measures were taken whenever the person was put at extra risk by, for instance, being confined to bed by intercurrent illness. Sadly, there is currently little sign that other professionals have anything other than minimal awareness of the implications of foot risk factors in people with diabetes.20
Action to be taken if a new problem occurs
The final element of education for the patients with ‘at-risk’ feet concerns action to be taken if they have a new lesion. In brief, they should be encouraged to contact the medical professional who deals with them most closely as soon as possible, preferably by phone. It goes without saying that those who might take such phone calls should be aware of the urgency with which they should be handled.
Education of Patients at Greatly Increased Risk The principles of education for this group are very similar to those for the ‘at-risk’ group. The differences relate to frequency of review and to relative degrees of urgency, rather than to matters of substance. In general, this group might be expected to remain under long-term care by a multidisciplinary foot team and it is to this team that they might be advised to turn to in case of need.
THE EFFECT OF EDUCATION ON BEHAVIOUR CHANGE Factors other than the degree of risk must be taken into consideration when planning the content and presentation of educational material to be made available to an individual.31 New information does not generally result in the desired change in behaviour unless it is relevant to the persons and their lifestyle. For instance, it would serve no purpose to instruct persons to wash their feet regularly when they already do it five times each day as part of their usual religious observance. Advice on footwear must take into account the persons’ normal practice, including their mobility, employment and their culture.
Adherence and Non-compliance It is normal for people to express their independence by either doing what they think is best for themselves or doing what they want.
It is not normal to follow instruction without question.
On the other hand, people will follow instruction if they perceive the need for behaviour change, if the instruction is compatible with their own wishes and intentions and if they trust, for whatever reason, the person doing the instructing.
To that extent, it is counterproductive if instructors or educators express surprise when people display non-compliance (or non-adherence), and if they blame them for it.
The common sense model of illness behaviour32 provides an appropriate structure for considering factors underlying variation in adherence to self-care in diabetes, and with respect to foot care in particular.33 Patients hold implicit beliefs and apprehensions concerning the
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150 EDUCATION IN THE MANAGEMENT OF THE FOOT IN DIABETES
nature of their disease and the threat it poses, and these influence both their behaviour and their response to education. People’s understanding of their disease is affected by social and cultural contexts, as well as the quality of their communication with their health care professional.34 The implication is that adherence will be improved if professionals involved in patient education explore the patient’s understanding, beliefs and fears, and use these as a basis for choosing the advice that is given.
Depression
It has been estimated that some 14% of patients with diabetes have clinical depression , two to three times that in the general population,35,36 and this has been shown to be associated with both poor glycaemic control and chronic complications of diabetes.37,38 It therefore follows that a significant proportion of those at risk of foot complications will be depressed, and depression is associated with poor self-care behaviour, poor participation in education programmes for diabetes39 and reduced confidence in their ability to care for their feet.38 Those planning educational programmes might therefore consider the option of screening for depression with a view to instituting specific therapy.40,41 Vileikyte et al.38 commented that one reason for the inconclusive nature of the results of trials of education in this field might relate to the absence of any assessment of adherence to the intervention in half of the studies, and to failure to explore people’s understanding of the factors involved or their emotional reactions to them.
Transtheoretical Model of Behavioural Change The transtheoretical model of behaviour change , which deals with the evolution of behaviour change into a new habit , has been explored in a variety of clinical settings.42−44 Behaviour change may be regarded as being in one of the five stages: pre-contemplation, contemplation, preparation, action and maintenance.
With this in mind, educational interventions can be designed and tailored to facilitate transition from one stage to the next.
Thus, a technique such as motivational interviewing45 might be used to help a person who is in the pre-contemplative and contemplative stages (merely thinking about changing) to move to the stage of adopting new foot care practices.
In the preparative stage, information about foot care may be enough to trigger change in some people, while others may remain ambivalent.
This ambivalence may be the result of perceived barriers, such as insufficient time, money, other priorities and the attitudes of family and friends.45 If these barriers are significant, then they will obstruct the attempts of a professional to induce behaviour change.
Moreover, persons who believe that the advised health behaviour challenges their personal freedom or standards may react by exaggerating their problem behaviour.
For example, if prescribed footwear is regarded as unattractive by a woman because it has implications for the selection of other items of clothing (e.g. trousers rather than a skirt), then she may start to demonstrate a preference for the clothing with which the footwear is incompatible.
This has been termed ‘psychological reactance’.45 It follows that it is essential to base the structure of the education programme on the preferences and obligations of the patient, and these will not be perceived unless there is some form of initial assessment.
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THE STRUCTURE OF AN EDUCATIONAL PROGRAMME 151
INITIAL ASSESSMENT The initial assessment is based on the understanding that the process of education is one that is directed at an individual, and interventions should be tailored to help people change their behaviour in order to meet their personal needs.
The assessment involves determination of the degree of risk, exploration of the extent to which their current behaviour might enhance this risk, barriers to the adoption of improved foot care behaviour and consideration of which form of educational intervention might have the greatest impact.
The degree of risk can be assessed most simply from the presence of ischaemia, neu- ropathy or deformity and from whether or not the patient has had a previous foot problem.
Co-morbidities , such as those that result in immobilisation , may also increase the risk to the foot.
Assessment of current foot care behaviour involves assessment of patients’ usual daily activities and the extent to which they choose, or are required, to be on their feet each day.
It also involves looking at their shoes and using this to explore their preferences and precon- ceptions concerning the choice of footwear.
It is then necessary to define the extent to which physical, social and cultural factors might act as barriers to any change in foot care behaviour that is thought to be necessary.
Physical factors include the extent to which foot care might be limited by poor vision or other incapacity.
Social factors would include employment details and inescapable responsibilities to their family and other contacts.
Cultural issues would include those that influence the use of footwear and include those exerted by society, as well as the sometimes very powerful influence of people’s perception of the importance of their choice of footwear as an expression of their self-image.
THE STRUCTURE OF AN EDUCATIONAL PROGRAMME Integration with Other Facets of Diabetes Education There is a danger that foot care may be considered in isolation when it would be better integrated into other aspects of education about a person’s diabetes management.
In practice, it may often be better delivered as part of a general education package, which has the advantages of tailoring the package to the requirements of an individual as well as improving coordination between different members of the multidisciplinary team.
New models of care need to be adopted which help address the personal, social and environmental factors that condition the persons’ health and their capacity for self-care.
These factors influence both the content of the education programme and the way in which it is delivered.
Content There is an outstanding need to define which aspects of foot care behaviour are definitely associated with a reduction in ulcer incidence.
We have some preliminary evidence that pro- fessionals from different specialty subgroups (e.g. doctors, nurses, podiatrists) differ in how they rank the importance of different aspects of foot care behaviour.
Much of the advice to be found in different foot care leaflets (and which is presumably similar to that which is delivered verbally) has no grounding in science, and may occasionally be inconsistent.
Is there evidence, for instance, that drying carefully between toes after washing (any more than people would