Couch-to-5k or Couch to Ouch to Couch!? Who Takes Part in Beginner Runner Programmes in the UK and Is Non-Completion Linked to Musculoskeletal Injury?

vity has mental and physical health bene ts; however, globally, three-quarters of the population do not meet physical activity guidelines. TheCouch-to-5kis a beginner runner programme aimed at increasing physical activity. However, this programme lacks an evidence base, and it is unclear who is attracted to the programme; running also has a high rate of musculoskeletal (MSK) injuries. The aims of this study were to identify the characteristics of people taking part and the incidence of MSK injuries as well as exploring the experiences of people who dropped out of a modi ed 9-weekCouch-to-5kprogramme. A total of 110 runners (average age was 47.1 13.7 years) participated in the study, which involved completion of questionnaires (running experience and footwear information, quality of life (EQ-5D-5L), physical activity level (IPAQ-short form), MSK injury history and knee condition (SNAPPS and KOOS-PS)) at the start, middle and end of the programme and collecting sociodemographic information (age, gender, social economic status, relationship status, education level), as well as body mass index,

participated in the study, which involved completion of questionnaires (running experience and footwear information, quality of life (EQ-5D-5L), physical activity level (IPAQ-short form), MSK injury history and knee condition (SNAPPS and KOOS-PS)) at the start, middle and end of the programme and collecting sociodemographic information (age, gender, social economic status, relationship status, education level), as well as body mass index, running experience, footwear information, quality of life, physical activity levels, MSK injuries and knee condition. Fifteen drop-outs were interviewed to explore experiences of the programme. Runners were mainly females (81.8%) with an average age 47.1 years, average body mass index of 28.1 kg.m 2 , mainly from high socio-economic levels, married and educated to degree level. In total, 64% of the sample had previous running experience and were classi ed as active. Half the sample self-reported pain/discomfort and 37.2% reported anxiety/depression at the start of the programme via the EQ-5D-5L scale. Self-reported health scores increased (p= 0.047) between baseline (73.1 18.8 out of 100) and at the midpoint (81.2 11.6), but there were no signi cant differences between any other time points (end point 79.7 17.5,p> 0.05). Twenty-one injuries were reported during the programme (19%). Previous injury increased the risk of new injury (OR 7.56 95% CI from 2.06 to 27.75). Only 27.3% completed the programme. Three themes emerged from interviews; MSK injury, negative emotions linked to non-completion and design of the programme. TheCouch-to-5kmay not attract diverse inactive populations, but future work with larger sample sizes is needed to substantiate this nding. Dropping out was linked to MSK injury and progressive design, so future programmes should consider including injury prevention advice and more exible designs. Keywords:physical activity; exercise;Couch-to-5k; musculoskeletal injury; running 1. Introduction There is strong scienti c evidence to support the positive dose-response relationship between physical activity and chronic disease morbidity and mortality, highlighting the importance of physical inactivity as a public health issue [1–5]. The current World Health Organisation (WHO) guidelines state that adults aged 18–64 years should participate in at least 150 min of moderate-intensity aerobic activity or at least 75 min of vigorous-intensity Int. J. Environ.

support the positive dose-response relationship between physical activity and chronic disease morbidity and mortality, highlighting the importance of physical inactivity as a public health issue [1–5]. The current World Health Organisation (WHO) guidelines state that adults aged 18–64 years should participate in at least 150 min of moderate-intensity aerobic activity or at least 75 min of vigorous-intensity Int. J. Environ. Res. Public Health2023,20, 6682.

Int. J. Environ. Res. Public Health2023,20, 6682 2 of 17 aerobic activity, or an equivalent combination of moderate- and vigorous-intensity activity throughout the week [6]. However, global estimates indicate that only one in four adults are suf ciently active, with only “slow and uneven” progress being made in this area [7,8]. Running is one form of physical activity that may help contribute to meeting these guidelines. In England, between 2018 and 2019, 6.6 million adults reported running at least twice in the last 28 days; this increased to 7.3 million during the COVID-19 pandemic and reduced to 6.5 million in 2022 [9]. Running is one of the top three sport and leisure time activities adults participate in [10], and it is bene cial for health as it is associated with a reduction in all-cause mortality [11]. A popular beginner running initiative in the United Kingdom (UK) is theCouch-to-5k, invented by recreational runner, Josh Clark, in 1996 [12], which involves running three times a week with progressive increments over a nine-week period [12]. Although the programme can be followed by individuals, physical activity initiatives have increased effectiveness when combined with community-wide campaigns [13], and where exercise is a group norm, physical activity levels may increase due to an increase in group identity [14,15], speci cally in running activities [16]. Interestingly, there is no empirical evidence to support the design ofCouch-to-5k, despite its being central to the Of ce for Health Improvement and Disparities recent campaigns to increase people's activity levels, which are often promoted through the UK National Health Service (NHS) [17]. Indeed, a UK government press release published in January 2023 championed theCouch-to-5kprogramme, stating that the accompanying app had been downloaded 6.5 million times since it launched in 2016, and users had completed over 6 million runs in 2022 alone [17]. Such health apps have the potential to improve population physical activity levels using embedded behaviour change techniques, such as goal setting [18]. The most popular app is the NHS version; 322,700 people had rated the NHSCouch-to-5kapp an average of 4.8 stars out of 5, and it was number 25

users had completed over 6 million runs in 2022 alone [17]. Such health apps have the potential to improve population physical activity levels using embedded behaviour change techniques, such as goal setting [18]. The most popular app is the NHS version; 322,700 people had rated the NHSCouch-to-5kapp an average of 4.8 stars out of 5, and it was number 25 in all Health and Fitness downloads on the Apple©app store [19]. However, research is needed to identify characteristics and experiences of runners on this programme. Furthermore, while the effect of running on the cardiovascular system in inactive groups, such as those targeted by theCouch-to-5kis well understood [4,5], there is limited research that describes the impacts on the musculoskeletal (MSK) system [20]. An under- standing of MSK injury in novice runners is important as this is a deterrent from future engagement [21]. Smits et al. [22] reported that 78% of those injured were still absent from a running programme after six weeks. Buist et al. [23] stated that 40% of women and 37% of men did not re-start running after injury, and this pattern was higher in novice runners (48%) than those already engaged in running (24%). Evidence of the injury incidence for Couch-to-5krunners is limited; one paper reported an incidence of 49% [24], but more research is needed as it is unclear if MSK injury is a reason for non-completion of the Couch-to-5kprogramme and future deterrent of physical activity [20]. It is therefore also important to identify the risk factors for MSK injury in novice runners to develop injury prevention programmes. Age may be an influencing factor, but both younger and older runners have been reported as having more injuries [25–27]. Higher BMI values ( 30 kg.m 2 ) increase the risk of a running injury [23,24,26,27], and aBMI < 20 kg.m 2 may reduce the risk of an injury [26]. Previous injury (though not necessarily running related) and less running experience also increased injury rates [24–27]. New footwear was also attributed to a greater risk of injury [27]. The knee is the most common location of running injuries [24].

the risk of a running injury [23,24,26,27], and aBMI < 20 kg.m 2 may reduce the risk of an injury [26]. Previous injury (though not necessarily running related) and less running experience also increased injury rates [24–27]. New footwear was also attributed to a greater risk of injury [27]. The knee is the most common location of running injuries [24]. It is important to identify whether these risk factors are apparent in Couch-to-5krunners. In summary, it is still unclear who participates in theCouch-to-5kprogramme and if injury incidence is related to non-completion. Therefore, the aims of this study are to: 1. Identify the characteristics of people taking part in a modi edCouch-to-5kprogramme. 2.Identify the incidence of MSK injuries and potential risk factors for people taking part in a modi edCouch-to-5kprogramme. 3. Couch-to-5kprogramme. The quantitative hypothesis is that MSK injuries will be related to non-completion.

Int. J. Environ. Res. Public Health2023,20, 6682 3 of 17 The qualitative research question is: what are the experiences of people who do not complete theCouch-to-5kprogramme? 2. Materials and Methods 2.1. Research Design The study was an observational cohort study using quantitative and qualitative meth- ods and took place between May 2018 and May 2020. Quantitative data was collected using questionnaires at baseline, mid-way through and at the end of the programme. Runners who dropped out of the programme were also sent a questionnaire and asked to be inter- viewed. The completed interviews comprised the qualitative data. The study was carried out at a sports centre in North West England, UK. 2.2. Participants A convenience sample was used to recruit 110 participants from North West England to aCouch-to-5kprogramme. A power analysis was not performed; the sample size was determined by the number of participants willing to volunteer during the length of the study. Participants were recruited following attendance at a voluntary presentation session in which the lead researcher introduced and explained the study. The average age was 47.1 13.7 (range 17–75) years (females 46.7 13.6; males 48.9 14.3 years), and 81.8% were female. The inclusion criteria were any adults who registered for theCouch-to-5k programme, could provide written informed consent and could communicate in English. 2.3. Procedures The programme delivery was modi ed to include both community and individual level social support following the literature [13–16] (see Table). One group session a week was delivered on the running track at a local sports facility by a trained instructor. However, the session content was as per the original programme The two additional runs each week were self-directed through theCouch-to-5kNHS app as per the original programme [12]. All participants were asked to adhere to the three runs per week prescribed by theCouch-to-5k programme, but this was not systematically monitored. Table 1. The modified delivery ofCouch-to-5k, including the one instructor-led run each week, based on [ Run 1 (Instructor-Led) Run 2 (Self-Led) Run 3 (Self-Led) Week 1 Brisk 5-min walk, then 1-min run + 1.5-min walk 8 Brisk 5-min walk, then 1-min run +

to the three runs per week prescribed by theCouch-to-5k programme, but this was not systematically monitored. Table 1. The modified delivery ofCouch-to-5k, including the one instructor-led run each week, based on [ Run 1 (Instructor-Led) Run 2 (Self-Led) Run 3 (Self-Led) Week 1 Brisk 5-min walk, then 1-min run + 1.5-min walk 8 Brisk 5-min walk, then 1-min run + 1.5-min walk 8 Brisk 5-min walk, then 1-min run + 1.5-min walk 8 Week 2 Brisk 5-min walk, then 1.5-min run + 2-min walk 6 Brisk 5-min walk, then 1.5-min run + 2-min walk 6 Brisk 5-min walk, then 1.5-min run + 2-min walk 6 Week 3 Brisk 5-min walk, then 1.5-min run + 1.5-min walk +3-min run + 3-min walk 2 Brisk 5-min walk, then 1.5-min run + 1.5-min walk +3-min run + 3-min walk 2 Brisk 5-min walk, then 1.5-min run + 1.5-min walk +3-min run + 3-min walk 2 Week 4 Brisk 5-min walk, then 3-min run + 1.5-min walk + 5-min run + 2.5-min walk + 3-min run + 1.5-min walk + 5-min run Brisk 5-min walk, then 3-min run + 1.5-min walk + 5-min run + 2.5-min walk + 3-min run + 1.5-min walk + 5-min run Brisk 5-min walk, then 3-min run + 1.5-min walk + 5-min run + 2.5-min walk + 3-min run + 1.5-min walk + 5-min run Week 5 Brisk 5-min walk, then 5-min run + 3-min walk + 5-min run + 3-min walk + 5-min run Brisk 5-min walk, then 8-min run + 5-min walk + 8-min run Brisk 5-min walk, then 20-min run Week 6 Brisk 5-min walk, then 5-min run + 3-min walk + 8-min run + 3-min walk + 5-min run Brisk 5-min walk, then 10-min run + 3-min walk + 10-min run Brisk 5-min walk, then 25-min run Week 7 Brisk 5-min walk, then 25-min run Brisk 5-min walk, then 25-min run Brisk 5-min walk, then 25-min run Week 8 Brisk 5-min walk, then 28-min run Brisk 5-min walk, then 28-min run Brisk 5-min walk, then 28-min run Week 9 Brisk 5-min walk, then 30-min run

+ 3-min walk + 10-min run Brisk 5-min walk, then 25-min run Week 7 Brisk 5-min walk, then 25-min run Brisk 5-min walk, then 25-min run Brisk 5-min walk, then 25-min run Week 8 Brisk 5-min walk, then 28-min run Brisk 5-min walk, then 28-min run Brisk 5-min walk, then 28-min run Week 9 Brisk 5-min walk, then 30-min run Brisk 5-min walk, then 30-min run Brisk 5-min walk, then 30-min run

Int. J. Environ. Res. Public Health2023,20, 6682 4 of 17 2.4. Questionnaire Data Runners were asked to complete a questionnaire booklet during week one, week ve and week nine of the programme. Drop-outs were also sent a questionnaire within two weeks of non-attendance. The following variables were collected (see Appendix more details): # Socio-demographics at baseline only (age, gender, social economic status (SES), rela- tionship status, education level) #Self-reported body mass index (weight (kg)/height (m) 2 ), # Running experience using the following questions: Have you ever participated in running recreationally before? If yes, please expand. #Footwear perceptions using the following ve questions: 1. 2. 3. 4. How would you describe your footwear? Running specific/general sports/fashion. 5.How important do you think running footwear is to injury prevention? Very important/important/not sure/not important/not important at all. # Quality of Life (QoL) using the EQ-5D-5L [28]. This measurement tool is a generic instrument for describing and valuing health using ve dimensions: mobility, self- care, usual activities, pain/discomfort and anxiety/depression. The tool also includes a “Health Today Scale”, in which 0 represents the worst health the participant can imagine and 100 represents the best health the participant can imagine. Cronbach's alpha is reported as 0.82 and ICC as 0.78 [95% CIs 0.65 to 0.86] [29]. # Physical activity level using the IPAQ-Short Form [30]. This measurement tool collects information on vigorous and moderate exercise and walking and sitting time. Physical activity levels were then de ned as low (total PA MET-minutes per week <600), medium (total PA MET-minutes per week >600 and high (total PA MET-minutes/week >3000). (The corresponding correlation coef cient for test-retest reliability is reported as 0.69) [30]. # MSK injury history [31] using a standardized self-report form that asked participants if they had an injury that prevented them from doing usual daily activities (including strains, sprains, bursitis, fractures and other injuries to muscle, tendon, bone, joint or ligament). If yes, then the number of injuries, body part injured (from a check list of possible body parts) and cause of the injury was detailed [31]. # Knee condition using SNAPPS [32] and

they had an injury that prevented them from doing usual daily activities (including strains, sprains, bursitis, fractures and other injuries to muscle, tendon, bone, joint or ligament). If yes, then the number of injuries, body part injured (from a check list of possible body parts) and cause of the injury was detailed [31]. # Knee condition using SNAPPS [32] and KOOS-PS [33] questionnaire. SNAPPS is a self- report questionnaire that identifies people with patellofemoral pain and has a Cohen's kappa of 0.74 [32]. The KOOS-PS reports knee conditions based on activities of daily life and sports and recreation, and it has a reported Cronbach's alpha of 0.89 [ The questionnaire booklet was distributed by a member of the research team in person and via post for drop-outs. 2.5. Interviews All runners who completed a drop-out questionnaire (regardless of non-completion reason) were asked to take part in an interview. The semi-structured interviews, lasted be- tween 45 and 90 min and were audio-recorded on a digital voice recorder. The 11 interview questions were based on previous literature in this area and designed to explore personal insight for drop out. These questions explored perceptions of the programme, the impact of the programme on participants' health and wellbeing, potential injury episodes, and knowledge on injury prevention and treatments (see Appendix 2.6. Data Analysis Questionnaire data was imported into SPSS (IBM, Version 25). A descriptive anal- ysis provided information on socio-demographic characteristics of runners at baseline.

Int. J. Environ. Res. Public Health2023,20, 6682 5 of 17 Pearson's chi-squared analysis compared differences between categorical data (running experience and physical activity levels). Changes in QoL visual analogue score over time were analysed using Friedman's ANOVAs due to violation of normality. Injury incidence was presented as a percentage of total runners and number of injuries recorded per run- ner. To assess potential risk factors, comparisons of age, BMI, previous injury, running experience and trainer condition between injured and non-injured runners were completed using Mann–Whitney U tests (due to violation of normality) and chi-squared analysis. A logistical regression was used to present the odds ratio (OR) of completing the programme based on injury history. Signi cance was accepted atp< 0.05. Audio-recordings from the interviews were transcribed verbatim. An inductive and data-driven analytical strategy was used to identify and discuss the salient themes repeated across and within the transcripts [35]. Thematic analysis was utilized as it allowed for the identi cation of patterns and meaning across a dataset and provided a exible ap- proach [33]. Inductive thematic analysis of the data [36] was completed by one author (DC). Codes and emergent themes were checked by a second author (MO) to ensure consistency of coding. To ensure methodological rigor, credibility and trustworthiness [37,38], nal themes were cross-examined against the data in reverse from the themes to the data sheets. Any disagreements were discussed between authors (DC and MO) until an agreement was reached. The Braun and Clarke “15-point Checklist of Criteria for Good Thematic Analysis” [36] was used to ensure quality in the analysis process. 3. Results 3.1. Questionnaire Completion Figure 48.2% of the baseline sample had dropped out of the programme, and a further 16.4% dropped out by the end point, meaning a total drop out of 64.5% from baseline. Of the total runners who dropped out of the intervention, 74.6% of these were before the mid-way point. Twenty-one (29.6%) of the runners who ceased the programme completed a questionnaire booklet at the time of drop-out; unfortunately, reasons were not provided as to why more individuals did not return the questionnaire

The study examines who participates in Couch-to-5k and the link between injuries and programme non-completion.