Foot health and quality of life among university students: cross-sectional study

ABSTRACT BACKGROUND: Foot problems are believed to reduce quality of life and are increasingly present. Even among young adults of university age, untreated foot problems can lead to postural and mobility problems. Accordingly, our aim here was to determine the relationship between foot health and quality of life and general health among male and female university students. DESIGN AND SETTING: Observational cross-sectional quantitative study conducted at the Podiatric Medicine and Surgery Clinic of the University of Coruña, Ferrol, Spain. METHODS: A sample of 112 participants of median age 22 years came to a health center, where self-reported data were registered, including professional activity, and scores obtained through the Foot Health Status Questionnaire (FHSQ) were compared. RESULTS: In Section One of the FHSQ, the university students recorded lower scores of 66.66 in the footwear domain and 60 in the general foot health domain and higher scores of 84.37 in the foot pain domain and 93.75 in the foot function domain. In Section Two, they obtained lower scores of 60 in the overall health domain and 62.50 in the vigor domain and higher scores of 100 in the physical activity and 87.50 in the social capacity domain. Differences between males and females were evaluated using the Wilcoxon rank-sum test, which showing statistical significance (P < 0.05) regarding the dimensions of footwear and general foot health. CONCLUSIONS: These university students’ quality of life relating to foot health was poor. This appears to be associated with the university period, regardless of gender.

Based on these issues, it is important to consider illnesses and deformities of the foot, postural alterations and other underlying diseases as factors to be taken into account when planning treatment and preventive care activities. Moreover, there is a need for care and follow-up regarding foot health for university students that so far remains unattended. Such issues need to be addressed in seeking to ensure better quality of life and wellbeing for university students.
Thus, we sought to determine the state of foot health among male and female university students and its relationship to their overall quality of life and general health. At present little is known about the factors that affect the development of foot health. Foot problems are predisposing factors for the appearance of injuries in later life that could be prevented through implementing programs to improve the general condition of university students' feet. Advertisements were placed on the CPMS website and in University newsletters. Information leaflets were provided to students clinicians, students from another health science college of the University like nursing, medicine or physiotherapy. Additionally, notices were placed on local bulletin boards.

This study was approved by the Research Ethics
These students came to the Podiatric Medicine and Surgery Clinic. They were eligible for inclusion in the study through a non-probability consecutive sampling technique. The inclusion criteria were that they needed to be healthy volunteers without any relevant medical records or family history and that they gave consent for enrollment into the study. The exclusion criteria included immunodepression, histories of trauma and foot surgery, neurological alterations and lack of or only partial autonomy in performing daily activities. 19

Data collection
All measurements were made by a single researcher. Height, weight and body mass index (BMI) were determined during the visit to the clinic. The students then completed the Foot Health Status Questionnaire (FHSQ). This self-administered questionnaire on health-related quality of life is intended specifically for the foot and has been recognized as a validated test. 20 Lastly, the third section contains questions asking for sociodemographic data such as the participants' age and sex and about their medical records.

Sample size
The smallest clinically important difference in FHSQ scores is 21 points. 21,22 Assuming a standard deviation of around 29 for a bilateral hypothesis and an alpha of 5%, at least 94 students would be needed to detect a 21-point difference with 80% power. Students were enrolled consecutively until the sample size was achieved.

Statistical methods
Continuous variables were expressed as the median and interquartile range. Differences between men and women were compared using independent t tests if the data were normally distributed or the Wilcoxon rank-sum test if not. The data were analyzed using the SPSS statistics package. Alpha was set at 0.05, and all tests were two-tailed. The Foot Health Status Questionnaire version 1.03 was used to obtain quality-of-life scores relating to foot health.

RESULTS
A total of 112 university students of less than 33 years of age were enrolled. The sample analyzed included 85 women (75.9%) and 27 men (24.1%) between 18 and 33 years of age. Most students were normal weight (BMI of 22.27 kg/m 2 ). These results are shown in Table 1. Table 1 also shows the clinical domains of the FHSQ questionnaire and the sociodemographic characteristics of the informants. As can be seen, most of the informants were normal weight (BMI = 22.27 kg/m 2 ). All variables showed non-normal distribution (P < 0.05), and therefore the Wilcoxon rank-sum test was used. Table 2 shows a comparison of the scores obtained through the FHSQ. Section One of the FHSQ evaluated four specific foot domains, namely pain, function, health and footwear. The median scores were higher in relation to assessment of pain and function, and lower in relation to foot health and footwear. Section Two gave an assessment of four domains of general wellbeing: overall health, physical function, social capacity and vigor. In this section, the median foot pain scores for men and women were 87.50 and 81.25 respectively and the function scores for men and women were both 93.75, The foot health scores were 85 and 60 for men and women respectively, and the footwear scores were 75 and 58.33 for men and women respectively ( Table 2). The median scores for physical function and social capacity were significantly lower than those for overall health and vigor, for both men and women. The differences between males and females were statistically significant (P < 0.05) for the dimensions of the FHSQ questionnaire that assessed footwear and general foot health. These results appear in Table 2.

DISCUSSION
The purpose of this study was to determine the relationship between quality of life and foot health among male and female university students, given that the high prevalence of foot problems has been recognized by the governments as a threat to public health.
Foot health is essential to university students, in that it enables them to have greater autonomy, have control over their lifestyles and do physical activity. 26 In a study on the population in Spain aged 40 years or older, the following prevalences of podiatric medical abnormalities were found: claw toe (69.7%), hallux valgus (38.0%) and hallux extensus (15.8%). 15 The prevalences increased with age and were higher among females. 27 The results from the few studies on this topic indicate that the impact of foot health on quality of life is not as obvious as it appears  to be. 15,28 On the other hand, our results confirm that female university students have lower median footwear and general health scores than those of men, thus indicating that they have poorer quality of life in relation to these two domains. We did not find any differences in any other domain. This finding is consistent with studies from other authors. [29][30][31][32] Furthermore, our students had lower median scores for general health and vigor. This situation is associated with greater limitations in carrying out a wide range of physical activities, a lack of energy for participating in activities and an increased risk of becoming socially isolated. 8,22 Given these results, it seems necessary to point out the impor-

CONCLUSIONS
Over this study period, these university students had poor quality of life relating to foot health. This appears to be associated with the university period, regardless of gender. Therefore, there is a need to develop foot health behavior that enables proper care and follow-up for the feet. This is extremely important for