Australian secondary school principals’, parents’, and students’ attitudes to prescribed school footwear guidelines.

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Natalie Mazzella, Aaron Fox, Natalie Saunders, Danielle Trowell, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2592371/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Apr, 2023 Read the published version in Journal of Foot and Ankle Research → Version 1 posted 4 You are reading this latest preprint version Abstract Background Adolescents are often required to wear footwear that adheres to uniform guidelines at secondary school. There is a paucity of literature on factors influencing school footwear choice and what drives the development of school footwear guidelines. The aims of this study were to describe (i) current school footwear guidelines in secondary schools across Australia, (ii) factors that influence footwear choice in secondary school students and their parents, and (iii) principals, parents, and students’ beliefs on factors which contribute to school footwear guidelines. Methods An online survey was distributed to principals, secondary school students (aged 14–19 years) and their parents across Australia. The survey included questions on current school footwear guidelines, factors influencing footwear choice (for students and parents), participants beliefs on the effect footwear has on musculoskeletal health, current and previous lower limb pain, and beliefs on factors that contribute to school footwear guidelines. Parent and student responses to factors that influence their footwear choice were compared using proportional odds logistic regression. Students and parents’ responses to factors influencing footwear guidelines were compared to principal responses using proportional odds logistic regression. Significance was set at an alpha of < 0.05. Results 80 principals, 153 parents and 120 secondary school students responded to the survey. 96% (77/80) of principals reported that their schools have set guidelines for school footwear. 88% of principals considered comfort to be important when developing school footwear guidelines, though parents and students were 3.4 and 4.9 times more likely than principals to rate comfort as having lower importance in the development of guidelines. More than 40% of students reported experiencing musculoskeletal pain, and 70% of these students reported the pain to be exacerbated when in their school shoes. Less than a third of participants considered healthcare recommendations important to the development of footwear guidelines. Conclusions Nearly all principals that participated in this survey had set guidelines for school footwear. There is a discord between parents, students, and principals on the importance that factors such as comfort, play in the development of school footwear guidelines. Adolescent shoes footwear health youth Figures Figure 1 Figure 2 Background Adolescence is a period of rapid growth and development that has been accompanied with an increased rate of musculoskeletal pain and injury compared to childhood, particularly at the knee and foot ( 1 – 3 ). Adolescents spend a large percentage of their weekday time at school, where they often must adhere to school uniform guidelines ( 4 , 5 ). Anecdotally, secondary school uniform guidelines often require students to dress in formal attire and black, leather shoes, though secondary school footwear requirements have not been documented. School shoes are often designed with stiff, inflexible midsoles, a closed toe and elevated heel heights ( 6 ). Recent evidence has suggested that some of these footwear characteristics increase knee joint loads, reduce tactile feedback during walking and running, and reduce dynamic balance when compared to being barefoot ( 7 – 10 ). Cross-sectional studies have identified changes in paediatric foot development and gait characteristics including step length, velocity, and cadence when children go from being barefoot to shod in school and/or sport shoes ( 11 – 14 ). No research has yet investigated whether similar changes are apparent in an adolescent cohort when wearing school footwear. Little is known about the rationale and factors that contribute to school footwear guidelines for adolescents while attending secondary school. Research focused on footwear choice has primarily centred on adults and athletic footwear, with a common belief that footwear is an important factor in the prevention of running related injuries and the management of inflammatory arthropathy ( 15 – 17 ). Recreational adult runners believe that footwear for children and adolescents should include structural support ( 18 ) but there is no current consensus on the best options for school footwear for children and adolescents ( 19 ). Early in adolescence, parents and guardians are highly influential on their dependent’s behaviour ( 20 , 21 ). As adolescents mature, peer and friends’ opinions have a greater influence on establishing behavioural norms ( 21 , 22 ). Limited research has investigated what drives footwear selection in an adolescent specific cohort. Adolescent cross-country runners report that friends and family are a major source of information influencing their running shoe choice ( 23 ). However, adult footwear knowledge is often influenced by retail footwear stores, popular beliefs, and peers, as opposed to scientific evidence ( 15 , 18 ). It is likely that parents’ opinions are a major contributor to the selection of school footwear in adolescents. There is a need for greater understanding and consideration of child and adolescent opinions in footwear research ( 24 , 25 ). Exploring what secondary school students, as well as parents of secondary school students, consider important when choosing school footwear requires investigation. Development of school uniform guidelines is often the role of senior heads of school. There is little understanding on the determinants that inform these guidelines. Restrictive uniforms, peer pressure and a lack of school support are reported as barriers to participation in physical activity across adolescence ( 26 – 28 ). A recent study of principals and parents investigated barriers to school uniform changes in primary schools ( 29 ). Principals were not supportive of a uniform policy that allowed children to wear sports or recreational uniform full time, citing reasons such as school status and cost as barriers to change. In contrast, parents were supportive of the change, indicating a potential discord between parents and principals on school uniform guideline policies. It is not clear if these findings also extend to school footwear recommendations or across secondary schools. Given the effect that footwear can have on paediatric gait, and the barriers that traditional uniforms pose to physical activity participation ( 7 , 26 , 27 ), identifying the factors most important when selecting footwear for school is needed. Understanding what informs the development of uniform guidelines for school principals also requires investigation as school guidelines are a potential determinant to the selection of school footwear worn by students. Therefore, the aims of this study were to describe (i) current school footwear guidelines in secondary schools across Australia, (ii) factors that influence footwear choice in secondary school students and their parents, and (iii) principals, parents, and students’ beliefs on factors which contribute to school footwear guidelines. Methods Study Design This study was a cross-sectional anonymous online survey and has been reported using the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) ( 30 ). Ethical approval for this study was granted from the Deakin University Human Research Ethics Committee. Participants were informed of the purpose of the study, the research team involved and the expected completion time of the survey upon opening the survey weblink. Participants were informed that consent was implied upon completion of the survey on the online platform. Participants were advised that participation was voluntary and that they were free to exit the survey at any time. Incomplete responses were excluded from the survey analysis. Recruitment Secondary school students and parents of secondary school students were recruited from all states and territories across Australia from March 2021 to July 2022. Targeted advertising on social media was used in combination with posters placed at shoe stores and local sports medicine clinics. Advertisements were also distributed in school newsletters following approval from the relevant state education department and school principals. Principals were recruited from the contact information listed on their school’s website inviting them to participate in the study. Participants Eligibility criteria for each participant group were as follows: (i) students aged between 14–19 years of age and currently enrolled and attending a secondary school; (ii) parents with a child/children aged between 14–19 years of age currently enrolled and attending a secondary school; (iii) principals employed as a secondary school principal within a government or non-government school. Survey instrumentation A survey that was estimated to take 10-minutes was administered online using Qualtrics (Qualtrics, Provo, United States). Participants completed the survey once, at their own convenience (see Additional file 1). The survey was piloted by the research team and a small number of adolescents (aged 14–19 years) prior to distribution. To protect anonymity of responses, no IP data was collected or stored during the data recording process. Survey questionnaire The survey was comprised of five sections (Additional file 1). Section one collected baseline demographics such as age, gender, and school type. Section two gathered information on current footwear guidelines and footwear requirements for students (such as colour, fixation, material). Section three required respondents to indicate how important the following factors were to footwear choice: shoe comfort, school footwear guidelines, shoe price, opinion of peers and friends, shoe appearance, and healthcare recommendations. A four-point Likert scale was used for participants to respond from not at all important to very important. As secondary school principals are not involved in footwear selection, they did not provide responses to factors influencing footwear choice (section three). Section four assessed factors influencing the development of guidelines while at secondary school. Factors included foot health, school tradition, comfort, student uniformity, presentation of the school in the community and healthcare recommendations. Principals were asked how important these factors are to the development of their school footwear guidelines. Parents and students were asked how important they believed these factors are to the development of school footwear guidelines at the school they, or their children, attend. Participants responded to this using the same four-point Likert scale. If the participant’s school did not provide guidelines for student footwear, they were exempt from providing responses to this section of the survey. For any schools that did not provide guidelines for footwear, participants were asked to indicate reasons as to why they did not have guidelines. Finally, students and parents provided responses relating to current or past musculoskeletal pain and the effect that footwear has on their musculoskeletal health and/or pain (section five). Participants were able to indicate multiple sites of pain if applicable. Principals did not provide responses to this section of the survey. At the end of the survey, participants were given the opportunity to add any information using an open-ended response. Participants were able to review their responses prior to submission of the survey. Statistical analysis Survey responses were exported from Qualtrics into Microsoft Excel and RStudio (Version 3.5.2, RStudio Inc, Posit, Boston, United States) for analysis. Descriptive statistics were used to describe the characteristics of the principal, student, and parent responses. Postcode data from respondents was used to classify the school’s location as either urban or rural using the Australian Statistical Geography Standard ( 31 ). To protect anonymity of responses from principals, postcode data for their school was not collected. Participant responses across common items were reported descriptively to determine the frequency of each response. Responses between parents and students, and between male and female students, on factors that influence their footwear choice were compared using proportional odds logistic regression. The relative importance placed on factors influencing footwear guidelines was also assessed. Students and parents’ responses were compared to principal responses using proportional odds logistic regression. Differences in responses between principals from non-government and government schools were compared using proportional odds logistics regression. Significance was set at an alpha of < 0.05 and odds ratios (95% confidence intervals [CI]) were calculated. Results 405 participants commenced the survey. Of these, 52 responses were excluded due to being incomplete (n = 29), and/or being less than 14 years of age (n = 21) or being older than 19 years of age for student responses (n = 2). 120 secondary school students, 153 parents and 80 secondary school principals completed the survey in full (n = 353). Table 1 provides a summary of the demographic characteristics of the participants. Students spent an average of 7.98 [1.95] hours in their school shoes for an average 3 days per week. Table 1: Participant characteristics Characteristics n (%) Principals All 80 (22.7%) Female 34 (42.5%) Male Prefer not to say 44 (55.0%) 2 (2.5%) Years in current role 0-10 years >10 years 59 (73.8%) 21 (26.2%) Sector Non-Government Government 30 (37.5%) 50 (62.5%) Students All 120 (34.0%) Female 75 (62.5%) Male Prefer not to say 42 (35.0%) 3 (2.5%) Age Sector Government Non-Government 16.1 (1.48) years 64 (53.3%) 56 (46.7%) Location Rural Urban 73 (60.8%) 47 (39.2%) Parents All 153 (43.3%) Female 143 (93.5%) Male 10 (6.5%) Location Rural 98 (64.1%) Urban 55 (35.9%) Footwear characteristics 77 principals (96%) had set guidelines for school footwear for students. 87% (n = 67) of these principals required student’s footwear to be black and include a closed toe box, 73% (n = 56) reported a leather shoe was required and 57% (n = 44) reported fixation such as laces or buckles was required. There were no differences between principals from government and non-government schools on the type of shoe recommended for school. Musculoskeletal health 51 secondary school students (43%) experienced current pain in their legs or feet, and of these 36 students (71%) reported that their pain was worse when wearing school shoes. 28 students (46%) reported knee pain, 29 students (47%) reported foot and/or leg pain and 4 students (7%) reported dermatological pain (i.e., blisters or ingrown toenails). Factors influencing footwear choices Figure 1 presents the factors influencing footwear choice for secondary school students and parents of secondary school students. 111 students (93%) and 147 parents (96%) reported that comfort was either very important or moderately important to the type of shoe they, or their children, chose to wear to school. 44 students (37%) reported that the school guidelines and the appearance of the shoe were very important to the type of shoe they chose to wear to school. Only eight students (7%) considered their friend’s opinion very important. Female secondary school students were 2.1 [1.0 to 4.2] times as likely to rate appearance as having higher importance to shoe choice when compared to male secondary school students. Female students were 2.0 [1.0 to 4.1] times as likely to rate their parents’ opinion as having a low importance to their shoe choice when compared to male students. Figure 1 Importance of factors influencing footwear choice of secondary school students and parents of secondary school students. School footwear guidelines Of the 353 participants who responded to the survey, 258 (73%) attended, were a principal, or a parent at, a school that had set guidelines for student’s footwear. For the three principals who worked at schools with no footwear guidelines, parental pushback and tradition were cited as barriers to the implementation of guidelines. Twenty-two principals (29%) reported that occupational health and safety requirements were a major determinant of school footwear guidelines within their schools. Shoe cost and socioeconomic status was reported as an additional determinant to school guidelines by five principals (6%). Proportions for participant responses to school footwear guidelines are presented in Fig. 2. 68 principals (88%) reported that comfort was either very important or moderately important to the development of school footwear guidelines compared with 33 students (43%) and 67 parents (54%). Parents were 3.4 [2.0 to 5.8] and students 4.9 [2.7 to 9.1] times more likely to rate comfort as having lower importance to the development of school footwear guidelines when compared to principals. Parents were 2.8 [1.7 to 4.7] times and students 3.4 [1.9 to 6.2] times more likely to rate foot health as having lower importance to the school guidelines compared to principals. 22 principals (29%) considered healthcare recommendations very important to the development of school footwear guidelines, compared with only 19 parents (14%) and 11 students (15%) respectively. Parents were 2.9 [1.7 to 4.9] and students were 3.8 [2.1 to 6.9] times more likely to rate healthcare recommendations as having lower importance to the school guidelines compared to principals. Principals from non-government schools were 3.5 [1.3 to 9.9] times more likely to rate uniformity as having higher importance to footwear guidelines compared to principals from government schools. Overall, 56 principals (70%) reported that they would consider changing footwear guidelines for students while attending secondary school. Figure 2 Importance of factors influencing school footwear guidelines for principals, secondary school students and parents of secondary school students. Discussion This is the first study to investigate footwear requirements for secondary school students across Australia. Nearly all principals that participated in this study report that their school has guidelines on footwear for students to wear to school. Those principals that did not have guidelines for school footwear were based at a government school. Students spend an average of eight hours per day in their school shoes three days per week. Students are typically expected to wear an all-black closed in shoe with appropriate fixation (i.e., buckles or laces) with no differences in the shoes recommended between government and non-government schools. For the small number of schools that do not provide footwear guidelines, principals report that parental pushback and student resistance are the major barriers to implementation. Footwear comfort is highly valued by students and parents when selecting the shoes, they, or their children, choose to wear to school. These findings are consistent with studies performed in primary school aged children ( 8 , 25 ), as well as adult runners ( 15 , 18 ) and adults with inflammatory arthropathies ( 17 , 32 ). Parents of secondary school students consider their child’s opinion very important when selecting shoes. In contrast, more than half of students do not consider their parent’s opinion important. The majority of secondary school students who responded also did not consider the opinion of peers or friends important. This contrasts with previous literature on clothing choice in adolescents which suggests that peer opinion is highly influential on behaviour, particularly in older adolescent cohorts ( 20 , 21 ). Consistent with previous research in adolescent clothing choice, female students were twice as likely than male students to value appearance of the shoe important to footwear choice ( 33 ). For students, appearance of the shoe and comfort were the most important factors when selecting the shoes worn to school. The perception of comfort may be influenced by the appearance of the shoe as well as individual physiological factors, gender, wear time and psychosocial and developmental needs ( 24 , 25 , 34 ). As adolescence is a period of significant physical and psychosocial change, clothing, and by extension footwear, may provide adolescents with an opportunity to express their identity ( 35 ) which may go some way to explaining the high value placed on appearance by our cohort. Less than a quarter of parents and students feel that foot health is considered important when principals, or heads of school, design school footwear guidelines. However, our findings suggest that principals do believe these factors, along with occupational health and safety requirements, are important when designing footwear guidelines. Most parents and students believe that principal’s place greater importance on student uniformity and tradition when recommending school footwear for students. Previous research has demonstrated similar findings between principals and parents ( 29 ). Parents of primary school students were highly supportive of students wearing sports uniform daily in comparison to principals, who placed greater emphasis on school presentation. In our study principal’s report that they consider foot health, comfort, and presentation of the school important however, there is likely some differences in which factors take priority when developing school footwear guidelines. It is not clear whether our findings would have differed if participants were required to rank the factors in order of importance to footwear guideline development. Considering that 63% of students and 84% of parents indicated that school guidelines are important to footwear choice, a greater understanding of footwear guideline development may better support their decision making. Lower limb pain was commonly reported by participants in this survey, specifically at the knee and foot. Musculoskeletal pain of the lower limb is frequent in adolescents ( 3 ) and, according to the results of this study, may be influenced by shoes worn to school. Shoes are considered important to the prevention of running related injuries by adults ( 15 ). Running biomechanics, foot function, and balance can be influenced by shoes worn in adolescents and children ( 7 , 9 ). Footwear with elevated heel heights and stiff midsoles have been shown to elevate knee joint loading in adults and adults with anterior knee pain ( 36 , 37 ). However, there is no prospective evidence that demonstrates the effect that footwear has on pain and/or injury risk in an adolescent cohort ( 38 ). Recommendations from healthcare practitioners were not considered very important by most participants included in this survey. Considering that school shoes are the most common shoe worn by adolescents during the school week, identifying the effect that recommended school footwear may have on musculoskeletal health and lower limb biomechanics is needed. Limitations There were limitations of this study that require acknowledgement. Firstly, we did not collect responses from adolescents less than 14 years of age. This was due to the nature of the survey being online and anonymous. Adolescents aged 14 and above were included as they were deemed mature enough to understand the questions and respond appropriately. It is possible that younger adolescents may have different perceptions on the factors which influence their choice of school shoe that are not captured within this research. Secondly, we did not collect data on the specific type of shoe currently worn by students experiencing musculoskeletal pain in this study. Therefore, although secondary school students report musculoskeletal pain while wearing school footwear, an analysis of which type of school shoes contribute to pain was not possible. Future research may look to examine this. Finally, our sample only included data from students, parents, and principals from Australia. It is possible that perceptions relating to school footwear may differ across different cultures and countries. Similarly, selection bias is plausible as recruitment for this study was primarily performed across social media channels which may predispose similar cohorts of parents and students to participation or those already interested in this topic to respond. Conclusion Nearly all secondary school principals that participated in this survey required their students to wear an all-black, closed toed shoe for school. When designing these recommendations, principals report that they consider student comfort, foot health and school presentation to be highly important. In contrast, secondary school students and their parents believe that school tradition and student uniformity have higher importance to school footwear guidelines. Students and parents highly value comfort when choosing footwear worn to school. Greater communication from principals and schools on factors influencing their footwear guidelines may alleviate students and parents’ concerns relating to factors such as foot health and comfort. Abbreviations CI Confidence interval Declarations Ethics approval and consent to participate Ethics approval was granted through the Deakin University Human Research Ethics Committee (HEAG-H 16_2021). Participants provided informed consent on the online platform prior to participation within the study. Availability of data and materials Data from this survey is non-identifiable. Responses are anonymous with no identifying information collected nor any email or IP address information. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Funding This study is supported by PhD funding available through Deakin University up to the value of $2500. Author’s contributions NM and JB conceptualised the study. JB and NM drafted the manuscript. All authors designed the survey. All authors have read and approved the final manuscript. Authors information Centre for Sport Research, Deakin University, Waurn Ponds Victoria 3215, Australia. Centre for Sport Research, Deakin University, Waurn Ponds Victoria 3215, Australia. Centre for Sport Research, Deakin University, Burwood Victoria 3125, Australia. Centre for Sport Research, Deakin University, Burwood Victoria 3125, Australia School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia Queensland, 4072, Australia. Centre for Sport Research, Deakin University, Waurn Ponds Victoria 3215, Australia. 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Br J Sports Med. 2021;55(6):305-18. Supplementary Files Additionalfile1.pdf Cite Share Download PDF Status: Published Journal Publication published 29 Apr, 2023 Read the published version in Journal of Foot and Ankle Research → Version 1 posted Editorial decision: Minor revision 28 Mar, 2023 Reviewers agreed at journal 05 Mar, 2023 Editor assigned by journal 16 Feb, 2023 First submitted to journal 15 Feb, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2592371","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":180935437,"identity":"62cb4a86-519b-4eff-9893-b14a5f95f8a4","order_by":0,"name":"Natalie Mazzella","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIie3OsUvDQBTH8VeEZnngJj+wtP/CZUkj+sfklnQpLgfiUORAyFTqLP4VQXCOBOJyf0Aki9C1Q7JIBCnm5pJoN4f7Dse74cN7RC7X/y2ckKcFUQb7E38hYOLsaILIEvqdzM/ybdPegk8ft+lHa8Jr8u5fQKu8l1w8xULAgFHFyl+XUMTFDajoJ6KKROQn3WHVMgDXkBrdQOMhsqgzuQfP3s3869uS2a4j+yGy9PWrBouSgxMu7RYOMEoGiRrpAuybWJ1PDGTCsQrlZjF02HPTrq6m07c8bXbFnXzw8rSsPy97yWFj+0RHAJfL5XId9gO2z1PSa54RGAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-4624-6896","institution":"Deakin University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Natalie","middleName":"","lastName":"Mazzella","suffix":""},{"id":180935438,"identity":"45c175d7-8eb0-4640-be78-9de587c8151b","order_by":1,"name":"Aaron Fox","email":"","orcid":"","institution":"Deakin University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Aaron","middleName":"","lastName":"Fox","suffix":""},{"id":180935439,"identity":"225bd0cb-8957-40f0-9d53-150e0afcfbb4","order_by":2,"name":"Natalie Saunders","email":"","orcid":"","institution":"Deakin University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Natalie","middleName":"","lastName":"Saunders","suffix":""},{"id":180935440,"identity":"fd48a2ce-3eef-4802-b80d-059a16075b15","order_by":3,"name":"Danielle Trowell","email":"","orcid":"","institution":"Deakin University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Danielle","middleName":"","lastName":"Trowell","suffix":""},{"id":180935441,"identity":"f5d75c89-5552-4fb6-a4c7-76725941c5c3","order_by":4,"name":"Bill Vicenzino","email":"","orcid":"","institution":"University of Queensland - Saint Lucia Campus: The University of Queensland","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bill","middleName":"","lastName":"Vicenzino","suffix":""},{"id":180935442,"identity":"3f333d53-3d4b-409f-a6f0-8f7d60bda811","order_by":5,"name":"Jason Bonacci","email":"","orcid":"https://orcid.org/0000-0002-4333-3214","institution":"Deakin University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jason","middleName":"","lastName":"Bonacci","suffix":""}],"badges":[],"createdAt":"2023-02-15 22:51:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2592371/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2592371/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13047-023-00624-0","type":"published","date":"2023-04-29T20:38:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":34042050,"identity":"02afb933-9b22-4a61-8b3c-fcd661647e24","added_by":"auto","created_at":"2023-03-10 00:04:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22140,"visible":true,"origin":"","legend":"\u003cp\u003eImportance of\u003cstrong\u003e \u003c/strong\u003efactors influencing footwear choice of secondary school students and parents of secondary school students.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2592371/v1/5529778290087c442038ffee.png"},{"id":34042051,"identity":"3f56e27c-c420-4ca5-abcd-358b4e584c31","added_by":"auto","created_at":"2023-03-10 00:04:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":44148,"visible":true,"origin":"","legend":"\u003cp\u003eImportance of factors influencing school footwear guidelines for principals, secondary school students and parents of secondary school students.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2592371/v1/8373d6b6588ec54fd70ac159.png"},{"id":44727813,"identity":"2a47dd59-d7ee-48c4-a408-e413ac317842","added_by":"auto","created_at":"2023-10-16 20:55:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":520510,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2592371/v1/08ee624d-beb5-4848-9887-3b53640d00b2.pdf"},{"id":34042052,"identity":"cd24c304-370d-4299-8d78-eb0a0ec4e279","added_by":"auto","created_at":"2023-03-10 00:04:42","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":270288,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2592371/v1/6f19b8514c3886758a84e3f3.pdf"}],"financialInterests":"","formattedTitle":"Australian secondary school principals’, parents’, and students’ attitudes to prescribed school footwear guidelines.","fulltext":[{"header":"Background","content":"\u003cp\u003eAdolescence is a period of rapid growth and development that has been accompanied with an increased rate of musculoskeletal pain and injury compared to childhood, particularly at the knee and foot (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Adolescents spend a large percentage of their weekday time at school, where they often must adhere to school uniform guidelines (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Anecdotally, secondary school uniform guidelines often require students to dress in formal attire and black, leather shoes, though secondary school footwear requirements have not been documented. School shoes are often designed with stiff, inflexible midsoles, a closed toe and elevated heel heights (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Recent evidence has suggested that some of these footwear characteristics increase knee joint loads, reduce tactile feedback during walking and running, and reduce dynamic balance when compared to being barefoot (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Cross-sectional studies have identified changes in paediatric foot development and gait characteristics including step length, velocity, and cadence when children go from being barefoot to shod in school and/or sport shoes (\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). No research has yet investigated whether similar changes are apparent in an adolescent cohort when wearing school footwear.\u003c/p\u003e \u003cp\u003e Little is known about the rationale and factors that contribute to school footwear guidelines for adolescents while attending secondary school. Research focused on footwear choice has primarily centred on adults and athletic footwear, with a common belief that footwear is an important factor in the prevention of running related injuries and the management of inflammatory arthropathy (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Recreational adult runners believe that footwear for children and adolescents should include structural support (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) but there is no current consensus on the best options for school footwear for children and adolescents (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Early in adolescence, parents and guardians are highly influential on their dependent\u0026rsquo;s behaviour (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). As adolescents mature, peer and friends\u0026rsquo; opinions have a greater influence on establishing behavioural norms (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Limited research has investigated what drives footwear selection in an adolescent specific cohort. Adolescent cross-country runners report that friends and family are a major source of information influencing their running shoe choice (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). However, adult footwear knowledge is often influenced by retail footwear stores, popular beliefs, and peers, as opposed to scientific evidence (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). It is likely that parents\u0026rsquo; opinions are a major contributor to the selection of school footwear in adolescents. There is a need for greater understanding and consideration of child and adolescent opinions in footwear research (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Exploring what secondary school students, as well as parents of secondary school students, consider important when choosing school footwear requires investigation.\u003c/p\u003e \u003cp\u003e Development of school uniform guidelines is often the role of senior heads of school. There is little understanding on the determinants that inform these guidelines. Restrictive uniforms, peer pressure and a lack of school support are reported as barriers to participation in physical activity across adolescence (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). A recent study of principals and parents investigated barriers to school uniform changes in primary schools (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Principals were not supportive of a uniform policy that allowed children to wear sports or recreational uniform full time, citing reasons such as school status and cost as barriers to change. In contrast, parents were supportive of the change, indicating a potential discord between parents and principals on school uniform guideline policies. It is not clear if these findings also extend to school footwear recommendations or across secondary schools.\u003c/p\u003e \u003cp\u003eGiven the effect that footwear can have on paediatric gait, and the barriers that traditional uniforms pose to physical activity participation (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), identifying the factors most important when selecting footwear for school is needed. Understanding what informs the development of uniform guidelines for school principals also requires investigation as school guidelines are a potential determinant to the selection of school footwear worn by students. Therefore, the aims of this study were to describe (i) current school footwear guidelines in secondary schools across Australia, (ii) factors that influence footwear choice in secondary school students and their parents, and (iii) principals, parents, and students\u0026rsquo; beliefs on factors which contribute to school footwear guidelines.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study was a cross-sectional anonymous online survey and has been reported using the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Ethical approval for this study was granted from the Deakin University Human Research Ethics Committee. Participants were informed of the purpose of the study, the research team involved and the expected completion time of the survey upon opening the survey weblink. Participants were informed that consent was implied upon completion of the survey on the online platform. Participants were advised that participation was voluntary and that they were free to exit the survey at any time. Incomplete responses were excluded from the survey analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment\u003c/h2\u003e \u003cp\u003eSecondary school students and parents of secondary school students were recruited from all states and territories across Australia from March 2021 to July 2022. Targeted advertising on social media was used in combination with posters placed at shoe stores and local sports medicine clinics. Advertisements were also distributed in school newsletters following approval from the relevant state education department and school principals. Principals were recruited from the contact information listed on their school\u0026rsquo;s website inviting them to participate in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eEligibility criteria for each participant group were as follows: (i) students aged between 14\u0026ndash;19 years of age and currently enrolled and attending a secondary school; (ii) parents with a child/children aged between 14\u0026ndash;19 years of age currently enrolled and attending a secondary school; (iii) principals employed as a secondary school principal within a government or non-government school.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eSurvey instrumentation\u003c/h2\u003e \u003cp\u003eA survey that was estimated to take 10-minutes was administered online using Qualtrics (Qualtrics, Provo, United States). Participants completed the survey once, at their own convenience (see Additional file 1). The survey was piloted by the research team and a small number of adolescents (aged 14\u0026ndash;19 years) prior to distribution. To protect anonymity of responses, no IP data was collected or stored during the data recording process.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSurvey questionnaire\u003c/h2\u003e \u003cp\u003eThe survey was comprised of five sections (Additional file 1). Section one collected baseline demographics such as age, gender, and school type. Section two gathered information on current footwear guidelines and footwear requirements for students (such as colour, fixation, material). Section three required respondents to indicate how important the following factors were to footwear choice: shoe comfort, school footwear guidelines, shoe price, opinion of peers and friends, shoe appearance, and healthcare recommendations. A four-point Likert scale was used for participants to respond from not at all important to very important. As secondary school principals are not involved in footwear selection, they did not provide responses to factors influencing footwear choice (section three).\u003c/p\u003e \u003cp\u003e Section four assessed factors influencing the development of guidelines while at secondary school. Factors included foot health, school tradition, comfort, student uniformity, presentation of the school in the community and healthcare recommendations. Principals were asked how important these factors are to the development of their school footwear guidelines. Parents and students were asked how important they believed these factors are to the development of school footwear guidelines at the school they, or their children, attend. Participants responded to this using the same four-point Likert scale. If the participant\u0026rsquo;s school did not provide guidelines for student footwear, they were exempt from providing responses to this section of the survey. For any schools that did not provide guidelines for footwear, participants were asked to indicate reasons as to why they did not have guidelines.\u003c/p\u003e \u003cp\u003eFinally, students and parents provided responses relating to current or past musculoskeletal pain and the effect that footwear has on their musculoskeletal health and/or pain (section five). Participants were able to indicate multiple sites of pain if applicable. Principals did not provide responses to this section of the survey. At the end of the survey, participants were given the opportunity to add any information using an open-ended response. Participants were able to review their responses prior to submission of the survey.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eSurvey responses were exported from Qualtrics into Microsoft Excel and RStudio (Version 3.5.2, RStudio Inc, Posit, Boston, United States) for analysis. Descriptive statistics were used to describe the characteristics of the principal, student, and parent responses. Postcode data from respondents was used to classify the school\u0026rsquo;s location as either urban or rural using the Australian Statistical Geography Standard (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). To protect anonymity of responses from principals, postcode data for their school was not collected. Participant responses across common items were reported descriptively to determine the frequency of each response.\u003c/p\u003e \u003cp\u003eResponses between parents and students, and between male and female students, on factors that influence their footwear choice were compared using proportional odds logistic regression. The relative importance placed on factors influencing footwear guidelines was also assessed. Students and parents\u0026rsquo; responses were compared to principal responses using proportional odds logistic regression. Differences in responses between principals from non-government and government schools were compared using proportional odds logistics regression. Significance was set at an alpha of \u0026lt;\u0026thinsp;0.05 and odds ratios (95% confidence intervals [CI]) were calculated.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e405 participants commenced the survey. Of these, 52 responses were excluded due to being incomplete (n\u0026thinsp;=\u0026thinsp;29), and/or being less than 14 years of age (n\u0026thinsp;=\u0026thinsp;21) or being older than 19 years of age for student responses (n\u0026thinsp;=\u0026thinsp;2). 120 secondary school students, 153 parents and 80 secondary school principals completed the survey in full (n\u0026thinsp;=\u0026thinsp;353). Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e provides a summary of the demographic characteristics of the participants. Students spent an average of 7.98 [1.95] hours in their school shoes for an average 3 days per week.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTable 1: Participant characteristics\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eCharacteristics\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003en (%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cem\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003ePrincipals\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eAll\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e80 (22.7%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Female\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e34 (42.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Male\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Prefer not to say\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e44 (55.0%)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e2 (2.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eYears in current role\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; 0-10 years\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026gt;10 years\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e59 (73.8%)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e21 (26.2%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eSector\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Non-Government\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Government\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e30 (37.5%)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e50 (62.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cem\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eStudents\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eAll\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e120 (34.0%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Female\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e75 (62.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Male\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Prefer not to say\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e42 (35.0%)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e3 (2.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eAge\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eSector\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Government\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Non-Government\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e16.1 (1.48) years\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e64 (53.3%)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e56 (46.7%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eLocation\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Rural\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Urban\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e73 (60.8%)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e47 (39.2%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cem\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eParents\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eAll\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e153 (43.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Female\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e143 (93.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Male\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e10 (6.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eLocation\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Rural\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e98 (64.1%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Urban\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150.25pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:200%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e55 (35.9%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec10\"\u003e\n \u003ch2\u003eFootwear characteristics\u003c/h2\u003e\n \u003cp\u003e77 principals (96%) had set guidelines for school footwear for students. 87% (n\u0026thinsp;=\u0026thinsp;67) of these principals required student\u0026rsquo;s footwear to be black and include a closed toe box, 73% (n\u0026thinsp;=\u0026thinsp;56) reported a leather shoe was required and 57% (n\u0026thinsp;=\u0026thinsp;44) reported fixation such as laces or buckles was required. There were no differences between principals from government and non-government schools on the type of shoe recommended for school.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec11\"\u003e\n \u003ch2\u003eMusculoskeletal health\u003c/h2\u003e\n \u003cp\u003e51 secondary school students (43%) experienced current pain in their legs or feet, and of these 36 students (71%) reported that their pain was worse when wearing school shoes. 28 students (46%) reported knee pain, 29 students (47%) reported foot and/or leg pain and 4 students (7%) reported dermatological pain (i.e., blisters or ingrown toenails).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec12\"\u003e\n \u003ch2\u003eFactors influencing footwear choices\u003c/h2\u003e\n \u003cp\u003eFigure 1 presents the factors influencing footwear choice for secondary school students and parents of secondary school students. 111 students (93%) and 147 parents (96%) reported that comfort was either very important or moderately important to the type of shoe they, or their children, chose to wear to school. 44 students (37%) reported that the school guidelines and the appearance of the shoe were very important to the type of shoe they chose to wear to school. Only eight students (7%) considered their friend\u0026rsquo;s opinion very important. Female secondary school students were 2.1 [1.0 to 4.2] times as likely to rate appearance as having higher importance to shoe choice when compared to male secondary school students. Female students were 2.0 [1.0 to 4.1] times as likely to rate their parents\u0026rsquo; opinion as having a low importance to their shoe choice when compared to male students.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFigure 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eImportance of factors influencing footwear choice of secondary school students and parents of secondary school students.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec13\"\u003e\n \u003ch2\u003eSchool footwear guidelines\u003c/h2\u003e\n \u003cp\u003eOf the 353 participants who responded to the survey, 258 (73%) attended, were a principal, or a parent at, a school that had set guidelines for student\u0026rsquo;s footwear. For the three principals who worked at schools with no footwear guidelines, parental pushback and tradition were cited as barriers to the implementation of guidelines. Twenty-two principals (29%) reported that occupational health and safety requirements were a major determinant of school footwear guidelines within their schools. Shoe cost and socioeconomic status was reported as an additional determinant to school guidelines by five principals (6%).\u003c/p\u003e\n \u003cp\u003eProportions for participant responses to school footwear guidelines are presented in Fig.\u0026nbsp;2. 68 principals (88%) reported that comfort was either very important or moderately important to the development of school footwear guidelines compared with 33 students (43%) and 67 parents (54%). Parents were 3.4 [2.0 to 5.8] and students 4.9 [2.7 to 9.1] times more likely to rate comfort as having lower importance to the development of school footwear guidelines when compared to principals.\u003c/p\u003e\n \u003cp\u003eParents were 2.8 [1.7 to 4.7] times and students 3.4 [1.9 to 6.2] times more likely to rate foot health as having lower importance to the school guidelines compared to principals. 22 principals (29%) considered healthcare recommendations very important to the development of school footwear guidelines, compared with only 19 parents (14%) and 11 students (15%) respectively. Parents were 2.9 [1.7 to 4.9] and students were 3.8 [2.1 to 6.9] times more likely to rate healthcare recommendations as having lower importance to the school guidelines compared to principals.\u003c/p\u003e\n \u003cp\u003ePrincipals from non-government schools were 3.5 [1.3 to 9.9] times more likely to rate uniformity as having higher importance to footwear guidelines compared to principals from government schools. Overall, 56 principals (70%) reported that they would consider changing footwear guidelines for students while attending secondary school.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFigure 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eImportance of factors influencing school footwear guidelines for principals, secondary school students and parents of secondary school students.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first study to investigate footwear requirements for secondary school students across Australia. Nearly all principals that participated in this study report that their school has guidelines on footwear for students to wear to school. Those principals that did not have guidelines for school footwear were based at a government school. Students spend an average of eight hours per day in their school shoes three days per week. Students are typically expected to wear an all-black closed in shoe with appropriate fixation (i.e., buckles or laces) with no differences in the shoes recommended between government and non-government schools. For the small number of schools that do not provide footwear guidelines, principals report that parental pushback and student resistance are the major barriers to implementation.\u003c/p\u003e \u003cp\u003eFootwear comfort is highly valued by students and parents when selecting the shoes, they, or their children, choose to wear to school. These findings are consistent with studies performed in primary school aged children (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), as well as adult runners (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and adults with inflammatory arthropathies (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Parents of secondary school students consider their child\u0026rsquo;s opinion very important when selecting shoes. In contrast, more than half of students do not consider their parent\u0026rsquo;s opinion important. The majority of secondary school students who responded also did not consider the opinion of peers or friends important. This contrasts with previous literature on clothing choice in adolescents which suggests that peer opinion is highly influential on behaviour, particularly in older adolescent cohorts (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Consistent with previous research in adolescent clothing choice, female students were twice as likely than male students to value appearance of the shoe important to footwear choice (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). For students, appearance of the shoe and comfort were the most important factors when selecting the shoes worn to school. The perception of comfort may be influenced by the appearance of the shoe as well as individual physiological factors, gender, wear time and psychosocial and developmental needs (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). As adolescence is a period of significant physical and psychosocial change, clothing, and by extension footwear, may provide adolescents with an opportunity to express their identity (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) which may go some way to explaining the high value placed on appearance by our cohort.\u003c/p\u003e \u003cp\u003e Less than a quarter of parents and students feel that foot health is considered important when principals, or heads of school, design school footwear guidelines. However, our findings suggest that principals do believe these factors, along with occupational health and safety requirements, are important when designing footwear guidelines. Most parents and students believe that principal\u0026rsquo;s place greater importance on student uniformity and tradition when recommending school footwear for students. Previous research has demonstrated similar findings between principals and parents (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Parents of primary school students were highly supportive of students wearing sports uniform daily in comparison to principals, who placed greater emphasis on school presentation. In our study principal\u0026rsquo;s report that they consider foot health, comfort, and presentation of the school important however, there is likely some differences in which factors take priority when developing school footwear guidelines. It is not clear whether our findings would have differed if participants were required to rank the factors in order of importance to footwear guideline development. Considering that 63% of students and 84% of parents indicated that school guidelines are important to footwear choice, a greater understanding of footwear guideline development may better support their decision making.\u003c/p\u003e \u003cp\u003eLower limb pain was commonly reported by participants in this survey, specifically at the knee and foot. Musculoskeletal pain of the lower limb is frequent in adolescents (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and, according to the results of this study, may be influenced by shoes worn to school. Shoes are considered important to the prevention of running related injuries by adults (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Running biomechanics, foot function, and balance can be influenced by shoes worn in adolescents and children (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Footwear with elevated heel heights and stiff midsoles have been shown to elevate knee joint loading in adults and adults with anterior knee pain (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). However, there is no prospective evidence that demonstrates the effect that footwear has on pain and/or injury risk in an adolescent cohort (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Recommendations from healthcare practitioners were not considered very important by most participants included in this survey. Considering that school shoes are the most common shoe worn by adolescents during the school week, identifying the effect that recommended school footwear may have on musculoskeletal health and lower limb biomechanics is needed.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThere were limitations of this study that require acknowledgement. Firstly, we did not collect responses from adolescents less than 14 years of age. This was due to the nature of the survey being online and anonymous. Adolescents aged 14 and above were included as they were deemed mature enough to understand the questions and respond appropriately. It is possible that younger adolescents may have different perceptions on the factors which influence their choice of school shoe that are not captured within this research. Secondly, we did not collect data on the specific type of shoe currently worn by students experiencing musculoskeletal pain in this study. Therefore, although secondary school students report musculoskeletal pain while wearing school footwear, an analysis of which type of school shoes contribute to pain was not possible. Future research may look to examine this. Finally, our sample only included data from students, parents, and principals from Australia. It is possible that perceptions relating to school footwear may differ across different cultures and countries. Similarly, selection bias is plausible as recruitment for this study was primarily performed across social media channels which may predispose similar cohorts of parents and students to participation or those already interested in this topic to respond.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNearly all secondary school principals that participated in this survey required their students to wear an all-black, closed toed shoe for school. When designing these recommendations, principals report that they consider student comfort, foot health and school presentation to be highly important. In contrast, secondary school students and their parents believe that school tradition and student uniformity have higher importance to school footwear guidelines. Students and parents highly value comfort when choosing footwear worn to school. Greater communication from principals and schools on factors influencing their footwear guidelines may alleviate students and parents\u0026rsquo; concerns relating to factors such as foot health and comfort.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eConfidence interval\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was granted through the Deakin University Human Research Ethics Committee (HEAG-H 16_2021). Participants provided informed consent on the online platform prior to participation within the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from this survey is non-identifiable. Responses are anonymous with no identifying information collected nor any email or IP address information.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is supported by PhD funding available through Deakin University up to the value of $2500. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNM and JB conceptualised the study. JB and NM drafted the manuscript. All authors designed the survey. All authors have read and approved the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors information\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eCentre for Sport Research, Deakin University, Waurn Ponds Victoria 3215, Australia.\u003c/li\u003e\n \u003cli\u003eCentre for Sport Research, Deakin University, Waurn Ponds Victoria 3215, Australia.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCentre for Sport Research, Deakin University, Burwood Victoria 3125, Australia.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCentre for Sport Research, Deakin University, Burwood Victoria 3125, Australia\u003c/li\u003e\n \u003cli\u003eSchool of Health and Rehabilitation Sciences, The University of Queensland, St Lucia Queensland, 4072, Australia. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCentre for Sport Research, Deakin University, Waurn Ponds Victoria 3215, Australia. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBelikan P, Farber LC, Abel F, Nowak TE, Drees P, Mattyasovszky SG. 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Gait Posture. 2021;87:87-94.\u003c/li\u003e\n\u003cli\u003eSayer TA, Hinman RS, Paterson KL, Bennell KL, Fortin K, Kasza J, et al. Differences and mechanisms underpinning a change in the knee flexion moment while running in stability and neutral footwear among young females. J Foot Ankle Res. 2019;12:1.\u003c/li\u003e\n\u003cli\u003eMullen S, Toby E. Adolescent runners: The effect of training shoes on running kinematics. Journal of Pediatric Orthopaedics. 2013;33(4):453-7.\u003c/li\u003e\n\u003cli\u003eLythgo N, Wilson C, Galea M. Basic gait and symmetry measures for primary school-aged children and young adults whilst walking barefoot and with shoes. Gait \u0026amp; Posture. 2009;30(4):502-6.\u003c/li\u003e\n\u003cli\u003eCranage S, Perraton L, Bowles KA, Williams C. The impact of shoe flexibility on gait, pressure and muscle activity of young children. A systematic review. J Foot Ankle Res. 2019;12:55.\u003c/li\u003e\n\u003cli\u003eWegener C, Smith R, Hunt A, Vanwanseele B, Greene A, Burns J. Children\u0026rsquo;s rearfoot and midfoot motion while walking in school shoes. J Foot Ankle Res. 2011;4(S1).\u003c/li\u003e\n\u003cli\u003eWegener C, Hunt AE, Vanwanseele B, Burns J, Smith RM. Effect of children\u0026rsquo;s shoes on gait: a systematic review and meta analysis. J Foot Ankle Res. 2011;4(3).\u003c/li\u003e\n\u003cli\u003eDhillon GK, Hunt MA, Reid AL, Esculier JF. What are the perceptions of runners and healthcare professionals on footwear and running injury risk? BMJ Open Sport Exerc Med. 2020;6(1):e000767.\u003c/li\u003e\n\u003cli\u003eMcRitchie M, Branthwaite H, Chockalingam N. Footwear choices for painful feet - an observational study exploring footwear and foot problems in women. J Foot Ankle Res. 2018;11:23.\u003c/li\u003e\n\u003cli\u003eBrenton-Rule A, Dalbeth N, Edwards NL, Rome K. Experience of finding footwear and factors contributing to footwear choice in people with gout: a mixed methods study using a web-based survey. J Foot Ankle Res. 2019;12:3.\u003c/li\u003e\n\u003cli\u003eNguyen AP, Gillain L, Delieux L, Detrembleur C, Mahaudens P, Esculier J-F. Opinions about running shoes in runners and non-runners. Footwear Science. 2022:1-12.\u003c/li\u003e\n\u003cli\u003eDavies N, Branthwaite H, Chockalingam N. Where should a school shoe provide flexibility and support for the asymptomatic 6- to 10-year-olds and on what information is this based? A Delphi yielded consensus. Prosthetics and Orthotics International. 2015;39(3):213-8.\u003c/li\u003e\n\u003cli\u003eKirby J, Levin KA, Inchley J. Parental and peer influences on physical activity among Scottish adolescents: A longitudinal study. Journal of Physical Activity and Health. 2011;8:785-93.\u003c/li\u003e\n\u003cli\u003eFuligni AJ, Eccles JS, Barber BL, Clements P. Early adolescent peer orientation and adjustment during high school. Developmental Psychology. 2001;37(1):28-36.\u003c/li\u003e\n\u003cli\u003eRidgers ND, Timperio A, Crawford D, Salmon J. What factors are associated with adolescents\u0026apos; school break time physical activity and sedentary time? PLoS One. 2013;8(2):e56838.\u003c/li\u003e\n\u003cli\u003eEnke RC, Laskowski ER, Thomsen KM. Running shoe selection criteria among adolescent cross-country runners. PM\u0026amp;R. 2009;1(9):816-9.\u003c/li\u003e\n\u003cli\u003eMorrison SC, Price C, McClymont J, Nester C. Big issues for small feet: developmental, biomechanical and clinical narratives on children\u0026apos;s footwear. J Foot Ankle Res. 2018;11:39.\u003c/li\u003e\n\u003cli\u003ePrice C, Skidmore S, Ratcliffe J, Williams A. Children should be seen and also heard: An explorative qualitative study into the influences on children\u0026apos;s choice of footwear, their perception of comfort and the language they use to describe footwear experiences. J Foot Ankle Res. 2021;14(1):49.\u003c/li\u003e\n\u003cli\u003eAllender S, Cowburn G, Foster C. Understanding participation in sport and physical activity among children and adults: a review of qualitative studies. Health Educ Res. 2006;21(6):826-35.\u003c/li\u003e\n\u003cli\u003eDuffey K, Barbosa A, Whiting S, Mendes R, Yordi Aguirre I, Tcymbal A, et al. Barriers and Facilitators of Physical Activity Participation in Adolescent Girls: A Systematic Review of Systematic Reviews. Front Public Health. 2021;9:743935.\u003c/li\u003e\n\u003cli\u003eMartins J, Marques A, Sarmento H, Carreiro da Costa F. Adolescents\u0026apos; perspectives on the barriers and facilitators of physical activity: a systematic review of qualitative studies. Health Educ Res. 2015;30(5):742-55.\u003c/li\u003e\n\u003cli\u003eMcCarthy N, Hope K, Sutherland R, Campbell E, Hodder R, Wolfenden L, et al. Australian Primary School Principals\u0026apos;, Teachers\u0026apos;, and Parents\u0026apos; Attitudes and Barriers to Changing School Uniform Policies From Traditional Uniforms to Sports Uniforms. Journal of Physical Activity and Health. 2020;17:1019-24.\u003c/li\u003e\n\u003cli\u003eEysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2004;6(3):e34.\u003c/li\u003e\n\u003cli\u003eAustralian Bureau of Statistics. Australian Statistical Geography Standard 2022. Available from: https://www.abs.gov.au/statistics/standards/australian-statistical-geography-standard-asgs-edition-3/jul2021-jun2026. Accessed 15 September 2022. \u003c/li\u003e\n\u003cli\u003eRome K, Frecklington M, McNair P, Gow P, Dalbeth N. Footwear characteristics and factors influencing footwear choice in patients with gout. Arthritis Care Res. 2011;63(11):1599-604.\u003c/li\u003e\n\u003cli\u003eChen‐Yu JH, Seock YK. Adolescents\u0026rsquo; Clothing Purchase Motivations, Information Sources, and Store Selection Criteria: A Comparison of Male/Female and Impulse/Nonimpulse Shoppers. Family and Consumer Sciences Research Journal. 2002;31(1):50-77.\u003c/li\u003e\n\u003cli\u003eMenz HB, Bonanno DR. Footwear comfort: a systematic search and narrative synthesis of the literature. J Foot Ankle Res. 2021;14(1):63.\u003c/li\u003e\n\u003cli\u003eBadaoui K, Lebrun A-M, Su C-J, Bouchet P. The influence of personal and social identity on the clothing consumption of adolescents. Canadian Journal of Administrative Sciences / Revue Canadienne des Sciences de l\u0026apos;Administration. 2018;35(1):65-78.\u003c/li\u003e\n\u003cli\u003eHo KY, Blanchette MG, Powers CM. The influence of heel height on patellofemoral joint kinetics during walking. Gait \u0026amp; Posture. 2012;36(2):271-5.\u003c/li\u003e\n\u003cli\u003eBonacci J, Hall M, Fox A, Saunders N, Shipsides T, Vicenzino B. The influence of cadence and shoes on patellofemoral joint kinetics in runners with patellofemoral pain. J Sci Med Sport. 2018;21(6):574-8.\u003c/li\u003e\n\u003cli\u003eKrabak BJ, Roberts WO, Tenforde AS, Ackerman KE, Adami PE, Baggish AL, et al. Youth running consensus statement: Minimising risk of injury and illness in youth runners. Br J Sports Med. 2021;55(6):305-18.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-foot-and-ankle-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jfar","sideBox":"Learn more about [Journal of Foot and Ankle Research](http://jfootankleres.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/jfar/default.aspx","title":"Journal of Foot and Ankle Research","twitterHandle":"@jfootankleres","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent, shoes, footwear, health, youth","lastPublishedDoi":"10.21203/rs.3.rs-2592371/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2592371/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Adolescents are often required to wear footwear that adheres to uniform guidelines at secondary school. There is a paucity of literature on factors influencing school footwear choice and what drives the development of school footwear guidelines. The aims of this study were to describe (i) current school footwear guidelines in secondary schools across Australia, (ii) factors that influence footwear choice in secondary school students and their parents, and (iii) principals, parents, and students\u0026rsquo; beliefs on factors which contribute to school footwear guidelines.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn online survey was distributed to principals, secondary school students (aged 14\u0026ndash;19 years) and their parents across Australia. The survey included questions on current school footwear guidelines, factors influencing footwear choice (for students and parents), participants beliefs on the effect footwear has on musculoskeletal health, current and previous lower limb pain, and beliefs on factors that contribute to school footwear guidelines. Parent and student responses to factors that influence their footwear choice were compared using proportional odds logistic regression. Students and parents\u0026rsquo; responses to factors influencing footwear guidelines were compared to principal responses using proportional odds logistic regression. Significance was set at an alpha of \u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e80 principals, 153 parents and 120 secondary school students responded to the survey. 96% (77/80) of principals reported that their schools have set guidelines for school footwear. 88% of principals considered comfort to be important when developing school footwear guidelines, though parents and students were 3.4 and 4.9 times more likely than principals to rate comfort as having lower importance in the development of guidelines. More than 40% of students reported experiencing musculoskeletal pain, and 70% of these students reported the pain to be exacerbated when in their school shoes. Less than a third of participants considered healthcare recommendations important to the development of footwear guidelines.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e Nearly all principals that participated in this survey had set guidelines for school footwear. There is a discord between parents, students, and principals on the importance that factors such as comfort, play in the development of school footwear guidelines.\u003c/p\u003e","manuscriptTitle":"Australian secondary school principals’, parents’, and students’ attitudes to prescribed school footwear guidelines.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-10 00:04:37","doi":"10.21203/rs.3.rs-2592371/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2023-03-29T03:50:23+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2023-03-05T17:22:31+00:00","index":0,"fulltext":""},{"type":"editorAssigned","content":"","date":"2023-02-16T16:37:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Foot and Ankle Research","date":"2023-02-15T17:51:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-foot-and-ankle-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jfar","sideBox":"Learn more about [Journal of Foot and Ankle Research](http://jfootankleres.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/jfar/default.aspx","title":"Journal of Foot and Ankle Research","twitterHandle":"@jfootankleres","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"06da0881-113e-403e-9765-69e252aaf98a","owner":[],"postedDate":"March 10th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:46:39+00:00","versionOfRecord":{"articleIdentity":"rs-2592371","link":"https://doi.org/10.1186/s13047-023-00624-0","journal":{"identity":"journal-of-foot-and-ankle-research","isVorOnly":false,"title":"Journal of Foot and Ankle Research"},"publishedOn":"2023-04-29 20:38:05","publishedOnDateReadable":"April 29th, 2023"},"versionCreatedAt":"2023-03-10 00:04:37","video":"","vorDoi":"10.1186/s13047-023-00624-0","vorDoiUrl":"https://doi.org/10.1186/s13047-023-00624-0","workflowStages":[]},"version":"v1","identity":"rs-2592371","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2592371","identity":"rs-2592371","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}