A survey of people with foot problems related to rheumatoid arthritis and their educational needs

The aim of this study was to identify what people with RA need in relation to FHE and the potential barriers to its’ provision. This is the first study to describe the current provision of foot health education (FHE) to people with RA across the UK. It has identified the lack of access that many people with RA experience in relation to foot health services and this being a significant factor in accessing RA-related information and resources. The participants were very clear in what they required and desired in relation to FHE.

Forty percent (n = 217) of respondents stated that they received podiatry treatment, of which only 162 people receive NHS podiatry. This could reflect a lack of participant awareness of foot health service provision [18] and the geographical skew of a higher proportion of podiatry service provision for people with rheumatic diseases within certain areas of the United Kingdom, such as South Central England, North East England, Scotland and Northern Ireland with over 50% of sample participants from each of these regions were receiving podiatric treatment [28]. However, the largest numbers of participants receiving podiatric treatment were found as expected in the regions of higher population, particularly higher populations of elderly people, including the South West, South East and North West regions of England. This apparent ‘post-code’ lottery of foot health service provision across the UK means that many people with RA are denied access to those health professionals who are best placed to provide effective and timely FHE. However, poor access to rheumatology-related foot health services is by no means limited to the UK with similar issues relating to timely access to podiatric care identified in Australia [29, 30]. A lack of specialist podiatry services means that it is essential that FHE is provided in a way that is high profile, easily accessible and supports self-management for people with RA-related foot health problems.

The majority of the participants stated that they agreed with the aims of FHE, despite only one third of participants reporting that they had received FHE. Participants who gave a ‘don’t know’ response to the items in this part of the survey were more likely to be under the age of 59 years. This may be because younger participants tended to have shorter disease duration (<5 years) and therefore their educational needs were possibly not as defined. Alternatively, younger participants may have fewer foot symptoms, and hence less physical awareness of the impact that RA can potentially have on their foot health [18]. Further to this, the number of participants in the <59 years age group who had not received FHE (n = 198) was greater than those in the >60 years age group (n = 161) which could also have reduced their awareness of RA foot-related problems. Additionally, when asked if they; ‘were clear about what to ask my podiatrist or other AHP regarding my foot health’, participants in the younger age group were significantly (p = 0.004) more likely to either ‘not know’ or ‘disagree’ with the statement. The effect was small in magnitude as measured by the ϕ statistic (ϕ = 0.179).

The influence of age and disease duration on educational needs in patients with rheumatic disease has been identified by Dragoi et al., [31] who found that older patients with a longer disease duration expressed higher educational needs in relation to pain and movement. Some of the comparisons shown to be significant at the 5% level may not be considered significant in the context of a single finding from multiple testing with a Bonferroni correction applied to correct for multiple comparisons.

Participants rated the importance of the content of FHE as high overall, which supports the value that people with RA place on managing their foot health [18, 19]. Items about the impact that RA and its related medications have on the feet, the role of podiatrist, and the interventions that are used in foot health management and self-management rated particularly highly, showing synergy with the findings of a survey of practitioners’ perceptions of FHE [18]. Female participants rated certain items higher than males: the role of the podiatrist, information about RA medication and its effect on the feet, contact details and information about treatment options were more likely to be rated as very important by female participants. The phenomena of gender influence on educational need or engagement with information-seeking behaviour has been previously identified, with women expressing a higher educational need [31]. Further, they are engaged more in information seeking, positive health behaviours and demonstrating self-efficacy than males [32].

People with RA may benefit from self-managed foot care, providing that it is personalized and the individuals’ physical capability to undertake self-care is assessed [33]. This can help tailor the educational needs of the person in relation to ‘hands-on’ skill. However, their ‘information-needs’ also require recognition and personalization. This ‘needs analysis’ should take into account the potentially differing information needs and skills of those with early or established disease, and the age and gender of the individual concerned. This approach to the identification of educational needs has been shown to be successful in people with RA from a general context, both in the UK and other countries in Europe [22, 34, 35]. The development of a specific foot health educational needs tool could enable people with RA to identify and prioritise their educational needs in a way that is timely and prescriptive to their individual requirements.

The participants reported that they should receive FHE at the time of their diagnosis. The participants’ requirement for early provision of foot health information is supported by that of practitioners [36] and by findings from the qualitative analysis of the participants’ responses [18]. Caution should be exercised so that individuals are not overwhelmed with too much information at the point of diagnosis, although people view access to FHE earlier in the disease with RA as an enabler of self-management and as a way to potentially limit deterioration of foot health [18].

Despite the fact that people with RA and practitioners recognize the need for FHE at diagnosis, for many participants there were significant barriers in accessing it. A lack of access to foot health services and poor awareness of how RA can impact on foot health potentially inhibits individuals’ ability to understand what questions they should be asking health professionals about their feet. Being invited to articulate their foot health needs during the consultation is very important for people with RA to allow them to open a dialogue about their feet. However, this opportunity appears to be limited by time, the needs and assessment practices of the consulting practitioner in fulfilling their own clinical ‘agenda’ and the practitioners’ awareness of foot health problems related to RA [18]. Many participants in this study reported that they were not asked about their foot health either during the consultation with their podiatrist (n = 113) or with another AHP (n = 337), so this opportunity was lost.

Not only did participants lose the chance to engage in verbal FHE, a large number of participants did not receive written information either. Participants reported the provision of written information by any AHP or Rheumatologist to be low (13.6%, n = 74); this figure may be compared to a concurrent study of podiatrists, of which 69% (n = 29) stated they did provide written information [36]. Written material is a method of delivering information to people that is considered useful once they have left the clinical setting [37] and in increasing knowledge in the short term [38]. People with RA and related foot problems require written information in order to support verbal information provided during the consultation [19].

The most common methods of delivery for FHE were verbal information and sign posting to RA or arthritis-related websites. Although access to FHE can be seen to have been limited at the point of consultation, almost all the participants were able to access the Internet and use it for seeking foot health information from patient support group websites, such as NRAS. The NRAS website was the most likely to be used by participants in this study, although as participants were recruited via NRAS membership, this result is not surprising. Female participants were more likely to use web-based information than men, although the reasons for this are not clear. It may be that females are more motivated to self-care and seek information [32] and the impact of foot-related pathology has more of an impact on their self-image [39].

This study may be perceived to have limitations. Whilst this research reports the perspectives of people with RA in relation to FHE provision, it is limited to the views of people who were recruited through a UK patient support group (NRAS) who also had access to the internet. However, there is no evidence for any systematic differences between such patients and the wider RA population; hence no impact on the generalizability of results is expected. Further, the nature of the sample population and a number of questions within the online survey may mean that the data is subject to response and recall bias [40].