Summary

Objective: To evaluate the awareness of foot health and suitability of footwear among the elderly population in Hong Kong.

Design: Cross sectional survey.

Subjects: Elderlies recruited from 2002 Thematic Household Survey.

Main outcome measures: Demographics of the studied subjects, foot problems and effect on the elderlies' activity of daily living and shoe fitness.

Results: A total of 966 subjects were successfully contacted and 494 of them consented to a podiatric examination giving a response rate of 51.1%. More than ninety-six percent of the studied elders had at least one foot ailment diagnosed by the podiatrist. The three commonest foot ailments were hallux deformity (72.4%), problem nail (63%) and callus (48.2%). A wide gap in awareness was identified in all foot health conditions. 72.4% had hallux deformity but only 35.0% of them were aware of the condition. Hallux deformity was found to be significantly associated with secondary foot pathologies such as corn, callus and lesser toe deformities (p<0.001). 33.8%, 2.2% and 6.1% of the elders had athlete's foot, wart and wound on their feet but 64.1%, 63.6% and 80% of them were not aware of their conditions respectively. Only 12.3% of them were wearing proper shoes with all nine essential features to keep both feet healthy. 62.6% of the elders were wearing shoes narrower than the width of their feet. 45.5% female and 36.4% male were wearing shoes which were one shoe size smaller than their feet.

Conclusion: Foot problems are very common in the elderly. There is low awareness of foot problems and lack of knowledge on the choice of shoes in this elderly population. More health education in these areas is necessary to promote better foot health for them.

Keywords: Elderly, awareness, foot health, footwear.

摘要

目的：評估香港老年人口對足部健康的認知情況和穿鞋子的適當性。

設計：橫切面調查。

對象：從2002年起主題性住戶統計調查徵募的長者。

測量內容：受查者的統計學資料，足部問題，對日常生活及活動的影響以及適合的鞋子。

結果：在966名成功接觸的長者中， 494名長者同意進行足部檢查，回覆率為51.1%。受檢長者96.8%最少患一種足患。最常見的三種足患分別為大腳趾變形(72.4%)，指甲問題(63%)和結繭(48.2%)每項足部健康問題的認知程度都有很大的分歧。72.4%的長者患有大腳趾變形，當中只有35%知道這種情況。大腳趾變形與繼發性足部病變，如雞眼、結繭和小腳趾變形，有顯著的關係(p值<0.001)。33.8%雖然分別為2.2%和6.1%的長者患有腳癬，疣和足部傷口，但卻有 64.1%，63.6%和80%的長者不了解病情。只有12.3%的長者穿著合乎九種基本標準適當的鞋子來保障足部健康。62.6%的長者穿著較腳掌闊度窄的鞋子，45.5%的女長者和36.4%的男長者穿著細一號尺碼的鞋子。

結論：足部問題是常見的老年疾病。老年人對足部問題的認 知程度低並且缺足夠的知識來選擇合適的鞋子。因此，必須 加強足部健康教育促進長者的足部健康。

主要詞彙：長者、認知、足部健康、鞋子。

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Introduction

Foot health problems are common in the elderly due to pathological changes in their feet, difficulties involved in taking care of their extremities and the high prevalence of chronic diseases such as diabetes, stroke and osteoarthritis. Various studies showed a prevalence of foot ailments up to 94.2%.^1-6 Foot health is an important area for the care of the elderly as foot problems are associated with an impairment of instrumental activities in daily living (IADL), functional limitation in gait, increased risk of fall, poor perceived well-being, and decreased quality of life.^7-12 These are in turn associated with higher morbidity and mortality. 85% of lower extremities amputations (LEAs) were preceded by a foot ulcer which could be prevented by better awareness of foot health.¹³ However, foot complaints are frequently under-reported as many patients neglect their foot health problems and never seek medical advice^1,14,15 owing to factors such as lack of knowledge of the importance of proper foot care, cost, inaccessibility, or lack of services specific to foot care.¹⁶

Footwear plays an important role in the maintenance of foot health. Localized trauma from poorly fitting shoes is a common precursor to formation of calluses or callosities and blisters which can lead to infection or ulceration.^17,18 There is no standardized tool for the assessment of footwear suitability. Clinical foot wear assessment usually focuses on the style or type of shoes, and measurement of the forefoot width and length of the foot. Optimal shoe fit criteria should include: sufficient depth and width to prevent deformity of the digits by the shoes, a length of approximately 1 cm between end of toes and end of shoe for the digits to move on weight bearing, firm heal support that does not depress with sideway or vertical compression, cushioned but stiff sole with flexibility at the metatarsal-phalangeal joints only, restraining mechanism such as straps, laces or high cut slip on, less than 2.5 cm heel height, styles that protect foot from foreign objects, materials that facilitate ventilation of the foot and pliable enough to prevent injury to the digits.¹⁹

In Hong Kong, the limited accessibility to podiatrists' services makes health education and preventive foot care particularly important for the elderly, especially those with chronic illnesses such as diabetes. Elderly Health Services of the Department of Health commissioned a survey in 2002 to study the foot health conditions among community-dwelling elders aged 65 and above. This study aimed at assessing the elders' awareness of their foot health conditions and evaluating the fitting of their footwear in order to understand their health education needs so as to facilitate the planning of health promotion programmes.

Method

In the 2002 First Quarter Thematic Household Survey, the Frame of Quarters maintained by the Census and Statistics Department was used for sample selection.²⁰ The sample was selected randomly from records of all permanent and temporary structures in Hong Kong in accordance with a scientifically designed sampling scheme. All households in the sample were approached with letters and phone calls for the quarterly thematic household survey interview. During the interview of the thematic household survey in the first quarter of 2002, interviewees aged 65 and above were invited by the interviewers to give consent to provide contact phone numbers to Elderly Health Services of Department of Health so that we could contact them for the foot health survey. Those elderly who have had their foot amputated were excluded from the invitation. A total of 10,016 households were successfully enumerated. Among these 10,016 households, there were 3,447 persons aged 65 and above. Among them, 966 consented to provide their telephone number and were successfully contacted and invited to participate in this study.

A questionnaire including self perceived foot health and foot pain, number of falls in the past one year, and footwear preference was filled in by trained research assistants who directly interviewed the subjects with informed consent. This was followed by objective examination by a team of podiatrists with an average of seven years of clinical experience. They would examine the subjects' feet and their footwear; assess their foot health conditions, suitability of their footwear and the manner in which the elderly put on his/her footwear. They would also perform foot and shoe measurements. Each podiatrist was assigned to conduct a specific part of the examination for all subjects to minimize inter-observer variation. The clinical assessment was conducted between July 2002 and Dec 2002 in the Elderly Health Centres of Department of Health over the whole territory.

The gap in awareness of the elderly of their foot problems was shown by the discrepancies between their self reported foot problems and the findings of podiatrists' assessment. The suitability of their footwear was assessed by the presence of all nine essential features (Table 5) to keep both feet healthy in their footwear and by comparing their forefoot width and length with their shoes. One standard foot size of commercial shoes is 7 mm in width and length difference. A pair of suitable footwear should have a difference between the shoes width or length and the foot width or length within one foot size.

Statistical analysis

Data analysis was performed with the Statistical Package for the Social Sciences (Windows version 10.0; SPSS inc, Chicago, IL, United States). Univariate association was assessed using Chi squared test for categorical variables. A p-value of less than 0.05 was considered significant.

Results

Of the 966 elders, 494 were successfully assessed. 379 refused on the phone and 93 did not turn up on the date of assessment. The response rate was 51.1%.

50.8% of the respondents were male and 49.2% female. Compared to those in the 2002 Thematic Household Study, ¹⁷ elders participated in this study were younger (p<0.001, c² test) and with higher educational attainment (p<0.001, c² test). Besides, significantly more elders with arthritis (30.6%) participated. (p<0.001, c² test) (Table 1).

Awareness of foot health conditions

96.8% of the studied elders had at least one foot ailment as diagnosed by podiatrist after examination. The three commonest foot ailments were hallux deformity (72.4%), problem nail (63%) and callus (48.2%) (Figure 1). Other foot problems detected included lesser toe deformity (47.4%), athlete's foot (33.8%), pathological foot types (including pronated foot, supinated foot, spastic foot, grossly deformed and bound foot, and metatarsal adductus) (29.8%), corns (19.4%), wound (6.1%), wart (2.2%), and deficient circulation of the feet (2.6%) (Table 2).

When self-reported foot problems by the elders were compared with the findings of podiatrists' assessment, a wide gap in awareness was identified in all foot health conditions (Figure 2). 72.4% and 47.4% had hallux deformity (including hallux valgus, rigidus, hyperextended, interphalangeal valgus, and trigger hallux) and lesser toes deformity (including hammer toe, clawed toe, mallet toe, retracted toe, overlapping toes, and varus toes) but only 35.0% and 19.2% of them were aware of the conditions respectively. Hallux deformity was also found to be significantly associated with secondary foot pathologies of corn, callus and lesser toe deformities (p<0.001) (Table 3).

Nail problems were found in 63% of the studied population, but 48.7% of the elders were unaware of them. The three commonest nail problems were onychomycosis (29.8%), onychauxic (hypertrophied or thickened) nails (22.7%) and ingrown toenail (19.2%).

Feet with callous soles were the third most commonly found foot ailment (48.2%), but only 57.3% of the elders had self-reported the problem, and this was already the problem with highest awareness among these subjects. 65 elders (27.3%) of those with callus had pathological tyloma that warranted treatment. Corns were found in 96 studied subjects (19.4%), and only 43.8% of them were aware of the ailment.

33.8% of the elders had clinically diagnosed athlete's foot but nearly two-third (64.1%) of them were not aware of the infection. 2.2% had wart but 63.6% of them were not aware of it. 42.1% of the elders interviewed did not know what a wart was (Figure 3). 6.1% elders had a wound but 80% of them were not aware of it. Overlooking wounds on the feet increases the risk of infection and sepsis especially in patients with diabetes^17,18 and stroke.

Suitability of footwear

71.7% elders wore the pair of shoes that they wore daily or more than three days per week to the examination. The median duration of wearing the current pair of shoes was 12 months. 75.5% of respondents reported no inconvenience to daily living due to foot problem and 64.4% could walk from home to distance further than nearby places (Table 4). 70.9% had foot ache that varied with factors such as the weather. 15.3% elders had at least one fall in the last six months (Table 4). Among the fallers, the median number of falls was one with a range of 1 to 12.

As to the choice of shoes, 97.1% of elders considered their current pair of shoes average to comfortable (Table 4). However, only 12.3% of them were wearing proper shoes with all nine essential features to keep both feet healthy (Table 5). 31.9% elders were wearing shoes with heels worn down more than half towards one rim (Figure 4). 22.5% were wearing shoes with outsole already worn out (Figure 5), which were therefore not slip-proof. 26.3% of their shoes had excessive bulging and stretching marks indicating that elderly were using their feet as 'shoe stretcher' (Figure 6).

Walking shoes with and without fastener were the commonest choice of footwear (39.1% and 28.7% respectively) (Table 6). Sandals (15%), backless slippers (6.5%) and moccasin types (soft shoe material and sole) (6.3%) were also used. Some unhealthy shoes like court shoes (3.2%) and high heels shoes (0.4%) were still worn by the elders. Among the 223 elders who could be assessed on the way they put on their shoes, 148 (63.5%) of them had followed proper steps. Even when they wore proper walking shoes with fastener, only 36.5% of them employed the proper steps in using fastening action to secure the feet inside the shoes.

Forefoot width and length of the elders and their shoes were measured (Table 7). 3.3% and 4.7% had forefoot width and length difference between left and right feet of more than one shoe size respectively (Table 8).

62.6% of the elders were wearing shoes narrower than the width of their feet. 45.7% female and 36.4% male were wearing shoes which were one standard shoe size (i.e., 7 mm difference) smaller than their feet. The maximum difference in shoe width could be up to 3 shoe sizes smaller. This misfit problem was more prominent among the females (75.3% female, 51.0% male) (Table 9).

When assessing the length aspect, 56.3% males were wearing shoes more than two sizes longer than their feet and 11.9% were wearing shoes 4 sizes or even longer than their feet required. 26.3% footwear had excessive crease lines (Figure 7) which reflected that they were too big with excessive frictional movement of the foot inside the shoes making ripples and creases over the shoe cover material. For female, 17.5% were wearing shoes more than two shoe sizes longer but 10% wore shoes shorter than their feet and by as much as 10 mm (1.5 shoe size) (Table 9).

Foot health is closely related to foot hygiene and footwear hygiene. 72.3% and 86.0% of the elders were found to have good foot hygiene and footwear hygiene respectively (Table 10). Poor foot hygiene was found to be significantly associated with athlete's foot and problem nail (Table 11).

Discussion

Foot health problems are common among the elderly in Hong Kong with 96.8% of our studied population found to have at least one foot ailment. However, many of the studied subjects were not aware of their foot problems found by the podiatrists. It varies from 42.7% to 80.9% depending on the type of foot problems detected. Many patients also neglect their foot health problems and do not seek medical advice despite the fact that 41.2% of the elders have reported foot ache in the past six months and 24.2% reported inconvenience to daily living due to foot problems. Foot health is an important area in the care of elderly as foot problems may be associated with an impairment of IADL, functional limitation in gait, and an increased risk of fall. Another important finding is that 6.1% of our studied population had a wound on their feet but 80% of them were not aware of it. Overlooking wounds on the feet increases the risk of infection and sepsis especially in patients with diabetes and stroke. 85% of lower extremity amputations are preceded by a foot ulcer^17,18 which can be prevented by better awareness of foot health.¹³

This study also revealed that 33.8% of the elders have fungal infection and 2.2% have viral infection of their feet. Ignorance about fungal and viral foot infections delays treatment and leads to cross infection among family members and also in the community. These treatable conditions may be worsened by misunderstanding and attempted self-treatment. Education on foot hygiene and maintenance are important to prevent future infection and recurrence.

The commonest foot problem detected in this cohort was hallux deformity and yet there is a low awareness of this condition. A deformed big toe impairs foot function and reduces efficiency of the foot as a propeller. It can be associated with secondary foot pathologies like corns, callus and lesser toe deformity. Calluses and corns are also common among the elders and yet 80.6% of the elders perform various forms of self-treatment instead of seeking proper medical advice. Warts and corns have similar appearance but self-cutting of wart increases cross-infection and spreads the virus to the whole foot. Proper foot care technique is a priority area for education to enable elders or their carers to prevent the development and recurrence of these conditions.

Nail problems like ingrown toenail and onychauxis or the tickening of nails are also common. Ingrown toenail is painful but treatable and easily preventable through proper nail care and good toe protection. Elders with onychauxis and their carers who have difficulties in trimming the nails should receive education on nail care technique for effective nail reduction. Education about prevention of cross infection during nail care is also important as 29.8% of elders had onychomycosis which is infectious. All these problems can be minimized if the elders are aware of them and are willing to seek medical advice.

Choosing the proper type of shoes is important. Although 97.1% elders considered their current pair of shoes average to comfortable, only 12.3% of them were wearing proper shoes. This reflects the general lack of knowledge in choosing the right kind of shoes. Heels worn down more than half towards one rim give rise to instability in ankles and gait during walking, especially on uneven pavement. Worn out shoes are not slip-proof and may increase the risk of fall. Sandals, backless slippers and moccasin types (soft shoe material and sole) were also used by these elders despite they offered little protection and support to the feet. Some unhealthy shoes like court shoes and high heels shoes are still worn. Education on function of different shoe designs and understanding some shoe features to enable elders to choose footwear that offer better protection and comfort is important. Education on proper steps of putting on shoes such as fastening action to secure the feet inside the shoes is also important even when a pair of proper shoes has been chosen.

Good fitting shoes are very important in foot health, especially those with various degree of foot deformity. Unfit shoes can cause secondary foot pathologies like callus, corn, wound and thus chronic foot pain. Majority of elders in this study have their shoes that are too small and the elderly are using their feet as "shoe stretchers". This break-in action may cause direct skin damage and is dangerous to elders with diabetes. On the other hand, shoes that are too large or bulky may interfere with proprioception and balance. Education on shoe fitting technique and purchase practice are important.

Although the studied sample population was randomly selected from schematic household survey, this is a somewhat biased sample due to relatively low response rate. As pointed out before, the elders in this foot health survey are younger, more educated and with higher prevalence of arthritis. For the elderly of the general population, we might expect the foot problems to be more prevalent and receiving less awareness due to older mean age and lower education level.

Conclusion

Foot health problems are common in our elderly population and yet there is a low awareness and lack of knowledge on prevention and treatment of these problems. Footwear plays an important role in the maintenance of foot health. Majority of elders' shoes are too narrow and they are using their feet as "shoe stretcher". Health education on awareness and knowledge of common foot ailments, proper foot hygiene and foot care, good shoe fitting concept, choice of the proper shoe type and size for both the elders and their carers is necessary to improve this situation.

Key messages

1. Foot problems are very common in the elderly and more than 90% of the elderly have at least one foot ailment.
2. There is a low awareness of foot problems in the elderly population in Hong Kong.
3. The three commonest foot ailments are hallux deformity, problem nail and callus.
4. Foot health is closely related with foot hygiene and footwear hygiene.
5. Calluses and corns are also common among the elderly and yet 80.6% of the elders perform various forms of self-treatment instead of seeking proper medical advice.
6. There is a general lack of knowledge in choosing the right kind of shoes. Heels worn down more than half way towards one rim give rise to instability in ankles and gait during walking, especially on uneven pavements. Worn out shoes are not slip-proof and may increase the risk of fall. Sandals, backless slippers and moccasin types (soft shoe material and sole) offered little protection and support to the feet.

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References