This article has Open Peer Review reports available.
If the shoe fits: development of an on-line tool to aid practitioner/patient discussions about ‘healthy footwear’
© The Author(s). 2016
Received: 30 March 2016
Accepted: 20 May 2016
Published: 7 June 2016
A previous study highlighted the importance of footwear to individuals’ sense of their identity, demonstrating that shoes must ‘fit’ someone socially, as well as functionally. However, unhealthy shoes can have a detrimental effect on both foot health and mobility. This project utilises qualitative social science methods to enable podiatrists to understand the broader contribution of footwear to patients’ sense of themselves and from this an online toolkit was developed to aid footwear education.
Semi-structured interviews were conducted with six podiatrists/shoe-fitters and 13 people with foot pathologies, some of whom also completed shoe diaries. These were supplemented with some follow-up interviews and photographs of participants’ own shoes were taken to allow in-depth discussions.
Four areas related to ‘fit’ were identified; practicalities, personal, purpose and pressures, all of which need to be considered when discussing changes in footwear. These were incorporated into an online toolkit which was further validated by service users and practitioners in a focus group.
This toolkit can support podiatrists in partnership with patients to identify and address possible barriers to changing footwear towards a more suitable shoe. Enabling patients to make healthier shoe choices will help contribute to improvements in their foot health and mobility.
Foot problems are common in the general population  with 61 % of women and 30 % of men report suffering from foot pain . Poorly fitting footwear can be associated with the development of some foot conditions including corns and callus, hallux valgus and lesser toe deformities . Poorly fitting and inappropriate shoes can also lead to falls [4–6]. Information is now available to guide people when choosing suitable footwear as part of the Healthy Footwear Guide . This recommends that a ‘healthy’ shoe should be of adequate width and depth with a toe box and sole that allow for normal foot function. The heel should be stable and approximately 25 mm high and the shoe should keep the foot stable. Despite this marketing figures still suggest a major growth in fashion shoe consumption many of which would not be classed as appropriate according to the guidelines . In this context, podiatrists and patients could currently be seen to be on different ends of a continuum in relation to what is seen as ‘healthy’, desirable footwear from a medical perspective, but which is often perceived as unfashionable and thus unwearable over the long term by patients, despite potential negative implications for their health and well-being.
If it can be shown that the wearing of healthy shoes helps reduce the level or number of painful foot conditions seen, it is possible that the number of people in pain through their foot conditions could be reduced. This would be expected to create improvements in the foot health of the general population and in turn, reduce the burden being placed on NHS podiatry services. This project builds on previous Economic and Social Research Council (ESRC) funded research on the significance of footwear to individuals in terms of identity, transition and memory to examine the motivations, feelings and preferences that affect the footwear choices of patients who are receiving treatment and support from Podiatry Services . The purpose of this study was to use qualitative methods (via interviews and a focus group) to design a practical on-line toolkit to empower foot health practitioners to encourage healthier shoe choices in the people they treat. If more successful strategies can be used to persuade people to change their footwear in turn foot health and mobility could be improved.
A variety of recruitment mechanisms were used in order to reach out to both professionals and patients. Patient recruitment was targeted primarily in Yorkshire and the North East. Flyers and posters were made available in clinics, and eligible potential participants were also identified by practitioners and invited to consider participation. Information about the study was circulated at local diabetes support groups and social media was used extensively to promote the study, specifically through the development of a widely-circulated Facebook page. Practitioners were recruited through targeted advertising in Podiatry Now magazine and through circulation of emails to members of The College of Podiatry and other relevant mailing lists.
What factors shape and motivate the footwear choices and preferences of patients receiving treatment and support from Podiatry Services?
Where does conflict arise in negotiations between patients and podiatrists around healthy footwear choices?
How can these tensions be addressed through providing training to facilitate dialogue between patients and podiatrists?
All interviews were recorded, transcribed and transcripts and shoe diaries manually coded into themes and sub-themes. Each theme was analysed and summarised. Mapping out all the different themes present across the multiple means of data collection provided a template from which to build and develop the toolkit to ensure it was well-grounded in the data. Focus group and field trial data was used to further refine the on-line toolkit. The toolkit consists of details and findings from the study including a visual tool of recommendations for practice. It also includes information for patients and links to the Healthy Footwear Guide, The Society of Shoe Fitters and Sheffield Foot and Ankle Pain website.
Once the toolkit was formulated it was presented in a focus group of service users and practitioners to provide feedback and allow for final modifications.
These methods were deemed a highly appropriate means through which to engage both health professionals and the people they treat. It is hoped that the links between shoes, wellbeing and identity can be explored as rich data would be expected to be generated. Also the potential to explore all perspectives in more depth would be possible using qualitative research methods.
Themes and sub-themes generated from the interviews and focus group
Factor on which most shoe choices are based
Wearing similar or same shoe almost every day
Enjoyment gone from shoes
At odds with comfort
Used to be important
High cost of shoes prohibitive
People with disabilities are ‘exploited’/discriminated against in terms of footwear choices and costs
What they pay
Sense of shoes not matching self/lifestyle
Medicalisation—don’t want to be seen as someone with a disability etc.
Pride, wellbeing and self-esteem
Unhappy with shoes/wishes could wear different shoes
Creating a ‘look’ or a brand/image
Hates feet and having them on display
Minimise visibility of shoes
Getting out and about
Hard to find wide-fit shoes/shoes that fit
Shoe shopping has to be planned now
Limited access to shops
Prefer to shop online/catalogues or try shoes on at home
Staff lack knowledge to help
What makes a healthy shoe?
Support from Podiatrists
Good support and advice
Didn’t realise shoe advice part of pod role/never received it
Changing role of podiatrists/professionalisation
What would help?/recommendations for toolkit and for changing footwear
Offer examples of specific brands
Recognise patient as individual with individual needs
Get to know the patient and build rapport/build concordance
Understand mental wellbeing side of shoes/people’s feelings and emotions
LOCAL context—shops in area
Explain things more clearly
Show images of shoes
Shoe-fitting/foot-measuring in shops
Private area in shops
Knowing what pods do more
Not treating patients who won’t make the changes
Balance in managing situation
‘Car to bar’—changing shoe choice some of the time
Role of prevention
People don’t make the connection between foot conditions and shoes
Change people’s perceptions of healthy shoes?
Look at the bigger picture
These barriers were grouped into four distinct themes around the concept of ‘fit’:
Practicalities (physical fit)
Interviewer: Would you say that that’s the main priority then… comfort?
Frank: Comfort, yeah, definitely. And price as well because I’m on benefits. Because some of the wide-fitting shoes are ridiculous prices.
Charlie: Yeah, I mean I’m the same, it’s got to be the right price range to fit my pocket and my feet at the same time, do you know?
There were also difficulties in knowing what to look for in a good shoe, which stockists to purchase them from and actually getting to certain shops for some with mobility problems. Participants felt pictures of ‘healthy’ footwear and lists of local stockists could help with this. Difficulties were also discussed when actually trying to buy shoes in terms of choice and styles which may be limited if feet have specific deformities. The problems of purchasing footwear online were also highlighted, as it is difficult to ascertain fit and comfort until shoes have been tried on.
Personal (mental fit)
…people who wear these shoes [trainers] conform to a lifestyle that I do not conform to, so I feel a bit like a pretender wearing them as well. I feel that they hint to a lifestyle that I do not want to be associated with’
Many respondents commented that changing shoe buying and wearing habits were difficult, even if advised by a podiatrist. The positive benefits of changing footwear on foot health should be encouraged rather than emphasising the negative serious problems that may occur.
Purpose (lifestyle fit)
Interviewer: How do you think you’d feel if you were wearing something like that [Velcro-fastening shoe recommended by Podiatrist] to a formal occasion?
Elizabeth: I wouldn’t. There is no way. I’d sorted all my shoes out and I’d thrown them away and then I realised that my great-granddaughters were being christened and I thought ‘God’! So I had to go out and buy a pair of court shoes because, I said to my daughter, ‘there’s no way I can go to the christening, you know, with my feet like this… so I’ve been out and I’ve bought a pair of shoes’
Pressures (social fit)
I had some a while ago with the Velcro fastening and people laughed at them. My son in particular said ‘you look ridiculous wearing those shoes'
It is clearly important for practitioners to recognise this and where required, to work to bring the wider family ‘on board’ with any proposed footwear changes.
These themes formed the basis of the toolkit to help reconceptualise ‘fit’ in ways that reflect the wider understanding of the term apparent amongst the participants with foot pathologies (Fig. 1).
The links between foot pathologies and inappropriate shoes is well established  despite this it is still often difficult for people to obtain footwear that fits properly . This is exacerbated in those with specific foot deformities such as rheumatoid arthritis  and diabetes where correct footwear is often key to reducing the development or recurrence of foot deformities and pathologies. From this investigation in the context of footwear, fit is more than just physical. Whilst a ‘healthy’ shoe may be one that is perceived to fit well physically, results from this investigation indicate the importance of re-thinking what we mean by ‘fit’ and imagining it in a wider sense, in terms of practicalities, personal, purpose and pressures. Goodacre et al.  found that when compromises have to be made in footwear choice to accommodate specific foot conditions in rheumatoid arthritis; identity and social status can be affected. This can lead to poor compliance when wearing specialist orthopaedic footwear due to its ‘look’ . These themes were also found in this study where shoes should be able to ‘fit’ the person both mentally and socially if they are going to be worn.
It is hoped that this toolkit can act as a prompt or trigger for discussion in direct consultation with patients, for example in combination with techniques such as motivational interviewing (MI). MI techniques have been shown to effect lifestyle behaviour changes such as weight management and alcohol consumption . Using MI could help patients to identify how far the different types of fit and related barriers impact upon their own shoe choices working through the visual representation of the tool. This could help podiatrists to understand the values and motivations of their patient’s and to open up further dialogue and discussion around the next steps forward and how to make changes.
In order to further help with footwear change, practitioners could provide examples of different types of shoes either in picture format or using actual shoes to help to challenge this pre-conception that fashion and comfort are at different ends of the scale. Footwear recommendations should be tailored to take into account individual’s lifestyles but with the emphasis on how ‘healthy’ shoes could improve mobility and reduce pain.
The next stage of this work will be to ‘test’ the effectiveness of the toolkit in a large group of patients to investigate if it can help guide and change footwear choices in a podiatry practice context.
This research suggests that there are some areas of common ground between practitioners and patients on which to build. To maximise the chances of individuals making footwear changes, foot health professionals must work to address these four barriers that service users may encounter. Thinking more holistically about ‘fit’ allows foot health professionals to take into account individuals’ preferences and values, psychological and emotional wellbeing and the ways social pressures impact on footwear decisions. Consideration of fit in this wider sense will improve interaction between practitioner and service user and increase the likelihood that positive, long-term and sustainable footwear changes are made to make ‘every contact count’.
Both the visual tool and recommendations are available to download and print on the study website (www.sheffield.ac.uk/podiatrytoolkit).
This study was funded by an Innovation, Impact and Knowledge Exchange Collaboration Research and development award from The University of Sheffield. The funding body agreed the design of the study. This grant funded a research assistant who carried out the research (EN) with support from VR and LF.
WV and VR devised the study. EN carried out the interviews, focus group and conducted the qualitative analysis. LF, VR, RN and WV drafted the manuscript. All four authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Ethics committee approval was given from The University of Sheffield (003038) and NRES Committee North West – Liverpool Central Ethics Committees (177040). Research governance approval was obtained from the sponsor (STH18873 - Sheffield Teaching Hospitals NHS Foundation Trust). All participants gave informed and written consent to take part and for dissemination of the findings in peer reviewed journals.
Open AccessThis 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.
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