Foot health education for people with rheumatoid arthritis — some patient perspectives

National Health Service reviews and reports focus on the need for increased self-management in the overall management of patients with long-term conditions, such as Rheumatoid Arthritis (RA) [1, 2]. In support of this the Department of Health ‘information revolution’ [1] provides resources that aim to improve health related behaviour, support aspects of self-management and thereby maximise the potential for health benefits [1]. For people with RA, it is known that patient education, including verbal and written information, self-study, websites and psycho-educational programmes, have a positive effect in relation to disease management and general health [3].

Patient education is recognised as important for people with RA in relation to foot health [4‐6]. Up to 80% of people with RA report foot pain on a regular basis [7, 8]. Providing education during podiatry consultations, in the form of information on the purpose and use of clinical interventions, such as foot orthoses and specialist footwear [9], could potentially improve patients’ use of them [10].

The skills required to deliver patient education, are now embedded in the undergraduate curriculum and are considered a core component of podiatry care. Podiatrists perceive it as a valued and beneficial activity supporting aspects of foot management that patients can perform themselves [11]. Despite recommendations for an increased role of the patient in foot health [4‐6], little is known from the patient perspective.

It is important to consider that practitioners and patients may have diverging opinions about what is important [12]. Despite benchmark standards [13] that state that patient education should be patient centred, based around patient need, there is some evidence that this is not being fully met [14, 15].

For foot health education to meet the needs of the patient and support self-management we need to understand their perceptions of what and how it is currently delivered. Therefore, the aim of this study was to explore patients’ experiences of foot health education, in order to inform how the patients’ needs could be identified in clinical practice. In achieving this, effective education as an intervention could be delivered.

Out of twenty members of the support group approached, six participants who met the inclusion criteria initially consented. One was unable to attend the focus group due to ill health. All five participants were women, with a mean age of 62 years (SD 5.3) and mean disease duration 5.9 years (SD 2.7). All participants had experienced foot problems and had received National Health Service (NHS) podiatry services. Two participants had attended group Patient Education sessions, relating to RA but not foot health, subsequent to their diagnosis. The remaining participants had not received any formalised patient education. Participants’ names have been replaced with a pseudonym for confidentiality.

Using focus group methodology and a thematic approach to data analysis has revealed a richness of data about the participants’ experiences and opinions about the purpose, content, methods of delivery and barriers to foot health education provision.

The small sample size and restricted geographical area means that caution must be taken in generalising the results to the wider population. The homogenous nature of the focus group participants could have led to sample bias and may have influenced the results due to the gender of the group and group facilitator. As the participants were members of a patient support group, it could be argued that this was a group of highly motivated individuals who were well informed with regards their condition and the health system, influencing the results further. The influence of the ‘groupthink’ phenomena could be considered a limitation in the use of focus groups, especially where the group has a high degree of cohesiveness and homogeneity [27]. However, the aim of the focus group was to gain insight into patients’ views on foot health education and to this end the methodology was appropriate. The limitations and criticism of using established groups can be countered by the benefits that using participants from an already established support group can add richness to the data as the group are more aligned to the research topic [19].

The strengths of this study lie with congruency of the overall themes that emerged from this and a previous study that revealed the practitioners’ perceptions with regards to the purpose, timing, content, best methods of delivery and barriers to the provision of foot health education [28], allowing triangulation of the data sources to better understand the area. This agreement reinforces the need for the development of a foot health education strategy that embraces both perspectives [29]. Identifying service users’ views as part of the development of foot health education has already been shown to be successful in an elderly population [30].

The role of health professionals in foot health management, accessing foot health services, general foot health information in the context of RA and good foot care self-management practices were considered to be essential components of foot health education provision. These areas have also been identified as key topics within foot health guidelines [5].

These participants were confused about the role of ‘podiatrists’ and ‘chiropodists.’ This resulted in a lack of clarity about the services they could access and what to expect from them. Discarding the title ‘chiropodist’ may help to improve understanding of the podiatry profession from the public perspective, an issue that has been identified by members of the podiatry profession [28, 31‐33]. Where ‘specialist’ roles were discussed during the focus group, there was the perception that the term ‘specialist podiatrist’ generated more confidence in the practitioner. Information about the podiatrist’s role and scope of practice is required to ensure that patients are aware of the level of expertise they can expect from the individual practitioner.

When foot health information was sourced it was reported as “frightening” or written in language that was difficult to interpret. All participants had used the Internet to seek foot health information, suggesting it is a well utilized resource. There is no lack of web based foot health information. Arthritis Research UK and the National Rheumatoid Arthritis Society (NRAS) provide resources that address foot health from both a general and RA specific perspective [34, 35]. However, the participants were unaware of these resources, although all were members of NRAS. Patients concerns about locating high quality, patient-centred information relating to RA have been identified [36]. The findings of this study support this. Furthermore, a study of podiatrists found they directed patients to these web sites infrequently [28] potentially reinforcing patients’ perception that there is a lack of such information.

Participants wanted patient education leaflets to support verbal information given during consultations. Written information was considered an aide memoir, prompting questions at future appointments, especially as there is a risk of being ‘overwhelmed’ with information at the point of diagnosis. Written information for people with RA is considered the most effective way for people to refer to information once they have left the hospital setting [37]. The participants in this study viewed that RA had a negative impact on memory retention with pain and depression leading to poor cognitive function [38‐40]. Written information was thus seen as highly valuable. Despite evidence for the effectiveness of patient information leaflets being weak [41], they are beneficial in increasing patient knowledge in the short term [42] but this must be individualised and supported by the practitioner for it to be effective [43], although this evidence relates to people with diabetes, the same may be true in RA.

Generally, group education was not viewed as beneficial by those members who had attended these sessions, as neither foot health education nor self-management was addressed. The potential value of group education was thought to be in providing a supportive environment for general foot health information and self-management education, if planned and facilitated appropriately. The implementation of group foot health self-management programmes for people with RA may be an effective method of delivery, providing members can perform self care tasks, such as basic nail cutting [44].

During their consultations with health professionals, participants found that individual information and education was often not provided as limited consultation time restricted them from asking questions. Individuals without foot pathology or few symptoms may not request foot health information, as they perceive their needs to be minimal [45]. However, within the context of a patient-centred consultation it is still important to identify their educational needs early in the disease [5]. This view was strongly articulated by the participants, as they felt let down and un-prepared for the way in which RA affected their feet and thus their daily activities. The feet are often the first part of the body to be affected in RA [7] with most experiencing foot pain early in the disease [8]. It is therefore essential to provide foot health education in a timely and targeted way.

In this study, the development of a strong and trusting therapeutic relationship was viewed as a critically influential factor for appropriate education. McInnes et al. [46] advocate a timely and individualized approach to diabetes foot health education provision. This requires investment of the practitioner’s time and identifying the patient’s agenda through using motivational interviewing techniques [47]. Identifying a person’s ‘readiness’ to change and motivation to engage in positive health behaviours is a key component of a patient-centred approach and should be undertaken during the course of any consultation [48].

Participants described the experience of being ‘listened to’ more by female practitioners as resulting in positive outcomes. This perceived higher level of empathy was also identified in a study with practitioners, who found it easier to advise female patients on ‘difficult’ foot health issues such as foot wear styles [28]. ‘Gender related communication skills’, most notably ‘patient-centeredness’, as opposed to gender alone, are thought to influence the development of a positive therapeutic relationship [49]. Although female practitioners are more likely to exhibit such skills [50], this does not preclude male practitioners from developing and demonstrating them. Thorough assessment and developmental feedback in relation to communication skills at undergraduate level may ensure similarities in development by male and female practitioners. It should be taken into consideration that the participants and facilitators of this study and the study with practitioners [28] were all female. The fact that the group participants and facilitators were of the same gender could have influenced the results. The development of a dynamic discussion is more likely where there is group homogeneity from both a gender and shared experience perspective [51]. Further research, exploring the perspectives of men, could provide a more comprehensive picture of the foot health education needs of people with RA.

Patients in this study wanted access to information from a variety of sources, together with a tailored approach and verbal explanation, to meet their needs. Group education was considered beneficial if structured, with ground rules applied so that individual needs were respected. However, patients strongly considered information should be staged according to their needs and preferences as their disease progressed. To achieve this, the patients’ needs must be identified to guide them to the most appropriate foot health information. An Education Needs Assessment Tool, focusing on RA and its management has been developed and evaluated [52]. A similar approach to identifying foot health educational needs would enable practitioners to tailor their education provision to patients’ needs.

This study provides insight into the patient perspective on foot health education provision for people with RA. There were clear similarities to practitioner perspectives [27]. The data will inform a survey to ascertain the views of a wider population of people with RA and Podiatrists.

Time is needed during consultations to ascertain patients’ needs and readiness to engage in positive foot health behaviour. Written information, supported with a practitioner’s explanation and tailoring to the patients’ needs, will reduce anxiety and facilitate better patient education and patient uptake of positive foot health behaviours. Further, this will encourage a therapeutic relationship enabling positive health behaviour and self-management, as recommended in the Darzi report [2]. Teaching and assessment of undergraduate communication skills to ensure patient-centred consultation skills may result in an improved patient experience of the consultation and reduce gender bias overall.