Independent factors associated with wearing different types of outdoor footwear in a representative inpatient population: a cross-sectional study

Independent factors associated with wearing different types of outdoor footwear in a... Background: Footwear can have both a positive and negative impact on lower limb health and mobility across the lifespan, influencing the risk of foot pain, ulceration, and falls in those at risk. Choice of footwear can be influenced by disease as well as sociocultural factors, yet few studies have investigated the types of footwear people wear and the profiles of those who wear them. The aim of this study was to investigate the prevalence and factors associated with outdoor footwear type worn most often in a representative inpatient population. Methods: This study was a secondary data analysis of a cohort of 733 inpatients that is highly representative of developed nations’ hospitalised populations; 62 ± 19 years, 55.8% male, and 23.5% diabetes. Socio-demographic, medical history, peripheral arterial disease, peripheral neuropathy, foot deformity, foot ulcer history, amputation history and past foot treatment variables were collected. Participants selected the footwear type they mostly wore outside the house in the previous year from 16 types of footwear. Multivariate logistic regression identified independent factors associated with outdoor footwear types selected. Results: The most common outdoor footwear types were: running shoes (20%), thongs/flip flops (14%), walking shoes (14%), sandals (13%) and boots (11%). Several socio-demographic, medical history and foot-related factors were independently associated (Odds Ratio; 95% Confidence Interval)) with different types of footwear. Running shoes were associated with male sex (2.7; 1.8–4.1); thongs with younger age (0.95 for each year; 0.94–0.97), being female (2.0; 1.2–3.1) and socio-economic status (3.1; 1.2–7.6); walking shoes with arthritis (1.9; 1.2–3.0); sandals with female sex (3.8; 2.3–6.2); boots with male sex (9.7; 4.3–21.6) and inner regional (2.6; 1.3–5.1) and remote (3.4; 1.2–9.5) residence (all, p <0.05). Conclusions: We profiled the types of outdoor footwear worn most in a large diverse inpatient population and the factors associated with wearing them. Sex was the most consistent factor associated with outdoor footwear type. Females were more likely to wear thongs and sandals and males boots and running shoes. Overall, this data gives insights into the socio-demographic, medical and other health factors that are related to footwear choice in a large diverse population primarily of older age. Keywords: Footwear, Inpatient, Sex, Arthritis, Neuropathy, Diabetes, Running shoes, Flip flops, Walking shoes, Sandals * Correspondence: alex.barwick@scu.edu.au School of Health and Human Sciences, Southern Cross University, Southern Cross Drive, Bilinga, QLD 4225, Australia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 2 of 8 Background footwear types worn most in the year prior to hospitalisa- Footwear can impact lower limb health and general tion in a large representative inpatient population. This was mobility both positively and negatively across the life- a secondary data analysis of a multi-site cross-sectional span [1]. Different footwear features have an effect on observational study that investigated foot disease in an the biomechanics of standing and gait and hence can in- inpatient population, and has been described in detail fluence musculoskeletal function and dysfunction [2, 3]. elsewhere [24, 25]. Briefly, on one designated study day, all As a result, footwear is of relevance to a diverse range of adult inpatients admitted into hospital for any medical rea- population groups. Certain footwear can contribute to son (except those with cognitive deficits, in maternity and the development of pain [4], complications of diabetes in psychiatric wards) in five public hospitals in Queensland including ulceration [5], and imbalance that increases (Australia) were invited to participate [24]. 883 eligible par- the risk of falls [6, 7]. Accordingly, footwear displaying ticipants were invited and 733 (83%) consented. The demo- certain features are often recommended in the prevention graphic, social determinant and medical history make-up of and management of these conditions in specific popula- this sample has been reported to be highly representative of tions [8–12]. typical inpatient populations present in developed nations Footwear can be classified based on distinctive combina- [24–26]. Self-reported history and foot physical examin- tions of features into types such as sandals and boots [13]. ation was performed using a validated data collection in- Outdoor footwear requires features that protect the foot strument (the Queensland Foot Disease Form) [24, 25, 27]. from the external environment, but has further require- The items contained in this instrument have demonstrated ments to promote lower limb health and mobility. Such at least moderate criterion validity, inter and intra-rater requirements include: adequate width, depth and length to reliability in two different studies [24, 27]. accommodate the foot; a soft, flexible and protective upper; The self-reported explanatory variables were grouped low heel height; stable heel counter and limited available into the domains of socio-demographics (age, sex, indi- torsion for overall shoe stability; adequate outsole grip to genous status, country of birth, socioeconomic status, prevent slipping; and being fit for purpose [1, 12]. Footwear geographical remoteness), medical conditions history (dia- also has individualised psychosocial requirements, as choice betes, hypertension, dyslipidaemia, myocardial infarct, of footwear type is also influenced by sociocultural, psycho- cerebrovascular accident, chronic kidney disease, cancer, logical and other health factors [14, 15]. arthritis, depression, smoking, mobility impairment, vision For some populations complying with recommended impairment), and past foot treatment in the year prior to footwear features can be challenging, such as older people hospitalisation (by podiatrist, general practitioner, special- and those with arthritis. For example, foot deformity may ist physician, surgeon, nurse, orthotist and other) [24, 25]. change the shape of the foot causing difficulty in fitting The clinically-diagnosed explanatory variables were all standard prefabricated footwear [16]. Such constraints in foot-related conditions and obtained following physical footwear choices have also been shown to affect individu- examination, including: amputation history, foot ulcer ality, well-being and quality of life [16]. history (current or previous), peripheral artery disease Some previous research has investigated the outdoor (PAD) severity, peripheral neuropathy and foot deformity. footwear worn by specific patient groups. Those with arth- PAD severity was diagnosed based on a toe systolic pres- ritis have been found primarily to wear athletic or walking sure of < 70 mmHg, as mild (51-70 mmHg), moderate shoes [17, 18] and sandals [17, 19]. However, many people (31-50 mmHg) and critical (< 30 mmHg) PAD [28, 29]. with arthritis [19, 20], diabetes [21, 22], and older people Peripheral neuropathy was diagnosed as the failure to [23] often also wear inadequate footwear including sense a 10-g monofilament on at least two or more plantar thongs/flip flops [19–22] and slippers [22], or even go forefoot sites on one foot [30, 31]. The presence of three barefoot [21, 22]. To our knowledge, no previous research or more of the following in one foot was the basis for the has investigated the outdoor footwear worn in a large diagnosis of a foot deformity: small muscle wastage, bony diverse population and the profiles of those who wear prominence, prominent metatarsal heads, hammer or claw them. Information on the types of people who wear toes, limited joint mobility or Charcot deformity on one certain footwear in a representative inpatient population foot [30, 32]. may provide a starting point for further research into The outcome variable for this study was the self-reported potential causal influences on footwear choices that could footwear type worn most outside in the previous 12 months. be used to guide footwear behaviour change interventions Each participant was presented with a validated footwear in future. type picture chart [13], modified with permission to add drawings of socks only and barefoot (no footwear) options. Methods Participants were asked “from this chart displaying 16 dif- Theaim of this studywas to investigate the prevalence and ferent types of footwear, what is the type of shoes you have factors independently associated with different outdoor worn most outside the house over the past 12 months?” Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 3 of 8 [24, 25]. The chart displayed drawings and titles of walking Table 1 Main outdoor footwear types worn in the previous 12 months shoes, running shoes, oxford shoes, moccasins, boots, ugg boots, high heels, thongs/flip flops, slippers, backless slip- Rank Footwear Type Number % (95% CI) pers, court shoes, mules, sandals, bespoke footwear, socks 1 Running shoe 148 20.4% (17.6–23.5) only, and barefoot [13]. Participants were asked to select 2 Thongs/flip flops 103 14.2% (11.8–16.9) one type of footwear only [24, 25]. 3 Walking shoe 98 13.5% (11.2–16.2) 4 Sandal 95 13.1% (10.8–15.7) 5 Boot 78 10.7% (8.7–13.2) Statistical analysis 6 Oxford shoe 50 6.9% (5.3–9.0) All data were analysed using SPSS 22.0 for Windows (SPSS Inc., Chicago, IL, USA) or GraphPad Prism (Graph- 7 Court shoe 49 6.7% (5.1–8.8) Pad Software Inc., San Diego, CA, USA). Descriptive 8 Moccasin 42 5.8% (4.2–7.7) statistics were used to display all variables. Prevalence with 9 Slipper 20 2.8% (1.8–4.2) 95% Confidence Intervals (95% CI) was evaluated for all 10 Bespoke footwear 12 1.7% (0.9–2.9) footwear outcome variables. Associations between 11 Barefoot 12 1.7% (0.9–2.9) explanatory and outcome variables were analysed using 12 Backless slipper 7 1.0% (0–2.0) univariate logistic regression. All variables achieving a statistical significance of p < 0.2 were included in 13 Ugg boot 6 0.8% (0–1.8) backwards stepwise multivariate logistic regression ana- 14 Socks only 3 0.4% (0–1.3) lysis until only variables reaching statistical significance 15 Mule 2 0.3% (< 0–1.1) remained (p < 0.05) (Unadjusted Model) [24, 33, 34]. The 16 High heel 1 0.1% (< 0–0.9) unadjusted model was then adjusted for age, sex, socio- Total 726 100% economic status and geographical remoteness by entering these variables into the model with the variables remaining in the unadjusted model (Adjusted Model) Thongs/flip flops [24, 33, 34]. Collinearity, goodness of fit, significance, Thongs/flip flops were worn by 14.2% (11.8–16.9) of partic- parsimony and variance were assessed at each step and ipants. Thongs had univariate associations with: age, female found to be acceptable [33, 34]. Cases with missing data sex, second least disadvantaged socioeconomic status, outer were excluded, as the proportion of missing data cases regional residence, arthritis, depression, smoking, mobility was minimal (< 5% in all cases) [24, 33, 34]. impairment, past foot treatment by a podiatrist, peripheral neuropathy, foot deformity and mild and moderate PAD (all, p < 0.05) (Supplementary Table S1). In the adjusted Results multivariate model, thongs were independently associated Table 1 displays the numbers and prevalence (% and 95 with younger age (0.95 per year; 0.94–0.97), female sex (2.0; CI) of each of the 16 different types of outdoor footwear. 1.2–3.1) and the second least disadvantaged socioeconomic Participant characteristics and univariate analyses for group (3.1; 1.2–7.6; all, p <0.05). each footwear type with a prevalence of > 1% are pre- sented in Supplementary Tables S1-S4 (Additional file 1). Walking shoes Table 2 displays the results of the multivariate logistic Walking shoes were worn by 13.5% (11.2–16.2) of the par- regression of unadjusted and adjusted models for each ticipants. Walking shoes had univariate associations with: footwear type. Outdoor footwear types with ≤1% preva- age, cerebrovascular accident, arthritis, mobility impair- lence (backless slipper (1%; 0–2.0), ugg boots (0.8%; 0–1. ment, past foot treatment by a podiatrist, and foot deform- 8), socks only (0.4%; 0–1.3), mules (0.3%; < 0–1.1) and ity (all, p < 0.05) (Supplementary Table S1). In the adjusted high heels (0.1%; < 0–0.9) were not entered into univari- multivariate model, walking shoes were independently asso- ate or multivariate analyses. ciated with arthritis (1.9; 1.2–3.0; p = 0.005). Running shoes Sandals Running shoes were worn by 20.4% (17.6–23.5) of partici- Sandals were worn by 13.1% (10.8–15.7) of the partici- pants. Running shoes had univariate associations with: male pants. Sandals had univariate associations with: age, fe- sex, depression and past podiatry treatment (all, p < 0.02) male sex, smoking and mobility impairment (all, p <0.05) (Supplementary Table S1). In the adjusted multivariate (Supplementary Table S2). In the adjusted multivariate model (OR; 95% CI), running shoes were independently model, sandals were independently associated with female associated with being male (2.7; 1.8–4.1; p < 0.001). sex (3.8; 2.3–6.2; p <0.01). Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 4 of 8 Table 2 Independent factors associated with outdoor footwear type worn most in the past 12 months (Odds Ratios [95% CI]) Risk Factor Unadjusted p Value Adjusted p Value Running Shoes Male 2.65 [1.77–3.95] < 0.001 2.69 [1.79–4.05] < 0.001 Thongs/flip flops Age (year) 0.96 [0.94–0.97] < 0.001 0.95 [0.94–0.97] < 0.001 Female 1.81 [1.15–2.85] 0.011 1.95 [1.23–3.11] 0.005 Socioeconomic status 0.010 0.055 Least disadvantaged 1.00 1.00 Second least disadvantaged 3.22 [1.41–7.33] 0.005 3.05 [1.23–7.56] 0.016 Middle 2.14 [0.98–4.69] 0.057 2.05 [0.90–4.67] 0.086 Second most disadvantaged 2.14 [0.90–5.09] 0.084 1.72 [0.68–4.33] 0.252 Most disadvantaged 1.11 [0.51–2.43] 0.791 1.08 [0.48–2.39] 0.857 Walking shoes Arthritis 2.23 [1.45–3.43] 0.001 1.92 [1.21–3.03] 0.005 Sandals Female 3.52 [2.18–5.67] < 0.001 3.78 [2.30–6.22] < 0.001 Non-Smoker 15.94 [2.19–116.19] 0.006 Overfitted Boots Male 9.35 [4.21–20.73] < 0.001 9.67 [4.33–21.64] < 0.001 Geographic Remoteness 0.008 0.031 Major city 1.00 1.00 Inner regional area 2.47 [1.37–4.44] 0.003 2.57 [1.29–5.13] 0.007 Outer regional area 2.05 [0.93–4.52] 0.074 2.16 [0.92–5.09] 0.078 Remote area 3.05 [1.18–7.91] 0.022 3.38 [1.20–9.53] 0.022 Very remote area 3.04 [1.02–9.06] 0.047 2.84 [0.82–9.89] 0.101 Oxford Shoes Age 1.02 [1.00–1.04] 0.025 1.02 [1.01–1.04] 0.013 Male 6.62 [2.78–15.78] < 0.001 6.73 [2.79–16.20] < 0.001 Court shoes Age 1.04 [1.02–1.06] 0.001 1.03 [1.01–1.05] 0.008 No Smoking History 2.20 [1.13–4.28] 0.020 2.06 [1.04–4.08] 0.039 Past Podiatry Treatment 2.22 [1.18–4.19] 0.014 2.58 [1.32–5.02] 0.005 Moccasins Female 2.13 [1.12–4.05] 0.021 2.00 [1.05–3.83] 0.036 Slippers Male 6.66 [1.52–29.09] 0.012 7.31 [1.65–32.38] 0.009 Chronic kidney disease 4.50 [1.77–11.47] 0.002 3.34 [1.22–9.10] 0.019 Bespoke shoes Past podiatry treatment 9.68 [2.59–36.14] 0.001 13.86 [3.03–63.46] 0.001 Barefoot Age 0.96 [0.93–0.99] 0.018 0.95 [0.01–0.99] 0.010 Peripheral neuropathy 8.84 [2.44–32.09] 0.001 7.51 [1.60–35.22] 0.011 Sex removed from model as all but one person wearing court shoes were female; Missing: Excluded missing cases Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 5 of 8 Boots past foot treatment including by a podiatrist, general prac- Boots were worn by 10.7% (8.7–13.2) of participants. titioner, surgeon, physician, nurse or orthotist, amputation Boots had univariate associations with: age, male sex, history, foot ulcer history, peripheral neuropathy, and foot inner regional, outer regional, remote and very remote deformity (all, p < 0.05) (Supplementary Table S4). In residence, smoking, mobility impairment, past foot treat- the adjusted multivariate model, bespoke shoes were ment by a podiatrist, peripheral neuropathy and foot independently associated with past podiatry treatment deformity (all, p< 0.05) (Supplementary Table S2). In (13.9; 3.0–63.5; p =0.001). the adjusted multivariate model, boots were independ- ently associated with male sex (9.7; 4.3–21.6; p < 0.001), No shoes (barefoot) inner regional residence (2.6; 1.3–5.1, p = 0.007) and No shoes were worn by 1.7% (0.9–2.9) of participants. remote area residence (3.4; 1.2–9.5; p = 0.022). Wearing no shoes had a univariate association with per- ipheral neuropathy (p = 0.006) (Supplementary Table S4). Oxford shoes In the adjusted multivariate model, wearing no shoes was Oxford shoes were worn by 6.9% (5.3–9) of the partici- independently associated with younger age (0.95 per year, pants. Oxford shoes had univariate associations with: 0.01–0.99; p = 0.01) and peripheral neuropathy (7.5; 1.6– age, male sex and being born overseas (all, p < 0.05) 35.2; p =0.011). (Supplementary Table S2). In the adjusted multivariate model, oxford shoes were independently associated with Discussion older age (1.02 per year; 1.01–1.04; p = 0.013) and male Footwear is important to the maintenance of general sex (6.7; 2.8–16.2; p < 0.001). mobility and lower limb health, with some footwear types more recommended than others in the treatment and Court shoes prevention of foot-related disease [1, 17, 35]. This study Court shoes were worn by 6.7% (5.1–8.8) of the partici- sought to describe the outdoor footwear types worn most pants. Court shoes had univariate associations with: age, in the year prior to hospitalisation by a representative female sex, arthritis, history of smoking, mobility impair- sample of adult inpatients, and to investigate the factors ment and past foot treatment by a podiatrist (all, p <0.05) associated with their wear. The most commonly worn out- (Supplementary Table S3). Sex was excluded from multi- door footwear type was running shoes which does fall variate analyses as all but one participant that wore court within footwear recommendations for many pathological shoes were female. In adjusted multivariate analyses, populations [24]. This was followed by thongs/flip flops, court shoes were independently associated with older walking shoes, sandals and boots. Previous studies have age (1.03 per year; 1.01–1.05; p = 0.008), non-smoking also found running shoes, thongs/flip flops, walking shoes history (2.1; 1.04–4.08; p = 0.039) and past podiatry and sandals to be popular footwear amongst specific treatment (2.6; 1.3–5.0; p = 0.005). pathological populations including those with arthritis [17–19, 36], diabetes [22], and those at risk of falls [37]. Moccasins Although comparison with these condition-specific stud- Moccasins were worn by 5.8% (4.2–7.7) of participants. ies is challenging due to the differing conditions, Moccasins had a univariate association with female sex geographical locations and methods used to categorise (p = 0.021) (Supplementary Table S3). In the adjusted footwear type, taken together it does appear that running multivariate model, moccasins were independently asso- shoes, thongs/flip flops, walking shoes and sandals are ciated with female sex (2.0; 1.1–3.8; p = 0.036). popular outdoor footwear in diverse populations. We found that some socio-demographic factors, med- Slippers ical conditions, foot conditions and past foot treatment Slippers were worn by 2.8% (1.8–4.2) of participants. were independently associated with different outdoor foot- Slippers had univariate associations with: age, male sex, wear types worn. Male sex was independently associated chronic kidney disease and critical PAD (all p< 0.02) with wearing running shoes (OR 2.7), boots (OR 9.7), (Supplementary Table S3). In the adjusted multivariate oxford shoes (OR 6.7) and slippers (OR 7.3). Whereas, in model, slippers were independently associated with male stark contrast, female sex was associated with wearing sex (7.3; 1.7–32.4; p = 0.009) and chronic kidney disease thongs/flip flops (OR 2.0), sandals (OR 3.8), moccasins (3.3; 1.2–9.1; p = 0.019). (OR 2.0) and court shoes (only one male participant wore court shoes). This is similar to previous research that has Bespoke shoes found marked differences in men’s and women’spreferred Bespoke shoes were worn by 1.7% (0.9–2.9) of partici- footwear [4, 38]. pants. Bespoke shoes had univariate associations with: dia- Although men and women have similar footwear needs, betes, cerebrovascular accident, chronic kidney disease, footwear type is chosen along gender lines, following Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 6 of 8 sociocultural influences, rather than medical or foot barefoot and peripheral neuropathy in the 12 participants conditions [14]. Oxford shoes and boots are traditionally who indicated they primarily do not wear footwear male footwear, and sandals and court shoes traditionally outdoors. Further research should investigate whether this female. While associations between different footwear is a relationship that is present in the larger population as types and gender are perhaps not surprising, our findings there are clinical implications. People who have lost were from one of the first studies to adjust for multiple protective sensation have significantly increased needs for other factors (socio-demographic, medical, and foot footwear features that promote physical protection from condition factors). The gender relationships still remained external trauma and support to improve mobility [42]. in adjusted multivariate analyses. This may have relevant Walking shoes were associated with arthritis (OR 2.2), clinical consequences, with females much more likely to similar to previous research that reported comfort and choose footwear types with features that are not in line fit to be priorities when choosing footwear in this popu- with recommended characteristics for footwear that lation [16, 17, 19]. Pain caused by arthritis may motivate promotes general lower limb health and mobility. For the wearing of comfortable and stable walking shoes. example, sandals, court shoes and thongs/flip flops are less Chronic kidney disease was associated with wearing likely to have a protective upper, adequate outsole grip, slippers (OR 3.3); we hypothesise that this might be stable heel counter and limited available torsion than resulting from general ill-health and inability to don and running shoes, boots and oxford shoes [39]. Furthermore, doff shoes, or increased need to keep poorly perfused women are more likely to report footwear difficulties [40] feet warm. and pain when wearing footwear [41], with the types of This study provides, for the first time, insights into the footwear chosen likely a reason. typical outdoor footwear worn in the year prior to being Age was also related to footwear choice, with both an inpatient and the factors associated with them. It does health and generational sociocultural factors likely to play however, have several limitations. This was a secondary a role in this relationship. Younger age was associated analysis of data from the Foot Disease in Inpatients Study with increased likelihood of wearing thongs/flip flops (OR [24, 25]. The large amount of analyses performed in this 0.95 per year of age) and going barefoot (OR 0.95 per year and previous papers using this large existing database does of age); while older age was associated with increased like- increase the risk of type 1 error. Inpatients are typically lihood of wearing oxford shoes (OR 1.02 per year of age) older and have more chronic conditions compared to the and court shoes (OR 1.03 per year of age). A likely reason general population and our sample was highly representa- for this is that aesthetic footwear preferences are likely to tive of these characteristics. Thus, our findings are not as be different in older generations compared to those in likely to be generalisable to unhospitalised populations; younger ones. Additionally, as people age they are more however, an older population is more vulnerable to foot- likely to value the health-promoting features of footwear related conditions and thus a very relevant population to such a comfort, stability and fit over aesthetics [17, 19]. study in regards to footwear worn. Another limitation is There were several other associations observed among that all sites were in Queensland, Australia, which has a sociodemographic and outdoor footwear types. The tropical climate. The likely effect of this climate on a observed association between wearing boots and living in person’s year round footwear may influence the results, a regional (OR 2.6) or remote (OR 3.4) area could be further limiting their generalisability. The cross-sectional cultural and related to higher prevalence of occupations nature of the study means causal pathways cannot be requiring the wearing of boots, such as farming and confirmed. Some common sense explanations have been mining. The associations between thongs/flip flops and discussed that further research should investigate these. the second least disadvantaged socio-economic group (OR The explanatory variables investigated reported high valid- 3.1) and between court shoes and non-smoking (OR 2.6) ity and reliability [24, 25]; however, although foot condi- have less clear potential explanations. Differing fashion tions were diagnosed using gold standard clinical testing, trends across social groups might potentially be respon- various others were self-reported. Lastly, the self-reported sible. Future research should examine whether these outcome of outdoor footwear type mostly worn in the relationships exist in other populations and include inves- previous year is vulnerable to recall bias and may not tigations of the motivations of these footwear choices. represent the range of outdoor footwear types worn by Independent relationships were observed between past the participants’ as it only allowed for one footwear type podiatry treatment and bespoke shoes (OR 13.9) and court to be selected. shoes (OR 2.58). Someone requiring bespoke footwear is likely to have foot deformity and associated problems that Conclusions necessitate treatment by a podiatrist. The reason for the Running shoes, thongs/flip flops, walking shoes, sandals relationship with court shoes is less clear. Unexpectedly, and boots were the most common outdoor footwear types there was a large association (OR 7.5) between going prior to hospitalisation in a large representative inpatient Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 7 of 8 population. Various socio-demographic, medical history Brisbane, QLD, Australia. Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, and foot-related factors were identified as independently Amsterdam, the Netherlands. Wound Management Innovation Cooperative associated with outdoor footwear use in this study. Age 6 Research Centre, Brisbane, QLD, Australia. Allied Health Research and sex were most consistently linked with particular foot- Collaborative, Metro North Hospital and Health Service, Brisbane, QLD, Australia. wear types, with females and younger populations tending towards footwear that is not recommended for general Received: 11 December 2017 Accepted: 25 April 2018 mobility and lower limb health. Overall, our findings provide valuable new population-based insights into the socio-demographic and health factors that potentially References 1. 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Musculoskeletal conditions of the foot and Lloyd Reed is employed by Dominion Cross (Ascent footwear), however this did ankle: assessments and treatment options. Best Pract Res Clin Rheumatol. not play any role in the results of this study or preparation of the manuscript. All 2012;26:345–68. other authors declare that they have no competing interests. 9. Bus S, Armstrong DG, Deursen R, Lewis J, Caravaggi C, Cavanagh P. IWGDF guidance on footwear and offloading interventions to prevent Funding and heal foot ulcers in patients with diabetes. Diabetes Metab Res Rev. This work was kindly supported by grant funding from Queensland Health 2016;32:25–36. (Queensland Government, Australia) and the Wound Management 10. Spink MJ, Menz HB, Fotoohabadi MR, Wee E, Landorf KB, Hill KD, Lord SR. Innovation Cooperative Research Centre (Australia). Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomised Availability of data and materials controlled trial. BMJ. 2011;342:d3411. The datasets used and/or analysed during the current study are available 11. Williams AE, Davies S, Graham A, Dagg A, Longrigg K, Lyons C, Bowen C. from the corresponding author on reasonable request. Guidelines for the management of the foot health problems associated with rheumatoid arthritis. Musculoskeletal Care. 2011;9:86–92. 12. van Netten JJ, Lazzarini PA, Armstrong DG, Bus SA, Fitridge R, Harding Authors’ contributions K, Kinnear E, Malone M, Menz HB, Perrin BM. Diabetic foot Australia AB conceived the study, contributed to data-analysis and wrote the guideline on footwear for people with diabetes. Journal of Foot and manuscript; JvN conceived the study, contributed to data-analysis and Ankle Research. 2018;11:2. writing of the manuscript; SH contributed to study design, data-collection 13. Barton CJ, Bonanno D, Menz HB. Development and evaluation of a tool for and writing of the manuscript; LR contributed to study design, data-collection the assessment of footwear characteristics. JFAR. 2009;2:10. and writing of the manuscript; PL conceived the study, designed the study, 14. Hockey J, Dilley R, Robinson V, Sherlock A. Worn shoes: identity, Memory coordinated data-collection, analysed the data and contributed to writing and Footwear. Socio Res Online. 2013;18:20. of the manuscript. All authors approved the final version of the manuscript. 15. Belk RW. Shoes and self. Adv Consum Res. 2003;30:27–33. 16. Naidoo S, Anderson S, Mills J, Parsons S, Breeden S, Bevan E, Edwards C, Ethics approval and consent to participate Otter S. "I could cry, the amount of shoes I can't get into":a qualitative Ethics approval for this study was obtained from two Human Research Ethics exploration of the factors that influence retail footwear selection in women Committee (HREC); The Prince Charles Hospital HREC (Ethics No. HREC/13/ with rheumatoid arthritis. J Foot Ankle Res. 2011;4:21. QPCH/5) and Queensland University of Technology HREC (Ethics No. 17. Brenton-Rule A, Hendry GJ, Barr G, Rome K. An evaluation of seasonal 1300000367). Site specific authority was also obtained from each hospital variations in footwear worn by adults with inflammatory arthritis: a and written informed consent was voluntarily obtained from all participants. cross-sectional observational study using a web-based survey. J Foot Ankle Res. 2014;7:36–6. Publisher’sNote 18. Paterson KL, Wrigley TV, Bennell KL, Hinman RS. A survey of footwear Springer Nature remains neutral with regard to jurisdictional claims in advice, beliefs and wear habits in people with knee osteoarthritis. J Foot published maps and institutional affiliations. Ankle Res. 2014;7:43–3. 19. Silvester RN, Williams AE, Dalbeth N, Rome K. 'Choosing shoes': a Author details preliminary study into the challenges facing clinicians in assessing footwear School of Health and Human Sciences, Southern Cross University, Southern for rheumatoid patients. J Foot Ankle Res. 2010;3:24. Cross Drive, Bilinga, QLD 4225, Australia. School of Clinical Sciences, 20. Rome K, Frecklington M, Mcnair P, Gow P, Dalbeth N. Footwear Queensland University of Technology, Brisbane, QLD, Australia. Institute of characteristics and factors influencing footwear choice in patients with Health and Biomedical Innovation, Queensland University of Technology, gout. Arthritis Care Res. 2011;63:1599–604. Barwick et al. 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National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes (Part of the Guidelines on Management of Type 2 Diabetes). Melbourne Australia. 2011 31. Schaper NC. Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies. Diabetes Metab Res Rev. 2004;20:S90–5. 32. Abbott CA, Carrington AL, Ashe H, Bath S, Every LC, Griffiths J, Hann AW, Hussein A, Jackson N, Johnson KE, et al. The north-west diabetes foot care study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med. 2002;19:377–84. 33. Hosmer Jr DW, Lemeshow S, Sturdivant RX. Applied logistic regression. New York: Wiley; 2013. 34. Tabachnick BG, Fidell LS. Using multivariate statistics. 6th ed. Boston: Pearson; 2013. 35. Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, Doherty M, Geenen R, Hammond A, Kjeken I. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72:1125–35. 36. Carter K, Lahiri M, Cheung PP, Santosa A, Rome K. Footwear characteristics in people with inflammatory arthritis in Singapore. J Foot Ankle Res. 2016;9:29. 37. Bowen C, Ashburn A, Cole M, Donovan-Hall M, Burnett M, Robison J, Mamode L, Pickering R, Bader D, Kunkel D. A survey exploring self-reported indoor and outdoor footwear habits, foot problems and fall status in people with stroke and Parkinson's. J Foot Ankle Res. 2016;9:39–9. 38. Isip JDQ, de Guzman M, Ebison A Jr, Narvacan-Montano C. Footwear appropriateness, preferences and foot ulcer risk among adult diabetics at Makati medical center outpatient department. Journal of the ASEAN Federation of Endocrine Societies. 2016;31:37–43. 39. Bergin SM, Gurr JM, Allard BP, Holland EL, Horsley M, Kamp MC, Lazzarini P, Nube VL, Sinha AK, Warnock JT, et al. Australian diabetes foot network: management of diabetes-related foot ulceration - a clinical update. MJA. 2012;197:226–9. 40. Sullivan J, Pappas E, Adams R, Crosbie J, Burns J. Determinants of footwear difficulties in people with plantar heel pain. Journal of Foot and Ankle Research. 2015;8:40–0. 41. Paiva de Castro A, Rebelatto JR, Aurichio TR. The relationship between foot pain, anthropometric variables and footwear among older people. Appl Ergon. 2010;41:93–7. 42. Bergin SM, Nube VL, Alford JB, Allard BP, Gurr JM, Holland EL, Horsley MW, Kamp MC, Lazzarini PA, Sinha AK. Australian diabetes foot network: practical guideline on the provision of footwear for people with diabetes. Journal of Foot and Ankle Research. 2013;6:6. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Foot and Ankle Research Springer Journals

Independent factors associated with wearing different types of outdoor footwear in a representative inpatient population: a cross-sectional study

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Medicine & Public Health; Orthopedics; Rehabilitation
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Abstract

Background: Footwear can have both a positive and negative impact on lower limb health and mobility across the lifespan, influencing the risk of foot pain, ulceration, and falls in those at risk. Choice of footwear can be influenced by disease as well as sociocultural factors, yet few studies have investigated the types of footwear people wear and the profiles of those who wear them. The aim of this study was to investigate the prevalence and factors associated with outdoor footwear type worn most often in a representative inpatient population. Methods: This study was a secondary data analysis of a cohort of 733 inpatients that is highly representative of developed nations’ hospitalised populations; 62 ± 19 years, 55.8% male, and 23.5% diabetes. Socio-demographic, medical history, peripheral arterial disease, peripheral neuropathy, foot deformity, foot ulcer history, amputation history and past foot treatment variables were collected. Participants selected the footwear type they mostly wore outside the house in the previous year from 16 types of footwear. Multivariate logistic regression identified independent factors associated with outdoor footwear types selected. Results: The most common outdoor footwear types were: running shoes (20%), thongs/flip flops (14%), walking shoes (14%), sandals (13%) and boots (11%). Several socio-demographic, medical history and foot-related factors were independently associated (Odds Ratio; 95% Confidence Interval)) with different types of footwear. Running shoes were associated with male sex (2.7; 1.8–4.1); thongs with younger age (0.95 for each year; 0.94–0.97), being female (2.0; 1.2–3.1) and socio-economic status (3.1; 1.2–7.6); walking shoes with arthritis (1.9; 1.2–3.0); sandals with female sex (3.8; 2.3–6.2); boots with male sex (9.7; 4.3–21.6) and inner regional (2.6; 1.3–5.1) and remote (3.4; 1.2–9.5) residence (all, p <0.05). Conclusions: We profiled the types of outdoor footwear worn most in a large diverse inpatient population and the factors associated with wearing them. Sex was the most consistent factor associated with outdoor footwear type. Females were more likely to wear thongs and sandals and males boots and running shoes. Overall, this data gives insights into the socio-demographic, medical and other health factors that are related to footwear choice in a large diverse population primarily of older age. Keywords: Footwear, Inpatient, Sex, Arthritis, Neuropathy, Diabetes, Running shoes, Flip flops, Walking shoes, Sandals * Correspondence: alex.barwick@scu.edu.au School of Health and Human Sciences, Southern Cross University, Southern Cross Drive, Bilinga, QLD 4225, Australia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 2 of 8 Background footwear types worn most in the year prior to hospitalisa- Footwear can impact lower limb health and general tion in a large representative inpatient population. This was mobility both positively and negatively across the life- a secondary data analysis of a multi-site cross-sectional span [1]. Different footwear features have an effect on observational study that investigated foot disease in an the biomechanics of standing and gait and hence can in- inpatient population, and has been described in detail fluence musculoskeletal function and dysfunction [2, 3]. elsewhere [24, 25]. Briefly, on one designated study day, all As a result, footwear is of relevance to a diverse range of adult inpatients admitted into hospital for any medical rea- population groups. Certain footwear can contribute to son (except those with cognitive deficits, in maternity and the development of pain [4], complications of diabetes in psychiatric wards) in five public hospitals in Queensland including ulceration [5], and imbalance that increases (Australia) were invited to participate [24]. 883 eligible par- the risk of falls [6, 7]. Accordingly, footwear displaying ticipants were invited and 733 (83%) consented. The demo- certain features are often recommended in the prevention graphic, social determinant and medical history make-up of and management of these conditions in specific popula- this sample has been reported to be highly representative of tions [8–12]. typical inpatient populations present in developed nations Footwear can be classified based on distinctive combina- [24–26]. Self-reported history and foot physical examin- tions of features into types such as sandals and boots [13]. ation was performed using a validated data collection in- Outdoor footwear requires features that protect the foot strument (the Queensland Foot Disease Form) [24, 25, 27]. from the external environment, but has further require- The items contained in this instrument have demonstrated ments to promote lower limb health and mobility. Such at least moderate criterion validity, inter and intra-rater requirements include: adequate width, depth and length to reliability in two different studies [24, 27]. accommodate the foot; a soft, flexible and protective upper; The self-reported explanatory variables were grouped low heel height; stable heel counter and limited available into the domains of socio-demographics (age, sex, indi- torsion for overall shoe stability; adequate outsole grip to genous status, country of birth, socioeconomic status, prevent slipping; and being fit for purpose [1, 12]. Footwear geographical remoteness), medical conditions history (dia- also has individualised psychosocial requirements, as choice betes, hypertension, dyslipidaemia, myocardial infarct, of footwear type is also influenced by sociocultural, psycho- cerebrovascular accident, chronic kidney disease, cancer, logical and other health factors [14, 15]. arthritis, depression, smoking, mobility impairment, vision For some populations complying with recommended impairment), and past foot treatment in the year prior to footwear features can be challenging, such as older people hospitalisation (by podiatrist, general practitioner, special- and those with arthritis. For example, foot deformity may ist physician, surgeon, nurse, orthotist and other) [24, 25]. change the shape of the foot causing difficulty in fitting The clinically-diagnosed explanatory variables were all standard prefabricated footwear [16]. Such constraints in foot-related conditions and obtained following physical footwear choices have also been shown to affect individu- examination, including: amputation history, foot ulcer ality, well-being and quality of life [16]. history (current or previous), peripheral artery disease Some previous research has investigated the outdoor (PAD) severity, peripheral neuropathy and foot deformity. footwear worn by specific patient groups. Those with arth- PAD severity was diagnosed based on a toe systolic pres- ritis have been found primarily to wear athletic or walking sure of < 70 mmHg, as mild (51-70 mmHg), moderate shoes [17, 18] and sandals [17, 19]. However, many people (31-50 mmHg) and critical (< 30 mmHg) PAD [28, 29]. with arthritis [19, 20], diabetes [21, 22], and older people Peripheral neuropathy was diagnosed as the failure to [23] often also wear inadequate footwear including sense a 10-g monofilament on at least two or more plantar thongs/flip flops [19–22] and slippers [22], or even go forefoot sites on one foot [30, 31]. The presence of three barefoot [21, 22]. To our knowledge, no previous research or more of the following in one foot was the basis for the has investigated the outdoor footwear worn in a large diagnosis of a foot deformity: small muscle wastage, bony diverse population and the profiles of those who wear prominence, prominent metatarsal heads, hammer or claw them. Information on the types of people who wear toes, limited joint mobility or Charcot deformity on one certain footwear in a representative inpatient population foot [30, 32]. may provide a starting point for further research into The outcome variable for this study was the self-reported potential causal influences on footwear choices that could footwear type worn most outside in the previous 12 months. be used to guide footwear behaviour change interventions Each participant was presented with a validated footwear in future. type picture chart [13], modified with permission to add drawings of socks only and barefoot (no footwear) options. Methods Participants were asked “from this chart displaying 16 dif- Theaim of this studywas to investigate the prevalence and ferent types of footwear, what is the type of shoes you have factors independently associated with different outdoor worn most outside the house over the past 12 months?” Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 3 of 8 [24, 25]. The chart displayed drawings and titles of walking Table 1 Main outdoor footwear types worn in the previous 12 months shoes, running shoes, oxford shoes, moccasins, boots, ugg boots, high heels, thongs/flip flops, slippers, backless slip- Rank Footwear Type Number % (95% CI) pers, court shoes, mules, sandals, bespoke footwear, socks 1 Running shoe 148 20.4% (17.6–23.5) only, and barefoot [13]. Participants were asked to select 2 Thongs/flip flops 103 14.2% (11.8–16.9) one type of footwear only [24, 25]. 3 Walking shoe 98 13.5% (11.2–16.2) 4 Sandal 95 13.1% (10.8–15.7) 5 Boot 78 10.7% (8.7–13.2) Statistical analysis 6 Oxford shoe 50 6.9% (5.3–9.0) All data were analysed using SPSS 22.0 for Windows (SPSS Inc., Chicago, IL, USA) or GraphPad Prism (Graph- 7 Court shoe 49 6.7% (5.1–8.8) Pad Software Inc., San Diego, CA, USA). Descriptive 8 Moccasin 42 5.8% (4.2–7.7) statistics were used to display all variables. Prevalence with 9 Slipper 20 2.8% (1.8–4.2) 95% Confidence Intervals (95% CI) was evaluated for all 10 Bespoke footwear 12 1.7% (0.9–2.9) footwear outcome variables. Associations between 11 Barefoot 12 1.7% (0.9–2.9) explanatory and outcome variables were analysed using 12 Backless slipper 7 1.0% (0–2.0) univariate logistic regression. All variables achieving a statistical significance of p < 0.2 were included in 13 Ugg boot 6 0.8% (0–1.8) backwards stepwise multivariate logistic regression ana- 14 Socks only 3 0.4% (0–1.3) lysis until only variables reaching statistical significance 15 Mule 2 0.3% (< 0–1.1) remained (p < 0.05) (Unadjusted Model) [24, 33, 34]. The 16 High heel 1 0.1% (< 0–0.9) unadjusted model was then adjusted for age, sex, socio- Total 726 100% economic status and geographical remoteness by entering these variables into the model with the variables remaining in the unadjusted model (Adjusted Model) Thongs/flip flops [24, 33, 34]. Collinearity, goodness of fit, significance, Thongs/flip flops were worn by 14.2% (11.8–16.9) of partic- parsimony and variance were assessed at each step and ipants. Thongs had univariate associations with: age, female found to be acceptable [33, 34]. Cases with missing data sex, second least disadvantaged socioeconomic status, outer were excluded, as the proportion of missing data cases regional residence, arthritis, depression, smoking, mobility was minimal (< 5% in all cases) [24, 33, 34]. impairment, past foot treatment by a podiatrist, peripheral neuropathy, foot deformity and mild and moderate PAD (all, p < 0.05) (Supplementary Table S1). In the adjusted Results multivariate model, thongs were independently associated Table 1 displays the numbers and prevalence (% and 95 with younger age (0.95 per year; 0.94–0.97), female sex (2.0; CI) of each of the 16 different types of outdoor footwear. 1.2–3.1) and the second least disadvantaged socioeconomic Participant characteristics and univariate analyses for group (3.1; 1.2–7.6; all, p <0.05). each footwear type with a prevalence of > 1% are pre- sented in Supplementary Tables S1-S4 (Additional file 1). Walking shoes Table 2 displays the results of the multivariate logistic Walking shoes were worn by 13.5% (11.2–16.2) of the par- regression of unadjusted and adjusted models for each ticipants. Walking shoes had univariate associations with: footwear type. Outdoor footwear types with ≤1% preva- age, cerebrovascular accident, arthritis, mobility impair- lence (backless slipper (1%; 0–2.0), ugg boots (0.8%; 0–1. ment, past foot treatment by a podiatrist, and foot deform- 8), socks only (0.4%; 0–1.3), mules (0.3%; < 0–1.1) and ity (all, p < 0.05) (Supplementary Table S1). In the adjusted high heels (0.1%; < 0–0.9) were not entered into univari- multivariate model, walking shoes were independently asso- ate or multivariate analyses. ciated with arthritis (1.9; 1.2–3.0; p = 0.005). Running shoes Sandals Running shoes were worn by 20.4% (17.6–23.5) of partici- Sandals were worn by 13.1% (10.8–15.7) of the partici- pants. Running shoes had univariate associations with: male pants. Sandals had univariate associations with: age, fe- sex, depression and past podiatry treatment (all, p < 0.02) male sex, smoking and mobility impairment (all, p <0.05) (Supplementary Table S1). In the adjusted multivariate (Supplementary Table S2). In the adjusted multivariate model (OR; 95% CI), running shoes were independently model, sandals were independently associated with female associated with being male (2.7; 1.8–4.1; p < 0.001). sex (3.8; 2.3–6.2; p <0.01). Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 4 of 8 Table 2 Independent factors associated with outdoor footwear type worn most in the past 12 months (Odds Ratios [95% CI]) Risk Factor Unadjusted p Value Adjusted p Value Running Shoes Male 2.65 [1.77–3.95] < 0.001 2.69 [1.79–4.05] < 0.001 Thongs/flip flops Age (year) 0.96 [0.94–0.97] < 0.001 0.95 [0.94–0.97] < 0.001 Female 1.81 [1.15–2.85] 0.011 1.95 [1.23–3.11] 0.005 Socioeconomic status 0.010 0.055 Least disadvantaged 1.00 1.00 Second least disadvantaged 3.22 [1.41–7.33] 0.005 3.05 [1.23–7.56] 0.016 Middle 2.14 [0.98–4.69] 0.057 2.05 [0.90–4.67] 0.086 Second most disadvantaged 2.14 [0.90–5.09] 0.084 1.72 [0.68–4.33] 0.252 Most disadvantaged 1.11 [0.51–2.43] 0.791 1.08 [0.48–2.39] 0.857 Walking shoes Arthritis 2.23 [1.45–3.43] 0.001 1.92 [1.21–3.03] 0.005 Sandals Female 3.52 [2.18–5.67] < 0.001 3.78 [2.30–6.22] < 0.001 Non-Smoker 15.94 [2.19–116.19] 0.006 Overfitted Boots Male 9.35 [4.21–20.73] < 0.001 9.67 [4.33–21.64] < 0.001 Geographic Remoteness 0.008 0.031 Major city 1.00 1.00 Inner regional area 2.47 [1.37–4.44] 0.003 2.57 [1.29–5.13] 0.007 Outer regional area 2.05 [0.93–4.52] 0.074 2.16 [0.92–5.09] 0.078 Remote area 3.05 [1.18–7.91] 0.022 3.38 [1.20–9.53] 0.022 Very remote area 3.04 [1.02–9.06] 0.047 2.84 [0.82–9.89] 0.101 Oxford Shoes Age 1.02 [1.00–1.04] 0.025 1.02 [1.01–1.04] 0.013 Male 6.62 [2.78–15.78] < 0.001 6.73 [2.79–16.20] < 0.001 Court shoes Age 1.04 [1.02–1.06] 0.001 1.03 [1.01–1.05] 0.008 No Smoking History 2.20 [1.13–4.28] 0.020 2.06 [1.04–4.08] 0.039 Past Podiatry Treatment 2.22 [1.18–4.19] 0.014 2.58 [1.32–5.02] 0.005 Moccasins Female 2.13 [1.12–4.05] 0.021 2.00 [1.05–3.83] 0.036 Slippers Male 6.66 [1.52–29.09] 0.012 7.31 [1.65–32.38] 0.009 Chronic kidney disease 4.50 [1.77–11.47] 0.002 3.34 [1.22–9.10] 0.019 Bespoke shoes Past podiatry treatment 9.68 [2.59–36.14] 0.001 13.86 [3.03–63.46] 0.001 Barefoot Age 0.96 [0.93–0.99] 0.018 0.95 [0.01–0.99] 0.010 Peripheral neuropathy 8.84 [2.44–32.09] 0.001 7.51 [1.60–35.22] 0.011 Sex removed from model as all but one person wearing court shoes were female; Missing: Excluded missing cases Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 5 of 8 Boots past foot treatment including by a podiatrist, general prac- Boots were worn by 10.7% (8.7–13.2) of participants. titioner, surgeon, physician, nurse or orthotist, amputation Boots had univariate associations with: age, male sex, history, foot ulcer history, peripheral neuropathy, and foot inner regional, outer regional, remote and very remote deformity (all, p < 0.05) (Supplementary Table S4). In residence, smoking, mobility impairment, past foot treat- the adjusted multivariate model, bespoke shoes were ment by a podiatrist, peripheral neuropathy and foot independently associated with past podiatry treatment deformity (all, p< 0.05) (Supplementary Table S2). In (13.9; 3.0–63.5; p =0.001). the adjusted multivariate model, boots were independ- ently associated with male sex (9.7; 4.3–21.6; p < 0.001), No shoes (barefoot) inner regional residence (2.6; 1.3–5.1, p = 0.007) and No shoes were worn by 1.7% (0.9–2.9) of participants. remote area residence (3.4; 1.2–9.5; p = 0.022). Wearing no shoes had a univariate association with per- ipheral neuropathy (p = 0.006) (Supplementary Table S4). Oxford shoes In the adjusted multivariate model, wearing no shoes was Oxford shoes were worn by 6.9% (5.3–9) of the partici- independently associated with younger age (0.95 per year, pants. Oxford shoes had univariate associations with: 0.01–0.99; p = 0.01) and peripheral neuropathy (7.5; 1.6– age, male sex and being born overseas (all, p < 0.05) 35.2; p =0.011). (Supplementary Table S2). In the adjusted multivariate model, oxford shoes were independently associated with Discussion older age (1.02 per year; 1.01–1.04; p = 0.013) and male Footwear is important to the maintenance of general sex (6.7; 2.8–16.2; p < 0.001). mobility and lower limb health, with some footwear types more recommended than others in the treatment and Court shoes prevention of foot-related disease [1, 17, 35]. This study Court shoes were worn by 6.7% (5.1–8.8) of the partici- sought to describe the outdoor footwear types worn most pants. Court shoes had univariate associations with: age, in the year prior to hospitalisation by a representative female sex, arthritis, history of smoking, mobility impair- sample of adult inpatients, and to investigate the factors ment and past foot treatment by a podiatrist (all, p <0.05) associated with their wear. The most commonly worn out- (Supplementary Table S3). Sex was excluded from multi- door footwear type was running shoes which does fall variate analyses as all but one participant that wore court within footwear recommendations for many pathological shoes were female. In adjusted multivariate analyses, populations [24]. This was followed by thongs/flip flops, court shoes were independently associated with older walking shoes, sandals and boots. Previous studies have age (1.03 per year; 1.01–1.05; p = 0.008), non-smoking also found running shoes, thongs/flip flops, walking shoes history (2.1; 1.04–4.08; p = 0.039) and past podiatry and sandals to be popular footwear amongst specific treatment (2.6; 1.3–5.0; p = 0.005). pathological populations including those with arthritis [17–19, 36], diabetes [22], and those at risk of falls [37]. Moccasins Although comparison with these condition-specific stud- Moccasins were worn by 5.8% (4.2–7.7) of participants. ies is challenging due to the differing conditions, Moccasins had a univariate association with female sex geographical locations and methods used to categorise (p = 0.021) (Supplementary Table S3). In the adjusted footwear type, taken together it does appear that running multivariate model, moccasins were independently asso- shoes, thongs/flip flops, walking shoes and sandals are ciated with female sex (2.0; 1.1–3.8; p = 0.036). popular outdoor footwear in diverse populations. We found that some socio-demographic factors, med- Slippers ical conditions, foot conditions and past foot treatment Slippers were worn by 2.8% (1.8–4.2) of participants. were independently associated with different outdoor foot- Slippers had univariate associations with: age, male sex, wear types worn. Male sex was independently associated chronic kidney disease and critical PAD (all p< 0.02) with wearing running shoes (OR 2.7), boots (OR 9.7), (Supplementary Table S3). In the adjusted multivariate oxford shoes (OR 6.7) and slippers (OR 7.3). Whereas, in model, slippers were independently associated with male stark contrast, female sex was associated with wearing sex (7.3; 1.7–32.4; p = 0.009) and chronic kidney disease thongs/flip flops (OR 2.0), sandals (OR 3.8), moccasins (3.3; 1.2–9.1; p = 0.019). (OR 2.0) and court shoes (only one male participant wore court shoes). This is similar to previous research that has Bespoke shoes found marked differences in men’s and women’spreferred Bespoke shoes were worn by 1.7% (0.9–2.9) of partici- footwear [4, 38]. pants. Bespoke shoes had univariate associations with: dia- Although men and women have similar footwear needs, betes, cerebrovascular accident, chronic kidney disease, footwear type is chosen along gender lines, following Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 6 of 8 sociocultural influences, rather than medical or foot barefoot and peripheral neuropathy in the 12 participants conditions [14]. Oxford shoes and boots are traditionally who indicated they primarily do not wear footwear male footwear, and sandals and court shoes traditionally outdoors. Further research should investigate whether this female. While associations between different footwear is a relationship that is present in the larger population as types and gender are perhaps not surprising, our findings there are clinical implications. People who have lost were from one of the first studies to adjust for multiple protective sensation have significantly increased needs for other factors (socio-demographic, medical, and foot footwear features that promote physical protection from condition factors). The gender relationships still remained external trauma and support to improve mobility [42]. in adjusted multivariate analyses. This may have relevant Walking shoes were associated with arthritis (OR 2.2), clinical consequences, with females much more likely to similar to previous research that reported comfort and choose footwear types with features that are not in line fit to be priorities when choosing footwear in this popu- with recommended characteristics for footwear that lation [16, 17, 19]. Pain caused by arthritis may motivate promotes general lower limb health and mobility. For the wearing of comfortable and stable walking shoes. example, sandals, court shoes and thongs/flip flops are less Chronic kidney disease was associated with wearing likely to have a protective upper, adequate outsole grip, slippers (OR 3.3); we hypothesise that this might be stable heel counter and limited available torsion than resulting from general ill-health and inability to don and running shoes, boots and oxford shoes [39]. Furthermore, doff shoes, or increased need to keep poorly perfused women are more likely to report footwear difficulties [40] feet warm. and pain when wearing footwear [41], with the types of This study provides, for the first time, insights into the footwear chosen likely a reason. typical outdoor footwear worn in the year prior to being Age was also related to footwear choice, with both an inpatient and the factors associated with them. It does health and generational sociocultural factors likely to play however, have several limitations. This was a secondary a role in this relationship. Younger age was associated analysis of data from the Foot Disease in Inpatients Study with increased likelihood of wearing thongs/flip flops (OR [24, 25]. The large amount of analyses performed in this 0.95 per year of age) and going barefoot (OR 0.95 per year and previous papers using this large existing database does of age); while older age was associated with increased like- increase the risk of type 1 error. Inpatients are typically lihood of wearing oxford shoes (OR 1.02 per year of age) older and have more chronic conditions compared to the and court shoes (OR 1.03 per year of age). A likely reason general population and our sample was highly representa- for this is that aesthetic footwear preferences are likely to tive of these characteristics. Thus, our findings are not as be different in older generations compared to those in likely to be generalisable to unhospitalised populations; younger ones. Additionally, as people age they are more however, an older population is more vulnerable to foot- likely to value the health-promoting features of footwear related conditions and thus a very relevant population to such a comfort, stability and fit over aesthetics [17, 19]. study in regards to footwear worn. Another limitation is There were several other associations observed among that all sites were in Queensland, Australia, which has a sociodemographic and outdoor footwear types. The tropical climate. The likely effect of this climate on a observed association between wearing boots and living in person’s year round footwear may influence the results, a regional (OR 2.6) or remote (OR 3.4) area could be further limiting their generalisability. The cross-sectional cultural and related to higher prevalence of occupations nature of the study means causal pathways cannot be requiring the wearing of boots, such as farming and confirmed. Some common sense explanations have been mining. The associations between thongs/flip flops and discussed that further research should investigate these. the second least disadvantaged socio-economic group (OR The explanatory variables investigated reported high valid- 3.1) and between court shoes and non-smoking (OR 2.6) ity and reliability [24, 25]; however, although foot condi- have less clear potential explanations. Differing fashion tions were diagnosed using gold standard clinical testing, trends across social groups might potentially be respon- various others were self-reported. Lastly, the self-reported sible. Future research should examine whether these outcome of outdoor footwear type mostly worn in the relationships exist in other populations and include inves- previous year is vulnerable to recall bias and may not tigations of the motivations of these footwear choices. represent the range of outdoor footwear types worn by Independent relationships were observed between past the participants’ as it only allowed for one footwear type podiatry treatment and bespoke shoes (OR 13.9) and court to be selected. shoes (OR 2.58). Someone requiring bespoke footwear is likely to have foot deformity and associated problems that Conclusions necessitate treatment by a podiatrist. The reason for the Running shoes, thongs/flip flops, walking shoes, sandals relationship with court shoes is less clear. Unexpectedly, and boots were the most common outdoor footwear types there was a large association (OR 7.5) between going prior to hospitalisation in a large representative inpatient Barwick et al. Journal of Foot and Ankle Research (2018) 11:19 Page 7 of 8 population. Various socio-demographic, medical history Brisbane, QLD, Australia. Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, and foot-related factors were identified as independently Amsterdam, the Netherlands. Wound Management Innovation Cooperative associated with outdoor footwear use in this study. Age 6 Research Centre, Brisbane, QLD, Australia. Allied Health Research and sex were most consistently linked with particular foot- Collaborative, Metro North Hospital and Health Service, Brisbane, QLD, Australia. wear types, with females and younger populations tending towards footwear that is not recommended for general Received: 11 December 2017 Accepted: 25 April 2018 mobility and lower limb health. Overall, our findings provide valuable new population-based insights into the socio-demographic and health factors that potentially References 1. 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Journal of Foot and Ankle ResearchSpringer Journals

Published: May 29, 2018

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