A Preliminary Assessment of Barriers and Facilitators to Accessing Foot Care in Homeless Shelters: A Scoping Review

BACKGROUND: This scoping review aims to explore the most common foot problems people experiencing homelessness (PEH) experience, as well as to explore the potential strategies for addressing foot problems in PEH, such as foot clinics, foot screening, and foot care for adults experiencing homelessness. METHODS: A scoping review of the literature from MEDLINE (Ovid), CINAHL (EBSCOhost), Cochrane Register of Controlled Trials (Ovid), EMBASE (Ovid), PubMed, clinicaltrials.gov, Google Scholar, and Web of Science was conducted to identify relevant articles published from inception to April 14, 2023. Literature discussing foot problems, foot care, and intervention in PEH were included. Sixty-one articles were retained after screening by 2 independent reviewers. Data were extracted by 3 independent reviewers and disagreements were resolved by a fourth reviewer. Outcomes were determined after data extraction given the nature of the scoping review. Primary outcomes include foot problems, their severity, and their prevalence. The quality of studies included for data extraction was assessed using the Newcastle-Ottawa quality assessment scale and the National Institute of Health Quality Assessment Tool when applicable. RESULTS: We present a summary of the prevalence of foot pain and foot problems along with gender differences when data was available. Frostbites, foot ulcers, peripheral arterial disease, foot infections (including diabetic foot infection), and related amputations were also found to be prevalent in PEH, with data suggesting that homelessness is an independent risk factor for these foot problems. Strategies and interventions to address foot health for PEH were divided into 1) direct interventions in the field, such as wound care, or education of PEH during clinical encounters and 2) organizational interventions, such as expanding outreach efforts, coordinating resources to avoid interfering with shelter hours, or improving the timeliness of interventions by first responders. The literature shows that foot exams, appropriate footwear, and education, which can be provided in the context of mobile clinics, play a critical role in the detection and prevention of foot pathologies. Barriers to care were broken down into 4 categories: accessing and receiving care, comorbid health issues or substance use, emotional barriers, and social inequalities. CONCLUSIONS: Foot problems in PEH, which have been reported in the literature for decades, remain unchanged. Interventions and strategies to address this issue include provision of holistic care, enrollment in insurance programs, provision of supplies and education, and development of outreach services. Indeed, mobile clinics have been shown to eliminate multiple barriers to care for PEH. Although some screening tools were reported, their relevance and reliability have yet to be defined in further studies. While remaining gaps and barriers such as stigma, lack of follow-up care, and gratuity of services have been identified, alternative methods other than the aforementioned outreach efforts have yet to be described.

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