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Research Proposal: Psychosocial Barriers to Foot Health for

Adults Experiencing Homelessness Using Storytelling

Catherine E Hubka

Athabasca University

MHST/NURS 603: Facilitating Inquiry

Dr. Elizabeth Andersen

December 5, 2023
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Abstract
Purpose

A literature review and proposed participatory action research study is discussed to better understand

the psychosocial barriers people experiencing homelessness face when accessing foot care in an urban

setting.

Background

The literature review included recent international sources with a focus on 18 to 64-year-old homeless

individuals. Diabetic ulcers were excluded. A gap in knowledge of psychosocial barriers was identified.

Method

The proposed participatory action research study with a data collection method of storytelling is

recommended out of a large homeless shelter in urban Calgary, Alberta, Canada. The Storytelling

preparation will be guided with the nursing theory of Roy’s adaptation model and the session guided

with knowledge of the “art of listening”. This study has a goal of expanding the knowledge of

psychosocial barriers and continuing the participatory action cycle for eventual service change.

Keywords: People experiencing homelessness, foot health, foot care, barriers, urban, adults, literature

review, participatory research, storytelling, Roy’s adaptation model

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Research Proposal: Psychosocial Barriers to Foot Health for

Adults Experiencing Homelessness Using Storytelling

The amount of people finding themselves without stable housing is increasing in Canada

(Statistics Canada, 2023). Lasting effects from the COVID19 pandemic, housing shortages with rising cost

of living, and the continuous opioid crisis are all factors leading more people to be without a home

(Graveland, 2022). The last report from Statistics Canada (2023) was from 2016 and recorded 235,000

Canadians experiencing homelessness. Social determinants of health (World Health Organization, n.d.)

associated with homelessness include access to affordable care, education/ literacy level, social support,

poor nutrition, affordable housing (Gray & Beuscher, 2021), and income (Kelechi, 2023; Martins, 2008;

Mcenroe-Petitte, 2020). People experiencing homelessness have higher risks of a wide variety of chronic

illnesses, most prominently reported as vascular disease, diabetes mellitus, mental illness, dental, vision,

and foot conditions (Martins, 2008; Mcenroe-Petitte, 2020; Mullins et al., 2022; Schaffer et al., 2000;

Schoon et al., 2012).

Multiple sources report homeless individuals at a higher risk for foot conditions than people in

stable homes (Muirhead et al. 2011; D’Souza et al. 2021; To et al., 2015). They report homeless

individuals sustain a large variety of foot concerns due to violence, prolonged outdoor exposure, poorly

fitted footwear, lack of hygiene, and prioritizing basic needs. These include frostbite, trench foot,

fissures, traumatic wounds, skin/ bone infections, and concerns of pressure and malformations (D’Souza

et al., 2021; Martins, 2008; Muirhead et al., 2011; Mullins, et al. 2022). Researchers also present data

depicting discrimination towards homeless individuals from health care professionals (HCPs) (Cochrane

et al., 2019; Kirby & Nielsen, 2023). This study proposal includes a literature review to understand the

current knowledge of psychosocial and physical barriers for foot health among adult homeless

populations in an urban setting. Following is a proposed participatory action research study to explore

the identified gap in knowledge of psychosocial barriers.

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Background Review

Sourced Literature on Foot Care Barriers

For the literature search I used three databases: Journals@OVID Full Text found 34 relatable

sources, CINAHL Plus with Full Text found 44 sources, and ProQuest Nursing & Allied Health Source

found 17 related sources. After reviewing abstracts, I reduced my sources to twelve, eight, and seven

articles, respectively. Manually reviewing sourced reference lists increased my article selection to 30

total. Key search terms included: homeless OR ‘people experiencing homelessness’ OR ‘housing

insecure’, AND footcare OR ‘foot care’ OR ‘foot health’, AND barriers OR challenges, AND city OR urban

OR metropolitan. To ensure I obtained good coverage of the topic, I used NOT children, NOT elderly,

AND ‘service learning’, and NOT ‘diabetes mellitus’.

Population

To avoid labelling, I will not be using the term the homeless to refer to someone who is

experiencing this life event; people experiencing homelessness (PEH) will be used. For the review, I have

utilized D’Souza’s et al. (2021) definition of PEH as “those who were absolutely homeless (living in the

street with no physical shelter of their own), relatively homeless (living in spaces that do not meet

essential health and safety standards) or staying in an emergency shelter or transitional housing (short -

or long-term accommodation)” (p. e216). Adults ages 18 to 64 years is my focus population due to

prominence of foot problems (Muirhead et al., 2011) and this group being 76% of PEH population

(Statistics Canada, 2023).

Inclusion and Exclusion Article Criteria

Most research completed on foot conditions focuses on diabetes mellitus (DM) and depending

on the study, 6.2-23% of PEH are diagnosed with DM (To et al., 2015). Research is well saturated on DM

foot ulcers, and these articles were excluded if they did not heavily include PEH views. I also excluded

articles focused on service learning or health professional perspectives without data on PEH views or
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foot care. I retrieved international sources dated between the years 2004 to 2023 and written in English.

I recognize the differing political and systemic cultures between countries influence the experience of a

person who is homeless. The volume of articles available in Canada alone is limited to date, so sources

internationally were accepted to provide greater insight into this topic. The summary of my

inclusion/exclusion criteria is presented in Appendix A.

Literature Review Findings

The total number of articles after detailed analysis was 19. Settings of the studies and reports

ranged from United States of America (6), Australia (3), Canada (2), and United Kingdom (1). Keegan,

2017, and Martins, 2008 did not disclose a location. The remaining 5 scholarly sources utilized were

detailed system reviews to capture data from difficult to retrieve sources. Research by D’Souza et al. in

2021 and 2022 conducted in BC, Canada, and Muirhead et al. in 2011 conducted in Connecticut, USA,

found the greatest insights to barriers related to foot health in PEH. Among all the articles, common

concepts were promotion of health, bureaucracy, severity of psychosocial health effects, rapport, bias,

cooperation, fear, trust, pain, shame, community spirit, accessibility, equality, and knowledge

dissemination. Terminology included service-learning, trench foot, immersion foot, tinea pedis,

gangrene, osteomyelitis, and gout which are defined in Appendix B. Central categories included foot

health of PEH, barriers to access urban health care, perspectives of PEH towards accessing health

services, and perspectives of HCPs towards foot care services for PEH. As foot health of PEH is well

established in literature and not the focus of this paper, these findings have been summarized as risks

and benefits in Appendix C.

PEH Barriers Accessing Urban Health Care

Physical

Lack of insurance and low income was an overarching barrier (Muirhead et al., 2011). Low

income directly affects the ability for PEH to afford phones (Darbyshire et al., 2006), medications,
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treatments, footwear, socks, and healthy foods, in turn affecting foot health (Kirby & Nielsen, 2023;

Mcenroe-Petite, 2020; Thomas, 2019). Attending work (Mcenroe-Petite, 2020), “prime begging time”

(Thomas, 2019), lack of childcare (D’Souza & Mirza, 2022; Sturman & Matheson, 2020) impeded

attendance to foot care. Regular treatments of medicated dressings, hot/cold therapy, rest, and wraps

are all unrealistic in this population, making care difficult (Mullins et al., 2022; Thomas, 2019).

Furthermore, footwear and supplies being stolen, lack of sleep and long wait lists (D’Souza & Mirza,

2022) are barriers to foot health.

Psychosocial

Awareness of cost, availability, and the importance of foot programs noted to be a barrier by

multiple sources (D’Souza & Mirza, 2022; Muirhead et al., 2011; To et al., 2015). With a result of 49 % of

PEH not aware of a foot program and 48.4% assuming or not knowing the cost of it (p. 212), Muirhead et

al. (2011) deduced that word-of-mouth was unreliable for disseminating knowledge of services. Mullins

et al. (2022) reported a low 16% of PEH attended their foot clinic was self-referral (p.7). 62% of PEH in

Muirhead’s et al. (2011) study reported embarrassment and shame of the condition of their feet. An

overwhelming response from the other studies have similar reports of this effect on PEH self-esteem

preventing their attendance (D’Souza & Mirza, 2022; Mullins et al., 2022; Porter-O-Grady, 2021; To et

al., 2015; Thomas, 2019). Other barriers included dismissive care, mutual distrust (Sturman & Matheson,

2020), labelling with diagnosis, hasty care, lack of explanations, and non-empathetic staff (Darbyshire et

al., 2006; Mullins et al., 2022). They found PEH valued snacks and food being offered, calm

environments, active listening, and honest, non-judgmental, and meaningful engagement (Darbyshire et

al., 2006; Mullins et al., 2022).

Perceptions of PEH Towards Accessing Health Care

General Health Care Access

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The majority of PEH access an Emergency Department (ED) 1-3 times a year (Martins, 2008). ED

is the main access to care due to lack of easily accessible services due to cost, transportation (Sturman &

Matheson, 2020), client contacts (Schaffer et al., 2000), and clinic hours (Kirby & Nielsen, 2023). Thomas

(2019) obtained reports of PEH attending ED as a last resort with extreme illness due to lack of trust.

Sturman & Matheson (2020) recorded PEH acknowledging the ED being busy and being grateful for life

saving care. Most researchers reported on the PEH feeling invisible, dismissed, disrespected, not

trusted, or stigmatized (D’Souza & Mirza, 2022; Martins, 2008; Sturman & Matheson, 2020).

Footcare Access

D’Souza et al. (2021) reported 72.31% of PEH had foot problems while only 38.5% reported

them (p. e217). PEH reported the ability to wash your feet prior to foot care could help increase foot

care use (Muirhead et al., 2011). Porter-Ogrady (2021) reported most PEH try to complete their own

care to avoid the embarrassment. When PEH did obtain professional foot care, the responses were

resoundingly positive. The responses were human connection, not being judged, giving them hope, and

a feeling of value (D’Souza & Mirza, 2022; Keegan, 2017; Muirhead et al., 2011; Mullins et al., 2022;

Porter-O'Grady, 2021), that “you can’t put a price on” (Thomas, 2019, p. s21).

Perceptions of HCPs Towards PEH and Their Footcare

Volunteering for foot care provided humbling and rewarding interactions with PEH (Keegan,

2017; Thomas, 2019; Schmidt, 2023). HCPs felt “immediate gratification” after improving PEH foot

conditions (Schmidt, 2023). D’Souza et al. (2021) reports assessment of PEH’s feet is not a regular

practice. I found no literature of ED’s assessing PEH’s feet. In general, Kirby & Neilsen (2023) discussed

moral distress being common within ED staff due to high demands, insufficient resources, and non-

emergent needs for PEH. Mullins et al. (2022), Porter- O'Grady (2021), and Schaffer et al. (2000) all

discussed foot care being a good entry point of building trust and hope with PEH in health care.

Service Learning
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Foot care was a common way service learning was implemented. All the articles including

service learning resulted in positive outcomes for the students and respectful encounters with PEH

(Christensen & McKelvey, 2021; Schaffer et al., 2023; Schoon et al., 2012; Thomas, 2019). They reported

students obtained awareness of policy effects, personal growth, critical thinking, and a sense of

responsibility to society. Christensen & McKelvey (2021) reported students being surprised that the PEH

were kind and PEH trusted them.

Discussion

Varying study outcomes reflect the various settings, available resources, and sample sizes. It is

clear that PEH face many challenges to obtain foot care and physical barriers have been well explored.

The feeling of shame and embarrassment of the state of their feet is a prominent finding. Current

research into psychosocial barriers is limited. Considering that a significant percentage of PEH hesitate

to access foot care for these reasons (Muirhead et al, 2011), these barriers are worth exploring. The

need to keep some personal dignity with foot conditions being hidden offers insight into the reactions

PEH have when they do expose their feet. Porter-O'Grady (2021) paraphrased a psychiatrist's response

after the foot care programs effects “significantly” improved mental health interventions and wrote

“perhaps a key route to healing the mind was through treating the feet “(p. 74).

Strengths and Limitations

I utilized 3 databases and obtained a limited number of articles because of this. Using

international articles may make this review less generalizable to Canada. This review did not address

rural communities who are affected by homelessness (Homeless Hub, n.d.). Clinical or program

descriptions provide rich qualitative data, however they lack internal and external validity

(Bhattacherjee, 2012). Most included studies lacked female participants (Muirhead et al., 2011; Mullins

et al. 2022; Schaffer et al., 2000; Sturman & Matheson, 2020).

Studying the Gap in Knowledge

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Roy’s adaptation model (see Appendix D for model images) presents how a human reacts to a

situation through multiple “stimuli” (Louis, 2019). This theory would be useful in understanding how and

why a PEH reacts and behaves when presented with a foot problem. Assessing how PEH personal

relationships; social support; what part they are playing in the situation; their physical and mental

health; and what their values, beliefs, and self-worth are, can aid in the HCP implementing coping

strategies (Louis, 2019). Using RAM theory to implement a participatory action research study would be

ideal to empower the clients and understand the psychosocial views of the target population (Campbell

et al., 2021) to improve barriers to foot care.

Methods

I propose a participatory action research (PAR) study using storytelling (ST) out of one of the

“largest” homeless shelters in Canada, the Drop-In Centre (the DI; Calgary Drop-In Centre, n.d., about

us). PAR is an untraditional research method that is “collaborative, iterative, often open-ended and [an]

unpredictable endeavour, which prioritizes the expertise of those experiencing a social issue” (Cornish

et al. 2023, p.2). Cornish et al. (2023) describe four key concepts including: valuing the participant as the

expert, actions build on knowledge, the research and the process are equally valued, and collaboration

through open and in-depth communication (p.2). This research method can empower work on self-

esteem, accountability, problem solving skills, and confidence (Belaid et al., 2023, p. 5) and can first

improve incidence of poor health outcomes more immediate (p.4). These concepts integrate well with

the theory of RAM, outside of RAM’s goal of implementing a HCP purposed intervention (Masters,

2015). Instead, PAR generally collaborates with the participants and stakeholders to determine the next

steps to continue the cycle of the research (Cornish et al., 2023, p.3).

Participants
The participants of the study will be defined using D’Souza’s et al. (2021) definition of PEH (see

Appendix B or the background portion of this paper). The setting will be requested out of the DI to
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establish access to a diverse urban adult population that is experiencing homelessness. The DI will be a

stakeholder in this research and potentially collaborate in future cycles of this research. The writer has

previous affiliation with this shelter and has no current connections or affiliation at present. The

restrictions for public use of the DI’s services, which will serve as the exclusion criteria, include people

under the age of 18 years and people who have expressed inappropriate or aggressive behaviour to the

staff or other citizens accessing the services (Calgary Drop In Centre, n.d). Excluding youth experiencing

homelessness will reduce the unique variables of this population, including higher rate of mental illness

and being a legal dependent with potential for improved health care access (Darbyshire et al., 2006, p.

554). Persons without capacity or actively under the influence of a substance will be excluded as well,

due to the nature of this research design. Detailed inclusion and exclusion criteria can be reviewed in

Appendix E.

Procedures

Sampling

Convenience and snowball sampling (see Appendix B; Bhattacherjee, 2012) will be

initiated within the DI and other agreeable charitable services in Calgary through flyers and

word of mouth as PEH have limited access to other forms of communication (Darbyshire et al.,

2006; D’Souza & Mirza, 2022). I will collaborate with the DI staff to determine the most

appropriate wording to use and location to post the flyers (GC, 2022, article 3.2). This includes

translating the flyers language to the most common languages used within the posted area.

Collaboration with the health and other services in the DI will be required to achieve a wide

variety and enough participants to achieve data saturation with repeated themes among told

stories. A draft flyer is proposed in Appendix F, with an emphasis on the participants being a part of the

study, not the ones being studied (Cornish et al., 2023).

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Recruitment

Due to lack of available contact methods of PEH, I will collaborate with the DI to determine an

available space and time to accept drop in discussions for potential participants. After an open and

warm welcome, I would confirm the person's eligibility using the studies inclusion criteria. A short

introduction to the PAR, the reason for the research, and an overview of what would be expected of the

participant would commence. Confirmation of any urgent health care needs would be clarified and

redirected to the DI or an urgent health service (I.e. active foot concerns). I would discuss confidentiality

and the honorarium. Safeguarding the participants privacy is essential due to the population's

potential for vulnerability with low socioeconomic determinants (GC, 2022, article 4.7). If the

person is interested in joining the study, the consent would be discussed or completed (see next

section). Recognition of this population's cultural and socioeconomic statuses are critical in forming a

consent (GC, 2022, article 4.7).

Consent

The consent will include clear boundaries of ethical and lawful duty (I.e. compelled disclosure) of

the researcher (GC, 2022, article 5.2) as a participant may or may not be involved in illegal activities or

domestic violence and confidentiality is essential (Martins, 2008; Muirhead et al., 2011, p. 211; Mullins

et al., 2022). Ensuring understanding of the consent requires assessment of language barriers, literacy

level, and proofing the consent form for appropriate language used (GC, 2022, article 3.2). Utilizing

translation services or approved consent videos and verbal consent will be accepted. The risks and

benefits of the PAR study through ST will be included in detail to establish informed consent (see

Potential Participatory Risks; GC, 2022, article 3.2). If the participant needs any accommodation prior to

understanding or reflecting on the consent, it will be signed at another pre-arranged meeting.

Research design
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The art of ST originates from indigenous heritage (Rieger et al., 2023) and is now a useful tool in

qualitative social science research (Cornish et al, 2023, p.6). Rieger et al. (2023) recommends the

researcher is trained to ensure the key concepts of ST remain intact (p.7). Key concepts include the

power of voice, keeping the story whole, participant as the expert, listener as open and present, having

empathetic commitment, and seeking to understand and not critique (LeBlanc-Omstead & Kinsella,

2023; Rieger et al., 2023). In consultation with my institution, I will complete training recommended for

the “art of listening” (Rieger et al., 2023, p. 8). Training will increase my ability to assist participants in

their ST preparation and conduct the data collection without compromising the technique (Rieger et al.,

2023, p. 7). Appendix G contains a list of guided questions, with reflection from RAM, that participant

can use for deciding which story would be most appropriate to share (Cornish et al., 2023; Rieger et al.,

2023). I will collaborate with the participant on details including if any mental health support may be

needed during their ST (Leblanc-Omstead & Kinsella, 2023; Rieger et al, 2023), if audio recording is

acceptable to them or determine another mode of data collection (Rieger et al, 2023), help them

determine a pseudonym or code name for the duration of the research (GC, 2022, chapter 5).

ST can be emotionally taxing for the speaker and adequate time and support is required to

reflect on the repercussions of telling their story (Rieger et al., 2023, p. 11). When the participant has

confirmed they are ready for the next step, the meetings will be held at an agreed time in a private and

quiet setting to avoid interruptions. Tea, water, and healthy snacks will be provided to ensure biological

distractions are reduced and help create an inviting environment (Darbyshire et al., 2006; Rieger et al.,

2023). The participants' age, gender and ethnicity will be collected and coded. It is important for the

listener to avoid guiding or prompting during the ST and rather focus on encouraging elaboration with

non-leading questions, avoiding bias (Rieger et al., 2023). A research assistant will be hired and trained,

including TCPS2 completion, to assist with coordinating meetings, transcribing, and analyzing the
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transcribed data for any clarification. After transcription, the participant (the expert) will be involved in

helping to draw concepts from their own story (Cornish et al. 2023).

A standard honorarium of $20 will be given to the participant to compensate them for their time

and is based off Alberta’s minimum wage being $15/hour (Campbell et al., 2023, p.8; Government of

Alberta, n.d.). This compensation will not reflect the exact time spent preparing and telling their story as

this will vary between participants and the honorarium should not influence the amount of time the

participants takes to reflect or speak. The next step, which will not to be discussed in the initial phase of

this research proposal, would be determined by the participants and stakeholders following the PAR as a

cyclic process (Cornish et al., 2023).

Data Management

During the study, the transcribed data will be stored in the institutions' encrypted network

drives (GC, 2022, article 5.4). The audio recordings will be stored in a locked file cabinet at the DI and

only the research assistant, and I will have access to the drawer. Participants will have access to their

own recordings and interpretations upon request (Rieger et al., 2023). The data once processed will be

shared with the stakeholders and again, the participants. For storage, I will use the FAIR principles (GC,

n.d.a): using a “unique and persistent identifier”; ensuring the data is stored long term in a verified

repository (GC, 2022, article 5.4) for minimum of 5 years (GC, n.d.b); the interpreted data is readable;

coding is accurate to reflect transferability if possible (Mash, 2014). Collecting demographics of the

participants will be coded. This proposed data management plan is a living document and with any

changes, the Research Ethics Board assigned to this study will be notified.

Potential Participatory Risks

Other risks outside of personal stored data include risks of incidental findings and

traumatization from bringing up past experiences (Leblanc-Omstead & Kinsella, 2023; Rieger et al,

2023). The plan to discuss the potential of these risks prior to the ST is critical in mitigating them (Rieger
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et al., 2023). I will collaborate with the DI facility to discuss support from social work, nursing, or most

appropriate on-site staff to assist as required with a standard debrief for every participant. The setting

for the storytelling will be remotely monitored for both the participant and researcher’s safety if altered

behaviour occurs and the ST needs to stop (Slowther et al., 2006, p.66). Follow up appointments will be

booked a short time after the data collection to continue work on the analysis of the data and ensure

the participant does not have any delayed reactions from ST (Leblanc-Omstead & Kinsella, 2023).

“Compelled disclosure” is a risk for confidentiality in the case of concerns for the “protection of health,

life, or safety” of others, themselves, or the community (GC, 2022, article 5.2).

Proposed study strengths and limitations

Brydon-Miller et al. (2003) explains the nature of PAR leads to more valid results than any other

social science research as the data comes straight from the source and their setting (p. 25). However, all

interpretive methods still require rigour through dependability, credibility, confirmability, and

transferability (Bhattacherjee, 2012, p. 110; Kingsley & Chapman, 2013). This PAR design provides

dependability and confirmability through involving the participant in interpreting their own story and

the story not being paraphrased. Meticulous documentation and receiving training with the “art of

listening” prior to the study should lead to increased credibility. With the use of the translation service

as a third party, this may introduce validity concerns and difficulties in analysis, also an expense. A

limitation to this study may be low transferbility as the expense of completing, transcribing, and

documenting lengthy preparations and ST sessions may be difficult to obtain a large amount of

participants (Mash, 2014; Rieger et al., 2023, p.11-12).

Moral responsibility, trustworthiness, integrity, documentation, and follow through action are

all key concepts in PAR rigour (Kingsley & Chapman, 2013). These values align with the emancipatory

science that PAR is described as by Cornish et al. (see Appendix B; 2023) and with ST as the design,

critical reflection of the data will be required prior to any emancipatory action with the stakeholders
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(p.10). Another possible limitation is mortality threat (participants dropping out of the study;

Bhattacherjee, 2012, p.85) due to the transient nature of the population and often lack of available

contacts (Darbyshire et al., 2006). Participant engagement and the offer of the small honorarium

may assist with this threat.

Conclusion

PEH have well documented cases of poor foot health and physical barriers to access footcare.

After exploration of foot care barriers, a lack of understanding for psychosocial barriers was found and I

presented a study proposal for discovering PEH emotional and psychosocial experiences with their foot

health. Through participatory action research out of a prominent urban homeless shelter, sharing in

participants stories we hope to understand the internal and social barriers to PEH foot care. Currently

PEH are attempting to complete foot care themselves to avoid shame or due to multiple barriers

(Porter-O'Grady, 2021). This delay results in accessing the ED for emergent foot care and increasing risks

of serious illness and permanent decreased mobility with amputations (D’Souza et al., 2021). This

research has the potential to lead to a change invoked by the experts of this issue, the people

themselves (Cornish et al., 2023).

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Appendix A: Inclusion/ Exclusion Criteria of Articles Used

ARTICLES INCLUDED ARTICLES EXCLUDED

Focus on experiences of health care professionals Focus on experiences of health care
related to footcare for PEH. professionals with PEH and no relation to foot
health.
Articles between 2004 - 2023 Articles older than 2004, unless deemed highly
relevant
Written in English Written in non- English language
Focus on overall foot health for PEH Focus is Diabetic foot wounds in a population
with access to stable housing.
Qualitative experiences related to people Transitions out of hospital or into long term care
currently homeless accessing health care. facilities
PEH age range of 18-64 years of age Focus on PEH ages <17 years and >65 years.
Challenges and barriers preventing regular foot Focus on treatments of specific foot issues.
care for PEH
Focus on service-learning related to foot care Focus on service-learning with no mention of
foot care.
 23

Appendix B: Definitions

1. Conenvience Sampling - “a sample is drawn from that part of the population that is close to hand,
readily available, or convenient” (Bhattacherjee, 2012, p.69)
2. Emancipatory science- “PAR an emancipatory form of scholarship ... driven by interest in tackling
injustices and building futures supportive of human thriving, rather than objectivity and neutrality. It
uses research not primarily to communicate with academic experts but to inform grassroots collective
action “ (Cornish et al., 2023, p. 2)
3. Gangrene: ” local death of soft tissues due to loss of blood supply”
4. Gout: “a metabolic disease marked by a painful inflammation of the joints, deposits of urates in and
around the joints, and usually an excessive amount of uric acid in the blood”
5. Imersion foot: “a painful condition of the feet marked by inflammation and stabbing pain and followed
by discoloration, swelling, ulcers, and numbness due to prolonged exposure to moist cold usually
without actual freezing”. Medical term for “trench foot”
6. Osteomyelitis- “an infectious usually painful inflammatory disease of bone often of bacterial origin that
may result in the death of bone tissue”
7. People experiencing homelessness- “those who were absolutely homeless (living in the street with no
physical shelter of their own), relatively homeless (living in spaces that do not meet essential health and
safety standards) or staying in an emergency shelter or transitional housing (short - or long-term
accommodation)” (D’Souza et al., 2021, p. e216)
8. Service-Learning- health care professional students learning through active partication in community
work with marginalized or underserved populations (Lashley, 2007)
9. Snowball sampling - “start by identifying a few respondents that match the criteria for inclusion in your
study, and then ask them to recommend others they know who also meet your selection criteria”
(Bhattacherjee, 2012, p. 70)
10. Tinea pedis- Ringworm infection of the feet, otherwise known as “Athletes foot”
11. Trench foot: See imersion foot

Note: Unless, otherwised cited, definitions obtained from

https://www.merriam-webster.com/dictionary/
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Appendix C: Foot Health Findings in PEH

Risks

Chen (2014, as cited in To et al., 2015) reported foot pain in 56% of their 299-sample population.

Walking as the main mode of transport, with an average of 5 miles to reach needed services (D’Souza &

Mirza, 2022; Keegan, 2017; Muirhead et al., 2011), and often carrying heavy loads negatively affects

PEH’s feet (Mullins et al., 2022). Barshes et al. (2016, as cited in Kale et al. 2021) found failed treatment

of foot osteomyelitis and “major amputation” being significant in PEH (p. 12). Lack of shelter exposes

PEH to biochemical injuries (e.g., frostbite, burns, immersion foot) and decreased hygiene leading to

various infections (e.g., fungal, bacterial, tinea pedis) (D’Souza et al., 2021; Mullins et al., 2022; Porter-

O'Grady, 2021; Sturman & Matheson, 2020). These same researchers reported a lack of correctly sized

footwear and clean and dry socks placing PEH at higher risk for callous related wounds and infections.

Benefits

In contrast when foot health was placed as a priority, Moes (2019, as cited in Mullins et al.,

2022) reported " a reduction in pain as well as improved walking speeds six weeks” after correctly fitted

runners were provided (p. 2). Multiple foot care programs report an increase in trust from PEH and

subsequently an increased use and effect of other health services after foot care services were provided

(Mullins et al., 2022; Porter-O'Grady, 2021; Schmidt, 2023).

 25

Appendix D: Roy Adaptation Model (RAM)

Figure 1. “Diagrammatic representation of adaptive system” (Louis, 2019)

Figure 2. “Person as an adaptive system according to the RAM” (Louis, 2019)

 26

Appendix E: Sample Participant Inclusion/ Exclusion Criteria

Inclusion to the PAR Exclusion to the PAR

18 years of age or older Under 18 years of age
Any language available through translation Participant main language not available through
services translation services
Allowed in the Calgary Drop In Centre (DI) Not welcome in the DI due to previous behaviour
or misconduct
Cognitively intact and not activley using Cognitively impaired or intoxicated to the point
substances to intoxication of not being able to follow direction
Is medicall well enough, requiring maximum care Requires medical attention with admittance to
as outpatient, if any care required the hospital
Able to support the participant through Unable to mentally support the participant with
anticipated retraumatization, if any, with the anticipated re-traumatization and the
available DI supports available supports through the DI
Has a personal foot health experience to share, Has never had personal foot care concerns or
good or bad. interactions to discuss
People who have experienced homelessness People who have not experienced homelessness
defined by D’Souza et al., 2021, p. e216 (see defined by D’Souza et al., 2021, p. e216 (see
Appendix B) Appendix B)
 27

Appendix F: Research Flyer Draft

Are you willing

People to share a Please
Needed: personal story
Come of your foot health?
Share Your We wantof
Story to
know your thoughts about how or why you do or do not access foot care.
Foot Care
Be a Part of Change You Want toWould
What You See
We Welcome: Do:
1) 20 minute private talk
1) People
to see if you can join the study
experiencing homelessness
2) Not use your real name
2) Adults, 18 years
3) Help is available, if you
and older
want, for preparing your story
3) Personal
4) Work with the listener
experiences with foot health
on how you want the story
4) People allowed in
recorded
the Drop-In Centre
5) Personal details will be
removed

If you want to share your story and be a part of change:

Call: 000-000-0000 or come to the Calgary Drop-in Centre for drop in meetings every

Thursday from 10:00 am - 7:00 pm and ask for Catherine Hubka

 28

Appendix G: Guided Questions for Data Preparation

1) What is a personal story about when you could not or didn’t want to get help for a foot

problem? (Rieger et al., 2023)

2) What is a personal story about when you did get help for a foot problem? (Rieger et al., 2023)

3) How does foot health impact or change your life? (Masters, 2015, role function)

4) What were you feeling during your story? (Charisma on Command, 2017)

5) What were your thoughts while your story was unfolding? (Masters, 2015, self concept)

6) What should we take away from your story or what do you think needs to be done to improve

your foot health? (Charisma on Command, 2017; Cornish et al., 2023)

7) Who helped you with foot care access or encouraged you to care for your feet? (Masters, 2015,

interdependence )