Upskilling programmes for unregulated care providers to provide diabetic foot screening for systematically marginalised populations: how, why and in what contexts do they work? A realist review

Theme 1: contexts

The role of foot screening

Understanding the role of foot screening was a prominent context for the programme development. Evidence suggests that annual foot screening is just one step in a series of preventive care services needed together to reduce the incidence and recurrence of diabetes-related foot problems as it assesses risk and guides planning for appropriate foot care.43 47 49 60 80 82 83 Accordingly, the majority of the identified articles recommended the development of the UCPs’ educational interventions to deliver foot screening within the context of preventive foot care programmes that provide foot screening, risk stratification, referral and follow-up, and education in diabetes and appropriate foot care and footwear to effectively reduce limb loss17 31 47 49 52 60 69 71 83 see (online supplemental materials).

Reasons for health disparities

The reasons behind disparities in DFUs and foot screening among systematically marginalised groups were another context for developing the upskilling programme. Articles linked these disparities to a lack of access to preventive care and lower rates of utilisation despite the high rates of DFUs and amputations.17 31 32 36 37 39–41 46 48 51 52 62 68 72 73 75 Therefore, upskilling programmes aimed to enhance preventive care utilisation by training UCPs to deliver accessible preventive care through sites close to underserved communities, for example, community centres, community clinics, faith organisations, shelters or even through home visits.17 52 UCPs were also trained to perform other roles that go beyond foot screening, and risk assessment including educators (ie, delivering patient education and improving health literacy), promotors (ie, connecting individuals with community services) and advocates (ie, advocating for the patient during patient–provider communications) (see online supplemental materials).

Educational settings

The educational setting was also an important context. Fourteen interventions were developed to train UCPs, for example, CHWs and peers (community members who have diabetes) to lead patient educational programmes.16 17 36 37 41 44 46 51 57 58 62 65 68 73 Involving peers as educators in the delivery of self-management educational programmes was recognised to enrich the delivery and depth of self-management education as they share their own experiences and commitment to change.40 44 53 58 65 68 Seven articles focused on training family partners or caregivers either alone to provide assessment and basic treatment of acute or chronic wounds,74 or with patients as part of self-management education programmes.32 39 40 54 74 79 Considering the complexity of preventive foot care, six studies described the training for UCPs as part of multidisciplinary educational interventions that included other providers such as surgeons, primary care physicians, nurses or podiatrists.38 43 47 55 76 77

Theme 2: mechanisms

Twelve articles described the mechanisms employed in training UCPs.32 35 38–40 42 47 49 50 54 60 63 The training was any or a combination of the following: education sessions on diabetes knowledge in general including attitude, and behaviour change, dietary advice, weight reduction, exercise, benefits of smoking cessation and self-monitoring of blood sugars and foot care, or foot care specifically including foot assessment, risk stratification, criteria for referral and appropriate footwear.

Programme development

The identified educational programmes usually started by conducting a consensus process to develop curriculum content using, for example, focus groups. This process provided an opportunity for community members, patients and family caregivers to engage in all aspects of developing and implementing the training programme through community-based participatory research.32 37 54 80 Such partnership enabled the programme developers to consider the context of the targeted patients and the resources of the community as the target setting for practice.73 80

Programme components

Regardless of the focus or type of participants, the identified programmes focused on developing competency-based education interventions based on principles drawn from adult learning theories.17 34 42 65 68 One educational programme focused on Kolb’s experiential learning theory,84 which includes knowledge acquisition, skill development (communication, facilitation and behaviour change), and experiential learning in simulated settings.65 Other programmes generated their curriculum based on the six principles of Knowles’s adult learning theory,85 including self-directed, experience-based, goal-oriented, practical and problem-centred, relevancy-oriented, and respect-oriented.17 42 Another educational intervention was developed based on a problem-solving pedagogical perspective, which enabled patients and their family caregivers to learn and see how care is performed on a simulated patient, and then do the care themselves either on their own feet or on others.34

Considering these adult learning theories, identified programmes were mainly structured into three components.65

Component 1: knowledge acquisition

The identified programmes mainly delivered this component through didactic lectures. These lectures focused on the definition of diabetes, and its impact on the sensory, neurological, and vascular systems, signs, and symptoms of regular wounds versus those of infection, methods for proper primary foot care and protective footwear.65 This component also included knowledge on how to control diabetes, appropriate dietary choices and physical activity, even if the training was for diabetic foot care.17

Component 2: skills development

The second component focused on foot screening, risk assessment and action plan development based on certain criteria of referral.31 41 74 UCPs used several feasible assessment tools including the Ipswich Touch Test, the 3 min diabetic foot exam and the ACT NOW Checklist.64 78 86 The second component also focused on communication skills with patients to (1) learn more about their condition, living situation, culture and beliefs, and goals, (2) empower patients to take the lead in self-managing their condition by focusing on their feelings, exploring their problems choosing specific goals and making an action plan,35 38 43 71 and (3) educate patients on the effects of diabetes on feet, the importance of foot screening, appropriate footcare and footwear.76 77 Skills development also focuses on how to communicate with regulated care providers to advocate for an appropriate management plan that aligns with the patient’s needs.31 32 34

Component 3: experiential learning

The third component was an opportunity to test UCPs’ knowledge and skills through experiential scenarios. These scenarios included role-play situations where participants would take turns acting as simulated patients while others played the role of UCPs providing foot care during a training-related interaction. Simulation-based education is an interactive teaching method that offers a realistic learning environment for learners.87 Some studies also included group facilitation simulations, where learners try to cofacilitate open discussions with a group of patients or try to communicate with other UCPs who play the role of healthcare providers.35 38 43 Studies showed that this component provided a chance for learners to experience how their actions may impact the outcomes and reflect on what factors contributed to these outcomes.41 59 65 68

In addition to simulations, live patient examinations and interactive hands-on sessions with patients who have existing foot problems were also used to strengthen the reflective, critical and creative potential of professionals in their education practices.42 69 79 85

Culture competencies

Through our research, we retrieved 23 articles that discussed diabetic foot care for systematically marginalised communities including 8 for Latinos/Hispanics,17 36 41 46 51 62 72 75 4 for systematically marginalised communities in general,37 39 48 68 4r for Indigenous Population,52 54 67 80 3 for African,40 59 72 2 for Arabic31 32 and 2 for Chinese/Asian populations.72 73 In these articles, researchers highlighted the importance of delivering culturally tailored and linguistically appropriate preventive care or education for patients.37 59 To address these needs, cultural competency was incorporated into training programmes to increase UCPs’ awareness of and sensitivity to cultural differences, and appreciation of different cultural values, beliefs and behaviours.72 Cultural competency also enhances their abilities to care for patients from marginalised communities,36 72 88 89 and mediates between the patient’s culture and the biomedical healthcare system.90

Some programmes also adopted the patient-centred model91 where UCPs were trained to consider SDH92 including the social, economic and educational resources alongside the biomedical factors that may modulate the patient’s disease.26 51 59 92 93

Modes of delivery

The identified articles used a variety of methods to deliver their educational materials to accommodate learners’ different learning preferences including visual, aural, written or kinaesthetic.31 42 69 79 85 The knowledge acquisition component, for example, was delivered through didactics with photographic illustrations showing areas of increased pressure, such as hammer toes or hallux valgus deformity, and the resultant lesions on the individual’s foot.42 69 79 85 Didactics were followed by practical demonstrations, for example videos simulating patients to promote knowledge retention and subsequent reflection. Besides visual aids, training programmes also provided samples of footwear, insoles, shoes, model or foot skeletons for those who prefer kinaesthetic approaches and touching materials to enhance their learning.42 69 79 85 Demonstrations of wound care were also made available in multiple forms including written material, illustrations, images, videos, computer technology and smartphone demonstration videos. Such variety was necessary to meet different learning and language needs, to achieve learners’ engagement in care, and to ensure they have easy access to this information after training.42 69 79 85


To ensure the quality standards of services, training programmes included assessments of UCPs’ knowledge and skills to verify their competencies.41 47 To plan these evaluations, four articles recommended creating a blueprint to clarify the training objectives and scope of practice and define specific competencies.44 65 76 77 Thirteen articles highlighted the importance of pretraining assessments to identify levels of knowledge, educational needs and incentives. This information is essential to customised educational interventions for each group of UCPs.17 33 35 36 38 41 42 44 47 57 62 66 68 Post-training assessment was also a mandate to ensure that UCPs understood the extent of their responsibilities, and acquired the competencies needed to perform their expected roles.17 33 35 36 38 41 42 44 47 57 62 66 68 Ongoing assessments after the end of training were also considered to evaluate the ongoing effectiveness of the training programmes.17 76 77 These assessments were seen as part of the knowledge mobilisation process that drives programme refinements and increases their effectiveness for UCPs and patients.

Theme 3: outcomes

Identified articles evaluated the impact of upskilling programmes mainly on UCPs and patients.

Unregulated care providers’ outcomes

Eleven studies evaluated UCPs’ outcomes.35 38 42 47 50 51 53 57 60 66 68 Seven studies used attendance numbers to determine the extent of acceptability of the programme among UCPs.35 38 42 47 50 60 66 Preknowledge and postknowledge evaluations were used in seven studies.35 38 42 47 50 66 Four studies described assessing knowledge on foot care and risk stratification and criteria for referral using three surveys35 42 66 68 : the Michigan Diabetes Research and Training Center (MDRTC) Diabetes Attitude Survey94 95; the Diabetes Knowledge Test a modified version of the MDRTC Diabetes Knowledge Test96 and the Diabetes Confidence Survey.42 These studies showed higher scores postparticipation indicating increased levels of knowledge and readiness to deliver preventive services. One study used surveys to assess UCPs’ satisfaction and to collect feedback from learners and their clients.53

Patient-related outcomes

Evidence showed that educational interventions led by UCPs increased diabetes self-efficacy, foot self-care practices, self-glucose monitoring and foot care.16 34 36 41 43 54 57 58 62 UCPs also increased patients’ knowledge about diabetic foot care.33 36 41 44 45 48 51 57–59 63 68 In one study, researchers found that although patients preferred some form of home remedies, or herbals as the first option to DFUs which usually contributed to amputations, about 77% agreed to seek help in the hospital rather than other options after attending educational programmes provided by CHWs.33 Another study that evaluated the impact of an educational intervention led by CHWs in Mexican communities showed that participating patients had less proliferative diabetic retinopathy, fewer foot ulcers and reduced numbers of foot amputations than control group subjects leading to an estimated cost-effectiveness ratio of US$355 per quality-adjusted life-year gained.62 One study, however, showed that the educational programme increased the incidence rates of DFUs while reducing rates of amputations.31 The researchers related these results to increased awareness among patients and care providers leading to increased referrals for treatment.31 The number of patients screened33 47 51 56 58 60 61 64 and the number of patients referred to healthcare services52 57 69 were also outcomes that reflected the impact of foot care programmes

Modified programme theory

Although the literature confirmed our hypothesis on what mechanisms are needed to generate the proposed list of outcomes, our findings challenged our initial PrT in some other aspects. In our initial PrT, we assumed that understanding how and why upskilling programmes work depends solely on the adopted mechanisms. Our realist analysis, however, suggested that the context dictated the adopted mechanisms and determined the intended outcomes. We also expected that upskilling programmes for foot screening could, independently, reduce amputations and achieve health equity. However, the literature highlighted that preventive foot care programmes act as a bridge connecting patients and communities with the healthcare system. Other steps are needed to achieve these outcomes. For example, upskilling needs to include training on patient education, communication, advocacy and health promotion in addition to foot screening. It also needs to be developed within a multidisciplinary preventive foot care programme that provides foot screening, risk stratification, patient and healthcare providers education, access to patient data and referral pathways to connect patients to the healthcare system. The healthcare system, in turn, needs to deliver appropriate treatments for high-risk patients in a timely fashion. Based on these findings, we refined our initial theory and developed a modified PrT that better reflected our results (see online supplemental materials).

Risk of bias assessment

By using the Dixon-Woods tool,97 we found that the aims and objectives were clearly stated in all studies. Research designs were well suited for the studies. The information generated was highly valued for its contextual relevance. We also found limitations within the identified experimental articles. Demographics on study participants were rarely reported. Studies that qualified for the economic review had incomplete reporting and inclusion of important drivers of intervention cost and healthcare costs. Studies used self-reported questionnaires to assess the impact of educational interventions on UCPs’ knowledge without reporting on the validity and reliability of these questionnaires. Moreover, the identified studies lacked investigations regarding long-term outcomes including cost-effectiveness, healthcare utilisation and health equity.

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