CLUBFOOT TREATMENT
IN MALAWI:
AWARENESS, ACCESS &
OUTCOMES
Rubini Pathy, University of Toronto, Canada
Supervisors: Mercy Nkhalamba, Dr. Steve Mannion, Feet First UK
In collaboration with: Bertha Ndhlozi, Ahmed Mwawa, Sandy Chimangeni,
Malawi Against Physical Disabilities (MAP)
CONTENTS & PHOTOS MAY NOT BE REPRODUCED WITHOUT PERMISSION
MALAWI:
SUN, SAND, ROLLING HILLS
MALAWI’S PEOPLE
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13 million people
85% live in rural areas
Av. life expectancy: 41 yrs
Median age of pop’n: 16 yrs
MALAWI STATS
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One of the world’s least
developed countries
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54% of it’s 13 million
inhabitants live below the
poverty line
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Approx. 1 million
Malawians live with a
disability (incl. 150,000
children)
REHAB IN MALAWI
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Malawi Against Physical Disabilities (MAP)
z
Orthopedic Clinical Officers (OCOs), Physiotherapists,
Nurses, Workshop Staff (make assistive devices)
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Supported mainly by donations, some government assistance
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Specialty Clinics:
z Clubfoot
z Cerebral Palsy
z Polio
z Rural Outreach
BACKGROUND
¾ Clubfoot: major cause of disability in
children in developing nations
¾ Neglected clubfoot : stigma; can limit
education and social activity
¾ Non-operative treatment initiated in the 1st
year of life is ideal
¾ Ponseti Method:
z
z
suited to developing countries
Minimal surgical/technological expertise req’d
CLUBFOOT IN MALAWI
¾ 5000 children with untreated clubfeet &
500 more are born each year
¾ OCOs are trained in the Ponseti Method
¾ Need follow-up on awareness of & access
to treatment
OBJECTIVES
To examine:
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Parental knowledge and perspectives of
clubfoot & its treatment options
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Factors affecting awareness of clubfoot &
its treatment
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Barriers to accessing treatment
METHODS
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Participants: mothers of children receiving clubfoot
treatment
Location: MAP clinics in Lilongwe and rural areas
Research Tool: Questionnaire
RESULTS: DEMOGRAPHICS
¾ 50 mothers interviewed
(43 LL, 6 HC, 1 DH)
Average age of mothers
24.9
Average # of children per mother
2.8
% of mothers who:
Only had some primary school education
Were homemakers
Were married
Identified themselves as being Christian
70
76
88
87.5
RESULTS: AWARENESS
60% of mothers had not heard of Clubfoot prior to diagnosis
87.8% responded “Yes” to:
“Can you describe your child’s condition?”
RESULTS: AWARENESS
98% responded “Yes”
to: “Is your child’s
foot condition
correctable?”
RESULTS: ACCESS
RESULTS: ACCESS
Distance & Transportation
Accessing the nearest health facility
%
Travel Time:
44
44
12
< 1 hour
1 to 3 hours
> 3 hours
Mode of Transport: walking
public transit
private transit
70
28
2
RESULTS: ACCESS
RESULTS: ACCESS
Family Hx of Clubfoot
% diagnosed at birth
% receiving treatment
within 1st month of life
Yes (N=15)
86.7
86.6
No (N=35)
74.3
80
RESULTS: ACCESS
RESULTS: OUTCOMES
RESULTS:
MOTHERS’ RECOMMENDATIONS
¾ For Fellow Parents:
z
z
Seek treatment for the child at a hospital or
MAP immediately (90%)
Use own child as an example to other mothers
of positive treatment outcomes
¾ For MAP:
z
z
z
Conduct awareness campaigns, especially in
rural areas about clubfoot & its treatment
Educate staff at antenatal clinics & TBAs
Increase number of treatment locations
DISCUSSION
¾ Increasing Awareness of clubfoot and it’s
treatment
¾ Facilitating Access to treatment
¾ Supporting positive Outcomes
DISCUSSION:
CREATING AWARENESS
¾ Awareness Campaigns
z
z
Billboards in rural areas
Posters and flyers at each health centre
• maternity ward, outpt dept., antenatal & under 5s
clinic)
z
Visual representation on any promotional
material
• Minimal recognition of terms clubfoot / talipes
• Limited literacy / formal education
DISCUSSION:
CREATING AWARENESS
¾ Human Resources
z Mothers as Peer
educators
z Traditional Birth
Assistants (TBAs)
z Health care providers
at antenatal clinics
z Volunteers
z Liaise with other
rehab organizations
(MACOHA)
DISCUSSION :
EARLY DIAGNOSIS & TREATMENT
¾ Bottom Hospital in Lilongwe - treatment can
be initiated on 1st day of life
¾ Health centres and district hospitals – all 7
children began treatment within 1st month
¾ Fair level of awareness of clubfoot & its
treatment amongst health care providers &
TBAs
¾ Need more data especially in rural areas to get
a true picture of time of diagnosis & treatment
DISCUSSION : ACCESS
Majority walk > 1 hr
carrying child on back
DISCUSSION : ACCESS
¾ Lilongwe MAP:
z
z
z
Admits children living in villages to the in-patient
ward to receive weekly casting treatment
Mothers stay with children
Stay until bracing initiated
¾ Difficulty is initially identifying children in
rural areas – ties back to increasing awareness
DISCUSSION: OUTCOMES
¾ Positive outcomes despite low pre-diagnosis
awareness & hardships to accessing treatment
¾ Mothers become well-informed about
treatment and expected outcomes
z
z
Patient education by OCO and PT
Informally by observing other children’s progress
¾ Positive outcomes = early diagnosis &
treatment & facilitating access & informal peer
motivation
STUDY LIMITATIONS
¾ Small sample size – 50 mothers
¾ Lilongwe MAP’s catchement area: Lilongwe
and rural areas of Central Malawi
¾ Possible bias:
z
z
z
interviews at the clubfoot clinics
intrinsically motivated mothers
Those who attend may not have transportation /
access issues
FUTURE DIRECTIONS
¾ Survey OCOs and PTs re: their current
management of clubfoot
¾ Ongoing re-training / refresher courses
¾ # of castings & length of treatment prior to
braces
¾ % of children who do not complete treatment
and reasons why
¾ Long-term follow-up re: functional outcomes
after braces
SUMMARY
¾ Low pre-diagnosis awareness of clubfoot,
yet prompt diagnosis & treatment
¾ Mothers recognize benefits of early Dx and
Rx & are satisfied with outcomes
¾ Key Recommendations:
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z
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Awareness campaigns, especially in rural areas
Peer education
Improved perinatal counseling (TBA, clinics)
Ongoing training of OCOs and PTs
minimizing barriers - distance & transportation
REFERENCES
1.
Penny JN. The neglected clubfoot. Techniques in Orthopedics. 2005; 20: 153-66.
2.
Dobbs M, Rudzki JR, Purcell DB, et al. Factors predictive of outcome after use of the Ponseti method for
the treatment of idiopathic clubfeet. J Bone Joint Surg Am. 2004; 86: 22-7.
3.
Lehman WB, Mohaideen A, Madan S et al. A method for the early evaluation of the Ponseti (Iowa)
technique for the treatment of idiopathic clubfoot. J Pediatr Orthop B. 2003; 12: 133-40.
4.
Morcuende JA, Dolan LA, Dietz FR, et al. Radical Reduction in the rate of extensive corrective surgery for
clubfoot using the Ponseti Method. Pediatrics. 2004; 113: 376-80.
5.
Tindall AJ, Steinlechner CWB, Lavy CBD, et al. Results of manipulation of idiopathic clubfoot deformity
in Malawi by Orthopedic Clinical Officers using the Ponseti Method. J Pediatr Ortho.p 2005; 25: 627-9.
6.
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7.
Herzenberg JE, Radler C, Bor N. Ponseti versus traditional methods of casting for idiopathic clubfoot. J
Pediatr Orthop. 2002; 22: 517-21.
8.
Ponseti IV. Clubfoot management. J Pediatr Orthop. 2000; 20:699-700.
9.
Feet First. Preventing and Treating Physical Disability Worldwide: Treatment of Clubfoot.
www.feetfirstcharity.org
10.
Gennaro S, Thyangatbyanga D, Kersbbaumer R, Thompson J. Health Promotion and Risk Reduction in
Malawi, Africa, Village Women. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2001;30:224–
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11.
van den Broek NR, White SA, Ntonya C, Ngwale M et al. Reproductive health in rural Malawi: a
population-based survey. BJOG: An International Journal of Obstetrics and Gynaecology. 2003;110:902–
908.
ACKNOWLEDGEMENTS
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Dr. Massey Beveridge, University of Toronto
International Health Program
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Mercy Nkhalamba, Dr. Steve Mannion, Feet First UK
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Bertha Ndhlozi, Ahmed Mwawa, Sandy Chimangeni,
Malawi Against Physical Disabilities (MAP)
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MAP drivers, workshop staff, nurses
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Mothers who were interviewed
Thanks for listening! Questions?
Lake Malawi
[email protected]