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

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 [1‐5], 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 [18‐20], diabetes [21, 22] and geriatrics [23‐27]), 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.

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 [1‐5], 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.

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.