Study design and participants

This study was a cross sectional descriptive study with a quantitative design. The study was conducted in Harare, the capital city of Zimbabwe, targeting all medical rehabilitation centers from public hospitals to individual private clinics. There are three large public hospitals in Harare (Parirenyatwa Group of Hospital, Harare Central Hospital and Chitungwiza Central Hospital) all with well-established large rehabilitation departments. The ZSCP provides clinical and material support to these hospitals. Treatment of clubfoot is offered free of charge to the children in all the hospitals. In these hospitals, physiotherapists run the clubfoot clinics in collaboration with occupational therapists, rehabilitation technicians and hospital doctors who perform tenotomies under local anaesthesia.

To be included in this study, medical rehabilitation professionals had to be registered with the Medical Rehabilitation Practitioners Council of Zimbabwe (MRPCZ). The three group of professionals registered under MRPCZ with the clinical obligation to manage clubfoot patient in hospitals and clinics are physiotherapists, occupational therapists and rehabilitation technicians. Physiotherapists and occupational therapists are jointly trained for four years at the University of Zimbabwe, College of Health Sciences by the Department of Rehabilitation and graduate with an honours degree in either physiotherapy or occupational therapy. On the other hand, rehabilitation technicians are trained for two years at Marondera Rehabilitation Technicians Training School by physiotherapists and occupational therapists working under the Ministry of Health and Child Care for a diploma, partly covering aspects of physiotherapy, occupational and speech therapy. They are usually trained in large numbers so that they can be deployed as rehabilitation cadres to remotest areas including rural hospitals, provincial and district hospitals. In large central hospitals, rehabilitation technicians clinically work under the supervision of qualified physiotherapists and occupational therapists.

Additionally, only trained participants with a certificate of competence as proof were included in the study. Moreover, the trained rehabilitation professional should have treated at least two children with clubfoot using the PM after the training. Eligible participants not available in their clinical settings in the period of the survey were excluded from the study. At the time of the study, 51 medical rehabilitation practitioners were eligible, and 41 agreed and were available to participate in the study.

Instrument

A researcher-developed questionnaire was used to collect data. The questions were derived from the literature. The questionnaire was divided into three sections. Section A collected socio-demographic data of respondents such as gender, age, profession, place of work (public or private) and years of clinical practice. Section B consisted of closed-ended questions asking respondents to indicate on preselected factors their impression or opinions for the PM. Open ended responses were also elicited in order for the respondents to freely give their opinions on the PM. Some of the questions asked whether the participants were using the PM in treating children with clubfoot, and whether they thought it was relevant in treating clubfoot providing a reason for that. In addition, participants were also asked if they had previous experience or exposure to other methods of managing clubfoot and whether they felt the PM was better than other mentioned methods. Participants were also asked to rate their satisfaction of the PM and provide explanations for their opinions. Section C of the questionnaire consisted of a five point Likert scale from strongly disagree to strongly agree, inquiring about the perceived barriers and challenges faced by the medical rehabilitation professionals when delivering treatment of clubfoot using the PM. The participants were also asked to provide possible recommendations for improving the effectiveness of the PM in their clinical setting.

In a preliminary study, the questionnaire was tested for content validity by four experienced physiotherapists and one occupational therapists trained in the PM working as lecturers at the University of Zimbabwe, College of Health Sciences yielding a scale-level content validity index (S-CVI) of 0.71. After the validation, a test retest reliability of the English version of the questionnaire was conducted using 10 medical rehabilitation professionals working at a provincial hospital 80 km from Harare who had previously received formal training on the method and were using the technique in their daily practice. The re-test was conducted seven days later. The kappa coefficients of the primary ordinal outcome measures ranged from 0.32 to 0.72.

Procedure

The study was reviewed and approved by the Joint Research Ethics Committee for the University of Zimbabwe, College of Health Sciences and Parirenyatwa Group of Hospital (JREC; ref number = 266/14) and Medical Research Council of Zimbabwe (MRCZ; reference number = B/774). In addition, permission to involve medical rehabilitation professionals was obtained from their regulatory council called the Medical Rehabilitation Practitioners Council of Zimbabwe (MRPCZ). Clinical directors of all the three public hospital gave written permission for the study to be conducted. Written informed consents were obtained from medical rehabilitation practitioners who volunteered to participate in the study.

Data collection

After getting ethical and institutional approvals, data collection was conducted between January and March 2015. Data collection was divided into two stages: preparatory stage and questionnaire administration. In the preparatory stage, the researchers visited the research settings consecutively to explain the procedural issues of the research to the participants, to give them information letters and making appointments for data collection with them. This was necessary to minimise interrupting treatment sessions for patients. Thereafter, data collection was conducted for a period of one month, on dates agreed upon with the participants. The questionnaires were self-administered to the participants during their spare time and were collected immediately upon completion. The researcher was available to answer any question the participants had regarding the questions. This was done as well to minimise practitioner to practitioner discussions about the questions and responses.

Data analysis

Statistical analysis was performed using STATISTICA version 11. All responses from open ended questions were grouped into categories and equated to frequencies. Descriptive statistics such as the mean with the standard deviation were used to describe normally distributed continuous data and the median with the interquartile range was used to describe skewed data. The Shapiro Wilk test was used to assess for normality of age data. Data generated from open-ended questions were coded into categories for further analysis and then a thematic analysis was done.

Baseline characteristics of the participants

Perceptions towards Ponseti method of treating clubfoot

All participants indicated that they were actively involved in the weekly clubfoot clinics at their respective hospitals and clinics at the time of the study. However, 26 (63.4 %) had used other previous methods such as the Kite method in the correction of the clubfoot deformity prior to the training by the Zimbabwe Sustainable Clubfoot Programme. Their experience with the Kite method was on average of 6 years (SD = 2.86). The other rehabilitation professionals had no previous practical experience with any method of treatment.

Responding to the question about the relevance of the Ponseti technique, all participants felt that the method was relevant. Figure 1 shows some of the reasons described by the participants for the relevance of the PM. When asked to express their satisfaction with the results of the PM, all participants agreed that it yields better clinical outcomes or results than previous methods. Figure 2 shows some of the reasons given verbatim for the satisfaction with the PM. The majority of the participants felt that if the technique is correctly applied the clubfoot resolves early with only few castings.

Perceived challenges in using the Ponseti method

The participants were asked to indicate preselected list of barriers and challenges they are likely to encounter in their clinical work when treating clubfoot using PM on a Likert scale from strongly agree to strongly disagree. At the end of that section in the questionnaire, they were also asked to give their free perceived challenges using open-ended questions. One major challenge highlighted by the participants was the issue of compliance. The majority (25, 61.0 %) agreed or strongly agreed that non-compliance to treatment is a major issue of concern. In addition, 22 (53.7 %) of the participants agreed or strongly agreed that caregivers of children with clubfoot lacked insight on the Ponseti technique. Twenty (48.8 %) of the participants had a neutral perception on whether religion of the caregivers was a barrier to treatment, whereas 14 (34.1 %) agreed or strongly agreed that religion had a negative impact on treatment.

On the issue of the adequacy of their training, the majority of the participants 27 (65.9 %) agreed or strongly agreed that it was adequate. Other indicated challenges included lack of resources at the clubfoot clinics, mentioned by 23 (56.1 %), of the participants, and increased workload for the clinicians, agreed by 18, 43.9 %, of the participants.

Recommendations for improving clubfoot management

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.