Attitude and knowledge about foot health: a spanish view

ABSTRACT Objective: to explore attitudes towards patients' self-reported data about foot health-related beliefs from a behavioural and attitudinal perspective. Methods: a sample of 282 participants of a mean age of 39.46 ± 16.026 came to a health centre where self-reported demographic, clinical characteristics and beliefs relating to foot health data were registered, informants' completed all the stages of the research process. Results: the results of the analysis revealed an 8-factor factorial structure based on (1) podiatric behaviours, (2) the intention to carry out protective behaviour, (3) attitudinal beliefs, (4) normative beliefs, (5) needs, (6) apathy, (7) self-care, and (8) the general perception of foot health. They all explained 62.78% of the variance, and were considered as independent variables in a regression analysis to determine which provided the best explanations for the importance attributed to foot health. Conclusions: the participants in the study revealed a positive attitude in relation to foot health care and responsible behaviour.


Introduction
The increase in life expectancy and the high prevalence of foot pathologies related to obesity, diabetes, the practice of sport, vascular alterations, physical injury and a sedentary lifestyle (1) for which there is no total cure and where the therapeutic goal is to relieve or eliminate symptoms, avoid complications and improve the patient's wellbeing, means that classical medical measurements of outcome (mortality, morbidity, life expectancy) are insufficient to provide a thorough assessment of whether patients receive appropriate and effective treatment for foot diseases.
Also, such problems currently affect between 71 and 93% of general population and are a frequent cause of medical and foot care (2) since they have been shown to be neither minor nor banal and have a negative influence on functional capacity and quality of life (3)(4)(5) . These conditions are multifactorial in their origin and their high incidence was related with difficulty in putting shoes, pain, gait disturbance, reduced walking speed, variation in plantar pressures, risk of falls (6)(7)(8) . The pathologies and alterations more frequently found were claw toes, hallux valgus, hammer toes, overlapping toes, hallux extensus, pes planus, morton's neuroma, tailor's bunions, plantar fascitis and pes cavus (2,9) .
The research questions addressed therefore concern the following aspects: what attitudes and factors influence people's perception of foot diseases and the health professional who treat them? What are the most suitable methods we can use to increase our knowledge of these attitudinal aspects?
In order to attempt to provide an answer to these questions the overall research objective was defined as being to evaluate the social representations of foot health and the podiatric and psychological aspects involved in the analysis of human behavior.
We will thus be able to perceive whether the main motive is related to the negative impact of foot diseases on functional capacity and quality of life (10) and in this regard the main tool for the analysis of health research is the construction of questionnaires on a scientific basis (11) as a reliable method of measuring results and generating clinical evidence, The importance of a study of this kind lies in the possibility of analyzing particular behaviors and our knowledge of the psychosocial context, since they can potentially generate a risk of suffering from foot pathologies.
This will have a positive influence on patients' response and adherence to treatment characterized by the introduction of a variety of activities that people carry out in their everyday lives and the importance attributed to disease in general, which people will also apply to its causes (12) . All of this has an effect on the type of preventive behaviors that accompany a treatment or lessen the possibility of being affected by a foot or ankle pathology (13) .
In this regard, the present study analyzes beliefs relating to foot health, from a behavioral and attitudinal standpoint, due to the lack of knowledge of the criteria people take into account when evaluating the seriousness of everything that affects foot health.
We will now take a more detailed look at the significance of the outcome of this factorial analysis.
The criterion used to extract factors was to retain all factors with an eigenvalue higher than 1. The outcome could have been simplified had we increased this value, but we opted for the traditional criterion in order to maintain maximum variance and to obtain a more significant and easier to use set of 8 aspects related to the perception of foot care from the original instrument (Table 2).  This factor can thus help to prevent cardiovascular pathologies and contribute to a decrease in mortality.
Analysis of the importance attributed to foot health as determined by multiple regression analysis, provided information regarding the factors that most contributed to this determination of importance by the subjects in the study.
Thus, taking as variables the 8 factors extracted by means of factorial analysis, and as dependent variable the importance attributed to foot care by those interviewed, the following results were obtained (Table 3).
The factors that contributed to the attribution of importance to foot health were those that entered the regression equation, namely factors 1, 2, 4, 5 and 8, which between them explained 16.1 % of the variance.
Factor 1, "Foot care behaviors", contributed to the explanation of the importance attached to foot health with 7.9% of the variance. This was followed by Factor 4, "Attitudinal beliefs" (increasing the variance to 12.4%), Factor 8, "Health perception related to moving around on foot" (which raised the variance to 13.8%), Factor 5, "Real needs" (15.1%), and finally Factor 2, "Behavioral intention", which established the variance at 16.1% to explain the importance attributed to foot health (see Figure 2).
The most significant finding derived from these results is that the attribution of importance to foot health is determined by the strength of the following factors: the influence of behavior on subjects' assessment; attitudinal beliefs; the perception of the linkage between moving around on foot and health; and the existence of real needs to visit a health professional that will help to improve health in general, and foot health in particular.
These all provide a wealth of information related to preventive or therapeutic behaviors that lead to better health and an improved quality of life.  López-López D, García-Mira R, Palomo-López P, Sánchez-Gómez R, Ramos-Galván J, Tovaruela-Carrión N, et al.

Discussion
The response of subjects to disease depends on their previously held image of it, and the persons providing treatments act in a socio-cultural system that legitimizes their behaviors, and also assume a series of socially accepted roles and responsibilities.
In this regard, the response given by subjects to the attribution of the importance of foot health is determined not only by the influence exerted by behavior on the subjects' assessment, but also by that of attitudinal beliefs, health perception associated with moving around on foot, real needs and the intention to carry out self-care behaviors (16)(17)(18) .
The perception of disease in relation to foot health thus builds confidence and self-assurance that contribute to achieving a healthy lifestyle and avoiding situations of dependency, with moving around on foot being a vitally important habit in order to maintain fitness and prevent both physical and cognitive deterioration (19)(20)(21) .
In this regard, the attitudinal and normative We were therefore able to see that there is growing acceptance of podiatry and podiatrists in people's lives and personal activities, integrated into and conceptualized as part of a healthier lifestyle.

Conclusions
The present study revealed that people's attitudes and beliefs concerning foot health are related to the existence of real needs to visit a podiatrist and the demand for this kind of foot health professional to monitor foot health. This is the result of the existence of a positive social attitude in relation to podiatry and podiatric behaviors that increases the self-assurance and confidence needed to maintain their individual foot health and contribute to an improvement in underlying diseases and their general state of health, thereby helping them to lead a healthy life and avoid situations of dependency.