The further development of the Diabetes Foot Check app

Diabetes can lead to serious foot complications, such as (slow-healing) foot ulcers, which are associated with, amongst other things, neuropathy, circulatory problems and infection, and which can result in hospital admissions, amputations and a reduced quality of life.  It is therefore important that risks are identified at an early stage and that people with diabetes are supported in carrying out regular self-monitoring and seeking prompt advice from a healthcare professional. During the first wave of the coronavirus pandemic, Rondom Podotherapeuten developed the Diabetes Foot Check app to enable remote monitoring of patients.  The aim of this study was to improve the app’s user-friendliness and long-term usability, so that it can help to identify foot problems at an earlier stage and thereby help prevent complications.

In the Technology Support for Diabetes project, Eindhoven University of Technology, Fontys University of Applied Sciences and Stofloos collaborated on a two-year research project, funded by Regieorgaan SIA, to further develop the app and ensure it better meets the needs of practice.  We used a co-design approach: together with patients and healthcare professionals, the app was redesigned from the ground up, with an emphasis on usability, trust and the balance between digital support and face-to-face care where necessary.  An evaluation study was then carried out to understand how people experience the app, how engagement develops over time and what this requires of podiatrists’ work processes.   The insights gained from usage data, user experiences and feedback from professionals have been translated into concrete opportunities for improvement in both the design and implementation of the app within day-to-day care.

The evaluation shows that users generally regard the Voetencheck app as a valuable tool for regularly checking for risk factors for diabetic foot ulcers; in particular, the convenience of carrying out a check and the ease of submitting a photo are cited as key strengths.   We identified three distinct usage patterns: continuous use, frequent use and little to no use; these patterns help explain which factors encourage use (such as ease of use, accessible contact and social support) and which factors act as barriers (such as digital skills, physical limitations and difficulty with long-term engagement).   Podiatrists indicate that the app helps to identify signs of potential problems more quickly and to monitor patients remotely, but that systematically ‘incorporating’ and promoting the app during consultations in practice can still be challenging.   At project level, adoption has grown: more than 120,000 checks have now been carried out and approximately 7,200 photos submitted, with around a third of the photos requiring follow-up action.

We use the findings to further improve the app in terms of inclusivity and long-term use, for example by providing better support for taking useful photos, ensuring accessibility for people with varying levels of digital literacy, and tailoring reminders and guidance more effectively to an individual’s needs and routine. We are also focusing on implementation in healthcare practice: how can we help professionals to introduce, monitor and embed the app more easily into their work processes, without creating additional administrative burden. In addition, follow-up studies are underway: in the MEDIS project, we are investigating how social support (for example, from informal carers) can enhance usage, and in the Foot Check & AI project, we are exploring how AI can assist with photo quality and triage, so that serious cases are identified more quickly and professionals can use their time more effectively.  Finally, it remains important to continue assessing the (long-term) impact: not only on user experience, but also on healthcare outcomes and the burden on the healthcare system, whilst upholding the ‘human-in-the-loop’ principle that instils confidence in users.

Prevention, Diabetes, Foot Ulcers, E-health, Home Monitoring

Partner organisations: Rondom, Fontys Paramedical, Eindhoven University of Technology, Stofloos
Funding body: Regieorgaan SIA

Podosophia, Link: https://view.publitas.com/p222-2174/podosophia-3-2023-bewijsexemplaar/page/20-21

Mixed Methods Study into Self-Monitoring of Diabetes-Related Foot Ulcers, DOI: 10.3390/s23052547

Preventing Diabetic Foot Ulcers With eHealth: Rethinking Digital Care In Co-design, DOI: 10.21606/drs.2024.842

Diabetes Foot Check website: https://diabetesvoetencheck.nl/