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Literature Review: Foot Health Barriers for Adults Experiencing

Homelessness in the Urban Setting

Catherine E Hubka

Athabasca University

MHST/NURS 603: Facilitating Inquiry

Dr. Elizabeth Andersen

October 17, 2023

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Abstract

Purpose

A literature review to better understand the physical and psychosocial barriers people experiencing

homelessness face when accessing foot care in an urban setting.

Method

3 databases were used (Journals@OVID Full Text, CINAHL Plus with Full Text, and ProQuest Nursing &

Allied Health Source) to obtain 19 articles related to foot health in homeless populations. Recent

international sources were obtained with a focus on 18 to 64-year-old homeless individuals. Diabetic

ulcers were excluded.

Results

Central categories discussed are: 1) foot health of people experiencing homelessness (risks and

benefits), 2) barriers to accessing urban health care (physical and psychosocial), 3) perspectives of

people experiencing homelessness towards accessing health services (general health and foot care), and

4) perspectives of health care professionals towards foot care services for people experiencing

homelessness

Discussion

Physical barriers have been adequately explored though resolution to these barriers is slow. Findings on

psychosocial barriers are limited and self-esteem related. Further research into these barriers using

Roy’s adaptation model is purposed.

Keywords: People experiencing homelessness, foot health, foot care, barriers, urban, adults, Roy’s

adaptation model, literature review

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Literature Review: Foot Health Barriers for Adults Experiencing

Homelessness in the Urban Setting

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, 2019). 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, 2019; Mullins et al., 2022; Schaffer et al., 2000;

Schoon et al., 2002).

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 literature review is to understand the current knowledge of

psychosocial and physical barriers for foot health among adult homeless populations in an urban setting.

Method

Sourced Literature
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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 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

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
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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.

Results

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.

PEH Foot Health

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

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,

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). 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
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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.

Perceptions of PEH Towards Accessing Health Care

General Health Care Access

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 contact (Schaffer et al., 2000), and clinic hours (Kirby & Nielsen, 2023). Thomas

(2019) obtained reports of PEH only attending ED when they are extremely sick 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
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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. (2020) 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

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, 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
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PEH have when they do expose their feet. Porter-Ogrady (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).

Theory and Study Proposed

Roy’s adaptation model (see Appendix C 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 research study would be ideal

to empower the clients and understand the psychosocial views of the population (Campbell et al., 2021).

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, October 2023). 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).

Conclusion

PEH have well documented cases of poor foot health and physical or external barriers

preventing access to footcare. This literature review explored foot health of PEH, barriers to care, and

perceptions of both PEH and the HCP related to foot health. 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
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decreased mobility with amputations (D’Souza et al., 2022). Roy’s adaptation model is proposed to

address this gap in knowledge of psychosocial barriers to foot care. If HCP’s can better understand

personal views of PEH, adapted programs and attitudes could be a result.

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References

Bhattacherjee, A. (2012). Social science research: Principles, methods, and practices (2nd ed.). Textbooks

Collection. Book 3. http://scholarcommons.usf.edu/oa_textbooks/3

Campbell, D.J.T., Campbell, R.B., DiGiandomenico, A., Davidson, M.A., McBrien, K., Booth, G.L., &

Hwang, S.W. (2021). Using a community-based participatory research approach to meaningfully

engage those with lived experience of diabetes and homelessness. BMJ Open Diabetes Research

& Care, 9(1). https://doi.org/1-10. 10.1136/bmjdrc-2021-002154

Christensen, S. & McKelvey, M. (2021). Sight and Sole: Partnering to Enhance the Health of the New

Britain Homeless. Journal of Higher Education Outreach and Engagement, 25(2). 163-175.

Cochrane, A., Pithia, P., Laird, E., Mifflin, K., Sonley-Long, V., & Batt, A.M. (2019). Investigating the

Attitudes of Canadian Paramedic Students towards Homelessness. International Journal of

Caring Science, 12(3). 1781-1787.

D’Souza, M.S. & Mirza, N.A. (2022). Towards Equitable Health Care Access: Community Participatory

Research Exploring Unmet Health Care Needs of Homeless Individuals. Canadian Journal of

Nursing Research, 54(4). 451-463. https://doi.org/10.1177/08445621211032136

D’Souza, M.S., Mirza, N., & Karkada, S.N. (2021). Development of a foot care model to determine the

risk of foot problems among homeless adults in Canada. Health & Social Care in the Community,

29(5). e214-e223. https://doi.org/10.1111/hsc.13271

Darbyshire, P., Muir-Cochrane, E., Fereday, J., Jureidini, J., & Drummond, A. (2006). Engagement with

health and social care services: Perceptions of homeless young people with mental health

problems. Health and Social Care in the Community, 14(6). 553-562.

https://doi.org/10.1111/j.1365-2524.2006.00643.x
 12

Gray, M & Beuscher, T. (2021). Commentary: Social Determinants of Health and Its Impact on Wound,

Ostomy, Continence, and Foot and Nail Care. Journal of Wound Ostomy & Continence Nursing,

48(1). 75. https://doi.org/10.1097/WON.0000000000000733

Graveland, B. (2022, December 19). 'Perfect storm' of inflation, high prices driving more into

homelessness, say advocates. CBC News. https://www.cbc.ca/news/canada/calgary/calgary-

homelessness-prices-inflation-1.6691068

Homeless Hub (n.d) Rural Populations & Northern Communities [Webpage]. Retrieved October 13, 2023,

from https://www.homelesshub.ca/about-homelessness/population-specific/rural-populations-

northern-communities

Kale, N.N., Marsh, J., Kale, N.K., Miskimin, C., & Mulcahey, M.K. (2021). Musculoskeletal Injuries and

Conditions Among Homeless Patients. Journal of the American Academy of Orthopaedic

Surgeons. Global Research & Reviews, 5(11). E21.00241. https://doi.org/10.5435/JAAOSGlobal-

D-21-00241

Keegan, R. (2017). Washing the feet of the homeless: The service project that changed me. Nursing,

47(6). 46-48. https://doi.org/10.1097/01.NURSE.0000516221.31896.d4

Kelechi, T.J. (2023). Shoud Social Determinants of Health Shape Our Wound, Ostomy, Continence, and

Foot Care Clinical Research Agenda’s. Journal of Wound Octomy Continence Nursing, 50(5). 363-

364. https://doi.org/10.1097/WON.0000000000001015

Kirby, J. & Nielsen, L.W. (2023). An Ethics-informed, Policy-based Approach to the Management of

Challenges Posed by Living-at-Risk, Frequent Users of Emergency Departments. Canadian

Journal of Bioethics, 6(1). 44-55. https://doi.org/10.7202/1098557ar

Lashley, M. (2007). Nurses on a Mission: A professional Service Learning Experience with the Inner-City

Homeless. Nursing Education Perspectives. 28(1). 24-26.

 13

Louis, J.K. (2019). Application of Roy's adaptation model to the management of a patient with Pancreatic

Ductal Adenocarcinoma. Singapore Nursing Journal, 46(1),12-19.

Martins, D.C. (2008). Experiences of Homeless People in the Health Care Delivery System: A Descriptive

Phenomenological Study. Public Health Nursing, 25(5). 420-430. https://doi.org/10.1111/j.1525-

1446.2008.00726.x

Mcenroe-Petitte, D.M. (2020). Caring for patients who are homeless. Nursing, 50(3). 24-30.

https://doi.org/10.1097/01.NURSE.0000654600.98061.61

Muirhead, L., Roberson, A.J., & Secrets, J. (2011). Utilization of foot care services among homeless

adults: Implications for advanced practice nurses. Journal of the American Academy of Nurse

Practitioners, 23(4). 209–215. https://doi.org/10.1111/j.1745-7599.2011.00598.x

Mullins, R.M., Mannix, R.E., Marshall, N.J., & Lewis, V.J. (2022). Responding to foot health needs of

people experiencing homelessness: the role of a publicly funded community-based podiatry

service. Journal of Foot and Ankle Research, 15(15). 1-11. https://doi.org/10.1186/s13047-022-

00518-7

Porter-O'Grady, T. (2021). Wound and foot care nursing on the streets of the city: A view from here.

Journal of Wound Ostomy & Continence Nursing, 48(1), 69.

https://doi.org/10.1097/WON.0000000000000731

Schaffer, M.A., Mether, S., & Gustafson, V. (2000). Service learning: A strategy for conducting a health

needs assessment of the homeless. Journal of Health Care for the Poor and Underserved, 11(4).

385-399. https://doi.org/10.1353/hpu.2010.0746

Schmidt, K. (2023). Hope for Soles: Ministry from the Feet Up. Journal of Christian Nursing, 40(1). 14.

https://doi.org/10.1097/CNJ.0000000000001021
 14

Schoon, P., Champlin, B., & Hunt, R. (2012). Developing a sustainable foot care clinic in a homeless

shelter within an academic-community partnership. The Journal of nursing education, 51(12).

714-718. https://doi.org/10.3928/01484834-20121112-02

Statistics Canada. (2023, January 2). Homelessness Statistics in Canada for 2023. Made in Canada.

https://madeinca.ca/homelessness-statistics-canada/

Sturman, N. & Matheson, D. (2020). ‘I just hope they take it seriously’: homeless men talk about their

health care. Australian Health Review, 44(5). 748-754. https://doi.org/10.1071/AH19070

Thomas, D. (2019). Homeless Hope: a voluntary, nurse-led organisation working to educate and support

people sleeping rough. British Journal of Community Nursing, 24(12). S18-S21.

https://doi.org/10.12968/bjcn.2019.24.Sup12.S18

To, M.J., Brothers, T.D., & Zoost, C.V. (2015). Foot Conditions among Homeless Persons: A Systematic

Review. PLOS ONE, 11(12). e1067463. https://doi.org/10.1371/journal.pone.0167463

World Health Organization (n.d). Social determinants of health. W.H.O. Retrieved October 13, 2023,

from https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

Appendix A: Inclusion/ Exclusion Criteria
ARTICLES INCLUDED
Focus on experiences of health care professionals
related to footcare for PEH.
Articles between 2004 - 2023
Written in English
Focus on overall foot health for PEH
Qualitative experiences related to people
currently homeless accessing health care.
PEH age range of 18-64 years of age
Challenges and barriers preventing regular foot
care for PEH
Focus on service-learning related to foot care
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ARTICLES EXCLUDED
Focus on experiences of health care
professionals with PEH and no relation to foot
health.
Articles older than 2004, unless deemed highly
relevant
Written in non- English language
Focus is Diabetic foot wounds in a population
with access to stable housing.
Transitions out of hospital or into long term care
facilities
Focus on PEH ages <17 years and >65 years.
Focus on treatments of specific foot issues.
Focus on service-learning with no mention of
foot care.
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Appendix B: Definitions

1. Gangrene: ” local death of soft tissues due to loss of blood supply”

2. 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”

3. 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”

4. Osteomyelitis- “an infectious usually painful inflammatory disease of bone often of bacterial

origin that may result in the death of bone tissue”

5. Service-Learning- health care professional students learning through active partication in

community work with marginalized or underserved populations (Lashley, 2007)

6. Tinea pedis- Ringworm infection of the feet, otherwise known as “Athletes foot”

7. Trench foot: See imersion foot

Unless, otherwised cited, definitions obtained from

https://www.merriam-webster.com/dictionary/
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Appendix C: 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)