Original ResearchFeasibility, Acceptability and Effects of a Foot Self-Care Educational Intervention on Minor Foot Problems in Adult Patients with Diabetes at Low Risk for Foot Ulceration: A Pilot Study
Introduction
Foot ulceration is a common, serious and expensive chronic complication for persons with diabetes (1). The prevalence of foot ulcerations ranges from 4% to 10% among patients with type 2 diabetes mellitus (2), with a lifetime risk of developing a foot ulcer as high as 25% (3). If not treated appropriately, foot ulcerations contribute up to 85% of lower extremity amputations (4). Foot ulcerations and subsequent lower extremity amputation are associated with high diabetes-related hospitalizations, negative emotional reactions, physical suffering, loss of productivity, reduced quality of life and a huge financial burden for patients and the healthcare system in developed and developing countries 3, 5.
Much effort and research have been directed toward patient education to prevent foot complications among patients with diabetes during the past decades. Although a recent systematic review suggests that there is insufficient robust evidence that limited patient education alone is effective in achieving clinically relevant reductions in ulcer and amputation incidence (6), results of previous studies indicated that patient education on foot self-care plays a significant role in preventing foot complications in patients with diabetes, reducing the risk of diabetes-related foot complications by an estimated 49% to 85%; results of experimental studies that evaluated educational interventions supported their effectiveness in improving patients' foot self-care knowledge and behaviour, and reducing the rate of foot ulceration and amputation, particularly in high-risk patients 1, 3, 6, 7, 8. It is uncertain, however, whether development of minor foot problems (i.e. calluses, skin dryness and cracking, infection and trauma) that contribute to ulceration could be significantly reduced in patients with diabetes at low risk for foot complications.
Minor foot problems are common in individuals with diabetes and can lead to foot ulcers and lower extremity amputation if delayed or inappropriate treatment is given (9). Eighty-six percent of the eventual amputations resulted from a pivotal triggering event that is preventable; the event frequently involves a minor foot trauma such as wearing improper shoes and improper cutting of toenails. The devastating consequences of foot ulceration could be avoided in most cases 10, 11. Therefore, it is necessary to design and pilot explore the effects of educational interventions in preventing minor foot problems that can lead to ulceration and subsequent amputation in patients with diabetes.
In most experimental studies, evaluating foot self-care educational interventions, focusing on high risk, or a mix of participants at high and low risk for ulceration were included 1, 3, 6, 7, 8, 11. Participants at different risk for ulceration may respond differently to the intervention that affects the magnitude of its effects on the immediate and ultimate outcomes 7, 12, 13. Limited research has focused on the effects of educational interventions in patients with diabetes at low risk for foot ulceration. The latter group of patients who are majority of newly diagnosed, general diabetes population (14) may receive little, if any, information about foot complications and how to prevent them. Prevention of foot ulceration is far more important than its treatment. The potential consequences of poor foot care in diabetes are grave. The importance of foot health and foot care must be communicated at an early stage of the disease (15). To be more effective in preventing and reducing minor foot problems, and consequently preventing the development of major foot problems such as foot ulcerations and lower extremity amputation, foot self-care educational interventions must start as early as possible; that is, patient education should be initiated in patients with diabetes at low risk of developing foot ulcers, so that primary prevention of foot ulceration can be successfully achieved 15, 16. We designed a new educational intervention to enhance foot self-care among patients with diabetes at low risk of ulceration. The specific objectives of this pilot study were to examine the feasibility and acceptability of the intervention (17), and to explore the preliminary effects on reducing minor foot problems in adult patients with type 2 diabetes at low risk for foot ulceration.
Section snippets
Research design and sample
A 1-group pretest and posttest design was used to address the study objectives. After obtaining approval by the Research Ethics Board at the University of Toronto, the recruitment began at a family health team clinic. Participants were eligible if they: 1) had a diagnosis of type 2 diabetes, 2) have not received formal diabetes education, 3) resided in the family health team clinic's catchment area and were not planning to be away for at least 3 months, 4) were able to attend the on-site
Initial interest rate
A total of 94 persons with diabetes inquired about the study, and were screened for eligibility. Of these, 79 persons met the study eligibility criteria representing 87.7% of screened persons.
Enrollment rate
Nine of the 79 eligible persons declined further enrollment in the study. Three persons did not provide a specific reason for refusal. The remaining 6 persons offered the following reasons: family issue such as taking care of husband who had stroke at home (n=1); time issue such as inability to take days
Feasibility of the intervention
Several indicators have been used to assess the feasibility of an intervention 25, 37, 38. The most frequently reported indicators included participants' enrollment, attendance at the intervention sessions, adherence to intervention and withdrawal. Attendance at the intervention sessions also was used to reflect intervention acceptability in a diabetes self-management support intervention (39). The present study used Cole and Dendukuri's (25) definition of feasibility, that is, the feasibility
Conclusions
The results of this pilot study provided preliminary evidence that the intervention is feasible, acceptable and effective in reducing the occurrence of minor foot problems in patients with type 2 diabetes at low-risk for foot ulceration in a 3-month short-term period. Future research should evaluate its efficacy using a randomized clinical trial design, a large sample of patients with diabetes at low risk for foot ulcerations, and long-term evaluation of the foot self-care educational
Acknowledgements
Financial support received from the Provincial Nurse Educators Interest Group Research Award, Registered Nurses Association of Ontario; and Faculty of Nursing, University of Toronto.
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Use of Information Communication Technology Tools in Diabetic Foot Ulcer Prevention Programs: A Scoping Review
2022, Canadian Journal of DiabetesCitation Excerpt :Also, some authors used audiovisuals alongside phone (34), Web portal (37) and pedometer/infrared thermometer (26), and they reported improved foot self-care behaviour and reduced minor foot skin disorders, improved foot self-care knowledge and reduced recurrence of DFUs, respectively. Investigators in the studies using the phone alone reported improved foot self-care behaviour, knowledge and self-efficacy (30,32,33,36); reversed peripheral neuropathy and vasculopathy (36); decreased prevalence of foot skin and toenail disorders (29); and increased use of ideal footwear/socks (31). In trials on the pressure-sensitive insole system, Abbott et al (38) reported a significant decrease in DFU recurrence among participants, whereas Najafi et al (27) reported no DFU recurrence and insole adherence, with a mean daily wear duration of 5.38 (standard deviation=3.43) hours, equivalent to 45% of the daytime.
Effectiveness of a theory-based foot care education program (3STEPFUN) in improving foot self-care behaviours and foot risk factors for ulceration in people with type 2 diabetes
2019, Diabetes Research and Clinical PracticeCitation Excerpt :Integrating other educational sessions to improve other diabetic self-care activities (i.e. exercises, self-monitoring blood sugar) should be considered to achieve optimal effects in changing foot care behaviour in patients with diabetes. The 3STEPFUN demonstrated effectiveness in reducing the proportion of foot risk factors for ulceration in the sample, which is similar to findings in previous studies, including dry skin, cracked skin [22,23], and corns/callus [47]. In relation to the combined three modifiable foot risk factors (i.e. dry skin, cracked skin and corns/callus, abbreviated as DCC), the percentage of the foot risk factors for ulceration was significantly lower in the intervention group compared to those in the control group.