Important features of retail shoes for women with rheumatoid arthritis: A Delphi consensus survey (2024)

Peta Ellen Tehan, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing,^1,2,* William J. Taylor, Methodology, Supervision, Writing – review & editing,³ Matthew Carroll, Project administration, Software, Supervision, Writing – review & editing,² Nicola Dalbeth, Methodology, Project administration, Supervision, Writing – review & editing,^4,5 and Keith Rome, Conceptualization, Methodology, Project administration, Resources, Supervision, Writing – review & editing²

Expert identification

A sample of health professionals were identified by the researchers (PT and KR) from the United States of America, Europe, Australia and New Zealand, with expertise in RA and footwear. Participants were identified through professional networks, including New Zealand Rheumatology Association, Podiatric Rheumatology Care Association (UK), literature and guideline searching. Seventy-five (n = 75) were approached in writing and invited to participate. This number allowed for drop out at each stage. Dando [10] reported that the inclusion of a wide range of professions from a range of clinical backgrounds with a geographical diversity is good practice as it develops the participants to be a representative group [11]. A heterogenous group, with a range of stakeholders, encourages different outlooks and decision-making, which in turn enriches the data leading to better outcomes of credibility and acceptability [12]. The panel inclusion criteria were health practitioners or researchers with specialised knowledge in rheumatology and/or footwear prescription. This study received ethical approval from the Health and Disability Ethics Committee, New Zealand (17/NTB/3/AM03). All panel members provided informed electronic consent prior to participation.

Data collection

The Delphi technique was used to elicit the opinions of participating health professionals through three successive rounds of iterative questionnaires using online survey software (Qualtrics XM, Provo, UT) to identify specific retail footwear features that were important for women with RA. Responses to each round of the Delphi were collated, analysed and the results returned to participants in the form of another questionnaire until an acceptable degree of consensus was achieved [13, 14]. Reminders to participants were sent via email one week following the opening of the survey round, and participants were given an additional week to complete the survey before being classified as a non-responder.

The first round consisted of demographic and descriptive questions followed by one open-ended question, asking participants to list up to ten specific footwear features that they advised women with RA to look for when seeking retail footwear. Items for round two were generated based on the open-ended results of round one combined with additional items from the results of a scoping review which mapped the literature assessing footwear in arthritis [15], and a qualitative analysis of female patients with RAs’ perspectives on retail footwear [8]. In round two, participants were asked to rate fifty-eight (n = 58) items relating to retail footwear features for women with RA (S1 Table). All participants used a 9-point rating scale (1 = not at all important; 9 = absolutely essential) [16]. Consensus was defined by the RAND/University of California Los Angeles disagreement index (RAND/UCLA DI) whereby values >1 indicated panel disagreement or extreme variation in findings [16]. The lower the RAND/UCLA DI, the lower the level of disagreement (i.e. the higher the level of agreement) [16]. Medians, 30^th and 70^th percentile ranges were calculated for each item. Items which had median scores of between four and six, or where there was disagreement (RAND/UCLA DI > 1) were considered lacking consensus and were taken back to participants for further consideration in round three. Items where the median score was between seven and nine and RAND/UCLA DI <1 were considered agreed important, and items with a median score between one and three and a RAND/UCLA DI <1 were considered agreed not important. In round three, each item also included the group median rating and 30-70^th percentile range results from round two. All participants were emailed a copy of their individual responses from round two. The third round gave participants opportunity to change their answers in light of the group’s average. If the median score on items without consensus remained unchanged between rounds, the items were confirmed as lacking consensus.

Data analysis

Demographic data for all participants was collected and analysed using IBM Statistical Packages for the Social Sciences (SPSS) Version 25 for Windows (SPSS Inc., Armonk, NY, USA). Means and standard deviations were calculated for descriptive data, and for content items, medians and 30^th- 70th percentile ranges were calculated.

Delphi panel

Thirty-nine (n = 39) participants responded to the first round (Table 1), seventeen (n = 44%) were female with mean (SD) of 23 (10) years since qualifying as a health professional. The majority of participants were podiatrists (n = 21, 54%), but also included rheumatologists (n = 12, 31%), a physiotherapist (n = 1, 3%), rheumatology nurses (N = 2, 5%), a rehabilitation physician (n = 1, 3%) and health-related researchers (n = 2, 5%). The majority of participants were based in the United Kingdom (n = 16, 41%). Thirty-three (n = 33) responses were received for the second round, and thirty (n = 30) in the third round.

Results of Delphi survey

Fifty-one items (n = 51) were generated from the panel following round one. Themes were developed and included: general footwear fit and acceptability, specific footwear characteristics including heel, rearfoot, midfoot, forefoot, upper, outsole, fixation, and miscellaneous. These items, were taken to the panel in round two (n = 58). There was agreement that two items were not important; shoes should be one size larger than required (median 2 IPR 2–4); and shoes should be slip-on (median 3.0 IPR 2–5). Thirty-six (n = 36) items were agreed as important and twenty (n = 20) did not achieve consensus (Table 2). One item from round two (women should own two pairs of shoes which can be alternated) had a RAND/UCLA DI of 1.62 indicating disagreement and was taken back to the panel in round three for further consideration. Following round three, a further two items were accepted and eighteen (n = 18) did not reach consensus with minimal change between median scores from round two to round three, with all items RAND/UCLA DI index scores under one indicating no disagreement. Therefore, the Delphi survey was closed.

Six items had a median score of 9 indicating strong agreement from the panel as absolutely essential important features of retail footwear. These included shoes should be affordable (median 9 IPR 8–9), shoes should be deemed comfortable by the owner (median 9 IPR 9–9), shoes should be deemed satisfactory by the owner (median 9 IPR 8–9), shoes should not have seams over pressure areas of deformities (median 9 IPR 7.2–9), shoes should avoid pressure points in the foot (median 9 IPR 8–9) and shoes should be appropriately sized, with adequate length and width (median 9 IPR 9–9). All items reaching agreement are presented in Table 3.

The content analysis of items generated by the panel revealed three broad themes, footwear characteristics, which included items relating to the construction of the shoe and its anatomical features. Items such as: shoes should have a soft accommodative upper, shoes should have a sturdy rearfoot and shoes should have a heel height of no greater than 3cm were contained within this theme. The second theme, footwear acceptability related to women’s personal preferences and satisfaction. Items such as shoes should be available in a range of colours and styles, and shoes should be affordable were contained within this theme. The third theme, the psychosocial aspects of footwear, contained items such as shoes should look feminine and shoes should not cause self-consciousness.

Important items included those relating to sizing and fit, aesthetic, satisfaction, comfort, cushioning, fastening, heel height, toe box shape, material, weight and insole removability (Table 2). The panel agreed that shoes should be appropriately sized, with adequate length and width, be deep enough to accommodate an orthoses/insert, not have seams over pressure areas or deformities, and avoid pressure points in the foot.

There was consensus that shoes should be aesthetically pleasing, be available in a range of colours and styles, be deemed acceptable by the owner, look feminine, not cause self-consciousness, be appropriate for the social occasion and activity appropriate. There was also agreement that comfort, cushioning (in the heel, midfoot and forefoot) and affordability were very important. Important footwear characteristics relating to the rearfoot of the shoe included: a sturdy rearfoot, cushioned heel, broad heel base, heel height of no greater than 3 cm and a heel counter which conforms to the geometry of the calcaneus. Adequate midfoot support, metatarsal support and longitudinal arch support were all accepted as important midfoot features of a retail shoe. Important forefoot features included a toe box which was wide and deep, and able to accommodate toes. Other features included fastenings which were adjustable, well secured, and easy to put on and take off. Footwear made of breathable material, a conformable upper, textured outsole, lightweight with adequate shock absorption were also accepted as important features.

There was no agreement about the importance of the following items after round three: need for professional fitting, needing to own two pairs of shoes which can be alternated; that comfort should be preferable to aesthetic. Agreement was not reached about the importance of specific rearfoot footwear features including the need for a shoe to contain a heel stability cup, a stiff heel counter and absence of a sling back. Agreement was not reached about the importance of midfoot and forefoot features including a metatarsal rocker, adjustability in metatarsal areas, a round toe box and a semi-rigid shank; and other general features including leather upper, supportive inlay, Velcro^® fastenings, lace-up fastening, containing features found in running shoes, made from soft fabric and a boot style if support is required.

Future recommendations

Based on the results of this Delphi survey, future studies should aim to validate the recommendations made by the panel, determine how these findings align with patients’ views, and development of a patient reported outcome measure for retail footwear for use by clinicians and researchers should be considered. Furthermore, footwear manufacturers should take note of specific features which were considered important for women with RA and integrate these into future footwear designs.

S1 Table

Supporting Information.

(DOCX)

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29 Nov 2019

PONE-D-19-30180

Important features of retail shoes for women with rheumatoid arthritis: A Delphi consensus survey

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Reviewer #1: This Delphi study about features of retail shoes for women with rheumatoid arthritis is very important and strongly needed. The study is well designed consisted experts worldwide. Couple of minor points to revise:

-Background is very short. Can you consider broadening it to take into account footwear adherence and related factors.

-Dot is missing before the aim of the study at the end of Background.

-Through the text you separate the UK from Europe, to my knowledge UK is part of Europe. Moreover, in text and Table 1 location is based on coutry or continent - can you unify these? Maybe report countries where the experts came?

-Maybe one recommendation could also be for footwear manufacturer? And inclusion of the to future research projects.

Thank you, very good study and well written.

Reviewer #2: Thank you for the opportunity to review this manuscript. It is of interest to researchers and health professionals who provide foot care and advice for people who have RA.

My comments are minor and primarily relating to some of the grammar only.

Abstract - research is performed with participants rather than on participants. Please consider modifying to:

An international Delphi exercise using online survey software was conducted with 39 participants from health care backgrounds.

Also, there are multiple sentences that are missing full stops. Please reread and correct.

Introduction:

Consider amending for plural consistency: whilst offering the woman a choice in style

To: whilst offering women choices in style

Methods:

Amending: A sample of health professionals was

To: A sample of health professionals were

Expertise - based on your inclusion criteria - I would suggest that the expertise was footwear prescription rather than just footwear?

At times in the methods section there are tense issues and would urge the authors to use past tense throughout

Results:

female with mean (SD) of 23 (10) mean years - delete duplicate mean

I note that the methods describe presenting the 30th and 70th percentile, IPA and then IQR? Please present one of the other or describe why these have been used in each section.

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Reviewer #2: Yes: Cylie M Williams

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1 Dec 2019

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10 Dec 2019

Important features of retail shoes for women with rheumatoid arthritis: A Delphi consensus survey

PONE-D-19-30180R1

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Reviewer #2: Thank you for providing these changes. I only have one minor grammar change that I recommend based on the additions and that is to add the word ‘wearing or recommendations’ to the sentence following Spence as you can’t adhere to footwear but I wear to wearing or recommendations.

Lack of adherence with therapeutic footwear is multi-factorial, often compounded by a lack of acceptance of their underlying condition, and a disparity in expectations of the footwear

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17 Dec 2019

PONE-D-19-30180R1

Important features of retail shoes for women with rheumatoid arthritis: A Delphi consensus survey

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