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Patient-Centered Health Education Intervention to Empower Preventive Diabetic Foot Self-care Meryl Makiling, RN and Hiske Smart, CNS

ABSTRACT BACKGROUND: Diabetes impairs the body’s ability to produce or respond to the hormone insulin resulting in abnormal metabolism of carbohydrates and elevated glucose levels in the body. Because of these factors, diabetes can cause several complications that include heart disease, stroke, hypertension, eye complications, kidney disease, skin complications, vascular disease, nerve damage, and foot problems. Diabetes education allows patients to explore effective interventions into living their life with diabetes and incorporate the necessary changes to improve their lifestyle. OBJECTIVE: To educate patients diagnosed with diabetes or followed up for diabetes management by other departments with regard to their own responsibility in maintaining preventive foot self-care. METHODS: Ten patients completed a validated educational foot care knowledge assessment pretest to determine their existing knowledge about their own foot care after a thorough foot assessment. Preventive diabetic foot self-care education was conducted through a lecture, visual aids, and a return demonstration. Patients then took a posttest questionnaire with the same content as the pretest to determine their uptake of the educational content. RESULTS: Correct toenail cutting was the most identified educational need. It was a limitation in the pretest (30%), and it remained the lowest-scoring item on the posttest (70%). Walking barefoot was thought to be safe by 60% of participants pretest, but with remedial education, all participants identified this as a dangerous activity posttest. Participants also understood the high importance of having corns and calluses looked after by a health professional. CONCLUSIONS: Effective communication with patients by healthcare providers who can mold educational content to identified patient needs by teaching much needed skills is a key driver in rendering safe, quality healthcare education interventions. KEYWORDS: diabetes, diabetic foot, education, foot care, prevention, self-care

ADV SKIN WOUND CARE 2020;33:360–5.

DOI: 10.1097/01.ASW.0000666896.46860.d7

INTRODUCTION Type 2 diabetesmellitus is one of themost prevalent chronic disease burdens worldwide. Its prevalence rose from 4.7% in 1980 to 8.5% in 2014,1 currently affecting 422 million patientsworldwide. It is expected to be the seventhmost common cause of death in the world by 2030, primarily because of its rapid rise in middle- and low-income coun- tries.2 Diabetes is also a leading cause of severe morbid- ities and disabilities.1,2

Diabetes causes the body to completely or partially lost its ability to produce or respond to the hormone in- sulin, resulting in abnormal metabolism of carbohy- drates and elevated glucose levels in the body. Because of these metabolic changes, diabetes is associated with several complications such as heart disease, stroke, hy- pertension, eye complications, kidney disease, skin com- plications, vascular disease, nerve damage, and foot problems.2 Foot problems can range from mild to major damage to the foot structure and are associated with a pa- thology pathway that can include damage to the vascular blood supply and soft tissues and result in infection, all of which are magnified further by pressure and loss of pro- tective sensation known as peripheral neuropathy.3

People with these foot pathologies have a higher risk of developing a diabetic foot ulcer (DFU) and associated infection; this then carries the risk for a lower limb am- putation.2,3 Although some patients suffer from severe pain anddiscomfort in their feet—stinging, stabbing, shoot- ing, burning—others remain asymptomatic. However, having an insensate foot is the leading cause of uniden- tified foot complications in the early stages.3 The incidence of nontraumatic lower extremity amputation is at least 15 times greater in those with diabetes than without,4

followed by a high incidence of deathwithin 5 years there- after.5A 6-year follow-up study in SaudiArabia found that persons with a DFU were more likely to die during the study period than those without a DFU.5

In addition,management of a DFU is expensive, and if compounded with wound infection or amputation, the cost escalates accordingly.5,6 The duration of time to treat

Meryl Makiling, RN, is Staff Nurse, HVI-Podiatry Clinic, Cleveland Clinic, Abu Dhabi, United Arab Emirates. Hiske Smart, CNS, is Clinical Nurse Specialist, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain. The authors have disclosed no financial relationships related to this article. This article was originally published as Makiling M, Smart H. Patient-centred health educational intervention to empower preventive diabetic foot self-care. WCET J 2019;39(4):32-40. © Advances in Skin and Wound Care and World Council of Enterostomal Therapists.

Original Investigation


Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

and save asmuch of a foot as possible once aDFUdevelops is lengthy and requires an interprofessional approach to facilitate rehabilitation. However, if DFU development, surgical intervention, and amputation can be prevented with appropriate education interventions, cost savings and improved quality-of-life outcomes can be achieved. 7

In particular, patient education about basic foot care is important to reduce lower extremity complications.5,6

Nurses working in vascular and podiatry clinics encoun- ter patients with differing degrees of diabetic foot compli- cations. Patients who attend these clinics may have had diabetes for years. Themost common finding in the authors’ clinic is that patients are neither educated nor empowered with self-assessment methods to control their own disease and prevent complications in the early period just after initial diabetes diagnosis. Education interventions for persons with diabetes are

internationally accepted as a cornerstone of diabetes man- agement and patient empowerment, allowing them to make necessary changes to improve their lifestyle and pre- vent complications.7 These interventions enable patients to take control of their own disease and make correct life- style decisions to control their disease process and re- sultant outcomes. Diabetes education allows patients to identify their own requirements for needs-based learn- ing, a valuable adult learning concept that fosters in- creased adherence to best practice.8 The best time for this kind of intervention is early in the disease process, after diagnosis.8,9

These interventions require a health professional with sufficient knowledge of diabetesmanagement andpreven- tion who can convey the most essential content in bite- sized pieces in a short period. The education provided also requires regular follow-up with health professionals for monitoring uptake of lifestyle modifications and ongo- ing reassessment to determine whether more educa- tion is required. Targeting patients at increased risk

for DFU is therefore believed to constitute a cost- effective strategy to control progression to end-stage foot complication and mechanical destruction.8

It can be argued that the greatest weapon in the fight against diabetes mellitus complications is knowledge. Information can help people assess their risk of diabetes, motivate them to seek proper treatment and care earlier, and inspire them to take charge of their disease during their lifetime.7,8 Lectures accompanied by clinical dem- onstration are the preferred mode of teaching in a clinic setting given adult learning needs as identified by pa- tients themselves.10 This method also accommodates the language barrier between care providers and pa- tients.11 Information given to patients demonstrates how to conduct their own foot inspection and apply treatment if needed, with simultaneously assesses their ability to do so. This ensures that patients have sufficient knowledge and skills to undertake any required assess- ment interventions once at home and under self-care.

Objective The primary objective of the project was to educate pa- tients diagnosed with diabetes or followed up for diabe- tes management by other departments such as internal medicine and endocrinology with regard to the patient’s own responsibility inmaintainingpreventive foot self-care. This was completed through evaluating gaps in patient knowledge via a pretest-posttest design.




Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

METHODS On average, 20 new patients are referred to the authors’ podiatry clinic for diabetic foot screening every month (Figure 1). Most of these patients already have foot-related symptoms such as numbness, tightness, burning, and a tingling sensation that are signs of neuropathy. Most patients present with calluses over bony prominences, corns, and a dry plantar area indicative of peripheral neuropathy. Researchers decided to recruit, include, and group teach the first 10 patients in the clinic who met the following inclusion criteria: • diabetes diagnosis and formal referral to the podiatry clinic for foot screening • ability to speak and understand English (education materials were in English) • adults who could provide consent to participate • consent to take part in a confidential pretest and post- test educational foot care knowledge assessment

Assessments and Intervention Assessment materials were based on the Diabetes Foot Care Questionnaire (Figure 2) and the Diabetic Foot Risk Assessment (Figure 3) from the Diabetes Care Program ofNova Scotia 2009.8 The teaching plan and content were patterned on what clinicians normally taught patients visiting the podiatry and vascular clinic. Initially, nurses completed routine clinic assessments,

including vital signs and history taking, as well as a foot examination. Patients were then asked to answer the Di- abetes Care Program of Nova Scotia Diabetes Foot Care Questionnaire8 and complete the pretest (Figure 2). Foot care education was given through short lectures,

discussions, and visual aids (see Figures 4 and 5 for exam- ples). Educational content was associated with activities of daily living to make it more realistic. Patients’ and fam- ily members’ questions were then answered. Tomeasure the uptake of knowledge, patients then com-

pleted theposttest (the samecontent as thepretest; Figure2). The entire education process took about 10 to 15 minutes. All assessments were manually recorded in the patients’ notes folders.

RESULTS Based on the inclusion criteria, 10 patients (6 male, 4 female) were assessed and educated in this group learning session. Ages ranged from 40 to 70 years. Foot examinations revealed one patient with an existing DFU, two with previous ulcers on their legs that took more than 2 weeks to heal, and one person with a previ- ous DFU that had healed. No patients had a previous amputation. The majority of the patients showed signs of neuropathy and dry plantar areas (90%). Calluses over bony prominences and corns were present in 80% of the patients examined (Figure 6). None of the patients had


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