Case Study 5

Considering reach – Diabetic foot, India

Why do we need to assess reach as well as effectiveness? – Diabetic foot, India

Why this case study?

This illustrates the importance of assessing reach to ensure that populations with the greatest health need are reached by a new policy or intervention.


Why do we need to assess reach as well as effectiveness?


Christian Medical College, Vellore, Tamil Nadu, India

Health issue

Diabetic foot


Integrated Diabetes Foot Clinic, Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India

Target population

Type 2 diabetes mellitus patients affected with diabetic foot problems


Diabetic foot problems are the most common reason for hospitalization of diabetic patients and absorb some 20% of the total healthcare costs of the disease, more than all other diabetic complications put together. Treatment involves footwear modification and offloading (i.e. reducing pressure on affected areas of the foot).

Description of policy or intervention

An Integrated Diabetes Foot Clinic was set up in 2008 at the Christian Medical College in Vellore, India, with a core team of endocrinologists, diabetes nurse educators, vascular surgeons, physiotherapists and orthotists.

The clinic was equipped with tools for the diagnosis and treatment of diabetic foot, and radiological investigations were completed and reviewed within the same day. Meanwhile, patient-specific footwear was developed at the Prosthetics and Orthotics Centre.

In 2015, a retrospective study was carried out on 138 patients to assess the utility of low-cost footwear modifications (such as anterior rocker modifications) in reducing ulcer healing time.

What took place?

Over half of the group of patients using the anterior rocker modification had healed fully within 8–12 weeks; those noncompliant with or without anterior rocker foot- wear had a prolonged healing time of 4–6 months.

What have we learnt?

Adequate foot care and offloading techniques remain inaccessible for a significant proportion of diabetic patients due to socioeconomic factors and lack of awareness, leading to amputations and healthcare expenditure. So, although treatments may be effective their reach may be limited.

The care provided at the clinic had a greater reach. The study indicates that use of simple diagnostic criteria and development of cost-effective modifications such as the anterior rocker significantly reduced healing time and hence reduced economic burden.