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Life Without Shoes: A Look at the Benefits of Shoes

January 6, 2017
This week you will be hearing from Derek Roach, the Co-Founder of Flow Feet, an organization that truly understands the importance of shoes. To show their support for our mission, they collected 50 pairs of shoes during a one-day shoe drive.
While there are many benefits to wearing shoes, there are people across the globe that are not able to enjoy these benefits because of the lack of adequate footwear accessible to them. Soles4Souls makes it possible for those most in need of adequate footwear to own a good pair of shoes. Knowing just how important proper footwear is and the success Soles4Souls has in reaching these affected areas, we hosted a local shoe drive to contribute to this matter.

The shoe drive not only inspired those in our community to come out and support a worthy cause, it also reminded us of why proper footwear is so important in the first place.

From physical improvement to being able to participate in a society, shoes can improve quality of life, prevent injury of disease, help with healing for those with chronic foot conditions, offer support for inadequate arches or excess pronation, express one's self, enable a person to work in hazardous conditions, or even help land that coveted job.
Physical Benefits of Shoes
In the early 1900s, there was an epidemic of hookworms in Mississippi and other rural American states. Improper sanitary facilities in combination with the lack of foot protection lead to the parasitic worm being able to bore itself into a foot in a corkscrew-like manner. Severe illness would ensue after a hookworm infection with anemia being the biggest health concern. However, an educational health campaign reinforcing the importance of wearing shoes and sanitary public facilities helped make hookworms virtually unheard of in the affected areas.

While the hookworm epidemic is no longer a concern in the U.S., today the need for proper footwear is still critical as a way of reducing the risk of certain parasitic diseases and foot infections in third world countries.

Diabetics can also be susceptible to foot infections in the form of ulcers and can lead to amputation. It is important to have proper footwear to minimize diabetic foot infections and to provide support to feet for comfort and proper healing. Other foot conditions, like bunions, Charcot foot, and corns can also be alleviated with proper foot wear.

Shoes not only help our feet to heal but can also aid in support and stability of our foot. Not all feet are perfect, so properly fitting shoes can help align your feet, ankles, knees, hips and back to correct your gait and improve posture.

Without supportive shoes, the biomechanics of the body are off causing unnecessary impact and stress on parts of your feet and knees that aren't meant for shock absorption or pressure. This can eventually lead to back, knee and foot pain.

It is important to note that poorly fitted shoes can have a negative impact on your foot health. Accounting for the foot length and width can help prevent any foot development disorders. Keep in mind that growth spurts in children are rapid so a proper foot measurements on a regular basis is important. Replacement of shoes that no longer serve your feet as intended is necessary to maintain optimal foot conditions and protection for your feet.
The Cultural Importance of Shoes
The types of shoes worn differs from culture to culture, however, in most cultures, shoes are representative of social status or an extension of one's self. Shoes can affect our perception of others as well as ourselves.

Certain shoes can be seen as an item of decoration for fashion and can have less to do with functionality. In the Western World, high heels or stilettos can be expressive of a women's adulthood and sexuality. The shoes offer a sleek design while elongating their legs and changing their stance as a means for look and attraction.

However, not every culture uses shoes for fashion or a sign of wealth. There are many reasons for the use of shoes.

In South Africa, during the apartheid era, miners were not allowed to verbally talk underneath the surface in mine tunnels. For this matter, they developed a form of communication - also known as the "Gumboot Dance"- through foot taps and stamps, similar to Morse Code. The miners were forced to use Gumboots or Wellington boots as a means to obtain foot health while the miners were in the knee-high infected waters for hours daily. The Gumboots have become a cultural symbol for resistance for the South African miners.

Footwear is also used as a for ceremonies or religious devotions in various cultures. As part of the Indian culture, shoes are lavishly designed with embroidery, inlaid with precious stones and metals, and adorned with bells and tassels. The Indian culture praises the feet, so in ceremonious occasions, feet are clothed in beautiful garments for celebration and honor.

However, there are a wide range of cultural views of feet, while in America the idea of walking barefoot outside can symbolize freedom and attaching to one's youthfulness, people in Japan perceive feet as a body part that must remain clean, so wearing shoes outdoors in necessary in their society.
The Psychological Importance of Shoes
In the 1994 movie, The Sandlot, an autographed baseball signed by Babe Ruth is knocked into a neighboring backyard that is home to a perceived vicious dog. From there, a group of young boys develop intricate plans to stealthily obtain the highly-valued baseball. All of their attempts failed, except for one that included one of the boys who hopped the fence wearing a brand new pair of P.F. Flyers that were perceived by the group to make you run faster and jump higher.

Through the P.F. Flyers, the boy's confidence to take the feat head on increased because of his perception of the superhuman-like abilities wearing the shoes provided him. This type of perception is quite common and can not only boost the performance of a skill but can also provide benefits to the personality development of adolescents.

There is this perceived magical transformation to turn someone from ordinary to a superstar or model.

Similarly, an aspiring athlete may obtain a new pair of basketball shoes worn by their idol in an attempt to jump high or improve their jump shot, while a dancer's first Pointe shoes may symbolize an effort to explore more deeply the art of expression through ballet.

Through perception, shoes hold value that is unique to the wearer and their environment. For example, an expensive cowboy boot with quality leather and a rugged look can invoke a perception that the wearer has a strong personality type that is independent, callused, and alienated from civilization.While shoes have a basic functional purpose with many benefits, there are also beliefs and intrinsic values that accompany them. While the lack of shoes cannot strip one of individuality nor can the lack of shoes keep a person from traveling, life is a lot easier when shoes are present. Shoes allow us to travel farther, be more expressive, improve our performance and aid in overall health. From our soles to our souls, shoes contribute a great deal to our human experience.

While shoes have a basic functional purpose with many benefits, there are also beliefs and intrinsic values that accompany them. While the lack of shoes cannot strip one of individuality nor can the lack of shoes keep a person from traveling, life is a lot easier when shoes are present. Shoes allow us to travel farther, be more expressive, improve our performance and aid in overall health. From our soles to our souls, shoes contribute a great deal to our human experience.

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Life Without Shoes: A Look at the Benefits of Shoes - Soles4Souls

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This week you will be hearing from Derek Roach, the Co-Founder of Flow Feet, an organization that truly understands the importance of shoes. To show their support for our mission, they collected 50 pairs of shoes during a one-day shoe drive.

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How many pairs of shoes are in your closet? You likely have more than you really need or would like to admit you own. We tend to take them for granted, but in many developing countries, shoes play a key role to help protect against injuries, soil-transmitted diseases and parasites, and make it possible for children to attend school.

Soles4Souls started as a project to help provide shoes to disaster victims following the Asian tsunami disaster in 2004. After watching a news report showing a lone shoe wash up on a beach, Wayne Elsey knew how he wanted to make a difference. By connecting with other executives in the footwear industry, he arranged for the distribution of more than 250,000 pairs of shoes to disaster victims.

When Hurricane Katrina hit in 2005, he organized another shoe drive to distribute more than a million pairs of shoes. Based on these successes, he founded Soles4Souls, a registered non-profit organization that has distributed more than 17 million pairs of shoes in almost 130 countries around the world.

In 2012 alone, more than 4 million pairs will be distributed. Soles4Souls collects individual donations as well as donations from companies and participating sponsors. Surprisingly, they will even take single shoes! All kinds of new or gently worn shoes are accepted: athletic, dress, sandals, pumps, heels, work boots, cleats, or flip-flops.

"The lack of footwear is a significant problem facing people living in abject poverty and those affected by natural disaster," says Kevin Goughary, CFO, COO, and Interim CEO for Soles4Souls. "In developing nations, inadequate foot protection can lead to contraction of disease, particularly from ground-borne parasites such as hookworm that can enter the body through the feet. Living without shoes in harsh environments, as you can imagine, leaves the shoeless susceptible to cuts, abrasions, and overall discomfort as well.

There are also other health risks for barefoot people. Bacteria in the soil can enter injured feet and cause tetanus, which can lead to lockjaw, a health risk we don't consider in developed countries where most people are vaccinated. In high altitude areas of Africa, Central America and India, barefoot people are susceptible to podoconiosis, also called Mossy Foot, which causes massive, painful swelling due to an inflammatory reaction to volcanic minerals in the soil.

Beyond protecting health, shoes play an important extra role for children. "In many developing nations, shoes are required for children to attend school; so being without footwear will actually impact a child's opportunity to receive even the modest education that would otherwise be available," says Goughary.

Last year alone, Americans threw away 300 million pairs of shoes, which ended up in landfills. Shoes that are donated to Soles4Souls however do much more than just keep their new owners disease and injury free: Soles4Souls works to create sustainable micro-enterprises in developing countries to sell the shoes. "Gently used footwear is an ideal resource for people with little or no opportunity to make a living. It is amazing to know that shoes previously destined for landfills now help families provide for their children and help to build economic development that will improve more and more lives," says Goughary.

In the last two years, the company has expanded to include three new programs to help people in need. Clothes4Souls collects and distributes items of clothing.Hope4Souls stages immediate relief efforts to distribute bottled water, food and cleaning supplies in disaster zones in the U.S. and developing countries. Travel4Souls provides an opportunity for helpers to travel to developing countries and participate in the distribution, to experience firsthand the joy of helping someone in need. For many, this is a life-changing experience.
CONNECT THE DOTS
Soles4Souls is a registered charity recognized by the IRS. Individuals can donate shoes to participating drop-off locations or arrange to ship shoes directly to warehouses. You may also like to read our earlier stories, " ColaLife: An Innovative Initiative to Reduce Child Mortality," and " ColaLife Trial Goes Live in Zambia."

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How many pairs of shoes are in your closet? You likely have more than you really need or would like to admit you own. We tend to take them for granted, but in many developing countries, shoes play a key role to help protect against injuries, soil-transmitted diseases and parasites, and make it possible for children to attend school.

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Millions of bare feet prove we still aren't reaching the very poorest of the poor.

The international community is doing a lot to help the world's poor - spending billions of dollars (not enough, but still billions) to combat AIDS, TB and malaria, doing research, figuring out clever new uses of cell phones to help subsistence farmers increase productivity and getting microfinance loans to poor women.

And yet, millions of people worldwide suffer disfigurement and disability simply for a lack of shoes?

The disease I'm talking about is called podoconiosis and, chances are, you haven't heard of it. It is a much lesser-known cause of elephantiasis (see right, a condition also caused by mosquito-borne parasitic worms) that one researcher believes may nevertheless afflict more than 4 million people worldwide.

"This is a problem that could be entirely eliminated now, simply and at low expense," says Dr. Gail Davey, a British researcher who first encountered this much-neglected disease while working in Ethiopia nearly a decade ago.

The World Health Organization just issued a report on neglected tropical diseases that did not include mention of podoconiosis, which I guess makes this doubly neglected. For a more readable presentation on the WHO report, go here.

Podoconiosis, despite the large number of people likely afflicted, simply doesn't fit into the standard disease categories.

"I was trained in tropical medicine but I had never heard of it," Davey told me by telephone. I caught up with her as she was headed to Buenos Aires to meet with physicians and scientists there. Davey, who seems to be the world's leading (only?) expert on podoconiosis, is trying to draw more attention to this problem.

While in Seattle last spring, teaching a course on public health genomics at the University of Washington, Davey approached the Gates Foundation to see if they would be interested in throwing some money at this.

"This is pretty low hanging fruit," she says. It's cheap and easy to prevent and treat.

But Davey says the philanthropy had no interest, probably because the ailment didn't fit into their global health mission. Part of the problem with podoconiosis, Davey says, is that it's a disease caused by simply going barefoot and by chronic exposure to irritating alkali clay soils. It's not your typical infectious disease, or one that's known by many except those living in the very poorest and isolated communities.

Yet Davey says her research in Ethiopia, where she believes there are a million cases in this country alone, indicated this disease likely numbers in the millions worldwide. That's why she's in Buenos Aires this week, to expand surveillance and document just how big a problem this is worldwide.

"This is a disease that is directly caused by extreme poverty, by people too poor to buy shoes," stressed Davey. How can we hope to help the poor by solving much more complex problems, she says, if there appears so little interest in just getting shoes to people to prevent this disease?

Davey does appear to have one high-profile ally in her fight for attention to podoconiasis - Blake Mycoskie, founder of TOMS Shoes. Here's a video of Mycoskie and Davey in Ethiopia and below is a more recent one celebrating the one-millionth donated TOMS shoe:

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Foot note: Millions suffer simply for lack of shoes - Humanosphere

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Millions of bare feet prove we still aren't reaching the very poorest of the poor. The international community is doing a lot to help the world's poor - spending billions of dollars (not enough, but still billions) to combat AIDS, TB and malaria, doing research, figuring out clever new uses of cell phones to help subsistence farmers increase productivity and getting microfinance loans to poor women.

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Shoes are much more than a fashion statement. Shoes play a major role in granting people health and access to opportunities. Several nonprofits and charities work to give shoes to people who need them. Before learning about three organizations that help people without shoes, here is why living barefoot is problematic and even deadly.

Across the world, around 300 million people cannot afford shoes. Shoes are often part of a school or work uniform, so without shoes, children and adults have a harder time getting an education or contributing to the household income.

In addition, going barefoot presents a number of hazards, from burns and injury to catching an illness or fungus. Any one of these dangers could negatively impact someone by keeping them sick at home or in a hospital.

More than 20 million orphaned children are without shoes in sub-Saharan Africa, where temperatures frequently rise above 100 degrees Fahrenheit. These harsh temperatures can be physically agonizing to bare feet.

Orphaned or homeless children who are shoeless can be at further risk of injury if they search for food or other items in places like abandoned buildings and garbage dumps. They could step on glass, nails and other sharp objects that could cause an infection.

People without shoes, especially in underdeveloped areas of Africa and Asia, are also susceptible to hookworm disease. A hookworm burrowing into the foot causes this parasitic disease. Hookworms live in soil or water contaminated by feces.

Without treatment, hookworm disease and other parasitic infections can lead to chronic illness, amputations and death. Hookworm disease has adverse effects on school performance, childhood growth, work productivity and pregnancy, according to the World Health Organization.

Here are three organizations that help people without shoes.

1. The Shoe That Grows
This organization believes in "putting kids in the best possible position to succeed." It provideslong-lasting shoes to children in need. It's adjustable, expandable shoe design solves the problem of kids quickly outgrowing their shoes and needing new ones. The Show That Grows is working toward producing shoes in countries that need shoes and jobs, such as Haiti and Ethiopia. The organization works with partners that distribute the expandable shoes to underserved communities on every continent except Antarctica.

2. The Shoe Project
Shoes are not just a dream for people in underdeveloped countries. Some homeless people and others living in poverty in the United States need shoes to stave off extreme temperatures and infection, as well as to help them get back on their feet. The Shoe Project works around the world and in its home city of Cincinnati. In addition to breaking down education barriers and improving health, the organization believes "new footwear empowers people psychologically and economically to find a job." With a new pair of shoes, people can regain confidence and find opportunities.

3. Souls4Soles
This nonprofit began as a disaster relief agency, distributing shoes to people impacted by natural events like tsunamis and hurricanes. Today it has expanded distribution year-round. Souls4Soles accepts all kinds of shoes and sends good quality ones to distribution centers in 127 countries. Shoes in need of repair are sent to micro-enterprise programs where workers clean and refurbish the shoes to sell in their small businesses. The Souls4Soles website says donations provide a constant supply of product to thousands of entrepreneurs, which allows them to sustain their businesses and rise out of poverty.

These three organizations that help people without shoes, as well as several others around the world, have helped millions of children and adults that cannot afford the basic necessity of footwear. The shoes can change the life of someone living in poverty by allowing them to go to school or work, safeguarding them from injury and infection and giving them the confidence they need to take hold of their future.

- Kristen Reesor

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The Borgen Project | Three Organizations That Help People Without Shoes

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Shoes are much more than a fashion statement. Shoes play a major role in granting people health and access to opportunities. Several nonprofits and charities work to give shoes to people who need them. Before learning about three organizations that help people without shoes, here is why living barefoot is problematic and even deadly.

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World Health Organization (WHO), approximately 1.2 billion people in the world live in extreme poverty (less than one dollar per day). There are numerous diseases that infect millions of poor people in developing countries, yet we rarely hear about them. A leading cause of disease and infections originate in parasites.

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It's getting pretty cold in Kentucky and his job requires him to stand on his feet most days, but Richard Hudgins is not going to wear a pair of shoes until next winter.

Richard Hudgins, who works at a hair salon in Louisville, has vowed to go barefoot for a year to raise awareness and funds for the estimated 300 million people worldwide who can't afford shoes, WDRB reported. Hudgins launched his mission last month, just before a snow storm, and has already raised more than $1,000, according to his fundraising page.

He hasn't yet decided where he will donate the money, but Hudgins noted on his Facebook page that he's currently developing relationships with a number of nonprofits and shoe companies.

"Millions of children are without shoes and these kids are dying and having their limbs cut off just because they don't have anything to protect their feet," he told WDRB.

Children who have to go through their everyday lives without shoes are often at risk for a number of debilitating conditions, including hookworm. The condition can lead to stunted growth, decreased cognitive development, anemia and chronic fatigue, according to TOMS, a shoe company that donates a pair of shoes to someone in need each time a pair is purchased. Providing school uniforms and shoes to children who can't afford them can also help increase school attendance by 62 percent, the company noted.

Since 2007, TOMS has asked its supporters to go just one day each year without shoes to give them a sense of the struggles so many people face.

"Walking five miles anywhere is hard for most everyone. Walking five miles when you're sick is unimaginable," Amanda Schwartz, who works with Partners in Health -- an organization that has teamed up with TOMS -- wrote in a blog for HuffPost. "Walking five miles when you're sick and when you are a kid is terrifying. Can you imagine what it would be like to do that and to be barefoot?"
If you're feeling inspired to follow in Hudgins footsteps (yes, you can keep your shoes on), find out how you can support his cause, here.

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Man Going Barefoot For A Year For 300 Million People Who Can't Afford Shoes

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It's getting pretty cold in Kentucky and his job requires him to stand on his feet most days, but Richard Hudgins is not going to wear a pair of shoes until next winter.

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Hello! My name is Denise, and I am on the Soles4Souls Global Experiences Team. I have the privilege of facilitating several...

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Matthew J. To,

Thomas D. Brothers,

Colin Van Zoost

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Citation: To MJ, Brothers TD, Van Zoost C (2016) Foot Conditions among Homeless Persons: A Systematic Review. PLoS ONE 11(12): e0167463. https://doi.org/10.1371/journal.pone.0167463

Editor: Hajo Zeeb, Leibniz Institute for Prvention Research and Epidemiology BIPS, GERMANY

Received: January 16, 2016; Accepted: November 15, 2016; Published: December 9, 2016

Copyright: © 2016 To et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: Matthew J. To held a summer studentship with funding provided by the Dalhousie Medical Research Foundation (DMRF) Music in Medicine Summer Research Studentship. The funding organization had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; and in the preparation, review, and approval of the manuscript.

Competing interests: The authors have no competing interests.

Introduction

Given that foot problems are common among homeless persons, it is important to summarize the evidence on this topic to inform patient care and public health approaches. The objectives of this systematic review were to summarize current published literature related to foot conditions and associated interventions among homeless persons.

Methods

Overview

The review was guided by methodology outlined by the PRISMA statement ( S1 Checklist). [ 7] A systematic search strategy was developed to identify articles that reported foot problems among homeless populations. A protocol of the review has not been previously published.

Information Sources and Search Strategy

Articles were identified through a search of MEDLINE (1966-2016), EMBASE (1947-2016), and CINAHL (1982-2016) with no language exclusions. The search strategy was developed by one member of the research team (MJT) in consultation with a health sciences librarian and included terms related to homelessness that were cross-matched with foot health terms ( Box 1). The yield from bibliographic databases was complemented by manual searches of reference lists from relevant research articles. The search concluded in July 2016.

Box 1. MEDLINE, EMBASE, and CINAHL search strategies

MEDLINE

("Homeless Persons" [MeSH] OR "Homeless Youth" [MeSH] OR homeless*[all fields] OR fixed address[tw] OR runaway* OR street person[tw] OR street people[tw] OR street youth*[tw] OR squatter* OR underhouse* OR roofless* OR seeking shelter[tw] OR shelter seeking[tw] OR unhouse* OR street involved[tw] OR sleeping rough[tw] OR unstable hous*[tw] OR unstably hous*[tw] OR housing instability[tw] OR precarious hous*[tw] OR precariously hous*[tw] OR vulnerable hous*[tw] OR vulnerably hous*[tw] OR "Vulnerable Populations"[Mesh]) AND ("Podiatry" [mh] OR Podiatr* OR chiropod* OR foot* OR feet* OR "Foot Diseases" [MeSH] OR "Onychomycosis" [MeSH] OR onychomycos* OR "Diabetic Foot" [mh] OR diabetic feet[tw] OR "Tinea Pedis" [mh] OR athlete's foot[tw])

EMBASE

('homelessness'/exp OR homeless* OR 'no fixed address' OR runaway* OR 'street person' OR 'street persons' OR 'street people' OR 'street youth' OR 'street youths' OR squatter* OR underhouse* OR roofless* OR seeking NEAR/3 shelter OR unhouse* OR 'street involved' OR sleeping NEAR/3 rough OR unstabl* NEAR/3 hous* OR 'housing instability' OR precarious* NEAR/3 hous* OR vulnerabl* NEAR/3 hous*) AND ('podiatry'/exp OR podiatr* OR chiropod* OR foot* OR feet* OR 'foot disease'/exp OR 'onychomycosis'/exp OR onychomycos* OR 'diabetic foot'/exp OR 'diabetic feet' OR 'tinea pedis'/exp OR athletes foot)

CINAHL

(MH "Homeless Persons" OR MH "Homelessness" OR TX homeless* OR TX "fixed address" OR TX runaway* OR TX "street person*" OR TX "street people*" OR TX "street youth*" OR TX "squatter*" OR TX "underhouse*" OR TX "roofless*" OR seeking N3 shelter OR TX unhouse* OR street N3 involved OR sleeping N3 rough OR TX hous* N3 instability OR TX hous* N3 (unstable OR unstably) OR TX hous* N3 (precarious OR precariously) OR TX hous* N3 (vulnerable OR vulnerably) OR MH "Special Populations") AND (MH "Podiatry" OR MH "Podiatry Practice" OR Podiatr* OR chiropod* OR MH "Podiatric Care" OR MH "Foot Care" OR MH "Foot Diseases" OR MH "Onychomycosis" OR TX onychomycos* OR MH "Diabetic Foot" OR TX "diabetic feet*" OR TX "Tinea Pedis" OR TX "athlete's foot")

Data Extraction and Analysis

A standardized data extraction form was developed by the research team. Data were extracted by two independent reviewers (MJT, TDB) on the following variables: general study characteristics (e.g. primary author, year of publication, country of study, and source of funding); participants (age, sex, and sociodemographic data); study design; foot assessment methods; foot conditions and associated interventions; study findings. Quality of reports was independently assessed by two research team members (MJT, TDB) using the Downs and Black checklist. [ 8] The checklist has high internal consistency (Kruder-Richardson formula 20 = 0.89), test-retest reliability (r = 0.88), and inter-rater reliability (r = 0.75). The 27-item checklist assesses items related to reporting (clear description of objectives, participants, outcomes, findings, confounders, loss to follow-up, probability values), internal validity (biases, statistical analyses), external validity (representativeness of participants and treatment setting), and power. For the current review, 6 items related to randomized trials were excluded as no randomized interventions were identified. The checklist item that assessed adequacy of a study's statistical power was simplified to a score of 0 or 1. The maximum quality score that could be attained was 22. Discrepancies were resolved by consensus. Data on all study variables were summarized. Quantitative variables were analyzed using Microsoft Excel.

Results

The search yielded potentially eligible articles. After screening their titles and abstracts, 81 articles were deemed potentially relevant and full texts were retrieved to determine eligibility. Of these, 64 were excluded because they did not include homeless persons, did not present original research, or did not include data on clear foot health outcomes ( S1 Box). Therefore, 17 articles were selected for inclusion in the analysis ( Fig 1). Characteristics of included studies are presented in Table 1.

Setting

Twelve studies included in the review were conducted in the United States, [ 9]-[ 20] two in the United Kingdom, [ 21], [ 22] two in France, [ 23], [ 24] and one in Italy. [ 25] The majority of studies included homeless shelter residents or patients who attended clinics dedicated to serving vulnerable populations. Seven (50%) studies included patients from clinics that served homeless individuals, [ 9], [ 10], [ 13]-[ 15], [ 21], [ 22] while eight (47%) studies recruited participants directly from homeless shelters. [ 11], [ 12], [ 16], [ 17], [ 19], [ 20], [ 23], [ 24] One study recruited homeless individuals from a volunteer health service outreach association, [ 25] and another study recruited homeless individuals from a community kitchen. [ 18] Ten (59%) studies included participants from more than one location (e.g. shelters, clinics). [ 10], [ 11], [ 13], [ 15], [ 16], [ 19], [ 29], [ 23]-[ 25]

Sample

Studies included a median number of 363 participants (range 95-930). The mean age of participants across studies was 40 years old (mean ages ranged from 32-48 years old). Five studies did not provide mean age of participants.[ 13], [ 19], [ 21]-[ 23] Although two studies included adolescents and one included children, no additional details were provided about these participants. [ 13],[ 14] All studies enrolled a majority of male participants, ranging from 51-100% of study participants. Definitions of homelessness varied across studies and were generally inadequately described. Three studies used duration of homelessness as a criterion for study enrollment.[ 10], [ 11], [ 15] While duration of homelessness was provided in a total of seven studies, there were no details about participants' moves and housing transitions. Eleven (65%) studies included information about participants' ethnic background or country of origin. Study samples were generally comprised of a higher number of individuals from minority populations (e.g. African-American). However, no studies assessed differences in outcomes by race. Only six (35%) studies provided information about participants' level of education, employment, or income.[ 10], [ 11], [ 15]-[ 17], [ 19] Health insurance coverage rates were reported in three studies in the United States ranging from 14%-47%.[ 10], [ 15], [ 19]

Study Design and Foot Assessment

The majority of studies were observational and descriptive in nature, and only one measured the effects of a foot care intervention. Most studies involved a participant questionnaire and/or a combination of a foot assessment and retrospective chart review of health clinics that served homeless individuals. For 13 (76%) studies, foot health of homeless individuals involved a clinical assessment. Clinical foot exams were often performed by a clinician or medical student. Four (24%) studies retrieved information about foot health solely through self-reported survey data. One larger case-control study involving 698 individuals compared residents of homeless shelters with people attending a pre-travel clinic. [ 24] Only two studies longitudinally assessed participants' foot concerns over time. One study compared participants who remained homeless 18 months later with participants who obtained housing. [ 17] One interventional study of a mobile health service examined the effect of medical treatment on diabetic foot ulcers among homeless individuals during 17.6 ± 12 months. [ 19] No clinical trials or qualitative studies were identified in the systematic search.

Foot Conditions

Study participants reported a wide range of foot pathologies. Prevalence of any foot problem ranged from 9% to 65% across study populations. Calluses and corns were among the most common concerns in homeless populations, which were identified in 7.7-57% of study participants. [ 12], [ 14], [ 16], [ 19] Nail pathologies such as ingrown toenails were common, ranging from 15%-65% across study samples. [ 14], [ 16], [ 19] Foot infections were also highly prevalent among study populations. Tinea pedis was identified as a presenting concern in six studies. [ 11], [ 12], [ 14], [ 16], [ 19], [ 24] Rates of tinea pedis ranged from 3.2% to 38%. In addition, one case-control study involving 698 participants found that homeless individuals were significantly more likely to have tinea pedis and scratching lesions of the socks compared to people presenting to a pre-travel clinic. [ 24] Upon further analysis, presence of scratching lesions of the socks were independently associated with homelessness. Prevalence of pitted keratolysis of the feet (20.4%) and toenail onychomycosis (15.5%) were reported in one study. [ 12] Cellulitis was also found in two studies. [ 16], [ 22] Prevalence of foot injuries ranged from 24-43% in studies. [ 14], [ 19] Foot deformities (14%), trauma (6%) and fractures (2.5%) were common. [ 16], [ 21] Bunions (14%), hammertoes (7%), gout (6%), plantar warts (2-4%), and foot ulcers (0.7-4%) were also identified. [ 12], [ 14], [ 19] Foot problems related to neurological disorders ranged from 37-43% in one study. [ 14] Acute medical problems such as deep vein thrombosis, frostbite, and gangrene were also found. [ 16] One study found the prevalence of frostbite among homeless participants was 2%. [ 19] In the same study, immersion (trench) foot was observed in 5% of participants. [ 19]

Foot pathologies related to diabetes were found in several studies. [ 13], [ 18], [ 19], [ 23] Prevalence of diabetes ranged from 6.2-23%. Arnaud et al. screened 488 homeless shelter residents for diabetes which identified 35 previously diagnosed and 2 newly diagnosed individuals with diabetes. [ 23] They found that 41% of homeless individuals with diabetes had difficulty walking, 42% had a loss of foot sensitivity, 43% had permanently reduced mobility, and 17% had experienced lower limb amputation. One in three homeless persons with diabetes had a high or very high podiatric risk as defined by international classification, warranting regular foot care. [ 23] Macnee et al. screened 58 homeless individuals for diabetes using capillary blood sugar values and found that 12% of patients who attended the screening clinic reported foot problems. [ 13] In one study of homeless adults who used foot care services, 56% reported a history of diabetes, hypertension, peripheral vascular disease or a combination of the three. [ 18] In one study of 299 homeless shelter residents, approximately 9% self-reported having diabetes with 5% having diabetes mellitus type 2 and 4% having diabetes mellitus type 1. [ 19] However, 16% of participants reported numbness, 21% had tingling in their feet, and 21% had swollen feet suggesting that some individuals may have had undiagnosed diabetes. [ 19] In this study, 3% of participants reported having peripheral artery disease. [ 19]

The only interventional study identified in the review was a prospective study of 930 homeless individuals which included 21(2.3%) individuals with diabetic foot ulcers and were treated with removal of necrotic tissue, incision and drainage of infected areas and abscesses, wound care, antibiotics and analgesics as needed weekly by a mobile health services team for a mean (SD) of 17.6 ± 12 months. [ 25] Participants requiring complex interventions such as surgery or revascularization were hospitalized. Protective footwear was provided to all participants. Eighteen (86%) participants had significant improvement: 13 had their condition completely resolved, and 5 showed partial improvement and no longer needed medication. [ 25] One patient required foot amputation and negative pressure wound therapy and later died of septic shock and kidney failure. Two patients required amputation due to worsening of ulcers. [ 25]

One study found no significant differences in the reporting of foot problems between homeless men and women. [ 20] One longitudinal, non-interventional study found that homeless participants' podiatric concerns significantly decreased over time from 12.4% at baseline to 5.7% at 18 months. [ 17]

Mobility and function.

Walking was the primary means of transportation for many homeless individuals. In one study, 74% of respondents stated they were on their feet 5 hours or more each day. [ 19] One study found that homeless individuals walked a median of 5 miles daily. [ 18] Foot pain was reported by 56% of participants in one study, with 12% reporting they had pain all the time. [ 19] Homeless individuals were more likely to report pain in their feet when walking compared to housed participants (mean 2.0 vs. 1.7 on scale of 1-4, p = 0.003) and were more likely to report functional limitations when walking uphill (functional status score 6 vs. 8, p = 0.001). [ 10] However, in another study, homeless individuals were on average worried "a little" or "somewhat" about their skin, foot, or leg problems and reported associated restrictions in daily activities "a little of the time" or "not at all". [ 15]

Foot hygiene.

One study found that only 61% of homeless participants changed to a clean pair of socks daily and 72% of participants washed their feet daily. [ 19] In this study, 73% of participants trimmed their toenails at least once a month, and approximately 57% used lotion on their feet regularly. Seventy-six percent of participants reported keeping their feet dry, but 13% reported that they could not really feel whether their feet were dry or wet. [ 19] A survey conducted with 100 homeless adults examined foot hygiene attitudes and practices. [ 18] 52% of participants believed they needed foot care and 92% believed healthy feet were important and wanted to learn about how to maintain healthy feet. However, only 68% had access to clean water, 70% to soap, 56% to a towel, 44% to a nail clipper, 31% to a nail file, and 15% to a mirror. Only 26% reported ever having their feet examined by a health care provider. One study rated foot hygiene of participants and found that 58% had good foot hygiene, 38% had average foot hygiene with feet that were clean after simple washing, and 4% had poor foot hygiene. [ 21]

Footwear.

One study found that sneakers were the most common kind of footwear among homeless individuals (84%), followed by dress shoes (28%), sandals (22%), heels (3%), boots (3%), slippers (1%), and no shoes (1%). [ 19] This study found that approximately 73% of participants indicated that they were able to change shoes at least every 6 months. [ 19]

Homeless individuals often had improperly fitting shoes. [ 9], [ 13], [ 22] Macnee et al. found that 33% of individuals who presented at a foot screening clinic had ill-fitting shoes, [ 13] while Schwarzkopf et al. found that 43.5% of homeless men had foot and shoe size mismatch of greater than 1 size and 16.9% had foot and shoe size mismatch of greater than 1.5 sizes. [ 9] Rates of foot and shoe size mismatch greater than 1 size were significantly higher at a free clinic serving homeless individuals compared to a diabetic foot and ankle clinic and a foot specialist private practice. [ 9]

Access to foot care.

Homeless individuals were seen in shelters, general medical and foot clinics, medical centers, drop-in services, and emergency departments (EDs) for foot problems. In one study, 25% of homeless respondents reported being seen in the ED for a foot-related concern. [ 18] Another study found that 31% of homeless participants had visited a health professional for a foot problem. [ 19] Several studies reported that 20-21% of individuals who presented with a foot concern required further follow-up due to the severity of their condition. [ 11], [ 21], [ 22] Only one study explicitly surveyed participants about reasons for not accessing foot care services; [ 18] 62% of participants cited embarrassment due to the poor condition of feet, shoes, or socks as the main deterrent for receiving foot care. Among 19% of respondents who said they did not use foot care services even though they needed them, 3% said they were too busy. Other reasons included having to be around others, discomfort with others touching their feet, or not knowing where to go to receive care. When asked what would make it more likely for people to use foot care services, 27% said increased awareness. [ 18] One study found that independent predictors of participants who obtained foot care were longer duration of homelessness, residing in a homeless shelter, days of restricted activity, and medical comorbidities (e.g. hypertension, vision impairment, and tuberculosis). [ 15]

Discussion

The foot problems identified across studies represented a wide range of acute conditions and manifestations of chronic diseases. The high prevalence and severity of foot conditions can be attributed to a variety of physical, psychosocial, and service provision factors. Homeless individuals have an increased risk of physical injuries and repetitive minor trauma. [ 6] Poor foot hygiene, sleeping on the streets, and living in crowded environments such as homeless shelters increases exposure to pathogens and increases risk of acquiring infections. [ 28] Medical conditions such as frostbite, gangrene, and trench foot can occur due to lack of shelter and prolonged exposure to moist and cold environments. [ 6] Foot problems can also be a manifestation of chronic disease as evidenced by high rates of diabetes, peripheral vascular disease, and hypertension found across studies. [ 13], [ 18], [ 23]

Studies also frequently attributed foot problems in this population to poor footwear, [ 16], [ 21] and homeless individuals were more likely than their counterparts to have improperly-fitting shoes. [ 9], [ 13] Lack of access to clean socks and properly fitting shoes can cause and worsen foot problems. [ 6] Embarrassment related to the condition of their feet can prevent individuals from seeking appropriate health care. [ 13], [ 18] Many patients also may not be aware of foot care services or lack health insurance coverage. [ 10], [ 15] Interestingly, one study found that independent predictors of participants who obtained foot care were longer duration of homelessness, residing in a homeless shelter, days of restricted activity, and medical comorbidities. [ 15]

Although only one interventional study was identified in the literature review, the intervention which involved a mobile health team providing homeless individuals with medical and procedural treatment along with protective footwear for diabetic foot ulcers led to significant improvement in 86% of individuals, suggesting the effectiveness of a multifactorial treatment approach. [ 25]

This study adds to a growing body of literature that suggests homeless individuals experience foot problems that are often overlooked. [ 3], [ 5], [ 6] Given the prevalence and significant morbidity of foot health concerns, these findings have important service provision and public health implications. Homeless individuals often believe that healthy feet are important and are interested in receiving information about how to maintain adequate foot hygiene. Ensuring a private setting and cleaning individuals' feet before the clinical exam may reduce embarrassment and encourage use of foot care services. Since these individuals may not have material and financial resources that are necessary to maintain good foot hygiene such as clean water, soap, towels, nail clippers and files, [ 18] service providers should ensure that individuals have access to essential foot care items. Ensuring that individuals have clean socks and properly fitting shoes could help reduce the incidence of foot problems and improve mobility. Moreover, treating foot problems in these individuals may be an important step to addressing other unmet health and social needs of this population. [ 29] The low rates of health insurance coverage among homeless populations included in this review suggest that health providers and health systems should explore strategies to remove barriers for this population to receive foot care. [ 10], [ 15] The findings from this review suggest that an effective interventional approach could include optimization of foot hygiene and footwear, provision of necessary medications and procedures, and addressing the social factors that predispose homeless individuals to foot problems.

Limitations

This study was limited by a small body of literature related to foot conditions among homeless persons, with few studies specifically reporting on foot health as a primary study outcome. The review may not have been representative of the studies conducted on foot health among homeless individuals due to publication bias resulting from the small number of published articles on the topic. Low reported quality of several studies, which was evidenced by lack of details on participant characteristics and foot conditions, also limited the conclusions that could be drawn from them.

Our results are consistent with previous narrative reviews, case reports, and commentaries emphasizing the large burden of foot problems among homeless individuals, suggesting that more high quality data is needed. [ 3], [ 5], [ 6] Despite the prevalence of foot problems in this population, there are significant gaps between foot health needs and research studies to address these needs.

There is room for improvement in the quality of research reports given that a substantial proportion of studies did not include clear objectives and outcomes, provided limited data on participant samples, had low internal and external validity, and were insufficiently powered to detect clinically significant differences.

Future studies should assess foot health outcomes longitudinally and explore demographic and health status indicators that are associated with foot-related concerns. Comparative studies of homeless and housed individuals could yield more epidemiologic data and identify potential areas for intervention. Qualitative studies could further investigate facilitators and barriers to maintaining good foot health and accessing foot care services. Development of effective interventions to address the unmet foot health needs of this population should be prioritized. Interventional studies could explore multidisciplinary treatment approaches, provision of essential items such as clean socks and properly-fitting shoes, along with educational and outreach initiatives. Mobile interventions may be particularly effective in this population given the high burden of unmet medical and social needs.

Conclusion

Foot conditions are very common among homeless populations. This synthesis of what is known about foot-related conditions among homeless persons has important service provision and public health implications, highlighting the need for high quality, evidence-based interventions to address the foot health needs of this population. Ultimately, targeted efforts to screen for foot problems and manage associated physical and psychosocial factors could help to improve health and social outcomes for these individuals and could potentially reduce avoidable use of costly health care services.

Acknowledgments

The authors would like to thank Robin Parker for her assistance with developing the literature search strategy.

Author Contributions

1. Conceptualization: MJT CVZ.

2. Formal analysis: MJT TDB.

3. Funding acquisition: MJT CVZ.

4. Investigation: MJT TDB.

5. Methodology: MJT CVZ.

6. Project administration: MJT.

7. Supervision: CVZ.

8. Writing - original draft: MJT.

9. Writing - review & editing: MJT TDB CVZ.

References

1. 1. The 2012 Point-in-Time Estimates of Homelessness. 2012. Annual Homelessness Assessment Report. Washington, D.C.: The U.S. Department of Housing and Urban Development, 2012.

2. 2. The state of homelessness in Canada. 2013. http://www.homelesshub.ca/ResourceFiles/SOHC2103.pdf

3. 3. Hwang SW. 2001. Homelessness and health. CMAJ 164(2):229-33. pmid:11332321

4. 4. Argintaru N, Chambers C, Gogosis E, Farrell S, Palepu A, Klodawsky F, et al. A cross-sectional observational study of unmet health needs among homeless and vulnerably housed adults in three Canadian cities. BMC Public Health. 2013;13(1):577.

5. 29. Shtasel DL, Freudenreich O, Baggett TP. Case records of the Massachusetts General Hospital. Case 40-2015. A 40-year-old homeless woman with headache, hypertension, and psychosis. N Engl J Med. 2015 Dec 24;373(26):2563-70. pmid:26699172

# data[].attributes.attachment_link.title
Foot Conditions among Homeless Persons: A Systematic Review

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Introduction Foot problems are common among homeless persons, but are often overlooked. The objectives of this systematic review are to summarize what is known about foot conditions and associated interventions among homeless persons. Methods A literature search was conducted on MEDLINE (1966-2016), EMBASE (1947-2016), and CINAHL (1982-2016) and complemented by manual searches of reference lists.

# data[].attributes.attachment_link.readable_text
Abstract

Introduction

Foot problems are common among homeless persons, but are often overlooked. The objectives of this systematic review are to summarize what is known about foot conditions and associated interventions among homeless persons.

Methods

A literature search was conducted on MEDLINE (1966-2016), EMBASE (1947-2016), and CINAHL (1982-2016) and complemented by manual searches of reference lists. Articles that described foot conditions in homeless persons or associated interventions were included. Data were independently extracted on: general study characteristics; participants; foot assessment methods; foot conditions and associated interventions; study findings; quality score assessed using the Downs and Black checklist.

Results

Of 333 articles screened, 17 articles met criteria and were included in the study. Prevalence of any foot problem ranged from 9% to 65% across study populations. Common foot-related concerns were corns and calluses, nail pathologies, and infections. Foot pathologies related to chronic diseases such as diabetes were identified. Compared to housed individuals across studies, homeless individuals were more likely to have foot problems including tinea pedis, foot pain, functional limitations with walking, and improperly-fitting shoes.

Discussion

Foot conditions were highly prevalent among homeless individuals with up to two thirds reporting a foot health concern, approximately one quarter of individuals visiting a health professional, and one fifth of individuals requiring further follow-up due to the severity of their condition. Homeless individuals often had inadequate foot hygiene practices and improperly-fitting shoes. These findings have service provision and public health implications, highlighting the need for evidence-based interventions to improve foot health in this population. An effective interventional approach could include optimization of foot hygiene and footwear, provision of comprehensive medical treatment, and addressing social factors that lead to increased risk of foot problems. Targeted efforts to screen for and treat foot problems could result in improved health and social outcomes for homeless individuals.

Introduction

Given that foot problems are common among homeless persons, it is important to summarize the evidence on this topic to inform patient care and public health approaches. The objectives of this systematic review were to summarize current published literature related to foot conditions and associated interventions among homeless persons.

Methods

Overview

The review was guided by methodology outlined by the PRISMA statement ( S1 Checklist). [ 7] A systematic search strategy was developed to identify articles that reported foot problems among homeless populations. A protocol of the review has not been previously published.

Eligibility Criteria

All original research articles that reported on foot conditions in homeless persons were included in the review. Articles that did not present data on clear foot health outcomes (e.g. reviews, case reports, and commentaries) were excluded.

Information Sources and Search Strategy

Articles were identified through a search of MEDLINE (1966-2016), EMBASE (1947-2016), and CINAHL (1982-2016) with no language exclusions. The search strategy was developed by one member of the research team (MJT) in consultation with a health sciences librarian and included terms related to homelessness that were cross-matched with foot health terms ( Box 1). The yield from bibliographic databases was complemented by manual searches of reference lists from relevant research articles. The search concluded in July 2016.

Study Selection

Titles and abstracts of potentially eligible articles were screened by two independent reviewers (MJT, TDB). If it was unclear whether an article met the inclusion criteria, the full-text article was retrieved to determine eligibility. Articles that met the inclusion criteria were included in full-text analysis. Discrepancies in the screening process were resolved by consensus.

Data Extraction and Analysis

A standardized data extraction form was developed by the research team. Data were extracted by two independent reviewers (MJT, TDB) on the following variables: general study characteristics (e.g. primary author, year of publication, country of study, and source of funding); participants (age, sex, and sociodemographic data); study design; foot assessment methods; foot conditions and associated interventions; study findings. Quality of reports was independently assessed by two research team members (MJT, TDB) using the Downs and Black checklist. [ 8] The checklist has high internal consistency (Kruder-Richardson formula 20 = 0.89), test-retest reliability (r = 0.88), and inter-rater reliability (r = 0.75). The 27-item checklist assesses items related to reporting (clear description of objectives, participants, outcomes, findings, confounders, loss to follow-up, probability values), internal validity (biases, statistical analyses), external validity (representativeness of participants and treatment setting), and power. For the current review, 6 items related to randomized trials were excluded as no randomized interventions were identified. The checklist item that assessed adequacy of a study's statistical power was simplified to a score of 0 or 1. The maximum quality score that could be attained was 22. Discrepancies were resolved by consensus. Data on all study variables were summarized. Quantitative variables were analyzed using Microsoft Excel.

Results

The search yielded potentially eligible articles. After screening their titles and abstracts, 81 articles were deemed potentially relevant and full texts were retrieved to determine eligibility. Of these, 64 were excluded because they did not include homeless persons, did not present original research, or did not include data on clear foot health outcomes ( S1 Box). Therefore, 17 articles were selected for inclusion in the analysis (). Characteristics of included studies are presented in .

Table 1

First author (year)

Sample size (% male); % homeless

Mean age (range)

Setting

Assessment of foot conditions

Study findings

Quality score¹

Arnaud (2009)

Diabetics: 53.5 (34-73); non-diabetics: 45.4 (18-85)

9 homeless shelters in Paris, France

Questionnaire, clinical exam

Screening of participants identified 35 previously diagnosed and 2 newly diagnosed individuals with diabetes. Estimated prevalence of diabetes was 6.2%. 41% of diabetic patients had difficulty walking, 42% had a loss of foot sensitivity, and 17% had had a lower limb amputation. 1 in 3 homeless persons with diabetes had high podiatric risk.

16

Robbins (1996)

461 (53%); 100%

Screening clinic in Cleveland, USA

Questionnaire, clinical exam

Over 2 years, common foot problems were nail pathology (63-65%), corn and calluses (53-57%), fungal disease (33-53%), neurologic (37-43%), foot injury (24-43%), and bunions (33-43%). Foot problems related to diabetes, flat feet, and plantar warts were also noted.

8

Setting

Twelve studies included in the review were conducted in the United States, [ 9]-[ 20] two in the United Kingdom, [ 21], [ 22] two in France, [ 23], [ 24] and one in Italy. [ 25] The majority of studies included homeless shelter residents or patients who attended clinics dedicated to serving vulnerable populations. Seven (50%) studies included patients from clinics that served homeless individuals, [ 9], [ 10], [ 13]-[ 15], [ 21], [ 22] while eight (47%) studies recruited participants directly from homeless shelters. [ 11], [ 12], [ 16], [ 17], [ 19], [ 20], [ 23], [ 24] One study recruited homeless individuals from a volunteer health service outreach association, [ 25] and another study recruited homeless individuals from a community kitchen. [ 18] Ten (59%) studies included participants from more than one location (e.g. shelters, clinics). [ 10], [ 11], [ 13], [ 15], [ 16], [ 19], [ 29], [ 23]-[ 25]

Sample

Studies included a median number of 363 participants (range 95-930). The mean age of participants across studies was 40 years old (mean ages ranged from 32-48 years old). Five studies did not provide mean age of participants.[ 13], [ 19], [ 21]-[ 23] Although two studies included adolescents and one included children, no additional details were provided about these participants. [ 13],[ 14] All studies enrolled a majority of male participants, ranging from 51-100% of study participants. Definitions of homelessness varied across studies and were generally inadequately described. Three studies used duration of homelessness as a criterion for study enrollment.[ 10], [ 11], [ 15] While duration of homelessness was provided in a total of seven studies, there were no details about participants' moves and housing transitions. Eleven (65%) studies included information about participants' ethnic background or country of origin. Study samples were generally comprised of a higher number of individuals from minority populations (e.g. African-American). However, no studies assessed differences in outcomes by race. Only six (35%) studies provided information about participants' level of education, employment, or income.[ 10], [ 11], [ 15]-[ 17], [ 19] Health insurance coverage rates were reported in three studies in the United States ranging from 14%-47%.[ 10], [ 15], [ 19]

Funding

Seven (41%) studies were supported by a government agency. Five studies reported a non-governmental source of funding and eight studies did not include a source of funding.

Study Design and Foot Assessment

The majority of studies were observational and descriptive in nature, and only one measured the effects of a foot care intervention. Most studies involved a participant questionnaire and/or a combination of a foot assessment and retrospective chart review of health clinics that served homeless individuals. For 13 (76%) studies, foot health of homeless individuals involved a clinical assessment. Clinical foot exams were often performed by a clinician or medical student. Four (24%) studies retrieved information about foot health solely through self-reported survey data. One larger case-control study involving 698 individuals compared residents of homeless shelters with people attending a pre-travel clinic. [ 24] Only two studies longitudinally assessed participants' foot concerns over time. One study compared participants who remained homeless 18 months later with participants who obtained housing. [ 17] One interventional study of a mobile health service examined the effect of medical treatment on diabetic foot ulcers among homeless individuals during 17.6 ± 12 months. [ 19] No clinical trials or qualitative studies were identified in the systematic search.

Methodological Quality

The reported methodological quality in the majority of studies was generally moderate with a median score of 12 (range 8-20). The main study objectives were unclear in 2 (12%) studies. The main outcomes were inadequately described in 4 (24%) studies. Studies often lacked details on the sample such as mean age, sociodemographic data, recruitment procedures, and eligibility criteria. Data were often missing from reports without explanation and only 4 (24%) studies reported on participants lost to follow-up. Several studies appeared to have low internal and external validity and appeared to be insufficiently powered to detect clinically meaningful differences.

Foot Conditions

Study participants reported a wide range of foot pathologies. Prevalence of any foot problem ranged from 9% to 65% across study populations. Calluses and corns were among the most common concerns in homeless populations, which were identified in 7.7-57% of study participants. [ 12], [ 14], [ 16], [ 19] Nail pathologies such as ingrown toenails were common, ranging from 15%-65% across study samples. [ 14], [ 16], [ 19] Foot infections were also highly prevalent among study populations. Tinea pedis was identified as a presenting concern in six studies. [ 11], [ 12], [ 14], [ 16], [ 19], [ 24] Rates of tinea pedis ranged from 3.2% to 38%. In addition, one case-control study involving 698 participants found that homeless individuals were significantly more likely to have tinea pedis and scratching lesions of the socks compared to people presenting to a pre-travel clinic. [ 24] Upon further analysis, presence of scratching lesions of the socks were independently associated with homelessness. Prevalence of pitted keratolysis of the feet (20.4%) and toenail onychomycosis (15.5%) were reported in one study. [ 12] Cellulitis was also found in two studies. [ 16], [ 22] Prevalence of foot injuries ranged from 24-43% in studies. [ 14], [ 19] Foot deformities (14%), trauma (6%) and fractures (2.5%) were common. [ 16], [ 21] Bunions (14%), hammertoes (7%), gout (6%), plantar warts (2-4%), and foot ulcers (0.7-4%) were also identified. [ 12], [ 14], [ 19] Foot problems related to neurological disorders ranged from 37-43% in one study. [ 14] Acute medical problems such as deep vein thrombosis, frostbite, and gangrene were also found. [ 16] One study found the prevalence of frostbite among homeless participants was 2%. [ 19] In the same study, immersion (trench) foot was observed in 5% of participants. [ 19]

Foot pathologies related to diabetes were found in several studies. [ 13], [ 18], [ 19], [ 23] Prevalence of diabetes ranged from 6.2-23%. Arnaud et al. screened 488 homeless shelter residents for diabetes which identified 35 previously diagnosed and 2 newly diagnosed individuals with diabetes. [ 23] They found that 41% of homeless individuals with diabetes had difficulty walking, 42% had a loss of foot sensitivity, 43% had permanently reduced mobility, and 17% had experienced lower limb amputation. One in three homeless persons with diabetes had a high or very high podiatric risk as defined by international classification, warranting regular foot care. [ 23] Macnee et al. screened 58 homeless individuals for diabetes using capillary blood sugar values and found that 12% of patients who attended the screening clinic reported foot problems. [ 13] In one study of homeless adults who used foot care services, 56% reported a history of diabetes, hypertension, peripheral vascular disease or a combination of the three. [ 18] In one study of 299 homeless shelter residents, approximately 9% self-reported having diabetes with 5% having diabetes mellitus type 2 and 4% having diabetes mellitus type 1. [ 19] However, 16% of participants reported numbness, 21% had tingling in their feet, and 21% had swollen feet suggesting that some individuals may have had undiagnosed diabetes. [ 19] In this study, 3% of participants reported having peripheral artery disease. [ 19]

The only interventional study identified in the review was a prospective study of 930 homeless individuals which included 21(2.3%) individuals with diabetic foot ulcers and were treated with removal of necrotic tissue, incision and drainage of infected areas and abscesses, wound care, antibiotics and analgesics as needed weekly by a mobile health services team for a mean (SD) of 17.6 ± 12 months. [ 25] Participants requiring complex interventions such as surgery or revascularization were hospitalized. Protective footwear was provided to all participants. Eighteen (86%) participants had significant improvement: 13 had their condition completely resolved, and 5 showed partial improvement and no longer needed medication. [ 25] One patient required foot amputation and negative pressure wound therapy and later died of septic shock and kidney failure. Two patients required amputation due to worsening of ulcers. [ 25]

One study found no significant differences in the reporting of foot problems between homeless men and women. [ 20] One longitudinal, non-interventional study found that homeless participants' podiatric concerns significantly decreased over time from 12.4% at baseline to 5.7% at 18 months. [ 17]

Mobility and function

Walking was the primary means of transportation for many homeless individuals. In one study, 74% of respondents stated they were on their feet 5 hours or more each day. [ 19] One study found that homeless individuals walked a median of 5 miles daily. [ 18] Foot pain was reported by 56% of participants in one study, with 12% reporting they had pain all the time. [ 19] Homeless individuals were more likely to report pain in their feet when walking compared to housed participants (mean 2.0 vs. 1.7 on scale of 1-4, p = 0.003) and were more likely to report functional limitations when walking uphill (functional status score 6 vs. 8, p = 0.001). [ 10] However, in another study, homeless individuals were on average worried "a little" or "somewhat" about their skin, foot, or leg problems and reported associated restrictions in daily activities "a little of the time" or "not at all". [ 15]

Foot hygiene

One study found that only 61% of homeless participants changed to a clean pair of socks daily and 72% of participants washed their feet daily. [ 19] In this study, 73% of participants trimmed their toenails at least once a month, and approximately 57% used lotion on their feet regularly. Seventy-six percent of participants reported keeping their feet dry, but 13% reported that they could not really feel whether their feet were dry or wet. [ 19] A survey conducted with 100 homeless adults examined foot hygiene attitudes and practices. [ 18] 52% of participants believed they needed foot care and 92% believed healthy feet were important and wanted to learn about how to maintain healthy feet. However, only 68% had access to clean water, 70% to soap, 56% to a towel, 44% to a nail clipper, 31% to a nail file, and 15% to a mirror. Only 26% reported ever having their feet examined by a health care provider. One study rated foot hygiene of participants and found that 58% had good foot hygiene, 38% had average foot hygiene with feet that were clean after simple washing, and 4% had poor foot hygiene. [ 21]

Footwear

One study found that sneakers were the most common kind of footwear among homeless individuals (84%), followed by dress shoes (28%), sandals (22%), heels (3%), boots (3%), slippers (1%), and no shoes (1%). [ 19] This study found that approximately 73% of participants indicated that they were able to change shoes at least every 6 months. [ 19]

Homeless individuals often had improperly fitting shoes. [ 9], [ 13], [ 22] Macnee et al. found that 33% of individuals who presented at a foot screening clinic had ill-fitting shoes, [ 13] while Schwarzkopf et al. found that 43.5% of homeless men had foot and shoe size mismatch of greater than 1 size and 16.9% had foot and shoe size mismatch of greater than 1.5 sizes. [ 9] Rates of foot and shoe size mismatch greater than 1 size were significantly higher at a free clinic serving homeless individuals compared to a diabetic foot and ankle clinic and a foot specialist private practice. [ 9]

Access to foot care

Homeless individuals were seen in shelters, general medical and foot clinics, medical centers, drop-in services, and emergency departments (EDs) for foot problems. In one study, 25% of homeless respondents reported being seen in the ED for a foot-related concern. [ 18] Another study found that 31% of homeless participants had visited a health professional for a foot problem. [ 19] Several studies reported that 20-21% of individuals who presented with a foot concern required further follow-up due to the severity of their condition. [ 11], [ 21], [ 22] Only one study explicitly surveyed participants about reasons for not accessing foot care services; [ 18] 62% of participants cited embarrassment due to the poor condition of feet, shoes, or socks as the main deterrent for receiving foot care. Among 19% of respondents who said they did not use foot care services even though they needed them, 3% said they were too busy. Other reasons included having to be around others, discomfort with others touching their feet, or not knowing where to go to receive care. When asked what would make it more likely for people to use foot care services, 27% said increased awareness. [ 18] One study found that independent predictors of participants who obtained foot care were longer duration of homelessness, residing in a homeless shelter, days of restricted activity, and medical comorbidities (e.g. hypertension, vision impairment, and tuberculosis). [ 15]

Discussion

The foot problems identified across studies represented a wide range of acute conditions and manifestations of chronic diseases. The high prevalence and severity of foot conditions can be attributed to a variety of physical, psychosocial, and service provision factors. Homeless individuals have an increased risk of physical injuries and repetitive minor trauma. [ 6] Poor foot hygiene, sleeping on the streets, and living in crowded environments such as homeless shelters increases exposure to pathogens and increases risk of acquiring infections. [ 28] Medical conditions such as frostbite, gangrene, and trench foot can occur due to lack of shelter and prolonged exposure to moist and cold environments. [ 6] Foot problems can also be a manifestation of chronic disease as evidenced by high rates of diabetes, peripheral vascular disease, and hypertension found across studies. [ 13], [ 18], [ 23]

Studies also frequently attributed foot problems in this population to poor footwear, [ 16], [ 21] and homeless individuals were more likely than their counterparts to have improperly-fitting shoes. [ 9], [ 13] Lack of access to clean socks and properly fitting shoes can cause and worsen foot problems. [ 6] Embarrassment related to the condition of their feet can prevent individuals from seeking appropriate health care. [ 13], [ 18] Many patients also may not be aware of foot care services or lack health insurance coverage. [ 10], [ 15] Interestingly, one study found that independent predictors of participants who obtained foot care were longer duration of homelessness, residing in a homeless shelter, days of restricted activity, and medical comorbidities. [ 15]

Although only one interventional study was identified in the literature review, the intervention which involved a mobile health team providing homeless individuals with medical and procedural treatment along with protective footwear for diabetic foot ulcers led to significant improvement in 86% of individuals, suggesting the effectiveness of a multifactorial treatment approach. [ 25]

This study adds to a growing body of literature that suggests homeless individuals experience foot problems that are often overlooked. [ 3], [ 5], [ 6] Given the prevalence and significant morbidity of foot health concerns, these findings have important service provision and public health implications. Homeless individuals often believe that healthy feet are important and are interested in receiving information about how to maintain adequate foot hygiene. Ensuring a private setting and cleaning individuals' feet before the clinical exam may reduce embarrassment and encourage use of foot care services. Since these individuals may not have material and financial resources that are necessary to maintain good foot hygiene such as clean water, soap, towels, nail clippers and files, [ 18] service providers should ensure that individuals have access to essential foot care items. Ensuring that individuals have clean socks and properly fitting shoes could help reduce the incidence of foot problems and improve mobility. Moreover, treating foot problems in these individuals may be an important step to addressing other unmet health and social needs of this population. [ 29] The low rates of health insurance coverage among homeless populations included in this review suggest that health providers and health systems should explore strategies to remove barriers for this population to receive foot care. [ 10], [ 15] The findings from this review suggest that an effective interventional approach could include optimization of foot hygiene and footwear, provision of necessary medications and procedures, and addressing the social factors that predispose homeless individuals to foot problems.

Limitations

This study was limited by a small body of literature related to foot conditions among homeless persons, with few studies specifically reporting on foot health as a primary study outcome. The review may not have been representative of the studies conducted on foot health among homeless individuals due to publication bias resulting from the small number of published articles on the topic. Low reported quality of several studies, which was evidenced by lack of details on participant characteristics and foot conditions, also limited the conclusions that could be drawn from them.

Our results are consistent with previous narrative reviews, case reports, and commentaries emphasizing the large burden of foot problems among homeless individuals, suggesting that more high quality data is needed. [ 3], [ 5], [ 6] Despite the prevalence of foot problems in this population, there are significant gaps between foot health needs and research studies to address these needs.

There is room for improvement in the quality of research reports given that a substantial proportion of studies did not include clear objectives and outcomes, provided limited data on participant samples, had low internal and external validity, and were insufficiently powered to detect clinically significant differences.

Future studies should assess foot health outcomes longitudinally and explore demographic and health status indicators that are associated with foot-related concerns. Comparative studies of homeless and housed individuals could yield more epidemiologic data and identify potential areas for intervention. Qualitative studies could further investigate facilitators and barriers to maintaining good foot health and accessing foot care services. Development of effective interventions to address the unmet foot health needs of this population should be prioritized. Interventional studies could explore multidisciplinary treatment approaches, provision of essential items such as clean socks and properly-fitting shoes, along with educational and outreach initiatives. Mobile interventions may be particularly effective in this population given the high burden of unmet medical and social needs.

Conclusion

Foot conditions are very common among homeless populations. This synthesis of what is known about foot-related conditions among homeless persons has important service provision and public health implications, highlighting the need for high quality, evidence-based interventions to address the foot health needs of this population. Ultimately, targeted efforts to screen for foot problems and manage associated physical and psychosocial factors could help to improve health and social outcomes for these individuals and could potentially reduce avoidable use of costly health care services.

Supporting Information

S1 Box
Reasons for exclusion of 67 full-text articles identified from systematic literature search:
(DOCX)

S1 Checklist
PRISMA Checklist.
(DOC)

Acknowledgments

The authors would like to thank Robin Parker for her assistance with developing the literature search strategy.

Funding Statement

Matthew J. To held a summer studentship with funding provided by the Dalhousie Medical Research Foundation (DMRF) Music in Medicine Summer Research Studentship. The funding organization had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; and in the preparation, review, and approval of the manuscript.

Data Availability

All relevant data are within the paper and its Supporting Information files.

References

1. The 2012 Point-in-Time Estimates of Homelessness. 2012. Annual Homelessness Assessment Report. Washington, D.C.: The U.S. Department of Housing and Urban Development, 2012.

7. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. . 2009;339:b2700 doi: [ 10.1136/bmj.b2700 PMC free article]

20. Chong MT, Yamaki J, Harwood M, d'Assalenaux R, Rosenberg E, Aruoma O, et al. Assessing health conditions and medication use among the homeless community in Long Beach, California. [ J Res Pharm Pract. 2014. April;3(2):56-61. doi: 10.4103/2279-042X.137073 PMC free article]

28. Moy JA, Sanchez MR. The cutaneous manifestations of violence and poverty. Arch Dermatol. 1992;128:829-3

29. Shtasel DL, Freudenreich O, Baggett TP. Case records of the Massachusetts General Hospital. Case 40-2015. A 40-year-old homeless woman with headache, hypertension, and psychosis. N Engl J Med. 2015. December 24;373(26):2563-70. doi: 10.1056/NEJMcpc1405204

# data[].attributes.attachment_link.title
Foot Conditions among Homeless Persons: A Systematic Review

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Foot problems are common among homeless persons, but are often overlooked. The objectives of this systematic review are to summarize what is known about foot conditions and associated interventions among homeless persons. A literature search was conducted on MEDLINE (1966-2016), EMBASE (1947-2016), and CINAHL (1982-2016) and complemented by manual searches of reference lists.

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