Train-the-Foot-Trainer programme

Training healthcare professionals to deliver simple but effective diabetic foot care, which is sadly lacking in many parts of the world, is high priority for D-Foot International.

In 2003, the Step-by-Step diabetic foot training course was developed and piloted in a number of countries. In 2012, this initiative was revised to region-wide Train-the-Foot-Trainer programmes.

This teaches experts about course structure, how to educate others to run SbS courses, strategic planning and developing expertise in clinical care and education.

Step-by-Step programmes and Step-by-Step courses.

The International Working Group on the Diabetic Foot together with the Diabetic Foot Society of India (DFSI) and the Muhimbili University College Of Health Sciences Dar es Salaam, Tanzania (MUCHS), has initiated in 2003 a foot care project called “Step by Step, improving diabetic foot care in the developing world”. The World Diabetes Foundation (WDF) financially made this possible. Among other successful projects are the programmes in the Caribbean region, which were financed by Rotary Clubs in several countries (lead by the Rotary Club of Ledbury, UK), Rotary International and the International Diabetes Federation (IDF).

Background of the Train-the-Foot- Trainer (TtFT) course:

Step-by-Step programme

The Step-by-Step programme (SbS) is a two-year project. Teams consisting of a doctor and a nurse or paramedic, were invited to attend a basic and an advanced course. During the two years data collection is mandatory. D-Foot International developed a data collection tool (DIAFI). The goal is to improve educational skills and the management of diabetic foot problems. By doing so, this has created a cascade effect and sustainability in the region/country. An experienced national and international faculty is responsible for teaching the course material and the practical sessions. Medical equipment and educational materials are provided to all participants. Very successfully pilot programmes and studies were held in India and Tanzania in 2004 and 2005 (ref 1, 2). A more recent publication has shown that well executed SbS programmes have a significant reduction in amputation rate (ref 3).

From Step by Step programmes to Train the Foot Trainer Courses:

“How to set up a Step by Step Programme”

The spin-off effect of these courses was significant. This programme has been successfully introduced in a dozen other countries since and there is a rapidly increasing demand for these programmes in more countries. As a result, it was felt that in order to sustain this good work, a new model had to be adopted, which was robust both financially and in manpower terms.

For this reason, in 2010, the Step by Step Development and Research Group (SSDRG) initiated the Train the Foot Trainer course to reach more regions in a shorter period of time. In this way, the IWGDF could could meet the growing demands more effectively.

The first pilot project was the TtFT course held in the SACA (South and Central America) region in December 2012. Today we can conclude that this project has been a great success: More than 4000 health care providers have been trained in less than 3 years, in almost all Latin American countries.

The second TtFT course was held in Tobago for the Caribbean region. It will integrate the Central American Region and as well as some countries of the SACA regions, in particular, those who were not able to follow the first course in Brazil.

The Third TtFT course took place in Europe, Bled, Slovenia and was mainly intended to create networking in Eastern and Southern Europe. An integration with many organisations was established, including DESG, EASD, DFSG, EWMA, IDF Europe and UNMF, with an overall intention to unite Europe as a whole. The first outcome was presented in a satellite session at the DFSG meeting in Stuttgart in September 2016.

The 4th IWGDF Western Pacific Train-the-Foot-Trainer course took place in Bangkok from 20-23 November 2016. It was attended by 60 delegates from 13 countries within the region and had several observers.

The positive outcome of the TtFT program was already felt by the creation of many new friendships, the cooperation for future successful propagation of knowledge, and the promotion of the profession of podiatry. The Permanent Secretary of Public Health of Thailand sent representatives to meet Kristien Van Acker, President of D-Foot International, and Matthew Garoufalis, President of the International Federation of Podiatrists, to learn more about having podiatry in Thailand.

The fifth edition of the TtFT program is scheduled to be held in Johannesburg, South Africa, in August 2018, in cooperation with the Pan-African Diabetic Foot Study Group.

TtFT Course Outline

  1. Aim

To equip experts in the diabetic foot to deliver effective, well structured, sustainable diabetic foot training programmes with demonstrable outcomes

  1. Statements
    1. This training course is NOT a diabetic foot training course, where related skills and knowledge are purely taught
    2. It IS a training programme, which teaches course structure, organisation, delivery methods and evaluation skills
    3. It IS a course run for experts to train others to become experts in clinical and education skills and knowledge
  1. Course objectives
  • For each of the delegate teams to organise and implement a “Step by Step” training programme for their own country (educational, organisational and public relations)
  • To develop and support a regional based diabetic foot-care working group which facilitates sustainable development of integrated inter-island foot care services
  • To develop and support an ongoing mentorship programme for existing and new diabetic foot champions in this region
  • To train trainers from their own localities to deliver SBS training programmes
  • To evaluate the delivered course
  • To collect and disseminate the outcomes presented by the programme (national / regional {SACA} / international {IWGF, IDF, etc.})
  • To identify and find solutions for their needs and to reduce barriers to implementation.
  1. Intended course outcomes
  • To service development and referral pathways.
  • To drive and implement policy making.
  • To provide a support mechanism for local champions.
  • To have a sustainable impact upon service provision and clinical outcomes.
  • To undertake minimum dataset collection to drive change and support research.
  • To encourage the development of further national training programmes with a national faculty to meet local needs


Delegate selection criteria for TtFT programme

The following criteria are a guide to facilitate eligible delegates to attend the TtFT programme. Delegates are to be selected by the Local Faculty.

  1. Delegates from a region /country must be selected as a team consisting of a doctor/surgeon and an allied health care professional
  2. The delegates must be recognised as an expert working in the field of the diabetic foot (see definitions below)
  3. A delegate ideally should be actively involved in post-graduate education.
  4. A delegate should have managerial and organisational skills and experience.
  5. A delegate should have the following characteristics: commitment, innovation/drive, reflective, passionate, experience as a team leader, ability for teamwork.
Diabetic Foot Care Assistant Certificate

In countries where podiatry does not exist as a speciality, there is a need for a standardized, basic level foot care course.

D-Foot offers diabetic foot care education to healthcare professionals who wish to obtain a Diabetic Foot Care Assistant certificate, and to use these acquired skills clinically.

In the future, this programme will be organised with the International Federation of Podiatrists (FIP-IFP). Diabetic Foot Care assistants will be replaced by 'Diabetic Podiatry assistants' - who will provide the first level of Podiatry care for Diabetes. - See chapter: Cooperation DFI and FIP-IFP

Diabetic foot e-learning package

Jointly with UNFM, we developed an “e-foot care” online learning module to address basic diabetic foot care skills and knowledge. All delegates undertook this training package prior to attending the Train-the -foot-Trainer course. The purpose of this was to ensure all delegates were familiar with the foundation content of the basic Step by Step course (SbS). Additionally, it can be later used by delegates to facilitate the SbS courses that they will subsequently run, or to assist in training their clinical colleagues.

Currently, the online training course consists of a series of video lectures, supported by PowerPoint presentations, and practical workshop videos with self- assessment sections. We envisage that we will be developing further e-learning modules in a wide range of topics that will supplement the TtFT programmes. The modules will also provide part of a comprehensive diabetic foot interactive training programme. We hope to cover topics such as foot surgery and off-loading in the near future.

e-foot care is perfect for remote learning but of course should be used with the support and mentorship by experienced diabetic foot practitioners.

DIAFI data collection tool


In order to develop clinical practice, improve our programmes and lobby for support, gathering activity and outcome data is crucial. Recording reliable and accurate data is of paramount importance to validate your work, effect-change and drive patient care. Data collection is perhaps one of the biggest stumbling blocks for many clinicians and services. Additionally, ensuring that the data you collect is comparable with other centres locally, nationally or even internationally is challenging.

In an attempt to standardise and simplify this task, D-Foot worked with UNFM to set up the DIAbetes Foot Initiative (DIAFI), a data collection software, housed on a memory stick. This has been designed as a mobile tool - it allows clinicians to collect data quickly, on any computer, and cover predetermined parameters.

Additionally, the software analyses the downloaded data immediately and allows for anonymised data export for further international statistical analysis. This novel and exciting data collection system is undergoing further development and simplification, although it is already in clinical use. This is a very exciting system that is easy to use and could potentially help provide a uniform dataset of basic diabetic foot parameters from around the world. This could help us learn, share, compare and drive clinical care globally.

Over time, D-Foot International aspires to publish a Diabetic foot Atlas.