by Dr. Emily Nicholls,
Lecturer, University of Portsmouth, UK
Professor Victoria Robinson,
Director, Centre for Women’s Studies at University of York, UK
Dr. Lisa Farndon,
Podiatric Development Facilitator, Sheffield Teaching Hospitals, UK
Lecturer, University of Portsmouth, UK
Professor Victoria Robinson,
Director, Centre for Women’s Studies at University of York, UK
Dr. Lisa Farndon,
Podiatric Development Facilitator, Sheffield Teaching Hospitals, UK
'Stiletto heels, they can put you in another world. It's how you walk and how you carry yourself.’ (Elizabeth, 80s)
What is it about shoes? From Dorothy’s red shoes in the Wizard of Oz to Cinderella’s glass slippers, shoes are imbued with meaning and significance, with Pond arguing that shoes ‘seem to have the magic power to make you into someone else’ (1985: 13). Stepping into the right pair can even take you to ‘another world’, in the words of 80-year old Elizabeth, a participant in a recent research project* involving patients and foot health specialists in the UK. For many of us, wearing shoes is both a physical, embodied experience and a way to express our self-image and aspects of our identity (Seferin and Van der Linden, 2012, Branthwaite et al., 2013, Farndon et al., 2016). But for those with complex and long-term health conditions, shoe choice may be more intimately bound up with issues of mobility, health, (dis)ability and the ways in which one’s identity is displayed to others and informed by the diverse relationships we have with one another.
Our recent project sought to explore some of the reasons why patients – including those with more complex health needs – may be reluctant to make changes to their shoe choices and may encounter barriers to acting on the advice of podiatrists (Vernon et al., 2011). From bunions and blisters to severe foot pain, deformities and neuropathy, the conditions experienced by those accessing Podiatry Services can have a significant impact on overall health, well-being and mobility, particularly for those with complex health needs who may be at risk of complications, such as amputation. Research shows there is a real correlation between ill-fitting footwear and increased risk of pain, falls, calluses, blisters and ulcers (Parnés, 2007), yet a significant proportion of people with complex health needs wear ill-fitting shoes (Harrison et al., 2007; Silver et al., 2011) and podiatrists and other foot care specialists frequently report difficulties in encouraging patients to make real changes to their footwear. This project brought together a diverse team of researchers previously from the University of Sheffield and expert practitioners from Podiatry Services, Sheffield Teaching Hospitals to explore some of these tensions and consider how they might be resolved in practice.
Our work builds directly on a previous UK ESRC funded project, ‘If the Shoe Fits, Footwear, Identification and Transition’ involving one of the research team (Vicki Robinson), which showed the centrality of footwear to individuals' sense of their embodied identity. This more recent project involved interviews with podiatrists, shoe fitters and their patients; with several of the patient participants taking part in follow-up interviews and completing ‘shoe diaries’ to chart their everyday, lived experiences of choosing and wearing shoes. Some of the patients involved in the study had complex, long-term health conditions and were accessing Podiatry Services alongside receiving support from other services as part of managing conditions such as cancer and diabetes. We noted that these participants were often engaged in complex processes of managing their health, well-being and identities, with shoe choice playing a role in this. For these participants, shoes occupied a dual position as both an aid or impediment to mobility and health yet also a key part of dress and appearance, with shoes often playing a role in how identity as ‘sick’ or ‘well’ was portrayed to others and at times acting as ‘a symbol displayed by owners to reinforce their self-image’ (Gillath et al., 2012: 424).
Several of the participants with more complex health needs prioritised physical comfort over fashion and described a discrepancy between the types of shoes they would like to wear and the types of shoes that they actually wore, as illustrated by Frank, a diabetic in his 50s:
Our work builds directly on a previous UK ESRC funded project, ‘If the Shoe Fits, Footwear, Identification and Transition’ involving one of the research team (Vicki Robinson), which showed the centrality of footwear to individuals' sense of their embodied identity. This more recent project involved interviews with podiatrists, shoe fitters and their patients; with several of the patient participants taking part in follow-up interviews and completing ‘shoe diaries’ to chart their everyday, lived experiences of choosing and wearing shoes. Some of the patients involved in the study had complex, long-term health conditions and were accessing Podiatry Services alongside receiving support from other services as part of managing conditions such as cancer and diabetes. We noted that these participants were often engaged in complex processes of managing their health, well-being and identities, with shoe choice playing a role in this. For these participants, shoes occupied a dual position as both an aid or impediment to mobility and health yet also a key part of dress and appearance, with shoes often playing a role in how identity as ‘sick’ or ‘well’ was portrayed to others and at times acting as ‘a symbol displayed by owners to reinforce their self-image’ (Gillath et al., 2012: 424).
Several of the participants with more complex health needs prioritised physical comfort over fashion and described a discrepancy between the types of shoes they would like to wear and the types of shoes that they actually wore, as illustrated by Frank, a diabetic in his 50s:
‘I have to think about comfort more than anything else. No matter what they look like, even though I don't like them, I still get them if they fit okay’
These findings to an extent challenge the assumption that podiatrists and patients have different – even opposite – priorities and values; moving beyond this dichotomy allows us to recognise that physical comfort and pain reduction may constitute shared priorities that can form a useful starting point for practitioner-patient consultations, particularly for patients with complex needs. However, for those patients who did make considerable changes to their shoe choices, this could be associated with particular costs:
‘It [my shoe choice] says ‘he's disabled’. It says ‘he's disabled and that's what he is’. You see a disabled person but I'm more than that. I'm a person in my own right with thoughts, feelings, ability, strengths, values... I've got intelligence but if you look at my shoes, on looking at my feet it looks like I don't care, it looks like it devalues me as a person’ (Nigel, 40s)
Nigel had at the time of interview been very recently diagnosed with diabetes, and the difficulties he experienced in making various lifestyle changes – such as changing diet - were apparent. In particular, Nigel’s recent adoption of what he called ‘fuddy duddy’ velcro shoes appeared to undermine his sense of himself as a ‘young lad’ and to redefine him as a ‘disabled person’. Shoes were crucially bound up with pride and identity for Nigel, and with his sense of what it means to be a man. The changes he was making to his footwear might be viewed on the one hand as positive steps towards adopting ‘healthier’ footwear, but this came with real consequences including social isolation and withdrawal and a sense that part of his old identity was ‘missing’. This builds on previous research with patients with chronic and long-term health conditions; for example Goodacre and Candy (2011) report that for women with Rheumatoid Arthritis, restricted shoe choice may limit their ability to present themselves to others in the way they desire.
Other participants with complex health needs were more resistant towards making changes to their shoe choices, in part because physical comfort was not always their priority. The emotional, psychological and social aspects of ‘comfort’ were also mentioned, echoing Seferin and Van der Linden’s (2012) point that distinctions can be drawn between physical comfort and psychological comfort:
Other participants with complex health needs were more resistant towards making changes to their shoe choices, in part because physical comfort was not always their priority. The emotional, psychological and social aspects of ‘comfort’ were also mentioned, echoing Seferin and Van der Linden’s (2012) point that distinctions can be drawn between physical comfort and psychological comfort:
‘As long as I feel comfortable, not only just with my feet but inside as well, that's important’ (Megan)
Megan was in her 40s and had experienced a number of health complications, including recently having a stroke. She also suffered from a neuroma – a ‘nerve tumour’ between her toes – and very severe foot pain. Shoes remained an extremely important and central part of Megan’s life, holding an almost transformative power for her in some contexts, where she described stepping into the ‘right’ pair of shoes as giving her bodily confidence and a sense of belonging. Part of her resistance to podiatrist advice around changing her footwear was linked to maintaining a sense of ‘control’ over her body, as she felt this was one of the only areas relating to her health and lifestyle where she could make her own decisions in the face of the numerous other lifestyle changes, medical interventions and treatment programmes required:
‘…with the shoes I just think, no, it's the only thing I feel I can say no or rebel against if I'm honest… whereas everything else I just have to go with what they [medical professionals] say because otherwise I wouldn't be here. Where my shoes are concerned that is the only bit of control I've got’
Whilst Nigel felt that his revised shoe choices redefined him as ‘disabled’, part of the reason that Megan refused to change her shoes was tied to her resistance to be defined by her condition:
‘…with everything that's wrong with me on the inside, the last thing I want is a pair of big shoes that just look so ugly and unattractive that people think ‘oh she's got something wrong with her feet as well’… I had a stroke a couple of years ago and nobody would know. And I don't use walking aids or anything because I just flatly refuse anything like that, so the last thing I want is my shoes to stand out. I don't define myself by my medical condition… I'm me and I just like to carry on as I always have’
Likewise, Colin who was in his early 50s and was undergoing chemotherapy for cancer identified a tension between accepting the constraints that his ‘condition’ put on him and a need to retain a sense of ‘dignity’:
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These examples highlight how shoes occupy a dual and arguably contradictory position as both an aid to mobility (like walking aids and grab rails) yet also a key part of dress and appearance, meaning individuals with complex health conditions may experience tensions and difficulties in their attempts to make shoe choices that provide physical comfort yet also convey their identity in the ‘right’ way to others. It may be that retaining some control over shoe choice through avoiding wearing ‘the grandfather shoes’ allowed participants to feel a sense of dignity and choice in light of the embodied, daily experiences of pain felt in bodies that they themselves defined as a ‘problem’. Such decisions marked a refusal to be defined solely by their medical condition and part of an ongoing process of carrying on ‘as I always have’ despite changes in their health and mobility, as well as an attempt to blend in and minimise the attention drawn to the perceived limitations and ‘problems’ of their own bodies. As Hockey et al. (2013) suggest, footwear can be used as a ‘vehicle’ to provide insights into who we are or – perhaps more importantly - who we want to be; for some of the participants resisting the changes to footwear suggested by podiatrists and continuing to wear the shoes they liked became a tool to resist being read as ‘sick’ or ‘disabled’.
These findings suggest that consideration of some of the ways in which patients’ foot conditions and shoe requirements intersect with long-term, chronic and complex health conditions is extremely important. Clearly, recognising the links between people’s shoes and wider sense of who they are is crucial if podiatrists are to help patients to make sustainable changes to their footwear habits that do not simultaneously have a negative impact on their sense of self and well-being. As part of this, an understanding of the ways in which shoes may work towards constructing or resisting particular types of embodied identity is critical.
These findings suggest that consideration of some of the ways in which patients’ foot conditions and shoe requirements intersect with long-term, chronic and complex health conditions is extremely important. Clearly, recognising the links between people’s shoes and wider sense of who they are is crucial if podiatrists are to help patients to make sustainable changes to their footwear habits that do not simultaneously have a negative impact on their sense of self and well-being. As part of this, an understanding of the ways in which shoes may work towards constructing or resisting particular types of embodied identity is critical.
* This collaborative project was funded through the University of Sheffield's Impact, Innovation and Knowledge Exchange (IIKE) scheme, with a contribution of time, resources and expertise from Sheffield Podiatry Services, Sheffield Teaching Hospitals, UK. The findings of the study have been used to develop an online footwear ‘toolkit’ to assist foot health professionals as part of their training and to inform and develop practice. This website and associated tools and publications have been designed to highlight and explore potential barriers to changing footwear and support practitioners to engage in dialogue with patients to address these barriers in ways that take patients’ preferences, motivations and values into consideration. The full footwear toolkit is available at http://www.sheffield.ac.uk/podiatrytoolkit
References
BRANTHWAITE, H., CHOCKALINGAM, N., GROGAN, S., et al. 2013. Footwear choices made by young women and their potential impact on foot health. Journal of Health Psychology, 18, 1422-1431.
FARNDON, L., ROBINSON, V., NICHOLLS, E, and VERNON, W. 2016. If the shoe fits: development of an on-line tool to aid practitioner/patient discussions about ‘healthy footwear’. Journal of Foot and Ankle Research, 9(17), pp. 1-6.
GILLATH, O., BAHNS, A. J., GE, F., et al. 2012. Shoes as a source of first impressions. Journal of Research in Personality, 46, 423-430.
GOODACRE, L. J. & CANDY, F. J. 2011. ‘If I didn’t have RA I wouldn’t give them house room’: the relationship between RA, footwear and clothing choices. Rheumatology, 50, 513-517.
HARRISON, S., COCHRANE, L., ABBOUD, R., et al. 2007. Do patients with diabetes wear shoes of the correct size? Int J Clin Pract, 61, 1900-4.
HOCKEY, J., DILLEY, R., ROBINSON, V., et al. 2013. Worn Shoes: Identity, Memory and Footwear. Sociological Research Online, 18, 20.
PARNÉS, A. 2007. If the shoe fits…footwear and patients with diabetes. International Journal of Clinical Practice, 61, 1788-1790.
POND, M. 1985. Shoes Never Lie, New York, Berkley Publishing Group.
SEFERIN, M. & VAN DER LINDEN, J. 2012. Protection or pleasure: female footwear. Work: A Journal of Prevention, Assessment and Rehabilitation, 41, 290-294.
SILVESTER, R. N., WILLIAMS, A. E., DALBETH, N., et al. 2011. Choosing shoes: A preliminary study into the challenges facing clinicians in assessing footwear for rheumatoid arthritis patients. Journal of Foot and Ankle Research, 4, O43.
VERNON, W., BORTHWICK, A. & WALKER, J. 2011. The management of foot problems in the older person through podiatry services. Reviews in Clinical Gerontology, 21, 331-339.
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