anyway) results in decreased incidence of tinea pedis, or that the use of moisturising cream has a specific benefit on the incidence of foot cracks or ulcers? Is it known that the application of moisturising cream between toes causes any harm? Thus, it could be argued that some foot care advice may currently be too detailed and may be no better than that which simply relies on general principles. It could also be argued that the use of detailed guidelines, with lists of prescriptive instructions, may sometimes have a potential adverse effect , if failure to follow them induces a sense of guilt in the patient who goes on to get an ulcer. Guilt may lead to delayed self-referral and the ulcer may worsen as a result.
Delivery The scientific basis of foot care education for people with diabetes is in its infancy but there is relevant experience in other fields.
Similar issues have been addressed in the management of rheumatoid arthritis, for instance, and it has been shown that behavioural interventions (such as those providing skills practice, goal setting and home programmes) have significant positive effects on functional ability, mood and morbidity.46 However, these reviewers also reported that the greatest benefit in rheumatoid arthritis was observed in response to behavioural interventions, while those based simply on didactic measures (such as information giving and attempts at persuasion) and counselling (enhancing social support and discussion of problems) had little effect.
Even so, the responses to behavioural therapy were only modest and their clinical relevance was unclear.47 Kruger and Guthrie10 compared the effect on foot care behaviour of two different educational interventions: didactic alone versus didactic combined with a ‘hands-on’ practical demonstra- tion.
There was no difference in knowledge between the two groups at 6 months, but those receiving the practical programme had better foot care behaviour.
Barth et al.9 showed that an intensive education programme had a greater short-term effect on knowledge and foot care behaviour, but it was not associated with any reduction in the incidence of new foot problems.
Media and resources
There are no data relevant to foot care available to help determine whether education is best delivered simply in person or combined with materials and technologies such as interactive Web site, video, CD-ROM, audiotape or foot care leaflet.
Television facilities are now commonplace in hospital waiting areas and could be used to present a foot care video, featuring an influential member of the professional team (or a patient), running intermittently.
The content need not be complex and could comprise a simple explanation of the main risk factors for ulcer development and a demonstration of good foot care practice.
There would be an inherent danger, however, that repeated delivery might lead to annoyance, and some may resent being treated as a captive audience in this way, with the associated intrusion into their thoughts and privacy.
It might be better for such a facility to be simply available in a separate area rather than being imposed on all.
Leaflets
Most would feel that the provision of educational leaflets was an essential part of routine care , the evidence from other fields is that the impact of educational leaflets on behaviour is not
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THE STRUCTURE OF AN EDUCATIONAL PROGRAMME 153
great,46 and is very dependent on both content and design.
Content is inevitably based on the beliefs and practice of the author(s), and our own unpublished data indicate that these may vary between different professional groups.
Design is also important: texts that are easy to read can increase the reader’s motivation and interest.48 Readability depends on many factors including print legibility, use of illustrations and the complexity of words or sentence structure.
Tests of readability and comprehension tests , such as Flesh Reading Ease Scores49 and the Cloze procedure50 , can be simply and easily applied.
Evaluation of leaflets in this way indicated that readability, comprehension and usefulness were the biggest overall predictors of whether UK National Health Service nurses intended to follow safe manual handling practices.48
Group Versus Individual Education Groups allow for interaction and shared learning31 and Malone and colleagues used group teaching to effect a major reduction in amputation.12 However, the delivery format will be influenced to a large extent by the client group.
Younger people at risk of ulceration are a high priority for education and may respond better to individually tailored sessions, which are timed to suit them, although it is also possible that some would prefer the informality of group teaching and would find it less intimidating.
It follows that if both group and individual sessions are available, the opportunity to join a group should be offered to all.
Group education sessions might be held at the hospital, general practitioner’s surgery, community-based clinics or local sports and community centres , provided the venue has a suitable room with the required audiovisual equipment, is easily accessible and can accommodate people with disabilities.
People with persisting wounds, who are unable to drive, are wheelchair dependent or who live alone may require special transport arrangements to be made, and this will affect participation and attendance and, hence, choice of venue.
Those with diabetes-related or other medical problems may be already committed to multiple hospital attendances and may be unwilling to attend.
Flexible arrangements will be needed to accommodate those who are working.
Individual education
Individual education has some advantages.
The session speed and content can be tailored to suit the person’s needs and abilities, and information about foot care can be specific to what is known about his/her particular problem.
There may be greater scope to employ motivational or cogni- tive behavioural techniques.
Individual sessions also provide an opportunity for goal setting and review, and so may be used to target those who have difficulty in embracing behaviour change for whatever reason.
Individual education may also be more suited to people with impaired mobility and who are less able to travel with ease, since it will be associated with more options for where the education might take place.
Superficially, individual education may appear more time consuming and expensive, but this is justified if it is shown that the benefit is greater.51
Timing and Intensity Optimal timing of foot care education is not known, and nor is its ideal intensity , the number and duration of separate sessions. In the absence of specific information, the format adopted will vary with the group or individual being educated, and the availability of educational resources.
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154 EDUCATION IN THE MANAGEMENT OF THE FOOT IN DIABETES
People’s response to education diminishes over time,6,9 and this means that whatever the content and the mode of delivery, the process should involve systematic repetition and reinforcement.
EDUCATING THE EDUCATORS It would be wrong to assume that any health care professional (such as podiatrist, nurse or doctor) has the skills necessary to deliver effective patient education simply by virtue of his/her title and knowledge.
The delivery of diabetes education requires specialist skills and training.31 This is recognised in the United States, for example, by the Registered Diabetes Educator qualification that is held by a wide range of health professionals.
Health care professionals may, therefore, require additional training in psychological skills (e.g. active listening), teaching skills (e.g. theories of learning, managing groups), psychosocial skills (interactions between diabetes and the social environment), team building and organisation of care (multidisciplinary team work) and in evaluating behaviour and the impact of treatment.
Training staff in new or specialist skills also means that they may need support to apply what they have learned, by freeing up time and releasing them from some of their existing duties.52 The need for such special training may, however, limit the extent to which effective education can be implemented in clinical practice.
ASPECTS OF TRIAL DESIGN IN EVALUATING FOOT CARE EDCUATION One main reason for the lack of evidence concerning the effectiveness of education is the problem posed by trial design in this field.
Choice of Intervention The criticism which can be levelled at any study that fails to show a positive effect is that the choice, or delivery, of the intervention was at fault.
There is no answer to this, other than to say that the value of any programme lies in the extent to which it can be extrapolated to larger populations.
Although education is best delivered by those with special training, skills and resources, the focus of research in the foreseeable future should be on the evaluation of interventions that are simple and capable of being implemented on a large scale.
Consideration should, however, be given to whether or not education should be studied in isolation or as part of an integrated package of improved care.
There is good evidence that its incorporation as part of a package of care is associated with improved clinical outcomes in populations that are socially disadvantaged or that otherwise have access to limited medical surveillance.
There may be a better case for studying education in isolation in communities that already have equitable access to good primary health care services.
Outcome Measures The aim is to demonstrate that education induces behaviour change and that behaviour change induces an improved clinical outcome. The demonstration of the effect of an intervention