Perla Zarate Abbott
University of the Incarnate Word
University of the Incarnate Word
The concept of social justice emphasizes the need for the basic essentials of life, including health care, for all. Catholic social teaching confirms this with the principles of human dignity, common good and community, and option for the poor and vulnerable. When health care access and quality is compromised, persons with diabetes experience a greater risk for complications including a higher risk for lower extremity amputations (Centers for Disease Control and Prevention, 2005). Poverty and ethnic minority status are accompanied by health care disparities as reflected in a higher incidence of lower extremity amputation in these groups. (Wachtel, 2005). A foot care program, sponsored by the University of the Incarnate Word’s School of Nursing and Health Professions and St. Philip of Jesus Parish (UIW/SPJ) Health Ministry, works with older, primarily Hispanic, adults to improve self care practices and reduce the risk for amputation. The program involves nurses, nursing students and clients in health promotion relationships. This paper presents the challenges older adults encounter in maintaining healthy feet, the essentials of the foot care program, an initial outcome evaluation and a presentation of the program’s impact on client health and student learning.
Fair treatment in life is the expectation of all persons. Unfortunately, access to the essentials of life is not available to all. The value system that all persons deserve reasonable opportunities for political, economic, and social resources to remedy their situation is called social justice (National Association of Social Workers, 2008). Social justice ensures fundamental rights so persons can remain healthy and empowered. The Catholic Church promotes this value system in its Catholic Social Teaching. Among the major themes of Catholic Social Teaching are preserving the dignity of the human person, common good and the community, and protecting rights and responsibilities especially for the poor and vulnerable (Office for Social Justice, St. Paul and Minneapolis, n.d.). Upholding the sanctity and dignity of human life is a primary principle of social teaching, and ensuring that the community also enjoys this right is essential. This leads to the responsibility of each person to protect the human rights of their family and community.
"Upholding the sanctity and dignity of human life is a primary principle of social teaching..."
Among the fundamental rights that all persons deserve is health care. The United States Conference of Catholic Bishops (1982), following the example of the healing ministry of Jesus, addresses the necessity of assuring quality health care for all persons, and promotes educating the community about health and advocating community improvements in the availability of health care. Following the theme of health education for the community, a university health ministry in South Texas affiliated with a local parish began a foot care program for older Mexican American adults, especially for, but not limited to, persons with diabetes.
The focus of the foot care program is to educate the public about proper foot care and to identify health concerns needing attention. Learning proper foot care can eventually reduce the risk of amputation among persons with diabetes, as problems can be discovered and addressed in a faster timeframe. The foot nurse program also considers the economic status of the population served. The South Central sector of San Antonio, where many of the health ministry’s clients reside, is 82% Hispanic and 34% of the population live below poverty level (2006 Bexar County Community Health Assessment). This increases the risk of lack of adequate health care or access to care for this population. The lack of access to quality care in an impoverished population prohibits optimal glycemic management, magnifying the risk for long term complications. According to Wachtel (2005), poverty is the primary non-biologic factor associated with amputation among persons with diabetes.
"One important relationship concept is dignity (or dignidad)..."
The success of the program is dependent on the relationships of the participants. As Boakari (2006) explains, education requires a relational process between the transmitter and the recipient of information. Thus, behavior change, e.g. adapting self care of feet, is best accomplished in a trusting therapeutic relationship. Many clients of the foot care program are Hispanic. For this population, certain relationship concepts are important for trust to develop between client and health care provider and for health interventions to be successful (National Alliance for Hispanic Health, 2001). One of the principles of social justice is upholding the sanctity of human dignity. Part of ensuring this for the Hispanic client is the approach used to start the health education intervention. One important relationship concept is dignity (or dignidad), which can be upheld by recognizing economic status and making suggestions for improvement of health that are realistic for the Hispanic client (Zarate-Abbott et al., 2008). Other relationship concepts to be considered are respeto and personalismo (National Alliance for Hispanic Health, 2001). Dignity is also upheld by approaching the Hispanic client with respect (or respeto) by using, for example, the third person to address an older Hispanic adult. Included with respect is the manner in which the relationship is initiated, an important factor linked to the concept of personalismo, where the relationship changes from formal to personal. It is important to remember that although the older Hispanic adult looks forward to a less formal relationship with their health care provider, which promotes development of trust, they still desire respect by consideration of their age and prefer being addressed in the third person. By gaining trust through personalismo, the nurse can begin to relate to the Hispanic client in a manner which increases learning because the client feels the nurse respects their culture and is concerned for their well being (National Alliance for Hispanic Health, 2001).
"...60% to 70% of persons with diabetes have symptoms of nerve damage."
Diabetes affects approximately 10.3 million (20.9 %) persons age 60 or older in the United States (Centers for Disease Control and Prevention, [CDC], 2005). In addition, the chance for Mexican Americans is 1.7 times greater to develop diabetes than for non-Hispanic whites. Diabetes increases the risk of heart disease, hypertension, blindness, nervous system disease, kidney disease, and amputation. The American Diabetes Association (n.d.) lists major foot complications associated with diabetes; these include neuropathy, skin changes, calluses, foot ulcers, poor circulation, and amputation. Diabetic neuropathy occurs in approximately half of the diabetic population and involves damage to the nervous system. In particular, nerve damage to the lower extremities occurs. Diabetic neuropathy involves loss of feeling, pain sensation, or temperature differentiation, which can increase the risk of injury to the feet. Ultimately, the risk for amputation also increases. The CDC (2005) estimates that 60% to 70% of persons with diabetes have symptoms of nerve damage. The agency also estimates that more than 60% of non-traumatic amputations occur in persons with diabetes and that neuropathy is highly linked as a contributing factor. As described by Singh, Armstrong, and Lipsky (2005), one of the most important tools for foot ulcer prevention is the Semmes-Weinstein monofilament, which helps assess sensitivity loss to the feet of persons with diabetes. The American Diabetes Association (2003) recommends an annual foot exam including sensation, muscle, circulatory, and skin assessment for persons with diabetes as part of preventive care.
In a study of 776 United States veterans in the Northwest United States, it was found that diabetic neuropathy is one of the risk factors for eventual lower extremity amputation (Adler, Boyko, Ahroni, & Smith, 1999). Insensitivity to monofilament testing was one of the factors associated with increased risk for loss of a lower limb in persons with diabetes (RR = 2.9, odds ratio = 1.1-7.8). Diabetic neuropathy can also affect balance and gait. Bruce, Davis, and Davis (2005) conducted a longitudinal study on two groups of persons with type 2 diabetes in Australia, free of baseline problems with mobility and ability to do activities of daily living. The authors concluded that peripheral neuropathy increased mobility problems by 40% among the participants. In another study of 1,666 participants in Texas, the majority Mexican American, it was found that Mexican American participants with diabetes had a significantly higher rate of amputation than non-Hispanic whites (p = 0.003) (Lavery, Armstrong, Wunderlich, Tredwell, & Boulton, 2003). Mexican Americans had higher rates of amputation than non-Hispanic whites despite similar findings regarding foot infections and ulceration. This may indicate differences in access to health care including specialty services, patient education and compliance, disease severity, or cultural factors.
"Mexican Americans had higher rates of amputation than non-Hispanic whites..."
Although diabetes is a major concern for proper foot care, arthritis can also affect the foot and ability to walk. Lawrence, Felson, Helmick, Arnold, Choi, and Deyo, et.al. (2008) estimate that 27 million adults in the United States have clinical osteoarthritis. The authors also reported that nearly 41% of adults with arthritis had an associated limited activity ability because of the disease. In a longitudinal study of 7,543 older adults without mobility issues at baseline, Covinsky, Lindquist, Dunlop, Gill, and Yelin (2008) found that older adults with arthritis at middle age reported an increase in limited activity as they became older (34%, HR = 2.15, 95% CI = 1.89-2.44). Difficulties in performing usual activities of daily living and walking were found to affect functioning. This raises a major concern for safety and self care ability.
Older adults have an increased risk for falls, a risk which is aggravated by poor foot health. The CDC (2008) reports falls as the primary cause of injury for older adults. In addition, the CDC reports women are more likely to fall than men. In a study of 96 community dwelling older adults, a total of 52 % fell at least once during a period of one year (Berg, Alessio, Mills, & Tong, 1997).
Twenty-nine of the participants reported arthritic symptoms as part of their health history. Trips and slips accounted for more than half of the reported falls. In addition, falling may be related to an eventual loss in functional physical health. A longitudinal health study in Australia of randomly selected women age 70 to 75 years at
initiation, found that falling was a significant factor associated with physical decline (Sibbritt, Byles, & Regan, 2007). The authors found that arthritis was the most common health problem reported by more than 60% of the participants. Additionally, problems with the feet were strongly linked in predicting a person’s eventual physical decline among participants who initially reported being satisfied with their physical ability.
A recommendation for fall prevention among older adults is regular exercise, especially that which focuses on strength and balance. For persons with arthritis, a regular exercise regimen is vital. Range-of-motion, strengthening, and aerobic exercises are recommended to loosen stiff tender joinots (Mayo Foundation for Medical Education and Research, 2006). Among the easiest to perform is the range-of-motion exercises which can be integrated into the daily routine. It is important to recognize that even the most minimal movement is beneficial. In a study of falls among a group of community dwelling older adults, it was concluded that general recommendations for older adult safety should include development of physical abilities to avoid falls (Berg, Alessio, Mills, & Tong, 1997).
"...problems with the feet were strongly linked in predicting a person’s eventual physical decline ..."
The UIW/SPJ Health Ministry foot care program is designed to provide preventive foot
care education and no-cost screenings to Mexican American elders with diabetes living
in the economically disadvantaged area of south San Antonio, Texas. Following evidence-based
protocols using national and state guidelines, the foot care program provides these
services to match the needs of established outreach sites of the health ministry.
The nurses use an educational resource “Feet Can Last a Lifetime” (available in English
and Spanish) to provide specific guidance designed to prevent lower extremity amputation
(U.S. Department of Health and
Human Services, 2003). Other resources, for example, a bilingual handout on fall prevention, are utilized as needed.
The nurse performs an assessment of circulation, sensation (using the Semmes-Weinstein monofilament), skin integrity, and muscle strength. Nursing interventions include cleansing, moisturizing, massage, and, in addition, instruction and demonstration of range-of-motion exercises of the foot and ankle. Appropriate referrals are made for any problems encountered with the client’s feet. Each session with the client concludes with a small incentive gift such as a pair of diabetic socks or moisturizing lotion. Furthermore, special attention is given to cultural aspects of the care, such as guidance on commonly used home remedies and includes the concepts of dignidad, personalismo, and respeto.
The initial goal was to reach approximately 200 individuals at the outreach sites. Repeat assessments would increase client’s knowledge of the purpose of the foot assessments and decrease severity and incidence of diabetes related foot problems. At the end of two years, 311 clients had received an initial foot assessment and care, and the total visits numbered 706.
"Addressing any health care disparity requires a partnership between client and health care provider."
In addition, nursing students from the university assist the foot care nurses as part of their clinical experience in the course Health Promotion across the Lifespan. Beginning with the Fall Semester of 2006, the students were given formal instruction and practice on how to properly perform a foot assessment, teach self care and exercises, and document interventions and referrals. Their clinical experience fit the definition of service learning as an educational strategy for students to learn while they are providing a community service (National Service Learning Clearing House, 2008). As repeated visits by the foot care nurse and students continued, the clients demonstrated knowledge of foot self-care, ultimately decreasing the number of referrals of minor foot problems that are preventable through self-care practices. The foot care nurses are in the process of collecting outcome data to quantify these changes in self care.
Furthermore, the relationship between the nurses and clients at the outreach sites make learning possible. As Boakari (2006) states: “…for social justice to be real, it has to be understood in its essence as a relational requirement…” (p. 1). The interdependency of the nurse and the client is key to the success of the program. Addressing any health care disparity requires a partnership between client and health care provider. As part of the goal to help the elders increase their knowledge and skills regarding self foot care, it is important to recognize that trust is vital. Education and skill demonstration are provided in a bilingual manner, in terms that the client can understand and bilingual resources are also part of the program. Learning can occur as part of the foot assessment sessions and through planned teaching events. The goal is that clients will share what they learn with others at the outreach sites and at home, ultimately increasing the number of self referrals for encountered problems with their feet. This sharing of knowledge and/or abilities is an example of contributive justice.
When the project was in place for nine months, the staff initiated an evaluation of the outcomes of the project to determine if expectations were being met. With University Institutional Review Board approval, a review of existing records was conducted. In addition, the record review also identified the characteristics of the clients served and the incidence and type of foot problems in this population.
"...the client with diabetes has an increased risk for intractable infection and ultimate amputation..."
At the time of the review, 97 individuals had participated in the foot screenings and had received basic foot care from a Health Ministry nurse. The majority of clients were Mexican American elders with a mean age of 73. The age range of 35-95 reflects a few younger clients who requested the services of the foot care nurses. The majority (92%) of clients were women.
A history of chronic illness was frequently reported during the initial assessment. For example, 51 (51%) had diabetes and 62 (65%) had arthritis. A variety of foot problems were identified with the most common being dystrophic or mycotic nails (52%). This finding is significant because dystrophic nails are difficult to cut safely. The presence of arthritis is also a barrier to self care of feet and nails. However, only one fourth of clients had a current podiatrist.
Skin problems on the feet and lower leg were also common. Calluses were observed in 50 individuals (52%) and impairment in skin integrity in 10 (10%). Seven (7%) reported that they had received successful treatment for a foot ulcer in the past. Because the client with diabetes has an increased risk for intractable infection and ultimate amputation and because a history of ulceration increases this risk, knowledge regarding the need to seek care immediately when skin integrity is compromised is critical.
Referrals were required for 26 individuals (27%) so the nurse gave each client a copy of the foot assessment record to give to their primary care provider to request a referral to podiatry. As most of the clients belonged to a Medicare Health Maintenance Organization, the nurses could not refer the clients directly to a provider nor could the client self refer. Managed care systems require that all specialty care be managed by the primary care provider. This practice contributes to health care disparities as individuals able to pay out of pocket or able to afford greater insurance coverage would be more likely to receive podiatry care.
Knowledge of self care practices increased as the records indicated all clients could identify something new that they learned during the initial session with the nurse. New knowledge of foot exercises was identified by 25% of clients while 20% stated they learned to dry between their toes. Keeping the area between the toes clean and dry is important for reducing the risk of fungal infections that favor a warm moist environment. Other clients identified application of lotion “but not between the toes” (20%) and foot massage techniques as new foot care practices (17%).
"Managed care systems require that all specialty care be managed by the primary care provider."
The record review confirmed that the expected outcomes of the project were being met. However, the review also raised additional questions regarding client perceptions of barriers to self care and the benefits of foot care. The documentation form was edited to collect this information. The following three cases illustrate some of the barriers encountered by clients and positive outcomes after intervention by the foot care nurse.
An elderly woman presented for foot care with extremely overgrown toenails which limited her to wearing men’s slippers for comfort. She mentioned she had podiatry care when she lived in another state, but since returning to Texas, she did not. Although not diabetic, severe arthritis prevents her from being able to bend adequately to reach her toes; further, she did not have family members who could help with foot care. She also had long, thick, brittle, discolored toenails, and their size limited what the foot nurse could do with instruments available. She also brought the nurse’s attention to what she described as a “bone spur” on one of her heels, an odd-looking area with occasional discomfort. After numerous recommendations by the foot nurse to ask her primary care provider for a referral, she finally received an evaluation from a podiatrist. The “bone spur” turned out to be a callous, which was shaved down by the podiatrist. Her toenails now look healthy, she is more comfortable, and she plans to continue visiting the podiatrist for care. The foot nurse can now trim her toenails between these visits.
The nurse was supervising nursing students who were assessing the feet of an elderly woman with diabetes. They noticed bony deformities on one foot that were unlike any they had seen before. The woman also complained of difficulty walking which interfered with her ability to be as active as she desired at the senior center. Upon further investigation the team learned that the woman had been diagnosed with Charcot foot a year earlier, but had not been able to take advantage of the treatment option because the co-pay was more than $180.
"...the woman … had not been able to take advantage of the treatment option because the co-pay was more than $180."
Charcot foot is a softening of the bones in the foot. This results from nerve damage caused by the high blood sugars that result when diabetes is poorly controlled. The bones are weakened enough to fracture, and eventually change shape. When the arch collapses, the foot takes on the shape of a rocker-bottom and the person has difficulty walking (American College of Foot and Ankle Surgeons, 2004). The treatment recommended for the client was a Charcot Restraint Orthotic Walker which is essentially a custom-made boot designed to prevent further fractures and enable the patient to walk without pain.
The team was able to obtain funding for the co-pay and assisted with arrangements for the custom fitting of the boot. After 6 months of use, the client reports that she is walking without pain, has decreased swelling and has adjusted well to the use of the boot.
"Spiritual care is also a part of the nursing care provided at the centers."
As part of the routine foot assessment, the nurse asks the clients about current medications. During home visits, the clients frequently show the medication containers to the nurse since it is difficult for some to remember the names and doses. During a visit with an elderly client, the nurse discovered that a client was taking three statins to control her cholesterol, all at the same dose. Apparently, each was prescribed by a different physician. Due to serious potential side effects, the nurse explained to the client that she should consult with her primary physician for clarification. The client’s son-in-law happened to visit while the nurse was there, and the situation was explained to him. As a fire fighter with emergency medical training, he knew the seriousness of the matter. He said he would assist the client in obtaining clarification. Shortly thereafter, the nurse learned that the correct medication at the correct dose was now prescribed. The client and her family expressed gratitude that the error had been discovered.
Spiritual care is also a part of the nursing care provided at the centers. During the preparatory class, the instructor used the example of Jesus washing the feet of the apostles as a model for the service they would provide with humility and respect. (The Gospel of John, Chapter 13). Nursing student Maritza Aguera reflected on this during an interview with a reporter from Conexión, a local community newspaper. She stated that when she saw the image of Jesus on the PowerPoint slide, she realized the significance and value of the foot care program. Maritza described her thoughts at the time: “I remember when I was listening to the lecture about foot care, all I could think was “WASH SOMEONE’S FEET?!” but when I saw the picture of Jesus washing the feet of his disciples, it really touched my heart! After doing foot care for the seniors, I realized that it was truly a blessing to do this!” (personal communication, 2008). For Maritza this service was an excellent way to fulfill the mission of the School of Nursing and Health Professions: “to extend the healing ministry of Jesus Christ, the Incarnate Word …” (School of Nursing and Health Professions, n.d.).
After each clinical day, the students reflected on their experience. They reported witnessing firsthand the health care disparities the seniors experienced. Access to recommended foot care was limited to those who had adequate insurance coverage. Even with insurance, foot care was often not the priority for the health maintenance organization. Under a capitated insurance system, the majority of expenditures might be for cardiac care and medication, leaving little funding for podiatry care. The students also reported noting the lack of basic foot care for seniors who had vision or dexterity problems. They verbalized understanding of the impact of poor foot care on mobility, comfort, and risk for falls, and for those with diabetes, an increased risk for amputation.
"Transportation issues are frequently a barrier to health care access..."
In the summer of 2008, a McNair Scholar chose to work with the foot care nurses to complete a research project. The McNair Scholars Program assists first generation college students in learning skills to prepare them for graduate study. Sarah Salazar, biology major, plans to become a podiatrist and work in her community on the west side of San Antonio. Because her mother has diabetes, she was aware that podiatry services were unavailable in her neighborhood, and she plans to open a practice there to improve access to podiatry care. Transportation issues are frequently a barrier to health care access which leads to disparity in some communities. Sarah also recognized that persons who are disadvantaged economically are less likely to have appropriate foot care education. As Sarah asserts, “Everyone deserves the right to be treated with respect and be given the best advice that a practitioner can give no matter the patient income situation” (personal communication, 2008).
To effectively address health care disparities, one needs to consider three major elements of health care: access, quality, and cost. In the foot care program, access is facilitated because the nurses go where the clients are, either at the senior centers or their homes. The clients receive quality care because the assessment and interventions are evidence based practices. Also, time with the client is relatively unlimited when compared to a standard clinic visit. Time is available for discussion and clarification of questions. Additionally, the quality of care is enhanced by the attention given cultural considerations and language barriers. The care can be provided at no cost to the client because of grants from the Kronkosky Charitable Foundation, Baptist Health Care Services, St. Luke’s Health Care Ministries, CHRISTUS fund and Methodist Health Care Ministries
The success of any effort to address the social injustice of health care disparities is enhanced by the interdependent relationship of client and health care provider. In this case, the health promotion partnership between client and nurse has enriched the experience for both. As the program continues, the nurses receive feedback from clients and learn better ways to accomplish the objectives of the program.
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