I en nyligen publicerad artikel beskriver bland andra Ulla Hellstrand Tang, överortopedingenjör på verksamhet Ortopedteknik och sterilteknik, och Roland Zügner, specialistfysioterapeut på verksamhet Ortopedis forskningsenhet, hur patienter egenvårdar sina fötter.
Artikeln ger mer information om vilka förväntningar som personer med diabetes har på apotekens service kring egenvård av fötterna.
Sjutton personer som lever med diabetes i Västra Götalandsregionen svarade på en enkät om sina förväntningar på stöd från apoteken avseende egen vård av fötterna och hur de kände att de hanterade egen vård av sina fötter.
Studien fann att personer som lever med diabetes skötte sin fotvård på olika sätt. Tjänsterna som erbjuds från apoteken bör förbättras för att främja god fotvård för personer som lever med diabetes och för att förebygga utvecklingen av diabetesfotsår.
Studien, som är utförd av forskare från Sahlgrenska Universitetssjukhuset, Göteborgs Universitet, Göteborgs Diabetesförening, Malmö Universitet, och Örebro Universitet, har gett en pusselbit om personers förväntningar på apotekens service. Kunskap som behövs för att komma ett steg närmare en person-centrerad service på apotekens, en viktig aktör för personer med diabetes.
Press release
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Patients’ Expectations of Evidence-Based Service at the Pharmacy Regarding Information on Self-Care of the Feet for Persons with Diabetes at Risk of Developing Foot Ulcers – A Cross-Sectional Observational Study in Sweden
Discussion
Self-Management of Risk Factors for Developing Diabetic Foot Ulcers
In the current study, 17 patients with diabetes participated in a study describing their expectations regarding support from the pharmacy to improve the self-care of their feet. The participants also reported how they managed the self-care of their feet. Surveys were filled in and the participants assessed their foot status by using the MyFoot Diabetes software. In addition, their foot status was examined by an HCP.
The participants gave several examples of how they self-managed their feet – by wearing shoes indoors and outdoors; wearing socks; moisturising their feet; walking; wearing compression stockings as often as possible; inspecting their feet; checking their feet; being physically active; being aware that their feet are OK; seeking help to prevent DFU; washing their feet; cutting their nails. One participant did not report any action and one did not know. Worries regarding foot health were reported by four of the 17 participants. Supporting findings, from Al Sayah et al, regarding how patients with diabetes manage the care of their feet, show that the self-care varies, and that on average 14% of respondents performed foot self-care behaviours 6 days/week or more.61 The authors of the present study found that some groups were less likely to perform the recommended self-care, eg, men, patients with duration less than 10 years and patients at a younger age.
Expectations of Support from the Pharmacy to Improve Self-Care of the Feet
The participants expected that they would be given competent information from the personnel at the pharmacy to improve the self-care of their feet, eg, information about which ointments/creams to use. Only one of the 17 participants had been given information by the pharmacy on how to perform self-care on his/her feet. Obviously, there is a gap between the expectations of individuals living with diabetes when it comes to whether and how the personnel at the pharmacy support the self-care of the feet. The participants wanted the staff at the pharmacy to be competent and to give relevant, customised information on care of the feet and what ointment/cream to use to moisturise the feet, Table 6. Some participants requested more information about their products.
The study reveals that individuals with diabetes have expectations of support and help from the pharmacy. The gap between the participants’ expectations and reality is also described in the report from the Swedish Medical Products Agency, which concluded that the quality and security of customers should be the focal point when giving objective, expert and individual advice on self-care to their customers.20 A long-awaited improvement in education was suggested. In the report, the reality is described; the staff at the pharmacy have different professions and educations regarding self-care. Bearing this in mind, it is not surprising that there is a lack of quality indicators in Sweden to evaluate whether the service at the pharmacies is of a good standard.36 The Swedish National Board of Health and Welfare concluded in a report that the pharmacies do not have a national assignment regarding advice on self-care and that the staff needed more skills and competence.36
Improvements in competence, regarding advice on the self-care of the feet, among the staff working at the pharmacy, are hopefully being developed in parallel with new evidence-based advice being available on the internet from FASS or 1177, for example.36,62
Risk Factors for Developing DFU and the Responsibility of the Staff at the Pharmacy
Questions arise regarding the responsibility of the staff working at the pharmacy. How should the staff at the pharmacy be able to give individual advice on self-care of the feet that correspond to the customers’ risk factors, eg, the presence of dry skin on the heel or the presence of neuropathy? This question needs to be discussed in the community of HCPs and staff at the pharmacy to clarify when the advice given at the pharmacy is about self-care and when the customer/patient should be referred to healthcare for treatment. Another question is whether it is appropriate that pharmacies develop/use self-tests of the feet, eg, MyFoot Diabetes, as a basis for giving personalised advice on self-care of the feet. Table 3 reveals that the participants had several risk factors; one of them had an ongoing foot ulcer (risk classification 4) and the other 16 patients ran a high risk of developing DFU (risk classification 3). Twelve of the 17 participants had neuropathy, according to the foot examination following the D-Foot routine. Differences according to the presence of neuropathy, self-reported and measured with the D-Foot, are presented in Table 4. The differences are not surprising, as there are many symptoms of neuropathy and several measurements are used.7 Table 4 shows that, of 17 assessments of neuropathy, two differed when comparing the presence of neuropathy examined with the D-Foot as compared with the self-test performed using MyFoot Diabetes. As mentioned above, it is important to know whether and how staff at the pharmacy should act and how the advice on self-care of the feet should be formulated if an individual says that the self-test with MyFoot Diabetes reveals that he/she has neuropathy. The role of self-care activities led by pharmacists needs to be further investigated. Previous studies have shown, in a meta-analysis, an increase in self-care activities following interventions led by pharmacists on foot care (1.20 95% CI [0.49, 1.90] = 95.0% <0.001) and the self-monitoring of glucose levels (1.62 95% CI [0.92, 2.32] = 70.5% = 0.005), according to Bukhsh et al.63 Moreover, a new method presented by Gerber et al includes pharmacists, physicians, case managers, nurses and community-based peer health promoters designed to test and evaluate team-based care to realise therapeutic goals (levels of haemoglobin A1c, LDL-cholesterol levels and blood pressure) in the treatment of diabetes.64
To summarise, the self-care of the feet varied, Table 6, but all the 13 participants, with dry skin on their feet, used emollients. Nine participants had problems reaching their toes, but they all dried their feet after washing. Eight of 17 had not accessed podiatry during the last 12 months, nor had they been prescribed footwear. However, the majority, 13 of 17, had been given information regarding the self-care of their feet from an HCP and had had their feet examined, Table 5.
Method – Discussion
The population in the current study included relatively more patients with diabetes type 2, as compared with the national percentage, 90% of a total of 500,000 persons living with diabetes.65 The reason for this was that the study population was mainly recruited from primary care, where most of the patients with type 2 receive their treatment. According to age and the percentage of women, the study population did not deviate from the larger population of individuals living with diabetes in Sweden. Of the participants aged 70 years, 14 had diabetes type 2 and seven were women.
With few exceptions, all the surveys were filled in at the time the workshop was run. Two people, who did not have time to fill in all the surveys at the workshops, were given a second opportunity to fill in the surveys, as the surveys were sent to them by post and included a stamped, addressed envelope to return their answer in. In addition, one participant gave the answers to a survey by phone to the principal investigator.
The method chosen, an observational descriptive study, is relevant when a new area of research is explored, with the rationale to better formulate further research questions.66 To improve coming measurements regarding patients’ expectations of evidence-based service at the pharmacy with information on self-care of the feet for persons with diabetes at risk of developing foot ulcers, the questionnaire,
Additional improvements, suggested for future studies, are as follows: Firstly, having several separate rooms available so that people’s integrity is secured when the participants fill in the surveys and have their feet examined. Secondly, validating the survey that asked questions about expectations of support from the pharmacy regarding the self-care of their feet, with questions such as the following: What are your expectations of support from the pharmacy? How do you feel that the pharmacy meets your expectations of support? To differentiate the answers, five options are suggested, including very high expectations, high expectations, moderate expectations and low to very low expectations. Thirdly, investigating how the staff at the pharmacy think they manage to give evidence-based, personalised advice on self-care of the feet and how individuals living with diabetes prefer to receive advice (orally, in writing or by digital links).
Conclusion
Patients with diabetes who risk developing foot ulcers expect the staff at the pharmacy to be competent and give them evidence-based, personalised advice so that they can manage the self-care of their feet.
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