{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,2]],"date-time":"2026-05-02T18:40:57Z","timestamp":1777747257582,"version":"3.51.4"},"reference-count":54,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2023,4,30]],"date-time":"2023-04-30T00:00:00Z","timestamp":1682812800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"QUT Health Research Services"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Sensors"],"abstract":"<jats:p>Adherence to using offloading treatment is crucial to healing diabetes-related foot ulcers (DFUs). Offloading adherence is recommended to be measured using objective monitors. However, self-reported adherence is commonly used and has unknown validity and reliability. This study aimed to assess the validity and reliability of self-reported adherence to using removable cast walker (RCW) offloading treatment among people with DFUs. Fifty-three participants with DFUs using RCWs were included. Each participant self-reported their percentage adherence to using their RCW of total daily steps. Participants also had adherence objectively measured using dual activity monitors. After one week, a subset of 19 participants again self-reported their percentage adherence to investigate test\u2013retest reliability. Validity was tested using Pearson\u2019s r and Bland\u2013Altman tests, and reliability using Cohen\u2019s kappa. Median (IQR) self-reported adherence was greater than objectively measured adherence (90% (60\u2013100) vs. 35% (19\u201347), p &lt; 0.01). There was fair agreement (r = 0.46; p &lt; 0.01) and large 95% limits of agreement with significant proportional bias (\u03b2 = 0.46, p &lt; 0.01) for validity, and minimal agreement for test\u2013retest reliability (K = 0.36; p &lt; 0.01). The validity and reliability of self-reported offloading adherence in people with DFU are fair at best. People with DFU significantly overestimate their offloading adherence. Clinicians and researchers should instead use objective adherence measures.<\/jats:p>","DOI":"10.3390\/s23094423","type":"journal-article","created":{"date-parts":[[2023,5,1]],"date-time":"2023-05-01T12:12:11Z","timestamp":1682943131000},"page":"4423","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["The Validity and Reliability of Self-Reported Adherence to Using Offloading Treatment in People with Diabetes-Related Foot Ulcers"],"prefix":"10.3390","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8044-3554","authenticated-orcid":false,"given":"Anas","family":"Ababneh","sequence":"first","affiliation":[{"name":"Faculty of Nursing, Applied Science Private University, Amman 11931, Jordan"},{"name":"School of Nursing, Queensland University of Technology, Brisbane, QLD 4059, Australia"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5743-2731","authenticated-orcid":false,"given":"Kathleen","family":"Finlayson","sequence":"additional","affiliation":[{"name":"School of Nursing, Queensland University of Technology, Brisbane, QLD 4059, Australia"},{"name":"Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD 4059, Australia"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4451-0577","authenticated-orcid":false,"given":"Helen","family":"Edwards","sequence":"additional","affiliation":[{"name":"School of Nursing, Queensland University of Technology, Brisbane, QLD 4059, Australia"},{"name":"Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD 4059, Australia"}]},{"given":"David G.","family":"Armstrong","sequence":"additional","affiliation":[{"name":"Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0320-8101","authenticated-orcid":false,"given":"Bijan","family":"Najafi","sequence":"additional","affiliation":[{"name":"Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6420-6046","authenticated-orcid":false,"given":"Jaap J.","family":"van Netten","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, 1105 AZ Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1012 WX Amsterdam, The Netherlands"},{"name":"Amsterdam Movement Sciences, Ageing & Vitality and Rehabilitation and Development, 1105 AZ Amsterdam, The Netherlands"},{"name":"School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD 4059, Australia"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8235-7964","authenticated-orcid":false,"given":"Peter A.","family":"Lazzarini","sequence":"additional","affiliation":[{"name":"Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD 4059, Australia"},{"name":"School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD 4059, Australia"},{"name":"Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, QLD 4032, Australia"}]}],"member":"1968","published-online":{"date-parts":[[2023,4,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"964","DOI":"10.2337\/dc19-1614","article-title":"Global disability burdens of diabetes-related lower-extremity complications in 1990 and 2016","volume":"43","author":"Zhang","year":"2020","journal-title":"Diabetes Care"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2367","DOI":"10.1056\/NEJMra1615439","article-title":"Diabetic foot ulcers and their recurrence","volume":"376","author":"Armstrong","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"110189","DOI":"10.1016\/j.diabres.2022.110189","article-title":"Trends in diabetes-related foot disease hospitalizations and amputations in Australia, 2010 to 2019","volume":"194","author":"Quigley","year":"2022","journal-title":"Diabetes Res. Clin. Pract."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1186\/s13047-020-00383-2","article-title":"Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer","volume":"13","author":"Armstrong","year":"2020","journal-title":"J. Foot Ankle Res."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1007\/s00125-022-05845-9","article-title":"Global trends in the incidence of hospital admissions for diabetes-related foot disease and amputations: A review of national rates in the 21st century","volume":"66","author":"Lazzarini","year":"2022","journal-title":"Diabetologia"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e14961","DOI":"10.1111\/dme.14961","article-title":"Cost-effectiveness of guideline-based care provision for patients with diabetes-related foot ulcers: A modelled analysis using discrete event simulation","volume":"40","author":"Zhang","year":"2023","journal-title":"Diabet. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e3274","DOI":"10.1002\/dmrr.3274","article-title":"Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)","volume":"36","author":"Bus","year":"2020","journal-title":"Diabetes\/Metab. Res. Rev."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e3275","DOI":"10.1002\/dmrr.3275","article-title":"Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: A systematic review","volume":"36","author":"Gooday","year":"2020","journal-title":"Diabetes\/Metab. Res. Rev."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1","DOI":"10.2337\/db20182-1","article-title":"Diagnosis and Management of Diabetic Foot Complications","volume":"2018","author":"Boulton","year":"2018","journal-title":"ADA Clin. Compend."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1097\/01.ASW.0000450831.65667.89","article-title":"Diabetic foot ulcer off-loading: The gap between evidence and practice. Data from the US Wound Registry","volume":"27","author":"Fife","year":"2014","journal-title":"Adv. Skin Wound Care"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2118","DOI":"10.2337\/dc08-0771","article-title":"Use of pressure offloading devices in diabetic foot ulcers: Do we practice what we preach?","volume":"31","author":"Wu","year":"2008","journal-title":"Diabetes Care"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1186\/s13047-014-0035-8","article-title":"A survey of offloading practices for diabetes-related plantar neuropathic foot ulcers","volume":"7","author":"Raspovic","year":"2014","journal-title":"J. Foot Ankle Res."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1186\/s13047-015-0072-y","article-title":"How do Australian podiatrists manage patients with diabetes? The Australian diabetic foot management survey","volume":"8","author":"Quinton","year":"2015","journal-title":"J. Foot Ankle Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1111\/iwj.12835","article-title":"The efficacy of removable devices to offload and heal neuropathic plantar forefoot ulcers in people with diabetes: A single-blinded multicentre randomised controlled trial","volume":"15","author":"Bus","year":"2017","journal-title":"Int. Wound J."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1371","DOI":"10.2337\/dc15-2373","article-title":"Role and determinants of adherence to off-loading in diabetic foot ulcer healing: A prospective investigation","volume":"39","author":"Campbell","year":"2016","journal-title":"Diabetes Care"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e002640","DOI":"10.1136\/bmjdrc-2021-002640","article-title":"Factors associated with adherence to using removable cast walker treatment among patients with diabetes-related foot ulcers","volume":"10","author":"Ababneh","year":"2022","journal-title":"BMJ Open Diabetes Res. Care"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"869","DOI":"10.1177\/1932296819849092","article-title":"Measuring Plantar Tissue Stress in People With Diabetic Peripheral Neuropathy: A Critical Concept in Diabetic Foot Management","volume":"13","author":"Lazzarini","year":"2019","journal-title":"J. Diabetes Sci. Technol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1177\/19322968211070850","article-title":"Smart Offloading Boot System for Remote Patient Monitoring: Toward Adherence Reinforcement and Proper Physical Activity Prescription for Diabetic Foot Ulcer Patients","volume":"17","author":"Park","year":"2022","journal-title":"J. Diabetes Sci. Technol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2075","DOI":"10.1016\/j.apmr.2012.06.019","article-title":"New Monitoring Technology to Objectively Assess Adherence to Prescribed Footwear and Assistive Devices During Ambulatory Activity","volume":"93","author":"Bus","year":"2012","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"100","DOI":"10.7547\/0980100","article-title":"A method for assessing off-loading compliance","volume":"99","author":"Crews","year":"2009","journal-title":"J. Am. Podiatr. Med. Assoc."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"417","DOI":"10.1007\/s11892-009-0068-8","article-title":"Controversies in off-loading: Should big brother be watching?","volume":"9","author":"Crews","year":"2009","journal-title":"Curr. Diabetes Rep."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1186\/s13047-019-0327-0","article-title":"Gender differences in attitudes and attributes of people using therapeutic shoes for diabetic foot complications","volume":"12","author":"Jarl","year":"2019","journal-title":"J. Foot Ankle Res."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1767","DOI":"10.2147\/PPA.S175738","article-title":"Methodological considerations of investigating adherence to using offloading devices among people with diabetes","volume":"12","author":"Jarl","year":"2018","journal-title":"Patient Prefer. Adherence"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"470","DOI":"10.1007\/s13142-015-0315-2","article-title":"Self-report measures of medication adherence behavior: Recommendations on optimal use","volume":"5","author":"Stirratt","year":"2015","journal-title":"Transl. Behav. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1598","DOI":"10.2106\/JBJS.16.00170","article-title":"The objective measurement of brace-use adherence in the treatment of idiopathic clubfoot","volume":"98","author":"Sangiorgio","year":"2016","journal-title":"JBJS"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"336","DOI":"10.1097\/BPO.0b013e318168d154","article-title":"Accuracy in the prediction and estimation of adherence to bracewear before and during treatment of adolescent idiopathic scoliosis","volume":"28","author":"Morton","year":"2008","journal-title":"J. Pediatr. Orthop."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"943","DOI":"10.2519\/jospt.2018.8275","article-title":"Self-reported home exercise adherence: A validity and reliability study using concealed accelerometers","volume":"48","author":"Nicolson","year":"2018","journal-title":"J. Orthop. Sport. Phys. Ther."},{"key":"ref_28","first-page":"e3268","article-title":"Definitions and criteria for diabetic foot disease","volume":"36","author":"Bus","year":"2019","journal-title":"Diabetes\/Metab. Res. Rev."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1177\/1932296816662959","article-title":"Can\u2019t stand the pressure: The association between unprotected standing, walking, and wound healing in people with diabetes","volume":"11","author":"Najafi","year":"2016","journal-title":"J. Diabetes Sci. Technol."},{"key":"ref_30","unstructured":"Ababneh, A.N. (2021). Adherence to Wearing Removable Cast Walkers in Patients with Diabetes-Related Foot Ulcers: A Mixed Methods Investigation, Queensland University of Technology."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1002\/(SICI)1097-0258(20000315)19:5<723::AID-SIM379>3.0.CO;2-A","article-title":"Interval estimation for Cohen\u2019s kappa as a measure of agreement","volume":"19","author":"Blackman","year":"2000","journal-title":"Stat. Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"781","DOI":"10.1016\/S2213-8587(16)30012-2","article-title":"Reporting standards of studies and papers on the prevention and management of foot ulcers in diabetes: Required details and markers of good quality","volume":"4","author":"Jeffcoate","year":"2016","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"471","DOI":"10.2174\/1573399815666191001101910","article-title":"Prevalence and Associates of Foot Deformities among Patients with Diabetes in Jordan","volume":"16","author":"Ababneh","year":"2020","journal-title":"Curr. Diabetes Rev."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"855","DOI":"10.2337\/diacare.21.5.855","article-title":"Validation of a diabetic wound classification system: The contribution of depth, infection, and ischemia to risk of amputation","volume":"21","author":"Armstrong","year":"1998","journal-title":"Diabetes Care"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1002\/nur.4770130405","article-title":"A critical review of visual analogue scales in the measurement of clinical phenomena","volume":"13","author":"Wewers","year":"1990","journal-title":"Res. Nurs. Health"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"731","DOI":"10.4172\/2155-6113.1000731","article-title":"A Simple Visual Analog Scale is a Valuable Tool to Assess Self-Reported Adherence in HIV-Infected Patients on Antiretroviral Treatment in a Resource-Limited Setting","volume":"8","author":"Erb","year":"2017","journal-title":"J. AIDS Clin. Res."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"3182","DOI":"10.1080\/09638288.2019.1587792","article-title":"The validity and accuracy of wrist-worn activity monitors in lower-limb prosthesis users","volume":"42","author":"Smith","year":"2019","journal-title":"Disabil. Rehabil."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Burton, E., Hill, K.D., Lautenschlager, N.T., Thogersen-Ntoumani, C., Lewin, G., Boyle, E., and Howie, E. (2018). Reliability and validity of two fitness tracker devices in the laboratory and home environment for older community-dwelling people. BMC Geriatr., 18.","DOI":"10.1186\/s12877-018-0793-4"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Kooiman, T.J., Dontje, M.L., Sprenger, S.R., Krijnen, W.P., van der Schans, C.P., and de Groot, M. (2015). Reliability and validity of ten consumer activity trackers. BMC Sport. Sci. Med. Rehabil., 7.","DOI":"10.1186\/s13102-015-0018-5"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1016\/j.ijcard.2015.03.038","article-title":"Fitbit(R): An accurate and reliable device for wireless physical activity tracking","volume":"185","author":"Diaz","year":"2015","journal-title":"Int. J. Cardiol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"2595","DOI":"10.2337\/diacare.26.9.2595","article-title":"Activity patterns of patients with diabetic foot ulceration: Patients with active ulceration may not adhere to a standard pressure off-loading regimen","volume":"26","author":"Armstrong","year":"2003","journal-title":"Diabetes Care"},{"key":"ref_42","unstructured":"Portney, L.G., and Watkins, M.P. (2009). Foundations of Clinical Research: Applications to Practice, Pearson\/Prentice Hall."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1177\/096228029900800204","article-title":"Measuring agreement in method comparison studies","volume":"8","author":"Bland","year":"1999","journal-title":"Stat. Methods Med. Res."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"276","DOI":"10.11613\/BM.2012.031","article-title":"Interrater reliability: The kappa statistic","volume":"22","author":"McHugh","year":"2012","journal-title":"Biochem. Med."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"176","DOI":"10.4187\/respcare.06436","article-title":"Objective versus self-reported adherence to airway clearance therapy in cystic fibrosis","volume":"64","author":"Oates","year":"2019","journal-title":"Respir. Care"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"425","DOI":"10.1378\/chest.09-3074","article-title":"Accurate assessment of adherence: Self-report and clinician report vs electronic monitoring of nebulizers","volume":"140","author":"Daniels","year":"2011","journal-title":"Chest"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1345\/aph.1D252","article-title":"Measurement, correlates, and health outcomes of medication adherence among seniors","volume":"38","author":"Vik","year":"2004","journal-title":"Ann. Pharmacother."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1097\/00126334-200402010-00016","article-title":"Is the influence of social desirability on patients\u2019 self-reported adherence overrated?","volume":"35","author":"Wagner","year":"2004","journal-title":"JAIDS J. Acquir. Immune Defic. Syndr."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1190","DOI":"10.1016\/j.gerinurse.2021.07.001","article-title":"Experiences of and factors associated with dietary sodium adherence in heart failure from patients\u2019 and their caregivers\u2019 perspectives: A qualitative study","volume":"42","author":"Heo","year":"2021","journal-title":"Geriatr. Nurs."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1111\/iwj.13010","article-title":"Perceptions and experiences of diabetic foot ulceration and foot care in people with diabetes: A qualitative meta-synthesis","volume":"16","author":"Coffey","year":"2019","journal-title":"Int. Wound J."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"451","DOI":"10.7547\/87507315-91-9-451","article-title":"Continuous activity monitoring in persons at high risk for diabetes-related lower-extremity amputation","volume":"91","author":"Armstrong","year":"2001","journal-title":"J. Am. Podiatr. Med. Assoc."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"225","DOI":"10.2337\/diacare.28.1.225-a","article-title":"Evaluation of the Portable HealthWear Armband: A device to measure total daily energy expenditure in free-living type 2 diabetic individuals","volume":"28","author":"Mignault","year":"2005","journal-title":"Diabetes Care"},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Van Remoortel, H., Raste, Y., Louvaris, Z., Giavedoni, S., Burtin, C., Langer, D., Wilson, F., Rabinovich, R., Vogiatzis, I., and Hopkinson, N.S. (2012). Validity of six activity monitors in chronic obstructive pulmonary disease: A comparison with indirect calorimetry. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0039198"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1123\/JAPA.2013-0103","article-title":"Assessing physical activity in older adults: Required days of trunk accelerometer measurements for reliable estimation","volume":"23","author":"Rispens","year":"2015","journal-title":"J. Aging Phys. Act."}],"container-title":["Sensors"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1424-8220\/23\/9\/4423\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:27:16Z","timestamp":1760124436000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1424-8220\/23\/9\/4423"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,4,30]]},"references-count":54,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2023,5]]}},"alternative-id":["s23094423"],"URL":"https:\/\/doi.org\/10.3390\/s23094423","relation":{},"ISSN":["1424-8220"],"issn-type":[{"value":"1424-8220","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,4,30]]}}}