Footprints Walking on Country

Aim

To improve early identification and prevention of diabetes-related foot complications for people in rural and geographically dispersed communities through accessible outreach screening and structured referral pathways.

Outcomes

• 1,087 patients screened between February 2024 and September 2025
• 440 referred for podiatry assessment (40.5%)
• Confidence interval analysis demonstrated the referral rate estimate was precise and statistically reliable
• Median referral action time: 36 days
• 135 hospital admissions potentially avoided
• Seven Emergency Department presentations potentially avoided
• 457 community-based service interactions delivered
• 30 outreach locations serviced across regional areas
• Aboriginal and Torres Strait Islander consumers comprised 11.1% of service users compared with 2.3% of the local population, indicating engagement at almost five times the expected rate

Background

Diabetes-related foot disease is a major cause of preventable hospitalisations, amputations, and health inequity. Rural and geographically dispersed populations face additional barriers to timely preventive care, including long travel distances, limited-service availability, workforce shortages, and transportation constraints. These factors lead to delayed assessment, lower screening participation, and greater reliance on hospital-based services for conditions that could otherwise be managed earlier in community settings. Aboriginal and Torres Strait Islander peoples experience a disproportionately high burden of diabetes-related foot complications, including earlier onset, higher ulcer rates, and increased risk of amputation, underscoring the need for accessible, culturally appropriate prevention strategies.

Local needs assessments identified a higher chronic disease burden, lower rates of preventative screening, and increased emergency department presentations across regional communities within the Sunshine Coast catchment. Stakeholder consultation and service data indicated that many individuals were not accessing routine foot screening due to practical barriers rather than a lack of willingness. Without early detection and intervention, preventable complications frequently progressed to infection, ulceration, or hospital admission.

Prior to implementation, no structured outreach pathway existed for preventative diabetes and foot screening across these locations. Existing services were primarily clinic-based, requiring patients to travel to fixed sites, which limited access for individuals experiencing geographic, financial, mobility, or social barriers. This highlighted a clear service gap between community need and available care models.

Footprints Walking on Country was developed to address this gap by delivering screening directly within communities through a mobile outreach model. Initially designed for rural areas of the Sunshine Coast, the service expanded into selected urban locations after identifying unmet needs among vulnerable groups facing similar access challenges, including people experiencing homelessness.

The program commenced screening in February 2024 and transitioned to fully funded status in 2025, following demonstrated demand, strong community engagement, and measurable early outcomes. The central problem addressed was how to provide timely, preventative assessment for at-risk individuals before deterioration occurs and hospital care becomes necessary.

Discussion

Delivering screening directly in rural communities improved access, strengthened trust, and enabled earlier identification of risk. Bringing care closer to home reduced geographic and transport barriers that often delay assessment in regional populations. The program's success was supported by several enabling factors, including strong executive and organisational support, integration with existing care pathways, and alignment with regional health priorities focused on prevention and health equity. The use of a purpose-built mobile clinic enabled safe clinical assessment in locations without existing health infrastructure. Community acceptance and local engagement were also critical, as trust and visibility influenced willingness to participate in screening.

Key lessons included the importance of community collaboration, culturally respectful delivery, and flexible scheduling to meet local needs. Establishing clear referral pathways and maintaining strong communication with primary care and specialist providers ensured continuity of care and reduced fragmentation across the service system. Early implementation highlighted operational challenges, including logistical coordination, service awareness, and scope clarification. Addressing these issues through iterative review and adjustment strengthened service delivery and improved efficiency over time.

Limitations included the short duration of outcome follow-up to date and reliance on early indicators, such as referral rates and service utilisation, as proxies for long-term clinical impact. Continued monitoring will be required to assess sustained reductions in hospital presentations and complications. Resource allocation and workforce availability remain important considerations for expansion.

The model shows strong potential to scale and spread across Queensland Health settings where distance, access, or service availability limit engagement with preventative care. It may be particularly suited to regions with dispersed populations, limited access to specialists, or communities facing barriers to attending clinic-based services.

Future directions include expansion of outreach locations, refinement of referral pathways, and continued strengthening of collaboration to support integrated care delivery. Planned service development includes closer alignment with SCHS Podiatry, with outreach sessions incorporating scheduled on-site podiatry clinics to enhance timely assessment, streamline escalation, and reduce delays in specialist care.

With foot screening now well established, the next phase of the program will place greater emphasis on preventing type 2 diabetes and on expanding diabetes self-management education to support earlier intervention and risk reduction. Ongoing evaluation will inform service optimisation and guide the model's adaptation for implementation in other regions where access barriers limit preventive care.

References

Australian Government Department of Health. (2021). National Aboriginal and Torres Strait Islander Health Plan 2021-2031. https://www.health.gov.au/resources/publications/national-aboriginal-and-torres-strait-islander-health-plan-2021-2031

Australian Institute of Health and Welfare (2017). Burden of lower limb amputations due to diabetes in Australia: Australian Burden of Disease Study 2011. Canberra: Australian Institute of Health and Welfare. Retrieved from https://www.aihw.gov.au/reports/burden-of-disease/lower-limb-amputations-due-to-diabetes/summary

Australian Institute of Health and Welfare (2024). Aboriginal and Torres Strait Islander health performance framework summary report.

Aboriginal and Torres Strait Islander Health Performance Framework - Summary report - AIHW Indigenous HPF

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Chuter, V., Quigley, F., Tosenovsky, P., Ritter, J., Charles, J., Cheney, J., Fitridge, R. (2022). Australian guideline on diagnosis and management of peripheral artery disease: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. Journal of Foot and Ankle Research, 15(1), 51-51. https://doi.org/10.1186/s13047-022-00550-7

Chuter, V., West, M., Hawke, F., & Searle, A. (2019). Where do we stand? The availability and efficacy of diabetes related foot health programs for Aboriginal and Torres Strait Islander Australians: a systematic review. Journal of Foot and Ankle Research, 12, 17. https://doi.org/10.1186/s13047-019-0326-1

Frescos, N., Jansen, S., Stopher, L., & Kaminski, M. (2022). The financial burden of diabetes-related foot disease in Australia: a protocol for a systematic review. Wound Practice and Research, 30(4), 223-227. https://doi.org/10.33235/wpr.30.4.223-227

Gerrard, J., Godwin, S., Chuter, V., Munteanu, S., West, M., & Hawke, F. (2021). Release of the national scheme's Aboriginal and Torres Strait Islander health and cultural safety strategy 2020-2025; the impacts for podiatry in Australia: a commentary. Journal of Foot and Ankle Research, 14(1), 38. https://doi.org/10.1186/s13047-021-00466-8

Sunshine Coast Hospital and Health Service. (2022a). Local Area Needs Assessment, Summary Report 2022. Queensland Government.

Sunshine Coast Hospital and Health Service (2022b). Sunshine Coast Aboriginal and Torres Strait Islander Health Equity Strategy 2022-2031.

Queensland Government. https://www.sunshinecoast.health.qld.gov.au/__data/assets/pdf_file/0009/104022/schhs-health-equity-strategy.pdf