A Scoping Review of Footwear Worn by People With Diabetes in Low- and Middle-Income Countries: Implications for Ulcer Prevention Programs

Mexico,primary care center

N=87, 68% neuropathic51% with foot deformityMean 6 years of education

• 99% standard

• 82% [of footwear] in good condition

• 52% footwear material: leather

• 51% open shoes

• 63% flat shoe tips

Brazil,basic health units

N=197, 91% with income at or less than minimum wage47% with less than 5 years of education

• 74% open-shoe sandal type

• 30% soft and closed-in shoes

• 4.1% tight closed-in shoes

• 1.0% pointy shoes

India,outpatient department of tertiary care hospital

N=350, 44% rural29% with graduate education66% neuropathic65% at moderate and 10% at high risk of DFU

• 65% more than 35 shore units

• 35% 16–35 shore units

• 0% 8–15 shore units (where shore units are a unit of hardness, and 8–15 was considered appropriate for footwear for people with diabetes)

India,podiatry division of tertiary care center

N=361, all hospitalized for DFU93% neuropathic

• 80% sandals

• 16% closed shoes

• 2.5% therapeutic footwear

• 1.4% barefoot

Brazil,2 family health units

N=85, 72% with family income at or less than 2 minimum wages19% said comfortable and closed shoes ideal

• 87% open sandals

• 9.4% closed and soft

• 3.5% closed and tight

Jamaica,hospital diabetes clinic

N=72, diabetes clinic attendees81% female32% with post-secondary education

• Females: 88% slippers, 85% open-toe shoes, 85% broad round-toe shoes, 62% leather shoes, 62% sneakers, 43% high-heel shoes, 36% pointed- toe shoes, 22% canvas shoes, 17% plastic shoes

• Males: 93% slippers, 50% open-toe shoes, 71% broad round-toe shoes, 71% leather shoes, 57% sneakers, 50% pointed toe shoes, 21% canvas shoes, 6.9% plastic shoes, 6.9% work boots

South Africa,outpatient department of diabetes clinic

N=280, 76% with altered limb sensation92% visited clinic monthly9.3% had previous DFU3.6% had previous amputation

• 83% sandals and flip-flops

Ethiopia,outpatient department of medical center

N=370, 44% female39% illiterate53% urban31% farmers36% had previous DFU

• 23% sandals/slippers

• 28% shoes without socks

Philippines,outpatient department of medical center

N=170, 73% female47% college educated8.8% had active DFU62% at some risk of DFU

• Females: 40% sandals, 31% flip-flops, 10% slip-ons, 8.8% ballet flats, 8.8% rubber shoes/sneakers, 0.7% pointed-toe shoes, 0.7% platform shoes

• Males: 35% sandals, 22% flip-flops, 20% slip-ons, 13% rubber shoes, 11% boat shoes

India,hospital surgery department

N=38, regular foot patients at outpatient department21% female47% illiterate18% had previous amputation

• 32% Hawaii slippers

• 55% ordinary slippers/chappals

• 5.3% therapeutic footwear

• 2.6% shoes (ordinary)

• 2.6% sandals

• 2.6% no footwear

Malaysia,diabetes clinic

N=166, 68% unemployed75% with income less than 1,500 Ringgit42% had foot problem

• 69% flip-flops or thongs

• 47% sandals

• 1.2% custom-made shoes

Thailand,tertiary care diabetes clinic

N=438, patients visiting diabetes clinic78% at low risk of DFU3.9% had active DFU

• 67% slippers

• 8.8% low-heel shoes

• 3.5% sports shoes

• 1.4% high-heel shoes

• 19% others

Pakistan,hospital diabetes management center

N=90, 7.8% with dull foot sensation82% received foot care information11% had previous DFU

• 43% soft-heel shoes

• 41% sandals

• 12% leather shoes

• 2.2% high-heel shoes

Brazil,diabetes and hypertension treatment center

N=235, patients attending health center34% with incomplete elementary schooling72% with diabetes duration for 10 years or longer38% with income less than minimum wage11% had previous DFU or amputation

• 59% open footwear

India,health center serving urban and rural patients

66 cases and 66 controls, all cases had ulcers due to footwearcontrols had diabetes but no DFU96% neuropathic35% of cases with diabetes duration less than 5 years53% cases, 62% controls use shoes 5 hours/day or less

• Cases: 32% sandals with strap and toe grip; 18% sandals with strap, toe grip, and MCR insole; 29% Hawaii beach sandals; 6.1% sandals with MCR insole, soft outsole, and adjustable front and back straps; 3.0% slip-on shoes with covered uppers; 1.5% slip-in sandals without toe grip

• Controls: 26% sandals with strap and toe grip; 16% sandals with strap, toe grip, and MCR insole; 47% Hawaii beach sandals; 3.0% slip-on shoes with covered uppers

Thailand,referral hospital

N=511, 65% at low risk of DFU33% neuropathic13% had active DFU

• 67% Hawaii slippers

• 8.0% low-heel shoes

• 3.7% sports shoes

• 1.4% high-heel shoes

Brazil,family health unit

N=63, all insulin users68% female67% never received foot care information

• 70% socks and closed-toe shoes

Iraq,hospital diabetes center

N=250, 71% urban31% neuropathic44% with diabetes duration less than 5 years20% had previous DFU

• 44% round-toe shoes

• 33% sandals

India,rural chronic disease clinic

N=103, patients attending clinic53% found to have high diabetes awareness5.8% at high risk of DFU2.9% had active DFU

• 79% slippers (chappals)

• 16% sandals without strap

• 3.0% sandals with strap or floaters

• 0% shoes or footwear with therapeutic insole

Sri Lanka,outpatient department of hospital

88 cases and 80 controls, cases had leg/foot ulcers larger than 2.5 cm²Controls were people with diabetes without ulcers49% cases, 25% controls with income less than Sri Lankan rupee 15,000

• Cases: 75% slippers, 16% sandals, 9.2% covered shoes

• Controls: 55% slippers, 24% covered shoes, 21% sandals

Thailand,7 hospitals

N=539, all at moderate to high risk of DFU68% with income less than 10,000 Baht66% had loss of sensation78% visited foot clinic in the previous 6 months21% had chronic ulcer

• Inside: 47% barefoot, 39% slippers or flip-flops, 6.1% closed shoes, 5.4% clog shoes, 3.2% sandals

• Outside: 0.7% barefoot, 43% slippers or flip-flops, 25% closed shoes, 18% clog shoes, 13% sandals

Malaysia,3 hospital outpatient clinics

N=174, 39% had previous DFU28% had active DFU

• 38% open sandals without back support

• 13% open sandals with forking

• 13% closed shoes without laces or adjustable straps

• 13% closed shoes with laces or adjustable straps

• 8.6% open sandals with back support

• 8.6% high-heel shoes

• 1.7% orthotic or custom-made shoes

• 3.4% other

Nigeria,multiple hospitals

• Females: 53% slippers, 19% sandals, 15% half-shoes, 13% shoes, 0% custom-molded shoes

• Males: 37% slippers, 29% sandals, 17% shoes, 14% half-shoes, 1.9% sports shoes, 1.3% boots, 0% custom-molded shoes

Nigeria,not stated

• Females: 45% slippers, 24% sandals, 18% half-shoes, 11% shoes, 1.3% sports shoes, 1.3% custom-molded shoes

• Males: 35% sandals, 26% slippers, 17% half-shoes, 15% shoes, 5.1% boots, 1.3% sports shoes, 1.3% custom-molded shoes

India,rural hospital

N=200, patients without diabetic foot, amputated food, or foot ulcersNone did daily foot self-inspection3.0% had previous foot exam by physician

• 85% chappals