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Predictors of podiatry utilisation in Australia: the North West Adelaide Health Study

  • Hylton B Menz1Email author,
  • Tiffany K Gill2,
  • Anne W Taylor2 and
  • Catherine L Hill3
Journal of Foot and Ankle Research20081:8

https://doi.org/10.1186/1757-1146-1-8

Received: 02 June 2008

Accepted: 19 August 2008

Published: 19 August 2008

Abstract

Background

Foot problems are highly prevalent in the community; however no large population-based studies have examined the characteristics of those who do and do not access podiatry services in Australia. The aim of this study was to explore patterns of podiatry utilisation in a population-based sample of people aged 18 years and over living in the northwest region of Adelaide, South Australia.

Methods

The North West Adelaide Health Study is a representative longitudinal cohort study of 4,060 people randomly selected and recruited by telephone interview. The interview included questions regarding healthcare service utilisation in the past year. Data were also collected on education, income and major medical conditions.

Results

Overall, 9.5% of the total sample and 17.7% of those who reported foot pain had attended a podiatrist in the past year. Participants who had accessed podiatry treatment were more likely to be female, be aged over 45 years, be obese, and have major chronic medical conditions (osteoporosis, osteoarthritis, diabetes, cardiovascular disease and high blood pressure). Those who reported foot pain but had not accessed a podiatrist were more likely to be male and be aged 20 to 34 years.

Conclusion

Only a small proportion of people who report foot pain have accessed podiatry services in the past year. There is a need to further promote podiatry services to the general community, particularly to men and younger people.

Background

Foot pain is a highly prevalent condition reported by at least one in five people in the general population [1, 2]. The prevalence of foot pain increases with age [15], is more prevalent in females [1, 2, 6, 7] and the obese [2, 8, 9], and is associated with self-reported disability [10], inability to perform activities of daily living [7, 11, 12] and reduced health-related quality of life [2, 13, 14]. Despite the significant impact of foot disorders, several intervention studies have shown that foot pain associated with common conditions such as corns and calluses, nail disorders and plantar fasciitis can be effectively managed with a range of conservative and surgical techniques [15, 16].

The provision of foot health services to manage foot pain and disability is primarily (although not exclusively) the domain of the podiatry profession [17]. However, although several studies have evaluated foot health service provision in specialist disciplines (such as rheumatology [1820], diabetes [21, 22] and geriatrics [2327]), few have examined the characteristics of people who do and do not access podiatry services in the general community. In the UK, a population-based survey of 792 people aged over 60 years reported that only 33% of those with foot problems had received podiatry treatment, with those who accessed podiatry being more likely to be female, older, and living alone [28]. Similarly, the Cheshire Foot Pain and Disability Survey of 3,417 people aged between 18 and 80 years reported that only 36% of those with disabling foot pain had accessed podiatry services in the last six months [1], which was partly attributed to a relative shortage of National Health Service podiatry resources for younger people.

In Australia, the 2004–2005 National Health Survey of 25,906 people included a question regarding consultations with health professionals in the last two weeks, and found that 6.7% of the population had consulted a podiatrist [29]. The likelihood of accessing podiatry services increased steadily with age, and those who consulted a podiatrist were twice as likely to be female. However, whether this level of access of podiatry services is adequate cannot be ascertained from these data, as the survey did not collect any information regarding the presence of foot problems. Furthermore, although data were collected on other demographic factors and major health conditions, no analyses were undertaken to compare the characteristics of those who did and did not consult a podiatrist in the last two weeks.

To the authors' knowledge, the only population-based Australian study to examine rates of podiatry utilisation in relation to need was conducted in rural south-east Queensland in 1995 [5]. This study – the West Moreton Rural Health Needs Assessment survey – involved an interviewer-administered general health survey of 600 people aged 18 years and over, and incorporated several questions regarding foot problems and health service utilisation. Of the 154 people who reported foot problems, 102 (66%) had sought treatment in the previous year. However, only 16% reported receiving treatment from a podiatrist, with the majority (71%) seeking treatment from their general practitioner. Consistent with the findings of the National Health Survey [29], women and those aged over 65 years of age were more likely to seek podiatric treatment for their foot problem.

Developing a more thorough understanding of the number and characteristics of people who do and do not consult podiatrists may assist in evaluating the adequacy of podiatry resources and help identify specific gaps in service provision. Therefore, the aim of our study was to explore patterns of podiatry utilisation in those who took part in the North West Adelaide Health Study, a population-based survey of 4,060 people aged 18 years and over living in the northwest region of Adelaide, South Australia.

Methods

Setting and study population

The North West Adelaide Health Study (NWAHS) was established in 2000 in the north-western region of Adelaide, South Australia [30]. The north-west region of Adelaide comprises approximately half of the population of the city of Adelaide and a third of the population of the state of South Australia. The region also reflects the demographic profile of the state, covering a broad range of ages and socioeconomic areas. The study was designed in response to a need to assess the prevalence of priority conditions and examine their progression over time in a population-based community-dwelling cohort, to inform policy decisions about health care provision in South Australia.

Participants for Stage 1 of the study (which was conducted between 2000 and July 2003) were recruited randomly from the Electronic White Pages telephone listings and an initial telephone interview was conducted. The overall response rate for an interview and attendance at the clinic assessment was 49.4%. Those within each household, who were last to have a birthday and aged 18 years and over were interviewed and invited to attend a clinic assessment.

Between 2004 and 2006, Stage 2 of the study was conducted. Where possible, all participants were contacted and invited to participate in a Computer Assisted Telephone interview (CATI), a self-completed questionnaire and/or a clinic assessment. Stage 2 specifically focused on the collection of information relating to musculoskeletal conditions, with n = 3,502 respondents providing information relating to podiatry use in the telephone questionnaire and n = 3,206 respondents attending the clinic. Ethical approval for the study was obtained from the North West Adelaide Health Service Ethics of Human Research Committee, and written informed consent was obtained from all participants.

Data collection

As part of the self completed questionnaire, information relating to demographics, smoking, self-reported prevalence of diabetes and levels of physical activity using the questions from the Australian National Health Survey [31] were collected. As part of the clinic assessment, height, weight, waist and hip circumference were measured, blood was taken, and all participants attending the clinic in Stage 2 were asked: "On most days do you have pain, aching or stiffness in either of your feet?". If they answered yes to this question, they were regarded to have foot pain. As part of the CATI, the self-reported prevalence of osteoporosis and cardiovascular disease were determined, as was the health service utilisation in the past 12 months.

Statistical analysis

Data were weighted by age and sex, and probability of selection within the household, to the population of the north-west suburbs of Adelaide. Analysis was undertaken using SPSS Version 15 to determine the prevalence of podiatry consultation, and associations between age, sex, body mass index (BMI), selected chronic diseases, health risk factors and musculoskeletal pain (including foot pain). Frequencies were determined for the prevalence values (foot pain and podiatry use) and demographic characteristics of the sample. Univariate and multivariate logistic regression analyses were also undertaken. Variables that were significant at p < 0.25 at a univariate level were included in the logistic regression models as described by Hosmer and Lemeshow [32]. The multivariate logistic regression used a backwards stepwise method, with non-significant variables removed at each step. The Hosmer and Lemeshow Goodness of Fit test is an indicator of the fit of the model; a significant value indicates that the model is not a good fit for the data [32]. The Omnibus test also is a test of how well the independent variables in the model jointly predict the dependent variable. If significant, this indicates that the model is a good fit for the data [33]. Variables in the final model were significant at the level of p < 0.05.

Results

Sample characteristics

Sample characteristics are shown in Table 1. The characteristics of the NWAHS cohort demonstrate that this is a relatively young, heavy cohort with 38% under 40 years; and the mean BMI in the overweight range. A previous analysis of this dataset indicated that 17% had foot pain, with those reporting foot pain more likely to be female, be aged 50 years and over, be obese and also report knee, hip and back pain [2].
Table 1

Demographic characteristics of participants in the NWAHS.

Variable

 

Sex

 

   Male

1718 (49.1)

   Female

1784 (50.9)

Age

 

   20 to 34 years

996 (28.4)

   35 to 44 years

711 (20.3)

   45 to 54 years

620 (17.7)

   55 to 64 years

477 (13.6)

   65 to 74 years

355 (10.1)

   75 years and over

344 (9.8)

Education

 

   Secondary

1450 (44.5)

   Trade/Apprentice/Certificate/Diploma

1202 (36.9)

   Degree

560 (17.2)

   Other/not stated

49 (1.5)

Income

 

   Up to $20,000

613 (18.8)

   $20,000–$40,000

745 (22.8)

   $40,001–$60,000

697 (21.4)

   $60,001–$80,000

495 (15.2)

   $80,001–$100,000

314 (9.6)

   More than $100,000

263 (8.1)

   Not stated

133 (4.1)

Note: Values are n (%) unless otherwise noted.

Prevalence and predictors of podiatry service utilisation

Overall, n = 334 (9.5%; 95% CI 8.6–10.5) respondents who responded to questions regarding health service use reported that they had consulted a podiatrist in the last 12 months. Participants who had accessed podiatry treatment were more likely to be female, be aged over 45 years, have completed only secondary education, earn $20,000 or less per year, be obese, have major chronic medical conditions (osteoporosis, osteoarthritis, diabetes, cardiovascular disease and high blood pressure), were less likely to consume intermediate to high risk levels of alcohol, or be current smokers (p < 0.05, unadjusted univariate analysis) (Table 2). Sex, age, arthritis, diabetes and smoking status were confirmed as significant predictors in multivariate logistic regression (Hosmer and Lemeshow Goodness of Fit χ2 = 10.96, p = 0.204; Omnibus test χ2 = 295.93, df = 9, p < 0.001) (Table 3).
Table 2

Characteristics of participants who accessed podiatry services (n = 334) in the previous 12 months (univariate analysis).

Variable

n

%

Odds ratio (95% CI)

p value

Sex

    

   Male

102

5.9

1.00

 

   Female

232

13.0

2.38 (1.86–3.03)

< 0.001

Age

    

   20 to 34 years

37

3.7

1.00

 

   35 to 44 years

35

4.9

1.36 (0.85–2.18)

0.206

   45 to 54 years

39

6.3

1.75 (1.11–2.78)

0.017

   55 to 64 years

52

10.9

3.20 (2.07–4.96)

< 0.001

   65 to 74 years

60

17.0

5.35 (3.48–8.22)

< 0.001

   75 years and over

110

32.1

12.32 (8.26–18.37)

< 0.001

Education

    

   Secondary

167

11.8

1.00

 

   Trade/Apprentice/Certificate/Diploma

101

8.5

0.70 (0.54–0.91)

0.007

   Degree or higher

36

6.4

0.51 (0.35–0.75)

< 0.001

   Other/not stated

5

10.5

0.88 (0.34–2.25)

0.787

Income

    

   Up to $20,000

94

15.9

1.00

 

   $20,001–$40,000

80

11.0

0.65 (0.47–0.90)

0.008

   $40,001–$60,000

51

7.4

0.42 (0.30–0.61)

< 0.001

   $60,001–$80,000

32

6.5

0.37 (0.24–0.56)

< 0.001

   $80,001–$100,000

14

4.6

0.26 (0.14–0.45)

< 0.001

   More than $100,000

20

7.4

0.42 (0.25–0.71)

0.001

   Not stated

17

13.7

0.84 (0.48–1.45)

0.524

Chronic conditions

    

   Osteoporosis

37

28.0

4.04 (2.72–6.01)

< 0.001

   Arthritis

147

19.8

3.48 (2.75–4.40)

< 0.001

   Diabetes

65

29.4

4.58 (3.34–6.30)

< 0.001

   Cardiovascular disease

55

23.6

3.32 (2.40–4.60)

< 0.001

   High blood pressure

116

14.3

1.85 (1.45–2.37)

< 0.001

   High cholesterol

126

9.9

1.01 (0.80–1.29)

0.924

   Obese (BMI ≥ 30 kg/m2)

108

11.6

1.31 (1.03–1.68)

0.031

Alcohol consumption

    

   Non drinker (no risk)

159

10.2

1.00

 

   Low risk

129

9.7

0.95 (0.74–1.21)

0.655

   Intermediate to very high risk

7

4.1

0.38 (0.18–0.81)

0.013

Current smoker

24

3.7

0.31 (0.20–0.48)

< 0.001

No physical activity (sedentary)

79

9.5

0.99 (0.76–1.31)

0.967

Note: The weighting of data can result in rounding discrepancies or totals not adding.

Table 3

Multivariate predictors of accessing podiatry services in the last 12 months.

Variable

Odds ratio (95% CI)

p value

Sex

  

   Male

1.00

 

   Female

2.32 (1.77–3.05)

< 0.001

Age

  

   20 to 34 years

1.00

 

   35 to 44 years

1.21 (0.75–1.94)

0.439

   45 to 54 years

1.16 (0.71–1.89)

0.554

   55 to 64 years

1.75 (1.09–2.82)

0.021

   65 to 74 years

2.53 (1.54–6.11)

< 0.001

   75 years and over

5.99 (3.81–9.42)

< 0.001

Chronic conditions

  

   Arthritis

1.65 (1.23–2.22)

0.001

   Diabetes

3.11 (2.17–4.46)

< 0.001

Current smoker

0.46 (0.29–0.73)

0.001

Of those who attended the clinic assessment and reported that they had foot pain (n = 538), 17.7% (95% CI 14.7–21.2, n = 95) had consulted a podiatrist in the last 12 months. Those who reported foot pain but had not accessed a podiatrist were more likely to be male, be aged 20 to 34 years, earn between $40,000 and $60,000 per year and be current smokers, or were less likely to have major chronic medical conditions (osteoporosis, osteoarthritis, diabetes, cardiovascular disease and high blood pressure) (p < 0.05, unadjusted univariate analysis) (Table 4). Sex and age were confirmed as significant predictors in multivariate logistic regression analyses (Hosmer and Lemeshow Goodness of Fit χ2 = 4.14, p = 0.844; Omnibus test χ2 = 53.57, df = 6, p < 0.001) (Table 5).
Table 4

Characteristics of participants who reported foot problems and did not access podiatry services (n = 443) in the last 12 months (univariate analysis).

Variable

n

%

Odds ratio (95% CI)

p value

Sex

    

   Female

233

77.2

1.00

 

   Male

210

88.9

2.36 (1.45–3.84)

0.001

Age

    

   75 years and over

40

58.7

1.00

 

   65 to 74 years

61

73.4

1.94 (0.98–3.84)

0.058

   55 to 64 years

87

84.0

3.69 (1.81–7.52)

< 0.001

   45 to 54 years

105

86.0

4.32 (2.14–8.74)

< 0.001

   35 to 44 years

62

89.3

5.85 (2.38–14.37)

< 0.001

   20 to 34 years

88

95.9

16.43 (5.26–51.28)

< 0.001

Education

    

   Secondary

249

82.4

1.00

 

   Trade/Apprentice/Certificate/Diploma

142

81.9

0.96 (0.59–1.57)

0.883

   Degree or higher

39

82.0

0.97 (0.44–2.16)

0.940

   Other/not stated

12

84.1

1.12 (0.26–4.91)

0.877

Income

    

   Up to $20,000

90

72.0

1.00

 

   $20,001–$40,000

121

81.8

1.74 (0.98–3.09)

0.057

   $40,001–$60,000

92

91.0

3.91 (1.78–8.58)

0.001

   $60,001–$80,000

43

78.8

1.45 (0.68–3.09)

0.342

   $80,001–$100,000

33

85.4

2.28 (0.86–6.04)

0.097

   More than $100,000

35

91.3

4.09 (1.23–13.52)

0.021

   Not stated

28

88.5

2.98 (0.93–9.50)

0.065

Chronic conditions

    

   Osteoporosis

24

64.5

0.36 (0.18–0.72)

0.004

   Arthritis

173

75.3

0.42 (0.26–0.66)

< 0.001

   Diabetes

42

68.7

0.42 (0.23–0.76)

0.004

   Cardiovascular disease

36

68.4

0.42 (0.22–0.79)

0.007

   High blood pressure

134

76.4

0.57 (0.36–0.90)

0.015

   High cholesterol

186

80.3

0.76 (0.49–1.19)

0.235

   Obese (BMI ≥ 30 kg/m2)

187

81.9

0.84 (0.61–1.49)

0.841

Alcohol consumption

    

   Non drinker (no risk)

198

80.5

1.00

 

   Low risk

198

82.8

1.17 (0.74–1.85)

0.508

   Intermediate to very high risk

29

95.1

4.68 (0.89–24.76)

0.068

Current smoker

90

92.6

3.14 (1.42–6.93)

0.005

No physical activity (sedentary)

136

83.5

1.10 (0.67–1.82)

0.707

Note: The weighting of data can result in rounding discrepancies or totals not adding.

Table 5

Multivariate predictors of not accessing podiatry services in the last 12 months in people who reported foot pain.

Variable

Odds ratio (95% CI)

p value

Sex

  

   Female

1.00

 

   Male

2.11 (1.27–3.50)

0.004

Age

  

   75 years and over

1.00

 

   65 to 74 years

1.94 (0.97–3.88)

0.061

   55 to 64 years

3.53 (1.72–7.26)

0.001

   45 to 54 years

4.26 (2.09–8.67)

< 0.001

   35 to 44 years

5.42 (2.19–13.42)

< 0.001

   20 to 34 years

15.08 (4.80–47.34)

< 0.001

Discussion

The aim of this study was to examine the prevalence and predictors of podiatry service utilisation in a population-based sample of people aged 18 years and over who took part in the North West Adelaide Health Study (NWAHS). The findings indicate that 9.5% of the cohort had consulted a podiatrist in the past 12 months. Of those who reported foot pain, only 17.7% had consulted a podiatrist. Our analysis indicated that the typical podiatry patient is an older, obese woman with limited education, relatively low income, and multiple chronic diseases. In contrast, those with foot problems who have not consulted a podiatrist tended to be younger men without chronic diseases.

The total proportion of people who reported accessing podiatry services in the NWAHS (9.5%) was higher than the 2004–2005 Australian National Health Survey (6.7%) [31] and the West Moreton Rural Health Needs Assessment survey (3%) [5]. The difference between the current study and the National Health Survey is most likely due to the different timeframes contained within the health care utilisation questionnaires used (previous 12 months for the NWAHS compared to the previous two weeks in the National Health Survey). However, it is also possible that the NWAHS population had greater access to podiatry than the national average. The Australian Institute for Health and Welfare's Podiatry Labour Force study estimated that in 2003, the number of full-time equivalent podiatrists per 100,000 population in South Australia was 17.4, higher than all other states included in the survey (Victoria: 13.0, Tasmania: 12.4, New South Wales: 9.3 and Queensland: 7.7) [34].

The proportion of people who reported foot pain and who had consulted a podiatrist (17%) was substantially lower than similar studies conducted in the UK (33 to 36%) [1, 28], but similar to the rate reported in the West Moreton Rural Health Needs Assessment survey (16%) [5]. In the UK, the National Health Service provides free podiatry care to approximately 4% of the population, with the majority of recipients being aged over 65 years [35]. In Australia, relatively limited podiatry services are provided by the public sector, and in most settings access to podiatry is restricted to those with "high risk" feet, i.e.: those with chronic conditions such as diabetes or rheumatoid arthritis. Subsequently, the awareness and utilisation of podiatry among older people is likely to be higher than younger people [27]. The lack of publicly-funded podiatry services for people without chronic diseases, combined with an inability or reluctance to pay for private services, may explain the very low levels of podiatry consultation in younger people (as low as 4 to 10% in those aged 20 to 44 years).

However, it is also possible that some degree of foot health service provision is currently being met by other health care professionals, particularly general practitioners. A survey of 1,130 people aged over 65 years of age in the Netherlands indicated that 30% sought foot treatment from their general practitioner rather than a podiatrist/chiropodist [26]. Similarly, in the West Moreton Rural Health Needs Assessment survey, 71% of those with a foot problem had consulted their general practitioner, with no podiatry consultations reported by those aged 18 to 24 years [5]. Interestingly, the National Health Interview Survey in the US indicated that while treatment of corns, calluses and nail disorders were almost exclusively provided by podiatrists, management of musculoskeletal foot conditions and acute injuries (such as ankle sprains) were more likely to be managed by medical practitioners [3]. Given the high prevalence of older people accessing podiatry services, it is possible that younger people do not consider consulting a podiatrist for musculoskeletal foot conditions, as they associate podiatry with routine management of skin and nail problems in older people. If this is correct, there may be a need for the podiatry profession to promote a greater awareness of the scope of podiatry practice to young and middle-aged people.

Consistent with anecdotal observations, our results indicate that the typical patient attending podiatry is an older, obese woman with limited education, relatively low income, and multiple chronic diseases. This patient profile is not surprising given the available evidence relating to the role of increased age [15], female sex [1, 2, 6, 7], obesity [2, 5, 8, 9] and comorbidities [2, 9, 12, 36] in the development of foot problems. The role of socio-economic status, however, is equivocal. Lower levels of education have been found to be associated with foot problems in some studies [3, 9] but not others [12, 13, 36]. Similarly, while some studies have found that people with foot problems have lower income levels [3] others have failed to find such an association [9, 13]. These discrepancies are likely to reflect differences in how income levels are defined, differences in educational systems between countries, and variability in adjustment for confounders in the statistical models. Nevertheless, in the current study the association between accessing podiatry services and socio-economic factors was no longer significant after other variables were considered.

The major strength of this study is the use of a population-based sample with excellent response rates over a broad age range. However, the findings of this study need to be interpreted in the context of several limitations. Firstly, we defined foot pain according to a single question rather than using foot-specific questionnaires, such as the Manchester Foot Pain and Disability Index [14, 37] or Foot Health Status Questionnaire [38]. Secondly, we were unable to examine the participants' feet in the study to ascertain the underlying cause of their pain. Thirdly, we did not ask participants whether they had accessed other health care professionals for management of their foot pain. As such, we cannot necessarily conclude that the proportion of people with foot pain who have not accessed a podiatrist is an accurate indicator of unmet need.

Despite these limitations, the results of this study provide the first detailed insights into the number and characteristics of people who do and do not access podiatry services in Australia, based on a large representative sample. The findings may assist in the future planning and development of foot health services, and provide some direction for promotional activities for the podiatry profession. Although the important role that podiatry plays in the maintenance of foot health in older people should not be ignored, there would appear to be a large number of young to middle-aged people with foot pain who are currently unaware of, or unable to access, podiatry services in Australia.

Conclusion

The findings of this population-based study indicate that approximately 10% of the general population has consulted a podiatrist in the past 12 months. Those who attend podiatry are more likely to be female, be aged over 45 years, be obese, and have major chronic medical conditions. The large proportion of people who report foot pain but have not accessed podiatry services (82%) suggests that there may be a need to further promote podiatry services to the general community, particularly to men and younger people.

Declarations

Acknowledgements

This study received financial support from a grant from Human Services Research and Innovation Program (large projects) 2000–01, Department of Health, South Australia. HBM is currently a National Health and Medical Research Council fellow (Clinical Career Development Award, ID: 433049). We would also like to acknowledge the contribution of the NWAHS staff and participants.

Authors’ Affiliations

(1)
Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University
(2)
Population Research and Outcome Studies Unit, Department of Health
(3)
Rheumatology Unit, Queen Elizabeth Hospital

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© Menz et al; licensee BioMed Central Ltd. 2008

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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