Intervention study of a foot‐care programme enhancing knowledge and practice among nurses and care workers at in‐home service providers

Abstract Aim To evaluate the foot‐care educational programme for nurses and care workers at in‐home service providers. Design A non‐randomized controlled study with random cluster sampling method. Methods Study participants were nurses and care workers of 21 in‐home service providers, including home‐visit nursing and care providers, 1‐day care service centres or care centres with rehabilitation programme in Japan. Foot‐care programme with foot‐care tools as a package or standard care comprising 3–5 sessions over 2 months was provided to 110 participants (87 were on analysis). The outcomes were changes in foot‐care knowledge and scores in pre–post interventions. Data were analysed with descriptive statistics, t test, logistic regression analysis and ANCOVA. Results Before adjusting for background, total scores of knowledge and practice categories were higher than the baseline in the intervention group (43 participants) compared with the control group (44 participants). After background correction due to potential bias of non‐random cluster sampling, significant between group differences were observed in mean score changes in skin and consultation subscales of the practice category.


| BACKG ROU N D
A lack of knowledge, practice and perception regarding foot-care among caregivers and health professionals negatively affects the efficacy of foot-care. Older people are more likely to seek professional help than help from family members (Miikkola, Lantta, Suhonen, & Stolt, 2019). In particular, community-dwelling older people living without any family support (Kim, Yang, & Lee, 2016) frequently seek physical care from nurses or care workers (Ergin, Belgin, & Tanyer, 2018). These individuals require foot-care regardless of the presence of foot-related illnesses.
Healthcare demands and costs are expected to increase worldwide as the global population ages (World Bank Group, 2018). The Japanese society is ageing due to ongoing demographic changes, posing serious challenges for community-based healthcare systems (World Health Organization, 2017). Accordingly, the Japanese government has promoted in-home health care (Japanese Nursing Association, 2019) to address the dramatic increases in nursing burden as well as the elevated costs of medical care (Ministry of Health, Labour, & Welfare, 2016). In the Japanese system, older people use two types of insurance system to obtain health services: the national insurance and long-term care insurance (Fujii, 2019). Nurses and care workers who work at in-home service providers play a great role in supporting clients who need some assistance in relation to maintaining their health, the daily activities of living and simple rehabilitation. They have contacts with the client's body during care and, thus, have better opportunities to observe their foot-related problems. There is no podiatry care in Japan, unlike in other countries such as the UK, Finland and Australia (Boulton, Vileikyte, Ragnarson-Tennvall, & Apelqvist, 2005;Miikkola et al., 2019). Although nurses and care workers take care of the foot, they may overlook some foot-related issues due to the complexity of the problem in the community. The current prevalence rate of foot diseases in the community is unknown in Japan.
As such, there has been limited research on the role of nurses and care workers in foot-care for community-dwelling older people, regardless of the type of foot disease concerned (Miikkola et al., 2019;Stolt et al., 2013).
Drawing from and analysing previous research on foot-care and clinical experiences, this study develops a foot-care programme for nurses and care workers. This study seeks to evaluate it vis-à-vis enhancing the knowledge and skills among these professionals who assist older people as in-home service providers.

| Research question
The specific research questions were as follows: (a) What are the effects of the foot-care programme on nurses and care workers' knowledge and practice of foot-care? (b) What are nurses and care workers' learning perceptions of foot-care programme?

| Design
This was a non-randomized controlled trial with random cluster sampling method conducted in N city of A prefecture in Japan (August-October 2019). This study followed the TREND statement (Des Jarlais, Lyles, Crepaz, & Trend Group, 2004).
The participants (nurses and care workers) were recruited from 21 in-home service providers that expressed interest and willingness to incorporate the foot-care programme. Beforehand, invitation letters were sent to randomly selected 450 providers of in-home service listed by the Ministry of Health, Labour and Welfare (hereafter, MHLW). The providers include home-visit care providers, home-visit nursing providers, daycare service centres and daycare centres offering a rehabilitation programme. An author visited the providers that positively reponded to the invitation letter using a postcard. The author explained the contents of the study. Providers who agreed to participate in the study were non-randomly allocated to the intervention and control groups because some providers decided to participate in the control group due to their circumstance, such as summer events or shortage of personnel at the time of study. Each provider did not know one another as well as the type of intervention.
The sample size was determined based on G ※ Power. Cohen's (Cohen, 1988) parameters for effect sizes (small = 0.2, medium = 0.5 and large = 0.8) were used. Target sample size and drop rate were considered based on previous literatures although data obtained using the same type of study design were limited. When the effect size of 0.5 was considered, the number of participants was 64 for each group. By considering 36% as the percentage of those predicted to discontinue their participation, 200 nurses and care workers with a ratio of 20/80% (1:4) were set as the initial target. Within the recruiting period, however, a total of 110 nurses and care workers were expected to enrol in the study. The inclusion criteria were as follows: (a) providing physical care for clients at in-home service providers that never receive intervention programme from other studies and (b) working either part-time or full-time and having no plan to quit the job during the study.
In Japan, many care-related tasks overlap between the duties of nurses and care workers. Job exceptions are the clinical and medical practices that nurses perform under the law. In the absence of podiatry licences, unlike those reported in other countries (Boulton et al., 2005;Carter et al., 2017;Miikkola et al., 2019;Wylie et al., 2019), the number of physicians with extensive knowledge of foot and foot-care is limited. Nurses and care workers also have limited knowledge. Therefore, those working for in-home service providers have tremendous limitations in terms of reference and care.
The primary outcome was changes in foot-care knowledge and practice scores collected before and after the intervention for both groups. Before the intervention, demographic data were obtained, including sex, profession, working status, age, working experiences and the number of clients cared for in a day. The instrument was employed to assess foot-care knowledge and practices of the nurses and care workers. The knowledge category consisted of seven scales (nail, skin, vascular and neurologic disorder, toe and arch, infection, shoes and socks and sedentary behaviour) with 30 questions coded as a "yes" (1 point), "no" (0 point) or "I do not know" (0 point). The practice category consisted of six subscales (skin assessment, nail, skin, hygiene, movement and toe exercise and consultation) with 20 questions coded as a "strongly relevant" (5 points), "more relevant" (4 points), "neutral" (3 points), "less relevant" (2 points) and "not relevant" (1 point). Higher scores indicated higher knowledge and practice of foot-care. Content validity of the instrument was well examined by a review of the abundant literature, four experts, two nurses and one care worker on the field, nine experts with CVI method, a panel of six experts consisting of three university faculty members with relevant experience in foot research, one surgeon with extensive knowledge of foot, one field nurse with foot-care certification from a private school and one foot-care worker with more than 20 years of experiences. The reliability coefficient of practice subscales was evaluated with Cronbach's alpha and the ceiling effects via two-stage studies. A high accuracy rate of knowledge items was achieved.
The second outcome was programme-related learning perception. The instrument measured participants' perception of increasing knowledge on hygiene and exercise, the effect on sedentary behaviour on a body, early detection of foot, vascular and neurologic impediment, skin and nails. It was also asked if they were willing to learn about foot in future and they want to increase interest in foot. Participants were asked nine questions coded as "I disagree" (1 point), "I somewhat disagree" (2 points), "I somewhat agree" (3 points) and "I agree" (4 points) at the postintervention period.

| Method
The foot-care programme was developed with integrated tools as a package for this study. Foot-care knowledge and practice of nurse and care workers as well as working circumstances of them are different. Therefore, a variety of tools were prepared as introductory educational foot-care programme.
The tools included the following: (a) an 68-slide PowerPoint presentation material (hereafter PPT); (b) a 10-min motion picture material (hereafter MP); (c) a 19-page picture story card; (d) a 78-page foot-care booklet; (e) a one-page foot-care assessment sheet; and (f) a one-point foot-care advice card. A nail file for each participant and a foot file for each provider were given. Animation characters, "Hikaru, Mamoru and Spia" (character names) coming from a planet called "foot star," were developed for the study and used in all the tools. The tools were validated by experts on several occasions throughout the study.
Previous studies have demonstrated the use of various tools to enhance diabetic patients' knowledge and practice on footcare through intervention studies. Some of these tools include PowerPoint presentations, pamphlets, iPads, forms to review on foot self-care, foot-care kits (soap, towel, washcloth mirror, etc.), assessment tools (monofilaments) and web pages linked to PDF (Borges & Oswald, 2008;Hunt et al., 2014;McDonald, Shah, & Wallace, 2013;Sharoni et al., 2017;Waheida et al., 2015).
Intervention group underwent the foot-care programme. Three to five sessions were held with the tools during a 2-month survey period.
Each session was conducted during the day or night, depending on provider's work condition. Table 1 shows the procedure of the programme.
Interventions and data collection were conducted by the primary researcher who is a registered nurse with an authorized certificate in footcare from the Japanese Society for Foot Care and Podiatric Medicine (Web site available only in Japanese, 2019) and a foot-care-related certificate from the Japan Foot-Care Fusspflege school (Web site available only in Japanese, 2019). Participants in the control group offered regular care. At the end of the intervention, the information on the exposure to the tools was collected by asking the participants in the interventon group (Table 2). All participants were asked to answer foot-care knowledge and practice questions at two points of the study period.

| Analysis
The participants included in the analysis were those who answered 80% or more of the knowledge (24 out of 30) and practice questions (16 out of 20) at both. We excluded one person who answered "I don't know" for all the questions. Data were analysed with descriptive analysis. For knowledge score, an answer of "I do not know" was counted as "no." In the case of "no answer," knowledge problems were counted as incorrect answers. The background of each group was first compared for the comparability between the intervention and control groups. The Fisher's exact test or Student's t test was applied. After confirming that the distribution of each evaluation item was not significantly different from the normal distribution, Student's t test was applied for the score change between the intervention and control groups. The t test was used for the score changes for the pre-and postintervention of each group. Because randomization was not possible, propensity scores (predicted probability that each participant belongs to the intervention group) were calculated with multiple logistic regression analysis for background adjustment. The reason for using the propensity score is that the number of subjects in this study was not sufficiently large and there was a concern about the decrease in power due to a decrease in the degree of freedom in the adjustment by ordinary covariance analysis.
The effects of intervention were verified by covariance analysis with the change of each evaluation item (after-before) as dependent variables. The independent variables were interventions (intervention/ non-intervention), the propensity scores and the pre-intervention performance of the evaluation item. Data input was conducted by

| Ethics
The research was carried out in accordance with the Helsinki  Figure 1 shows the consort. The analysis was 43 for 11 providers in the intervention group and 44 for 10 providers in the control group. Mean ages were 47 (SD 11.8) and 50 (SD 11.6) years in Data indicated that the educational foot-care programme resulted in significant improvements in some areas of practice (question 1).

| RE SULTS
Participant perceptions were quite high (>50% responded "I think so") in the understanding of hygiene and the effects of sedentary behaviours on the body. Table 3 shows the demographic data and daily activity information. To avoid confusion, the author repeatedly told participants that the study intervention is for nurses and care workers, not directly for the client.
Before adjusting for demographic characteristics (Table 4), the significant differences in knowledge and practice were not recognized between the intervention and control groups. Scores of the subscales of nail, skin infection, shoes and sedentary behaviour in knowledge category and of the subscales of skin and consultation in practice category were significantly improved from the baseline in the intervention group. Score changes of these subscales were higher compared with the control group. After adjusting for the deflection of the demographic characteristics with logistic regression analysis (Table 5), significant differences were recognized in the mean score changes in the skin and a consultation subscales in the practice category with ANCOVA between the intervention and the control group (p = .041, p = .037).

TA B L E 3 Demographic characteristics
The changes in score of these subscales were higher in the intervention group compared with the control group (1.17, 1.08 versus − 0.08, 0.20) ( Table 4). The practice score of nail and movement and toe exercise was higher in the control group compared with the intervention group.

| D ISCUSS I ON
This is the first non-randomized interventional study to identify the efficacy of the foot-care programme for nurses and care workers at in-home service providers. Data were collected before and after the intervention, and they show a significant improvement of practice in the intervention group. Participants' learning perception varies depending on the questions, but more than 50% perceived better learning in the intervention group.
The strength of the programme is its focus on nurses and care workers. Additionally, care workers were included in the study because of their countless roles in detecting signs and symptoms of health issues at home services (Haugstvedt, Aarflot, Igland, Landbakk, & Graue, 2016;Tingström et al., 2015). Many older people living in the community were not able to care for their feet due to the physical changes of ageing. The prevalence of foot problems of older people varies depending on the type of research (21%-87%) (Awale et al., 2017;Menz, 2016;Rodríguez-Sanz et al., 2018). A variety of foot problems were reported (Muchna et al., 2018;Nguyen et al., 2010). Nurses and care workers play a key role to supplement the insufficiency of self-foot-care of older people (Stolt et al., 2012). The results of this study echo that of a previous study on the efficacy of nursing educational sessions. Another strength of this study was a combination of intervention tools as Note: Student's t test: before and after intervention of each subscale. Paired t test: comparison between intervention and control group.

TA B L E 4 (Continued)
an integrated package. To account for learner variability in terms of foot-care education in Japan and work time constraints, the author developed several tools to provide more opportunities to expose foot-care learning. The method employed by such tools included combined listening, watching, reading and interactive exercising.
We followed the beneficial effects of practice sessions reported in the previous literature (Fan et al., 2013;Seyyedrasooli et al., 2015).
This study employed 10-20-min practice sessions with a mix of a large and small group approach. Despite the short time, it showed that the intervention was effective in practice to a certain extent. Skin checks and care of the feet were emphasized in a series of interventions. The scattered delivery of information of this area might lead to an improvement of the scores. Skin problems were high because of ageing (Laube, 2004). Questions about the foot file were not included in the questionnaire. However, since there were clients who have issues of keratotic lesions (corns and calluses) at the time of assessment, how to use the foot file was included in the training session. In a large-scale epidemiology study, Menz (2016) stated that keratotic lesions triggered by nail disorders and structural deformities commonly result in foot pain. This highlights why the use of the foot-care file should be included in future evaluations.
Sharing information with the participants by assessing the client's feet together led to a score improvement in consultation.
During the training sessions, the main author suggested med- Before adjusting for background data, a total of the scores in subscales of knowledge and practice improved for both groups.
Score improvment in both groups may be associated with background-related factors between groups such as number of nurses and work experiences. This study was not able to execute randomize allocation. Therefore, the number of the allocations was almost even. There were more females, nurses, participants with part-time statuses, age and those with extensive working experiences in the control group.
Change of scores of the intervention group was higher in five subscales out of six in knowledge and five subscales out of seven in practice compared with the results of the control group. The score changes for the nail in knowledge category significantly improved in the intervention group at the pre-and postinterventions; however, score changes for the nail in practice category improved higher in control group. Due to time constrains and insufficient nail cutting materials, interventions to enhance nail practice skills had some limitations. Uneven knowledge and skills of the nail of each participant at the time of intervention may reflect the results. The toenails of older people include thickened, elongated and ingrown nail. Confusion often exists concerning who should perform nail care (Malkin & Berridge, 2009). They also may not know where to consult with foot problem; however, not enough research on this issue has been reported in Japan.
The use of foot-care sessions opened the first door for nurses and care workers at in-home service providers to deal with the complexity of foot-care for older people. This programme is best suited to the current Japanese society due to the predicted high prevalence of foot problems of the community-dwelling older people. Delivery of best foot-care for older people faces many hurdles. Seeing the doctor due to foot problems is challenging for clients. Referral to the doctor with extensive knowledge and practice of foot is not customized in Japan. Therefore, wide basic knowledge and practice skills of foot and foot-care should be improved among nurses and care workers in the community.
Nurses and care worker require bending to see or care of feet and concentration on look the site carefully, while they have responsibility to carefully watch many older people going beyond frail status, in particular 1-day service providers. Foot-care time allocation in care schedule requires an understanding of the significance of the foot-care in-home visiting nurses or care providers. Like barrier to diabetic foot-care (Guell & Unwin, 2015), countless barrier to footcare of the older people in the community. Foot-care is challenging; therefore, efficient and easy-to-understand foot-care programmes need to be further explored. Future large and in-depth studies are needed to confirm the validity of the programme developed in this study.

| Limitations
There are some limitations associated with this study. The invervention was conducted based on personal instructions of the main author. The foot-care educational programme exercised in this study has not been standardized because of lack of exercise worldwide for the targeted population. Further, randomized allocation was difficult due to circumstances of Japanses care system. The exposure to all tools to all participants was difficult due to time constraints. Dropout rates are a limitation of this study (N = 11 for intervention and N = 12 for control groups). Although the practice scores were significantly improved in the intervention group, it was only 20 questions. All areas of practice did not reflect in only 20 questions. Additionally, only 30 knowledge questions did not cover a variety of foot-care issues although the essence of the problems was focused through extensive preparation. The instruments were newly developed, and evidence of validity and reliability is limited. However, those measure important content. The exposure to all tools was difficult for participants due to time constraints. As far as practice, introduction of nail care requires time and equipment.