Original Investigation

Patient-Centered Health Education Intervention to

Empower Preventive Diabetic Foot Self-care
Meryl Makiling, RN and Hiske Smart, CNS

ABSTRACT INTRODUCTION
Downloaded from http://journals.lww.com/aswcjournal by BhDMf5ePHKbH4TTImqenVI1NGeaZoDmOJQXSSGddU26Qwnaj0pcnR/f+NwWlP0LZ584/HdA/cck= on 07/05/2020

BACKGROUND: Diabetes impairs the body’s ability to produce or respond to the Type 2 diabetes mellitus is one of the most prevalent chronic
hormone insulin resulting in abnormal metabolism of carbohydrates and elevated disease burdens worldwide. Its prevalence rose from
glucose levels in the body. Because of these factors, diabetes can cause several 4.7% in 1980 to 8.5% in 2014,1 currently affecting 422 million
complications that include heart disease, stroke, hypertension, eye complications, patients worldwide. It is expected to be the seventh most
kidney disease, skin complications, vascular disease, nerve damage, and foot problems. common cause of death in the world by 2030, primarily
Diabetes education allows patients to explore effective interventions into living their because of its rapid rise in middle- and low-income coun-
life with diabetes and incorporate the necessary changes to improve their lifestyle. tries.2 Diabetes is also a leading cause of severe morbid-
OBJECTIVE: To educate patients diagnosed with diabetes or followed up for diabetes
ities and disabilities.1,2
management by other departments with regard to their own responsibility in
Diabetes causes the body to completely or partially
maintaining preventive foot self-care.
METHODS: Ten patients completed a validated educational foot care knowledge lost its ability to produce or respond to the hormone in-
assessment pretest to determine their existing knowledge about their own foot care sulin, resulting in abnormal metabolism of carbohy-
after a thorough foot assessment. Preventive diabetic foot self-care education was drates and elevated glucose levels in the body. Because
conducted through a lecture, visual aids, and a return demonstration. Patients then took of these metabolic changes, diabetes is associated with
a posttest questionnaire with the same content as the pretest to determine their uptake several complications such as heart disease, stroke, hy-
of the educational content. pertension, eye complications, kidney disease, skin com-
RESULTS: Correct toenail cutting was the most identified educational need. It was a plications, vascular disease, nerve damage, and foot
limitation in the pretest (30%), and it remained the lowest-scoring item on the posttest problems.2 Foot problems can range from mild to major
(70%). Walking barefoot was thought to be safe by 60% of participants pretest, but damage to the foot structure and are associated with a pa-
with remedial education, all participants identified this as a dangerous activity posttest.
thology pathway that can include damage to the vascular
Participants also understood the high importance of having corns and calluses looked
blood supply and soft tissues and result in infection, all of
after by a health professional.
CONCLUSIONS: Effective communication with patients by healthcare providers who which are magnified further by pressure and loss of pro-
can mold educational content to identified patient needs by teaching much needed tective sensation known as peripheral neuropathy.3
skills is a key driver in rendering safe, quality healthcare education interventions. People with these foot pathologies have a higher risk
KEYWORDS: diabetes, diabetic foot, education, foot care, prevention, self-care 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
ADV SKIN WOUND CARE 2020;33:360–5.
pain and discomfort in their feet—stinging, stabbing, shoot-
DOI: 10.1097/01.ASW.0000666896.46860.d7
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 death within 5 years there-
after.5 A 6-year follow-up study in Saudi Arabia 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.

ADVANCES IN SKIN & WOUND CARE • JULY 2020 360 WWW.ASWCJOURNAL.COM

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

Figure 1. PATIENT REFERRAL DISTRIBUTION AT THE for DFU is therefore believed to constitute a cost-
AUTHORS’ VASCULAR CLINIC 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
and save as much of a foot as possible once a DFU develops knowledge and skills to undertake any required assess-
is lengthy and requires an interprofessional approach to ment interventions once at home and under self-care.
facilitate rehabilitation. However, if DFU development,
surgical intervention, and amputation can be prevented
with appropriate education interventions, cost savings and Objective
improved quality-of-life outcomes can be achieved. 7 The primary objective of the project was to educate pa-
In particular, patient education about basic foot care is tients diagnosed with diabetes or followed up for diabe-
important to reduce lower extremity complications.5,6 tes management by other departments such as internal
Nurses working in vascular and podiatry clinics encoun- medicine and endocrinology with regard to the patient’s
ter patients with differing degrees of diabetic foot compli- own responsibility in maintaining preventive foot self-care.
cations. Patients who attend these clinics may have had This was completed through evaluating gaps in patient
diabetes for years. The most common finding in the authors’ knowledge via a pretest-posttest design.
clinic is that patients are neither educated nor empowered
with self-assessment methods to control their own disease Figure 2. PRE- AND POSTTEST EDUCATIONAL FOOT CARE
and prevent complications in the early period just after KNOWLEDGE ASSESSMENT QUESTIONNAIRE
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 diabetes management and preven-
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

WWW.ASWCJOURNAL.COM 361 ADVANCES IN SKIN & WOUND CARE • JULY 2020

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

METHODS Figure 3. THE DIABETES CARE PROGRAM OF NOVA
On average, 20 new patients are referred to the authors’ SCOTIA DIABETIC FOOT CARE QUESTIONNAIRE8
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
of Nova 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.
To measure the uptake of knowledge, patients then com-
pleted the posttest (the same content as the pretest; Figure 2).
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

ADVANCES IN SKIN & WOUND CARE • JULY 2020 362 WWW.ASWCJOURNAL.COM

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

Figure 4. VISUAL AID ON RISKY FOOT CONDITIONS TO AVOID

had any prior foot education before the study com- With regard to patients’ foot care activities, their cur-
menced, and only one participant had searched the in- rent self-management seemed to be inadequate; 30% of
ternet to find a bit of information on his own about foot participants could not see the sole of their foot (Figure 7).
care and footwear. The pretest revealed that most of Further, 20% admitted they did not wash their feet every
the patients were in need of specific education and skills day, and 50% complained that it was difficult to clean be-
related to their own foot care. tween their toes and make sure the skin was dry after

Figure 5. VISUAL AID ON ACTIONS THAT ADD TO FOOT SAFETY

WWW.ASWCJOURNAL.COM 363 ADVANCES IN SKIN & WOUND CARE • JULY 2020

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

Figure 6. CURRENT LEG OR FOOT PROBLEMS Figure 8. CURRENT SAFETY PRACTICES WITH REGARD
TO FOOT CARE

washing their feet. The use of moisturizer during foot on how to properly take care of their feet. By providing
care was not popular, with 70% of participants stating group-based educational intervention sessions, the needs
they did not routinely moisturize their feet. In addi- of many patients can be directly identified and addressed.7,8
tion, 70% of patients cut their own toenails. During the education session, visuals (Figures 4 and 5)
In terms of patients’ current safety practices with regard were provided to each patient and their family to assist
to foot care, 60% of patients wore open-toed and open-heeled them in understanding information provided in the lec-
sandals or shoes. Within this patient sample, 90% (n = 9) tures and discussions. This helped alleviate any lan-
admitted to walking barefoot more often than wearing guage barriers that potentially existed between the
shoes indoors, as well as sitting cross-legged on the floor patient and the educator because patients could trans-
on pillows (Figure 8). late concepts not fully understood using the visual de-
When comparing the differences in results between the scriptors and clinical demonstrations provided.11 Time
pre- and posttests, a number of issues were noted was taken to answer all participant questions during
(Figure 9). Correct cutting of toenails was identified as group discussions, so attendees could learn through
a knowledge deficit in the pretest (30%), and it remained the experiences of other patients in similar situations.
the lowest-scoring item posttest; only 70% of participants Family members, if present, were also involved in the
indicated they would use a straight cut when cutting teaching sessions, although they did not take the pre-
their toenails. On the pretest, 90% of participants indicated and posttest to help reinforce the retention of taught in-
they went barefoot, and only 40% indicated they under- formation for patients.
stood that walking barefoot was dangerous. However, post- The most important finding of this study relates to toe-
test, all participants indicated they understood walking nail cutting. Despite patients’ difficulty in seeing the plan-
barefoot to be dangerous. tar aspect of their own foot, they still cut their own toenails.
It was a limitation in the pretest (30%), and it remained
DISCUSSION the lowest-scoring item posttest (70%). Cutting toenails
Diabetes is an increasing cause of mortality worldwide. without sufficient visualization on a foot that has a loss
It has a greater incidence of nontraumatic lower extremity of protective sensation (ie, in peripheral neuropathy) in-
amputation than any other chronic disease in the world. creases the risk for traumatic injury with far-reaching
Because of this, patients with diabetes need to be educated
Figure 9. PRE- AND POSTTEST RESULTS
Figure 7. CURRENT FOOT CARE ACTIVITIES

ADVANCES IN SKIN & WOUND CARE • JULY 2020 364 WWW.ASWCJOURNAL.COM

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

consequences.3–5 Toenails should be cut in a straight line Overall, posttest scores revealed participants had a better
after a bath or shower when nails are soft and clean; other understanding of the importance of preventive foot as-
practices can lead to infection and foot ulceration. Persons sessments and skin care and had increased their ability
with diabetes in particular should avoid cutting into the cor- to conduct their own foot self-care and/or in conjunction
ners of toenails to prevent the development of ingrown with a family member or carer. Sufficient knowledge reten-
toenails, which can lead to infection and foot ulceration.12 tion was achieved for all patients who participated in
By implementing the elements identified in the DESMOND this study.
study7,8—namely, by initiating early teaching interven-
tions that are fully adopted by patients with the needed
lifestyle adaptations—this risk factor should be mitigated CONCLUSIONS
effectively. Further, toenail clipping should be taught Involving patients in their own plan of care is an integral
as a skill to both patients and their immediate caregiver/ part of disease awareness and prevention of complications.
family circle because this skill is generally poorly exe- Most of the patients in this study had not implemented
cuted and creates a huge risk for lower limb loss. the principles and practices of basic foot care into their daily
In addition, patients in West Asian and Arabic regions care routine; they were most likely unaware of the gravity of
have lifestyle habits that may add to their risk for devel- complications that follow lax practices over the longer term.
oping a DFU later in the diabetes disease process. This Cultural practices play a vital role and will remain a
includes the use of open-toed and open-heeled slip-on challenge to address in the Western Asian/Arabic cultural
footwear that is traditional in the region. The current study environment. However, lack of knowledge can be addressed
group was observed demonstrating some of these prac- within a patient-centered approach based on patient-
tices by simply wearing this type of footwear when they identified needs. Despite all of the challenges, proactive
attended the clinic. Further, common practice in these re- patient-centered health education remains the responsi-
gions is to be barefoot inside the house and leave shoes bility of healthcare providers. Providers should use every
at the front door. patient visit as an opportunity to provide specific educa-
Walking barefoot was of initial concern in the pretest; tion to ensure mastery of all skills related to foot self-care
90% of respondents indicated they went barefoot. This such as toenail clipping, skin care, and approved foot-
concern was mitigated somewhat by participants stating
in the pretest that they understood walking barefoot to be
wear to prevent DFUs. •
dangerous and confirmed in the posttest when all partici-
pants identified walking barefoot as dangerous. However, REFERENCES
in practice, walking barefoot in houses is a family- 1. World Health Organization. Diabetes fact sheet. 2018. www.who.int/news-room/fact-sheets/detail/
mandated habit that can be very hard to address. Suffi- diabetes. Last accessed April 3, 2020.
cient time during education sessions to address this issue 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
of wearing footwear in the house is therefore vital for Heart Association and the American Diabetes Association. Diabetes Care 2015;38(9):1777-803.
situations where bony prominences or foot deformi- 3. Sibbald RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation: an update.
ties are problematic. This issue was easily corrected 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
with the intervention, as was the importance of having compared with the non-diabetic population: a systematic review. PLoS One 2017;12(8):e0182081.
corns and calluses looked after by a professional rather 5. Al-Rubeaan K, Almashouq MK, Youssef AM, et al. All-cause mortality among diabetic foot patients
than with self-care. and related risk factors in Saudi Arabia. PLoS One 2017;12(11):e0188097.
In summary, patients may be reluctant at first to accept 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.
this kind of information, but with proper explanation and
7. Gillett M, Dallosso HM, Dixon S, et al. Delivering the Diabetes Education and Self-management for
better understanding, self-assessment and foot care skills Ongoing and Newly Diagnosed (DESMOND) programme for people with newly diagnosed type 2
can be taught. Effective communication with patients and 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’
healthcare providers is key to safe and quality health- and patient change: some insights from the DESMOND (Diabetes Education and Self-management for
care.11 This is applicable especially in the West Asian region, Ongoing and Newly Diagnosed) randomized controlled trial. Diabetic Med 2008;25:1117-20.
where most healthcare workers are expatriates but most 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).
patients are native Arabic speakers with limited profi-
10. Steinsbekk A, Rygg LØ, Lisulo M, Rise MB, Fretheim A. Group based diabetes self-management
ciency in English. Group teaching and interventions with education compared to routine treatment for people with type 2 diabetes mellitus: a systematic
demonstration followed by patient feedback and demon- review with meta-analysis. BMC Health Serv Res 2012;12:213.
strations have proven effective in overcoming many 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.
of these challenges and establishing trust despite major 12. The International Working Group on the Diabetic Foot. IWGDF Guidelines on the Prevention and
language differences. Management of Diabetic Foot Disease. IWGDF; 2019.

WWW.ASWCJOURNAL.COM 365 ADVANCES IN SKIN & WOUND CARE • JULY 2020

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