Little is known about how educating runners may correct common misconceptions surrounding heat safety and hydration strategies.
To investigate (1) beliefs and knowledge about heat safety and hydration strategies among recreational runners and (2) the effectiveness of an educational video in optimizing performance in the heat.
A total of 2091 (25.1%) of 8319 runners registered for the 2017 Falmouth Road Race completed at least 1 of the 3 administered surveys.
A 5.3-minute video and an 11-question survey regarding heat safety and hydration strategies were developed, validated, and implemented. The survey was e-mailed to registrants 9 weeks before the race (PRERACE), after they viewed the video (POSTEDU), and the afternoon of the race (POSTRACE).
The total score for responses to 2 multiple choice questions and nine 5-point (response range = strongly agree to strongly disagree) Likert-scale questions.
The PRERACE results showed that more than 90% of respondents recognized the importance of staying hydrated beginning the day before the planned activity, correctly identified that dark color urine is not a sign of euhydration, and believed that dehydration may increase the risk for heat syncope. Conversely, fewer than 50% of respondents knew the number of days required to achieve heat acclimatization, the role of sweat-rate calculation in optimizing one's hydration strategy, or the risk of water intoxication from drinking too much water. An improvement in survey score from PRERACE to POSTEDU was observed (mean difference = 2.00; 95% confidence interval = 1.68, 2.33; P < .001) among runners who watched the video, and 73% of the improvement in their scores was retained from POSTEDU to POSTRACE (mean difference = −0.54; 95% confidence interval = −0.86, −0.21; P < .001).
The video successfully shifted runners' beliefs and knowledge to enable them to better optimize their performance in the heat.
Runners shifted their beliefs and knowledge about optimizing their performance in the heat after viewing the educational video.
A gap remained between runners' knowledge and actual race-day behavior, suggesting that some runners did not follow the recommended heat-safety and hydration-strategy behaviors despite perceiving the importance of these behavioral modifications.
More investigation is needed to determine the effectiveness of using such an educational intervention to modify runners' race-day behaviors.
Researchers should examine the association between runners' beliefs and behaviors on being admitted to the medical tent.
Operators of on-site medical care at road-race events confront challenges that are uniquely different from challenges confronted in traditional organized sports. Runners participate in races at their own discretion with no medical screening requirements. Therefore, road-race events attract runners with a wide range of training backgrounds, ages, and health statuses. In 2015, the International Institute of Race Medicine1 published guidelines addressing evidence-based practices to manage the various medical conditions that are commonly seen at road-race events. In this article, participant education was highlighted as a critical factor in preventing unnecessary medical attention at races.1 Educational tools have been used in other sport settings, such as the “Heads Up Football” program,2 which contains materials related to medical conditions of and safety considerations for American youth football players. However, standardized education modules for recreational runners to prevent common injuries observed at road-race events are lacking.
Based on previously published data3–9 that identified the types of medical conditions and incidents requiring on-site medical care at road-race events, education on heat-related conditions may have a large effect in reducing road-race medical encounters during summer road races. In particular, DeMartini et al3 published the largest dataset (n = 274), based on 18 years of medical records, of patients with exertional heatstroke (EHS) or heat exhaustion treated at the Falmouth Road Race medical tents. This is the largest published dataset of patients with EHS treated at a race, and further effort is warranted to reduce the incidence of exertional heat illness (EHI) and decrease the number of medical tent visits.
The risk of EHI is multifactorial and may be heightened at the Falmouth Road Race due to the high prevalence of warm weather when the race takes place (mid-August).3 Given that the weather conditions, race distance, and competition date may be nonmodifiable, runners should focus on the modifiable risk factors that are unique to them. For example, a lack of heat acclimatization and poor physical fitness are associated with greater risk of EHI.10–14 The risk of hyponatremia from consuming too much water has also been a concern among runners, so appropriate education regarding hydration strategies is warranted.1 Authors14,15 of case reports have suggested that exercise intensity unmatched to one's physical fitness may induce physical strain that is beyond one's capacity to maintain thermoregulatory and cardiovascular stability. Therefore, runners must have adequate training and be able to recognize their own physical capacity when exercising in the heat. Recent illness has also been reported as a risk factor for EHS15 and increases the likelihood that a runner will not complete a race.16,17 Using certain medications has been associated with EHI and gastrointestinal distress, suggesting that runners who are ill enough to be taking these medications should consider postponing event participation.16–19 Moreover, a lack of adequate fluid intake may result in cardiovascular and thermoregulatory strain and increase the risk of EHI.15,17,20
Despite the increased prevalence of surveillance studies at road-race events,4–6,16 few researchers have investigated runners' intentions and actual behaviors on race day. Moreover, assessments of runners' knowledge of the aforementioned risk factors and the usefulness of a standardized education module to improve runners' knowledge are needed to explore methods that can help prevent incidents of EHI. Therefore, the purpose of our study was 2-fold: (1) to investigate the beliefs and knowledge about heat safety and hydration strategies among recreationally active runners who were registered at the 2017 Falmouth Road Race and (2) to evaluate the effectiveness of video education on heat safety and hydration strategies in shifting runners' beliefs and knowledge to better optimize their performance in the heat.
Educational Video and Survey Development
One researcher (Y.H.) created (1) a short (5.3-minute) educational video containing evidence-based recommendations to optimize running performance in the heat and mitigate the EHI risk and (2) a set of 11 questions to evaluate beliefs about heat safety and hydration. The content validity of the video and questions was assessed by expert reviewers (not authors), who included 4 certified athletic trainers with doctoral degrees in exercise physiology and specializations in environmental heat, thermoregulation, and hydration. The reviewers were instructed to rank each survey question from 1 (not relevant) to 4 (relevant) for its relevance, clarity, and importance in evaluating the effectiveness of the heat safety and hydration educational video to shift runners' beliefs about preparing for exercising in the heat. The criteria used to retain each item depended on overall reviewer agreement about the relevance of the item, and the information was synthesized by the primary researcher. The revised questions were sent to 4 reviewers (not authors) who were recreationally active runners (ie, they regularly ran for at least 30 minutes, 3 or more times each week) who would be similar to the population expected to participate in the Falmouth Road Race. These reviewers followed the same procedure as the expert reviewers to rate the relevance, clarity, and importance of each question, and the questions were further refined according to the overall reviewer agreement.
An online survey link (Qualtrics LLC, Provo, UT) to a prerace questionnaire (PRERACE) was sent to the registrants of the 2017 Falmouth Road Race (n = 8319) 9 weeks before the race. The PRERACE consisted of 7 questions concerning training history and habitual and planned behaviors associated with the race, 11 questions structured to evaluate beliefs about heat safety and hydration while exercising in the heat (Table 1), and 3 questions on participant demographics. Reminder e-mails were sent 3 and 6 weeks after the initial e-mail to maximize the response rate while allowing time for the runners to implement the suggested behavioral modifications covered in the video.
Registrants who completed the PRERACE were prompted to view a 5.3-minute educational video that contained evidence-based recommendations for optimizing running performance in the heat and strategies to mitigate the risk of EHI (Appendix). Registrants who viewed the educational video were instructed to complete the same 11 questions from the PRERACE to assess any shift in their beliefs toward heat safety and hydration immediately after viewing the video (POSTEDU). Lastly, a postrace questionnaire (POSTRACE) was sent to registrants (n = 8284; n = 35 opted out from the e-mail list at the PRERACE mail distribution) on the afternoon of the race day. The POSTRACE contained 8 questions concerning behaviors on race day, the same 11 questions regarding their beliefs about heat safety and hydration (Table 1), and 5 questions on the educational video for respondents who indicated they had watched the video before the race. Participation in the surveys was voluntary. Participants indicated written informed consent by completing the survey, and the study was approved by the University of Connecticut-Storrs Institutional Review Board.
We calculated the response rate as the number of survey respondents divided by the total number of runners who received the survey. The survey score was calculated from the 11-question survey by counting the number of correct or favorable answers (ie, those supported by scientific evidence and included in the video). The change in survey score was calculated using a paired t test for the PRERACE and POSTRACE comparison, an unpaired t test for the EDUYES and EDUNO comparison, and 1-way analysis of variance for PRERACE, POSTEDU, and POSTRACE comparisons. All parametric and nonparametric data are reported as mean ± standard deviation (SD) and median ± SD, respectively. Mean differences (MDs) and 95% confidence intervals (CIs) are reported for group mean comparisons. We used χ2, Kruskal-Wallis, or Mann-Whitney tests for all nonparametric group comparisons. The α level was set a priori at .05. All statistical analyses were completed using Prism 7 (version 7.0a; GraphPad Software Inc, La Jolla, CA).
Response Rates and Participant Characteristics
The response rate for the PRERACE was 25.1% (n = 2091), and 10.9% (n = 227) of these respondents participated in the POSTEDU. A total of 1789 (85.6%) of the PRERACE respondents reported that they were training for the 2017 Falmouth Road Race. Forty-three respondents (21.1 per 1000 runners) gave a history of heat syncope, heat exhaustion, EHS, classic heatstroke, or rhabdomyolysis in the 3 years before the study.
The response rate for the POSTRACE was 22.4% (n = 1854), and 9.4% (172/1831) of the respondents reported that they were ill during the 7 days leading up to the day of the race. Furthermore, 49.1% (n = 84/171) of the respondents who described feeling ill during these 7 days were still ill the day before the race.
Knowledge on Heat Safety and Hydration: PRERACE Observations
Overall, the PRERACE respondents demonstrated a fair understanding of heat-safety and hydration-related behaviors and knowledge, with a median score of 8 (Tables 2 and 3). For example, 96.4% (1869/1938) of the respondents answered strongly agree or agree to the statement about the importance of staying hydrated starting the day before the planned activity (question 1), 73.1% (1417/1938) correctly identified dark urine color and thirst as indicators of dehydration (question 3), 91.7% (1778/1938) believed that dehydration may place a runner at risk for heat syncope (question 4), 89.7% (1738/1938) knew that a lack of quality sleep may negatively influence performance in the heat (question 8), 93.2% (1807/1938) correctly recognized that dark-colored urine is not a sign of euhydration (question 10), and 80.8% (1565/1938) were aware that recent illness may increase the risk for EHI (question 11). However, respondents demonstrated a poor understanding (ie, percentage of correct answers less than 50%) about the number of days required to acquire heat acclimatization (question 6: 47.4% [918/1938]), using sweat rate to optimize a hydration strategy in the heat (question 7: 36.9% [715/1938]), and the possibility of water intoxication from drinking too much water (question 9: 49.6% [962/1938]).
The top 3 plans for optimizing hydration status on the day of the race were drinking an ample amount of water the night before the race (91.3% [1837/2012]), avoiding alcohol the night before the race (74.0% [1488/2012]), and drinking at water station(s) along the course (76.9% [1547/2012]). Only 33.4% (673/2012) of the runners reported “following thirst” as their hydration plan, and 28.8% (579/2012) indicated that they planned to drink at all water stations along the course.
Effectiveness of Video Education
A total of 164 runners answered the 11 questions on their beliefs and knowledge about heat safety and hydration at the PRERACE, POSTEDU, and POSTRACE (EDUYES; Table 4), whereas 826 runners answered the 11 questions at the PRERACE and POSTRACE (ie, no video intervention; EDUNO; Table 5). The Kruskal-Wallis test showed favorable shifts in beliefs and knowledge about heat safety and hydration among EDUYES respondents for 6 of the 11 questions (questions 1 [H = 32.2], 2 [H = 46.1], 4 [H = 40.3], 5 [H = 31.1], 7 [H = 152.9], and 8 [H = 136.7]; all P values < .001; Table 4). The Mann-Whitney test showed favorable shifts among the EDUNO respondents in their answers to questions 4 (U = 321 351, P = .02), 5 (U = 310 547, P = .001), 7 (U = 293 974, P < .001), 8 (U = 317 403, P = .006), and 9 (U = 301 658, P < .001; Table 5) despite no exposure to the video education; however, the percentage of runners with correct answers at the POSTRACE was greater among the EDUYES than the EDUNO respondents for all questions (Table 6). We observed a small difference in the survey score for the PRERACE between the EDUNO and EDUYES respondents (MD = 0.28; 95% CI = 0.03, 0.52; t988 = 2.22, P = .03). Among the EDUYES respondents, survey scores improved from the PRERACE to the POSTEDU (MD = 2.00; 95% CI = 1.68, 2.33; P < .001), and 73% of the improvement was retained from the POSTEDU to the POSTRACE (MD = −0.54; 95% CI = −0.86, −0.21; F2,489 = 15.83, P < .001). The improvement in the survey score from the PRERACE to POSTRACE was greater for the EDUYES than the EDUNO respondents (MD = 0.92; 95% CI = 0.67, 1.17; t988 = 7.28, P < .001).
Intentions and Observed Behaviors Surrounding Race Day: PRERACE and POSTRACE Comparison
A total of 176 runners completed the survey regarding behaviors surrounding race day at the PRERACE, POSTEDU, and POSTRACE (EDUYES), whereas 884 runners completed the same questions at the PRERACE and POSTRACE (EDUNO). The average number of hours of sleep reported on the PRERACE was greater than on the POSTRACE among the EDUYES (PRERACE = 7.00 ± 0.96 hours; POSTRACE = 6.57 ± 1.17 hours; MD = 0.43; 95% CI = 0.25, 0.62; t175 = 4.60, P < .001) and EDUNO (PRERACE = 6.98 ± 0.91 hours; POSTRACE = 6.56 ± 1.13 hours; MD = 0.41; 95% CI = 0.33, 0.49; t866 = 10.31, P < .001) respondents. The level of motivation reported on the PRERACE did not differ between the EDUYES and EDUNO respondents (MD = 0.02; 95% CI = −0.23, 0.27). We observed an increase at the percentage of participants who knew their sweat rate at the POSTRACE among the EDUYES (PRERACE = 12.5%; POSTRACE = 23.7%; |$x_1^2$| = 7.64; P = .006) and EDUNO (PRERACE = 10.0%; POSTRACE = 13.9%; |$x_1^2$| = 6.52; P = .01) respondents.
The top 3 hydration strategies used by the EDUYES and EDUNO respondents were similar; runners consumed ample amounts of water the night before the race (EDUYES = 89.2% [157/176]; EDUNO = 86.3% [763/884]), drank at water station(s) along the course (EDUYES = 84.1% [148/176]; EDUNO = 75.8% [670/884]), and avoided alcohol the night before the race (EDUYES = 66.5% [117/176]; EDUNO = 56.8% [502/884]). “Following thirst” was reported by only 32.4% (57/176) and 36.8% (325/884) of the EDUYES and EDUNO respondents, respectively. The percentages of runners who drank at all water stations along the course were 26.7% (47/176) and 35.2% (311/884) among the EDUYES and EDUNO respondents, respectively.
The main goals of our study were to identify the current beliefs and knowledge about heat safety and hydration strategies among recreationally active runners participating in the 2017 Falmouth Road Race and to investigate the effectiveness of video education in shifting runners' beliefs and knowledge to better optimize their performance in the heat. The results of the PRERACE showed that runners had some knowledge about good hydration practices and considerations for running in a warm-weather race, which was further improved POSTEDU and maintained at the POSTRACE by those who had watched the educational video. However, not all runners adopted the recommended practices, such as calculating their sweat rate to establish an individualized hydration plan and using thirst to gauge dehydration status. This suggests that, despite the improved awareness and corrected misconceptions about heat safety and hydration strategies among runners, not everyone achieved successful behavioral adaptations.
Given the results of this study, the transtheoretical model of change that divides behavioral adaptation into 5 stages (precontemplation, contemplation, preparation, action, and maintenance) needs to be considered.21 For example, one may internalize the need for change (precontemplation to contemplation) through video education, establish a plan for the change (preparation), and finally take action (action and maintenance). At the POSTRACE, when registrants were asked whether they found the educational video helpful in modifying their behaviors during training and the race, 61.7% (92/149) agreed that the video influenced the way they trained. Of those who responded that the video was helpful, the top modifications they implemented after viewing the video were drinking water the night before an early morning run (96.7% [89/92]), using urine color to gauge hydration status (71.7% [66/92]), and matching training intensity to one's health status and fitness capabilities (62.0% [57/92]). Conversely, runners who did not find the video helpful during their training most commonly indicated that they already followed the outlined recommendations (31.6% [18/57]). This response may suggest that these runners were no longer in the precontemplation phase for the recommended behaviors in the video. Lastly, a small number of runners also indicated that they followed their usual routine (n = 5) or that the video content did not apply to them (n = 2). Some runners learned about the video too late for it to be useful for their training (n = 3), affecting their success in the preparation stage of the model.
When asked about the influence of the educational video on race-day behavior, 67.8% (101/149) of the runners answered that the video helped them to modify their race-day behaviors. Thus, 67.8% of the runners reached the action stage of the model. Specifically, 53.5% of runners (54/101) reported that they modified their race-day hydration strategies using the methods outlined in the video (eg, staying well hydrated from the night before, using the sweat rate to calculate fluid needs during exercise, using thirst and urine color to gauge hydration status, not blindly drinking water from all water stations). Twelve (11.9%) runners also commented that they modified their running pace in response to the high air temperature and humidity level during the race. The responses among those who did not find the video helpful in modifying race-day behaviors were similar to those of the runners who noted that they already followed the recommendations outlined in the video (33.3% [16/48]), suggesting that they may have already been in the maintenance stage of the behaviors surrounding heat safety and hydration strategies.
Our observations were restricted to the registrants who completed the surveys. Whereas the response rate for the PRERACE was 25.1%, the rate of participation was reduced at POSTEDU because participation in the survey was voluntary. Consequently, our comparison between the EDUYES and EDUNO respondents was limited to 176 runners who responded to the PRERACE, POSTEDU, and POSTRACE and 884 runners who responded to the PRERACE and POSTRACE but did not receive video education. Lastly, findings from our study should not be generalized to runners participating in other road-race events.
The educational video successfully shifted runners' beliefs and knowledge about optimizing their performance in the heat. However, some gaps remained between the runners' knowledge and actual race-day behavior, suggesting that certain runners did not follow the recommended heat safety and hydration strategies despite the perceived importance of these behavioral modifications. The effectiveness of using such an educational intervention to modify runners' behaviors on race day needs further investigation. Furthermore, researchers should examine the association between beliefs and behaviors when runners are admitted to the medical tent.
We thank Christianne M. Eason, PhD, ATC; William M. Adams, PhD, ATC; Lesley W. Vandermark, PhD, ATC; and Rebecca M. Lopez, PhD, ATC, for assistance in developing the survey instrument used in the study.