Introduction

As a nurse who works with vulnerable populations, I have seen how foot health affects homeless patients in the hospital setting. I often witnessed that foot health was rarely addressed in their care plan. Although distressing, this issue has not received much attention, in my opinion. Because of the pandemic, there has been an increase in housing needs due to many losing income stability and the dwindling availability of social services. As a result, there is an increased need for low-income housing and health care resources.^1-2 In the United States, health care resources usually available to this population were especially strained during the pandemic for those who were already homeless and suffering from COVID-19.² With the increased number of vulnerable individuals in need of health care, clinicians should implement strategies to help those the most in need of wound care.

The Homeless Population and Foot Health

Increased numbers of homelessness and those in transitional housing have resulted in greater numbers of those with limited access to foot care. Previous studies on foot care have focused on provider and primary care, with emphasis on diabetic foot disease and neuropathy globally. These studies included the use of a diabetic foot assessment tool that determines referral needs based on the score, among other uses. ^3-7 The assessment tool used by D’Souza and colleagues⁷ provided a method for nursing students to assess all types of patients' feet across community settings. As a health care semi-structured interview guide, the assessment tool was developed through guidance from current literature, clinicians who work in the community setting, and social workers. The study identified a gap in knowledge, namely, that wound care professionals do not know whether these populations can provide their own foot assessment and care.⁷

Subsequently, my colleagues and I asked members of the community various questions relating to their ability to care for their feet in our study that is soon to be featured as a poster presentation at WOCNext 2023, ICN July 2023, and ACHNE June 2023. Some of the questions asked if those interviewed could provide their own foot care and if they were not able to do so if there was someone who could help them.⁸ Briefly, I will describe some anecdotal preliminary results and experiences from our research.

The Study

The feet can be neglected. My colleagues and I have seen people in community centers, low-income housing, transitional housing, and homeless shelters in the community setting. In our study, we observed that homeless individuals had the greatest need for foot health care, followed by transitional housing, a senior community center, and senior low-income housing.⁸Overall, those in the homeless population have the following needs that contribute to poor foot care and other complications^7-8:

• Shelter
• A place to bathe
• Access to foods and nutrition
• A support system
• Clothing (especially socks and shoes)

Foot care assessments revealed an increased need for access to podiatrists and wound care providers regarding referrals, especially for those with diabetes, chronic diseases such as lower extremity venous stasis, lower extremity arterial disease, neuropathy, nail and foot infections, and open wounds.⁸ Additionally, we observed the inability to perform one's own foot care among seniors and homeless individuals. For example, many in this population had difficulty trimming their nails since many cannot bend over to reach their nails or see their feet. In addition, most could not bend their knee or pull their foot up to rest on their thigh to perform foot care. We also observed numerous thick nails (Onychauxis) in older individuals and those with chronic diseases. Our study showed that those with these thick nails are not able to trim them, even if they could access their feet.⁸

Conclusion

If the needs of foot health are not addressed in the acute care setting, other health care centers, or community settings, there is an estimated increase in those with developing wounds, infections, emergency visits, and amputations from lack of attention and care, further burdening the already overwhelmed health care system.^2,7 Moreover, the engagement of student nurses to demonstrate competency in foot assessment has resulted in changed perspectives. The nursing students who participated in this study changed their view of not only members of the community but also those in other vulnerable populations. There is a need for change in how we, as wound care professionals, perceive foot health for these at-risk populations so that they can receive the foot care they need.

References

1. Douglas M, Katikireddi SV, Taulbut M, McKee M, McCartney G. Mitigating the wider health effects of covid-19 pandemic response. BMJ. Published April 27, 2020;369m1557 doi: 10.1136/bmj.m1557
2. United Way NCA.The Impact of the COVID-19 Pandemic on Homelessness in the United States. United Way of the National Capital Area. Published January 12, 2021; Accessed January 25, 2023. https://unitedwaynca.org/blog/the-impact-of-the-covid-19-pandemic-on-ho…
3. Keukenkamp R, Busch-Westbroek TE, Barn R, Woodburn J, Bus SA. Foot ulcer recurrence, plantar pressure and footwear adherence in people with diabetes and Charcot midfoot deformity: A cohort analysis. Diabet Med. 2021;38(4):e14438. doi:10.1111/dme.14438
4. Lazzarini PA, Crews RT, van Netten JJ, et al. Measuring Plantar Tissue Stress in People With Diabetic Peripheral Neuropathy: A Critical Concept in Diabetic Foot Management. J Diabetes Sci Technol. 2019;13(5):869-880. doi:10.1177/1932296819849092
5. Schaper NC, van Netten JJ, Apelqvist J, et al. Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36 Suppl 1:e3266. doi:10.1002/dmrr.3266
6. Woodbury MG, Sibbald RG, Ostrow B, et al. Tool for rapid and easy identification of high-risk diabetic foot: validation & clinical pilot of the simplified 60 second diabetic foot screening tool. PLOS. June 29, 2015;10(6): e0125578. doi: 10.1371/journal.pone.0125578
7. D'Souza M S, O'Mahony J, Achoba A. Exploring Foot Care Conditions for People Experiencing Homelessness: A Community Participatory Approach. J Prim Care Community Health. January 28, 2022. 13. 21501319211065247. doi:10.1177/21501319211065247

About the Author

Ivy Razmus, RN, PhD, CWOCN is an Assistant Professor at the University of Detroit Mercy where she is currently teaching in the BSN Nursing program. Her research focus is on pressure injury prevention for pediatric patients including neonatal patients. She has experience as a Manager of Pediatric populations both neonatal and pediatric intensive care; as a quality analyst within a health system focusing on nursing sensitive quality indicators and root cause analysis; and as a CWOCN in the acute, critical and outpatient settings in the adult population.