Discussion
Running injury rates are high,26 and assessing knowledge about the effects of footwear on injury risk is potentially useful in addressing the issue. In a recent paper by Fokkema et al, nearly half of runners identified ‘not knowing what to do’ as a significant barrier to injury-prevention behaviours.27 This outlines the need for accessible and evidence-based educational resources like the online module designed in this study. Our primary findings were that perceptions about running shoes and injury risk differ between runners and HCPs, and that an online module is deemed useful to communicate the latest scientific evidence. This information can now be used to improve knowledge translation strategies to runners, and evaluate if improved knowledge changes behaviour, and ultimately reduces injury risk.
Footwear was generally perceived as an important part of running injury prevention by both runners and HCPs. This is in accordance with another study, in which runners ranked footwear as the second most important factor in preventing injury, just behind ‘progression of the training programme’.27 Our data show that comfort was heavily accounted for when selecting a new pair of shoes. Since runners in our sample ranked ‘injury prevention’ as the third criterion for selecting running shoes, it is possible that they also associate comfort with injury prevention.
Runners commonly search for information on injury prevention.27 Our sample reported seeking advice from footwear retailers and websites more commonly than from HCPs. This outlines the importance of designing trustworthy sources of information for the public, but also to educate HCPs to ensure they are seen as knowledgeable on the topic. This is important as HCPs play a key role in the clinical management of injuries, and runners must therefore feel comfortable discussing multiple strategies—including footwear—during treatment planning.
Despite individual variations, our data do not support results from a previous study which reported that runners commonly perceive wearing the wrong shoe for foot type as a risk factor for running injuries.28 Differences between studies could be due to our recruitment occurring mainly through social media. It is possible that our sample was more aware of the scientific evidence than the general population of runners. Similarly, the level of knowledge in our sample of HCPs (87% runners) may not be representative of all HCPs. Beliefs can be influenced by personal experience and interests. For example, our group previously found that recommendations about running and knee joint health were more restrictive when coming from non-running HCP than from running HCP.29
Our evidence-based educational module was deemed helpful by a majority of respondents. However, the fact that perceptions at PRE differed between participants who went on to read the module and answer the POST questions compared with those who did not outlines the need to identify and target individuals who may benefit from an educational module. It is possible that those who declined to read the module and answer to POST did not feel the need to learn, did not want to challenge their beliefs or simply did not have time. Importantly, it remains uncertain if changes in knowledge would translate into changes in behaviour30 and eventually, reduced injury risk. A recent randomised clinical trial did not report changes in injuries in runners receiving an online multifactorial prevention programme compared with a group who did not.31 Unfortunately, no follow-up on compliance to the educational programme or perception on usefulness was provided in that study, which limits the interpretation of their results and comparisons with the current study. Despite obtaining a relatively high rating for overall usefulness, the efficacy of our module in reducing injuries remains purely hypothetical and should be tested in a future trial.
The design and inclusion of the educational module represent a strength of the current study. Our rigorous process that involved feedback from HCPs, as well as runners without research knowledge, was essential in optimising internal and external validity.32 However, this study also has limitations. First, given that research on running footwear is constantly evolving, the module will need periodic updating when tested in future trials. Second, using online data collection may be subject to response bias. It is impossible to ascertain if respondents provided honest answers, including if they were indeed runners or HCPs. This is an intrinsic limitation of such a study design. Third, our sample may not be representative of the whole population of runners and HCPs. Many factors including sources and strategies for recruitment, language and level of education can have a significant influence on responses and the effects of an educational module. In addition, footwear perceptions and preferences have even been suggested to be country specific.33 Despite improving generalisability by providing the questionnaire in two languages, research is needed to help assess beliefs in multiple countries and languages to eventually adapt educational resources to different cultures. Fourth, differences in the perceptions of those who filled out PRE compared with those who completed both PRE and POST, and the fact that less than half of participants decided to fill out the POST questions, represent potential sources of bias and outline the need to correctly identify individuals who could benefit from an educational module. Fifth, the absence of a control group receiving no education precludes us from concluding that changes noted by exploratory analyses were indeed due to the module, since simply participating in an online survey study about footwear could have influenced responses. Finally, it is uncertain if the effects of the educational module would last through time, given that we only explored immediate changes in perceptions. Since respondents’ anonymity was prioritised, we were unable to follow-up at a later time.