Summary
The Diabetes Footcare in Dark Skin Tones handbook – a free, multimedia-rich education resource with an active communication campaign – supports healthcare professionals (HCPs) to deliver better, more equitable footcare for people with dark skin tones. Co-created by nine contributors including footcare specialists, diabetes clinicians, primary care professionals and a person living with diabetes, it offers clear guidance for thorough clinical assessment, standardised documentation and culturally sensitive communication. It brings together these elements for the first time in simple, accessible language, making it practical for everyday use and enabling earlier recognition of complications to improve outcomes for people living with diabetes.
Innovation/Novel approach to an existing problem
Effective diabetes-related footcare relies on thorough clinical assessment, including history-taking, touch, communication and visual examination. A major challenge is that standard guidance often describes visual signs, like redness, in ways suited to light skin, making them harder to detect in dark skin. This leads to delayed recognition, worse outcomes and higher rates of amputation and mortality. Diabetes Africa conducted a survey of 42 HCPs who reported the most common challenge was recognising skin colour changes in dark skin, alongside difficulties with communication and assessing tissue health. This confirmed a clear training and confidence gap. The Diabetes Footcare in Dark Skin Tones handbook (https://diabetesafrica.org/footcare-handbook/) was developed to address this inequity in a structured, practical, engaging, visually rich, easy-to-navigate and accessible way for busy HCPs. A key innovation is the integration of an existing objective skin tone scale throughout real clinical case studies. Rather than listing it as a standalone tool, the handbook demonstrates how to use it consistently; each case includes identified skin tones, helping professionals document and compare changes over time. This supports standardised, safer practice that clinicians can apply immediately. The handbook uses clear visual resources to support learning: side-by-side photos of conditions in different skin tones, a detailed visual guide, and embedded links to audio and video materials. These elements help HCPs develop the skills to recognise important signs they might otherwise miss, while supporting a range of learning styles. Importantly, the handbook also covers communication and cultural humility. It offers practical advice on using respectful, objective language and understanding that skin tone does not equate to culture or ethnicity. The handbook was co-authored and reviewed by a multidisciplinary group, including diabetologists, podiatrists, nurses, educators and people living with diabetes. Language was carefully reviewed for clarity and accessibility across primary, community and secondary care settings. The handbook is free to download, removing cost barriers. It has been promoted through conference presentations, dedicated webinars and a social media campaign to ensure it reaches a wide audience.
Equality, Diversity and Variation
Healthcare outcomes for diabetes-related foot disease show stark inequalities. In the UK, diabetes causes over 184 amputations every week. Five-year mortality after major lower-limb amputation exceeds 50%. People of Black ethnicity are at higher risk of delayed presentation and poorer survival. Traditional resources emphasise recognising redness as a critical sign of infection or ischaemia, which may not be visible or may appear differently in dark skin tones. This creates a structural inequity in diagnosis and treatment. The handbook was designed to reduce inequalities through free access and an active dissemination strategy, addressing the need for practical, usable guidance, with appropriate language and communication guidance on describing skin tone objectively and respectfully. It standardises how skin tone is documented.
Impact to Patient Care
The handbook’s impact reaches patients directly by improving the safety, quality, and experience of their care. By equipping clinicians with practical, standardised guidance. HCPs have reported being more aware, more thorough in assessment, and more confident in discussing early signs with patients. They reported feeling more equipped to discuss skin tone differences with patients in an objective, respectful way, helping to build trust and encourage patients to share observations about their own skin. Individuals who downloaded the handbook said that it helped them with conversations with their HCPs.
Results
Over 12 months since its launch, the handbook has been downloaded over 30,000 times (36,000+ as of July 2025), demonstrating broad adoption by HCPs from primary, community, and secondary care, including GPs, podiatrists, nurses and wound-care specialists. To ensure quality and consistency of learning, the handbook uses an integrated approach: it standardises the use of an objective skin tone scale across case studies and includes photos comparing the same conditions across skin tones. These practical tools enable consistent documentation and more reliable monitoring of skin tone changes, reducing the historic reliance on “redness” alone. Post-launch surveys of healthcare professionals who downloaded the resource or attended dissemination events revealed: 92% reported the handbook changed their practice; 57% identified the photos and skin tone tool as the most helpful aspects; 100% said they would recommend the resource to colleagues. Respondents reported improved confidence recognising early signs of complications, greater thoroughness in assessment, and better discussions with patients about what to monitor and report. This represents a clear, demonstrable improvement in clinical practice quality and consistency. By addressing a critical diagnostic gap, the handbook directly supports improved outcomes for people with diabetes who have dark skin. Earlier recognition and reporting of subtle signs help reduce the risk of advanced presentation, avoidable amputations and associated mortality. Standardised documentation supports better continuity of care between services, while clearer patient-clinician communication builds trust and empowers patients to engage more actively in their care. The project was funded through a hands-off sponsorship model with Mölnlycke, a wound-care education company, which covered development, authorship, publication, and launch costs.
User Feedback
Feedback was gathered systematically and informally to ensure a rounded understanding of its value and impact. An anonymous online survey was run for HCPs who had downloaded or used the handbook, designed to encourage open, unbiased responses. In addition, feedback was collected through webinars, lectures, and professional conference presentations, using feedback forms and discussions. HCPs consistently praised the handbook’s practical, relevant design. Formal survey responses showed clear practice change. Feedback also highlighted how the handbook improved communication and cultural humility. The handbook also received praise internationally, showing its broader relevance and the pioneering nature of this work. User feedback has directly shaped plans for future development.
