Highlights
- The nurse-led program significantly reduced treatment-seeking delay intentions and actual delay behaviors in patients with diabetic high-risk foot.
- Participants in the intervention group showed marked improvements in foot care knowledge, self-care behaviors, and self-efficacy compared to the control group.
- While the incidence of diabetic foot ulcers did not differ significantly between groups, the intervention group sought medical attention significantly faster upon ulcer development.
- Post-discharge support via WeChat proved to be an effective tool for maintaining long-term adherence to foot care protocols.
Background: The Clinical Challenge of Diabetic High-Risk Foot
Diabetic foot disease remains one of the most debilitating and costly complications of diabetes mellitus, frequently leading to lower-extremity amputations and increased mortality. The phase categorized as diabetic high-risk foot (DHRF)—characterized by the presence of peripheral neuropathy, peripheral arterial disease, or foot deformities without active ulceration—represents a critical clinical window. During this pre-ulcerative stage, effective prevention strategies can significantly alter the patient’s trajectory.
However, a major barrier to successful prevention is the high prevalence of treatment delay. Many patients fail to recognize early warning signs or underestimate the severity of minor skin breaks, leading to postponed medical consultation. By the time professional care is sought, simple lesions have often progressed to deep infections or gangrene. Current routine discharge education often lacks the personalized intensity required to change deep-seated health behaviors. Consequently, there is an urgent need for structured, nurse-led interventions specifically designed to enhance risk perception and streamline the medical-care pathway.
Study Design and Participant Characteristics
To address this gap, researchers conducted an assessor-blind, two-arm randomized controlled trial (RCT) with a repeated-measures design. The study was situated in the endocrinology and metabolism department of a university-affiliated hospital in Guizhou province, China. A total of 70 patients diagnosed with diabetic high-risk foot were recruited and randomly assigned to either the intervention group or a usual-care control group.
The study utilized a longitudinal approach, collecting data at five distinct time points: baseline (T0), discharge (T1), 3 months (T2), 6 months (T3), and 12 months (T4). This design allowed the researchers to evaluate the durability of the intervention’s effects over a full year, providing a robust assessment of behavioral change and clinical outcomes. Statistical analysis was performed using generalized estimating equations (GEE) to account for the correlation between repeated measurements and to examine the interaction between group and time.
The Nurse-Led Health Education Intervention
The core of the study was a structured nurse-led program that moved beyond traditional didactic teaching. The intervention was multi-faceted, focusing on psychological drivers of behavior as much as clinical knowledge.
Personalized Risk and Harm Perception
Unlike standard education, the nurse-led program began with a personalized assessment of each patient’s specific risk factors. Nurses provided targeted education on the individual’s risk level, using delay-consequence alerts to foster a realistic understanding of the potential for amputation or death if symptoms are ignored. This approach aimed to increase the “perceived threat,” a key component in health behavior models.
Workshops and Practical Guidance
During hospitalization, participants attended weekly classes and practical workshops. These sessions focused on foot care behavior guidance, including proper nail trimming, daily foot inspections, and the selection of appropriate footwear. By involving patients in hands-on workshops, the program sought to build self-efficacy—the patient’s confidence in their ability to perform these tasks daily.
Medical-Care Pathway and WeChat Support
A critical component of the intervention was the medical-care pathway planning. Patients were taught exactly when and where to seek help, reducing the cognitive load and decisional conflict often associated with seeking medical care. Post-discharge, this was reinforced through a WeChat-based platform, which allowed for continuous support, reminders, and a direct line of communication with the nursing team for 12 months.
Key Findings: Knowledge, Behavior, and Clinical Outcomes
The results of the study were highly encouraging, demonstrating consistent superiority of the nurse-led intervention across several domains.
Primary Outcomes: Treatment Delay Intention and Behavior
At the 12-month follow-up (T4), participants in the intervention group reported a statistically significant reduction in treatment delay intention compared to the control group (p < 0.05). Most importantly, among the patients who did develop a foot ulcer during the study period, those in the intervention group demonstrated significantly shorter actual delay times before seeking professional medical help (p < 0.05). This suggests that the program successfully translated theoretical knowledge into life-saving action.
Secondary Outcomes: Knowledge, Behavior, and Self-Efficacy
The intervention group showed significantly higher scores in foot care knowledge, foot care behavior, and self-efficacy at all follow-up intervals (T1 through T4) compared to baseline and the control group (p < 0.05). The GEE analysis confirmed a significant group-by-time interaction, indicating that the improvements in the intervention group were not only achieved but were sustained throughout the one-year study period.
Clinical Incidence
While the incidence of new diabetic foot ulcers was lower in the intervention group than in the control group, the difference did not reach statistical significance (p > 0.05). This may be attributed to the relatively small sample size (n=70) and the complex, multi-factorial nature of ulcer development, which includes physiological factors beyond the scope of education alone. However, the reduction in treatment delay among those who did develop ulcers is a vital clinical success, as early intervention is the strongest predictor of ulcer healing without amputation.
Expert Commentary: Bridging the Gap in Diabetic Foot Care
The findings of Xie et al. underscore the transformative potential of specialized nursing in diabetes management. By focusing on the “intention-behavior gap,” this study addresses a common failure in patient education: knowing what to do but failing to do it in a timely manner. The use of WeChat as a longitudinal support tool is particularly relevant in the modern healthcare landscape, providing a cost-effective method for chronic disease management.
However, some limitations must be considered. The study was conducted in a single center in China, which may limit the generalizability of the findings to different cultural or healthcare contexts. Additionally, while the 12-month follow-up is commendable, larger multi-center trials are needed to confirm if such interventions can statistically reduce the absolute incidence of ulcers and amputations across a broader population. Clinicians should view this nurse-led model as a blueprint for integrating behavioral psychology with clinical foot care to protect high-risk patients.
Conclusion
The nurse-led health education program developed in this study is an effective strategy for improving the self-management capabilities of patients with diabetic high-risk foot. By significantly enhancing foot care knowledge, behavior, and self-efficacy, the program successfully reduced treatment-seeking delay. These results advocate for the integration of structured, nurse-led educational interventions and digital follow-up tools into standard diabetic care protocols to prevent the progression of high-risk foot conditions into limb-threatening complications.
Funding and Registration
This study was registered at the Chinese Clinical Trial Registry (ChiCTR2400083760). Participant recruitment was initiated in June 2024. The authors declare no conflicts of interest regarding the funding or execution of this research.
References
Xie Y, Liu Z, Ming Y, Wang Q, He K, Nie P, Wang Z, Huang R. The effect of a nurse-led health education intervention on treatment delay in patients with diabetic high-risk foot: A randomised controlled trial. Int J Nurs Stud. 2026 Mar;175:105316. doi: 10.1016/j.ijnurstu.2025.105316. Epub 2025 Dec 12. PMID: 41468860.
