September 2018

People with Diabetes Foot Complications Do Not Recall Their Education: A Cohort Study #483437456

This excerpt details findings from a study that sought to document recall of key educational messages immediately after a podiatry consult and 1 month later.

By Julia Yuncken, Cyclie M. Williams, Rene Stolwyk, Terry P. Haines

Podiatrists play a large role in education for the prevention of foot complications in people with diabetes. Subsequently, podiatrists also regularly teach self-management strategies for people with or without foot complications relating to their diabetes. Current diabetes guidelines recommend education provision; however, there are no clear guidelines on what information should be covered in a consultation and what is the most effective education medium (ie, written, verbal, technology aided).

This cohort study aimed to document how and what diabetes specific foot health information was provided during podiatry consultations and what information was retained 1-month post consultation.

Outcome measures

The primary outcome measure was patient participant-podiatrist concordance in response to the question “What was the key message from the consultation?” This question was verbally asked by researcher JY, of both participant pairs following the consultation, and of the patient participant 1 month following the consultation. The study’s principal researcher (Rater 1) and a podiatrist who was not one of the study investigators (Rater 2) separately examined both the patient participant response and corresponding podiatrist response and classified this dyad as being in “full agreement,” “partial agreement,” or “no agreement.”

Patient participants were phoned at 1 month following the consultation to collect the secondary outcome measure. These included qualitative responses about general diabetes knowledge such as “Can you tell me in your own words how diabetes can affect your feet?”, “Thinking about your consultation and your foot health, what did the podiatrist tell you about diabetes and problems with blood flow?” and “Thinking about your consultation and your foot health, what did the podiatrist tell you about diabetes problems with feeling in the feet?”

Demographic measures

The Montreal Cognitive Assessment (MOCA) was used as a measure of baseline cognitive function…. Participants were included if they had a score greater than 26 as under this score was indicative of cognitive decline.

The Problem Areas in Diabetes (PAID) scale measures a person’s diabetes related emotional distress. It correlates with concepts such as social support, coping style, depression, future blood glucose control and health beliefs. The PAID scale contains 20 questions relating to negative emotions in regards to the personal impact of diabetes. Once completed, a score is calculated between 0 and 100; a score of 40 or higher may indicate emotional burnout whilst an extremely low score (≥10) in conjunction with poor blood glucose control may indicate denial regarding their diabetes….


Eligible participants were approached in a sequential order according to their presentation and screened against the study inclusion criteria. Following inclusion, the PAID questionnaire was completed and the podiatry appointment commenced. There was no effort to standardize the podiatry appointment. During the appointment, the researcher silently observed and recorded what information relating to diabetes was provided and how it was delivered, oral or written or both. This was recorded via a tick the box data collection sheet. Data collection sheet included content and how it was delivered. This data collection sheet was standardized to each observation. At the conclusion of the appointment, podiatrists and the participating patient were separately asked the question “What was the key message from the consultation?” This information was also collated on the data collection sheet.

One month following the appointment, each participant was contacted via the telephone. Participants were again asked the same question “What was the key message from the consultation?”

Paired participant responses to the question about the key message (both at baseline following the appointment and 1 month later) were written verbatim by the principle researcher while in person with the podiatrist and patient participant or on the phone with the patient participant…and comparisons were made….


Three podiatrists and 24 patient participants were recruited for the study. Patient demographics are shown in Table 1.

Diabetes related foot health education was provided verbally in all cases. Two patients received hand written personalized information at the end of their consultation. Each consultation room had a brochure stand with current, plain English diabetes and foot health related tri-fold handouts, however none of these handouts were used for any of the observed consultations. The verbatim paired key educational messages were compared from the initial appointment and at 1-month post appointment (Table 2).

The themes most commonly highlighted as a key message by the podiatrist were foot inspections and who to contact if the patient participant had any foot related concerns or issues. The patients identified regular foot inspections and footwear as the primary categories of education. Comparison of podiatrist and patient participant responses were poor in both the initial response at the time of the appointment and at the 1 month follow up with only 25% of responses in full agreement at both time points. The highest level of agreement was found between the patient at the time of the appointment and the patient response at the 1 month follow up, 41%. No agreement was found between the podiatrist and the patient 58% of the time, at the time of the appointment and 45% of the time at the 1 month follow up.

The secondary outcomes highlighted four major themes in the responses, including:

  • Threat appraisal prompting action: Responses suggested that the patients had an awareness of the problems that they faced and were able to draw a connection to actions that might mitigate this risk.
  • Lack of recollection: Responses indicate that participants either did not absorb any information relating to podiatrist driven education during the consultation, a lack of education provided by the podiatrist, or that the participant did not realize that they were receiving education messages and only absorbed information at a subconscious level.
  • Difficulty understanding physiological concepts: Responses indicate that some information may have been absorbed during the consultation, but with insufficient clarity for the participant to understand the full picture.
  • Repetition causing inattention: Response indicates that there is potential danger in providing an educational message that the participant has previously been exposed to without checking whether they had already heard and understood this message.


Education is a vital component of the treatment regime for people with diabetes. Good understanding of diabetes related complications ensures a greater understanding of the disease process, and how to prevent costly, both emotionally and financially, complications of the disease. This study highlights that approximately 50% of patient participants did not hold the same key message following a consultation as their podiatrist.

This article has been excerpted from “People with diabetes foot complications do not recall their education: a cohort study,” by the same authors, which appeared in Journal of Foot and Ankle Research. 2018;11:12. References have been removed for brevity. Use is per the Creative Commons Distribution 4.0 International License. To read the full article, go to

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