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Patient-Centered Health Education Intervention to Empower Preventive Diabetic Foot Self-care Meryl Makiling, RN and Hiske Smart, CNS

ABSTRACT BACKGROUND: Diabetes impairs the body’s ability to produce or respond to the hormone insulin resulting in abnormal metabolism of carbohydrates and elevated glucose levels in the body. Because of these factors, diabetes can cause several complications that include heart disease, stroke, hypertension, eye complications, kidney disease, skin complications, vascular disease, nerve damage, and foot problems. Diabetes education allows patients to explore effective interventions into living their life with diabetes and incorporate the necessary changes to improve their lifestyle. OBJECTIVE: To educate patients diagnosed with diabetes or followed up for diabetes management by other departments with regard to their own responsibility in maintaining preventive foot self-care. METHODS: Ten patients completed a validated educational foot care knowledge assessment pretest to determine their existing knowledge about their own foot care after a thorough foot assessment. Preventive diabetic foot self-care education was conducted through a lecture, visual aids, and a return demonstration. Patients then took a posttest questionnaire with the same content as the pretest to determine their uptake of the educational content. RESULTS: Correct toenail cutting was the most identified educational need. It was a limitation in the pretest (30%), and it remained the lowest-scoring item on the posttest (70%). Walking barefoot was thought to be safe by 60% of participants pretest, but with remedial education, all participants identified this as a dangerous activity posttest. Participants also understood the high importance of having corns and calluses looked after by a health professional. CONCLUSIONS: Effective communication with patients by healthcare providers who can mold educational content to identified patient needs by teaching much needed skills is a key driver in rendering safe, quality healthcare education interventions. KEYWORDS: diabetes, diabetic foot, education, foot care, prevention, self-care

ADV SKIN WOUND CARE 2020;33:360–5.

DOI: 10.1097/01.ASW.0000666896.46860.d7

INTRODUCTION Type 2 diabetesmellitus is one of themost prevalent chronic disease burdens worldwide. Its prevalence rose from 4.7% in 1980 to 8.5% in 2014,1 currently affecting 422 million patientsworldwide. It is expected to be the seventhmost common cause of death in the world by 2030, primarily because of its rapid rise in middle- and low-income coun- tries.2 Diabetes is also a leading cause of severe morbid- ities and disabilities.1,2

Diabetes causes the body to completely or partially lost its ability to produce or respond to the hormone in- sulin, resulting in abnormal metabolism of carbohy- drates and elevated glucose levels in the body. Because of these metabolic changes, diabetes is associated with several complications such as heart disease, stroke, hy- pertension, eye complications, kidney disease, skin com- plications, vascular disease, nerve damage, and foot problems.2 Foot problems can range from mild to major damage to the foot structure and are associated with a pa- thology pathway that can include damage to the vascular blood supply and soft tissues and result in infection, all of which are magnified further by pressure and loss of pro- tective sensation known as peripheral neuropathy.3

People with these foot pathologies have a higher risk of developing a diabetic foot ulcer (DFU) and associated infection; this then carries the risk for a lower limb am- putation.2,3 Although some patients suffer from severe pain anddiscomfort in their feet—stinging, stabbing, shoot- ing, burning—others remain asymptomatic. However, having an insensate foot is the leading cause of uniden- tified foot complications in the early stages.3 The incidence of nontraumatic lower extremity amputation is at least 15 times greater in those with diabetes than without,4

followed by a high incidence of deathwithin 5 years there- after.5A 6-year follow-up study in SaudiArabia found that persons with a DFU were more likely to die during the study period than those without a DFU.5

In addition,management of a DFU is expensive, and if compounded with wound infection or amputation, the cost escalates accordingly.5,6 The duration of time to treat

Meryl Makiling, RN, is Staff Nurse, HVI-Podiatry Clinic, Cleveland Clinic, Abu Dhabi, United Arab Emirates. Hiske Smart, CNS, is Clinical Nurse Specialist, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain. The authors have disclosed no financial relationships related to this article. This article was originally published as Makiling M, Smart H. Patient-centred health educational intervention to empower preventive diabetic foot self-care. WCET J 2019;39(4):32-40. © Advances in Skin and Wound Care and World Council of Enterostomal Therapists.

Original Investigation


Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

and save asmuch of a foot as possible once aDFUdevelops is lengthy and requires an interprofessional approach to facilitate rehabilitation. However, if DFU development, surgical intervention, and amputation can be prevented with appropriate education interventions, cost savings and improved quality-of-life outcomes can be achieved. 7

In particular, patient education about basic foot care is important to reduce lower extremity complications.5,6

Nurses working in vascular and podiatry clinics encoun- ter patients with differing degrees of diabetic foot compli- cations. Patients who attend these clinics may have had diabetes for years. Themost common finding in the authors’ clinic is that patients are neither educated nor empowered with self-assessment methods to control their own disease and prevent complications in the early period just after initial diabetes diagnosis. Education interventions for persons with diabetes are

internationally accepted as a cornerstone of diabetes man- agement and patient empowerment, allowing them to make necessary changes to improve their lifestyle and pre- vent complications.7 These interventions enable patients to take control of their own disease and make correct life- style decisions to control their disease process and re- sultant outcomes. Diabetes education allows patients to identify their own requirements for needs-based learn- ing, a valuable adult learning concept that fosters in- creased adherence to best practice.8 The best time for this kind of intervention is early in the disease process, after diagnosis.8,9

These interventions require a health professional with sufficient knowledge of diabetesmanagement andpreven- tion who can convey the most essential content in bite- sized pieces in a short period. The education provided also requires regular follow-up with health professionals for monitoring uptake of lifestyle modifications and ongo- ing reassessment to determine whether more educa- tion is required. Targeting patients at increased risk

for DFU is therefore believed to constitute a cost- effective strategy to control progression to end-stage foot complication and mechanical destruction.8

It can be argued that the greatest weapon in the fight against diabetes mellitus complications is knowledge. Information can help people assess their risk of diabetes, motivate them to seek proper treatment and care earlier, and inspire them to take charge of their disease during their lifetime.7,8 Lectures accompanied by clinical dem- onstration are the preferred mode of teaching in a clinic setting given adult learning needs as identified by pa- tients themselves.10 This method also accommodates the language barrier between care providers and pa- tients.11 Information given to patients demonstrates how to conduct their own foot inspection and apply treatment if needed, with simultaneously assesses their ability to do so. This ensures that patients have sufficient knowledge and skills to undertake any required assess- ment interventions once at home and under self-care.

Objective The primary objective of the project was to educate pa- tients diagnosed with diabetes or followed up for diabe- tes management by other departments such as internal medicine and endocrinology with regard to the patient’s own responsibility inmaintainingpreventive foot self-care. This was completed through evaluating gaps in patient knowledge via a pretest-posttest design.




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METHODS On average, 20 new patients are referred to the authors’ podiatry clinic for diabetic foot screening every month (Figure 1). Most of these patients already have foot-related symptoms such as numbness, tightness, burning, and a tingling sensation that are signs of neuropathy. Most patients present with calluses over bony prominences, corns, and a dry plantar area indicative of peripheral neuropathy. Researchers decided to recruit, include, and group teach the first 10 patients in the clinic who met the following inclusion criteria: • diabetes diagnosis and formal referral to the podiatry clinic for foot screening • ability to speak and understand English (education materials were in English) • adults who could provide consent to participate • consent to take part in a confidential pretest and post- test educational foot care knowledge assessment

Assessments and Intervention Assessment materials were based on the Diabetes Foot Care Questionnaire (Figure 2) and the Diabetic Foot Risk Assessment (Figure 3) from the Diabetes Care Program ofNova Scotia 2009.8 The teaching plan and content were patterned on what clinicians normally taught patients visiting the podiatry and vascular clinic. Initially, nurses completed routine clinic assessments,

including vital signs and history taking, as well as a foot examination. Patients were then asked to answer the Di- abetes Care Program of Nova Scotia Diabetes Foot Care Questionnaire8 and complete the pretest (Figure 2). Foot care education was given through short lectures,

discussions, and visual aids (see Figures 4 and 5 for exam- ples). Educational content was associated with activities of daily living to make it more realistic. Patients’ and fam- ily members’ questions were then answered. Tomeasure the uptake of knowledge, patients then com-

pleted theposttest (the samecontent as thepretest; Figure2). The entire education process took about 10 to 15 minutes. All assessments were manually recorded in the patients’ notes folders.

RESULTS Based on the inclusion criteria, 10 patients (6 male, 4 female) were assessed and educated in this group learning session. Ages ranged from 40 to 70 years. Foot examinations revealed one patient with an existing DFU, two with previous ulcers on their legs that took more than 2 weeks to heal, and one person with a previ- ous DFU that had healed. No patients had a previous amputation. The majority of the patients showed signs of neuropathy and dry plantar areas (90%). Calluses over bony prominences and corns were present in 80% of the patients examined (Figure 6). None of the patients had



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had any prior foot education before the study com- menced, and only one participant had searched the in- ternet to find a bit of information on his own about foot care and footwear. The pretest revealed that most of the patients were in need of specific education and skills related to their own foot care.

With regard to patients’ foot care activities, their cur- rent self-management seemed to be inadequate; 30% of participants could not see the sole of their foot (Figure 7). Further, 20% admitted they did not wash their feet every day, and 50% complained that it was difficult to clean be- tween their toes and make sure the skin was dry after




Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

washing their feet. The use of moisturizer during foot care was not popular, with 70% of participants stating they did not routinely moisturize their feet. In addi- tion, 70% of patients cut their own toenails. In terms of patients’ current safety practices with regard

to foot care, 60%of patientswore open-toed andopen-heeled sandals or shoes. Within this patient sample, 90% (n = 9) admitted to walking barefoot more often than wearing shoes indoors, as well as sitting cross-legged on the floor on pillows (Figure 8). When comparing the differences in results between the

pre- and posttests, a number of issues were noted (Figure 9). Correct cutting of toenails was identified as a knowledge deficit in the pretest (30%), and it remained the lowest-scoring item posttest; only 70% of participants indicated they would use a straight cut when cutting their toenails. On the pretest, 90% of participants indicated they went barefoot, and only 40% indicated they under- stood that walking barefoot was dangerous. However, post- test, all participants indicated they understood walking barefoot to be dangerous.

DISCUSSION Diabetes is an increasing cause of mortality worldwide. It has a greater incidence of nontraumatic lower extremity amputation than any other chronic disease in the world. Because of this, patients with diabetes need to be educated

on how to properly take care of their feet. By providing group-based educational intervention sessions, the needs ofmany patients can be directly identified and addressed.7,8

During the education session, visuals (Figures 4 and 5) were provided to each patient and their family to assist them in understanding information provided in the lec- tures and discussions. This helped alleviate any lan- guage barriers that potentially existed between the patient and the educator because patients could trans- late concepts not fully understood using the visual de- scriptors and clinical demonstrations provided.11 Time was taken to answer all participant questions during group discussions, so attendees could learn through the experiences of other patients in similar situations. Family members, if present, were also involved in the teaching sessions, although they did not take the pre- and posttest to help reinforce the retention of taught in- formation for patients. Themost important finding of this study relates to toe-

nail cutting. Despite patients’difficulty in seeing the plan- tar aspect of their own foot, they still cut their own toenails. It was a limitation in the pretest (30%), and it remained the lowest-scoring item posttest (70%). Cutting toenails without sufficient visualization on a foot that has a loss of protective sensation (ie, in peripheral neuropathy) in- creases the risk for traumatic injury with far-reaching




Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

consequences.3–5 Toenails should be cut in a straight line after a bath or showerwhen nails are soft and clean; other practices can lead to infection and foot ulceration. Persons with diabetes in particular should avoid cutting into the cor- ners of toenails to prevent the development of ingrown toenails, which can lead to infection and foot ulceration.12

By implementing the elements identified in theDESMOND study7,8—namely, by initiating early teaching interven- tions that are fully adopted by patients with the needed lifestyle adaptations—this risk factor should bemitigated effectively. Further, toenail clipping should be taught as a skill to both patients and their immediate caregiver/ family circle because this skill is generally poorly exe- cuted and creates a huge risk for lower limb loss. In addition, patients in West Asian and Arabic regions

have lifestyle habits that may add to their risk for devel- oping a DFU later in the diabetes disease process. This includes the use of open-toed and open-heeled slip-on footwear that is traditional in the region. The current study group was observed demonstrating some of these prac- tices by simply wearing this type of footwear when they attended the clinic. Further, common practice in these re- gions is to be barefoot inside the house and leave shoes at the front door. Walking barefoot was of initial concern in the pretest;

90% of respondents indicated they went barefoot. This concernwasmitigated somewhat by participants stating in the pretest that they understood walking barefoot to be dangerous and confirmed in the posttest when all partici- pants identified walking barefoot as dangerous. However, in practice, walking barefoot in houses is a family- mandated habit that can be very hard to address. Suffi- cient time during education sessions to address this issue of wearing footwear in the house is therefore vital for situations where bony prominences or foot deformi- ties are problematic. This issue was easily corrected with the intervention, aswas the importance of having corns and calluses looked after by a professional rather than with self-care. In summary, patientsmay be reluctant at first to accept

this kind of information, but with proper explanation and better understanding, self-assessment and foot care skills can be taught. Effective communicationwith patients and healthcare providers is key to safe and quality health- care.11 This is applicable especially in theWest Asian region, where most healthcare workers are expatriates but most patients are native Arabic speakers with limited profi- ciency in English. Group teaching and interventions with demonstration followed by patient feedback and demon- strations have proven effective in overcoming many of these challenges and establishing trust despite major language differences.

Overall, posttest scores revealed participants had a better understanding of the importance of preventive foot as- sessments and skin care and had increased their ability to conduct their own foot self-care and/or in conjunction with a familymember or carer. Sufficient knowledge reten- tionwas achieved for all patients who participated in this study.

CONCLUSIONS Involving patients in their own plan of care is an integral part of disease awareness andprevention of complications. Most of the patients in this study had not implemented the principles and practices of basic foot care into their daily care routine; theyweremost likelyunaware of the gravity of complications that follow lax practices over the longer term. Cultural practices play a vital role and will remain a

challenge to address in theWestern Asian/Arabic cultural environment. However, lack of knowledge can be addressed within a patient-centered approach based on patient- identified needs. Despite all of the challenges, proactive patient-centered health education remains the responsi- bility of healthcare providers. Providers should use every patient visit as an opportunity to provide specific educa- tion to ensure mastery of all skills related to foot self-care such as toenail clipping, skin care, and approved foot- wear to prevent DFUs.•

REFERENCES 1. World Health Organization. Diabetes fact sheet. 2018.

diabetes. Last accessed April 3, 2020.

2. Fox CS, Hill Golden S, Anderson C, et al. Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care 2015;38(9):1777-803.

3. Sibbald RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation: an update. Adv Skin Wound Care 2011;24(6):415-36.

4. Narres M, Kvitkina T, Claessen H, et al. Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: a systematic review. PLoS One 2017;12(8):e0182081.

5. Al-Rubeaan K, Almashouq MK, Youssef AM, et al. All-cause mortality among diabetic foot patients and related risk factors in Saudi Arabia. PLoS One 2017;12(11):e0188097.

6. Jelinek H. Clinical profiles, comorbidities and complications of type 2 diabetes mellitus in patients from United Arab Emirates. BMJ Open Diabetes Res Care 2017;5(1):e000427.

7. Gillett M, Dallosso HM, Dixon S, et al. Delivering the Diabetes Education and Self-management for Ongoing and Newly Diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis. BMJ 2010;341:c4093.

8. Skinner TC, Carey ME, Cradock S, et al. on behalf of the DESMOND Collaborative. ‘Educator talk’ and patient change: some insights from the DESMOND (Diabetes Education and Self-management for Ongoing and Newly Diagnosed) randomized controlled trial. Diabetic Med 2008;25:1117-20.

9. Kalayou KB. Assessment of diabetes knowledge and its associated factors among type 2 diabetic patients in Mekelle and Ayder Referral Hospitals, Ethiopia. J Diabetes Metabol 2014;5(378).

10. Steinsbekk A, Rygg LØ, Lisulo M, Rise MB, Fretheim A. Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus: a systematic review with meta-analysis. BMC Health Serv Res 2012;12:213.

11. Khalid A. Culture and language differences as a barrier to provision of quality care by the health workforce in Saudi Arabia. Saudi Med J 2015;36(4):425-31.

12. The International Working Group on the Diabetic Foot. IWGDF Guidelines on the Prevention and Management of Diabetic Foot Disease. IWGDF; 2019.


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