Foot ulcers are one of the biggest problems affecting patients with diabetes: the affliction affects 15–25% of this population, according to one Dutch study published by the University of Utrecht in 2014. Physical disabilities due to the wound or resultant loss of limbs, resulting in the reduction of quality of life or morbidity, are the main consequences for patients with diabetes. It is little wonder, then, that around the world, stemming the rate of these severe consequences has become a key goal for diabetes-focused medical groups.

Cutting the amputation rate

The statistics are sobering: a 2000 study by the Global Lower Extremity Amputation Study Group found that 25–90% of all amputations originate from a diabetic foot ulcer. However, early recognition and management of independent risk factors for ulcers and amputations are proved to prevent or delay the onset of adverse outcomes.

"Mainly university hospitals demonstrated that, thanks to good patient education, hospital stays can be reduced, and patient satisfaction and effectiveness of care can be improved."

According to a 2012 study led by Dr Johannes Dorresteijn and Professor Gerlof Valk from the University Medical Center Utrecht, the Netherlands, it is patient education that is the key to reducing the incidence of the amputation and improving ulcer treatment. Patient education encompasses all educational activities directed at patients and their families, including therapeutic and health education, and clinical health promotion.

For the development of patient education, five important factors are identified by Dutch patient resource centre the Helen Dowling Institute:

1. research and evidence-based standards

2. the organisation of care

3. training and methodological support

4. professional values

5. acknowledgment, funding and placing of patient education in health policy.

The current situation

Patient education has to be undertaken by trained healthcare professionals. Nowadays, nearly all healthcare settings introduce different types of patient education. One method of educating patients is via counselling.

Counselling is an important aspect of patient education and is now well recognised and established in clinical practice. Counselling can also be an essential activity to help patients and their families improve their self-management and the efficacy with which they maintain their quality of life.

Unfortunately, according to WHO Working Group Reports, clinical practice demonstrates that patient ducation is often poorly designed and taught. The problem is that most healthcare professionals talk to patients rimarily – or sometimes only – about their disease, rather than training them in the daily management of it or teaching them how to adapt the treatment to their particular chronic disease.

Often, education programmes will not even touch on elements like teaching patients about effective hygiene, financial problems, coping with the effects a situation may have on surrounding family and loved ones, depression and anxiety, and the ways to carry on after a change of routine or living conditions.

Studies have shown that it is essential that trained healthcare professionals take part in patient education to enable patients and their families to manage the treatment of the condition and prevent complications from arising. WHO Working Group Reports also lists that after developing and testing a patient education programme, it is therefore key to train healthcare professionals in carrying it out. The report also summarises that if all patients received such an education, the overall costs of these operations and social care could be reduced.

This is no mean feat, as patient education within western Europe is mainly determined by the healthcare system, and has to cover not only general education, but also the rights and ethical issues within the field of patient education. Various reports and studies indicate that Belgium, Germany, the Netherlands and the UK are all countries where these general features are present. In nearly all western-European countries, general practitioners hold an important role within primary healthcare and are seen as the gatekeepers of the healthcare system.

In several western European countries like Belgium, France or the Netherlands, GPs and hospitals have contributed to the development of patient education. In these countries, mainly university hospitals demonstrated that, thanks to good patient education, hospital stays can be reduced, and patient satisfaction and effectiveness of care can be improved.

In recent times, chronic shortages in the UK healthcare sector have seen many patients bypass their GPs and go straight to the emergency wards of hospitals, which creates headaches for the healthcare system as a whole and muddies the roles of these two elements of the healthcare sector.

Walk this way

In the past few years, patient education for people suffering from a chronic disease, such as diabetes, has begun to receive a growing level of attention and, within all healthcare settings, nurse-led educational programmes are being developed to attain higher rates of success and engagement. This is also visible in the curricula of healthcare training.

Healthcare training and communication play an important role in effective patient education; the patients must be educated on their role but, unless those working in the healthcare sector have received the proper knowledge themselves, the entire process could become pointless and even have adverse effects.

Until the early 1990s, patient education in the different healthcare services in central and eastern Europe could be characterised as uniform due to the obvious effects of communism and socialised medicine.

Nowadays, patient education in these regions is provided in as many diverse ways as it is in western Europe, and is offered mostly according to the main features of the healthcare facilities and healthcare systems in those places. One Slovakian study on patient education programmes in the wider central-European region surmised that this coverage was spurred by evidence in studies that showed the effectiveness of educational activities, not only in terms of patient knowledge, but also in the motivation and willingness to be educated and promote health.

"There is insufficient focus on primary prevention in the education of patients; the attention given to this topic is paid most frequently to the prevention of complications."

In general, though, there is insufficient focus on primary prevention in the education of patients; the attention given to this topic is paid most frequently to the prevention of complications (secondary prevention) instead. Deficits in patient information about chronic complications of wounds due to insufficient education may be a significant contributor to the various complications being seen at the moment.

Future directions

As it becomes clearer that patient education is contributing to patient safety and quality of care across central and eastern Europe, issues related to patient safety are being addressed at the policy level, although the focus is still mainly on secondary care. While this is a step forward, more attention has to be paid to primary care and the role of GPs. The role of nurses in patient education must also be highlighted.

Traditionally, it has been national and cultural differences within Europe that define patient education, but now, it is also the differences in the healthcare systems themselves. Combining forces through more European collaboration may not only reduce the differences between the countries, but also promote and strengthen patient education in all healthcare settings, and optimise internalisation and centralisation in healthcare and patient-safety promotion across Europe.