Fay Crawford


Fay is a Health Services Researcher and a Podiatrist who has conducted evaluations of preventative interventions for foot ulceration for people with diabetes, using observational and trial data. Her collaborative research has led to changes in the timing of foot risk assessments in NHS Scotland and has been incorporated into clinical guidelines, nationally and Internationally.

She is Professor of Health Services Research at the University of Essex in the UK.

Presentation at The SoTV/EWMA 2024 Conference, London

Predicting and preventing foot ulceration in diabetes

Learning objectives

After attending this session, persons will be able to:

  • Identify those at risk of developing a diabetes related foot ulceration
  • Identify potentially effective interventions to prevent foot ulceration
  • recognise ineffective interventions for the prevention of foot ulceration in diabetes
  • Understand the remaining clinical uncertainties in the prevention of foot ulceration
  • Recognise the main methodological weaknesses in published trials of interventions to prevent foot ulcertion in people with diabetes


Diabetes-related foot ulcerations give rise to considerable morbidity, generate a high monetary costs

for health and social care service budgets and are known to precede most diabetes-related amputations. The development of foot ulcers relates to systemic complications of diabetes and hyperglycaemia; peripheral nerve damage or vascular disease and are therefore preventable.

Different risk factors for diabetes-related foot ulceration have been reported in observational studies conducted in different parts of the world over the last 30 years. Research funded by the National Institute of Health Research (NIHR) enabled the development of a prognostic model incorporating data from 16,385 people with diabetes to support the development of the first Clinical Prediction Rule which gives clinicians and patients a personal, numerical risk of developing a foot ulcer within a two-year period.

Uncertainty also exists regarding the frequency of foot risk assessments. NHS England and the National Institute of Clinical and Care Excellence recommend people with diabetes have foot risk assessments annually.  Our research funded by NIHR used routinely collected data to examine changes in foot risk categories over time in 10,421 people with diabetes from a single health board in Scotland. The data show that changes in risk categories occur slowly and after 8 years only 11% of people’s risk of foot ulceration had changed. NHS Scotland has subsequently changed the frequency for foot risk assessments to biennially.

Effective interventions to prevent diabetes-related foot ulcerations in those at risk have been identified in randomised controlled trials and data from our systematic review of trial data found some evidence of effectiveness for certain strategies but on-going uncertainty about who benefits most from them. Weaknesses in the design of studies as well as a lack of clear reporting, hampers the search for effective preventative treatments and make it difficult to know whether those with first-time or recurrent foot ulcers benefit equally. Further randomised controlled trials are therefore needed to address these concerns.

In this presentation Fay Crawford will explain the various methodological approaches that have been used to evaluate components of this complex intervention, what has been learned and what further evaluations are needed.