Clubfoot is a common problem in Zimbabwe with minimum incidence rates comparable to the rest of the world [9]. With the recent introduction of the PM in the country as the preferred method of treatment of clubfoot and the continued investment by the ZSCP in the training of health workers across the country, there is a huge need to evaluate the effectiveness of the PM in managing clubfoot. Our study, which is the first in the country, makes such an attempt by documenting the opinions of medical rehabilitation professionals, who are the service providers, on the application and effectiveness of the PM for clubfoot management. This issue has been rarely investigated, so comparisons with other studies are difficult. This study should be seen a pilot study just describing baseline opinions of a sample of trained medical rehabilitation professionals largely working in public hospitals in Harare, Zimbabwe.
The results of the present study may be important for generating a hypothesis on the perceptions of effectiveness of PM as it is applied in Harare hospitals to correct the clubfoot deformity. The perceived opinions of the participants enrolled in the study, however, might not correlate with the actual results of treatment. This is a major limitation of this study. Future studies using larger samples and robust study designs are needed to fully understand the effectiveness of the Ponseti method in correcting the clubfoot deformity in Zimbabwean hospitals.
The present study targeted medical rehabilitation professionals because all the established clubfoot clinics in large central hospitals in Harare are run mainly by physiotherapists in collaboration with occupational therapists and rehabilitation technicians. The central role of paramedical health care professionals in the management of the clubfoot has been consistently reported in literature. In Uganda, paramedical healthcare professionals run clubfoot clinics in large hospitals [20]. In Malawi, orthopaedic clinical officers are heavily involved [24]. In South Africa, physiotherapists are also heavily involved [23]. In Zimbabwe, physiotherapists, occupational therapists and rehabilitation technicians work together during the clubfoot clinics. This is primarily due to resource allocation. At any hospital in the country, all these professionals work in the same department. In addition, the clubfoot clinics are run on weekly basis at every hospital in the country, hence collaboration is inevitable. This organisation ensures adequate human resources for the clinics, which are normally replete with patients. The local hospital doctors only come in to perform the tenotomies, when necessary. On the other hand, rehabilitation technicians, by nature of their training which provide them with some competences in physiotherapy, occupational therapy and speech therapy, attend to all patients with musculoskeletal conditions. This probably explains the increased number of rehabilitation technicians in the present study compared to occupational therapists.
In terms of demographics, the final sample of participants had more females than males, a true reflection of the gender distribution of medical rehabilitation professionals in Zimbabwe. Most participants trained in the PM were working in government health institutions rather than private rehabilitation clinics. This relates directly to the fact that the ZSCP sponsored clubfoot clinics were established in large government referral hospitals to localise the services and involve the human resources available in these settings. The majority of the participants were senior clinicians with five or more years of experience in clinical settings. Their opinion and general impression on the PM application and its relative effectiveness in this setting are important to consider given that they had probably witnessed other methods of correcting the clubfoot before the PM was introduced. Indeed, most of the participants stated that they had previous exposure and practical experience with the Kite method.
The effectiveness of the Ponseti method
All medical rehabilitation professionals felt that the PM is relevant and effective in treating clubfoot in children. These findings are consistent with a number of studies that have reported excellent results with the PM [7, 15, 22–27]. The PM has reduced total health care costs, clubfoot surgery frequency and has also changed the patterns of surgery performed for clubfoot in Nigeria [25]. Similar findings were reported in India [15]. Interestingly, participants in the present study who had prior experience in other conservative methods such as the Kite method felt that the PM was more effective. The opinions and impressions of the clinicians confirm that the PM should be considered a standard treatment of congenital talipes equino varus. Shabtai et al. [28] reported that PM has become the gold standard for the treatment of idiopathic clubfoot over the last two decades. In the present study, idiopathic CTEV was the most common type of clubfoot diagnosed in the children. On average, the participants were attending to eight children every week with this condition. This indicates the frequency of use of the PM by the medical rehabilitation practitioners.
A number of reasons were postulated for the relevance of the PM compared to other previously used methods. The PM was perceived to be effective yielding better clinical results improving the functional prognosis of the condition in a shorter period. This is consistent with other studies [15, 29, 30]. It is suggested that with good technique the clubfoot should be corrected in two months with weekly castings [17]. In addition, the participants felt that the Ponseti technique was understandable from a biomechanical, anatomical and scientific point of view unlike the previous methods. Abbas et al. [27] attributed 95 % success rate in correcting clubfoot in clinical practice to sound understanding of the patho-anatomy of clubfoot. Consistent with these findings, Ponseti [17] recommends sound understanding of the functional anatomy in the manipulation and casting of the foot for an effective correction of the deformity. Methodical and meticulous application of the casts and braces possibly minimize the risk of recurrences. Recurrences, however, are known to occur in up to one-third of patients in spite of 100 % success rate which may be achieved with the initial correction [31]. Nevertheless, in the present study, the participants highlighted the potential of less recurrences with the PM as another important reason for the relevance of the Ponseti technique as compared to previous methods. These findings are consistent with other results reported in the literature [21].
Challenges faced in the treatment of clubfoot using Ponseti
Among the perceived barriers and challenges mentioned by the participants, the most outstanding was the lack of adequate insight of the PM by the caregivers. Although more research is needed on this issue, these findings suggest a need to educate the caregivers of children with clubfoot on the PM and the implications for defaulting treatment. Non-compliance to treatment was also highlighted as a challenge faced by the clinicians. Future studies are needed to determine the level of knowledge of the treatment program and expectations among caregivers and assess for an association with defaulting history. The risk associated with defaulting weekly treatments should be probably be emphasised to caregivers to increase their awareness. Because of the long term rehabilitation required for the clubfoot, non-adherence to hospital appointments is inevitable. However, it should be addressed and impressed on the caregivers from the outset. Rigid adherence to the clubfoot programme has been reported to be associated with decrease in the rate of relapse and number of patients requiring more extensive surgical intervention [29].
In Uganda, in order to address the challenge of lack of compliance to treatment of clubfoot, posters and pamphlets were designed and distributed to village health teams, healthcare centers, churches, and schools [20]. They also employed radio as a way to educate the population at large [20]. Although much more community education is still required, these efforts are commendable and provide an effective platform from which to launch further programs and efforts. In Peru, in a study evaluating the barriers to using the PM among physicians, 27 of 32 (84.4 %) felt that the lack of parental knowledge about the PM was a barrier to its success [5]. Inadequacy of knowledge, non-compliance of caregivers and financial constraints were also highlighted by number of other studies in the literature [15, 30, 32]. Lack of resources to use during treatment was also indicated strongly as a barrier to effective treatment by 23 (56.1 %) of the participants in the present study. These findings are consistent with a number of studies [30, 33, 34]. In the present study, increased patient demand for treatment at clubfoot clinics could account for the lack of adequate resources in the local hospitals. This highlights the huge need for more rehabilitation professionals trained in the PM.
Recommendations for improving clubfoot management
Recommendations and suggestions on how to improve the PM in Zimbabwe were given based on the current situation, challenges and previous experiences of the medical rehabilitation professionals in the treatment of the clubfoot deformity. The outstanding recommendation was that the services must be decentralised to the smaller health centres so as to reduce the workload in the central hospitals. It is possible that as the PM gains credence and increase access for rural patients, there will be increasing demand for the services in tertiary institutions. In Uganda, clubfoot detection and treatment is being decentralised to improve access to the facilities [20]. Since 2011, the Zimbabwe Sustainable Clubfoot Programme has been conducting training in-service training workshops countrywide in a bid to decentralise the service to grassroots level.
It has been suggested that caregivers need to be educated about the details pertaining to their child’s treatment and outcome expectations so that they see the importance of compliance throughout the course of treatment and maintenance [20]. The same suggestion has been given in this study by the medical rehabilitation professionals that caregiver understanding of clubfoot deformity and the PM can improve compliance with all stages of treatment. Increasing level of awareness could drastically improve the rate and spread of success of the Ponseti method and reduce the risk of recurrences.