PUBLIC
HEALTH
*I-1
A Podiatric Health Screening in Harlem DAVID 1. ROSENSTEIN, DMD, MPH RICHARD BAERG, DPM, MPH GLENN GASTWIRTH, DPM JOSEPH FOX, DPM
Introduction A high percentage of children of all age groups are afflicted with some degree of foot pathology.1 Cole, in his study, found that of 1080 children examined, 528 had improper footgear.2 He did not correlate that number with associated foot abnormalities, but found a higher incidence of improper footgear in females. Shapiro and Rhee found that a significantly higher proportion of girls were weanrng unsatisfactory footgear, and a higher percentage had related postural and orthopedic problems.3 Other studies have also found a large number of improperly fitted footgear, as well as a high amount of foot pathology.46 Of the studies that have been done in the past, no attempt to relate foot pathology to independent variables has been made. In this study of the children of Harlem, we examined the following three independent variables and studied their. effects on foot pathology: properly fitted footgear, sex, and income.
Methodology On May 8, 1972, 836 preschool children from 33 Head Start centers in Harlem were screened for possible foot pathology by the podiatric medical staff of the New York College of Podiatric Medicine. The 836 children represented approximately 50 per cent of all Head Start children in the Harlem Community. All of the children were in the 2- to 6-year-old age group and were from the same socioeconomic background. The children were examined for evaluation of footgear, gait, postural and podiatric orthopedic abnornalities, and podiatric skin and nail conditions.
Results The children's shoes were evaluated as to proper fit and wear. Of the screening population of 836 preschool 634 AJPH JUNE, 1975, Vol. 65, No. 6
children, 631 youngsters presented properly fitted shoes with normal wear. This represented 75 per cent of the children evaluated; however, 205 youngsters or 25 per cent of the population screened wore poorly fitted or excessively worn footgear (Table 1). Those children with improper footgear were then compared with those children found to have properly fitted footgear. As can be seen in Table 1, there are no significant differences in foot pathology for the two groups. Children free of foot pathology were few (Table 1). For both groups of children, there is a high amount of gait problems and pronation. Additionally, no differences in foot pathology were noted between males and females. The only difference noted in this study of proper footgear was that children with no foot pathology were 3 times as likely to have properly fitted footgear.
Discussion The difference Cole noted between males and females was not found in this study. It would appear that the difference noted by Cole may have been the result of foot fashion in1959 and that his study dealt with an older age group of children. The results indicate that an extremely high percentage of Head Start children have some foot pathology. In fact, only 85, or 10 per cent, were found to be free of foot disease. This parallels other findings of a higher prevalence of pathology among low income children.7 Those findings were significantly higher than findings of foot pathology in children from higher income levels.6 Our initial impression, that we would find a larger percentage of foot pathology among children with improper footgear, was not supported by our results. Only one area still remains in question-that of being free from foot pathology. In this one area, it appears that improper footgear impedes the likelihood of being free from foot pathology. While this remains a clear possibility, there remains one other possibility. The alternative hypothesis is that foot pathology causes excess wear for at least some children in this group.
TABLE 1-Correlation between Fit of Footgear and Foot Pathol-
ogy* Properly Fitted Footgear Pathology Abnormal gait pattern
Bowleg/knocknee Pronation in static stance Subcutaneous nodules/masses Over/underlapping toes Dermatophytosis Contact dermatitis Nail pathology Corns Calluses Hallux valgus No pathology
Improper Footgear
No.
%
No.
%
298 123 436 8 135 9 9 5 27 14 24
47 20 69 2 21 1 1 1 4 2 4 12
104 46
5 22 80 2 15 2 1 6 7 4 4 4
77
165 5 31 3 1 13 15 9 9 8
* Each child may have more than one disease entity, accounting for a total higher than 836.
One final comparison needs noting. Data from the National Center for Health Statistics show the podiatry visits by income.8 There is a direct correlation between family income and podiatric visits, a situation identical to that in dentistry. We see, then, a similar situation for Head Start children in podiatry and dentistry. In both areas, for the poor there is a demonstrated increase in pathology and a decrease in doctor visits. Both the dentist and the podiatrist have in common the fact that each practitioner, particularly when treating children, is engaged in a preventive practice. Just as the dentist can intercept small cavities and repair pathology, so can the podiatrist intercept podiatric and related pathology in children.
As is the case with so many other conditions, low income groups seem to be more susceptible to foot pathology. As is also the case, the poor have less access to proper care for this pathology. While further work would seem to be in order, particularly for adults, this study suggests that poverty and foot pathology are correlated. In an advanced society, where prevention is stressed in medicine, it appears that the foot has been neglected. The children from low income homes have enough obstacles in their path without the addition of foot problems. If podiatric care can reduce the foot pathology in poverty areas to the level found in other areas of our society where preventive podiatric care is available, the benerits to society would far outweigh the costs. Preventive care can no longer be thought of as a luxury, but must be afforded equitably to all segments of society.
References 1. Bier, E. H. One Thousand and Ninety-seven Children Given Foot Examinations. J. Am. Coll. Orthop. 8:2536, 1969. 2. Cole, A. E. Foot Inspection of the School Child. J. Am. Podiatry Assoc. 49:446-454, 1959. 3. Shapiro, J., and Rhee, C. S. Podiatry Screening Project for Children in the District of Columbia. Public Health Rep. 85:803-808, 1970. 4. Kirielis, R. W. How the Lubbock School Health Council Organized to Meet the Health Needs of Students. J. Sch. Health 24:133-135, 1954. 5. Gamble, F. 0. Report on Foot Surveys. J. Natl. Assoc. Clin. 42:43, 1952. 6. Greenberg, F. A Report of Foot Examinations of School Children. J. Am. Podiatry Assoc. 53:508-509, 1959. 7. Brunswick, A., and Josephson, E. Adolescent Health in Harlem. Am. J. Public Health (Suppl.) 62, 1972. 8. Wilder, C. S. Family Use of Health Services. National Center for Health Statistics, Ser. 10, No. 55, 1969.
Conclusions For this group of children screened in Harlem, it appears that improper footgear was of little consequence, with the possible exception of the correlation between properly fitted footgear and the absence of any foot pathology. It also appears that sex differences are not identified at this early age as contributing to foot pathology.
Dr. Rosenstein is Associate Professor, University of Oregon Dental School, Division of Extramural Programs, Portland, Oregon. Dr. Baerg is Vice-President and Dean, California College of Podiatric Medicine, San Francisco, California, Drs. Gastwirth and Fox practice in New York,
New York. This paper was presented to the Podiatric Health Section at the annual meeting of the American Public Health Association, San Francisco, California, on November 6, 1973.
Editor's Note: The articles which appear in PUBLIC HEALTH BRIEFS have been condensed by the authors for publication in the American Journal of Public Health. An extended version of each report published in this Journal Department is on file at APHA headquarters. Single copies of the extended version are available for a limited period of time from the American Journal of Public Health, APHA, 1015 Eighteenth Street, NW, Washington, DC 20036. When requesting the extended report, please cite the title of the published article, name of principal author, and -the AJPH issue in which the condensed report appeared in PUBLIC HEALTH BRIEFS.
PUBLIC HEALTH BRIEFS 635
HEALTH
*I-1
A Podiatric Health Screening in Harlem DAVID 1. ROSENSTEIN, DMD, MPH RICHARD BAERG, DPM, MPH GLENN GASTWIRTH, DPM JOSEPH FOX, DPM
Introduction A high percentage of children of all age groups are afflicted with some degree of foot pathology.1 Cole, in his study, found that of 1080 children examined, 528 had improper footgear.2 He did not correlate that number with associated foot abnormalities, but found a higher incidence of improper footgear in females. Shapiro and Rhee found that a significantly higher proportion of girls were weanrng unsatisfactory footgear, and a higher percentage had related postural and orthopedic problems.3 Other studies have also found a large number of improperly fitted footgear, as well as a high amount of foot pathology.46 Of the studies that have been done in the past, no attempt to relate foot pathology to independent variables has been made. In this study of the children of Harlem, we examined the following three independent variables and studied their. effects on foot pathology: properly fitted footgear, sex, and income.
Methodology On May 8, 1972, 836 preschool children from 33 Head Start centers in Harlem were screened for possible foot pathology by the podiatric medical staff of the New York College of Podiatric Medicine. The 836 children represented approximately 50 per cent of all Head Start children in the Harlem Community. All of the children were in the 2- to 6-year-old age group and were from the same socioeconomic background. The children were examined for evaluation of footgear, gait, postural and podiatric orthopedic abnornalities, and podiatric skin and nail conditions.
Results The children's shoes were evaluated as to proper fit and wear. Of the screening population of 836 preschool 634 AJPH JUNE, 1975, Vol. 65, No. 6
children, 631 youngsters presented properly fitted shoes with normal wear. This represented 75 per cent of the children evaluated; however, 205 youngsters or 25 per cent of the population screened wore poorly fitted or excessively worn footgear (Table 1). Those children with improper footgear were then compared with those children found to have properly fitted footgear. As can be seen in Table 1, there are no significant differences in foot pathology for the two groups. Children free of foot pathology were few (Table 1). For both groups of children, there is a high amount of gait problems and pronation. Additionally, no differences in foot pathology were noted between males and females. The only difference noted in this study of proper footgear was that children with no foot pathology were 3 times as likely to have properly fitted footgear.
Discussion The difference Cole noted between males and females was not found in this study. It would appear that the difference noted by Cole may have been the result of foot fashion in1959 and that his study dealt with an older age group of children. The results indicate that an extremely high percentage of Head Start children have some foot pathology. In fact, only 85, or 10 per cent, were found to be free of foot disease. This parallels other findings of a higher prevalence of pathology among low income children.7 Those findings were significantly higher than findings of foot pathology in children from higher income levels.6 Our initial impression, that we would find a larger percentage of foot pathology among children with improper footgear, was not supported by our results. Only one area still remains in question-that of being free from foot pathology. In this one area, it appears that improper footgear impedes the likelihood of being free from foot pathology. While this remains a clear possibility, there remains one other possibility. The alternative hypothesis is that foot pathology causes excess wear for at least some children in this group.
TABLE 1-Correlation between Fit of Footgear and Foot Pathol-
ogy* Properly Fitted Footgear Pathology Abnormal gait pattern
Bowleg/knocknee Pronation in static stance Subcutaneous nodules/masses Over/underlapping toes Dermatophytosis Contact dermatitis Nail pathology Corns Calluses Hallux valgus No pathology
Improper Footgear
No.
%
No.
%
298 123 436 8 135 9 9 5 27 14 24
47 20 69 2 21 1 1 1 4 2 4 12
104 46
5 22 80 2 15 2 1 6 7 4 4 4
77
165 5 31 3 1 13 15 9 9 8
* Each child may have more than one disease entity, accounting for a total higher than 836.
One final comparison needs noting. Data from the National Center for Health Statistics show the podiatry visits by income.8 There is a direct correlation between family income and podiatric visits, a situation identical to that in dentistry. We see, then, a similar situation for Head Start children in podiatry and dentistry. In both areas, for the poor there is a demonstrated increase in pathology and a decrease in doctor visits. Both the dentist and the podiatrist have in common the fact that each practitioner, particularly when treating children, is engaged in a preventive practice. Just as the dentist can intercept small cavities and repair pathology, so can the podiatrist intercept podiatric and related pathology in children.
As is the case with so many other conditions, low income groups seem to be more susceptible to foot pathology. As is also the case, the poor have less access to proper care for this pathology. While further work would seem to be in order, particularly for adults, this study suggests that poverty and foot pathology are correlated. In an advanced society, where prevention is stressed in medicine, it appears that the foot has been neglected. The children from low income homes have enough obstacles in their path without the addition of foot problems. If podiatric care can reduce the foot pathology in poverty areas to the level found in other areas of our society where preventive podiatric care is available, the benerits to society would far outweigh the costs. Preventive care can no longer be thought of as a luxury, but must be afforded equitably to all segments of society.
References 1. Bier, E. H. One Thousand and Ninety-seven Children Given Foot Examinations. J. Am. Coll. Orthop. 8:2536, 1969. 2. Cole, A. E. Foot Inspection of the School Child. J. Am. Podiatry Assoc. 49:446-454, 1959. 3. Shapiro, J., and Rhee, C. S. Podiatry Screening Project for Children in the District of Columbia. Public Health Rep. 85:803-808, 1970. 4. Kirielis, R. W. How the Lubbock School Health Council Organized to Meet the Health Needs of Students. J. Sch. Health 24:133-135, 1954. 5. Gamble, F. 0. Report on Foot Surveys. J. Natl. Assoc. Clin. 42:43, 1952. 6. Greenberg, F. A Report of Foot Examinations of School Children. J. Am. Podiatry Assoc. 53:508-509, 1959. 7. Brunswick, A., and Josephson, E. Adolescent Health in Harlem. Am. J. Public Health (Suppl.) 62, 1972. 8. Wilder, C. S. Family Use of Health Services. National Center for Health Statistics, Ser. 10, No. 55, 1969.
Conclusions For this group of children screened in Harlem, it appears that improper footgear was of little consequence, with the possible exception of the correlation between properly fitted footgear and the absence of any foot pathology. It also appears that sex differences are not identified at this early age as contributing to foot pathology.
Dr. Rosenstein is Associate Professor, University of Oregon Dental School, Division of Extramural Programs, Portland, Oregon. Dr. Baerg is Vice-President and Dean, California College of Podiatric Medicine, San Francisco, California, Drs. Gastwirth and Fox practice in New York,
New York. This paper was presented to the Podiatric Health Section at the annual meeting of the American Public Health Association, San Francisco, California, on November 6, 1973.
Editor's Note: The articles which appear in PUBLIC HEALTH BRIEFS have been condensed by the authors for publication in the American Journal of Public Health. An extended version of each report published in this Journal Department is on file at APHA headquarters. Single copies of the extended version are available for a limited period of time from the American Journal of Public Health, APHA, 1015 Eighteenth Street, NW, Washington, DC 20036. When requesting the extended report, please cite the title of the published article, name of principal author, and -the AJPH issue in which the condensed report appeared in PUBLIC HEALTH BRIEFS.
PUBLIC HEALTH BRIEFS 635
