Success Story of Step by Step After Ten Years
A Model for Developing World 2004 -2014

Dr. Zulfiqarali G. Abbas, Consultant Physician, Chairman of Step by Step Foot Project

CONGO 2009



Tanzania has a huge burden of non-communicable diseases, not the least being diabetes and its complications like diabetic foot, which is on the increase and cannot be ignored.

Education is the most important prevention of foot lesions in diabetics. There is an urgent need to increase the knowledge of all those who care for diabetes. Need for developing urgently diabetic foot education and treatment short training programme for under developed countries. Such training is being implemented successfully in the field and is being continuously monitored and evaluated and develops teaching resources. Main aim is to minimize the rate of amputation by fifty percent (50%).

Step by step project was implicated for the first time in Tanzania as a pilot project in 2004. We were fortunate to have this project in our country. Due to its extreme success we had several other step by step foot projects in Tanzania. First step by step target 15 centres in 14 regions of Tanzania. It was done for district and regional hospitals. This followed by another step by step foot project targeting for private centres along with government all together 30 centres from 21 region of Tanzania. In total 45 centres were trained throughout Tanzania. Twice podiatrist courses were done. Lastly, due to success we manage to do step by step for surgeons. Twenty surgeons were trained from same centres where we had trained doctors and nurses and the full team was achieved of physician, surgeon and nurse from same hospitals.

This project has succeeds its goals, aims and objectives in the education and prevention of amputations.

Successful establishment of this model of diabetic foot care in Tanzania has encouraged other countries to do likewise. To date, the model has been exported to various other countries in Africa (Democratic Republic of Cong, Guinea, Botswana, Malawi, Kenya, S. Africa, Ethiopia, and Egypt), Pakistan, Saudi Arabia, and the Caribbean (Barbados, St Lucia, St Maarten, St Kitts, and the British Virgin Islands). December 2012, a Step by Step foot care work shop was successfully conducted in Brazil with participants from all 14 countries in continental South America.

Finally, one of the least visible but important upshots of the Step by Step Program has been the highlighting of the importance of epidemiology and surveillance activities for characterizing foot complications in persons with diabetes, and for monitoring disease progression and outcomes, such as temporal trends of amputations rates and mortality.

Our Goal:

Our patients with high risk feet are walking step-by-step towards the road to amputation and by implementing this project we wish to take them around step-by-step to the road of safety

Objectives of this Project:

To create more awareness of diabetic foot problems
 To provide sustainable training of health care professionals in diabetic foot management
 To facilitate the transfer of information and expertise among health professionals
 To reduce the risk of lower limb complications in people with diabetes
To empower people with diabetes to care for their feet better, detect problems earlier and seek timely help when problems arise

Projects at a Glance: First main project was launched in 2004.

 Initially 15 teams of doctors and nurses working in the same hospitals.
 They were offered a 3 day basic course in 2004 followed by a 3 day advanced course in 2005. It was compulsory for the team to attend both the basic and the advanced course.
 National and International faculty specialized in diabetic foot were responsible for teaching and demonstrating practical sessions.
 Emphasis was given on live case demonstration, hands on experience and practical problem solving.
Delegates were provided a set of podiatry instruments, educational material prepared for this project for the doctors, nurses and patients. DVDs for the patient education and for health care professionals.

Attending delegates were trained in preventative diabetic foot care.

- Primary prevention: screening of high-risk feet and proper advice on preventive footwear. • Secondary prevention: management of trivial foot lesions like callus removal, treatment of nail pathologies, de-roofing blisters. • Tertiary prevention: prompt referral to specialist for advanced foot lesions.

Second main project was in 2009:

 Thirty teams of doctors and nurses working in the same hospitals.

 They were also offered a 3 day basic course in 2009 followed by a 3 day advanced course in 2010. It was compulsory for the team to attend both the basic and the advanced course.
 Everything else same as above.

Third main project for surgeons was in 2009:

 Twenty teams of surgeons working in the same hospitals of physicians and nurses.  They were also offered a 3 day basic course in 2009 followed by a 3 day advanced course in 2010. It was compulsory for the team to attend both the basic and the advanced course.  One full day was spent in the operation theater and observed life patients operated. DVD was produced for the surgeons.

Outcome of step by step foot project: Aims:

To determine the effectiveness of the Step by Step intervention in reducing rates of amputation among persons with diabetic foot ulcers who were referred to the diabetes clinic at Muhimbili National Hospital


 Over the entire study period (i.e., 2001 – 2008), the mean annual amputation rate among referrals was 17.6%

 Before the Step by Step program, trends in rates of amputation were upward  Following the institution of the program, rates of amputation among referrals decreased significantly to a low of almost 2 SD below the mean in 2008 (P<0.01)


 Forty three centres combined or separate foot clinics across the country  Regular screening program  Better management  Reduction of amputations rate  Teaching other colleagues in the hospital – cascading effect  Future more training  Rolled up to other developing countries


 Institution of the Step by Step Foot Project in 21 regions in Tanzania resulted in a significant reduction in rates of amputations among patients with foot ulcers referred to a large tertiary centre in Dar es Salaam.
 These data suggest improved foot ulcer management at the regional level following Step by Step, before patients are referred for specialist care

Abbas ZG, Lutale JK, Bakker K, Baker N, Archibald LK. The 'Step by Step' Diabetic Foot Project in Tanzania:
A model for improving patient outcomes in less-developed countries. Int Wound J. 2011 Apr;8(2):169-75.