Exploring Foot Care Conditions for People Experiencing Homelessness: A Community Participatory Approach


People experiencing homelessness are faced with complex challenges and are at high risk of illness due to inequities and disparities in access to health care services.


To explore the health and foot care problems related to people experiencing homelessness in British Columbia.


A community participatory research approach was used with a sample of 65 people experiencing homelessness. Data were collected using a survey questionnaire and face-to-face semistructured interviews.


Thematic findings shows risk of foot injuries, lack of foot care resources, and absence of family support. Barriers to equitable access to services for most participants experiencing homelessness were lack of housing (76.92%), inability to work (72.31%), and inability to afford the cost of living on their own (63.08%).


There is a pressing need for early screening and detection by health care professionals and enhanced foot care services to reduce foot problems and improve foot care wellness of homeless people. Addressing foot-related care are necessary steps in promoting health, preventing illness, and improving access to health services among people experiencing homelessness.

Keywords: access to care, community health, emergency visits, health outcomes, primary care, underserved communities

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Homelessness is caused by lack of affordable housing, unemployment, poor mental health, and low social support. 1 Lack of access to necessities like food, clothing, shelter, transport, social services, and health care affect people’s lives. Hence, poverty, unemployment, and lack of housing and income is a vicious cycle of poverty affecting homeless people’s lives. Socioeconomic status is a significant contributing factor to mental health and health status. People experiencing homelessness have higher prevalence of physical health problems, including respiratory illnesses, musculoskeletal disorders, chronic pain, malnutrition, and infectious disease. Chronic illness such as diabetes, hypertension, poor dental hygiene, skin, and foot conditions are reported as higher compared to the general population. 2 They are vulnerable to mental health changes, substance use, trauma, and domestic violence. 3 Many people experiencing homelessness resort to remedial spaces such as foster care, community placements, and institutionalized care without adequate plans for a future safe dwelling to meet their needs. While health care services address several health care concerns of people experiencing homelessness, there is a lack of services that focus on this population’s foot-related health care needs. 4

In 2018, 25 216 Canadians experienced absolute homelessness in shelters and 6789 people in transitional housing. 5 People experiencing chronic homelessness accounted for 60% of all respondents, whereas episodic homelessness accounted for 8% of all respondents. 6 One-quarter of respondents (25%) had not used a shelter in the past year. It is reported that 53% of people were less likely to stay in a shelter if they were staying with others. Many homeless choose not to access health care for foot care and health problems such as calluses, blisters, and trench foot. 7 Commonly, health illnesses in homeless people have comorbidities such as respiratory conditions, skin problems, foot disorders, hypertension, cirrhosis, HIV, and injuries. 8 People experiencing homelessness are exposed to social stigmatization, social isolation, unstable living conditions, chronic health problems, 9 and difficulties accessing healthcare.10,11 Many homeless people are compounded by these complex challenges and at high risk of illness due to inequities and disparities in access to health services. 12 Overall health is affected alongside the inability to receive foot care due to constant walking in poor weather conditions. In many instances it remains undetected thereby increasing foot related problems in people experiencing homelessness and ultimately affecting their quality of life. Conditions of shoes, socks, and foot odor was a significant deterrent to using foot care services.

Chen et al 13 conducted a review of the literature and found 3 articles found poor foot conditions and foot infections among the homeless. Another study reported that 18 out of 21 people experiencing homelessness reported foot pain and foot ulcers. 14 Six healthcare professionals were interviewed concerning foot care access experiences on the street and validated foot conditions were common. 15 The barriers identified by 26 homeless men and women in the interview were limited income, limited health care access, lack of healthy food availability, lack of access to primary care physicians, and waiting on entitlement decisions. 16 The prevalence of foot-related problems across people experiencing homelessness is corn and calluses (7.7%-57%), nail pathologies (15%-65%), infections (3.2%-38%), and injuries (24%-43%). 17 People experiencing homelessness (9%-65%) are more likely to have foot infections, pain, functional limitations, bunions, hammertoes, gout, plantar warts, foot ulcers, and frostbite. 17 They are at high-risk for developing foot problems, which could lead to further health-related consequences such as multimorbidity, surgery, amputation, increased hospitalization, and disability. 18 People experiencing homelessness report feeling stigmatized and discriminated against by some health care professionals, which in turn prevents them from accessing health care supports and services.19,20 People experiencing homelessness with mental health illness and substance abuse feel further difficulties in accessing and finding trusting health care professionals. 21 Thus people experiencing homelessness have poor access to health care, leading to higher utilization of emergency services.

Primary care is considered important for access and care of people who are homeless. It is viewed as an easier approach to health care services to improve health. There are currently few foot care services existing for people experiencing homelessness in the interior region of British Columbia. There are gaps in the literature regarding the social barriers to homeless people’s foot care needs and stakeholders’ perspectives, and the provision of homeless people services. Community and health services often overlook foot care needs of people experiencing homelessness, which leads to increased utilization of emergency services and deterioration in their health. Since people experiencing homelessness are underrepresented in health service research, little is known about their unmet health care needs, particularly in smaller cities where resources are limited. The objective of this study is to explore barriers and facilitators of foot care conditions related to people experiencing homelessness in British Columbia.