While there was some cross-platform commonality, there were several key differences in relation to the tone and nature of how platforms were utilised and engaged with, and these are identified throughout the results, but the final theme is dedicated to identifying platform specific phenomenon. Table 5 gives an overview of the themes, sub-themes, and a brief description in relation to the phenomenon identified.

Table 5 Themes, sub-themes, and a brief descriptionTheme 1: attitudes and beliefs toward feet; connect and disconnect

Beliefs and attitudes toward feet, foot health, and footwear were expressed in a myriad of ways, demonstrating the utility of SoMe as a data collection mechanism for foot health related phenomena. These results demonstrate how foot health in itself is not always consciously valued specifically in relation to the foot, but for what good foot health facilitates and how footwear is sometimes a competing influence in relation to that foot health. These factors have implications for motivation to self-care and seek treatment for foot health.

Sub-theme 1: wider social and cultural phenomenon—foot bones aren’t just connected to your heel bone

Expressions about feet were more often about what feet facilitate such as dancing, travel, hobbies, social occasions, and sport. Positive attitudes were expressed for feet that will not ‘let you down’, fast running feet, or special occasions such as getting married. Beliefs related to how feet are hardworking, while concurrently longing for pretty feet. Connecting within social worlds and a sense of self was consistently evidenced, for example footwear and self-expression, getting comfortable with new trends such as wearing trainers with dresses, and fitting in socially and at work, even if it induced pain or pathology. Excitement toward activity shoes was expressed but mostly where it prioritised aesthetics of the footwear, above function and performance.When foot health had been lost, connections were established through engagement with others that shared a similar foot health experience rather than with the podiatrists present on SoMe who were proactive in demonstrating capacity to treat that condition.

Positive attitudes about feet were less prevalent, where the vast majority related to babies and young children who were celebrated as being comfortable with their feet, exploring them and being barefoot. This conversely suggests that adults often are not comfortable with their own feet which has implications for proactivity to manage foot health. there were several common expressions that related to this, indicating how feet should be hidden away and not visible to others. Beliefs connected to commonly held theories about caring for feet were also expressed, but were often contrary to foot health focussed clinical evidence. These include the role of devices for non-pathological flat feet, theories about ‘over’ pronation, advocates for barefoot shoes and forefoot running, running technique, and the impact on muscles, joints, or callus formation, and how shoes are coffins or traps that lock feet in.. Several expressions connected the season to a change in attitude or behaviour, such as getting feet summer ready.

Sub-theme 2 – when feet stand apart: disconnect and disassociation

There was a predominance of negative attitudes about feet themselves, suggesting stigma around feet and fetish, ridicule, and mockery in relation to feet, and a strong association with those common pathologies that were associated with stigma. Table 6 provides some examples.The most prominent example relates to a foot health Facebook page that is ‘about’ sharing foot health problems and advice, where some posts broke those rules of engagement with expressions that ridiculed feet. Even in activity areas where foot health is important, feet were not valued, for example, describing other swimmers as ‘foot touchers’ as a derisory comment toward other swimmers. Comments about foot fetish were often utilised to humiliate, linked to disgust, or common pathologies such as fungal feet and bunions, and qualified with expression such as ‘lmao’Footnote 1 and ‘lol’.Footnote 2

Table 6 Negative descriptors relating to feet

Disconnect was expressed toward health and service providers, such as commercially led foot measuring services offering inconsistent service or advice, and healthcare professionals who could not explain or help manage symptoms, reinforced by expressions of how only those with a shared experience can truly understand. There was also disparity over whether the benefit was worth the risk when treatments were painful such as steroid injections, and knowledge gaps e.g., the importance of checking feet for people with diabetes, and whether first shoes hindered development or helped support ambulation. There was also confusion about footwear e.g., when flat shoes caused pathology, or avoiding high heels did not prevent it. There was also frustration toward institutional footwear policies that did not prioritise comfort, foot health, or practicality, such as schools and workplaces. Several posts also suggested a disconnect with the lower limb, with implications for propensity to engage proactively with lower limb health, with links to a lack of intellect or competence. Examples include references to a person having brains in their feet, being unable to tie shoelaces, footballers having nothing upstairs and interviewing a person’s feet. Shame was also suggested when foot pathology caused deformity, for example some Instagram posts suggested strategies to turn back time through cosmetic treatments, to hide pathology.

Theme 2: beyond attitudes and beliefs: symbolic representations and the impact when foot health is lost

While not beliefs and attitudes, these sub-themes inform understanding of perceptions toward feet, and concepts that may influence foot health behaviour through the expression of symbolic references, and the impact when foot health is compromised.

Sub-theme 1: symbolic references

Physical representations such as tan lines, dirt, and callus were expressed as a metaphorical badge of honour, where feet were valued for how they facilitated some activities but where the result was impaired foot health. This suggests that the impact of doing many things that people enjoy and value has a negative impact upon foot health.Similarly footwear was not always linked to foot health and protection, where footwear was utilised as an expression of self, with shoes sometimes customised to reflect self-identity and personality. There were symbolic negative attitudes expressed between feet and worthiness, for example being fit (or not) to polish somebody’s shoes and kissing the feet of revered statues. The importance of footwear was also indicated when it was no longer wearable due to pathology or post-pregnancy, symbolising something lost.

Sub-theme 2: the value of feet, and the impact when foot health is lost

The impact of diminished foot health on activities of daily living such as going to the bathroom, gardening, walking, sports, and shopping, with implications for social participation or capacity to care for others. One Tweet acknowledged a Catch-22 scenario where a diabetic foot ulcer meant that healthcare professional recommended activity to prevent disease progression could no longer be continued. Being on feet all day, and activities such as sightseeing and running were also impeded by foot pain or pathology. Several posts related to the impact of pregnancy, and how for many foot pain, hobbling, or swelling was the only negative experience, how foot shape changes, and can impact footwear choice. The language tended to be emotive or relate to a sense of futility such as likening living with diabetic foot pathology to being on a boat full of holes (Table 7).

Table 7 Language used to describe the impact when foot health is lost

Many posts shared the impact impaired foot health can have on mental health. Fear was associated with both having a toenail surgically removed, and the prognosis when foot health in diabetes was ignored for 3 years, indicating fear as one reason for foot health reactivity. For many, aesthetics mattered when foot health was impaired, such as bunions that made feet look like ‘paddles’. Sequalae included impaired sleep, reduced quality of the next day, and sense of self for example when clinically appropriate footwear was indicated.

Some motivators to care for foot health were indicated when diminished foot health from pathology or pregnancy also impacted capacity to work, particularly if the role was non-sedentary. Barriers to proactive foot care self-management including financial implications related to the cost of footwear and treatment products or services. However very few posts related to seeking appropriate clinical treatment. Footwear could also create a health dichotomy when safety boots provided protection but were sometimes a barrier to returning to work after foot pathology. Others alluded to the positive impact of treatment with a professional foot health clinician or aesthetic treatment. These included multiple expressions about pedicure-related expressions suggesting ‘love’ for ‘new’ feet post-pedicure, and celebrations of ‘new’ feet post-surgery. These posts were infrequent and greatly outnumbered by posts sharing negative impact.

Theme 3: SoMe specific engagement in relation to foot health

How people related to feet, foot health, and footwear differed across the three platforms, and this needs to be transparent such that implications for self-management to prevent foot health can be situated within the context from where the data was extracted.

Sub-theme 1: platform specific overview

There were several characteristics that were unique to each platform in relation to who engaged, how, and for what purpose Table 8).

Table 8 Overview of differentiating characteristics of the 3 SoMe platforms

On Facebook, bi-directional engagement with others sharing an experience and trusting the advice was prominent both in and outside of pathology, with disconnect from those that did not, which included clinicians. This included expressions that ‘rated’ the advice from others with a shared experience over that of foot health specialists.

Many Tweets were orchestrated by professionals, but even though the topics posted reflected the common pathologies often stigmatised, or conditions where there was a lack of knowledge or that had a significant impact, there was still little engagement. In relation to foot health, there were lots of products and ‘quick fixes’ on offer to meet foot health needs though these were commercially derived and not necessarily underpinned by evidence. The potential for SoMe to influence purchasing habits was identified, with tweets relating to trends and where to find them, and advice on how to emulate a look, primarily targeted at women.

What this research illuminates that directly relates to the medium utilised for data extraction is that what matters to people is not always foot health itself, but what was transparent across all 3 platforms was the importance and value of feet for what they facilitate, the importance of aesthetics, and the lack of knowledge about how to achieve a healthy looking foot that also supports that activity foot pain free. This is important to informing truly person-centred care to meet these gaps and provide the care that holistically meets needs and resonates such that foot health is more proactively engaged with.

Sub-theme 2: the power of SoMe to connect and inform

Several Facebook page posts indicated the power of SoMe to connect people with shared experiences. While some self-management strategies appeared to be underpinned by efficacious clinical advice, others were clearly attributed to advice from companies selling products. An example includes alleviating neuropathy with a homemade tea tree oil foot spray, or equipment to self-treat an ingrowing toenail. On Twitter and Instagram health education was promoted, such as exercise or checking feet daily. Twitter was also about connecting service and product providers to the marketplace. Empowerment and foot health was occasionally advocated outside of a pathological domain but related to a specific activity, for example exercises to strengthen dancer’s feet. However, one Facebook post shared information from a clinical encounter, that was taken to a subsequent appointment for another engager, positively informing one clinician’s practice. There was an implicit trust in some expressions predominantly from those who had shared a similar experience, relating to foot pathology diagnoses, treatment or product recommendations, or non-clinicians such as the reflexologist who informed an engager that serious foot pathology was the result of a traumatic event in childhood, signifying the gap between efficacious clinical practice and the wider public’s perception of that evidence and scope of professional practice.