A step ahead of Step-by-Step

Objectives

The successful implementation of the "Step-by-Step" project in Tanzania has laid the ground for further efforts to address foot problems related to diabetes.

Although the "Step-by-Step" project implemented under the WDF funded project WDF03-056 has improved the availability of diabetic foot care, access to this type of care remains practically non-existent for most of the people with diabetes.

The reason for this is probably that the public health implications of the increasing incidence and prevalence of diabetes related foot complications have been unaddressed for many years in Tanzania. While approximately 40-70% of all lower extremity amputations in Africa are related to diabetes, in Tanzania there is no effective infrastructure for the screening and management of diabetic foot problems.

With almost 1 million people suffering from diabetes and many more expected to present in the future, Tanzania faces an increasing need for a health care system which can tackle the complications resulting from diabetes. Therefore, the WDF has decided to support this projects that intends to improve diabetic foot care by following the lessons learned from the "Step-by-Step" project.

The objective of the project is to improve diabetic foot care in Tanzania.

Approach

Health care providers from 30 health centres from different regions or districts across Tanzania will be trained. It is expected that half of these centres will be private and half will be governmental.

It is a prerequisite for having a team participate in the training that the centre has an already established diabetes clinic. From each centre one doctor and one nurse will participate in the training. Thus, a total of 60 health care providers will be trained.

Two training sessions will be conducted - a basic course and a subsequent advanced course. Both of them will be held in Dar es Salaam due to practical necessities.

The basic course will be interactive and includes workshops with less emphasis on lectures. Two sets of curricula will be implemented - 1 for doctors and 1 for nurses. In total the course will last for 4 days with the first 3 days being an expanded version of the original "Step-by-Step" methodology and the last day comprising a podiatry course where the participants will get the opportunity to use some of the acquired skills and knowledge.

During the course, participants will be shown how to obtain the relevant history of the patients, perform physical examinations, screen for neuropathy and ischemia, classify, stage and identify high-risk feet, organise appropriate foot care management and education, and act in a timely manner towards those with advanced foot problems. Moreover, issues related to referral of patients will be discussed and there will be a focus on disseminating the obtained information to other health care providers.

Upon return to their home health centres the trained health care providers are expected to establish foot screening and care as part of the already existing diabetes clinic. In this manner they will educate patients and share their acquired knowledge and skills with their fellow health care providers. In addition, they are to apply the different aspects from the training course including screening for foot complications, surveillance of mortality and morbidity, and treatment for diabetic foot problems.

One year after the basic course the advanced course will be conducted. This course will include advanced subjects and techniques as well as how to address and manage complicated cases.

Supervision/coaching of the performance of the foot care teams will be conducted by the project manager in between the basic and advanced courses as well as upon completion to ensure appropriate adoption and implementation of the techniques.

Since the trained health care providers are supposed to educate and disseminate their obtained knowledge to both patients and health care providers the project will create not only awareness on diabetic foot problems and improve care of them, but also reduce the number of amputations.

Results at completion

- Training provided to 30 to 60 medical professionals from 15 to 30 medical centres
- 43 diabetic foot clinics are now in operation throughout Tanzania.
- Significant reduction of the amputation has been reported, from 58% in 2009 to 15% in 2011