Foot education improves knowledge and satisfaction among patients at high risk for diabetic foot ulcer

Foot Self-Care Behaviour among People with Type 2 Diabetes mellitus Living in Rural Underserved Area of North India: A Community-Based Cross-Sectional Study

The objective of this study was to ascertain the foot self-care behaviour and its associated factors among people with type 2 diabetes mellitus (T2DM) living in the rural resource-constrained health setting of Punjab, North India. A community based cross sectional study was undertaken in the randomly selected underserved rural area of District Fatehgarh Sahib, Punjab, North India. A pre-validated Nottingham Assessment of Functional Footcare (NAFF) scale was administered to assess foot self-care behaviour, and participants were classified based on the percentage of a maximum possible score of 84 on the scale, as poor, if the score was <50%, satisfactory if score 50%-70% and >70% good foot self-care behaviour. A total of 700 participants' responses were recorded. The study results revealed that 84% (588) of the respondents had poor, 16% (112) had satisfactory, and none were following good foot self-care behaviour. An outcome of multivariable logistics regression suggested satisfactory foot self-care behaviour was significantly associated with foot self-care education, with an adjusted odds ratio (aOR) of 2.83 (95%, CI:1.62 - 4.93; p <0.01) among respondents who had received foot self-care education, literate than illiterate (aOR 2.50 95%, CI:1.31- 4.74; p <0.01) and women compared to men (aOR 1.69 95%, CI: 1.06 -2.70; p -0.26). This study revealed that foot self-care behaviours were alarmingly low among people with T2DM living in rural resource-constrained health settings of Punjab, North India, suggesting an urgent need to disseminate foot self-care education to prevent diabetes foot related complications.

A review on diabetic foot challenges in Guyanese perspective

BACKGROUND

Diabetes mellitus signifies a major public health threat worldwide. Type 2 diabetes has been reported as the fourth leading cause of death and has affected 15.5% of the adult population in Guyana, South America. Diabetes has also led to major lower extremity amputation at the only referral public hospital in Guyana. Diabetic foot and related complications are known to be multifactorial.

CONCLUSION

In this review, we highlight the information on the diabetic foot and related complications with an emphasis on Guyanese background.

Diabetes Nurse Educators' Prioritized Elder Foot Care Behaviors

Purpose

The purpose of this study was to identify diabetes nurse educators' perceptions of the most important foot care behaviors for elderly people to enact in daily care.

Methods

A structured, open-ended questionnaire was mailed to a regionally stratified random sample of 90 diabetes nurse educators. Subjects were asked to identify and rank order 8 foot care behaviors perceived important for elderly people with diabetes to enact daily. Data were transcribed and coded into categories and domains using descriptive content analysis.

Results

Forty-seven diabetes nurse educators responded with a total of 346 foot care behaviors perceived important for elders. Twenty-one major foot care behavior content categories were grouped into 4 domains of descending importance: foot/nail care, footwear/shoes, general health, and foot emergencies.

Conclusions

Diabetes nurse educators generated a range of baseline data for developing a reliable, valid, and patient foot care knowledge outcome measure to support national diabetes patient education and self-management program guidelines.

Type 2 diabetes-related foot care knowledge and foot self-care practice interventions in the United States: a systematic review of the literature

Introduction

The purpose of this systematic literature review is to review published studies on foot care knowledge and foot care practice interventions as part of diabetic foot care self-management interventions.

Methods

Medline, CINAHL, CENTRAL, and Cochrane Central Register of Controlled Trials databases were searched. References from the included studies were reviewed to identify any missing studies that could be included. Only foot care knowledge and foot care practice intervention studies that focused on the person living with type 2 diabetes were included in this review. Author, study design, sample, intervention, and results were extracted.

Results

Thirty studies met the inclusion criteria and were classified according to randomized controlled trial (n=9), survey design (n=13), cohort studies (n=4), cross-sectional studies (n=2), qualitative studies (n=2), and case series (n=1). Improving lower extremity complications associated with type 2 diabetes can be done through effective foot care interventions that include foot care knowledge and foot care practices.

Conclusion

Preventing these complications, understanding the risk factors, and having the ability to manage complications outside of the clinical encounter is an important part of a diabetes foot self-care management program. Interventions and research studies that aim to reduce lower extremity complications are still lacking. Further research is needed to test foot care interventions across multiple populations and geographic locations.

Diabetic foot: prevalence, knowledge, and foot self-care practices among diabetic patients in Dar es Salaam, Tanzania - a cross-sectional study

Background

At the time of diagnosis, more than 10 % of people with type 2 diabetes mellitus have one or two risk factors for a foot ulceration and a lifetime risk of 15 %. Diabetic foot ulcers can be prevented through well-coordinated foot care services. The objective of this study was to determine knowledge of foot care and reported practice of foot self-care among diabetic patients with the aim of identifying and addressing barriers to preventing amputations among diabetic patients.

Methods

Patients were randomly selected from all public diabetic clinics in Dar es Salaam. A questionnaire containing knowledge and foot care practice questions was administered to all study participants. A detailed foot examination was performed on all patients, with the results categorized according to the International Diabetes Federation foot risk categories. Statistics were performed using SPSS version 14.

Results

Of 404 patients included in this study, 15 % had foot ulcers, 44 % had peripheral neuropathy, and 15 % had peripheral vascular disease. In multivariate analysis, peripheral neuropathy and insulin treatment were significantly associated with presence of foot ulcer. The mean knowledge score was 11.2 ± 6.4 out of a total possible score of 23. Low mean scores were associated with lack of formal education (8.3 ± 6.1), diabetes duration of < 5 years (10.2 ± 6.7) and not receiving advice on foot care (8.0 ± 6.1). Among the 404 patients, 48 % had received advice on foot care, and 27.5 % had their feet examined by a doctor at least once since their initial diagnosis. Foot self-care was significantly higher in patients who had received advice on foot care and in those whose feet had been examined by a doctor at least once.

Conclusions

The prevalence of diabetic foot is high among patients attending public clinics in Dar es Salaam. There is an urgent need to establish coordinated foot care services within the diabetic clinic to identify feet at risk, institute early management, and provide continuous foot care education to patients and health care providers.

A comparison of two methods of foot health education: the Fremantle Diabetes Study Phase II

AIMS

To compare the effectiveness of two different methods of education on foot health, behaviours and attitudes in patients with type 2 diabetes.

METHODS

Community-based patients were consecutively allocated to written education (Group A) or an interactive educator-led session (Group B). A quantitative Foot Score (maximum 90 points score based on severity of treatable pathology), the Nottingham Assessment of Functional Foot Care (NAFFC) survey score (maximum 30 points reflecting frequency of foot care behaviours) and a 6-question survey of attitudes to foot complications were administered at baseline and 3 months.

RESULTS

154 patients (mean±SD age 68±10 years, 59.7% males, median [interquartile range] diabetes duration 11.5 [5.6-18.9] years) were recruited. There was a greater change (Δ) in Foot Score from baseline to 3 months in Group A (8.3±3.6, Δ-1.8 (95% CI: -2.4 to -1.2) vs Group B (6.8±2.6, Δ-0.1 (-0.7 to 0.4); P<0.001), but no change in NAFFC survey score in either group (P=0.13). In the attitudes survey, Group B felt they better understood how to prevent foot complications than Group A after education (P=0.031).

CONCLUSIONS

Written information was more effective at improving foot health while interactive education improved confidence in undertaking preventive measures, suggesting that the most effective foot care education should include both components.

Patient education for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus.

OBJECTIVES

To assess the effects of patient education on the prevention of foot ulcers in patients with diabetes mellitus.

SEARCH METHODS

We searched The Cochrane Wounds Group Specialised Register (searched 03 September 2014); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 8).

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) that evaluated educational programmes for preventing foot ulcers in people with diabetes mellitus.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data extraction and assessment of risk of bias. Primary end points were foot ulceration or ulcer recurrence and amputation.

MAIN RESULTS

Of the 12 RCTs included, the effect of patient education on primary end points was reported in only five. Pooling of outcome data was precluded by marked, mainly clinical, heterogeneity. One of the RCTs showed reduced incidence of foot ulceration (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.14 to 0.66) and amputation (RR 0.33, 95% CI 0.15 to 0.76) during one-year follow-up of diabetes patients at high risk of foot ulceration after a one-hour group education session. However, one similar study, with lower risk of bias, did not confirm this finding (RR amputation 0.98, 95% CI 0.41 to 2.34; RR ulceration 1.00, 95% CI 0.70 to 1.44). Three other studies, also did not demonstrate any effect of education on the primary end points, but were most likely underpowered. Patients' foot care knowledge was improved in the short term in five of eight RCTs in which this outcome was assessed, as was patients' self-reported self-care behaviour in the short term in seven of nine RCTs. Callus, nail problems and fungal infections improved in only one of five RCTs. Only one of the included RCTs was at low risk of bias.

AUTHORS' CONCLUSIONS

In some trials, foot care knowledge and self reported patient behaviour seem to be positively influenced by education in the short term. Yet, based on the only two sufficiently powered studies reporting the effect of patient education on primary end points, we conclude that there is insufficient robust evidence that limited patient education alone is effective in achieving clinically relevant reductions in ulcer and amputation incidence.

Podiatric physicians' perspectives on their role in promoting self-care in high-risk patients with diabetes

BACKGROUND

Foot self-care is key in preventing morbidity in high-risk diabetic patients. Motivational interviewing (MI) is an approach to encourage behavior change by patients that can be used in medical settings. The goal was to explore how podiatric physicians promote self-care in such patients and whether they use MI techniques.

METHODS

We conducted a 19-question online survey of US-based practicing podiatric physicians. Most answers were on a 5-point scale. The MI index was the sum of answers to five relevant questions.

RESULTS

Of 843 podiatric physicians, 86% considered foot self-care to be very important for high-risk diabetic patients, and 90% felt that it was their role to discuss foot self-care with them; 49% felt that they had training and were successful in promoting behavior change, but most were definitely (38%) or possibly (46%) interested in learning more. Only 24% of respondents scored at least 15 of 20 on the MI index. Higher MI scores were associated with more face time and more time discussing foot self-care but were not related to podiatric physicians' age, sex, geographic location, percentage of time in surgery, or years in practice. Reported barriers to counseling were lack of reimbursed time and poor patient engagement.

CONCLUSIONS

Most podiatric physicians view self-care behavior among high-risk diabetic patients and their role in promoting it as very important; most feel already proficient, but only a few demonstrate MI skills; most are willing to learn more. Success in behavioral counseling, such as MI, is likely to require more time and may be encouraged by a move from fee-for-service to outcome-based reimbursement.

Patient education for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus.

OBJECTIVES

To assess the effects of patient education on the prevention of foot ulcers in patients with diabetes mellitus.

SEARCH METHODS

Eligible studies were identified by searching The Cochrane Wounds Group Specialised Register (searched 1 August 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); Ovid MEDLINE (2009 to July Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 31, 2012); Ovid EMBASE (2009 to 2012 Week 30); and EBSCO CINAHL (2009 to 26 July 2012).

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) that evaluated educational programmes for preventing foot ulcers in people with diabetes mellitus.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data extraction and assessment of risk of bias. Primary end points were foot ulceration or ulcer recurrence and amputation.

MAIN RESULTS

Of the 12 RCTs included, the effect of patient education on primary end points was reported in only five. Pooling of outcome data was precluded by marked, mainly clinical, heterogeneity. One of the RCTs showed reduced incidence of foot ulceration (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.14 to 0.66) and amputation (RR 0.33, 95% CI 0.15 to 0.76) during one-year follow-up of diabetes patients at high risk of foot ulceration after a one-hour group education session. However, one similar study, with lower risk of bias, did not confirm this finding (RR amputation 0.98, 95% CI 0.41 to 2.34; RR ulceration 1.00, 95% CI 0.70 to 1.44). Three other studies, also did not demonstrate any effect of education on the primary end points, but were most likely underpowered. Patients' foot care knowledge was improved in the short term in five of eight RCTs in which this outcome was assessed, as was patients' self-reported self-care behaviour in the short term in seven of nine RCTs. Callus, nail problems and fungal infections improved in only one of five RCTs. Only one of the included RCTs was at low risk of bias.

AUTHORS' CONCLUSIONS

In some trials, foot care knowledge and self reported patient behaviour seem to be positively influenced by education in the short term. Yet, based on the only two sufficiently powered studies reporting the effect of patient education on primary end points, we conclude that there is insufficient robust evidence that limited patient education alone is effective in achieving clinically relevant reductions in ulcer and amputation incidence.

Patient education for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus.

OBJECTIVES

To assess the effects of patient education on the prevention of foot ulcers in patients with diabetes mellitus.

SEARCH STRATEGY

Eligible studies were identified by searching the Cochrane Wounds Group Specialised Register (22 December 2009), the Cochrane Central Register of Controlled Trials (Cochrane Library 2009 Issue 4 ), Ovid MEDLINE (1950 to November Week 3 2009), Ovid MEDLINE In-Process & Other Non-Indexed Citations (Searched 22/12/09), Ovid EMBASE (1980 to 2009 Week 51) and EBSCO CINAHL (1982 to December 22 2009).

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) which evaluated educational programmes for preventing foot ulcers in people with diabetes mellitus. There was no restriction on language of the publications.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data extraction and assessment of risk of bias. Primary end-points were foot ulceration or ulcer recurrence and amputation.

MAIN RESULTS

Eleven RCTs were included. Three studies described the effect of foot care education as part of general diabetes education compared with usual care. Two studies examined the effect of foot care education tailored to educational needs compared with no intervention. Finally, six studies described the effect of intensive compared with brief educational interventions. Pooling of outcome data was precluded by marked, mainly clinical, heterogeneity. Four RCTs assessed the effect of patient education on primary end-points: foot ulceration and amputations. One of these studies reported a statistically significant benefit of one hour group education after one year of follow-up in people with diabetes who were at high risk for foot ulceration; RR amputation 0.33 (95% CI 0.15 to 0.76); RR ulceration 0.31 (95% CI 0.14 to 0.66), however this study was at high risk of bias and may have overestimated the effect due to a unit of analysis error. One similar, but methodologically superior study did not confirm this finding; RR amputation 0.98 (95% CI 0.41 to 2.34); RR ulceration 1.00 (95% CI 0.70 to 1.44). The other two studies did not detect any effect of education on ulcer incidence or amputation but were underpowered. Patients' foot care knowledge was improved in the short term in five of eight RCTs in which this outcome was assessed, as was patients' self reported self care behaviour in the short term in seven of nine RCTs. The effects on callus, nail problems and fungal infections were described in five of the included studies, of which only two reported temporary improvements after an educational intervention.Only one of the included RCTs was considered to be at low risk of bias.

AUTHORS' CONCLUSIONS

Most of the RCTs included in this review are at high or unclear risk of bias. In some trials, foot care knowledge and self reported patient behaviour seem to be positively influenced by education in the short term. This, however, must be viewed with caution. The ultimate goal of educational interventions is preventing foot ulceration and amputation but only four RCTs reported these outcomes and only two reported sufficient data to examine this. Based on these two studies, we conclude that there is insufficient robust evidence that limited patient education alone is effective in achieving clinically relevant reductions in ulcer and amputation incidence.Future research should focus on evaluating the effect of more comprehensive and/or intensive prevention strategies which may also include patient education (complex interventions).

Improving foot self-care behaviors with Pies Sanos

Participants who received Pies Sanos, a 15-min intervention designed to improve diabetes self-efficacy and foot self-care behaviors in adult patients with type 2 diabetes who lived in a predominantly Mexican American community, performed more-complete foot self-care 1 month later in their homes. Recruited when they presented for nonurgent care to the emergency department in two community hospitals near the U.S.-Mexico border, participants were randomized into one of three groups. At follow-up, there was a significant difference in observed foot self-care behaviors between groups, F(2, 135) = 2.99, p < .05, as well as a significant difference within the intervention, t (47) = -4.32, p < .01, and control group, t (46) = -2.06, p < .05, for baseline and follow-up self-reported foot self-care behaviors. Baseline diabetes self-efficacy was significantly and positively correlated with both baseline (r = .335, p < .001) and follow-up ( r = .174, p < .05) foot self-care behaviors.

Patient education for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus.

OBJECTIVES

To assess the effectiveness of patient education on the prevention of foot ulcers in patients with diabetes mellitus.

SEARCH STRATEGY

Eligible studies were identified by searching the Cochrane Wounds Group Specialised Register, (September 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2004).

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) which evaluated educational programmes for the prevention of foot ulcers in people with diabetes mellitus. There was no restriction on language of the publications.

DATA COLLECTION AND ANALYSIS

Two reviewers undertook data extraction and assessment of study quality independently.

MAIN RESULTS

Nine RCTs were included. Four trials compared the effect of intensive with brief educational interventions; two of these reported clinical endpoints. One study involving high-risk patients reported a reduction in ulcer incidence (Peto OR: 0.28 (95% CI 0.13 - 0.59)) and amputation rate (Peto OR: 0.32 (95% CI 0.14 - 0.71)) after one year. The other RCT did not find an effect at seven years follow-up. Participants' foot care knowledge significantly improved with education in two trials. In one trial foot care knowledge improved significantly in the control group, in contrast to the intervention group. Non-calcaneal callus was significantly reduced by education in one trial. One RCT did not find that patient foot care education, as part of a general diabetes education program, reduced foot ulceration compared with usual care. Patient education as part of a complex intervention, targeted at both people with diabetes and doctors, reduced the number of serious foot lesions at one year in one RCT (OR: 0.41(95% CI 0.16 -1.00)) and improved foot care behaviour. Evidence from three RCTs comparing the effect of patient-tailored education in addition to usual care was conflicting.The methodological quality of the nine included RCTs was poor. The internal validity score (range 0 - 10) of individual RCTs ranged from 2 to 5.

AUTHORS' CONCLUSIONS

RCTs evaluating education for people with diabetes, aimed at preventing diabetic foot ulceration, are mostly of poor methodological quality. Weak evidence suggests that patient education may reduce foot ulceration and amputations, especially in high-risk patients. Foot care knowledge and behaviour of patients seem positively influenced by patient education in the short term. Because of conflicting results and the methodological shortcomings more RCTs are needed.

Diabetic foot care: multilingual translation of a patient education leaflet

The American Orthopaedic Foot and Ankle Society "Diabetic Foot Care" patient education leaflet was revised to improve the layout and emphasis of key concepts of preventive care. This included review of daily foot and shoe examination, danger signs, daily washing and foot care, shoe fitting, medical care, and avoidance of dangerous acts. The leaflet was expanded to occupy two sides of a page, retaining the capability of production in tear-off sheet format to facilitate distribution to patients in the clinical office. Furthermore, the leaflet was translated into 19 other languages for diabetic patients in the United States and around the world with limited English language comprehension.

Incorporating foot care education into diabetic foot screening

Rehabilitation nurses care for patients with diabetes who have strokes, orthopedic surgery, and spinal cord injuries; therefore, they should be knowledgeable about foot screening technique and foot care education so that they can identify patients who are at risk for foot skin breakdown. The objectives of diabetic foot screening are to identify foot problems, determine a foot risk category and management category for patients, and to instruct patients with diabetes and their families in proper foot care. The screening technique is simple and can be used in clinic settings or at the bedside. Incorporating foot care education into the foot screening process increases or reinforces patients' knowledge of self-care. Such knowledge empowers patients to join with their healthcare teams to decrease the incidence of ulceration and amputation.

Individualized education can improve foot care for patients with diabetes

Providing individualized education to home care patients with diabetes can significantly improve their foot care practices. A nurse researcher from the Intercollegiate College of Nursing at Washington State University conducted a study of 40 home healthcare patients with Type 2 diabetes and found that an individualized educational intervention led to improved foot care knowledge, self-care practices, and confidence performing foot related self-care.

A randomized pilot study of improving foot care in home health patients with diabetes

PURPOSE

The purpose of this study was to test the effectiveness of an educational intervention to improve patients' foot care knowledge, self-efficacy, and self-care practices.

METHODS

A prospective, randomized, single center, 2-group design was used with a convenience sample of 40 home care patients from a Medicare-certified home health agency. Baseline measures of foot care knowledge, self-efficacy, and reported self-care practices were obtained at study entry and 6 weeks later to control for foot care interventions provided during routine home care services. After obtaining the 6-week baseline measures, patients who were randomized to the intervention group received individualized education about proper foot care. All patients were interviewed a third time 3 months after study entry to determine the effectiveness of the intervention.

RESULTS

The educational intervention improved patients' knowledge, confidence, and reported foot care behaviors.

CONCLUSIONS

A brief, individualized educational intervention about standard foot care topics improved patients' foot care knowledge and self-efficacy as well as reported self-care practices. Incorporating such interventions into routine home care services may enhance the quality of care and decrease the incidence of lower-extremity complications.

Specialist nurses in diabetes mellitus

BACKGROUND

The patient with diabetes has many different learning needs relating to diet, monitoring, and treatments. In many health care systems specialist nurses provide much of these needs, usually aiming to empower patients to self-manage their diabetes. The present review aims to assess the effects of the involvement of specialist nurse care on outcomes for people with diabetes, compared to usual care in hospital clinics or primary care with no input from specialist nurses.

OBJECTIVES

To assess the effects of diabetes specialist nurses / nurse case manager in diabetes on the metabolic control of patients with type 1 and type 2 diabetes mellitus.

SEARCH STRATEGY

We carried out a comprehensive search of databases including the Cochrane Library, MEDLINE and EMBASE to identify trials. Bibliographies of relevant papers were searched, and hand searching of relevant publications was undertaken to identify additional trials (Date of last search November 2002).

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trials of the effects of a specialist nurse practitioner on short and long term diabetic outcomes were included in the review.

DATA COLLECTION AND ANALYSIS

Three investigators performed data extraction and quality scoring independently; any discrepancies were resolved by consensus.

MAIN RESULTS

Six trials including 1382 participants followed for six to 12 months were included. Two trials were in adolescents. Due to substantial heterogeneity between trials a meta-analysis was not performed. Glycated haemoglobin (HbA1c) in the intervention groups was not found to be significantly different from the control groups over a 12 month follow up period. One study demonstrated a significant reduction in HbA1c in the presence of the diabetes specialist nurse/nurse case manager at 6 months. Significant differences in episodes of hypoglycaemia and hyperglycaemia between intervention and control groups were found in one trial. Where reported, emergency admissions and quality of life were not found to be significantly different between groups. No information was found regarding BMI, mortality, long term diabetic complications, adverse effects, or costs.

REVIEWER'S CONCLUSIONS

The presence of a diabetes specialist nurse / nurse case manager may improve patients' diabetic control over short time periods, but from currently available trials the effects over longer periods of time are not evident. There were no significant differences overall in hypoglycaemic episodes, hyperglycaemic incidents, or hospital admissions. Quality of life was not shown to be affected by input from a diabetes specialist nurse/nurse case manager.

Patient education for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus.

OBJECTIVES

To assess the effectiveness of patient education on the prevention of foot ulcers in patients with diabetes mellitus.

SEARCH STRATEGY

Eligible studies were identified by searching the Wounds Group Specialised Trials Register, which is compiled from regular searches of the major health care databases including MEDLINE, Cinahl and EMBASE, hand searching of wound care journals and relevant conference proceedings. For this review the Register was searched up to March 2001.

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) which evaluated educational programmes for the prevention of foot ulcers in people with diabetes mellitus. There was no restriction on language of the publications.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of study quality were undertaken by two reviewers independently.

MAIN RESULTS

The methodological quality of the 8 included RCTs was poor. The internal validity score (range 0 - 10) of individual RCTs ranged from 2 to 4. Four trials compared the effect of intensive with brief educational interventions; 2 of these reported clinical endpoints. One study involving high-risk patients reported a reduction in ulcer incidence (Peto OR: 0.28 (95% CI 0.13,0.59)) and amputation rate (Peto OR: 0.32 (0.14,0.71)) after 1 year. The other RCT did not find an effect at seven years follow-up. Participants' foot care knowledge significantly improved with education in 2 trials. In one trial, foot care knowledge was significantly worse at 6 months, although foot care behaviour improved significantly. Non-calcaneal callus was significantly reduced by education in one trial. One RCT did not find that patient foot care education, as part of a general diabetes education program reduced foot ulceration compared with usual care. Patient education as part of a complex intervention targeted at both people with diabetes and doctors reduced the number of serious foot lesions at one year, in one RCT (OR: 0.41(0.16-1.00)) and improved foot care behaviour. Evidence from 2 RCTs comparing the effect of patient-tailored education in addition to usual care was conflicting.

REVIEWER'S CONCLUSIONS

RCTs evaluating education for people with diabetes, aimed at preventing diabetic foot ulceration, are mostly of poor methodological quality. Existing data suggests that patient education may reduce foot ulceration and amputations, especially in high-risk patients. Foot care knowledge and behaviour of patients seem positively influenced by patient education in the short term. Because of conflicting results and the methodological shortcomings more RCTs are needed.