INTRODUCTION

The prevalence of diabetes mellitus (DM) is rising at an increasingly rapid rate worldwide.1 It is closely associated with the development of foot ulcers and responsible for a high percentage of amputations. Approximately one in four people with DM will develop a foot ulcer in their lifetime, and 7 of 10 amputations performed are due to DM.2,3

Diabetic foot (DF) is a common but devastating complication of DM. It is a group of syndromes in which neuropathy and peripheral vasculopathy of varying severity lead to infection, ulceration, tissue destruction, and possible amputation. Approximately 15% of patients with DM develop foot ulcers, and DF precedes amputation in 85% of cases.4

Diabetic foot is the most common cause of nontraumatic lower-extremity amputation. Prevention of DF ulceration is crucial to reduce the associated high morbidity, mortality, and amputation risk. Early diagnosis of diabetic neuropathy and peripheral arterial disease, health promotion, and self-care are among the most effective preventive measures.5,6 With adequate preventive measures and appropriate health education, 49% to 85% of foot complications in people with DM could be avoided.3

Self-management is important for the treatment of DM conditions, and patients are encouraged to play an active role in their care. Thus, healthcare professionals need to promote educational strategies that provide patients with the opportunity to assume a self-management role. According to Pinilla et al,4 patients who receive education about DM and the importance of foot health are more likely to perform regular self-care practices. The opposite occurs with a lack of education, and approximately a quarter of patients with high risk factors do not examine their feet.4 Positive results are achieved by providing patients with the necessary knowledge and skills to manage their own disease.7 Increasing patient knowledge and disease awareness has significant benefits with respect to treatment adherence, decreased complications associated with the disease, and improved quality of life.8,9 There is a good correlation between knowledge, attitude, and practice of self-care with respect to DM.1 Education on podiatric self-care in people with DM is an essential part of disease management.1 However, few patients receive adequate diabetes education.10

Andalusia, Spain has a number of diabetic foot care units, two of which are located in the province of Seville, in the Virgen Macarena and Virgen del Rocío University Hospitals. However, they are focused on the treatment of torpid wounds rather than on preventing the onset of complications.11 Podiatrists are not included in these units because podiatric care is excluded from the portfolio of services offered by the Social Security of the Andalusian Health System.11 Screening for this complication is carried out in primary care by the nursing staff, who establish the patient’s risk of a complication (low, moderate, or high). The frequency of assessments varies by risk status (annual, half-yearly, or quarterly/each visit). Patients are referred to the podiatrist when they present with foot ulcer risk (having diabetic neuropathy or peripheral artery disease) or DF. Podiatric coverage of these patients is insufficient. It is necessary to extend training, prevention, and management through health education of the foot in at-risk patients with DM not only once per year (ie, when there is a high risk or an established complication) but also earlier as a preventive measure.11–13

The main objective of this research was to test the effect of a podiatric health education activity on foot self-care in a group of people with DM in the province of Seville. The secondary objective was to determine the effect of this activity on the degree of disability related to foot pain.

METHODS

The type of study was quasi-experimental pretest and posttest. This study was approved by the Bioethics Committee of the Virgen Macarena and Virgen del Rocío University Hospitals of Seville, code 0227-N-17.

Participants

To recruit patients, the researchers contacted various associations of patients with DM in the province of Seville. With the support of these associations, the researchers organized health activities. The associations shared the information among their members, and interested patients came in separately to participate. Data collection was carried out in Lebrija, Morón de la Frontera, and Alcalá de Guadaira (Seville). Patients were included if they were 18 years or older, had a previous diagnosis of DM, and signed the informed consent form prior to the intervention. Patients with DF or other complications were included. Patients were excluded if they refused to participate in the study, were disoriented or had alterations in their mental faculties, or had other cognitive difficulties that prevented them from understanding the questionnaires by themselves or with the help of the clinician.

Data Collection

Patients self-reported the following data: name, sex, date of birth, marital status, year of diagnosis of DM, and type of DM. In addition, prior to the podiatric health education activity, researchers administered questionnaires to each participant to assess their foot pain-related disability and podiatric self-care. To determine foot pain-related disability, participants completed the Manchester Foot Pain and Disability Index (MFPDI); scores on this tool range from 0 to 38, with higher values corresponding to greater disability.14 The participants’ degree of foot self-care was measured using the University of Malaga Foot Self-care (APD-UMA) questionnaire. Scores on this scale range from 16 to 80, with higher values indicating better levels of foot self-care.15

Intervention

After participants completed the questionnaires, they then participated in a podiatric health education activity consisting of a 1-hour informative group talk presented by the researchers. The talk covered general aspects of the foot (eg, anatomy, vascularization, the importance of the foot in daily life), general topics related to DM (eg, epidemiology, DM types, treatment), podiatric complications related to DM (eg, vasculopathies, neuropathies, DF, amputations), specific foot care in people with DM (eg, hygiene, hydration, nail cutting, most frequent injuries, daily foot inspection), recommendations on footwear and sock characteristics for different activities (eg, shape, materials, heel), and the role of the podiatrist. Afterward, there was a 30-minute discussion period during which participants could ask questions and clarify any aspect of the talk.

One month after the intervention, researchers contacted participants by telephone and readministered the MFPDI and APD-UMA questionnaires.

Data Analysis

The investigators used IBM SPSS Statistics 22 for Windows for the statistical analysis. Descriptive values (mean, maximum, minimum, and SD) were calculated for the quantitative variables: age, duration of DM, MFPDI score, and APD-UMA score. Preintervention and postintervention values were recorded for both questionnaires. Frequencies were calculated for the qualitative variables: location, sex, marital status, and type of DM. The Shapiro-Wilk test was used to determine whether the questionnaire scores followed a normal distribution. The APD-UMA questionnaire scores followed a normal distribution, but the results obtained from the MFPDI questionnaire did not.

The researchers compared the preintervention and postintervention questionnaire scores to determine if there were significant differences across time. Because the APD-UMA questionnaire scores followed a normal distribution, investigators used a Student t test for independent samples to test if the preintervention/postintervention scores differed significantly. In contrast, to compare the preintervention and postintervention MFPDI questionnaire scores, researchers used the Wilcoxon signed-rank test for related samples. P < .05 was considered statistically significant.

RESULTS

The total sample consisted of 29 participants, 13 men (44.8%) and 16 women (55.2%), whose mean age was 58.69 (SD, 16.7; range, 18–83) years. A total of 34.5% had type 1 DM, and 65.5% had type 2 DM (Table 1).

Table 1 - CHARACTERISTICS OF THE SAMPLE Sociodemographic Variables n (%) or Mean (SD), Range Sex Male 12 (44.8) Female 16 (55.2) Location Lebrija 12 (41.4) Morón de la Frontera 7 (24.1) Alcalá de Guadaira 10 (34.4) Marital status Single 4 (13.8) Married 20 (69.0) Widowed 4 (13.8) Other 1 (0.03) Type of DM Type 1 10 (34.5) Type 2 19 (65.5) Age, y 58.69 (16.17), 18–83 DM duration, y 17.62 (13.47), 0–47

Descriptive statistics for the preintervention and postintervention values of the APD-UMA and MFPDI questionnaires are shown in Table 2. For the APD-UMA questionnaire, the postintervention values were significantly higher than the preintervention values (P = .001), indicating a higher degree of self-care after the intervention. For the MFPDI questionnaire, the postintervention values were lower than the preintervention values (P = .029), indicating a lower degree of disability.

Table 2 - DESCRIPTIVE VALUES FOR THE APD-UMA AND MFPDI Scale Minimum Maximum Mean (SD) APD-UMA preintervention 43 76 59.96 (8.69) APD-UMA postintervention 52 89 67.39 (6.99) MFPDI preintervention 0 104 11.65 (20.07) MFPDI postintervention 0 16 4.52 (5.47)
DISCUSSION

This study was carried out in a rural setting (three towns in the province of Seville) because, according to the literature, levels of podiatric self-care are lower in rural than in urban areas.16,17 There is a great need for this type of education intervention in this setting.

In this study, the authors used the MFPDI questionnaire, which was previously validated in Spain by Gijon-Nogueron et al.14 Also using the MFPDI, Roddy et al18 found that people with DM have a greater degree of disability than people without DM, offering evidence for its suitability for use in this population. In the present study, more than 70% of the sample was older than 50 years, which offers reliability in the results obtained because the MFPDI has been demonstrated to be suitable for use in adults older than 50 years.18

In accordance with other research results,19–21 the present study found that education intervention on foot care increases not only the knowledge of patients with DM, but also their self-care practices for their feet, as shown in the results obtained from the APD-UMA questionnaire. The baseline mean APD-UMA score was 59.96; this score rose to 67.39 after the intervention. This finding is contrary to the results of Baba et al,22 which reported an increase in foot health, but not in foot self-care practices. This may be due to patients having difficulty putting their knowledge into practice. In the study by Rodríguez-Moreno et al,10 the mean APD-UMA score was 59.07, which was similar to the preintervention value in the present study. However, 42% of those interviewees had foot ulcers.10 This highlights the importance of increasing levels of self-care through interventions to promote the prevention of complications.

In their research on the education of patients with DM, Tankova et al23 demonstrated that therapeutic education is essential. After a 5-day structured education program with follow-ups at 6 months and 1 year postintervention, the rate of acute complications such as severe hypoglycemia decreased, and patients’ quality of life improved. However, in this structured education, despite working with a multidisciplinary team (doctors, nurses, and a rehabilitation therapist), there were no podiatrists to provide adequate training in DF prevention,23 even though disability from localized pain in the feet and its effect on gait are closely related to poorer quality of life.24

In the present research, the results indicate that appropriate intervention decreases the degree of disability. Whereas a mean score of 11.65 was obtained on the MFPDI scale preintervention, this value decreased to a mean of 4.52 postintervention. Thus, therapeutic education not only increases self-care, but also decreases minor problems such as dry skin or calluses, likely leading to a better quality of life.25

The education method appears to play a role in the effectiveness of the intervention. Numerous studies19–21,26–28 have shown that with therapeutic education either by written or audiovisual means,22,29 or through practical or theoretical interventions,30 the levels of knowledge and self-care of patients with DM increase. In contrast, other types of interventions have not improved self-care outcomes.31,32 In a study by Xiang et al,31 a group of patients with poorly controlled DM and related complications adopted the role of mentor for other patients with DM who did not yet present these complications. Other research has tested interventions carried out through text messages. For example, in the study by Nepper et al,32 patients received text messages about self-care in general including foot care, but no significant results were found. In contrast, the research by Moradi et al33 also used a text message-based intervention, but the texts exclusively referred to foot self-care; patients showed improvements in both knowledge and practices of foot self-care. The authors believe that the adaptation of the interventions according to the characteristics of the target group could be the key for success.

Limitations and Strengths

One limitation of this study is the relatively short follow-up period. Although other studies reevaluated patients after 6 months or 1 year, in this study the investigators reevaluated participants after 1 month, the same follow-up period used in the study by Rahaman et al.29 Extending this time period would help determine the curve of forgetting after the training session.

Another limitation is the lack of a control group. Future research should include a comparison group to determine if scores would have improved regardless of intervention. Similarly, the investigators did not consider whether patients had recently received any other forms of DM education from other sources.

However, the methodology of the study is novel because patients were recruited through associations rather than recruiting individuals who come for consultation. Although this increases selection bias, this is a key factor in proving the effectiveness of a podiatric intervention in people with DM without previous foot complications or who do not seek care in consultation.

CONCLUSIONS

Therapeutic education is fundamental for the prevention of complications such as DF in patients with DM. It is possible to increase the level of self-care and decrease the degree of foot-related disability in patients with DM through informative talks. It is important to increase patient education on a regular basis, not only during routine podiatry care but also through podiatric health education activities with the help of existing patient associations to achieve good primary prevention.

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