ARTICLE IN PRESS

COMMENTARY

The role of patient education in preventing foot ulcers: the elusive Pimpernel?
Louise Stuart*, Phillip Wilesy
*

University of Salford, Directorate of Podiatry Consultant Physician, Diabetes Centre, Pennine Acute Trust, UK

Foot complications can have severe consequences for people with diabetes. An estimated 15% of people with diabetes will have a foot ulcer at some point.1 World Diabetes Day in November 2005 aims to put feet rst and prevent diabetes-related amputations. In the UK, the National Service Framework for Diabetes2, the Scottish Intercollegiate Guideline Network (SIGN)3 and National Institute for Health and Clinical Excellence (NICE)4 provide us with the Magna Carta for diabetes care. Patientcentred care is crucial to the delivery of such standards. There are now two national evidencebased programmes for type 1 and type 2 diabetes: Diabetes Adjustment for Normal Eating (DAPHNE)5 and Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND),6 but there is remarkably little consensus about how to deliver patient-centred education to patients with or at risk from diabetes-related foot disease. There are few surprises in the systematic review of the literature by Bazian,13 the ndings of which show little denitive evidence that education alone has a signicant effect on foot health for people with diabetes. A key problem is the lack of a gold standard against which structured education based on patient-centred principles can be measured. Patient Education in Diabetes, recently published by the Department of Health in England,7 recommends that patient educational models should be based upon the NICE appraisal8 and should

 

be quality assured be audited.

 

have a structured written curriculum have trained educators

There is little evidence that people with diabetes receive structured foot care education consistent with these criteria. The review by Bazian reveals a lack of robust studies on the efcacy of footspecic education to prevent ulcers in people with diabetes. The review concludes that no educational strategy should be delivered in isolation, but it should be a component of multidisciplinary care. Rayman and colleagues have reported a marked reduction in amputation rates as a result of integrated multidisciplinary patient care.8 We cannot assume that this reduction is as a result of education. Education is only one aspect of the multifaceted management of such patients and it remains extremely difcult to isolate its effects from those of other related confounding variables.9 What is structured education? How many people auditing diabetes care have ticked the box for structured education simply because they have covered a list of predetermined topics? Is this really what we mean by structured education? Surely the concept of structured education involves enhancing or supporting self-efcacy10 and includes not only providing information to patients but also providing a framework for fundamentally unlocking their potential to improve their health behaviour. Disappointingly, only one of the studies in the Bazian review measured self-efcacy as an important component of behavioural change.

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360 Education cannot be considered and measured independently from overall clinical management. Health policy now requires the provision of structured education for all people with diabetes, so it may never now be possible to carry out controlled studies. While there can be no doubt about the value of a structured approach, structure is only one of the ingredients for an effective education programme. There must be continuous reinforcement of the educational, empowering message in each consultation, including the foot clinic. All healthcare professionals are involved in delivering education, so all need to learn to be effective educators. We are not all natural communicators, but patient-centred skills can be taught and this needs to be part of our routine training. The lack of such training has been described as the most critical issue impeding the delivery of highquality diabetes education and care.11 Education is a tool with which to empower people with the condence to manage their own diabetes. Ultimately, as Alberti says in the international curriculum for diabetes health professional education, We need to recognise that to deliver high-quality diabetes care, integration of both skills in education delivery as well as clinical management are needed and it is not one or the other.12 Perhaps the quest to determine the isolated impact of education in preventing foot ulcers is destined to remain the elusive Pimpernel. L. Stuart, P. Wiles
editor. Diabetes in America. 2nd edn. Bethesda: National Institutes of Health; 1995. p. 40927. Department of Health. National Service Framework for Diabetes. London: Department of Health; 2003. Scottish Intercollegiate Guidelines Network. Management of Diabetes. Edinburgh: SIGN, 2001. Available from: www.sign. ac.uk/guidelines/fulltext/55/index.html National Institute for Clinical Excellence (2002). Management of Type 2 Diabetes (clinical guideline). London: NICE, 2002. Available from: www.nice.org.uk DAFNE Study group. Training in exible, intensive insulin management to enable dietary freedom in people with Type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. Br Med J 2002;325: 7469. Davies MJ, Heller S, Khunti K, Skinner TC. The DESMOND (diabetes education and self management for ongoing and newly diagnosed) programme: from pilot phase to randomised controlled trial in a study of structured group education for people newly diagnosed with type 2 diabetes mellitus. Diabetic Med 2005;22:110. Department of Health. Structured Patient Education in Diabetes. Report from the Patient Education Working Group. London: Department of Health; 2005. National Institute for Clinical Excellence. Patient education models (technology appraisal). London: NICE, 2003. Available from: www.nice.org.uk/page.aspx?o=68326 Rayman G, Krishnan ST, Baker NR, Wareham AM, Rayman A. Are we underestimating diabetes-related lower-extremity amputation rates? Results and benets of the rst prospective study. Diabetes Care 2004;27:18926. Norris SL, Engelgau MM, Narayan KM. Effectiveness of selfmanagement training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24:56187. Bandura A. Social cognitive theory: an agentic perspective. In: Annual Review of Psychology. Palo Alto: Annual Reviews, pp. 126. International Diabetes Federation. International Curriculum for Diabetes Health Professional Education. 2002. Bazian Ltd. Education to prevent foot ulcers in diabetes. London: UK, in press, doi:10.1016/j.ebhc.2005.07.002.

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References
1. Reiber GE, Boyco E, Smith DG. Lower extremity ulcers and amputations in individuals with diabetes. In: Harris MI,

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