“I’d consider myself low risk now, because I’ve got my sugars under control and I don’t wear sandals anymore” (Nick, 55-year-old male, had T1 diabetes for 32 years, two toes amputated, and a third under treatment for an infected cut). Awareness of diabetic foot ulcer risk is often limited and underestimated, even in those at the highest risk.
One problem associated with diabetes is changes in nerve function (neuropathy). This can lead to changes in sensation in the feet such as pins and needles, the feeling of wearing socks when they are not there, or no pain at all.
Pain is a key factor motivating changes in behavior, such as changing your shoes when there is excessive rubbing. Where there is no pain message, a person with diabetes has little or no feedback to let them know that a blister may be forming. In some cases, it may go unnoticed. Often with diabetes wounds heal slower and can become infected faster. If a wound is untreated it can quickly become an ulcer, and in some cases might result in amputation or even death.
Our technology, Socksess, aims to reconnect people who have neuropathy with their feet, by using a smart-sensing sock that can detect excessive rubbing, and send an alert to the wearer to check their feet for signs of damage.
The technology sounds impressive, but it needs to be acceptable and useful to someone like Nick. Nick, like many people with diabetes, knew that foot care was important, but not exactly why; and he even knew friends and family who had experienced lower leg amputations, but either he did not fully understand the cause, or did not feel that the risk applied to him. It is often difficult to accept one’s own vulnerability to something, especially if it is something that is frightening.
Considering the behaviors that are required to engage with a technology, as well as the user needs and preferences, is essential when designing health technologies. The Person-Based Approach is a methodology that systematically describes best practice in combining information from previous research with interviews and focus groups with patients, carers and healthcare practitioners alongside technology development. This allows for changes and improvements to be made early, not only saving time and cost, but also producing a product that is more acceptable to the users it is designed for. Alongside this process, public involvement groups work as another source of feedback and validation.
Using this approach, we have been able to provide contextual data to our engineering teams, helping them to understand what would be important to people with diabetes, as well as their carers and healthcare professionals, if they were to engage with this technology effectively. This means developing a product that will not only be acceptable to use, but will also facilitate behavior changes that are essential for the technology to be effective, such as responding appropriately to the alerts and engaging in self-care activities.
For Nick to use our technology effectively, it not only needs to be something he can integrate into his life (the sock should be comfortable and attractive, and the feedback system should integrate with his lifestyle needs); it also needs to help him understand the implications of nerve changes in the feet and the importance of self-care. It is not only a cool piece of tech, it is a self-management tool that can empower him to play an active role in maintaining his own foot health and preventing re-ulceration while continuing to engage in activities that are meaningful to him.