The Baqai Institute of Diabetology and Endocrinology (BIDE) is first and only multidisciplinary tertiary care diabetes Institute in Karachi, Pakistan. One of the learnings they have documented, presented at meetings and prepared for publication in the scientific journals is this: Therapeutic footwear is the most cost-effective way to manage diabetic foot ulcers and prevent ulcers in at-risk feet.
Yet such footwear is scarce in Karachi, and even harder to find outside the Pakistan’s economic capital. So in 2015, BIDE approached WDF with an idea for producing low-cost, long-lasting, fit-for-purpose footwear across Pakistan inspired by D-foot International’s FLIRT-bird project.
They would create ‘footwear teams’ in 10 health care institutions across the country. The teams would consist of a footcare assistant to educate, screen and examine diabetes patients, and a footwear technician (cobbler) to create customised footwear for patients who need it. Both the clinical activities and the cobbler’s workshop would be located in the diabetes clinic, ensuring one-stop, comprehensive diabetes foot care for patients. After the initial start-up costs, the project would be sustainable.
“We often forget the footwear. It doesn’t make sense to treat wounds if you don’t provide footwear to people who need it,” says Mette Skar, WDF programme manager. “If the wound is not properly offloaded and the cause of the wound not removed, it will return.”
Assistance from a Master Trainer
First, the project team needed to decide where the project centres would be located. They placed the project hub in the BIDE hospital in Karachi, then identified 10 tertiary level facilities across the country with the interest and capacity to participate.
As Professor Abdul Basit, Director of BIDE, says: ”It is not an achievement to develop diabetic footwear in Karachi or a couple of major cities. The achievement is to extend footwear services to every nook and corner of Pakistan.”
Next, they needed to train the HCPs and cobblers who would make up the new footwear teams. They were in luck: Bent Nielsen, a foot care expert based in Denmark, was willing and able to help. He travelled to Pakistan in August 2016 to hold a week-long, hands-on Train the Trainer session at BIDE’s facility in Karachi. (See the course manual on WDF’s website.)
The trained BIDE team held a follow-up course in December, teaching the footwear teams how to manufacture footwear for people with diabetes. When the newly trained cobblers and footcare assistants returned to their clinics, they sent pictures of their work to the BIDE team for review and took part in weekly online meetings to discuss issues and progress.
Constraints and solutions
The project faced a variety of start-up issues: problems with finding space, acquiring equipment, and losing trained staff to attrition and transfers. But the experienced team managed them, and by November 2016, Project Manager Dr Asmat Nawaz informed his colleages in Pakistan and Denmark that Footwear for every diabetic, WDF15-1272 was ready to launch.
Features of Therapeutic Footwear
As the project rolled out, however, an unexpected issue arose. As Dr Zahid Miyan, head of BIDE’s Diabetic Foot Care department and the project’s director, wrote in a report in January, 2018: “All the patients referred to the risk assessment clinics did not report.”
Footwear for people with diabetes was still a new concept in Pakistan, he explained. A number of patients were declining the offer of customised shoes: some did not want to take the time for a fitting, while others felt the shoes were too expensive. Many of those who declined found the shoes unattractive.
The BIDE team set to work, updating their educational materials and creating a film to underscore the value of the custom footwear. They further lowered the costs by the using approved, locally available material and utilising the services of locally trained teams, according to Dr Riaz A. Memon, the Project Coordinator. They also launched several new designs. Together, these steps significantly increased the number of patients opting for the customised footwear.
Footwear fit for a pilgrimmage
One of the new designs was tailored to a special group: pilgrims. Participating in the Hajj – the annual pilgrimage to Mecca – is a religious duty that must be carried out at least once by all adult Muslims who are physically and financially capable of undertaking the journey. Islamic law requires that various parts of the foot remain uncovered during the Hajj. So, with the guidance (FATWA) from religious scholars, the project team added Hajj sandals to their catalogue of designs.
A few of the new designs: (from left) Hajj shoes, Risk Category 2 for men, Risk Category 0 for women.
The Hajj footwear was a great success, Dr Miyan says. “It not only has been liked by the pilgrims but has also been very helpful for them to perform the Hajj without suffering any foot problems.”
Clear clinical impact
By the time the project closed in May 2020, the 10 project centres were up and running. More than 171,000 diabetes patients have been screened for diabetic foot complications, 15,743 people with foot ulcers had been treated, and 20,000 pairs of low-cost shoes had been manufactured and put to use.
Upon the project’s completion, Bent Nielsen wrote to the project team: “I am highly impressed with the progress of the project and by the skills and the learning abilities of the cobblers and foot care assistant … the work done for different risk categories is up to the mark.”
The project’s most important outcome – its impact on patients - is clear, according to the BIDE team and Ms Skar. Only a small proportion of at-risk patients served by the project developed first or recurrent ulcers during its 3-year duration.
“During the project, high and very high-risk patients had no new amputations,” Ms Skar from WDF says. “This is a clear indication of the clinical impact of the project and the great potential of customised footwear to prevent diabetes related foot complications in at-risk people.”
While the WDF funded project is completed, the journey has just begun, Dr Miyan says. Customised footwear is a central element of BIDE’s new Certified Diabetic Foot Training Course, which is part of Pakistan’s Continuing Medical Education (CME) programme. BIDE has also presented the project and conducted footwear workshops at various national forums and conferences.
This has created a demand for more basic footwear facilities – demand that BIDE hopes to meet by opening its training programme and experience to others, he says, adding:
“With these efforts, we see good prospects for expanding the model not only to other institutions across the country but also to many low- and middle-income countries in various regions of the globe.”