All the participants are described in terms of age, duration of disease, foot pain and current footwear usage (Table 1).
Significant statements and meanings emerged from analysis of the transcripts that were identified as factors, which contribute to their health behaviour and choice to wear or not to wear the footwear. These statements were then organised into themes. The analysis revealed two main themes from both the female and male groups. These were the participants' feelings about their footwear and their feelings and experiences of the practitioner/s involved in providing the footwear. Additional themes were revealed from the female participants, which were feelings about their feet, behaviour associated with the footwear, and their feelings about what would have improved their experience.
Theme 1 – Feelings about their feet (female group)
The female participants expressed feelings about how their feet were visibly different from other people who they considered 'normal'. This visibility was identified as being how the feet looked and how they impacted on their ability to walk 'normally' because of the pain. None of the male participants talked about the appearance of their feet. The females had concern for how others see them, the loss of femininity and demonstrated emotions such as frustration, anger, anxiety, loss and sadness, which were expressed both verbally and in the way these statements were said.
".....well it shows in your face...the pain you know...maybe because you are stood on them...makes you self conscious as well...I look and feel like an old lady". Rose
"I can't walk normally... If you shuffle around people notice and (thinks for a time)........it shows in your face...pain shows in your face...makes you look old and I feel ...when I look in the mirror god what must my husband think..." Lily
"I feel and look rubbish most of the time.... I don't feel feminine or sexy any more...especially how my feet look...they look awful...... ". Daisy
Theme 2 – Feelings about their footwear (Female and male group)
Statements and meanings about the footwear itself formed the second theme. In the female group, the negative feelings and emotions about their feet were reinforced by the reaction of 'others' to the footwear. They considered themselves as being visibly different whilst wearing the footwear and this impacted on how they viewed themselves and how they viewed that others saw them. Again, the emotions of shame, sadness, and anger were not only identified as being associated with their feet but also with the footwear.
"The shoes....as soon as I see a person I can say oh yes she's got hospital shoes on..... I compare my boots with other people and they are more feminine and pretty and that makes me feel sad". Daphne
"I think I knew that the shoes had to... well...like...treat my feet...its like wearing a splint....I have some of those for my hands...but shoes are different...they are meant to make you look nice...in my early 20s I used to wear sexy stilettos...no chance now even if I don't walk in them (looked sad)". Carol
"I felt very tearful the first time I had the shoes...humiliated....I would get dressed up and then I feel like a clown... just don't feel dressed...I feel untidy...that makes me angry". Lena
Just one of the male participants made a comment about the visible impact of the footwear and this was in relation to walking speed,
"I can walk faster in these shoes, which is good so I don't hold people up.." Arthur
This response is different than the females, who talked about the visibility of the footwear as an item of clothing. The main focus of the male participants was the construction of the footwear and the fact that it was free.
"I am really pleased with these shoes ...to have a pair of hand made shoes makes you feel great..." Arthur
"... oh this footwear is great...good and strong and my toes are comfy now caus they have soft linings in them ...they're hand made you know." George
Theme 3 – Behaviour with the footwear (female group)
The loss of femininity and how the footwear impacts on the female participants' sexuality was further expressed through how it affects the participants' behaviour. This impact on their behaviour with the footwear became the third theme. This theme was not apparent in the men's dialogue, with no mention of changed behaviour. The female participants, who had chosen to wear the footwear, did acknowledge that it improved their mobility in respect of reducing foot pain. However, it did restrict activities, particularly those perceived as social ones. There was evidence of compromise, with the footwear influencing the types of clothes worn. Trousers were viewed as being more suitable to wear with the footwear rather than dresses.
"I can't complain as I feel my mobility would not be as good with out these...Its important to be mobile and pain free...on a day to day basis they are just about ok...but when I go out I wear other shoes then pay for it after." Rose
"....I don't go out much...I can't get normal shoes on ...I am stuck with these..I can go shopping but I don't go to family do's...that makes me sad". Joan
"Well I suppose that I have a pair of shoes I can wear when things get really bad and at least I have something to put on my feet if I get really desperate... they do restrict what you can wear though, I do tend to wear trousers a lot and I would love to wear a feminine dress..". Maud
"Don't go out much but sometime makes me feel like crying and I panic when I do get an invite 'caus I think oh gosh these boots". Lena
Again the emotions of shame, sadness, and anger were identified as being associated with the impact of this footwear on the females participants' activities in addition to the feelings about their feet and the footwear.
Theme 4 – Feelings about the practitioner (Female and male groups)
Statements and meaning in relation to the participants' feelings about the dispensing practitioner formed the fourth theme. It was expressed that they had trust in the practitioners' skills in the assessment and dispensing of the footwear. Two female participants described the practitioner as being a 'nice person', which was linked to them visibly trying options if there were issues or problems with the fit of the footwear. However, there were several negative attributes identified by the remaining female participants, for example, being dismissive of the patients concerns and having poor communication skills.
"There was no discussion....if fact I don't really think it mattered what I thought ...just said I had difficult feet and that made me feel ashamed". Daisy
"I don't feel there was a two way conversation about what was available and how much say I had in what was going on ...". Daphne
The female participants perceived that the practitioners lacked knowledge about RA, pain and their needs in relation to footwear.
"I think generally there is not much understanding about how rheumatoid arthritis affects the person...well...we are people aren't we ....we are just not a pair of feet we have feeling... and sometimes I feel that they (practitioners) don't understand....". Alison
The recurring expression of the emotions of shame, sadness, and anger were expressed by the females as being associated with the consultation. Additional emotions of guilt and feelings of powerless were also expressed.
"I had chosen two pairs that I liked and after he had measured me he said I couldn't have those and pointed out a pair in the catalogue ... I asked if I could perhaps try the other and he said there was no point as my feet were really bad... made me feel guilty and ashamed". Joan
"I don't need...how can I say? (thinks) sympathy is wrong...it makes me feel...well its not helpful...condescending...its not a positive thing at all...makes me feel pathetic and powerless and now it makes me angry". Yvonne
The nuances of the non-verbal aspects of the therapeutic relationship were perceived as important by the women involved, with the practitioners' body language, such as head scratching or looking concerned, being mentioned as reinforcing these feelings.
"He pulled a face when he saw my feet....that made me feel... ashamed really..... and upset". Lily
The female participants' perception of the practitioners' attitude tended to reinforce the negative view of their foot problems and issues in relation to the footwear. In contrast, there was an air of camaraderie between the male participants and the male practitioners. All the men expressed trust in the skill of the practitioners and described them as 'friendly' and 'nice chaps'.
"The chap that makes them is good at his job...supports Man U (football team) too so we get on great!" John
The male participants did not mention the requirement for the practitioners to have knowledge of their condition. The only negative comment was that two of the participants expressed concern that they got to know one practitioner and then they moved to another hospital. This reflects the known problems with continuity inherent in the contracting arrangements for these practitioners with the National Health Service.
Theme 5 – Feelings about what would have improved their experience (female group)
The female participants were very clear about what would have improved their experience and the statements in relation to this formed the fifth theme. The opportunity for time to consider their options before being referred for the footwear, to have more information on which to base their choices and to be able to voice their opinions were identified by the female participants as factors that would have improved their experience.
" I would have liked more choice as to whether to have the footwear in the first place... I felt I didn't have time to consider whether I wanted it or not....just....well...went along with what the doctor said". Daisy
In addition, knowing that they were being listened to and the feeling of trust in the practitioner were seen as important factors in the consultation.
"It is good to talk to someone who listens even though there is nothing that can be done...if you understand it helps .....trouble shared I suppose and all that....I feel very sad that I wasn't listened to...if I had it might have been better." Maud
"I think that the fitter....well any health person needs to listen to us more...I don't feel I was listened to about the footwear and now I feel guilty that I don't wear them...what a waste...that makes me angry." Yvonne
"Communication is a big word it is a very...you know knowing what's available...that alone ...if I had known what was going on yeah definitely knowing what is available and a two way thing..." Alison
"you assume they know their job but we know our bodies don't we ..I know what will work....and its not just a matter about what will work for our bodies ...it has to feel right.....look right and ...well its more about how we feel in the head isn't it?.." Carol
In contrast the male participants did not mention any aspect of their experience that needed improving. Acknowledgement by the practitioner that the females had unique knowledge of their own disease would have made them feel important and included in the process, would have enhanced their experience and perhaps avoided some of the negative emotions.
