Step-by-Step Diabetes Foot Care Project

The Step-by-Step Diabetes Foot Care project was based on the premise that by systematically using relatively simple steps, diabetic foot complications may be significantly reduced. These steps include:

• regular inspection of the feet at every patient visit;
• early detection of loss of sensation in the patient's feet;
• continuous follow up of high risk patients; and
• patient education in preventive foot care and early warning signs.

During the first phase of the project, a 3-day training course was conducted in India and Tanzania for medical teams of doctors and nurses. In Tanzania 15 teams of one doctor and one nurse were trained, each representing a district or state. The teams were taught the principles of basic foot care education and practical management guidelines. The course was followed by a second, advanced training programme after 1 year. These teams provided on the job training to a further 125 medical officers and 176 nurses. The first phase also included the establishments of 14 foot care clinics, covering 14 regions in Tanzania, and 563 patient education sessions. Supporting educational materials for patients, doctors, and nurses were also provided.

The second phase of the project took place in Tanzania, and was designed to build on lessons learned and successes of phase one. Health care providers from 28 health centres from different regions or districts across Tanzania were trained. The prerequisite for having a team participate in the training was that the centre had an already established diabetes clinic. From each centre one doctor and one nurse participated in the training. Each of the foot care teams were provided with a foot care kit to manage preventive foot care for people with diabetes.

The first basic course was interactive and included workshops with less emphasis on lectures. Two sets of curricula were implemented - 1 for doctors and 1 for nurses. During the four day course, the first 3 days were an expanded version of the original "Step-by-Step" methodology and the last day comprised a podiatry course where the participants had the opportunity to use some of the acquired skills and knowledge. During the course, participants were shown how to obtain the relevant history of the patients, perform physical examinations, screen for neuropathy and ischemia, classify, stage and identify high-risk feet, organise appropriate foot care management and education, and act in a timely manner towards those with advanced foot problems. Moreover, issues related to referral of patients were discussed, focusing on disseminating the obtained information to other health care providers.

Upon return to their home health centres the trained health care providers were expected to establish foot screening and care as part of the already existing diabetes clinic. In this manner they were able to educate patients and share their acquired knowledge and skills with their fellow health care providers. In addition, they applied the different aspects from the training course including screening for foot complications, surveillance of mortality and morbidity, and treatment for diabetic foot problems. A year later, 15 foot care teams from 15 foot clinics were selected for an additional round of podiatry training.

To support health workers, education materials created during the first phase of the project were reprinted and distributed to health care providers and people with diabetes.

Health

According to the World Diabetes Foundation, over 190 million people in the world suffer from diabetes. Many people with diabetes lose the feeling in their feet and may not be aware of skin injuries developing into infected ulcers. Left untreated, the infection spreads, leading to gangrene which requires amputation. In Tanzania, around 1 million people have diabetes. 33% of patients admitted for diabetic foot ulcers undergo amputation with a 54% mortality rate in patients who present late. Diabetes related amputations are to a large extent preventable when simple measures are applied. Evidence shows that amputation rates can be reduced by 49-85% if strategies for preventing and treating diabetic foot lesions are implemented. By the end of the project, more than 12,000 patients received foot care at the established clinics.