Diabetic foot care training for community nurses in Samoa

A group selfie shows 5 women and two men smiling at the camera. The nurses are wearing scrubs. Nalini and Katrina are holding gifts including lavalavas, fans, and flowers.

Diabetes and its complications are a large and ever-growing burden within the Pacific Islands. Polynesia and Micronesia have the world’s highest age-standardised diabetes prevalence rate of over 25%, with Melanesia not far behind at 15%¹.  With this high prevalence of diabetes also comes a high incidence of diabetic foot complications, one of the most serious complications of diabetes ².

Without appropriate care, diabetic foot complications can be life-threatening and in the Pacific are leading to a growing number of amputations, surgical debridement and hospitalisation. It has been estimated that 17% of Pacific Islanders with diabetes will require an amputation over their lifetime³.Image description: A nurse wearing safety glasses, a gown and gloves probes a toe ulcer with sterile forceps. Behind her we can see a dressing trolley

In order to address the growing need for services, in June 2015 Motivation Australia and the Samoa National Health Service (NHS), established a multi-disciplinary Diabetic Foot Clinic (DFC) at the Tupua Tamasese Meaole (TTM) hospital in Apia. This work was part of an Australian Aid funded, Samoa Integrated Mobility Device Service project. You can find out more about establishing the DFC here.

After some changes at the NHS, the DFC is now staffed by nurses, who continue to provide regular, quality wound management and education services to Samoan clients with diabetic foot ulcers. Offloading services are provided by an orthotist, through the Mobility Device Service, also located at TTM.

Along with building DFC services at TTM, Motivation Australia and the NHS acknowledge that the best way to prevent amputations from diabetic foot ulcers is to improve prevention and early treatment. To achieve this the involvement of health personnel at the community level is essential.

In order to build on the capacity of community-level personnel, Motivation Australia sent a training team of Prosthetist Orthotist Katrina McGrath and Podiatrist Nalini Natesan, to provide training and mentoring to community nursing personnel from the DFC and a number of District Hospitals and Health Clinics from across Samoa’s main island of Upolu.

The training utilised Keep Moving learning modules

  • The Healthy and diabetic foot,
  • Screening for at-risk feet,
  • Shoes for healthy feet,
  • Assessment of clients with diabetic foot ulcers,
  • Infection control,
  • Wound management of diabetic foot ulcers and Introduction to offloading.

The training also included multiple practical sessions where participants could put their knowledge and skills into practice.

The training was very well received by the participants and many commented that they would like more opportunities to learn more about the diabetic foot in order to help their clients as much as possible. The training provided a good opportunity to strengthen knowledge and skill of DFC and community personnel to provide improved management for at risk of or presenting with diabetic foot ulcers. Motivation Australia hopes to continue to work with the NHS to strengthen diabetic foot management at the community level.

Motivation Australia would like to thank everyone involved in making the DFC training a success. Particular thanks go to Tuala Dr. Tile Ah-Leong Lui and DFC nurse Taiaopo E’etau for their logistical support, and their warm welcome of the training team.

Thank you also to the Australian Government for their financial support of this activity. Motivation Australia hopes to continue to support the NHS to further strengthen diabetic foot management across Samoa.

DFC File review

The visit also provided the opportunity to complete a file review of a sample of 42 clients. While the available data was not complete, it is indicative of the cost reduction for the NHS, and health benefits for clients of the DFC.

Some key outcomes of the review include:

  • For the 13 clients who had a date of healing documented the average healing time was 123 days (range 20 – 398 days), with an average of twelve appointments (range 4 – 26).
  • 52% of clients had documented hospital admissions prior to being a client at the DFC, while only 5% of clients had documented hospital admissions after DFC treatment.

This graph demonstrates that before attending the DFC, 22 of the clients were admitted to hospital for surgical debridement or amputation. After attending the DFC, only 2 clients were admitted to hospital.

  • For 36 clients, over 266 appointments, the average Blood Sugar Levels (BSLs) for clients was 13.1mmol/L (with range 3.5mmol/L to 28.2mmol/L).
  • Random BSL’s over 11mmol/L can indicate hyperglycaemia, which can damage blood vessels and nerves and affect healing. 62% of all BSLs reviewed for the 36 clients were in the hyperglycaemic range. This highlights the need for improved control of sugar levels.

This graph represents the information written above - showing the blood sugar levels of clients at 266 appointments.




¹ NCD Risk Factor Collaboration, 2016. Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4·4 million participants. The Lancet 387, 1513–1530. doi:10.1016/S0140-6736(16)00618-8

² Schaper, N.C., Netten, J.J.V., Apelqvist, J., Lipsky, B.A., Bakker, K., 2016. Prevention and management of foot problems in diabetes: a Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance Documents. Diabetes Metab. Res. Rev. 32. doi:10.1002/dmrr.2695

³ Fiji Non Communicable Disease Steps Survey., 2002. . Suva,  Fiji.