Lorraine H. Marchand, MA, Wendy Campbell, MA, and Robert J. Rolfsen

Abstract

In November 1995, the first nationwide campaign to increase awareness that diabetes-related amputations can be prevented was announced, the result of a collaboration among 10 public and private partners. The campaign, “Feet Can Last a Lifetime,” was organized by staff at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). It featured patient workshops on foot care, health-care provider workshops on detecting insensate feet, a mass media public information campaign, and dissemination of foot-care information kits to people with diabetes and to health-care professionals. The campaign’s audiences included people with diabetes and their families; health-care providers; partner organizations and their affiliates; the news media; and the general public. A well-recognized health communications model guided development, implementation, and evaluation of the campaign. Campaign methodology was based on this six-stage model and incorporated strategies for reaching each target audience. The methodology included creating a theme, inviting interested organizations to participate, developing audience-specific communication materials, implementing a mass media campaign, and conducting community-level educational workshops. Results were measured in several ways and revealed some weaknesses. Overall, however, the campaign succeeded in increasing awareness that diabetic foot amputations can be prevented. While this campaign was launched nationally, it can serve as a model for regional and local efforts. Health-care providers can refer to this model in developing their own amputation-prevention workshops and generating media coverage.

The Problem

“An ounce of prevention is worth a pound of cure,” is certainly an appropriate maxim when discussing foot care for people with diabetes. Consider these statistics.

• An estimated 54,000 diabetes-related lower extremity amputations (LEAs) are performed annually,¹ with hospital and surgical costs totaling $500 million per year.²

• The 5-year survival rate for these patients is ~ 50%.³

• Between 50% and 75% of these amputations can be prevented.⁴

Despite these compelling figures, Kenny and colleagues5 found that ~ 53% of family physicians reported adherence to recommendations for semiannual foot examinations for patients with type II diabetes. Adherence was ~ 64% for family practitioners treating patients with type I diabetes.

Campaign Goal and Objectives
To increase awareness that diabetes-related LEAs can be prevented, 10 federal, voluntary, and professional organizations (Table 1) joined forces in November 1995 for National Diabetes Month, to launch the “Feet Can Last a Lifetime” public health campaign.

The campaign’s goal was to increase awareness among health-care providers, people with diabetes and their families, and the general public that LEAs can be prevented with daily foot care, use of appropriate footwear, and regular examinations by health-care providers. The campaign’s objectives were:

• to hold local workshops to educate and instruct patients and providers on diabetic foot care and detection of problems,

• to use the mass media to increase public, patient, and provider awareness that LEAs can be prevented, and

• to develop and distribute education- al materials about amputation prevention to health-care providers and people with diabetes.

Communications Approach
The communications approach incorporated principles of social marketing, health education, and mass communication, and was based on a well-recognized health communications model that identifies six stages of activity.⁶ These stages were used to guide the development and dissemination of communication materials for each of the target audiences.

When developing public health programs, health-care professionals may want to refer to these stages or consider an alternate communications model.

1. Planning and Strategy Selection: identifying the problem, the target audience, and the goals and objec tives of the campaign, and developing the message and evaluation component.

2. Selecting Channels and Materials: identifying existing materials that can be used in the program, channels most appropriate for reaching target audiences, and types of materials best suited for the message and audiences.

3. Developing Materials and Pretesting: developing different approaches for communicating the message and testing it with the tar get audiences.

4. Implementation: introducing the campaign to the target audiences.

5. Assessing Effectiveness: analyzing results of measurements developed in stage 1 and determining whether the target audiences are receiving the message, whether the channels of communication are appropriate, and whether the campaign needs to be adjusted.

6. Feedback to Refine Program: using evaluation results to improve the program.

In the Planning and Strategy stage, campaign developers recognized that several partner organizations already had programs and materials in place to promote foot care. Although the “Feet Can Last a Lifetime” campaign was new, it also supported and expanded ongoing activities.

The organizers also recognized that several equally worthy diabetes messages were competing for attention in November (National Diabetes Month), including the National Eye Institute’s annual diabetic eye disease awareness campaign and the release of new statistics on the prevalence of type II diabetes at a news conference sponsored by the American Medical Association, the American Diabetes Association (ADA), and NIDDK.

The partners, aware that they needed an interesting media angle, decided to focus attention on the Department of Veterans Affairs, which was seeking to increase visibility of its amputation prevention program. Focusing on the VA gave the partners an opportunity to present amputation prevention from a unique perspective. First, veterans receiving their health care though VA hospitals have a high incidence of diabetes-related amputations, some 9,000 each year. Second, Veterans Day is in November, creating a natural tie-in for the news media.

Campaign Methodology

The “Feet Can Last a Lifetime” campaign was designed and implemented in five steps over a 4-month period. Providers may want to consider these five steps when developing local foot-care activities.

1. Create a campaign identity.

2. Identify coalition partners.

3. Develop targeted communication materials.

4. Develop and implement a mass media campaign.

5. Support/conduct local foot care workshops and outreach activities.

Creating a campaign identity. The planning group discussed the importance of developing an attractive and attention-getting slogan that presented the issue of amputation in a non-threatening manner. The group decided on “Feet Can Last a Lifetime: If you have diabetes, take steps for healthy feet” because it is nonjudgmental and encourages people to take care of their feet. The graphic design accompanying the slogan showed four pairs of feet, representing different age groups and ethnicities. Since diabetes disproportionately affects minorities, it was important that the design reflect cultural diversity. The slogan and logo are not copyrighted, and educators are encouraged to use the campaign identity when developing local programs. If educators prefer to develop their own logo, they should consider contacting a local graphic artist or working with the art department at their institution.

Identifying coalition partners. The cornerstone of the campaign was the participation and coordinated activities of coalition partners. Having multiple organizations endorse a message not only enhances believability and campaign credibility, but also increases the number of communication channels available for dissemination.

The partnership’s success was due to the mutually beneficial nature of this relationship. While 10 public and private agencies participated in the campaign’s premiere, other organizations could have been involved. Materials and messages already developed by partner organizations were featured in the information kits, enabling partners to reach a broader audience while supporting the campaign’s goals and objectives.

To participate as a partner, organizations had to meet three criteria.

1. Demonstrate an interest or involvement in amputation prevention.

2. Serve populations at risk for LEAs.

3. Have a network of hospitals, clinics, or chapters willing to promote the campaign locally.

Most of the 10 partners have local affiliates and programs, and educators may want to consider contacting their local ADA, JDF, CDC, and VA hospital to discuss forming a foot-care partnership. Other potential partners could include churches, community groups, podiatrists, and pedorthic specialists.

Developing targeted communication materials. Four information kits were developed to support the campaign. Each was designed for a specific audience: patients/consumers, health-care providers, partner organizations (technical assistance kit), and the news media (media kit). These kits are all still available. Ordering information is listed at the end of this article.

The patient/consumer kit provides practical information on foot care and includes a foot-care fact sheet, a reprint of the CDC’s “Taking Charge of Your Diabetes: Prevent Foot Problems,” a JDF Countdown magazine article called “Fit Feet,” and new Medicare guidelines for therapeutic shoe reimbursement prepared by the Pedorthic Footwear Association. The kit also contains a home-care item: a towel bar/doorknob hanger with foot-care tips that can be placed in a bathroom or bedroom, where people are likely to examine their feet.

The materials for health-care providers were designed for two purposes: to provide materials that could be duplicated and distributed to patients, and to educate providers on screening for nerve damage using the technique endorsed by the Lower Extremity Amputation Prevention (LEAP) program.

The kit features the LEAP screening instructions and a monofilament (a device to identify loss of protective sensation), a patient video on foot care and footwear selection, and a foot screening training video for health-care professionals. The kit also includes a reprint of a July/August 1995 Diabetes Spectrum From Research to Practice section on preventing lower extremity amputations, and patient education materials. A full-color poster with foot-care tips, a promotional button, and doorknob hangers also are included. Health-care providers can purchase the kit for $15 (for shipping and handling). A foot-care slide set for health-care professionals, developed by the Indian Health Service and National Diabetes Information Clearinghouse, is also available for $15. Educators are encouraged to use these materials in developing and conducting local programs.

The technical assistance kit was developed to aid partner organizations in planning and conducting local workshops and generating media coverage. Three months before the campaign launch, NIDDK staff conducted a needs assessment among partners to gauge the types of assistance needed. The technical assistance kit includes fact sheets and articles appropriate for distribution to patients; a guide to working with the news media; print and radio public service announcements; a news media kit including sample press releases; and the campaign poster, doorknob hangers, and promotional buttons. Many of the partner organizations specifically requested promotional materials during the needs assessment.

Diabetes educators may want to use the technical assistance kit for guidance in planning and publicizing patient workshops. These materials are not copyrighted, and educators may reproduce as many copies as they need.

It is well documented that a comprehensive mass media strategy can be one of the best ways to reach large, diverse audiences. However, messages are usually more believable when heard from a trusted source, such as a local physician, nurse, or other health-care provider. While partner hospitals and clinics developed workshops to educate patients and health-care providers on amputation prevention, other partner organizations used materials in the technical assistance kit to strengthen and supplement existing programs. Media coverage drew attention to these efforts and increased public awareness.

Implementing a mass media campaign. A comprehensive mass media campaign was considered an effective means for reaching providers and people with diabetes with the foot-care message. The strategy was to generate national news coverage for the campaign and local coverage for community-based efforts. The media kit was distributed to 1,500 media outlets, including national newspapers, selected local newspapers, minority media, syndicated columnists, and wire services. A video news release (VNR) was produced and promoted to the 850 television and cable stations around the country. Staff placed follow-up telephone calls to media to increase coverage.

Diabetes educators may want to use the media materials, including sample press releases, found in the “Feet Can Last a Lifetime” technical assistance kit, to facilitate local media coverage. A guide for working with the media and print and broadcast public service announcements are included in the kit. Educators associated with hospitals and clinics should consider working with the public relations staff at their institutions to a develop a media list and to place media calls.

Campaign Evaluation

The evaluation component of the campaign was developed during the planning phase and implemented following the launch. Measures of the campaign’s success included:

• numbers of patients/providers reached through local educational workshops and free community screenings,

• numbers of the general public potentially reached through national and local media, and

• numbers of providers/consumers requesting educational materials through the toll-free telephone num- ber.

In developing the evaluation component of their own programs, diabetes educators should consider what can be measured. For example, if a foot-care workshop is held, educators could develop and distribute an evaluation form to assess the effectiveness of materials and the workshop. If media coverage is a component of the program, educators may want to track how many people received their message by monitoring media placements and gathering audience demographics. Educators may want to consult with the public relations staff at their institution for information on media monitoring.

Media evaluation. Media coverage was tracked by newspaper and television monitoring services. Broadcast monitoring reports showed that the three television networks, ABC, CBS, NBC, and the Cable News Network used the VNR, which was distributed via satellite on November 3, 1995. Local television stations also used the VNR and interviewed local spokespeople, including physicians at VA hospitals. Approximately 40 million people received the foot-care message through local and national television coverage. Several local radio stations interviewed partner spokespeople for a total listenership of 3 million. Print readership totaled 10 million. In all, approximately 53 million people potentially received the foot care message.

Materials Distribution Evaluation. Counting the calls made to a toll-free phone number managed by the National Diabetes Information Clearinghouse was another component of evaluation. To date, the clearinghouse has distributed about 4,000 health-care provider kits and 100,000 consumer kits. Both provider and consumer kits included response cards to assess reaction to the materials; 500 health-care providers and 700 consumers responded.

According to providers who responded, the most useful items were the monofilament, the patient and provider videos, the doorknob hanger, and the poster. Seventy-five percent of responding providers indicated that they had shared all of the materials, including the printed information, with their patients. Several professionals noted that the kit design could be improved so that materials did not spill out. Twenty-four percent indicated that they needed additional quantities of door knob hangers.

Consumers indicated that they had read the materials. Forty-five percent noted that the Medicare information on therapeutic shoes was helpful. Seventy-eight percent indicated that they would like to see a mirror added to the kit, for assistance in examining their feet. And 35% requested additional information on topics such as nerve disease, diet, and exercise.

Evaluation Conclusions

The “Feet Can Last a Lifetime” campaign was effective in increasing foot- care awareness among modest numbers of people with diabetes and health-care providers. Evaluation of the campaign and input from the 10 partner organizations revealed that the effort could be improved in the following ways.

• The campaign was conceived in June 1995, and implemented in November of the same year. Four months’ lead time was not adequate for all partner organizations to have programs in place. In the future, it would be preferable to have a 9- month lead time.

• National Diabetes Month has become saturated with media and consumer messages. A spring cam paign emphasizing fitness activities and athletic shoe selection may be more effective.

• The amputation prevention message alone was not compelling enough to capture the media’s attention. Several reporters commented that 54,000 amputations was not a high enough number to interest their readers/viewers. In contrast, when HRSA announced that a $10 monofilament could save $1.4 mil lion per year in amputation-related expenses, the media responded. In the future, the monofilament’s role in amputation prevention should be emphasized.

• The National Diabetes Outreach Program (NDOP) of the NIDDK reproduced 4,000 health-care provider kits at a cost of $15 each and 100,000 patient/consumer kits at a cost of $1 each. The supply of both kits was depleted within 6 months of the launch. Due to the cost of reproducing the kits, the campaign is in need of a corporate or volunteer agency sponsor.

How to Participate in
“Feet Can Last a Lifetime”

The “Feet Can Last a Lifetime” campaign is ongoing and is seeking new partners to help spread the foot-care message to diabetes patients and health-care providers. Sponsors willing to reproduce and distribute the health-care provider kits also are needed. Organizations interested in reproducing large quantities of the health-care provider kits can purchase the art work on computer disk for $500 (includes duplication of disk, shipping and handling). Master copies of the other three kits (consumer/patient, media, and technical assistance) are available at no charge. These materials are not copyrighted, and individuals are encouraged to reproduce quantities as needed.

For more information about participating in the program or to request master copies of the free kits or the provider kit on disk, please write to Lorraine Marchand at the correspondence address listed on the first page of this article. Although the campaign had to be temporarily discontinued in June 1996, limited quantities of the patient/consumer and health-care provider kits are now available. Please call 1-800-438-5383 for ordering instructions.

Acknowledgments

The following individuals assisted in planning and implementing the “Feet Can Last a Lifetime” campaign: Marc Safran and Dawn Satterfield, CDC; Leonard Pogach, VA; Jim Mitchell, HRSA; Nancy Hultquist, PFA; Leonard Levy, CCPM; Elizabeth Miller, ADA; Hardy Stone, IHS; and Kris Ernst, AADE.

References

¹Reiber GE, Smith D, McNamara K, Preston S: The epidemiology of amputation in the United States, 1989-1992. In Diabetes in America (2nd ed.). Harris Ml, Ed. Department of Health and Human Services, National Institutes of Health, 1995.

²Reiber GE: Epidemiology of the diabetic foot. In The Diabetic Foot (5th ed.). Levin WM, O’Neal LW, Eds. St. Louis, Mo., Mosby, 1992, p. 1-13.

³Sibert S: Amputation of the lower extremity in diabetes mellitus. Diabetes 11: 297-99, 1992.

⁴Pecoraro RE, Reiber GE, Burgess EM: Pathways in diabetic limb amputations: basis for prevention. Diabetes Care 13:513-21, 1990.

⁵Kenny SJ, Smith PJ: Survey of physician practice behaviors related to diabetes mellitus in the U.S. Diabetes Care 16:1507-10, 1993.

⁷Bratic-Arkin E: Making Health Communication Programs Work. U.S. Department of Health and Human Services, National Cancer Institute, 1992, p. 5-6.

Lorraine H. Marchand, MA, is director of the National Diabetes Outreach Program of the National Institute of Diabetes and Digestive and Kidney Diseases in Bethesda, Md. Wendy Campbell, MA, is president of Campbell and Company in Alexandria, Va., and a consultant to the National Diabetes Outreach Program. Robert J. Rolfsen is director of the Lower Extremity Amputation Prevention Program of the Gillis W. Long Hansen’s Disease Center in Carville, La.