DOI: 10.31038/ASMHS.2021515

Abstract

Foot disorder pathologies, caused by diabetes mellitus, result in diminishing the quality of life for patients and straining the economic fabric of both governmental institutions and private organizations. Patients afflicted with diabetes suffer from disabilities, which can in many cases lead to foot amputation and other various complications. Often, patients also suffer from chronic pain caused by diabetic foot neuropathy, which may make them unable to continue with their employment and have a negative effect on their daily lives. Patients with mental health disorders are adversely affected by diabetic foot pathologies due to their lack of timely follow-up and limited access to medical providers. The goal of this Practicum experience was to develop and deliver a PowerPoint presentation to provide clinical guidance and education to primary care clinicians who evaluate diabetic patients (many with mental health issues) who otherwise might not have an opportunity to be evaluated by a podiatrist in a timely manner. This author created the PowerPoint presentation based on the review of literature and the input from the committee members. The PowerPoint presentation on diabetic foot care was limited to the primary care clinical staff at the Queens County Medical Center in Queens, New York. The purpose of the practicum is for these clinicians to learn how to perform a comprehensive evaluation of the lower extremities in patients with diabetes, including awareness of risk factors prone to increasing risk of foot ulceration, screening for neurological foot deficits, analyzing treatment options for patients with diabetic foot maladies, andrevention strategies to prevent diabetic foot complications.

Keywords

Diabetic neuropathy, Diabetic foot care, Diabetic foot ulcer, Podiatry, Psychiatry and diabetes, Diabetes screening

Introduction

Nature of the Problem

Diabetes is a disorder, which can cause severe medical problems with the physiology of persons afflicted with it, and the silent nature of this malady can lead to medical disability in a manner where late intervention is futile. One of the greatest pathologies caused by diabetes is neuropathy in the peripheral lower limbs, which can cause not only physical injuries affecting mobility in patients but also issues with pain and poor healing, which can lead to chronic pain syndromes [1]. Diabetes occurs due to glucose not being properly regulated by either lack of insulin production by the pancreas or the inability of the body to use its own insulin in an effective manner. This process auses grave health consequences including lower-extremity amputations, a disease that is the seventh leading cause of death in the United States [2].

Patients, suffering from mental health problems, are especially harmed by diabetes as the lack of timely access to podiatric providers often leads to diabetic foot neuropathy. Neuropathy, which leads to loss of sensation in lower extremities of patients (due to the fact that these are longest nerves as they are involved in innervating all the way the bottom of the feet), can often cause ulcerations and foot sores, which are overlooked by these patients. The disorder of diabetic foot disease (DFD) is a combination of peripheral neuropathy and arterial disease, which often leads to an end result of foot ulceration and lack of appropriate management that can lead to lower extremity amputation complicated with an open wound infection or osteomyelitis [3]. Furthermore, this lack of foot malady awareness can cause these patients to not seek care for their feet and further compound these problems and, in many cases, lead to avoidable foot amputations. Additionally, these psychiatric patients face further barriers as they lack financial resources to see specialist clinicians promptly, are prone to increased risk by being on psychiatric medicines, which often increase their blood sugar levels, and lack proper housing and follow- up, which could enhance their medical care [4]. Proper screening, evaluation, and timely management and prevention of foot maladies in patients with diabetes have shown to significantly reduce the incidences of lower foot amputation and better health outcomes for diabetic patients [5].

Significance to Patients with Mental Illness

The provision of providing cutting-edge information to primary care practitioners, which includes screening, diagnosing, and treating psychiatric patients with diabetic fool maladies, facilitate the optimal goal of improving foot health care in this underserved population. The majority of mental health patients face challenges in seeing a podiatrist on a routine basis and thus, are at increased risk of diabetic foot pathologies due to the increased levels of hyperglycemia caused by psychiatric medications. The timely intervention of podiatric are provided by primary care clinicians will lead to positive health outcomes for patients afflicted with mental illness and improve their quality of life.

Review of Literature

Overview

The Centers for Disease Control and Prevention (CDC) defines diabetes as a disorder, which leads to increased blood glucose levels in the body (CDC, 2015). Diabetes occurs due to glucose not being properly regulated by either lack of insulin production by the pancreas or the inability of the body to use its own insulin in an effective manner. This process auses grave health consequences, including lower-extremity amputations, a disease that is the seventh leading cause of death in the United States (CDC, 2015). According to the CDC, approximately 29.3 million people in the United States (9.3% of the population) have diabetes with another 86 million people having a pre-diabetic condition (CDC, 2015). The incidence of diabetes mellitus is expected to increase from 382 million people in 2013 to 592 million by 2035 with the vast majority of cases present in developing countries, which will also see the greatest increase in the number of these cases [6]. It is ironic that as the world has developed exponentially in the fields of basic health care, disease and infection management, and improved diet for all in the last several decades, the elevated incidences of diabetes is a reminder of how overindulgence in this abundance of dietary choices and lack of exercise can lead to such a blood glucose malady [6].

Diabetic Neuropathy

DFD is a combination of peripheral neuropathy and arterial disease, which often leads to an end result of foot ulceration and the lack of appropriate management of DFD can lead to lower extremity amputations complicated with an open wound infection or osteomyelitis [3]. The World Health Organization (WHO) in conjunction with the International Diabetes Federation (IDF) have set a goal of reducing amputations related to diabetes complication by up to 50% by initiating a multipronged approach of increasing patient education about diabetes, forming a multidisciplinary team of various specialties involved with the patient, and timely patient monitoring, which has shown to decrease amputation rates from 49% to 85% [7]. Neuropathy leads to loss of sensation in the lower extremities of patients (due to the fact that the bottom of the feet are enervated by the longest nerves in the body) and can often cause ulcerations and foot sores, which are overlooked by these patients. Furthermore, this lack of foot malady awareness can cause these patients to not seek care for their feet and therefore further compound these problems; a tragic complication leading to avoidable foot amputations [3].

Central Nervous System Effects

Diabetes can cause significant damage to the organs of the central nervous system, primarily the brain. The increased levels of glucose present in the blood stream cross the blood-brain barrier leading to consequences, which include (a) encephalopathy due to problems metabolizing the increased glucose in the blood stream; (b) elevated risk of brain stroke due to elevated intracranial pressure as a result of chronic, uncontrolled diabetes; (c) potential of brain damage and white matter changes in the cerebral cortex due to the long term use of insulin and other hypoglycemic medications; (d) possibility of seizures due to elevated blood sugars decreasing the seizure threshold; and (e) potential of cognitive changes when hyperglycemia goes unchecked for long periods of time [8].

Peripheral Nervous System Effects

The effects of long-term elevated serum glucose levels have a deleterious effect on the nerves of the peripheral nervous system. The first effect, causing the most common nerve damage in diabetes mellitus, is called diabetic neuropathy, which impedes the sensation perceived by the sensory nerves as they relay messages to the brain [9]. Additionally, motor nerves are also affected as they slow down messages from the brain to move muscles in a timely manner affecting body reflexes to stimuli [10]. The second effect is autonomic neuropathy, which is a process whereby gastrointestinal functions such as digestion are affected by elevated blood sugar levels. Furthermore, autonomic involuntary functions such as blood pressure and heart pulse are often disrupted while also leading to sexual dysfunction (CDC, 2015). Another adverse effect is diabetic gastroparesis, which affects the passage of food through the stomach, as muscles in the colon do not interact in an effective manner, leading to multiple systemic medical complications [9]. Moreover, the process called focal diabetes-related neuropathy causes individual cranial nerves to transmit signals less effectively resulting in vision loss and hearing problems [9].

Diabetic Foot Effects

Epidemiology

There is an increased incidence of diabetes in the world, especially as the accessibility of medical care has improved [6]. The world population is living longer although enduring more diseases as people age with the latest estimate of 592 million people diagnosed with diabetes by 2035 [6]. Males, especially over the age of 60, are at the highest risk of developing DFD with the presence of foot ulceration a major indicator leading to risk of foot amputation, a lifetime risk of almost 25% prevalence in the general population [3]. The rate of foot ulceration increased by 700% in patients with diabetic neuropathy when compared with patients without diabetes and its associated conditions [3]. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD) estimated that about 60% to70% of the world population with diabetes suffers from neuropathy (age and disease duration causing increased risk) and the highest rates are among people with diabetes for over 25 years [11].

Etiology

The lack of knowledge regarding this disease, unable to see providers on time, lack of screening protocols, difficulty in managing blood sugar levels, and the limited follow-up options available for patients often led to this result of foot amputation [3]. The loss of sensation due to sensory nerves being initially unresponsive to light stimuli makes the patients unaware of any stressors affecting their lower extremities, which often results in foot injuries being unheeded. Gradually, this loss of sensory stimuli perception ascends into more proximal areas of both feet bilaterally, and by then, most of the damage has been done in terms of nerve neuropathy. Often, patient complaints gradually evolve from tingling sensations and shock-like lower extremity pain to abnormal hot and cold sensation to their feet; a process that eventually leads to foot cramping with anatomic changes like hammer toes, flat feet, and foot pressure ulcerations [3]. These anatomic results are directly from motor nerves being affected during the later phases of DFD after initial sensory foot deprivation. Another common malady leading to foot dysfunction includes autonomic changes in the feet, which can often manifest itself as dry skin, cracked skin changes, excessive foot sweating at times, and loss of deep tendon reflexes. The difficulty of blood to flow back from the veins in the feet against gravity leads to foot edema, which is another major risk factor of DFD [3].

Risk Factors

There are various risk factors which can make an individual prone to be diagnosed with diabetes mellitus relative to the general population. Family history plays a significant part in elevating a person’s chance of getting diabetes. The elevated risk can be as high as 2.3 to 5.5 times a person without a familial history of diabetes [12]. Multiple other risk factors include obesity, waist circumference, inactivity, and history of gestational diabetes. Additionally, American Indians, Hispanics, and Asians were noted to have elevated risk of being diagnosed with diabetes compared to the general population [10]. It was also noted that losing muscle mass, co-morbid medical conditions, and gaining weight due to inactivity also led to increased prevalence of diabetes in the older population [10]. High blood pressure, increased triglycerides, and elevated cholesterol levels also were noted to be risk factors in developing this illness [12].

Oral Medications

There are multiple medications used to mitigate the adverse effects of diabetes by attempting to keep blood sugar levels down with the goal being to prevent long term central and peripheral manifestations of this disease. The majority of these classes of drugs include metformin, sulfonylureas, thiazolidinediones, meglitinides, dipeptidyl peptidase inhibitors, and glucagon receptor agonists, which are used as monotherapy and in combination, to treat adults with type 2 diabetes [13]. There was an average of 1% decline in Hemoglobin A1c (an indicator of blood sugar levels over the last three months) with these prescribed medications and there was no difference between a single drug or a combination.

Lifestyle

Patients with diabetes must adhere to a lifestyle, which includes awareness of risk factors prone to increasing their risk of foot ulceration, be aware of self-screening for neurological foot deficits, speak to their clinicians proactively regarding treatment options for diabetic foot maladies, andrevention strategies to prevent diabetic foot complications [14]. Additionally, patients must be encouraged to ensure compliance with foot care protocols and adherence to follow-up recommendations and appointments [14].

Diagnosis

History

A prominent risk factor, which leads to adverse effects from diabetes is the asymptomatic nature of this illness in its early stage. Patients are often not aware of their hyperglycemic status until they start experiencing symptoms. Early detection of diabetes leading to initiation of diet and exercise regimens with possible utilization of oral hypoglycemics has positive outcomes for patients. The signs and symptoms of diabetes include: (a) lethargy, (b) chronic feelings of hunger, (c) excessive urination with corresponding feelings of being thirsty most of the time, (d) dry skin, and (e) blurred vision [15]. Patients with diabetes are also prone to yeast infections due elevated blood sugars providing a nutritional source for yeasts and due to their immunocompromised status. Nerve damage associated with neuropathy can cause long duration for injuries to heal while also causing numbness and tingling in extremities. It takes a combination of factors, such as the patient history, family history, clinical foot exam, and the utilization of diagnostic exams, to best screen the patient for severity of DFD [15].

It is imperative that focused questions need to be asked during the history taking portion of evaluation which would include (a) is the patient’s blood sugar monitored by the patient on an ongoing basis and is it well controlled; (b) are the medications taken by the patient for diabetes causing any adverse side effects including episodes of hypoglycemia; (c) has the patient been referred to podiatrists, ophthalmologists, nephrologists to evaluate and manage systemic issues caused by their diabetes; (d) has the patient been involved in their diet management by exercising and eating in a health manner; (e) has the patient kept up-to-date with their immunizations including annual flu vaccine shots; and (f) has the patient made aware of all foot complications caused by diabetes and has the patient been educated in foot care, including keeping the foot area dry, examining the foot area on a regular basis for any bruises or injuries and ensuring that their toe nails are trimmed regularly by a podiatrist [3].

Physical Exam

The physical exam component of the evaluation of a patient with diabetes must ensure that the patient’s body mass index (BMI) is maintained in the normal range while also ensuring that the patient maintains a consistent exercise regimen (NIDDKD, 2008). Vital signs must be monitored for hypertension and orthostatic blood pressure must be performed regularly to rule out signs of autonomic neuropathy [7]. Physical exam techniques must also evaluate the foot of the patient regularly for injuries and pulses must be palpated to monitor for adequate blood flow to the extremities [7]. A combination of deep tendon reflexes, sensory lower extremity exams, and vibration tests must be performed to evaluate patient for any metabolic foot maladies [3]. An ophthalmology exam must be performed to rule out neo-vascularization in the retinal region and flame hemorrhages which are often noted in diabetic patients with poor blood sugar control (NIDDKD, 2008). A thorough skin examination must be performed to screen for skin atrophy, dryness, yeast infections and discoloration of the skin, which if often noted in diabetic patients [4].

Lab Studies

There are multiple scales, which can be used to measure foot maladies, and they might utilize measures, such as capillary refill, pedal pulses, foot deep tendon reflexes, pathological Babinski reflexes, and pedal edema on rating scales [15]. Commonly used screening diagnostic methods, such as neuropathy symptoms scores, Semmes-Weinstein monofilament, vibration perception on the lower extremities from distal to proximal, nerve conduction studies, and even nerve biopsy, are valid tools in the arsenal for diabetic neuropathy foot screenings [15].

Treatment

The mainstay of treatment is a coordinated approach by the patients and their clinicians regarding prompt screening, initial diagnosis of diabetes and subsequent awareness of systemic foot manifestations, and monitoring levels of blood sugars, ensuring that the foot is free of any added physical stress by managing weight and reducing risk factors, such as smoking and alcohol use and appropriate follow up with referral specialists [3]. A combination of clinicians would include the primary care clinician to coordinate care and refer to specialists, dietician to monitor weight and recommend food choices, diabetes educator who might suggest special techniques to care for the foot [3]. Additionally, an endocrine specialist is needed to follow up on glycemic control and management of medications, a podiatrist to ensure that the foot is evaluated thoroughly and recommend and fit podiatric shoes for the patient if necessary, and family support to help ensure that the patient is able to follow through with all his or her medical commitments [3].

Primary Interventions

In case of an open ulcer, there would be certain recommended treatments, which are considered standard protocols to include (a) debridement of the wound to help remove any foreign bodies and ensure that the food is free of infection; (b) changing the pressure points of the foot by utilizing podiatric foot inserts and making special leg casts as necessary; and (c) treatment of any infection by using topical and/or oral antibiotic agents to reduce opportunities for any spread of infection, which could lead to cellulitis and gangrene if unchecked [3]. Wound dressings also play a key role in maximizing the role of antibiotics and reducing chances of infection in patients with diabetic foot ulcers [3]. Common wound dressing techniques include wet-to-dry saline dressings; dressings with infused topical antibiotics covering the wound; and polyurethane dressings, which help ensure that the moisture conditions are optimal for wound healing [3]. Increasingly, there is greater use of growth factors in the treatment of diabetic foot ulcers that help with angiogenesis and increased cellular production, which can lead to more vascularization of the site. Furthermore, the role of vacuum-assisted closure, which can help remove redundant moisture in the wound, exposes wounds to rich oxygenated air therapy, and stem therapy is being studied in the quest to manage and treat diabetic foot complications [3].

Complications

Another common complication of diabetic neuropathy is peripheral artery disease (PAD), which manifests itself in the lower extremities by chronic leg pain, difficulty with healing of foot wounds, change in foot temperature, and lack of foot pulses bilaterally [16]. Commonly used screening tools for PAD include measuring the ankle-brachial index, foot ultrasounds, and contrast angiography [16]. Although these tools continue to be prevalent and utilization of these techniques have increased over the last several years, there continues to be increased rates of diabetic foot amputations due to a lack of timely screening and access to providers [3].

Prevention

The vast number of patients with diabetes are not initially seen by a podiatrist but rather by their primary care providers, including allied health professionals (physician assistants), and preventive strategies, screening, and treatment of foot ulcers has shown to decrease lower foot amputation rates by 49% to 85 % (NIDDKD, 2008). Physician assistants (PAs) can play a crucial role in mitigating the amputations connected with poor foot hygiene in diabetics by ensuring that their diabetic patients are screened in an appropriate fashion during their initial visit with an emphasis on thorough foot screening and follow-up referral to a podiatrist if available in a timely fashion (NIDDKD, 2008).

Patient Education

The screening criteria for DFD must include initial awareness and identification that a patient is vulnerable for foot ulcerations due to the diagnosis of diabetes. The patient must be made aware that routine inspection of the foot on a daily basis (while in the shower for example) is essential to prevent damage to the foot, shedding light on the symptoms to look out for in DFD, such as temperature changes in the foot, tingling, and painful feet [15]. It is important that the patient wears protective shoes, which helps reduce stress on specific parts of the foot and reduces exposure of the foot to outside risk factors, leading to foot trauma and keeping an eye out for any calluses, hammertoes, or hardening of certain areas of the foot [15]. There also needs to be regular follow-up by patients with their clinicians, depending on the nature of their DFD, which might range from a yearly foot examination to seeing a clinician every couple of months if there is already an ulceration present [15].

Patients and their families must be educated about checking that the shoes they wear do not provide excessive stress to the feet, provide adequate cushioning in their daily walking shoes, check daily between their toes for ulcerations, wash and then thoroughly dry their feet daily before bed, and use precaution if utilizing tools to cut toenails [15]. Active self-care and awareness of diabetic manifestation in feet, especially being vigilant in the presence of foot lesions and ulcerations, leads to positive long-term health outcomes for patients with diabetes [14]. The recommendations for foot care, which showed a potential decrease of lower foot amputations by almost 85%, included (a) always walking with comfortable shoes and not barefoot, (b) trimming toenails and not using abrasive items on feet, and (c) routine foot exams by a trained foot clinician [14-22].

Topics Based on the Literature

This author reviewed multiple research studies regarding the field of diabetic foot problems and the associated screening, diagnosis, treatment, and prevention protocols. It was imperative that the information regarding how prevalent diabetes is was included in the literature review of the topic, while also emphasize the frequency in which amputations occur in diabetic patients who neglect foot care [3]. The review of literature, after briefly touching on the definition of diabetes and related causes, focused on diabetic foot disorders. It was emphasized in the practicum review that screening and early diagnosis of diabetes can play a crucial role in reducing the frequency and intensity of foot infections [2].

The overarching theme of the practicum topics incorporated in the review of literature focused on complications of diabetes on a systemic manner, which primarily focused on the foot in this report. The importance of early intervention, including treatment with medication and emphasis of patient education, was dwelt upon as a compelling factor in decreasing the incidence of diabetic foot maladies. The author also emphasized the importance of referring patients to follow-up care with specialists due to the nature of diabetic disease and provided information for the primary clinician to implement treatment protocols during this initial treatment phase [15]. Finally, the review of literature accentuated the fact that early prevention, screening, treatments, and robust patient education would empower patients to take decisive steps in their diabetic foot care leading to positive health outcomes.

Discussion

Diabetic foot disorders can play a prominent role in affecting mobility in patients afflicted with this disease, which can often result in chronic pain and limited healing in the lower extremities [1]. The lack of insulin production by the pancreas in diabetic patients often lead to foot amputations, and this process is the one of the leading causes of death in the United States [9]. A combination of factors including lack of proper screening, timely evaluation, appropriate management and limited patient education work in conjunction to exacerbate this condition leading to poor patient outcomes [5]. Moreover, patients with limited financial and social resources can suffer additional negative consequences of this disease compared to the regular population due to their socio-economic circumstances [3].

Patients with mental health disorders encounter additional challenges due to psychiatric medications increasing blood sugar levels which further exacerbate their diabetic condition while also negotiating lack of proper housing and follow-up medical care [4]. This author focused on the barriers, which economically deprived patients face regarding diabetic care and the opportunities available to overcome them. The limited access to specialist foot providers, such as podiatrists, made it imperative that primary care clinicians, who after are the first to evaluate patients for medical purposes be educated in initial screening and management of diabetic foot maladies [7]. This author developed a PowerPoint presentation which was delivered to a group of primary care clinicians at the Queens County Medical Center, located in Queens, New York, which is at the front line of delivering care to indigent and socially deprived populations. It was the goal of this presentation that these primary care clinicians would be educated to treat patients early enough in the progression of diabetic foot disorders that diabetic related foot amputations will be minimized; a process leading to improved quality of life for these patients [5].

Conclusion

Lower extremity amputations lead to a decreased quality of life issues for patients with associated economic challenges and mobility issues. Timely screening, management, patient education, and appropriate follow-up can lead to mitigating the effects of diabetes not only on foot related problems, but on the overall health of patients. Patient education in conjunction with primary care provider education can play a crucial role in minimizing the devastating effects of this disease and lead to better health outcomes for patients, and reducing the financial expenses in the long term to the United States health care budget.

Appropriate and timely management of diabetes with its associated morbidities can lead to positive health outcomes for patients. The devastating consequences of diabetic related foot amputations not only leads to a poorer quality of life for affected patients but has caused increased economic harm to the community. Provider education regarding early screening and treatment of diabetes, which will lead to appropriate referrals to specialists, can help all the stakeholders affected by this disease on a personal and professional level. Governmental agencies, private institutions, and insurance companies will certainly benefit economically if there are more resources expended in the early phases of screening and patient education of diabetic patients. Finally, patients afflicted with this disorder would be able to be productive members of society without suffering the consequences of long-term foot pain and diabetic amputations.

Recommendations

Exploration of the diabetic foot disorders presents an opportunity for front line primary care clinicians to be leaders in the quest to reduce diabetic foot related morbidities. This innovative process would help enhance both patient and provider satisfaction while also providing economic savings to these institutions, which otherwise would be burdened by diabetic foot-related expenses. Further research could encompass patients not only suffering from psychiatric disorders, but also (a) patients with alcohol and substance abuse disorders, (b) native American and inner city populations without access to timely medical care, and (c) disabled patients who are unable to seek professional help due to mobility issues. Additional funding grants by governmental organizations and private charities to explore opportunities to expand diabetic care would certainly enhance research into this important topic. Finally, recognition about diabetic foot disorders and its horrendous consequences on patients can help pique further interest in researchers to explore alternative opportunities to improve patient care and provide a valuable service to society.

References

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DOI: 10.31038/ASMHS.2021511

Abstract

Respondents evaluated unique sets of 48 different combinations of elements (so-called vignettes), describing airline services, first rating interest, and second, selecting the emotion closest to their feel, from a list of five feelings/emotions. The test stimuli comprised mixtures of elements, features of the airline’s service, combined according to an experimental design. Each of 54 respondents evaluated a unique set of vignettes arrayed to ensure that the ratings could be analyzed by OLS (ordinary least-squares) regression. Two mind-sets emerged, MS1 being travel process and MS2 being fun and entertainment. The individual elements were linked to the emotions as well, providing a nuanced view of the elements beyond the ability to drive interest in the airline. The paper ends by introducing the PVI, personal viewpoint identifier, to assign a new person to a mind-set, providing a prescription of the specific words to say to the respondent to break through the everyday clutter, and excite interest in the offering.

Introduction

The world of travel and leisure collapsed during the 2020 Covid-19 pandemic [1-3]. Earlier in the decade, as travel was surging, the issues emerged about just ‘what’ the customer wanted in what was becoming a highly competitive environment. The period from 2009 to 2019 saw the emergence of the world from a financial debacle, the melt-down of 2008. Companies began to compete on what they could offer the customer. The emergence of e-commerce, and -shopping for travel changed the balance of knowledge, making the travel agent less important. Customers could use the Internet with programs like Kayak, Orbitz, and so forth to discover and piece together prices, amenities, schedules, etc. [4,5].

Within this world of information and increased customer demand, as well as direct to consumer, issues began to emerge about what features are important to acquire and satisfy customers [6]. In addition, however, interest in consumer requests was accompanied by a growing understanding that emotions play a role in decision making as well [7]. The question emerged about how to link elements to emotions as well, providing two pieces of information; how the element drives decisions, and how the element drives emotions, respectively In papers published by author Moskowitz and colleagues, introduced an approach using experimental design to design test stimuli, and a method to assess liking responses to these test stimuli, and especially determine the acceptance of the the underlying individual phrases, elements, the building blocks of the vignettes [8,9].

The study reported here presents one of the early studies in the use of the emerging psychological science of Mind Genomics to understand how people think about the features of travel, both in terms of motivation to act, and in terms of the linkage of emotion to the specific element. The ingoing assumption was that through the approach of Mind Genomics, explained below, it would be possible to do a simple study to understand the mental ‘valence’ of ideas in the mind of the consumer.

Understanding the Mind of the Consumer through Systematics (Mind Genomics)

Mind genomics is an emerging science with heritage from psychology, consumer research, statistics, and anthropology [10]. The objective of a Mind Genomics study is to understand how people make decisions about the everyday aspects of their lives. Mind Genomics works at the level of the granular, at the simplest levels of experience, which we might call ‘bottom-up’. This means that the information is specific, g expressed in the language of the person who is doing the experiencing, rather than in a summarizing, detail-sparse, high level language that might be used for a professional report.

The study reported here represents one of the earliest mindset cartographies, defined operationally as small studies which take a snapshot of an experience or a situation, with relatively few people. The objective of cartography is to map out the area, rather than confirm/falsify a hypothesis in the way Karl Popper and his associates might do so [11]. Mind Genomics reveal patterns which suggest a hypothesis, rather statistically test a hypothesis. The reason for that seemingly bold statement is that the conventional ways scientist to test hypothesis involve focusing the study, minimizing the noise so that the ‘signal’ can come through. Mind Genomics works in the opposite way, inserting ‘noise’ by testing the stimulus in y different ways, akin to the MRI (magnetic resonance image). It is the set of patterns generated by the MRI, and recombined, which lets the signal come through clearly.

Applying Mind Genomics to the Customer-facing Aspects of an Air Flight

We illustrate how Mind Genomics reveals the responses to an ordinary situation of the 21st century, specifically what people want as amenities on an airline. As the case study unfolds, we will see how Mind Genomics deals with what is interesting at a cognitive, interpretation level, and then at an emotional level, viz., the emotions selected by the respondent while reading a vignette.

The objective of the study was to identify the features of a flight as might offered by an airline seeking to burnish its image. Among the many offers that an airline could provide, in the language of the airline, how does Mind Genomics reveal the importance of the different offers, identify the emotions which relate or link to those offers, and uncover new mind-sets, groups of people showing different, even radically different responses to the same stimuli?

The process follows a series of steps, which we now explicate, showing the step, the data, and the conclusions emerging from each step.

Step 1: Select the Topic, Ask 6 Questions Relevant to the Topic, and for Each Question Provide 6 Answers

The original study was done in 2012. At that time, the primary design was the so-called ‘6×6’, or six questions, each with six answers, and a unique set of 48 combinations or vignettes for each respondent. The reason for the larger design can be traced to the early years of internet-based research. The respondents were recruited from a panel (Open Venue, Inc.,) located in Toronto Canada, but servicing the United States. Respondents at the time were not yet ‘oversampled’ by having every internet transaction followed by a short survey for satisfaction, or so it seems today.

During the first 15 years of these past two decades, it was possible to get consumer respondents to participate in interviews on the web lasting 15 to 20 minutes each. The dropout rate was low, around 33%, and the cost was modest. One benefit of the early introduction of Mind Genomics into internet-based research was the possibility of larger, longer studies, the current 6×6 design, and two rating questions. Today, with the shortening of attention span, with the various media and social media competing for attention, it is no longer possible to do the types of studies reported here. The studies can be of the same type, but significantly shorter. The new approach comprises 4 questions and four answers to each question and is known by the phrases ‘4×4’ or ‘four by four’.

Table 1 shows the 36 elements, arranged by question, and then the six answers (elements) to each question. It is important to keep in mind that the selection of elements need not be perfect. Most researchers are accustomed to thinking a great deal about the choice of elements. Some of that thinking comes from the fact that the researcher fails to perceive research as an iterative process and assumes that the research of this type is always final, conclusive. When the researcher realizes that one can do these early-stage cartographies quickly, inexpensively, and iteratively, the attitude changes from ‘getting the right elements for the not-to-be repeated study’ to ‘getting into the field, getting a feel of what ‘works’, and the iterating a few more times during the next day or two.’

Table 1: The six questions and the six answers to each question.

Step 2: Create Combinations of Answers (Vignettes), Present Them to the Respondent in Sets of 2-4 Answers, the Set Evaluated as a Single Offering

The underlying experimental design creates 48 unique combinations for each person. 36 of those combinations comprising four answers (elements), and 12 of those 48 combinations comprising three answers. No vignette can ever comprise two answers from one question to avoid combinations which could be mutually contradictory. The combinations are dictated by a single basic underlying design. The design is permuted so that the mathematical structure is the same, but the specific combinations differ for each respondent. The beauty of the design permutation strategy is that we know ahead of time that each respondent will have evaluated the precisely correct combinations to create an individual level model for that person. In the world of statistics, Mind Genomics uses a within-subjects design, which can be analyzed down to the level of a single respondent, that respondent level analysis becoming relevant for clustering the respondents into mind-sets.

The fact that each respondent evaluates a full experimental design makes Mind Genomics metaphorically akin to the MRI (magnetic resonance imaging). The MRI tool takes different snapshots of an underlying tissue, 2-dimensional, but puts them together afterwards by a computer program. The result is a three- dimensional represent Obtained by combining many-2 dimensional representations. The same holds for the Mind Genomics approach. We get a better understanding of the nature of responses to a situation by having many snapshots or many respondents looking at different combinations of the same topic. Rather than worrying about being correct in our initial choice of the stimuli to test, we create a pathway requiring absolutely no knowledge, although it does require that the researcher to identify phrases to use.

Before leaving this underlying experimental design, it is worth reinforcing the state above regarding Karl Popper’s view of the need to work with hypotheses. Mind Genomics differs from the conventional science which is interested in falsifying or confirming a hypothesis. To falsify with confidence, one would like to make the measures as free of variability as possible. In such a case, the strategy is to test the same stimuli many times to suppress by variability by averaging. Mind Genomics prescribes measuring the entire space, even with noise, letting the pattern emerge out of the seeming noise. Mind Genomics suppress the noise by averaging the underlying patterns, so that the noise drops out. The happy result is that Mind Genomics experiments (viz., studies, surveys) cover a great deal of the ‘design space,’ and reveal inherent patterns in a clear way. The underlying ‘story’ is easy to discern.

Step 3: Present the Test Stimuli, Vignettes, and Get Ratings

Figure 1 shows an example of four steps in the process, these steps manifesting themselves in screen during the Mind Genomics experiment. The four steps are shown as a single slide.

Figure 1: Example of the respondent experience, who sees instructions, a vignette and two ratings scales, use the airline, and select an emotion.

The top portion of Figure 1 shows the orientation/instructions. The instructions say as little as possible about the topic. The goal is to have the elements convey the information because it will be the reactions to the elements which make all the difference.

The second section of Figure 1 shows a four-element vignette, viz., and a vignette comprising four answers.

The third section of Figure 1 shows the first rating scale; ‘use this airline’ (expected action)

The fourth section of Figure 1 shows the second rating scale, ‘select an emotion.’

Often critics complain that it is impossible for a person to make a judgment unless the vignettes are complete. Experience over the last 35 years with Mind Genomics shows this criticism to be invalid, although there is some need for instruction. People have no problem once the vignette is put into context with a few relevant pieces of information. A vignette having only one piece of information is hard to evaluate. An example is a vignette presenting only the brand name, or a price or a benefit. There is no sense of a ‘something’ being evaluated. By the time we get to two and certainly three elements things become a lot easier. The ‘something’ emerges, although the something is simply a set of ideas strung together without connectives. Nonetheless, respondents very rarely say that they have a difficulty answering the questions when there are several elements in the same vignette.

A great deal of the criticism of Mind Genomics comes from individuals who are looking at the process as a long, tortuous process. Most of the people who complain are either academics or marketers. The typical run-of-the-mill person has no problem going through 48 of these vignettes, when the vignettes are properly presented. The respondent is instructed to rate the vignette, doing so by ‘intuition’ and ‘gut feel’. It is here that respondents occasionally begin by trying to be consistent, but since these vignettes come and go so quickly, a typical respondent simply stops trying to be consistent, goes into almost an automatic state, and responds honestly to the combinations. The respondent cannot game the system. That is exactly what is desired, in an honest evaluation. The mind genomics approach forces the respondent to be honest because no human being could follow this combination rapidly enough when the combinations come once a every 8-12 seconds each, in an unrelenting fashion. This evaluation time suffices for the respondent to read the vignette, or at least glance at the vignette, and assign two ratings.

After the respondent completed the evaluation of the 48 vignettes, they completed a second questionnaire, comprising a self-description, in terms of who they are, what they do, and what they think about traveling and airlines. The respondents also were asked to list one feature that they feel to be most important.

For Mind Genomics studies, the best practice is to work with a professional company which specializes in getting respondents to participate on these online studies, whether the studies are called surveys, experiments, or some other label. The respondents may not be totally representative of the entire population, but they are as close as one is going to get to a representative population of the ultimate consumer or relevant party. Efforts to get free panelists may work in some rare situations, but over the past two decades it has become the norm to use panel providers, who incentive the panelists to participate in these studies. In this way the data come in quickly, at relatively low cost.

Step 4: Prepare the Data for Analysis by Transforming the Rating to Create New Variables

The 9-point Likert Scale may be used in the way it is, but it will be far more relevant to create a new binary scale for question #1 (use the airline), and five new binary scales for question #2 (select the emotion from a set of five).

The rationale for creating a binary scale is the effort needed to understand and then to explain the meaning of each scale point on a 9-point scale. Managers make yes/no decision, and prefer black and white answers, or at least black and white measures (viz., not use the airline vs. use the airline). When the 9-point scale is transformed to a binary scale, no/yes, it becomes easier for the manager to understand and use the data. Managers can understand yes in know quite easily. It does not take a lot of effort to explain the results. There is of course a loss of granularity, but that is to be expected and welcomed because it also reduces the confusion in interpreting the results.

The first transformation is the binary transformation using scale #1, the 9-point rating scale. By convention, viz., long term processes in consumer research, the scale is divided between 6 and 7. Ratings of 6 and below are assigned the value 0. Ratings of 7 and above are assigned the rating 100.

The second transformation is done using scale #2, the emotion. Each of the five emotions becomes its own scale. When the emotion is selected (and the other four not selected), the newly created variable corresponding to the selected variable is assigned the value 100. The other four newly created variables, viz., those not selected, are assigned the value 0. It should be kept in mind that this second ‘scale’, viz., select the emotion, is not a rating scale in the way we think of scales, but rather the lowest form of measurement, called the nominal scale by psychophysicist SS Stevens [12]. The five scale points, 1,2,3,4, and 5, do not have any metric value. They are simply placeholders to tell us what was selected.

The two transformations j prepare the data for OLS (ordinary least squares) regression analysis, which link the transformed ratings to the presence/absence of elements.

One final note is in order. OLS regression requires variation in the dependent variable, viz., variation in the transformed rating. This variation can be vanishingly small, but it must be in the data to prevent the regression analysis from ‘crashing.’ A prophylactic measure adds a random number around 10^-5 to each newly transformed variable, a low number which does not material affect the OLS regression but prevents the OLS regression program from ‘crashing.’

Step 5: Create an Equation for Each Person, and Cluster People Based on the Pattern of Their Coefficients

The underlying experimental design enables the researcher to relate the presence/absence of the 36 elements to the responses, even at the level of the individual. This so-called ‘within-subjects design’ allows the estimation of the following equation at the level of each respondent, even though each respondent evaluated a unique set of 48 vignettes or combinations:

Binary Response Variable = k₀ + k₁(A1) + k₂(A2) … k₃₆(F6).

The foregoing equation uses the transformed variable from question #1, which had been transformed from a 9-point Likert Scale [13] to a binary scale (see Step 4 above).

Each respondent generates a vector of 37 numbers, an additive constant and 36 coefficients, one coefficient for each of the 36 elements. We ignore the additive constant, focusing just on the 36 coefficients. These coefficients show how the respondent weights the information to drive the judgment of ‘use.’

Through the statistical methods known as cluster analysis [14], we divide the respondents into two and then three groups, based upon the pattern of coefficients. In this case, with a small base size of 54 respondent we isolate two large clusters that were interpretable (MS1 and MS2), and a small cluster of 4 respondents that could not be interpreted. We thus selected a three-cluster solution, but do not pay attention to the third cluster, or third group (MS3). Note that the terms MS1, MS2, and MS3 are short-hand versions for the phrase mind-set, whose meaning will become clear.

At this point it is important to note that the entire clustering operation except for rejecting clusters or naming them is a purely mathematical operation, based upon creating groups of objects (respondents) showing mathematically ‘similar patterns.’ There is no attempt to name the mind-sets. Up to now everything is ‘objective,’ at least in the mathematical sense.

Step 6: Create an Equation for All Respondents, for Total, for Mind-sets, and for Genders

Step 5 showed the equation, estimated by OLS regression. The equation comprises both an additive constant (k₀), and 36 individual coefficients.

Binary Response Variable = k₀ + k₁(A1) + k₂(A2) … k₃₆(F6).

Table 2 shows the parameters of the equations, first estimated for all vignettes evaluated by the total panel, and then estimated for all vignettes evaluated by respondents assigned to MS1, and then respondents assigned to MS2. Table 2 shows only the positive coefficients. To show all coefficients (viz., 36 for each subgroup) overwhelms the reader, and prevents patterns from emerging clearly. Neither zero coefficient nor negative coefficients teach us as much as do the positive coefficients.

Table 2: Performance of the strong performing elements by Total Panel and by the two larger mind-sets.

The parameters are interpreted as follows:

Additive constant – This is the parameter k₀. The additive constant is the expect proportion of responses of value 7, 8, or 9 in the absence of elements. By design, all vignettes comprised three or four elements, so no vignettes ever comprised zero elements. The additive constant can be estimated, however, and represents the ‘baseline’ interest in using the airline, in the absence of any additional information. A simile is a statue. The additive constant is the base of the statue.

The elements, in turn, are the additive or subtractive values. We do not show the negative coefficients, which would subtract from the additive constant. We do show the positive coefficients because they are the more important for understanding the nature of the respondent’s thinking.

Table 2 shows a low additive constant, values 21-22, meaning that in the absence of elements (a theoretical situation, as noted above), we expected only one in five ratings to be ‘use the airline.’ It will be the elements, especially those with high coefficients, which drive the choice. These are the elements which ‘perform strongly.’ The operational definition of ‘perform strongly’ is a coefficient of +8 or higher, corresponding to a ‘t’ statistic of about 2 or higher, and a probably of randomness of 0.05 or lower. These cut-off points are obtained by an analysis of variance of the regression model data from the total panel. The strong performing elements are shown as shaded cells.

The strong elements for each mind-set tell the story, whether travel efficiency (MS1) or travel as fun and adventure (MS2). The names for the mind-sets are the major contribution in the interpretation. The creation of the elements requires critical thinking. The mind-sets themselves, however, emerge without any input from the researcher, other than being named.

The elements in Table 2 sorted by strongest to weakest, first by those elements which perform strongly among both mind-sets, then those elements which perform strongly among Mind-Set 1 (valuing travel efficiency (business travelers)), and then those elements which perform strongly among Mind-Set 2 (valuing travel as fun (leisure travelers)).

The data suggest strong performing elements, some performing well in both mind-sets. Two elements should not surprise, one dealing with price, the other with comfort:

When joining out club your 1st flight is 9 Dollars!

Extra legroom with your seat

One element has virtually no appeal at all

Baby Formula available on menu for nursing mothers

It is important to emphasize at this point that what seems obvious, namely the two different groups of respondents appear to emerge seamlessly, is in fact not so obvious at all. Consider, for example, another way to divide the respondents, viz., by gender. Table 3 shows radical differences between genders in their responses to the elements. The genders differ in terms of the elements which score highly. Yet, there is no clear story which summarizes the differences between the genders regarding the elements which perform strongly.

Table 3: Performance of the elements by Total Panel and by gender.

Step 7: Link Emotions to Elements

Question #2 required the respondent to select a single emotion/feeling to describe how the respondent felt after reading vignette. As described above, we can link the elements to each emotion/feeling by creating five new variables, as well as two summary variables (positive, negative)

The ordinary least-squares equation fits the same type of equation as we have seen above, without, however, the additive constant. In these analyses, coefficients of 10 or higher, are operationally considered to be strong.

We get a sense of the linkages for the Total Panel from Table 4. The Summary linkages suggest five strong linkages with positive emotions (comfortable, confident, and curious):

Table 4: Linkage of elements with emotions. Data from the Total Panel. Strong linkages of 10 or higher are shown in by the shaded cells.

When joining our club your 1st flight is 9 Dollars!

Extra carry-on bags….No extra charge when choosing our airline

Wider seats in both coach and first-class sections

Extra legroom with your seat

Comfy leather seats.

The summary also suggests five strong linkages to negative feelings/emotions (anxious, indifferent)

Private area for nursing infants

Baby Formula available on menu for nursing mothers

Book flights through our NEW mobile app

Mobile app reminds you of your flight 24 hours before boarding

Unlimited in-flight shopping with payment options available

It is important to recognize the potential power of linking elements to emotions. Knowing the linkage of an element with an emotion gives a sense of why the element performs the way it does and may increase the ability to fine tune the message to eliminate the negative feeling/emotion.

Step 8: Generalize the Results by Assigning a NEW PERSON to One of the Two Mind-sets

The data presented here provides an in-depth look at responses to offerings of amenities by airlines. The effort to create the study is relatively small; a day or even less should suffice to pick the topic, discuss the questions, select the answers, and run the study on the internet with 100-200 respondents. The newer versions, with four questions and four elements are even faster. The time for running the experiment is also short; 17-20 minutes for a panel or group of 50-100 people, who can run the study on the internet. Finally, the data analysis is automatic, with the researching getting the report within 1-2 minutes after the study is completed.

The issue is not the study, but rather the generalizability of the results, and the use of the data, both for knowledge-building and for direct marketing. Studies using 50-100 respondents can be set up and executed quickly, especially within the ‘new’ framework of 4×4, viz., four questions, each with four answers. The templated approach (www.BimiLeap.com) makes that effort simple. Yet, at the end of the single Mind Genomics experiment or iterated set of experiments, there is still the need to ‘use’ the data to solve real-world issues, perhaps involving hundreds, thousands, or even millions of people. How then can the researcher generalize the results?

A great deal of ‘foundational research’ regarding attitudes works from the top down, identifying general patterns of responses, so-called personas, which are akin to the mind-sets, but usually for a broader topic area, such as travel in general [15,16]. The objective of the research is to assign a new person to one of these general personas, and then attempt to offer that ‘persona’ (and thus the individual) the appropriate message. The effort is cumbersome, expensive, open to a great deal of interpretation. All too often the effort ends up with the researcher and the marketer ‘guessing’ what to communicate to and what to offer to each persona, viz., each overarching general ‘mind-set.’ The personas may be clear as general descriptions, but the descent from the general to the particular remains a stumbling block. That is, knowing the ‘general’ does not automatically mean knowing ‘the particular in this instance.’

Mind Genomics approaches the problem in a different fashion. Mind Genomics works at the granular level, from the bottom up, remaining in the granular. Here, the granular comprises the relevant, limited aspects of travel, represented by 36 different, concrete ideas, ideas which can be instantiated in specific actions. The emergent mind-sets are quite different from each other. Time after time, these mind-sets emerge as the key to both to better understand the customer, and to better put that understanding into action.

The focus on granularity has led to a simple, virtually algorithmic approach which assigns new people to the appropriate mind-set. The data from the mind-sets (Table 2) prescribe the appropriate messages. During the past several years, authors Gere and Moskowitz have developed the PVI, the personal viewpoint identifier. The PVI comprises a set of six specific statements, taken from the set of statements shown in Table 2. The statements are those which best differentiate among two or three mind-sets, when artificial and disturbing ‘noise’ or random variability in inserted into the data table, in a so-called Monte Carlo simulation [17]. The PVI works by creating six questions (six elements from the study), each rated on a two-point scale. The pattern of responses to the six questions generates the information need to assign a person to one of the two (or three) emergent mind-sets, discovered through the Mind Genomics experiment.

The PVI set-up is templated and uses the Mind Genomics output. Table 5 shows the set-up section for the PVI. Not shown are the inputs for the three optional questions about why the PVI respondent travels, and the full set of data from which the PVI will created the algorithm to assign the respondent to a mind-set.

Table 5: The first part of the set-up for the PVI template.

Table 5 shows the five initial steps requiring judgment. This information is not automatically provided by the PVI algorithm.

1. The first step requires the researcher to provide the names for the mind-sets.

2. The second step requires the researcher to provide feedback to the respondent who fills out the PVI, with the feedback sent in an email, as well as placed into a database. Respondents are not only interested in the mind-set to which they belong, but want to know about their mind-set, and the other mind-sets.

3. The third step, an optional one, allows the researcher to drive the respondent to a landing page, based upon the mind-set to which the respondent has just been assigned.

4. The fourth step, also optional, optional one, allows the researcher to drive the respondent to a video, based upon the mind-set to which the respondent has just been assigned. Either the respondent is guided to a landing page, to a video, or neither.

5. The fifth step shows the two questions to be used when the respondent rates each of the six elements in the PVI.

Figure 2 shows the actual PVI created for this study from the viewpoint of what the respondent receives to complete. The PVI link is shown below, and is current as of Spring, 2021.

Figure 2: The PVI screen as the respondent see it.

https://www.pvi360.com/TypingToolPage.aspx?projectid=1271&userid=2018

The PVI begins with a short orientation about the project, and then requests the respondent to answer several background questions, such as age, gender, etc.

The second part of the PVI comprises three questions about the respondent as a flier (viz., frequency, reason for flight, passenger class).

The third part of the PVI presents six questions, and the two answers. The order of these six questions varies from respondent to respondent. The pattern of answers assigns a respondent to one of the two mind-sets.

The respondent who participates in the PVI questionnaire devotes approximately 60-90 seconds to the study. The objective is to identify WHO the respondent is, WHAT the respondent thinks or does, and then the mind-set to which the respondent BELONGS. This knowledge can be used to understand what to offer to the person through a designated landing page or video ‘fine-tuned’ to the mind-set, or to understand the mind-sets of people in different populations regarding the topic. It is important to keep in mind that once the mind-set is determined, the data can be used to select the precise words to use in advertising, or for research.

The feedback emerging from the study might well be incorporated into the landing page or video, to which the newly ‘mind-typed’ respondent is directed as part of the search process. The prospect, no longer a respondent in the PVI, would be led to one of the two different landing pages or videos, constructed according to Figures 3 or 4, respectively.

Discussion and Conclusions

Figure 3: The structure of information for the landing page or video: Mind-Set 1: Business Travelers.

Figure 4: The structure of information for the landing page or video: Mind-Set 2: Leisure Travelers.

As presented here, the Mind Genomics method provides a fast, easy to use, inexpensive  knowledge creation and knowledge deployment system. The worldview of Mind Genomics differs from the worldview of applied research in that the data can be archived and directly integrated in a bigger database. The coefficients have ratio-scale properties (a 20 is twice as much as a 10), the coefficients are scale-independent since they come from a binary transform, and the coefficients can be stored for comparison across years, topics, and even disciplines. In a sense, the coefficients comprise the basis of a ‘wiki of the mind’.

The important thing to keep in mind is that the data are cognitively rich, and self-evident. That is, there is no tortuous experiment to tease out the way ‘nature works.’ The patterns emerge quite simply. The patterns which emerge are either meaningful or not meaningful. Mind Genomics simply restructures parts of everyday life, giving the information a numerical value based upon the linkage with either a rating question, or an emotion. Instead of those questions, the questions can deal with price, with occasion, and so forth, in which case the results emerging from the cartography would provide the foundation for a ‘cognitive economics,’ or ‘cognitive anthropology.’ Finally, the ability to mind-type many people on many mind-sets provides a unique opportunity to create a true ‘wiki of the mind’, linked with actual people, so that one may understand more fully how the ‘mind type’ manifests itself in the behavior of the everyday.

Acknowledgment

Attila Gere thanks the support of the Premium Postdoctoral Researcher Program of the Hungarian Academy of Sciences.

The authors wish to thank the late Steven Onufrey, Ms. Janna Kaminsky, and Prof. Martin Braun of Queens College for their help on this project, in Mathematics 101, Queens College of the City University of New York.

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