From 'what' to 'how' : capacity building in health promotion for HIV/AIDS prevention in the Solomon Islands

This paper describes a capacity building process undertaken within the HIV/AIDS prevention project of the Adventist Development and Relief Agency (ADRA) in the Solomon Islands. ADRA HIV/AIDS has recently reoriented its project structure, moving beyond its awareness raising approach to incorporate health promotion frameworks, theories, strategies and assumptions. These have been used to inform project practice in project planning, delivery and evaluation. This paper shares what has worked and not worked in the capacity building process, including a project evaluation of the initial HIV/AIDS awareness raising project and the application of a number of capacity building strategies, including utilising a volunteer Australian Youth Ambassador for Development (AYAD) funded by the Australian Agency for International Development (AusAID). Existing and new projects are outlined. The underlying theme is that any capacity building exercise must include structural support (e.g. management, national frameworks) to ensure the incorporation of new initiatives and approaches. With time this enables ownership by counterparts and external partnerships to develop. The presence of an AYAD volunteer has been an effective strategy to achieve this. Reflections from the evaluators, the AYAD volunteer and the HIV/AIDS team are included.

Foot pain and functional limitation in healthy adults with hallux valgus : a cross-sectional study

Background Hallux valgus (HV) is a very common deformity of the first metatarsophalangeal joint that often requires surgical correction. However, the association between structural HV deformity and related foot pain and disability is unclear. Furthermore, no previous studies have investigated concerns about appearance and difficulty with footwear in a population with HV not seeking surgical correction. The aim of this cross-sectional study was to investigate foot pain, functional limitation, concern about appearance and difficulty with footwear in otherwise healthy adults with HV compared to controls. Methods Thirty volunteers with HV (radiographic HV angle >15 degrees) and 30 matched controls were recruited for this study (50 women, 10 men; mean age 44.4 years, range 20 to 76 years). Differences between groups were examined for self-reported foot pain and disability, satisfaction with appearance, footwear difficulty, and pressure-pain threshold at the first metatarsophalangeal joint. Functional measures included balance tests, walking performance, and hallux muscle strength (abduction and plantarflexion). Mean differences (MD) and 95% confidence intervals (CI) were calculated. Results All self-report measures showed that HV was associated with higher levels of foot pain and disability and significant concerns about appearance and footwear (p < 0.001). Lower pressure-pain threshold was measured at the medial first metatarsophalangeal joint in participants with HV (MD = -133.3 kPa, CI: -251.5 to -15.1). Participants with HV also showed reduced hallux plantarflexion strength (MD = -37.1 N, CI: -55.4 to -18.8) and abduction strength (MD = -9.8 N, CI: -15.6 to -4.0), and increased mediolateral sway when standing with both feet with eyes closed (MD = 0.34 cm, CI: 0.04 to 0.63). Conclusions These findings show that HV negatively impacts on self-reported foot pain and function, and concerns about foot appearance and footwear in otherwise healthy adults. There was also evidence of impaired hallux muscle strength and increased postural sway in HV subjects compared to controls, although general physical functioning and participation in physical activity were not adversely affected.

Walking the Coleridge Way : using cultural tourism to change perceptions of Somerset after the foot and mouth epidemic of 2001

This paper explores one of the ways in which the Somerset region in the United Kingdom, devastated by the foot and mouth epidemic in 2001, is trying to free itself from recurring negative representations and create more positive images of the area. After the epidemic projects were sought that would promote a more positive image and draw tourists back to the area. One of these projects drew on literary tourism to reinvigorate the site. A Walking and Bridle trail called the ‘Coleridge Way Walk’ has been implemented to take the images of the area from ones of disease and dirtiness to ones of Romantic longing. The Coleridge Way Walk uses past imaginings to re-energise the area. This energy, in part, comes from ‘re-imagining’ the site through past imaginings. The Coleridge Way Walk uses the past to create future direction for the once tainted area.

The psychometric properties of the Spanish version of the Foot Health Status Questionnaire

Purpose: Clinical studies suggest that foot pain may be problematic in one-third of patients in early disease. The Foot Health Status Questionnaire (FHSQ) was developed and validated to evaluate the effectiveness of conservative (orthoses, taping, stretching) and surgery interventions. Despite this fact, there are few validated instruments that measure foot health status in Spanish. Thus, the primary aim of the current study was to translate and evaluate psychometrically a Spanish version of FHSQ. Methods: A cross-sectional study was designed in a university community-based podiatric clinic located in south of Spain. All participants (n = 107) recruited consecutively completed a Spanish version of FHSQ and EuroQoL Health Questionnaire 5 dimensions, and 29 participants repeated these same measures 48 h later. Data analysis included test–retest reliability, construct and criterion-related validity and factor analyses. Results: Construct validity was appropriate with moderate-to-high corrected item–subscale correlations (α = ≥0.739) for all subscales. Test–retest reliability was satisfactory (ICC > 0.932). Factor analysis revealed four dimensions with 86.6 % of the common variance explained. The confirmatory factor analysis findings demonstrated that the proposed structure was well supported (comparative fit index = 0.92, standardized root mean square = 0.09). The Spanish EuroQoL 5D score negatively correlated with the FHSQ pain (r = −0.445) and positively with general foot health and function (r = 0.261 − 0.579), confirming criterion-related validity. Conclusion: The clinimetric properties of the Spanish version of FHSQ were satisfactory.

Types of foot problems seen by Australian podiatrists

Background: Understanding frequency of foot problems can assist health care planners with resource deployment to new and emerging services such as paediatric podiatry and focus future research on the most salient foot conditions. Methods: A review of 2187 patient consultations during a three month period was conducted. Patient medical and podiatric history was coded using industry standards. All patients were recruited for convenience from a metropolitan university podiatry clinic. Results: 392 new patients were identified with mean age 40.6 years old (range 1–95), with 65% being female. Arthritic diseases, asthma, hypertension and allergies were the most common medical conditions reported. The frequency of new consultations in younger people (n = 102; 27%) exceeded those of the elderly (n = 75; 20%). Conversely, the elderly were nearly three times more prevalent in this cohort (n = 910; 43%) compared to younger people (n = 332; 16%). Conclusion: This study illustrates the diverse nature of pathology seen by podiatrists. Knowledge that skin lesions are highly prevalent is of relevance to health departments, given the aging nature of most populations. Moreover there appears to be a growing trend in the number of young people who present for care, however government funded access to these services are limited.

Australian Diabetes Foot Network : management of diabetes-related foot ulceration — a clinical update

Summary Appropriate assessment and management of diabetes-related foot ulcers (DRFUs) is essential to reduce amputation risk. Management requires debridement, wound dressing, pressure off-loading, good glycaemic control and potentially antibiotic therapy and vascular intervention. As a minimum, all DRFUs should be managed by a doctor and a podiatrist and/or wound care nurse. Health professionals unable to provide appropriate care for people with DRFUs should promptly refer individuals to professionals with the requisite knowledge and skills. Indicators for immediate referral to an emergency department or multidisciplinary foot care team (MFCT) include gangrene, limb-threatening ischaemia, deep ulcers (bone, joint or tendon in the wound base), ascending cellulitis, systemic symptoms of infection and abscesses. Referral to an MFCT should occur if there is lack of wound progress after 4 weeks of appropriate treatment.

Diabetes foot disease : the Cinderella of Australian diabetes management?

Diabetes is one of the greatest public health challenges to face Australia. It is already Australia’s leading cause of kidney failure, blindness (in those under 60 years) and lower limb amputation, and causes significant cardiovascular disease. Australia’s diabetes amputation rate is one of the worst in the developed world, and appears to have significantly increased in the last decade, whereas some other diabetes complication rates appear to have decreased. This paper aims to compare the national burden of disease for the four major diabetes-related complications and the availability of government funding to combat these complications, in order to determine where diabetes foot disease ranks in Australia. Our review of relevant national literature indicates foot disease ranks second overall in burden of disease and last in evidenced-based government funding to combat these diabetes complications. This suggests public funding to address foot disease in Australia is disproportionately low when compared to funding dedicated to other diabetes complications. There is ample evidence that appropriate government funding of evidence-based care improves all diabetes complication outcomes and reduces overall costs. Numerous diverse Australian peak bodies have now recommended similar diabetes foot evidence-based strategies that have reduced diabetes amputation rates and associated costs in other developed nations. It would seem intuitive that “it’s time” to fund these evidence-based strategies for diabetes foot disease in Australia as well.

Standardising practices improves clinical diabetic foot management: the Queensland Diabetic Foot Innovation Project, 2006-09

Objective. The aim of this paper is to report the clinical practice changes resulting from strategies to standardise diabetic foot clinical management in three diverse ambulatory service sites in Queensland, Australia. Methods. Multifaceted strategies were implemented in 2008, including: multidisciplinary teams, clinical pathways, clinical training, clinical indicators, and telehealth support. Prior to the intervention, none of the aforementioned strategies were used, except one site had a basic multidisciplinary team. A retrospective audit of consecutive patient records from July 2006 to June 2007 determined baseline clinical activity (n = 101).Aclinical pathway teleform was implemented as a clinical activity analyser in 2008 (n = 327) and followed up in 2009 (n = 406). Pre- and post-implementation data were analysed using Chi-square tests with a significance level set at P < 0.05. Results. There was an improvement in surveillance of the high risk population of 34% in 2008 and 19% in 2009, and treating according to risk of 15% in 2009 (P < 0.05). The documentation of all best-practice clinical activities performed improved 13–66% (P < 0.03). Conclusion. These findings support the use of multifaceted strategies to standardise practice and improve diabetic foot complications management in diverse ambulatory services.

Is simulation training effective in increasing podiatrists' confidence in foot ulcer management?

Background: Foot ulcers are a frequent reason for diabetes-related hospitalisation. Clinical training is known to have a beneficial impact on foot ulcer outcomes. Clinical training using simulation techniques has rarely been used in the management of diabetes-related foot complications or chronic wounds. Simulation can be defined as a device or environment that attempts to replicate the real world. The few non-web-based foot-related simulation courses have focused solely on training for a single skill or “part task” (for example, practicing ingrown toenail procedures on models). This pilot study aimed to primarily investigate the effect of a training program using multiple methods of simulation on participants’ clinical confidence in the management of foot ulcers. Methods: Sixteen podiatrists participated in a two-day Foot Ulcer Simulation Training (FUST) course. The course included pre-requisite web-based learning modules, practicing individual foot ulcer management part tasks (for example, debriding a model foot ulcer), and participating in replicated clinical consultation scenarios (for example, treating a standardised patient (actor) with a model foot ulcer). The primary outcome measure of the course was participants’ pre- and post completion of confidence surveys, using a five-point Likert scale (1 = Unacceptable-5 = Proficient). Participants’ knowledge, satisfaction and their perception of the relevance and fidelity (realism) of a range of course elements were also investigated. Parametric statistics were used to analyse the data. Pearson’s r was used for correlation, ANOVA for testing the differences between groups, and a paired-sample t-test to determine the significance between pre- and post-workshop scores. A minimum significance level of p < 0.05 was used. Results: An overall 42% improvement in clinical confidence was observed following completion of FUST (mean scores 3.10 compared to 4.40, p < 0.05). The lack of an overall significant change in knowledge scores reflected the participant populations’ high baseline knowledge and pre-requisite completion of web-based modules. Satisfaction, relevance and fidelity of all course elements were rated highly. Conclusions: This pilot study suggests simulation training programs can improve participants’ clinical confidence in the management of foot ulcers. The approach has the potential to enhance clinical training in diabetes-related foot complications and chronic wounds in general.

Does the use of store-and-forward telehealth systems improve outcomes for clinicians managing diabetic foot ulcers? : A pilot study

Diabetic foot ulcers are one of the most hospitalised diabetes complications and contribute to many leg amputations. Trained diabetic foot teams and specialists managing diabetic foot ulcers have demonstrated reductions in amputations and hospitalisation by up to 90%. Few such teams exist in Australia. Thus, access is limited for all geographical populations and may somewhat explain the high rates of hospitalisation. Aim: This pilot study aims to analyse if local clinicians managing diabetic foot complications report improved access to diabetic foot specialists and outcomes with the introduction of a telehealth store-and-forward system. Method: A store-and-forward telehealth system was implemented in six different Queensland locations between August 2009 and February 2010. Sites were offered ad hoc and/or fortnightly telehealth access to a diabetic foot speciality service. A survey was sent six months following commencement of the trial to the 14 eligible clinicians involved in the trial to gauge clinical perception of the telehealth system. Results: Eight participants returned the surveys. The majority of responding clinicians reported that the telehealth system was easy to use (100%), improved their access to diabetic foot speciality services (75%), improved upskilling of local diabetes service staff (100%), and improved patient outcomes (100%). Conclusion: This pilot study suggests that clinicians found the use of a telehealth store-and-forward system very useful in improving access to speciality services, clinical skills and patient outcomes. This study supports the recommendation that telehealth systems should be made available for diabetic foot ulcer management.

Standardising practices improves ambulatory diabetic foot management and reduces amputations : the Queensland Diabetic Foot Innovation Project, 2006 – 2009

Background Diabetic foot complications are recognised as the most common reason for diabetic related hospitalisation and lower extremity amputations. Multi-faceted strategies to reduce diabetic foot hospitalisation and amputation rates have been successful. However, most diabetic foot ulcers are managed in ambulatory settings where data availability is poor and studies limited. The project aimed to develop and evaluate strategies to improve the management of diabetic foot complications in three diverse ambulatory settings and measure the subsequent impact on ospitalisation and amputation. Methods Multifaceted strategies were implemented in 2008, including: multi-disciplinary teams, clinical pathways and training, clinical indicators, telehealth support and surveys. A retrospective audit of consecutive patient records from July 2006 – June 2007 determined baseline clinical indicators (n = 101). A clinical pathway teleform was implemented as a clinical record and clinical indicator analyser in all sites in 2008 (n = 327) and followed up in 2009 (n = 406). Results Prior to the intervention, clinical pathways were not used and multi-disciplinary teams were limited. There was an absolute improvement in treating according to risk of 15% in 2009 and surveillance of the high risk population of 34% and 19% in 2008 and 2009 respectively (p < 0.001). Improvements of 13 – 66% (p < 0.001) were recorded in 2008 for individual clinical activities to a performance > 92% in perfusion, ulcer depth, infection assessment and management, offloading and education. Hospitalisation impacts recorded reductions of up to 64% in amputation rates / 100,000 population (p < 0.001) and 24% average length of stay (p < 0.001) Conclusion These findings support the use of multi-faceted strategies in diverse ambulatory services to standardise practice, improve diabetic foot complications management and positively impact on hospitalisation outcomes. As of October 2010, these strategies had been rolled out to over 25 ambulatory sites, representing 66% of Queensland Health districts, managing 1,820 patients and 13,380 occasions of service, including 543 healed ulcer patients. It is expected that this number will rise dramatically as an incentive payment for the use of the teleform is expanded.

The feral horse foot. Part B : radiographic, gross visual and histopathological parameters of foot health in 100 Australian feral horses

Background It has been proposed that the feral horse foot is a benchmark model for foot health in horses. However, the foot health of feral horses has not been formally investigated. Objectives To investigate the foot health of Australian feral horses and determine if foot health is affected by environmental factors, such as substrate properties and distance travelled. Methods Twenty adult feral horses from five populations (n = 100) were investigated. Populations were selected on the basis of substrate hardness and the amount of travel typical for the population. Feet were radiographed and photographed, and digital images were surveyed by two experienced assessors blinded to each other's assessment and to the population origin. Lamellar samples from 15 feet from three populations were investigated histologically for evidence of laminitis. Results There was a total of 377 gross foot abnormalities identified in 100 left forefeet. There were no abnormalities detected in three of the feet surveyed. Each population had a comparable prevalence of foot abnormalities, although the type and severity of abnormality varied among populations. Of the three populations surveyed by histopathology, the prevalence of chronic laminitis ranged between 40% and 93%. Conclusions Foot health appeared to be affected by the environment inhabited by the horses. The observed chronic laminitis may be attributable to either nutritional or traumatic causes. Given the overwhelming evidence of suboptimal foot health, it may not be appropriate for the feral horse foot to be the benchmark model for equine foot health.

The feral horse foot. Part A : observational study of the effect of environment on the morphometrics of the feet of 100 Australian feral horses

Aim To better understand the morphology of, and the effect of different travel patterns and varying substrate environments on, the feral horse foot to better manage the feet of domestic horses. Methods The left forefeet of 20 adult feral horses from each of five geographically separated populations in Australia (n = 100) were investigated. Populations were selected on the basis of substrate hardness under foot and the amount of travel typical for the population. Feet were radiographed and photographed and 40 morphometric measurements of each foot were obtained. Results Of the 40 parameters, 37 differed significantly (P < 0.05) among the populations, which suggested that substrate hardness and travel distance have an effect on foot morphology. Harder substrates and longer travel distances were associated with short hoof walls and minimal hoof wall flaring. Softer substrates and moderate travel distances were associated with long flared walls, similar to that of typical untrimmed feet of domestic horses. Conclusions The morphology of the feral horse foot appeared to be affected by the distance travelled and by the abrasive qualities and mechanical properties of the substrate under foot. There were marked differences in some conformation parameters between the feral horses in the current study and domestic horses in previous studies. Although the conformation of the feral horse foot may have some prescriptive value, concerns regarding abnormal foot anatomy warrant further investigation.

Discrete loading of the foot during hurdle drills: A pilot investigation

Introduction: Lower limb function in hurdling is patently asymmetrical. The lead limb undertakes the preparatory and landing steps while the trail limb contends with the hurdle and recovery steps. Discrete loading profiles of these steps will reflect the asymmetrical function and may provide useful insight into injury mechanisms. A pilot study was undertaken to determine the loading profiles of the hurdle, landing and recovery steps of elite male hurdlers. Equivalent data for steps between hurdles, where the running action is more symmetrical, were used for the purpose of comparison, simultaneously minimising the confounding effect of speed. Methodology: In-shoe pressures were recorded (FScan, 200 Hz) for four elite male hurdlers while they completed a routine hurdle drill at a self-selected fast but sub-race speed. The drill comprised of three consecutive hurdles. Data for the hurdle, landing and recovery steps of the first and second hurdles, along with data for the running steps between hurdles 1 and 2, and 2 and 3, were used for the purpose of analysis. Peak pressures within 1cm2 masks were determined for the hallux, first, central and fifth metatarsals (T1, M1, M2–4 and M5 respectively). Peak pressure (kPa) and loading duration (ms) for the hurdle, landing and recovery steps are reported as a percentage of the respective limb-matched values for between-hurdle steps. Results/discussion: For between-hurdle steps, T1, M1 and M2–4 peak pressures were 312/357, 356/306 and 362/368 kPa, lead/trail limbs respectively. For the hurdle, landing and recovery steps, pressures at T1 and M1 increased. For T1 the increases were in the order of 17%, 36% and 8% (hurdle, landing and recovery steps, respectively) while the corresponding increases at M1 were 7%, 54% and 20%. Pressures at M2–4 were similar for all steps, while M5 loaded erratically. For the between-hurdle steps, the loading durations at T1, M1 and M2–4, were 160/162, 170/142 and 190/191 ms, respectively. For the landing step, loading duration decreased for T1, M1and M2–4 (−8%, −19% and −18%, respectively). In the hurdle step, loading duration decreased for the metatarsals but not for T1. Conclusions: The hurdling action leads to regional pressure increases that act for shorter durations in comparison to the between-hurdle running steps. These changes are most notable at the first metatarsal, a common site of foot injury.

The development of a kinematic model to quantify in-shoe foot motion

A multi-segment foot model was used to develop an accurate and reliable kinematic model to describe in-shoe foot kinematics during gait.