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October 2004, Vol 94, No. 10 | American Journal of Public Health 1664-1666
© 2004 American Public Health Association

FIELD ACTION REPORT

Aiming at "De Feet" and Diabetes: A Rural Model to Increase Annual Foot Examinations

Susie E. Beem, BS, Margaret Machala, RN, MPH, Craig Holman, DPM, Randal Wraalstad, DPM and Ann Bybee, RN, CDE

At the time this article was completed, Susie E. Beem and Margaret Machala were with South Central District Health, Craig Holman was with Magic Valley Foot Clinic, and Randal Wraalstad was with South Idaho Foot and Ankle Clinic, Twin Falls, Idaho. Ann Bybee was with St. Benedict’s Family Medical Center, Jerome, Idaho.

Correspondence: Requests for reprints should be sent to Susie E. Beem, South Central District Health, 1020 Washington St N, Twin Falls, ID 83301 (e-mail: sbeem{at}phd5.state.id.us).


   ABSTRACT
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Something is afoot in south central Idaho. After 2 years of work, the percentage of people with diabetes receiving recommended annual foot examinations has increased by 13.8%, exceeding the state average. This turnaround, from being the region with the lowest percentage of foot examinations in the state, was made possible when South Central District Health joined diabetes coalition members to develop a comprehensive program that maximizes limited resources in the rural, 8-county service area.

Key program components include (1) development of a curriculum on CD-ROM called 2 Minute Diabetes Foot Examination, (2) training area physicians and nurses in the curriculum, (3) incorporating the curriculum into the nursing program at the local college, (4) offering free foot-screening clinics to targeted populations, and (5) conducting public education and outreach.


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Studies show that diabetes is the most frequent cause of all nontraumatic lower limb amputations in the United States, accounting for 82 000 amputations per year.1 Because people with diabetes are vulnerable to nerve and vascular damage, poor circulation, and poor healing of foot ulcers, the American Diabetes Association recommends that all individuals with diabetes receive a thorough foot examination, at least annually, to identify high-risk foot conditions and prevent amputations.

Unfortunately, aggregated data from the 1997–1999 Idaho Behavioral Risk Factor Surveillance System (BRFSS) showed that only 52.7% of people with diabetes in south central Idaho had received a foot examination in the previous year. This was the lowest percentage in the state.2

Resources are limited in south central Idaho. The region comprises 6 rural and 2 frontier counties (those with fewer than 6 people per square mile) with 162 284 residents, according to the 2000 census. There is no mass transit system, and over 91% of the 11 500-square-mile region is designated a health professional shortage area in primary care.3

These were the problems that the Magic Valley Diabetes Coalition chose to address. This local coalition, which is facilitated by South Central District Health, originally comprised dietitians, nurses, certified diabetes educators, physicians, and people with diabetes. Podiatrists joined once the coalition decided to focus on foot examinations. One podiatrist expressed great concern with the growing number of diabetic amputations nationwide and thought that local physicians were not conducting preventive foot examinations owing to lack of knowledge, training, and existing tools.

This podiatrist realized that the common thread in foot care for people with diabetes is self-examination by the patient and foot examination during physician visits. After reading 2 Diabetes Care articles4,5 on the subject, he developed a training curriculum on CD-ROM titled 2 Minute Diabetes Foot Examination and partnered with another local podiatrist while District Health staff developed accompanying forms and evaluation tools. The CD-ROM training would increase awareness of the importance of foot examinations and teach providers how to quickly assess their diabetic patients’ feet. In addition, a CD-ROM is an excellent, easy-to-use resource for providers and their staff, especially for those in rural areas where it is not always easy to attend various trainings.

Two podiatrists, assisted by other coalition members, piloted the curriculum on the road and later trained health care professionals in their offices and at nursing homes, hospitals, and professional organization meetings. Copies of the CD-ROM were provided along with patient education posters for examination rooms that read, "If you have diabetes, please take off your shoes and socks." The BRFSS data helped explain the need for regular foot examinations for people with diabetes. Since resources for providers are limited, the CD-ROM, posters, and supporting materials for patients were provided free of charge to all training participants.

Coalition members also approached the College of Southern Idaho for help. The Nursing Department agreed to have the foot examination training offered to their registered nurse students and to incorporate an annual training into their curriculum (Figure 1Go). Besides training the students, coalition members also trained nursing faculty and the student nursing association. The faculty and student nursing association agreed to offer at least 2 free foot-screening clinics in the community annually.



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  		FIGURE 1—— Dr Holman demonstrates the 2 Minute Diabetes Foot Examination to nursing students at the College of Southern Idaho.

 
Finally, coalition members conducted free foot-screening clinics for targeted populations in 9 communities. These screenings reached 6 of the 8 counties in the region, including 1 of the frontier counties. The free screenings have been held at physician offices, senior centers, American Legion halls, churches, and South Central District Health offices. Community outreach and education about these clinics, including the importance of annual foot examinations, were accomplished through public service announcements on television and radio and in local newspapers. Coalition members also distributed educational materials (such as Foot Notes, supplied by the state diabetes program) widely throughout the community (Figure 2Go).



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  		FIGURE 2—— The state diabetes program supplies Foot Notes to provide to people with diabetes.

 

   DISCUSSION
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Since the program began in 2001, a total of 180 health care providers and 198 nursing students have been trained in the 2 Minute Diabetes Foot Examination. In addition, 214 people with diabetes have received a free foot examination at community clinics. Patient surveys reveal high satisfaction with the screenings, and most say they learned of the clinics through the newspaper. These surveys also revealed that some patients at these community clinics had attended a free clinic before, but most were new to the clinics and were either newly diagnosed with diabetes, had never had a foot examination, or had not had a foot examination in several years.

A major home health agency in the area now has its nurses perform a foot examination with every visit to patients with diabetes. Three long-term care units conduct frequent foot examinations for their residents with diabetes. Nurses at an outlying hospital sponsor a yearly free foot clinic and conduct foot examinations on a regular basis in the offices where they are employed. At 8 of the 9 trained physician practices, it was reported that staff were conducting regular foot examinations for all patients with diabetes. The student nursing association is providing 2 free foot clinics a year for the community at the junior college.

Most important, BRFSS data show that the percentage of people with diabetes in south central Idaho who report having a yearly foot examination increased, from 52.7% for the 3-year period 1997–1999 to 66.5% for 2000–2002. During the same period, the state average decreased from 66.6% to 59.8%.6

The program’s success can be attributed to the enthusiasm and dedication of Magic Valley Diabetes Coalition members. South Central District Health provides a part-time program coordinator to support the coalition and its activities through financial aid from the Idaho Diabetes Prevention and Control Program and the Centers for Disease Control and Prevention (CDC). The CDC grant also provides limited funds for public education materials, but the coalition has relied primarily on free materials from the National Diabetes Education Program, American Diabetes Association, and Lower Extremity Amputation Prevention Program. Increased funding could improve the program’s effectiveness by covering costs for additional education materials, CD-ROM replication, enhancement of program marketing, reimbursement for coalition member travel, and more staff time.


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Aiming at "de feet" of diabetes in high-risk groups, coalition members have begun training senior volunteers so they can provide foot examinations for homebound seniors. Training is also planned for volunteers in the Hispanic community to increase screenings for that high-risk population.

The program’s dissemination has been addressed through presentations at a statewide Diabetes Alliance of Idaho meeting and by working with the State Diabetes Program to distribute the 2 Minute Diabetes Foot Examination CD-ROM to interested health care providers throughout Idaho. The program was also accepted for oral presentation at the CDC Division of Diabetes Translation’s National Conference in April 2003.


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KEY FINDINGS

  • A short,concise curriculum on a CD-ROM can be cost-effective for training health care providers, especially in rural areas.
  • Offering training where health providers work is more effective than asking them to come to the trainer.
  • Incorporating foot examinations into the nursing school curriculum is one way to help sustain this service in the community.
  • A comprehensive community approach, addressing both provider and patient issues, helped increase the number of annual foot examinations for people with diabetes in south central Idaho.

 


   Acknowledgments
 
South Central District Health provides a part-time facilitator to support the coalition and its activities through a grant from the Idaho Diabetes Prevention and through Control Program Cooperative Agreement U32/CCU010 610–09 from the Centers for Disease Control and Prevention.


   Footnotes
 
Contributors
S. E. Beem, the diabetes project coordinator, and M. Machala, the project director, wrote the article. C. Holman created the CD-ROM, and together with R. Wraalstad and A. Bybee provided technical guidance and editing.

Peer Reviewed

Accepted for publication May 8, 2004.


   References
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 ABSTRACT
 INTRODUCTION
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1. ADA—basic diabetes information. Available at: http://www.diabetes.org. Accessed August 7, 2004.

2. Idaho Behavioral Risk Factor Surveillance System. Boise: Idaho Dept of Health and Welfare, Division of Health, Bureau of Health Policy and Vital Statistics; 1997–1999.

3. State Office of Rural Health and Primary Care, Idaho Dept of Health and Welfare. Availabe at: http://belize.hrsa.gov/newhpsa/newhpsa.cfm. Accessed September 10, 2004.

4. Laakso M, Lehto S, Pyorala K, et al. Risk factors predicting lower extremity amputations in patients with NIDDM. Diabetes Care. 1996;19:607–612.[Abstract]

5. Pecoraro R, Reiber G, Burgess E. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;13:513–521.[Abstract]

6. Idaho Behavioral Risk Factor Surveillance System. Boise: Idaho Dept of Health and Welfare, Division of Health, Bureau of Health Policy and Vital Statistics; 2000–2002.




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