This qualitative study achieved insight into these participants experiences on outcomes of orthoses from a service and orthoses user perspective. It also discovered factors that clearly influence outcomes such as the physical, psychological and socioeconomic consequences of living with chronic disease and preconceived expectations of orthotic services and the orthoses.
All participants were diagnosed with what could be considered chronic diseases, such as diabetes. Those who live with chronic disease are more likely to experience increased stress in daily life. This is thought to be associated with the fact that the course of chronic disease can be unpredictable and changes to health can happen on a regular basis with threats to their personal wellbeing, independence and a loss of socioeconomic stability [20, 21, 22].
Service users expressed their personal struggles with chronic disease specifically associated with the deterioration that occurred to their physical health over time and the fears they were not going to be able to fulfil their roles. Male participants talked of the loss of hobbies and careers as a result of their diabetic related co-morbidities. They also referred to the impact of chronic disease on their mental health, one participant talked of how it made them feel down and another talked of the depression that they suffered as a result. These difficulties can often lead to those living with chronic disease to withdraw from social encounters; this includes encounters which may involve treatment and rehabilitation settings, which could have a significant impact on the outcomes of care [20, 23].
Most service users presenting to healthcare providers will invariably hold pre-conceptions about the care they will receive  and these can directly influence the eventual outcomes of care [25, 26]. Therefore, clinicians within orthotic services need to be aware of the importance of managing service user expectations at the outset of treatment. Indeed, Lateef 2011  and have highlighted its relevance in improving outcomes.
The patient/professional relationship was an important aspect of care with some participants talking about how they could have open and honest conversations with their orthotist, where they felt listened to and included in decisions. Research has highlighted the importance of the patient/professional relationship, explaining how a good relationship can even increase the likelihood of adherence with medical interventions  and satisfaction . In relation to prescribed footwear, both Williams, Nester and Ravey (2016)  and Van Netten et al (2017)  identified that effective communication techniques could improve acceptance of footwear as a health intervention and hence outcomes with it. It was also important to users to maintain continuity in their care to allow for open and honest conversations about their requirements. This needs to be considered when thinking of how orthotic services are delivered. Issues related to a lack of continuity have been highlighted in orthotic practice, in an Arthritis Research UK report (2012)  when it was found that only thirty percent of service users were able to see the same practitioner on return appointments leading to patient dissatisfaction with the continuity of care.
Little is known about how patient education is communicated and how successful it is in use of orthoses and improving outcomes. The practice of providing information and expecting immediate change has been thought to create a negative culture of blame for service users as non-compliant . It is now considered that for health education to be viewed as successful it needs to motivate a patient to put the advice provided into practice [34, 35] Arts et al (2014)  highlighted that there is a lack patient information or education when footwear is provided and that it is not simply a knowledge transfer from professional to service user but is a process over time which starts with knowing the patient’s expectations and personal goals.
Participants also expressed dissatisfaction around their current orthotic allowance, which they felt was insufficient. One participant described frustrations around having to utilise her orthotic footwear for both domestic and social situations. A call to action paper for rheumatoid arthritis  found that forty five per cent of trusts only provided patients with one pair of shoes as standard, and a second pair were only offered for specific needs. When considering how most individuals wear different shoes for different life situations this may reflect an inadequate allowance and hence negatively influence the potential for positive outcomes.
Body image is thought to refer to a person’s mental representation of their body and chronic illness is considered to alter a person’s body image . When a visible orthosis is applied to the body it would seem inevitable that this perception of body image could be negatively affected. It has been highlighted by Williams Nester and Ravey  that therapeutic footwear, unlike any other intervention replaces something that is normally worn and is part of an individual’s body image and that footwear has to fulfil both the clinical requirements and social needs. These notions were also revealed within the focus group. Both male and female participants talked of how others would perceive them and their orthosis. Additional factors such as the length of time to receive their orthoses and waits between appointments contributed to dissatisfaction, but there was also gratitude related to the fact the devices did not come with a financial cost to the individual.
When prescribing orthotic devices services should give thought and consideration to the potential impact on body image that the device may have and ways these can be accommodated for service users to increase the likelihood of acceptance and satisfaction and hence outcomes. Some recent work focusing on acceptance of therapeutic footwear expressed the need to employ effective communication techniques to assist patients to be involved in choosing their footwear, rather than passively receive them 
These service users expressed frustrations related to what they felt where lengthy waiting times to receive their orthoses. This appeared to impact heavily on their perception of their quality of care and satisfaction with orthotic services. Waiting times in orthotic services have been highlighted previously. In 2012, the Arthritis Research UK Report  found that seventy five percent of orthotic users were unhappy with the length of time it took to receive their orthoses. Further, NHS England  found waiting times for an initial assessment to orthotic services could extend up to 58 weeks and resulted in dissatisfaction with care. In order to improve outcomes, there is a need to ensure orthotic devices are provided within a timely manner. This however is a challenge in the current climate which means an increased pressure on services combined with a shortage in orthotic services workforce .
Patient satisfaction is a complicated and multifaceted term though commonly used as indicator of quality care . Research into the concept of satisfaction in healthcare has questioned its validity as an outcome and how it may only demonstrate adequate care rather than positive health outcomes. Satisfaction can also be heavily attributed to other factors such as the relationship between service user and professional relationship rather than care received as a whole . This aligns with the what the participants in this study revealed in that they expressed their frustrations but would then talk positively of the treating orthotist. In this study, the participants expressed satisfaction with aspects of their care but not all of their care. All aspects could be considered to influence outcomes and thus need to be considered together to correctly evaluate overall satisfaction .
While the outcome measurements tools viewed during the focus group [17, 18, 19] were considered to be inappropriate for the complexity of these users’ conditions, ascertaining and adjusting the user’s perceptions and expectations prior to the intervention and then goal setting may be the way that outcome can be measured, albeit subjectively. Goals can be identified with patients and developed during the initial stages of treatment in order to create individualised goals and identify any potential barriers they could have in achieving them . However, there needs to be an understanding that these goals may not remain static with an evaluation and readjustment of goals and outcomes over the course of treatment. There is also a need to ensure that outcomes related to orthoses reflect the change brought on by the orthosis alone and different types of tools may be needed for this, this may be where the relevance of disease specific measures or clinical measures are highlighted. The use of validated tools for the disease group may be an effective way in ensuring the area to be measured is recorded accurately. Whilst there is a clear benefit to using technology for collection of outcome measurement in terms of access and visibility of data collected, it may be that certain patient groups would prefer a more traditional approach, and tools/databases which consider this will have more ability to capture as wide an audience as possible.
This study is not without some limitations as the researcher and the environment has the potential to introduce bias . The researcher attempted to deal with this by providing information to the participants about confidentiality and anonymity and also by sharing data with members of the research team. Further, the participant number could be considered to be small. However, the findings are not meant to be generalizable, but more to act as a exploration into a new area .
Based on the results from this study it is clear that further research is needed in relation to developing appropriate outcome measurement tools and methods for people with complex problems and multiple orthotic interventions.