February 2010

Marketing risk: Beyond diabetic foot education

Tactics borrowed from the advertising world could be just what is needed to effectively communicate the risks of foot ulcers and amputation to patients with diabetes and improve outcomes as a result.

By Jeffrey M. Robbins, DPM, Gerald Strauss, PhD, and Jennifer Regler, DPM

With all that is written about the prevention of diabetic foot ulcers and amputation, why have we had only limited success in their prevention?  It has been estimated that there is a 10-20 fold increase in rates of amputations1 for patients with diabetes and there are more than 70,000 amputations performed each year, of which 85% are preceded by a foot ulcer.2

We understand that prevention needs to be a combination of systemic disease control and self foot-care, which includes proper foot hygiene, foot inspection and proper foot gear. As health care professionals, we are at a loss for effective methods to influence behaviors in our patients, especially because behaviors are difficult to address in the short period of time we have with them. Apparently intelligence has little to do with an inability to care for one’s self, as many high functioning adults may have rather questionable personal habits. We all know highly successful and seemingly disciplined people who excessively eat, smoke, drink, and take unnecessary risks.

In this paper we will examine some of the methods used to influence behaviors, their relative effectiveness, and explore the concept of the marketing of risk as a potential strategy to consider in the quest to motivate patients to adopt and maintain healthy behaviors.

How effective is patient education?

Several studies have looked at the effectiveness of educational methods to produce voluntary changes in patient’s behaviors. Sun et al in a study from 2009 sought to assess the effectiveness of group education as a means of improving preventive foot care in the Taiwanese universal health care system.3

The study looked at 302 type II diabetics from the VA healthcare system in Taiwan divided into two groups; 155 received group lectures in addition to routine healthcare, and 147 received only routine care.  The participants were studied over a time period of two years, and the time dedicated to foot care totaled about four hours for those receiving group diabetic foot care lectures. A retrospective review of medical records and a structured interview were conducted to determine the foot care quality among the two groups. The assessment was based on foot care behaviors performed by the patients (e.g., foot inspection, examining between digits, wearing socks and shoes, avoiding walking barefoot), preventative foot care practices related to physician practices (e.g., Hemoglobin A1c testing, foot exams and specialist referrals) as well as patient self-perceived at-risk foot conditions (e.g., peripheral neuropathy, peripheral vascular disease and ulcers).

The study found that more than half of the patients in both groups denied performing proper self-care behaviors, suggesting that group education did not have a positive effect. In addition there was no significant difference between the two groups with regard to documented foot exams, percentage of foot symptoms documented in medical records, or the number of foot-care related referrals.  However, there was a significant difference in terms of the number of individuals perceiving themselves as having high risk foot conditions (56% in the group study group vs just 30% in the healthcare only group).

The study concluded that under the universal healthcare system a significant number of diabetics are not offered prophylactic foot care. In addition, a large percentage of high risk individuals were not aware of the potential outcomes related to their high risk foot conditions. The authors recommended that caregivers be made responsible for properly and individually educating their patients on diabetic foot awareness and proper self-care techniques, and that this should come from both primary care doctors and specialists in order to create a multidisciplinary approach toward diabetic foot care.3

Clearly primary care providers are not able to provide all of the self-care education that is required by patients with multiple medical conditions. They are forced to prioritize education, first addressing the most pressing issues confronting the patient while planning to address other educational needs in time.   That may require a referral to a specialist, in this case a foot care specialist, for amputation-specific preventive self-care education.

The American Diabetes Association’s Clinical Practice recommendations for National Standards for Diabetes Self-Management Educations (DSME) identify 5 overriding principles based on existing evidence:6

  1. Diabetes education is effective for improving clinical outcomes and quality of life, at least in the short term
  2. DSME has evolved from primarily didactic presentations to more theoretically based empowerment models
  3. There is no one “best” education program or approach; however, programs incorporating behavioral and psychosocial strategies demonstrate improved outcomes. Additionally, studies show that culturally and age-appropriate programs improve outcomes and that group education is effective
  4. Ongoing support is critical to sustain progress made by participants during the DSME program.
  5. Behavioral goal-setting is an effective strategy to support self-management behaviors.

Schmidt et al4 identified the importance of performing foot screenings in order to determine amputation risk levels for patients with diabetic foot disease, and suggest that it may be more important to have these individuals actively participate in preventive self foot care practices. Their study was designed to evaluate which self-care practices are currently performed by diabetic patients, as well as to see the differences between different groups based on level of diabetes education and level of risk for potential foot disease.

The study included 269 type I and type II diabetics who were divided into groups based on self-reported level of diabetes education and level of risk. The study found that individuals participating in more than three educational programs were significantly more likely to perform proper self-care activities (e.g., proper inspection of feet, wearing socks/shoes) than those involved in one or fewer educational programs. It was also determined that although patients who are at higher risk for diabetic foot disease are also more likely to seek professional foot care, they are not more likely to perform self-care activities. Therefore, it was concluded that there is significant need to improve self-care among the diabetic population regardless of risk level, and that several educational programs are needed to provide patients with proper instruction on adequate self-care to prevent complications of diabetic foot disease.4

Iversen et al5 examined the regularity of preventative foot care in diabetic patients. Data from the Nord-Trendelag Health Study were used to determine contributing factors related to demographics, lifestyle and disease. The study was based on a survey of 1,312 individuals with diabetes who did not have a history of foot ulceration.

Of the patients included in the study, 85% reported having regular clinical diabetic examinations (primary care), 31.7% reported having regular foot inspections performed by a healthcare professional, and 66.3% admitted to regular self-inspections. This study also found that those less likely to participate in regular prevention included: males, non-insulin dependent diabetics, those that had diabetes for a shorter duration of time, and individuals with microvascular complications.5

It is important not only to continually repeat instructions on self care behaviors but also to ensure that the same message is being delivered throughout the health care system. Patients will tend to follow the path of least resistance; in this case, the advice of the practitioner that is least inconvenient for the patient’s way of life is the advice that is most likely to be followed.

Searle et al7 examined the psychological and behavioral factors that influence on the presence and progression of chronic wounds. This study had two arms; one with diabetic patients without any history of foot ulcerations and one with diabetic patients with current foot ulcerations being actively treated by a podiatrist. The study found that patients with ulcerations have a difficult time understanding the reason for treating and preventing ulcerations and as such have a difficult time participating in self-care of their feet. The study also found that patients without a foot ulcer were unclear as to what a foot ulcer actually was and unaware of the main cause of foot ulceration. This left the practitioners frustrated and unsupported in their attempts to motivate patients.

Social marketing in behavior change

It seems that the literature on the efficacy of self care education is equivocal at best.  There seems to be no single program or theory that can claim unqualified success in convincing patients to voluntarily engage in self care behaviors.  In the case of diabetes we continue to see too many pedal complications including ulcer, infection and amputation and too many cardiovascular complications that lead to astounding mortality rates.

Social marketing and motivational interviewing are two methods that have been proposed for changing health-related behaviors in cases where education has proved insufficient.

In 1999, Rothschild8 was one of the first to proffer the notion of social marketing to affect change in human health behaviors. Rothschild lamented that social marketing had been co-opted by education and that not enough marketing strategies were utilized. In his 1999 article, he suggested that individuals who are not motivated or able to change on their own could be convinced to do so through a “marketing” approach based on incentives (for desired behavior) and consequences (for unwanted behavior).

One example of Rothschild’s model’s use in public policy and health behavior change involved smoking. Rothschild cited that smoking levels in the U.S decreased from 40% to 20% of the population between 1974 and 1999. He surmised that smoking cessation education efforts were mostly responsible for the decrease in individuals who had motivation and opportunity to quit and were prone to change, and also in those individuals who had motivation and opportunity to quit but were struggling with the ability to quit smoking. To advance the smoking cessation effort further, in those more recalcitrant to change, required other marketing and legal efforts. For example, forbidding smoking in public buildings and commercial establishments as well as congressionally mandated increases in tobacco taxation seem to reduce smoking rates further.

Andreasen9 examined Rothschild’s conceptualization further and investigated the barriers that have kept social marketing strategies from being utilized more fully.  Although the growth of social marketing has not been expansive, Andreasen cited its use by the Center of Disease Control and UNAIDS as a tool in fighting AIDS.

Andreasen defined four barriers to growth of social marketing:

  1. Lack of appreciation of social marketing at top management levels.
  2. Poor “brand positioning” and the perception that social marketing is manipulative and “not community based”.
  3. Inadequate documentation and publicity of successes.
  4. Lack of academic stature.

Andreasen’s article suggests that social marketing borrows from a number

of psychological behavior change theories10-13 and, potentially, vice versa. In fact, Andreasen uses the Stage of Change Theory10 to describe how best to market social marketing to those in a position to  pose barriers to its utilization (e.g., management). Andreasen proposes that marketing efforts should be tailored to the stage of change that is applicable to the targeted individual: precontemplation, contemplation, preparation, action, or maintenance. Andreasen also describes four factors that he views as ultimate driving forces of behavior:  benefits, costs, others, and self-efficacy (BCOS factors).

Andreasen proposed9 that a social marketing intervention be based on six benchmarks:

  1. Behavior change is the benchmark used to design and evaluate interventions.
  2. Projects consistently use audience research to (a) understand target audiences (formative research), (b) routinely pretest intervention elements before they are implemented, and (c) monitor interventions as they are rolled out.
  3. Careful segmentation of target audiences to ensure maximum efficiency and effectiveness in the use of scarce resources.
  4. The central element of any influence strategy is creating attractive and motivational exchanges with target audiences.
  5. The strategy attempts to use all four Ps of the traditional marketing mix (not just advertising or communications).  That is, it creates attractive benefit packages (products) while minimizing costs (price) whenever possible, making the exchange convenient and easy (place) and communicating powerful messages though media relevant to—and preferred by–target audiences (promotion).
  6. Careful attention is paid to the competition faced by the desired behavior.

It seems that many of these six elements can have clinical applications, although they are more likely to be adhered to in the context of a research protocol than in clinical practice. It may be that this lack of rigor in clinical practice (for obvious reasons, the foremost being time limitations) moderates the effectiveness of interventions.

However, research suggests that a technique called “motivational interviewing” can be successful in a clinical setting. Motivational interviewing, proposed by Miller and Rollnick in 1991,14 is designed to change an individual’s behavior by helping that individual to explore and resolve his or her ambivalence.

A recent meta-analysis15 examined 72 randomized controlled trials of motivational interviewing techniques in conjunction with treatment of a range of behavioral problems and diseases. The authors found that motivational interviewing was significantly more effective than traditional advice in three-quarters of the studies analyzed, with similar effectiveness in management of physiological (72%) and psychological (75%) conditions. The technique was associated with statistically significant improvements in weight reduction, total blood cholesterol, systolic blood pressure, blood alcohol content and standard ethanol content. There was no statistically significant effect on HbA1c levels or number of cigarettes smoked per day; however, those studies had fewer subjects and likely were limited in terms of statistical power. Just one encounter of 15 minutes was enough to produce an effect in 64% of the studies analyzed, and the effect size increased with the number of encounters.

Even more recently, another randomized controlled trial of 217 overweight women with type 2 diabetes found that motivational interviewing was associated with significantly greater weight loss and HbA1c reductions than a control condition involving health education sessions.16

Social marketing techniques may help with the clinical application of behavior change interventions, particularly when the target audience involves larger communities or populations. Motivational interviewing techniques seem to be the best clinical tool we have at our disposal at this time and are better suited to individual and group targets. It may be that combining the forces of social marketing and MI will have the most positive effect on clinical outcomes.

Making the case for marketing risk

Another approach may be to borrow from the advertising industry and begin to market risk as a strategy to motivate behavioral change. Marketing strategies can potentially motivate patients into pursuing education and information rather than having it thrust upon them, making the approach significantly more active than passive.

There are many examples of informational sound bites that have marketed risk to various cohorts. Some of these include “The Silent Killer” for hypertension, “Death by Tobacco” for tobacco use, “Stay in Circulation” for peripheral vascular disease, and “AIDS is a mass murderer” for AIDS and HIV. What these sound bites or slogans do is to communicate the serious risks in a short period of time and without a significant amount of information. It is akin to a 15 second television commercial that seeks to convince you to make a purchase you were not considering.

We believe a similar approach would be effective for patients who have diabetes and present with a foot ulcer. In order to communicate the risk associated with this foot ulcer to mortality, we may want to use the term “malignant diabetes”.  The use of the term ‘malignant’ to describe a condition that can quickly cascade into life threatening symptoms is not without precedent. Conditions other than cancer that have been described as malignant include malignant hypertension, a complication of hypertension characterized by a rapid life-threatening elevation of  blood pressure resulting in damage to the eyes, brain, lung and/or kidneys; and malignant otitis externa, an aggressive bacterial infection affecting the temporal bone and skull base.

Diabetes is rarely described as a fatal disease, nor does it have the same implication as a cancer diagnosis. However, when we look at the five-year mortality rates, we find that they are significantly higher for diabetic ulceration (46%)  than for Hodgkin’s disease (18%) or breast cancer (18%).

It is time for the multidisciplinary team that provides care for patients with diabetes and foot ulcers to properly communicate that mortality risk to patients, to provide more urgent motivation for compliance with self-care practices.

Jeffrey M. Robbins, DPM, is director of podiatry services at the VA Central Office and chief of the podiatry section at the Louis Stokes Cleveland Veterans Affairs Medical Center in Cleveland, OH. Gerald Strauss, PhD, is section chief of clinical health psychology and Jennifer Regler, DPM, is a podiatry resident at the Louis Stokes Cleveland VAMC.

  1. Boulton AJM, Cavanagh PR, Rayman G, eds. The foot in diabetes. 4th ed. West Sussex, England: John Wiley & Sons Ltd; 2006.
  2. Bild DE, Selby JV, Sinnock P, et al. Lower-extremity amputation in people with diabetes. Epidemiology and prevention. Diabetes Care 1989;12(1):24-31.
  3. Sun PC, Jao SH, Lin HD. Improving preventive foot care for diabetic patients participating in group education. J Am Podiatr Med Assoc 2009;99(4):295-300.
  4. Schmidt S, Mayer H, Panfil EM. Diabetes foot self-care practices in the German population. J Clin Nurs 2008;17(21):2920-2926.
  5. Iversen MM, Ostbye T, Clipp E, et al. Regularity of preventive foot care in persons with diabetes: results from the Nord-Trondelag Health Study. Res Nurs Health 2008;31(3):226-237.
  6. Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care 2010:33 (Supp 1): 89-96.
  7. Searle A, Gale, L, Campbell R, et al. Reducing the burden of chronic wounds: prevention and management of the diabetic foot in the context of clinical guidelines. J Health Serv Res Policy 2008;13(Suppl 3):82-91.
  8. Rothschild ML. Carrots, sticks, and promises: A conceptual framework for the management of public health and social issue behaviors. J Market 1999;63(4):24-37.
  9. Andreasen AR. Marketing social marketing in the social change marketplace. J Publ Pol Market 2002;21(1):3–13.
  10. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrated model of change. J Consult Clin Psychol 1983;51(3):390-395.
  11. Rosenstock IM The health belief model:  Explaining health behavior through expectancies. In: Glanz K, Lewis FM, Rimer BK, eds. Health behavior and health education. San Francisco: Jossey-Bass;1990:39-62.
  12. Bandura A. Self efficacy:  The exercise of control. New York:  Freeman; 1999.
  13. Bickel WK, Vuchinich RE, eds. Reframing health behavior change with behavioral economics. Mahwah, NJ: Lawrence Erlbaum; 2002
  14. Miller WR, Rollnick S, eds.  Motivational Interviewing: Preparing people to change addictive behavior.  New York: Guilford Press; 1991.
  15. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systemic review and meta-analysis. Br J Gen Pract 2005;55(513):305-312.
  16. West DS, DiLillo V, Bursac Z, et al. Motivational interviewing improves weight loss in women with Type 2 diabetes. Diabetes Care 2007;30(5):1081-1087.

10 Responses to Marketing risk: Beyond diabetic foot education

  1. Joseph M. Mozena, DPM, C.Ped. says:

    Thank you, Dr. Robbins et al. You made my list of sound bites with “malignant diabetes”. This sound bite will increase the importance of the diabetic foot to motivate the patient. Do you have a sound bite for increasing the patient’s confidence that he can win his battle with his diabetic foot?

  2. David A. Alexander, C.Ped. says:

    I applaud your research and consequential findings and do agree with a more direct and ” pull no punches ” aspect of patient education. Do you know of any constraints on graphic illustrations or information being presented to patients or their caregivers to enhance patient compliance?

  3. Jeffrey M. Robbins, DPM says:

    The motivational sound bite to encourage confidence in thier own abilities can be as simple as “you can do this” or “this is a battle you can win”. I also use a metophor to explain the effort that must be used in this battle. I compare it to driving your car on the highway at 65 miles an hour. It’s easy, just about everyone can do it! That said, there are details you must pay attention to. If your attention wanes for a moment you may hit the rough pavement on the side of the road. If you heed that warning and get back on the road you will be fine, but if you ignore it you will crsah and burn. You can pay attention 99% of the time but if could be that 1% that causes the crash or the foot injury or hyperglycemia. The point is that driving is easy and there are rules to follow which will keep you safe. In this case diet and exercise are inexpensieve but do require discipline. If you need help with that discipline it is availble and should be encouraged. Medictions are even easier to follow.

  4. Joseph M. Mozena, DPM, C.Ped. says:

    Thank you, Sir. Sometimes I say “Chin up, Battle on”. I learned these motivational words from my brother John D. Mozena, DPM. Because this sounds British to me I sometimes add “stiff upper lip”.

  5. Joseph M. Mozena, DPM, C.Ped. says:

    Upon reflection, the use of “sound bites” have been used since the beginning of Medicine example Primum Non Nocere—Above All, Do No Harm. Some of the “sound bites” I use to help my diabetic patients include:
    1. “Therapeutic Shoes are Insulin for the Feet”
    2. From the “Holiday Ulcer”, I started using the “Just this Once Ulcer”, example I wore my tuxedo shoes for my daughter’s wedding just this once. The “New Shoes Ulcer” example I wore my new shoes all day because they felt so good. The “I Did Not Ulcer” example I did not keep my doctor’s appointments as scheduled.
    3. During patient’s self foot inspection I ask them to “Look, feel, think, act”.
    4. ” Never underestimate shoes in foot care”
    5. ” We are friends in the fight for feet”
    Some of my favorite “sound bites” come from Mark Hinkes DPM especially his ones on cigarettes and on bathroom surgery.

  6. Joseph M. Mozena, DPM, C.Ped. says:

    Dr. Robbins, it is hard to express the deep respect I have for you and your work which has benefited my patients. For I have truly “stood on the shoulders of giants” like yourself and Armstrong, Brand, Cavanagh, etc.

  7. Jeffrey M. Robbins, DPM says:

    Many thanks for your kind words!

  8. I take a more straight forward approach with our patients with diabetes.
    Apart from the literature on hand about the Feet, Diabetes and different complications, we also take pictures of severe diabetic foot conditions and keep that on hand to show patients the downside of the disease.
    We also stress the importance of having the following doctors in their care team.
    We find with all three groups saying the same thing our patients tend to be more compliant.
    And we engage the spouse or caregiver.
    also they are more likely to report any changes they see.

  9. Jeffrey M. Robbins, DPM says:

    You have touch on a very important issue, the one of consistancy of message amoung all providers of care to patients with diabetes.

  10. I have put tv monitors into my waiting and treatemnt rooms. I am shocked and now amused that pts beleive or pay attention to my tv slide shows and videos more than me. Several tell me about the message as if it is new news to me. This is fabulous. I have found that I remember questions I ask at conferences more than anything I heard at a conference. I have the same messages as posters and hand outs but they do not have the impact of moving visuals. I think there is something to be said for creating teachers who can help their friends and family. I am certain that there is a bit more retention. Hopefully this creates a hippocrit sensation if they dont do what they suggest to friends and family. Behavior change is tough for all of us.

    My usual bites are the questions ” what do you value more for independence and mobility; your feet or your car. With your current behaviour which will last longer? How much did you spend on your last car repair. how much did you spend on foot wear? Your next pair of shoes/foot expense is coming out of your car budget not the clothing budget! It seems to work. Even I am shocked that they come back from the pedorthotists with 3 pairs of depth shoes and have orthotics in all of them. Many do not have insurance.

    Great paper. Love your passion to make a difference and change behaviour in all of us.

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