Impact of COVID-19 pandemic on foot care services in Ontario, Canada

On March 11, 2020, the World Health Organization (WHO) announced that the rapidly spreading novel coronavirus (COVID-19) had reached pandemic levels [1]. In Ontario, the most populous Canadian province, over half a million individuals contracted COVID-19 and there were approximately 9,100 deaths attributed to the virus as of June 30, 2021 [2]. During these 16 months, the province experienced three waves of COVID-19 that altered the delivery of health care (Fig. 1. Number of COVID-19 Cases in Ontario from March 2020 to June 2021) [2].

On March 19, 2020, the Chief Medical Officer of Health of Ontario (CMOHO) issued a directive for all health care providers requiring all non-essential and elective services be ceased or reduced to minimal levels, which impacted the provision of foot care services in the province [3, 4]. At this time, there were close to 800 chiropodists and podiatrists collectively providing foot care services to over 14 million Ontario residents [5, 6]. Practicing chiropodists and podiatrists in the province are regulated by the College of Chiropodists of Ontario (COCOO). For the purpose of this study, chiropodists and podiatrists will be referred to as foot care providers (FCPs).

Following the CMOHO directive, COCOO defined essential care as “urgent foot health problems”, which included sudden onset of pain, increasing signs of infection, and diabetic foot changes during this time of service interruption [7]. As non-essential foot care services restarted in June 2020, the COCOO recommended a careful and gradual restart to services and introduced new clinical practice guidelines for FCPs. These guidelines detailed safety measures to limit and prevent the spread of COVID-19 among patients, clinicians, and staff in clinical practices [3, 8]. The purpose of the current study was to understand how the COVID-19 pandemic impacted foot care service delivery, patient foot health, and the mental health and well-being of FCPs practicing in Ontario, Canada.

An exploratory cross-sectional study using internet-based survey methods was conducted to provide an accurate and detailed description of clinician services provided during the COVID-19 pandemic. Internet-based survey delivery is cost-effective and enables data to be retrieved in a timely and efficient manner [9]. All active members of the COCOO (94% chiropodists, 6% podiatrists) providing foot care services in the province of Ontario in April 2021 were eligible for inclusion (n = 773) (with the exception of the study’s authors) [5]. Clinician members were contacted by COCOO via email with a description of the study and a web link to the online survey, which was administered through an online survey platform (SurveyMonkey®). Initial survey questions focused on characterizing clinicians’ practices, while later questions examined their experiences providing foot care services during the COVID-19 pandemic (March 2020 through April 2021) (Fig. 1), including FCPs perceptions of patient volume, barriers to care, their mental health and emotional well-being. The survey consisted of 31 items, including 5 open-ended items and 26 multiple-choice items with the option to provide additional comments. Surveys were available to potential participants for an 8-week period beginning in April 2021. All participants were emailed by COCOO with a reminder to complete the survey after one month. The survey was anonymous with no identifying information collected. The study was approved by the Unity Health Toronto-St. Michael’s Hospital Research Ethics Board (REB#20–251). Accessing the web link and completion of the survey served as informed consent.

Descriptive statistics (frequencies, means and percentages) were used to report and characterize responses. Statistical analyses were performed with SPSS Version 28.0 (Chicago, IL). Open-ended responses and additional written comments to multiple choice were analyzed using an inductive approach to qualitative content analysis as described by Elo et al. and Hsieh et al. [10, 11].

This is the first study to report on the delivery of foot care services by chiropodists and podiatrists in Ontario and examines their experiences during a pandemic. In an effort to limit the transmission of COVID-19 in the community, FCPs pivoted their care delivery by incorporating measures mandated by the provincial government and COCOO [3, 8]. Our study illustrates the significant impact of the COVID-19 pandemic on the delivery of foot care services in the province, the surge of urgent foot health problems, and the emotional, mental, and financial impact on FCPs during the study period.

FCPs in Ontario have a fiduciary responsibility to follow mandates by their governing body. During the pandemic, FCPs closely adhered to these mandates including: pre-screening patients for symptoms of COVID-19, scheduling patients to allow for physical distancing, increasing sanitization of the clinical environment, and providing PPE for themselves, staff, and patients [8]. Survey respondents reported that scheduling, additional time to provide care, and increased operating costs were the greatest barriers to delivering foot care during the first three waves of the pandemic, along with patients’ trepidation to return to care. However, respondents expressed in the open-ended items that the practice changes contributed to their feeling optimistic and confident about their capability to provide foot care services during the current pandemic. Many indicated they will maintain these care delivery changes post-pandemic.

In our study, FCPs reported seeing a substantial decline in patient volume as a result of recommended changes in the provision of care. Scheduling was the most reported barrier due to screening requirements and physical distancing guidelines in support of safe delivery of services [3]. Clinicians also posited the decline to reluctance of their patients to receive in-person care. Patients had communicated their anxiety and fear to return for in-person foot care to their foot care providers. This reported drop in patient volume is consistent with literature published during this pandemic. Researchers in Slovenia reported a decline of 58% in clinic visits [12], while Shin et al. reported the number of patient encounters was reduced by 50% in Manchester, UK, and nearly 70% in Los Angeles, USA [13].

To offset the lack of in-person care, over half of FCPs incorporated telephone consultations and/or virtual care into their practices by the third wave of the pandemic. Many FCPs reported the challenge of providing care in this manner due to the important visual component inherent in foot care and patients lacking necessary technology or equipment to facilitate virtual care. Similarly promoted use of virtual care was described by Rogers et al. when they were unable to provide in-person care for their patients with foot ulcers in the USA [14]. In contrast, the majority of Australian podiatrists did not incorporate telehealth into their practice, continuing instead with high-risk in-person care [15]. The authors explained that there was limited evidence to support the use of virtual care in the context of general foot care and that funding had not been provided to public podiatry clinics to support its introduction [15].

Given the decline in patient volume and poor uptake of virtual care in clinical practices, FCPs anticipated a substantial increase in the number of diabetic foot problems as the pandemic continued. Diabetes mellitus is a chronic disease that is associated with poor foot outcomes, including peripheral neuropathy, structural foot deformity, foot ulceration, and lower leg amputation [16, 17]. Patients with this condition are at a higher risk for these common and morbid disease complications, necessitating routine monitoring and foot care [18]. Accordingly, over half of FCPs reported seeing patients with diabetic foot changes. FCPs also described an increase in the number of in-person visits for urgent foot health problems. They indicated that their patients sought foot-related care from their primary care physicians, and patients visited the Emergency Department for urgent foot-related problems. Almost a quarter of clinicians disclosed that at least one patient had undergone a non-traumatic or diabetes-related lower extremity amputation during the pandemic. These urgent foot health problems represent a potentially preventable burden on Ontario’s public health care system.

With regard to the financial impact of the COVID-19 pandemic on their clinical practices, the majority of FCPs described greater operating costs, including necessary PPE, sanitization supplies, and installation of physical structures. At the same time, the majority of FCPs were treating fewer patients. Despite these practice changes, only 24% of FCPs increased their treatment costs for patients. This may be because FCPs did not want to deter patients from returning to foot care or create additional barriers for patients at a time when many were experiencing a financial strain due to the pandemic.

Along with the described financial impact of the COVID-19 pandemic on the clinical practices of FCPs, providing patient care during a pandemic has also been shown to emotionally impact health care professionals, including the mental health and well-being of FCPs. In a systematic review of the mental impact of the COVID-19 pandemic on healthcare workers, Muller et al. reported that healthcare workers experienced anxiety, depression, and sleep problems during the pandemic [19]. Similarly, Evanoff et al. found that working in a clinical environment was associated with higher anxiety and decreased well-being [20]. In the current study, FCPs described similar experiences, including stress, fatigue, anxiety, and burnout. Muller et al. also found that healthcare workers were less likely to seek professional help [19]. More than half of FCPs in this study did not reach out for support or access resources to improve their mental health and physical wellness.

Despite the emotional and financial burden experienced by FCPs, they also communicated their adaptability and preparedness to face ongoing practice changes. This may have been influenced by the vaccination efforts underway, as well as the diminishing number of active COVID-19 cases in the province at the time of this survey. Furthermore, the implementation of physical structures, technological platforms, and enhanced infection control practices contributed to respondents’ confidence in delivering foot care services during another pandemic in the future. Finally, numerous respondents discussed their impressions of what factors are essential for future pandemic preparedness, including the guarantee of an adequate stockpile of PPE, coordinated communication from all government levels, and the creation of a practice crisis preparedness checklist or manual. These factors would minimize the disruption to delivery of foot care services during future global crises.

Given that there is no previously published literature describing the clinical practice of FCPs in Ontario, Canada, this study’s findings cannot be compared to pre-pandemic practice norms. The survey included both podiatrists and chiropodists, however, information was not collected to allow comparison by FCP designation. The study also employed a web-based survey methodology, which is known to have a lower response rate and may be affected by responder bias [9, 21, 22]. Nevertheless, the authors chose this methodology for its ease, speed, reach, affordability, and convenience. The response rate was consistent with other studies utilizing web-based surveys [15, 23].

Future research could examine hospital resource utilization data (e.g. hospital admissions and lower extremity amputations related to foot complications) and foot care procedure data from primary care practitioners to understand the overall impact of COVID-19 on the healthcare system. In addition, this study has highlighted areas for future research for more thorough understanding of clinician’s emotional well-being using validated questionnaires. As well, a qualitative research study would help gain insight into the patients’ perspective on the provision of foot care services during the pandemic. This would be important to further understand the impact on patients and explore the factors raised by FCPs that would better prepare health care providers for future pandemics.

This study describes the delivery of foot care services by chiropodists and podiatrists in Ontario, Canada during the COVID-19 pandemic. Foot care providers pivoted their clinical practice in accordance with governing guidelines as they dealt with increasing numbers of urgent foot health problems while patient volume declined. There was an impact on the mental, emotional and financial well-being of foot care providers as they adapted to continuing changes. Pandemic preparedness is necessary to provide foot care services and to navigate through future global epidemics.