Dermatology within the UK podiatric literature: a content analysis (1989-2010)

To ensure basic stability of the coding scheme, an assessment of reliability was undertaken employing the use of a second (independent) coder trained in content analysis – a process termed reproducibility [35]. An entire journal was purposively selected and coded by the second coder to test reproducibility. This journal represented around 8.5% sample of the total items coded.

The data from the two coders was then calculated using Krippendorff’s alpha (α) statistic. Although many different tests are available, this test is widely used and considered robust, taking into account chance agreement and, in addition, the magnitude of disagreements, adjusting also for the type of variable type (nominal, ordinal etc.,)[35‐37] which is not addressed by other reliability measures [38].

The Krippendorff’s alpha statistic ranges from .00 (no agreement) to 1.00 (perfect agreement) demonstrating a high level agreement from the data. Krippendorff’s alpha (α) statistic was calculated using the SPSS Statistics Package version 17 (SPSS Inc, USA) and the customized SPSS macro for Krippendorff’s alpha [37]. Reproducibility for this data were reported as 0.9727 - very high, indicating a high level of agreement between coders.

In the period from 1989-2010, a total of 1611 units appeared in the 6 journals analysed. The division of the units across the publications is given in Figure 1. Of these 88.0% (n = 1417) occurred in one journal - Podiatry Now (and its former titles) with just 12.0% (n = 194) spread across the remaining five journals.

The modal categories within all journals were course advertisements/reports (n = 673) followed by commercial advertisements (n = 562) and articles by podiatrists (n = 133). Over the study period a gradual increase in the number of references to dermatology was shown to rise from an average of around 40 per annum in 1989 to over 100 in 2010 (Figure 2).

The journal “Search” ran for 7 years from 1990 until being integrated into Podiatry Now [39] and was circulated primarily to managers within the NHS consequently little dermatological content was evident. In the latter half of its publication years, a number of short news items were published including reporting trials from medical research on warts [40], psoriasis [41], melanoma [42] and new products [43]. Only three dermatological papers appeared in the journal written by podiatrists; on the topics of fungal nail treatments [44], urea based emollients [45] and dry skin [46] and were generally small NHS departmental studies. Latterly, mentions of the dermatology were made when discussing the development of continuing professional development programmes in 1996 [47].

The British Journal of Podiatric Medicine and Surgery (BJPMS) was the official journal of the Podiatry Association (PA), published up until 1997 when it became part of the British Journal of Podiatry [39]. The PA was predominantly a group representing the interests of podiatric surgeons within the UK. Despite its surgical leanings, a small number of references to dermatological papers published in medical journals are made on topics such as onychomycosis and melanoma [48]. The topic of antifungals and steroid creams also occurs when discussions are made on prescription rights in 1996 [49]. As expected papers on nail surgery are evident, albeit in small numbers (n = 3) in the 7 year period.

The Foot (fully titled “The Foot – the International Journal of Clinical Foot Science”) differed from all the other podiatry journal analysed in this study as it is the only one which the editorial board is shared with another professional group; orthopaedic surgeons. The journal was launched in 1991 and was originally distributed with Society of Chiropodists members’ subscription free of charge until around 2001. It was hoped to showcase graduate research and become an academic journal with Index Medicus status [39, 50] and establish an impact factor - something at the time which had eluded all UK podiatric journals [51]. Analysis of its content revealed a total of 32 dermatological related papers. Of these 14 were published by medics and focussed primarily on skin tumours and common foot infections [52‐65] whilst podiatry lead author papers focused on mycoses [66‐71], wart infections [72‐74], electrosurgery [75, 76] and epidemiology [77]. Interestingly, other single papers by Podiatrists focused on less commonly encountered dermatological conditions [78‐82]. Three papers were investigations into the pathology of corns and callus [83‐85]. Nail surgery was a topic of eight papers [86‐93]. Minimal course advertisements and commercial advertising were evident in this academic publication.

The British Journal of Podiatry began in 1998, comprising of the two former journals – The Journal of British Podiatric Medicine and the British Journal of Podiatric Medicine and Surgery intending to carry editorials, refereed articles and professional information. In its 10 year history, 20 dermatological papers were identified written by Podiatrists with an additional 4 on nail surgery [94‐97]. Areas of dermatological focus included warts [98‐101], fungal infections [102, 103], case studies on tumours and unusual infections [104‐110]. Four studies looked at more academic areas and laboratory work relating to dermatology [111‐114]. Two papers looked at treatments for skin conditions [115, 116].

Less than 0.1% of all units occurred in this journal, explained by its three year lifespan during the study period. Only five publications were evident in the online journal. Four these were on the subject of melanoma, submitted by the author [117‐120] whilst one paper studied the epidemiology of callus patterns in the elderly [121].

This journal represented the vast majority of units (1417, 88%) within this analysis. In part this may be explained by its longevity compared to the other journals - none of which covered the entire period of study but also a reflection of the functions and audience types of each of the journals analysed. Podiatry Now as a professional journal covered many of the categories identified in this study when compared to the other publications which tended to focus more on academic papers only or one particular aspect of practice – podiatric surgery for example. The modal categories, within this journal, were course advertisements (699) and commercial advertisements (522) over 21 years. A full breakdown is given in Figure 3.

Throughout the twenty-one years, 77 dermatology related articles, authored by podiatrists, have been published in the journal. The publication rate has remained at a constant level averaging around 3-4 a year. The focus of the articles has varied slightly over this period. In the earlier years the attention has been on traditional skin problems such as warts [122‐125], fungal infections [126‐128] as well as general articles on common dermatoses such as psoriasis [129, 130]. At the end of the 1990’s although papers on the traditional topics were still being covered [131‐133], skin tumours became an interest with case studies emerging on melanoma [134], squamous cell carcinoma [135, 136] and Bowen’s disease [137]. At this time, inclusion of a section entitled “Clinical Picture Quiz” which invited authors to send in a clinical quiz for readers attracted a number of dermatological cases over the subsequent years [138‐140] including eight from the author [141‐148].

Physicians and other healthcare professionals published 14 and 7 dermatology related articles respectively in the journal. The majority of physician authored articles were reprints from other medical journals (n = 9) [149‐157]. The reasons for this are unclear. It may reflect a lack of suitable podiatric literature during this period on the subject or an editorial decision to include broader knowledge which may be relevant to podiatrists.

Throughout the study time frame, editorial commentary and correspondence on dermatological themes were rare, particularly in the latter half of this period. In the early part of the period studied, discussion of various dermatological topics in editorial comment was mainly through the writing of Colin Dagnall. Dermatological topics were briefly discussed in his column in the journal (simply entitled “Dagnall”) which ran until the December 1992 issue but also latterly by Dagnall through the correspondence pages. A few years on, references were made in the editorial about dermatological conditions such as fungal foot infections, warts and their treatments and were mentioned in the journal as part of the medianote section as well as occasional new product announcements. A small increase of the study period was also noted for news items and book reviews with an average of one unit per year in 1989, rising modestly to around 3 per year by 2010.

Course advertisements on dermatological topics and reports from the data demonstrate a significant increase with time (see Figure 4), on average, doubling during the study period from 20 to over 40, whilst nail surgery courses had virtually ceased.

The increase in the number of course advertisements could be explained by a number of possible factors. First, as the Society has grown in its membership, the number of local branches has increased along with the amount of activity. To accommodate this, the journal may have increased the advertisement of locally run courses. More likely however, was the political climate and the Governments move to improve health care in the late 1990’s. The paper entitled ‘A First Class Service’ [158] and subsequent communications [159] outlined the need for continuing professional development (CPD) within health care professions to maintain and improve quality as part of the clinical governance initiative [160]. The response from the Society of Chiropodists and Podiatrists was the launch of a programme of CPD modules in 2001 for its members [161] including a dermatology module, written by the author [162], which became a part of the core modules offered in 2003 [163]. Latterly, the introduction of mandatory CPD was placed on chiropodists and podiatrists with the introduction of the Health Professions Council (HPC) biennial audit cycles which began in 2006 [164]. Prior to the changes in the CPD process in 2003, only eight individual study days on dermatology had been advertised as update courses to members in the preceding 14 years but following the introduction of the topic as a core subject the numbers of advertisements for such courses increased dramatically to 15 courses in the following 7 years. This trend was mirrored by an increase in the number of course reports which were published in the journal.

The outlier observed in Figure 4 (77 course advertisements in 2006) represented a year in which a large number of dermatological courses were being run whilst simultaneously being heavily advertised. The reason for this is not clear. However, increased advertising in this year may be a reflection of the introduction of mandatory CPD by the Health Professions Council, influencing many local SCP branches to increase their educational provision for their members during this particular year. Similar but smaller increases were noted for the years 1999 (34) and 2000 (48). Both of these represent a disproportionate amount of advertising by an independent company for a course in electrosurgery. Other courses offering dermatological skills (cryosurgery) were identified. Both electrosurgery and cryosurgery courses were more frequently advertised in the first half of the study period suggesting that the need (or demand) for training in these modalities had decreased.

In 2004, inserts appeared within the journal Podiatry Now. These were published as update articles on various topics to enhance the availability of CPD to members [165]. Up until the end of 2010, nine articles had been published with a dermatological theme including fungal infections [166, 167], warts [168], psoriasis and eczema [169], emollients [170], cryosurgery [171], electrosurgery [172], melanoma [173] and non-mechanical causes of hyperkeratosis [174].

As part of the CPD process, distance learning modules in dermatology were noted to be advertised monthly within the journal, offered by a private company from 2003 continuously until the end of the study period (Figure 5). It is assumed that such courses were advertised as an alternative means for podiatrists to receive CPD, in particular for those in private practice who maybe geographically isolated or unable to travel to conferences and similar events. The steep rise in advertisements around 2005 maybe explained, once again, by the introduction of mandatory CPD for podiatrists at this time. The demise of the nail surgery course (Figure 6) could be explained as training in nail surgery techniques only became part of the undergraduate curriculum around the early 1980’s, following the introduction of local anaesthesia [175]. This meant many chiropodists/podiatrists who qualified before this period would be required to undertake an approved course to acquire the appropriate skills. By 2000, one could assume that all those requiring training would have sought it during this period and hence there was no need to run further courses.

Over the study period, physicians were providing the majority of dermatological lectures within podiatry (n = 118), with nearly twice as many advertisements as Podiatrists (n = 60) although an analysis of frequency counts suggested an increasing trend for more Podiatrists delivering lectures (Figure 7).

Many lectures by doctors were delivered at a local branch level by consultant dermatologists across the UK. The most frequent topics delivered were general dermatology of the foot and skin tumours/melanoma, when stated in the advertisement. The first conference dedicated wholly to podiatric dermatology was advertised in 2003 [176] and took place at the University College, Northampton. The conference ran for four years on annual basis and accounted for the conference advertising evident in the data from 2003 to 2006.

“Lectures by others” was a category used to denote advertised lectures on dermatological subjects not given by a podiatrist or physician (or occasionally, when the designation of the speaker was not stated). The majority of these were presentations on aspects of microbiology (particularly fungal infections) delivered by mycologists. In addition, some related to prescription only medicines listed as given by a “company representative” (for products such as Loceryl®, Dovonex® and Sporanox®) occurring across the whole of the study period.

Despite the raised profile of the dermatology within podiatry, it has rarely been advertised as a higher education module until recently – a total of five advertisements, with four being in the period 2007-2010 with modules offered by Universities across the UK (Universities of Stirling, Salford, and Sunderland with Glasgow Caledonian University and Queen Margaret University, Edinburgh).

Throughout the 21 year period, analysis of the amount of dermatology related advertising demonstrated an increase in number products advertised to podiatrists. This can be seen as a few products advertised in 1989, rising to around an average of 40 annual advertisements by 2010 (see Figure 8).

Initial advertisements focused on cryosurgical equipment but this is quickly overtaken in two years by the promotion of emollient products focused on the foot. These continue to be the major part of dermatological advertising in the latter part of the study period. Other frequent products include topical salicylic acid (Occlusal®) preparations, topical antifungal and antiseptic agents (Mykored®, Crystacide® and Monphytol®). The majority of the advertising occurred within Podiatry Now which could be explained as its role as a professional journal reaching all members of the professional body, advertisers would be well aware of its circulation over the other journals mentioned. Particularly heavy periods of advertising are noted in the period 2002 – 2004 which is a reflection of a few emollient and antifungal products being profoundly advertised within this period. The reasons for this are unclear.

In 1994, the first prescription-only medicine (POM) was advertised to UK podiatrists within Podiatry Now. The drug Terbinafine (Lamisil®) is an oral antifungal agent used in the treatment of tinea pedis and onychomycosis. Although UK podiatrists are not able to prescribe independently (just yet), access or supply this medication, the advertisement was carried. The motives of the pharmaceutical company are not clear but presumably this was based on the assumption that podiatrists encounter a lot of fungal foot disease and may consider referring on cases to general practitioners. Subsequently, this would actively promote the fact that a medication was available and ultimately raise awareness and prescriptions of the drug through the general practitioner. Following on in 1996, Itraconazole (Sporanox®) and Amorolfine nail lacquer (Loceryl®) other prescription only medicines were included in the same journal and ran several marketing campaigns. To accompany this, a number of evenings were advertised in the journal, hosted and presented by pharmaceutical representatives promoting antifungal agents and treatments for psoriasis (Dovonex®) to podiatrists. Despite the move in recent years towards increased access to medicines and prescribing, with the introduction of patient group directions and supplementary prescribing for podiatrists, no other advertisements for prescription only medicines have appeared in the journal.

Content analysis is defined as a research technique for making replicable and valid inferences from texts (or other meaningful matter) to the contexts of their use [35]. Neuendorf [177] defines it as the systematic, objective, quantitative analysis of message characteristics. As a technique it can be useful to discover and describe the focus of social attention [32]. The technique allows the researcher to sift through large quantities of data systematically allowing the discovery of inferences and the examination of patterns and trends in documents [33]. This content analysis aimed to give an overview of dermatology and its development within podiatry for the period 1989-2010. In undertaking this, measures were taken to ensure that the data were representative and reliability tests were been undertaken to assess the coding procedure. A full analysis of the mainstream podiatry journals was conducted, rather than a sample, for this period in an attempt to capture the most complete picture

It must be acknowledged that this data can only represent what has been published within these journals and may not fully present the true picture. For example, many courses which have been run during this period may not have been advertised using this medium and so will not have been included. In addition, frequency counting as the sole form of analysis can be misinterpreted, therefore attempts have been made to further analyse the data in order to describe and explain any findings. Content analysis is inherently reductive when placing the data into categories. When defining boundaries and definitions for the key terms it is accepted that there will be material which could be considered borderline. The definition which has been adopted as it emphasizes core podiatry skills – the routine palliative procedures for nails, corns and callus acting as a delineation from dermatology. To prevent overlap into areas of wound care and diabetes any themes related to common diabetic skin manifestations (vascular and neurological processes) were excluded from the analysis. Subsequently, papers have been excluded although it could be argued contribute in a broader sense to dermatology and podiatry including the work of Springett [178], Potter [179, 180] and Hashmi [113, 181] along with much of the literature pertaining to the diabetic foot.