by providers at each level and the steps required to obtain referrals, patients can better advocate for their medical and health needs [71].

Primary care is the first level of healthcare and the one most people are familiar with. Providers at this level include general practitioners (GPs), who are the first medical professionals that diabetic patients generally see when they have health issues, even if they may require further testing for diabetic complications such as diabetic foot. GPs also help diabetic patients by offering office visits and general checkups or suggesting specialist consultations [72].

When a patient with diabetic foot has health or medical needs that extend beyond the scope of GPs, they will typically be referred to a secondary care provider such as medical specialists (such as vascular surgeons, endocrinologists, etc.) who can provide additional expertise and more tailored services. This level of care also includes diagnostic tests and acute care [73].

The next level of healthcare is tertiary care, which usually occurs when a patient is hospitalized or requires a more specialized level of care concerning primary or secondary factors, such as complex treatments and procedures (i.e., amputation, wound care, etc.) [74].

Health issues where a diabetic patient’s health needs require an even higher degree of specialization are managed in the context of quaternary care (i.e., reconstructive surgery advanced wound management, etc.). If these levels of care are adequately structured and integrated, they may reduce waiting times for appropriate care [75].

Regarding interventions in the social sciences in the model, the main objective would be to act on all those social, cultural, and psychological aspects that patients with diabetic foot experience through dissemination, training, and social interaction events, not only among patients with the same problems, but also with the rest of the community to which they belong, to increase the empowerment of these patients [76].

The cultural, social, and economic dimensions of the patient are central to integration-based healthcare in which providers are more flexible to adapt the offer of services to the specific needs of patients. Considering these aspects improves the quality of relationships, creating and implementing bonds of trust with healthcare professionals. These dimensions thus aim to place the person at the center of diabetic foot care paths. In this context, sociocultural and health literacy should be aimed at empowering individuals, families, and communities [11].

The environmental dimension is considered a socio-spatial unit which is strongly shaped by the people who live there, by their social, cultural, and psychological dynamics, and by history and demographic characteristics, which, in fact, physically shape themselves over time concerning the environment built. Thus, the basic idea is that the physical environment should be improved, starting with greater means of public transport, together with the creation of a greater territorial vision for diabetic foot care. There is a considerable increase in the digitalization of diabetic foot patient care, although this requires an increase in internet coverage and related digital education, to make healthcare professionals and diabetic foot advice more accessible and affordable [77]. In this regard, a recent systematic review showed that telemedicine interventions have a positive effect on patients with diabetic foot [78].

4.3. Study Limitations

As with all research, this study is limited. Our findings are specific to the population, society, and culture of southern Italy and cannot be generalized to other areas or populations without validation. Although our sample varied in many social and clinical variables, it does not fully represent the entire population of diabetic foot patients.

Moreover, among the most critical types of bias in qualitative research are reflexivity bias, selection bias, response bias, and non-response bias.

Regarding reflexivity bias, the inherent subjectivity that researchers bring to the investigation process may influence data collection, interpretation, and analysis. While complete elimination of this type of bias may be challenging, acknowledging its presence and employing strategies such as triangulation, as used in this study, can help mitigate its impact, ensuring that research findings remain as unbiased and faithful representations of participants’ perspectives as possible.

Selection bias refers to the distortion or skewing of research outcomes caused by non-random or biased selection of participants for study inclusion. It is possible to address selection bias, as we have done in our study, transparently documenting the criteria for participant selection, striving for diversity in the sample, and considering the potential influence of the chosen participants on the study’s findings and conclusions.

Response bias refers to the distortion of data and findings due to participants’ conscious or unconscious inclination to provide inaccurate or socially desirable responses during data collection. This issue can be mitigated by triangulation, as applied in this study, to obtain a more accurate representation of participants’ perspectives and experiences.

Non-response bias pertains to the distortion of study outcomes caused by the differential participation of individuals who chose not to participate or could not be reached. In this regard, we tried to improve data collection methods to mitigate the impact of this type of bias on the research findings.

5. Conclusions

This study provides a new perspective on the influence of cultural factors on the health of diabetic foot patients. It also shows various factors related to a lack of knowledge and training, fear, and acceptance of diabetic foot. The results allow us to understand how key informants shape their culture and beliefs. This research provides health professionals and social scientists with valuable information which they can use to create culturally sensitive content. Therefore, the complex and multifaceted nature of diabetes requires an approach based on the integration of knowledge, disciplines, and social, cultural, and health contexts.

Future studies are needed to investigate the effects of the application of our results and the proposed integrated model for patients with diabetic foot, and to include the perspectives of healthcare providers. Hopefully, their insights might help uncover additional barriers to addressing cultural and social challenges in diabetic foot care. Future research should also focus on the role of cultural factors and their impact on clinical outcomes such as healing rates, complications, disease progression, and QoL.