INTRODUCTION

Health promotion developed in the 1980s and 1990s and has been described as a ‘unifying concept’ (Bunton & Macdonald 2002). While definitions of health promotion abound (Kickbusch 1997, Naidoo & Wills 2004, Tannahill 1985, World Health Organization 1986), it is more useful to consider the two key aspects (lifestyle and structural aspects) in relation to podiatric practice. The Department of Health (2009) has health promotion at the centre of the current ‘Be active, Be healthy’ strategy. This strategy focuses on England and promotes activity, critically underpinned by foot health as a key to mobility and activity. The types of activity promoted include walking and dancing and a ‘can do – change for life’ approach, and it sets a target of 2 million people being ‘more active’ by 2012. In relation to foot health, chiropody, podiatry, health promotion and patient education have value in their capacity to focus on where the difficulties lie in an enabling and empowering approach. By its very nature, in recent years the role of the podiatrist in the ‘modernised’ health service has evolved into a more policy-driven, collaborative and multiprofessional area of practice (Department of Health 2000a,b).

Borthwick and Nancarrow (2005) have argued for a reconfiguration of podiatric services and roles to reflect a fundamental shift in the therapeutic role to encompass health promotion. While this presents an exciting range of options for the practitioner it can change perceptions of the profession among the public and fellow professionals. Although many foot conditions and their resultant effects are amenable to health-promotion intervention, it has taken time for the health-promotion role of the podiatrist to be fully recognised. The scope to develop practice in terms of Tannahill’s (1985) three domains, particularly prevention and health education, is evident, particularly through educational, behaviour-change and empowerment approaches and self-care. This is evidenced in the work by Moore et al (2003) with regard to educational programmes in self-care. The increased demand for screening and education in diabetic care (Department of Health 2000b) and the predominance of older clients in the sector exerts pressures on the service, both within the National Health Service (NHS) and in the independent sector. While empowerment approaches go some way to promoting self-care and reducing dependency, the profession is responding with tiered care provision (Moore et al 2003). Borthwick and Nancarrow (2005) assert that health promotion, facilitation and preventive care are linked closely to changing roles in podiatry and have informed the changing nature of practice.

In order to understand fully the concept of health promotion we need to understand health as a multidimensional concept. It can be regarded as a negative paradigm in terms of the absence of disease, while others see it in a positive way as a sense of well-being. The World Health Organization (WHO) (1946) in its constitution defines health as ‘a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity’. In later years health was redefined as a resource for everyday life not an object of living; it is a positive concept emphasising social and personal resources as well as physical capacities (World Health Organization 1984). The term ‘health’ is complex, imprecise and widely contested, but the various connotations must be considered and appreciated in order for health improvement to be addressed (Scriven 2005, Seedhouse 2004).

The WHO (1984) defined health promotion as ‘the process of enabling people to increase control over, and to improve their health’. In 1986, the WHO produced the Ottawa Charter, which is regarded by many as a seminal text in health promotion. The charter outlined the importance of building healthy public policies, creating supportive environments and strengthening communities. It also emphasised the need for the development of personal skills and a reorientation of health services to focus on prevention for individuals, communities and populations. Health promotion involves both environmental and political actions, and recognises the link between health and health inequalities.

THE PODIATRIST’S ROLE AS A HEALTH PROMOTER/EDUCATOR

The importance of health promotion, health education and patient education is well documented, the emphasis being placed on educating individuals about the link between risk-taking behaviours and disease and providing the skills necessary to help them make changes (Bunton & Macdonald 2002, Naidoo & Wills 2000). Although health promotion is contemporaneous for many health professionals, it provides common ground. Key elements identified in the Ottawa Charter (World Health Organization 1986) for health promotion underpin the work of many allied health professionals. Podiatrists have the potential to enable and empower individuals to increase control over, and thereby improve, their health and well-being as recommended in the Charter (World Health Organization 1986). Podiatrists’ skills in advocacy and mediation may also contribute to the creation of supportive environments conducive to health promotion. Health promotion has been included in the curriculum at schools of podiatry for many years, but some might argue it is possibly not afforded the consideration it deserves. One could argue that, as an integral part of podiatrists’ work, this important topic is often overlooked. There appear to be poor levels of knowledge linking health promotion and podiatry, there being no defined syllabus or consistency of health promotion taught throughout the recognised schools of podiatry within the UK.

Feet are an overworked part of the human body, playing a major role in the everyday life of individuals. Therefore, foot afflictions have a great impact on the health and well-being of individuals so affected. Health promotion in podiatry is often regarded as addressing foot health and footwear implications (McMullan 2004), which, although relevant, comprise only a part of the holistic approach that must be embraced. For example, a large number of podiatric patients have podiatric problems associated with peripheral vascular disease, and the link between risk behaviours and disease is well documented (Hoffman 2003, Levy 1998). The role of health promotion in podiatry is essential to encourage healthful individual behaviours, especially as podiatrists have a unique opportunity of one-to-one patient contact, enhancing their ability to promote health and evaluate patient progress.

Prevention of foot and lower-limb problems, either by educational strategies or screening activities, is a key role for podiatrists, who have a pivotal role in maintaining the independence of their patients (O’Donnell 2005). This is particularly important for the elderly, where mobility is essential in everyday life (Turner & Merriman 2005). Immobility not only exacerbates pathological complications such as muscle wasting, osteoporosis and deep vein thrombosis to name but a few, but can have immense psychological implications, with loss of confidence and self-esteem, depression and isolation being attributable to a poor quality of life (Tyrrell 2006, Lorimer et al 2006). The ability of podiatrists to help keep patients ambulatory may be the dividing line between institutionalisation and remaining an active member of the community and society (Turner & Merriman 2005).

The podiatry profession, formerly known as chiropody, is depicted in the literature as a healthcare speciality devoted to the treatment and prevention of afflictions of the foot (Dagnell & Page 1992). However, while this is indeed the case, modern podiatric practice is moving away from the historical routine foot care to encompass a larger range of roles, skills and knowledge (Scriven 2005). The role of the podiatrist now includes the bigger picture, and as such health promotion and patient education are essential components of podiatric practice, particularly as the profession continues to expand its boundaries. In the current economic environment, reorganisation of health services together with associated changes in fund holding have empowered managers to explore more cost-effective treatment options. As such, podiatric surgery is now more widely recognised as being an accessible, cost-effective and efficient service (Borthwick 2000, Editorial 2002). Research also identifies the positive impact that podiatric surgery can have on patient health and well-being (Kilmartin 2000).

The ongoing development of the profession presently incorporates biomechanical expertise, foot surgery, an embryonic role in rheumatology and specialist diabetic care (Borthwick 2000, Bowen 2003, Clements 2001, Graham 2000). The podiatrist’s role in childhood foot problems (podopaediatrics) is ever-increasing (Thomson & Volpe 2001). A large proportion of the podiatrist’s workload is still concerned with the elderly, podiatric afflictions having many detrimental effects on the health and well-being of these individuals (Dolinis et al 1997, Menz & Lord 2001). Research shows that up to 80% of the adult population suffers some form of foot problem (Society of Chiropodists and Podiatrists 2007).

To understand why the role of the podiatrist as a health promoter/educator is so significant, the history of the emergence of the profession deserves consideration. The fundamental shift in the identity of the profession demands an increasing involvement in health-promoting strategies (Scriven 2005). Podiatry is a specialism in itself, in that the podiatrist is responsible for diagnosing and treating individuals without prior intervention by other healthcare professionals. In the 17th and 18th centuries podiatry and dentistry shared similar positions in the medical hierarchy, early chiropodists being medically qualified practitioners and regarded as foot surgeons. However, the dominance of medical interests in the 20th century limited podiatrists’ scope of practice, forbidding the use of local analgesia by chiropodists/podiatrists and hence surgical interventions.

In contrast, today’s podiatric practice has seen a shift back to a wide field of practice, once again encompassing not only routine foot care but also elective surgery. Legal access to local anaesthetics signalled the way forward in the development of podiatric specialisms, the use of local analgesia by podiatrists now being commonplace in everyday practice. Procedures by surgically qualified podiatrists may include forefoot surgery such as digital, metatarsal and bunion corrections, fusions and osteotomies. Digital or ray amputation, neuroma excisions, fasciotomies and rearfoot calcaneal osteotomies are also undertaken (Kilmartin 2000, Price & Tasker 2000).

These factors alone identify marked changes within the profession of podiatry. The acquisition of medical consultant posts plus associate specialist grade contracts within NHS healthcare in the UK has been the most significant achievement of the podiatry profession to date (Scriven 2005). The ever-changing role of the podiatrist encompasses a wide range of activities, and as such health promotion must complement these practices. The revision of the role of the podiatrist has also centred on patient empowerment, and the continuing benefits of this health-promotion approach are well documented (Farndon et al 2007, Laverack 2005, Moore et al 2003, Nancarrow 2003). The future of podiatry needs to remain holistic in its approach, adopting strategies identified in the Feet First report (Department of Health 1994), with expanding role boundaries, encouragement of specialisms and promotion of preventive care.

Possibly one of the most important changes in health promotion over the years has been educating people on how to manage their general health, with specific focus on key aspects. Patient empowerment as a basic right for individuals was emphasised by the WHO as an important component of health promotion (Laverack 2005). However, it can be argued that many allied health professionals may not be in a position to empower individuals, and this issue needs consideration in order to ensure that health promotion becomes an essential aspect of podiatric care, especially with podiatry entering this new specialist era.

The contribution of allied health professionals, including podiatrists, to health-promoting practice is also recognised by the UK government (Department of Health 2003). Ten key roles are identified for allied health professionals highlighting the importance of health promotion within their professional remit. The Standards of Proficiency set by the Health Professions Council (2003), with which podiatrists and other allied health professionals are registered, also reiterates the need for health promotion in professional practice. The Society of Chiropodists and Podiatrists further emphasises the importance of partnership, identifying the relevance of both clinical and educational interventions to maintain patient mobility, thereby improving health and well-being. Furthermore, podiatry education is underpinned by benchmark statements (Quality Assurance Agency for Higher Education 2001), which specifically identify the importance of health promotion within podiatry. A new White Paper ‘Choosing Health: Making Healthier Choices Easier’ (Department of Health 2004) encourages individuals to make choices conducive to health and encourages health workers to adopt health-promoting roles.

There is little literature relating to health promotion and podiatry, although there is a substantial evidence base relating to podiatry and diabetes (Foster 2004, Knowles 2004, O’Boyle et al 2000). The importance of the psychosocial approaches to podiatry, highlighting the need to consider the bigger picture surrounding patients’ health and well-being, cannot be ignored. The literature reminds us that podiatric practice must encompass not only pathological aetiologies but also the wider determinants of health (Mandy et al 2003). Furthermore, the emergence of specialisms within podiatry requires more emphasis on the health-promoting paradigm of empowerment within podiatry.

PATIENT EDUCATION

Podiatrists’ involvement in educating their patients in preventive strategies is essential to minimise problems in the lower limb, which may be attributable to patients’ lack of knowledge about their illness. This is not a new concept and it has been evidenced by many authors over the years (Bradshaw 1990, Dunlop & Baxter 2006, Valente & Nelson 1995, Wormald 1995). However, podiatrists need support to develop effective teaching techniques, conditions and communication tools (Ewles & Simnett 2003, Lockyer et al 1997). There is a range of teaching techniques, including one-to-one discussion, hard-copy information (handouts, leaflets) and DVDs, that can be used to enable practitioners to put their message across comprehensively. In addition, communication tools such as the internet and the media can assist, but these require careful management. The patient may use these routes to access information but, in the absence of practitioner input, they can create anxiety, misinformation and even undermine health. The role of the podiatrist in moderating this type of information and ensuring its appropriate use is an important aspect of patient care. While it is important to use language that is suitable to the patient, it is also necessary to introduce the patient to relevant podiatric terminology to assist their understanding of their treatment.

Although only one aspect of podiatric care, education has important connotations in that it helps both the patient (to know about foot health and understand treatment) and the practitioner (to invest time in preventing potential complications). There are direct implications on both sides, as well as more long-term benefits to the service in terms of cost-effectiveness in an already overstretched service. Making time for patient education in a busy schedule can be difficult, as can developing the health-promotion aspects of practice. A lack of training has been recognised as one obstacle facing allied health professionals wishing to promote health as part of their professional remit (Scriven 2005). As podiatrists have a unique one-to-one access to their patients this barrier needs to be removed to encourage their role as patient educators and health promoters.

Compliance is a key issue but the term can carry negative connotations, the term ‘concordance’ is now used more frequently, as it is more patient-focused. Bell et al (2007) have described concordance in terms of balancing the ‘power’ in healthcare communication between the adviser and recipient. Phipps and Bell (2009) propose the following key points with regard to adherence to treatment:

Other factors may also influence the person, such as: the level of impact of a change on their daily routine (and the cost–benefit of the change); the complexity of the change; they may not want, agree with or accept the advice/information; the timescale may be too long; and communication problems or mental health issues. Awareness of these issues is critical for the podiatric practitioner, in view of the need for concordance in all elements of podiatric intervention, as illustrated in Case Study 27.1.

Good communication is recognised as an essential factor in patient education, and the literature on this subject evidences a lack of these skills as being a dominant barrier. In podiatric practice the complexities of patient–podiatrist interaction, acknowledging the layout of the podiatric setting with the podiatrist based at the foot of the patient, can have a detrimental effect (Mandy et al 2003). A breakdown in patient–podiatrist communication could lead to patient non-concordance with advice, and evidence reminds us that patients respond more favourably to healthcare professionals with whom they can communicate effectively (Dunlop & Baxter 2006, Lutfey & Wishner 1999). Furthermore, some argue that the predominantly older age group of podiatric patients could limit the effectiveness of patient education (O’Boyle et al 2000). Podiatrists should therefore structure their advice to suit the target audience in terms of age and other indicators, and see this as an opportunity rather than a barrier to good communication.

It has been suggested, despite evidence to the contrary, that patient education, health education and health promotion are time-consuming activities having limited benefits (Morris 1998). Indeed, many health professionals would argue that the time allocated to an individual patient is already restricted and should be used for treatment. Research also indicates there may be scepticism amongst podiatry professionals with regard to health promotion, and such an attitude may affect the delivery of health promotion, particularly if it is felt that ‘talking time’ is time wasted time (Macleod Clark & Maben 1998, O’Boyle et al 2000). It could also be argued that time allocated to patient education/health promotion could have financial implications, which need to be evaluated and addressed.

However, what cannot be denied is the importance of education and prevention in healthcare, and as such these paradigms should be an integral part of podiatric practice if patient needs are to be addressed fully. Podiatrists must strive to improve concordance and adherence by using a person-centred approach, with treatment plans that are tailored around the patient’s lifestyle, for maximum efficiency (Aronson 2007, Phipps and Bell 2009). Empowerment and self-care must be encouraged at all times (Farndon et al 2007, Moore et al 2003). Research identifies the impact that front-line professionals such as podiatrists can have in identifying risk factors and advising/referring accordingly, once again emphasising the need to work in partnership with the patient. An example of this would be the integration of advice to stop smoking into routine podiatry services (Gray et al 2007, Rains et al 2006).

Multidisciplinary team working and collaboration between podiatrists, health promoters and other health professionals should be encouraged to maximise health improvement. The importance of this approach is emphasised in diabetic podiatric care, where patients benefit from a range of professional expertise to address foot problems associated with the systemic disease (Gadsby & McInnes 1998, Young 2003). Podiatrists have always had a large input in diabetic care, with research identifying the importance of preventive foot-care programmes in reducing amputation rates (Robbie 2002). It has been suggested that the podiatrist’s role could be enhanced further to include involvement in patient insulin dosage and patient health education regarding blood glucose monitoring (Kerr & Richardson 2000).

Collaboration is also invaluable when managing rheumatology patients, this newest specialist domain in podiatry again demanding emphasis on empowerment and self-care. The podiatrist, whether working in isolation or as part of a team, needs to work as a facilitator to ensure that patient podiatric needs are met and treated in relation to other manifestations of the disease (Woodburn & Helliwell 1997, Nancarrow 2003).

It is widely recognised that common foot problems, whether arising due to trauma, deformities or pedal complications of systemic disease, can affect the patient’s lifestyle and quality of life. The role of podiatrists in public health should encompass footwear, ambulatory and activity problems, and if possible screening should be used to identify childhood foot problems as well as pedal chronic disease. However, consideration should also be given to the health determinants that affect podiatric care, in particular the relevance of income status (e.g. footwear implications), living and working conditions, social support, and genetic manifestations. The literature evidences the relationship between socio-economic status and health, arguing that a patient’s needs are complex, with pathological aetiologies being only one of many factors affecting their health status (Brodie 2001, Helfand 1998, Helfand & Hausman 2001, Mandy et al 2003).

Until the last decade, the curriculum for podiatry training was based primarily on the medical model of health. While addressing podiatric complications and the restoration of physiological function is important, this model fails to consider the implications of behavioural, psychological and socio-economic influences on an individual’s health or illness status. Consideration of the determinants of health, especially inequalities in health that can affect the management of the podiatric patient, is paramount (Acheson 1998, O’Donnell 2005). Some argue that health promotion in podiatry has not made much progress over the years, and suggest the development of tailor-made programmes to address this. The literature reiterates the need to provide foot and general health education to younger age groups in order to furnish individuals with the skills necessary to make informed choices (Brodie 2001).

The primary challenges for healthcare professionals are how to make change acceptable, how to tell people about it, how to make change happen and how to sustain the change. It may be helpful for podiatrists to use theoretical frameworks to enable them to address the complexities involved in behaviour change. That said, podiatrists need to recognise not only the advantages but also the disadvantages of the behaviour-change approach (Naidoo & Wills 2000). Patient vulnerability, the perceived effectiveness of any change, the opinions of significant others and the severity of underlying disease can all influence an individual’s ability to change behaviour. Individuals need to have an incentive to change; they need to understand the benefits of making the changes and be empowered to confidently make those changes. Equity and autonomy are important principles, and each patient should be encouraged to achieve their individual potential. It is crucial to avoid ‘victim blaming’, which can occur when dealing with patients whose behaviour may have influenced their health and/or adversely affected their care.

Mandy et al (2003) identify the need for podiatry students to develop professional skills towards autonomous practice as a basis for life-long learning, reinforcing the message that reflective practice provides the means for learning from everyday experiences (Bolton 2005). However, behaviour change cannot be guaranteed to result from the acquisition of knowledge (Davies & Macdowall 2006).

EVIDENCE-BASED PRACTICE

The importance of evidence-based practice for healthcare professionals cannot be denied. Research identifies that podiatrists who underpin their professional practice with evidence-based knowledge can significantly contribute to the health improvement of individuals and the population as a whole (O’Donnell 2005). In the current climate of public distrust of expert knowledge podiatrists should strive not to make unvalidated or unqualified claims in health-risk advice, research identifying that it is not enough in the practice of promoting health to rely on good intentions and perceived wisdom (Dunlop & Baxter 2006, McQueen 2001, Naidoo & Wills 2005). Today’s environment is such that individuals may be less inclined to readily accept advice or information given by professionals, unless supported by theory. That said, not all knowledge can be supported by evidence, but such unsupported data should nevertheless be considered (McQueen 2001).

CONCLUSIONS

The WHO Ottawa Charter presents health promotion as a process of enabling individuals to take more control over and improve their health. The various connotations of what is meant by ‘health’ underpin our efforts to improve not only the physical but also the mental and social well-being of individuals (Ewles & Simnett 2003). Health can be regarded as a basic human right, an everyday resource for living, not just an objective of living, and be reiterated as a positive concept (Sidell et al 2003). As such health promotion must go beyond health-sector settings if we are to encourage healthful behaviours and lifestyles to improve well-being. The ultimate goal of health promotion is to increase not only health expectancy but to narrow the gap in health expectancy between countries and communities (Edelman & Mandle 2006). Health promotion works to reduce inequalities in health, addressing the determinants of health to achieve the greatest health gains for both individuals and the population as a whole.

Health promotion in podiatry must strive to follow the principles of the Ottawa Charter (World Health Organization 1986), and encompass a set of values that includes empowerment, equity, collaboration and participation. A bottom-up approach will encourage podiatry patients to take more control over their health. Podiatrists must avoid victim-blaming and always consider the social determinants of health underpinning patient lifestyles and behaviour. In an age where life expectancy is increasing, podiatric services are in great demand (Dunlop & Baxter 2006). In the long term, health promotion in podiatry should provide economic benefits in health services, and preventive strategies to improve long-term health gain. However, critics could argue that health promotion in podiatry may generate greater demand on an already overstretched service, and this possibility cannot be ignored.

The literature to date evidences the need for health promotion, health education and patient education in podiatry, but there is a gap in the available literature on this subject itself. The role of health promotion in podiatry should not be restricted to foot health education alone, but needs to encompass the wider variables such as behavioural and socio-economic determinants that affect the health and well-being of podiatry patients. However, although the role of health promotion and patient education is becoming more widely recognised as a requisite of podiatric care, in reality this role is still largely omitted in everyday practice. In order to address this, the podiatrists of the future need to be empowered with the necessary skills and knowledge to carry out this extended role.

Podiatrists aim to maintain patient mobility and independence, and as such patient empowerment is an essential aspect of podiatric care. The role of health promotion within podiatry is vital to ensure that podiatry patients receive the best possible care, including eduction in preventive strategies to help allay future health problems. The notion of making the healthy choice the easy choice is fundamental to success in health promotion, and is as relevant in podiatric care as in any aspect of lifestyle where choice applies.

In order to develop practice and improve podiatric standards, it is important to evaluate our understanding and progress. Evaluation helps us to understand the learning process more fully and can be considered in terms of process, outcome and impact. When we think about podiatric practice, the same approach can be applied to enable us to understand whether what we have done was successful in the way we did it, in the outcome it achieved and/or whether it had the intended effect. Evaluation should form an integral part of practice, encouraging reflection, which enables us to improve. With this in mind, before finishing this chapter consider evaluating your own learning: