Where do we stand? The availability and efficacy of diabetes related foot health programs for Aboriginal and Torres Strait Islander Australians: a systematic review

Diabetes mellitus is one of the fastest growing chronic diseases in the world [1]. Aboriginal and Torres Islander Australians experience four times the rate of diabetes compared to non-Indigenous Australians, with an overall incidence of 13% [2], and rates as high as 42% reported in some remote communities [3]. As the leading cause of lower limb amputation, and with high rates of associated mortality, diabetes related foot complications are a major but poorly recognised health care burden in Australia, estimated to cost in excess of $1.6 billion annually [4, 5]. Evidence demonstrates Aboriginal and Torres Islander Australians have a three to six fold increased risk of diabetes related foot complications including neuropathy, foot ulcer and lower limb amputation compared to non-Indigenous Australians [6, 7].

Consequently the National Health and Medical Research Council Guidelines for the prevention of foot complications in diabetes state that ‘Until adequately assessed all Aboriginal and Torres Strait Islander people with diabetes are considered to be at high risk of developing foot complications and therefore will require foot checks at every clinical encounter and active follow-up’ [8]. International guidelines suggest that up to 85% of diabetes related amputations could be prevented with early detection of problems and appropriate treatment [9]. Despite the evident need for effective preventative foot care in this population, available data indicate poor engagement with existing preventative care services in contrast to high rates of related hospitalisation and amputation [6, 7, 10].

A number of examples of culturally safe services for Aboriginal and Torres Strait Islander communities in Australia have increased access to combined diabetes care services and improved patient outcomes [11‐17]. These share common characteristics, including community consultation in the development, implementation and ongoing management of the service; involvement of Aboriginal Health Workers (AHW); and a focus on self-management and patient participation in health through improved health literacy. There is an obvious and urgent need to identify similarly successful stand-alone foot health programs for the prevention of diabetes related foot complications in Aboriginal and Torres Strait Islander Australians.

An electronic database search of PubMeD (using Lit.search https://​www.​lowitja.​org.​au/​litsearch from the Lowitja Institute which was developed as a search tool for Aboriginal and Torres Strait Islander health articles), Informit Indigenous collection, CINAHL, SCOPUS, and the Cochrane Library was conducted from database inception to 28th August 2018. Additional hand searches of grey literature sources were also conducted including of the Lowitja Institute, Menzies School of Health Research, Australian Indigenous HealthInfoNet (www.​healthinfonet.​ecu.​edu.​au), Services for Australian Rural and Remote Allied Health (www.​sarrah.​org.​au), and the Australia Institute of Health and Welfare (http://​www.​aihw.​gov.​au/​). Reference lists of included studies, clinical guidelines and review articles were also searched. Authors of included studies and reports were contacted where intentions of further evaluation was stated, and, where information was provided, it has been included in this review. The PubMed search strategy as generated from the Lowitja Institute is detailed in Additional file 1. Inclusion criteria were any published reports of stand-alone diabetes related foot care interventions, programs, services, educational resources or assessment of these interventions, designed for Aboriginal and Torres Strait Islander Australians. Interventions were excluded if foot care was embedded within a broader health program due to likelihood of variability in the extent and reporting of the foot care component, and, the confounding effect of the broader health care program on foot specific outcomes. Foot care programs not designed specifically for Aboriginal and Torres Strait Islander Australians were also excluded. One reviewer conducted the electronic searches (AS). Titles and abstracts were independently assessed by two reviewers (AS and VC). Disagreements were resolved by consensus and a third reviewer where necessary (MW).

Extraction of the study data and assessment of the methodological quality of the included studies was conducted by two authors (AS and VC) using the Observational Study and Qualitative Study Appraisal Checklists designed by Health Evidence Bulletins – Wales [18]. These checklists are designed for critical appraisal of observational and qualitative studies and were selected as they include a small number of key domains, are simple checklists rather than scales and were developed using a variety of literature sources [19].

The database and literature search resulted in a total of 1305 citations of which 75 were appropriate for full text review (Fig. 1). After review, 13 articles met the inclusion criteria (Table 1), and 62 studies were excluded (Additional file 2). The methodological quality of the included articles is detailed in Tables 2 and 3. Five articles were reports providing overviews of services provided or materials produced so quality assessment was not considered appropriate [20‐24]. Of the remaining articles, two were qualitative studies [25, 26] and six were cohort or cross-sectional studies [27‐32]. All of the studies provided detailed information regarding the population studied and aims of the investigations. One of the studies reviewed mainly hospital-based renal dialysis patients, which could make comparison to wider community-based populations difficult [30]. None of the trials reported any cost information related to development or implementation of the interventions.

The thirteen articles detailed foot programs which were conducted in New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Northern Territory (NT) with the majority in rural, regional or remote areas (Table 1). Five of the articles described delivery of podiatry services to Aboriginal communities [20‐22, 27, 28, 33], three described the development of specific foot education resources [23, 24, 26], and the remaining five assessed foot educational and training programs [25, 29‐32]. Seven of the thirteen reports described aspects of the Indigenous Diabetic Foot Program (IDFP) [21, 24, 25, 29‐32].

The aim of this review was to systematically evaluate the current literature to determine the availability and effectiveness of stand-alone foot health programs for the prevention of diabetes related foot complications in Aboriginal and Torres Strait Islander Australians.

While national and state governments have developed general Aboriginal and Torres Strait Islander health plans and strategies, no state- or nation-wide foot health programs for prevention of diabetes related foot complications were identified in the literature. Benefits of existing foot care programs for Aboriginal and Torres Strait Islander peoples are therefore largely restricted to the area/s in which they are delivered. Of the thirteen reports that met the inclusion criteria (Table 1), one detailed quantitative data related to clinical patient outcome measures following implementation of the program [28]. The most widely used program, the IDFP (Indigenous Diabetic Foot Program), has been assessed with regard to workshop attendee competency and client perceptions of the educational material provided. Evaluation of the IDFP’s impact in terms of patient outcomes and rates of diabetes related foot complications is yet to be undertaken/published [35].

Despite years of research, Aboriginal and Torres Strait Islander Australians still have worse health outcomes than non-Indigenous Australians. A key criticism of the research to date, both in Australia and in Indigenous populations of other countries, is a high concentration of descriptive research regarding populations, risks and measures, rather than a focus on assessment of the efficacy of interventions to close the health outcome gap [36, 37]. To enable an intervention to be successfully and widely implemented by front-line clinicians it must meet rigorously designed methodological standards, it must have been tested for its effectiveness and reproducibility, and it must be easily accessible in peer reviewed literature [36]. While six of thirteen reports (46%) in this review do describe interventions, only one (8%) of the reports [28] describes patient based clinical outcomes following implementation of a podiatry service. Overall, methodological quality of the studies that were eligible to be assessed was mixed. Lack of robust assessment of outcome data, including comparison to control data in relation to patient outcomes, was common to all studies. In addition, reporting of economic analysis related to development or implementation of the interventions was not provided in any study. Lack of documented follow-up evaluation of interventions, similar to that seen in the stand-alone foot programs in this review, has been described previously. A report investigating the implementation of 1082 Australian Indigenous health, cultural and education programs, found only 8% of programs were evaluated [38]. Additionally, in contrast to non-Indigenous health interventions, the majority of the reports included in this review were published in non-peer reviewed grey literature. These factors make it challenging for clinicians and researchers to locate and implement best practice evidence in relation to foot health programs for the prevention of diabetes related foot complications in Aboriginal and Torres Strait Islander Australians.

Although assessment of clinical outcomes following implementation of foot health strategies has not been commonplace in the past that seems to be changing. The current lack of evidence regarding successful components of Aboriginal and Torres Strait Islander focussed foot health programs in reducing diabetes related foot complications has been clearly recognised by those working in clinical areas. Programs and assessments that are currently underway have incorporated clinical and cost outcomes as part of their implementation plans. In WA the Moorditj Djena program [27] has recently conducted an internal review, the results of which will be published upon completion (private correspondence). The review includes a data linkage project to examine participant outcomes pre and post enrolment in the program. In particular, they examined the population reach of the program, the reach in high-risk settings, occasions of service versus comorbidity, and the number and duration of hospitalisations for diabetes-related conditions. NSW Health is currently in the planning stages of a Healthy Deadly Foot initiative (private correspondence). It has the potential to be the largest foot health program for Aboriginal and Torres Strait Islander Australians implemented to date. One metropolitan local health district (Central Coast), three rural and regional local health districts (Hunter New England, Illawarra Shoalhaven, Western NSW), and one speciality network (St. Vincent’s Health Network) have committed to the project. Goals include the development of AHW roles in local health districts and Aboriginal communities, delivery of appropriate cultural and clinical support, encouraging more Aboriginal and Torres Strait Islander people to train as podiatrists and an evaluation strategy to examine the outcomes of the project. In addition, in 2018, the authors of this report embedded an Aboriginal and Torres Strait Islander foot health clinic into the undergraduate podiatry program at the University of Newcastle. The clinic, led by an Aboriginal podiatrist and AHW, provides prevention and management services for diabetic foot complications for Aboriginal and Torres Strait Islander Australians in the local community. It also provides clinical placement to all undergraduate podiatry students as a mechanism to increase cultural awareness in the future podiatry workforce. The service is currently undergoing clinical and educational outcome evaluation for peer-reviewed publication. This includes evaluation of service utilisation with historical control data for the broader clinical service, effectiveness of diabetes education for improving client knowledge of diabetes self-care, and post-placement changes in self-perceived confidence in provision of culturally safe care in undergraduate students.

The results of this review should be viewed in light of several limitations. Although this review was designed to be comprehensive with a robust search on relevant databases, the search strategy may not have located all Australian health initiatives involving diabetes related foot disease specifically delivered for Aboriginal and Torres Strait Islander Australians. Many of these reports are located in grey literature sources and structured search engines are not available. Additionally, this review only describes programs where reports regarding the development, implementation, or effectiveness of initiatives were publically available. It is likely that programs exist that have not been published in any form; this is particularly probable where these involve individual practitioners, or are in small service delivery models.

No state- or nation-wide foot health programs for prevention of diabetes related foot complications in Aboriginal and Torres Strait Islander Australians were identified by this review. One report, a clinical audit of podiatry services offered at a NSW AHS, provided data supporting the clinical effectiveness of the program. The authors describe a high rate of adherence to the national guidelines regarding timing of podiatry appointments which may be related to classification of patients according to evidence based risk status, and provision of services in a culturally safe manner. More data regarding aspects of successful Aboriginal and Torres Strait Islander foot programs should soon become available with planning and assessment of programs already underway in both WA and NSW.