An Action Research approach to facilitating the integration of best

practice in the Assessment and Management of Diabetes Related Lower

Limb Problems in India.Michael Harrison-Blount MSc. BSc (Hons). MChS. MFPM RCPS (Glasg). CSci

Lecturer in Podiatry  School of Health Sciences

University of Salfordt: +44 0161 2953516

email; m.j.harrison-blount@salford.ac.uk | www.salford.ac.uk

• India has the second highest prevalence of people with diabetes in the world (65.1 million) [1]

• Predicted to increase to 120.9 million by 2030 [1].

• Aligned with this is an ‘epidemic’ of diabetic foot complications with ulceration and infections having devastating consequences for lower limb morbidity [2].

• Trivial and avoidable foot lesions known to precede 85% of leg amputations [3]

We know what's causing the problem

• 49 -85% of amputations relating to diabetes can be prevented with suitable healthcare and informed self care.[4].

• A multidisciplinary approach with preventative strategies can reduce amputation rates by more than 50% [5].

• regular visual examination is essential to allow early identification of trivial lesions, and allows timely intervention to prevent possible foot ulceration’ [6-9].

Yet…

The solution…A simple transfer of best practice from West to East?

Why this approach may not work• No dedicated foot service or podiatry provision

• Medics in india do not look at feet.

• Medics, in isolation, did not reflect on their own practice.

• Lack of knowledge on how to bring about a change in practice.

• Cultural barriers preventing effective change.

• An approach not used in podiatry to date but evidenced in nursing and social science [10,11].

• Action research aims to – • Improve quality of care at a clinical level

• Engages participants early in the change process

• Gives structure and direction to bridge the theory–practice gap

• Implementing new knowledge.

• Facilitate change in practice [12] • It was theorised that the use of action research to implement evidence based

practice could bring about change in those countries where the assessment and management of foot health is not standardised.

A better idea ?Action research as a tool to bring about change

Action research

[11,13-16]

PROBLEM IDENTIFICATION

Reflection on current practice

Ownership of the problems

Identify solutions to action change

RESULTS

Theme 1 - Local definition and recognition of need

Theme 2 - Process of current foot assessment

Theme 3 - Barriers to current diabetic foot care

Theme 4 - Content of assessment

Theme 5 - Desired Outcomes and the opportunity to change

Data CollectionFocus groupsObservations

Individual conversationsField notes

Data AnalysisThematic framework

approach

The focus group reported the following requirements

•Allow quick identification of ‘red flag’ pathologies

•Standardise the early identification and triage of the ‘at –risk’ foot.

•Be simple to complete, uncomplicated and easily reproducible.

•Not be limited to those patients with diabetes related foot problems.

•Guide referral to appropriate professionals for early management.

•Use evidence based practice

•Collect prevalence data regarding foot pathologies specific to India.

ACTION PLANNING

Development of a foot health assessment tool

Action and implementation

•Define the contents of the assessment tool

•Literature search of assessment guidelines

•Iterative process that used five rounds of questions, data collection and analysis techniques interspersed with feedback.

•

RESULTS

•36 studies included in the final qualitative synthesis

•Cross-referenced with national and local UK guidelines.

•20 risk factors and 40 screening tests/checks for possible inclusion in Delphi

•Final tool is 13 sections of the risk factors identified during this investigation.

•Each contains subsections made up of the relevant tests, assessment methods and visual checks used to identify foot pathologies.

Data Collection and analysis

Modified Delphi technique

OBSERVATION AND REFLECTION • Piloted by all nine panel members over a four week period.

• Panel members were observed using the tool for one of the pilot weeks.

• Brought to life their own efforts in practical terms, in front of their colleagues and patients, and thus reinforced the productivity of the exercise in which they had participated.

• Asked to consider, the practicalities of the risk factors and tests/assessments for suggested inclusion.

• Asked to suggest solutions and alternatives

Overall resultThe Action Research Approach facilitated the process whereby….

• Clinicians took local ownership of a clinical problem

• A modified Delphi method was utilised to facilitate consensus on the development of an evidence based assessment tool developed from within the local healthcare system.

• Clinicians are motivated to implement a locally created and owned foot health assessment tool.

• It has shown to address directly the problem of the division between research and practice.

• This in turn has resulted in the integration of evidence-based guidelines from the West with consideration to local cultural, organizational and professional needs and ultimately the needs of their patients.

• To develop and test a frame work where action research can be used to facilitate embedding evidence based practice in other fields of Podiatry and other health discplines in the UK.

The Next step

‘Tis better to light a small candle than cry in the darkness’(Anonymous)

• Harrison-Blount M, Cullen M, Nester CJ, Williams AE. The assessment and management of diabetes related lower limb problems in India-an action research approach to integrating best practice. Journal of foot and ankle research., (2014); doi:10.1186/1757-1146-7-30.

• Harrison-Blount M, Cullen M, Nester CJ, Williams AE. An Action Research approach to facilitating the adoption of a foot health assessment tool in India. Under review.

References1. International diabetes federation Diabetes Atlas 5th ed. (2012)., Retrieved from http//www.idf.org/diabetesatlas/5e/southeast-asia

2. Pendsey S, & Abbas ZG. World Diabetes Federation report., (2008); 03-056

3. Diabetes symposium on the diabetic foot. The Diabetic Foot Journal., (2007);10(2)

4. Apelqvist J. Diabetic foot ulcers: evidence, cost and management. The diabetic foot journal., (2007); 10: 6-8.

5. Scottish Intercollegiate Guideline Network (SIGN). Management of Diabetic Foot Disease. Clinical guideline 116. (2010). Retrieved from http://www.sign.ac.uk/guidelines/fulltext/116/index.html

6. McIntosh C and Newton V (2005) in White R ed Skin care in wound management: assessment, prevention and Treatment. Wounds UK publishing Aberdeen 47-73

7. National Institute for Clinical Excellence. Clinical Guidelines and Evidence Review for Type 2 Diabetes: Prevention and Management of Foot Problems. Clinical guideline 10. (2004). Retrieved from http//www.nice.org.uk/CG10

8. National Service Framework - Diabetes (2003)

9. National Institute for Clinical Excellence. Diabetic foot problems Inpatient management of diabetic foot problems. Clinical guideline 119. (2012). Retrieved from http//www.nice.org.uk/CG119

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12. Hart E, Bond M. Action Research for Health and Social Care. A Guide to Practice. Buckingham: Open University Press, 1995.13. Hughes I. The History of Action Research. Action Research Electronic Reader, The University of Sydney. (1995). Retrieved from

http://www.behs.cchs.usyd.edu.au/arow/Reader/rmasters.htm

14. McKernan J. Curriculum Action Research: A Handbook of Methods and Resources for the Reflective Practitioner. London: Kogan Page, 1991.

15. Malterud K. Action research – a strategy for evaluation of medical interventions. BMC Fam prac . (1995);12:476-481

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