The southern Tasmanian health literacy and foot ulcer development in diabetes mellitus study (SHELLED study)

Miss Pam Chen1, Dr Michele Callisaya1, Dr  Karen Wills1, A/Prof Tim Greenaway1, Prof Tania Winzenberg1

1University Of Tasmania, Sandy Bay, Australia

Background: Diabetic foot disease is the leading cause of non-traumatic amputations globally, but is largely preventable. Individuals with inadequate Health Literacy (HL) struggle to understand and conceptualise health information to the detriment of self-care. Poor HL is associated with poorer health outcomes in diabetes but little is known about its effects on foot health and foot disease. The SHELLED study aimed to determine the associations between HL and diabetic foot disease in adults with diabetes.

Methods: SHELLED is a prospective study of foot ulceration risk factors, and this is a cross-sectional analysis of baseline data. 222 participants were recruited from the Royal Hobart Hospital’s Diabetes outpatient clinics between January 2015 and July 2016. Individuals under 40 with a history of foot ulceration, amputation, psychotic disorders or dementia were excluded. Participants underwent a foot risk assessment for peripheral neuropathy, peripheral arterial disease and foot deformity according to published guidelines. HL was measured using the short form Test of Functional Health Literacy in Adults (s-TOFHLA) and the Health Literacy Questionnaire (HLQ). Covariates included diabetes and foot care self-efficacy, depression, diabetes distress, diabetes knowledge and foot care behaviour.

Results: Mean (SD) s-TOFHLA scores were 31.9 (6.8), with 204 individuals having adequate HL. Higher s-TOFHLA scores were associated with lower overall risk for foot disease (OR 0.96, 95% CI 0.932, 0.989), loss of protective sensation (OR 0.951, 95% CI 0.910, 0.995) and peripheral arterial disease (OR 0.963, 95% CI 0.924, 1.003) in univariable analyses, however this did not persist after including covariates. There were no associations between HL and foot deformity.

Conclusions: This is the first study to objectively assess associations between HL and risk factors for foot disease. Our findings highlight the complex nature of diabetic foot disease development, suggesting that prevention might require attention to aspects of prevention besides HL.


Pam is a PhD candidate with the Faculty of Health at the University of Tasmania, and a community podiatrist with the Tasmanian Health Service. Her research interests involve improving prevention and management of foot disease in people with diabetes. She is also the president of the Advanced Practicing Podiatrists – High Risk Foot Group and a member of the National Association of Diabetes’ Centres’ Foot Network Working Party.

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