Indicators to assess the functionality of clubfoot clinics in low-resource settings: a Delphi consensus approach and pilot study.

Background: This study aims to determine the indicators for assessing the functionality of clubfoot clinics in a low-resource setting. Methods: The Delphi method was employed with experienced clubfoot practitioners in Africa to rate the importance of indicators of a good clubfoot clinic. The consistency among the participants was determined with the intraclass correlation coefficient. Indicators that achieved strong agreement (mean≥9 [SD <1.5]) were included in the final consensus definition. Based on the final consensus definition, a set of questions was developed to form the Functionality Assessment Clubfoot Clinic Tool (FACT). The FACT was used between February and July 2017 to assess the functionality of clinics in the Zimbabwe clubfoot programme. Results: A set of 10 indicators that includes components of five of the six building blocks of a health system-leadership, human resources, essential medical equipment, health information systems and service delivery-was produced. The most common needs identified in Zimbabwe clubfoot clinics were a standard treatment protocol, a process for surgical referrals and a process to monitor dropout of patients. Conclusions: Practitioners had good consistency in rating indicators. The consensus definition includes components of the World Health Organization building blocks of health systems. Useful information was obtained on how to improve the services in the Zimbabwe clubfoot programme

What is a good result after clubfoot treatment? A Delphi-based consensus on success by regional clubfoot trainers from across Africa.

BACKGROUND: Congenital talipes equino-varus (CTEV), also known as clubfoot, is one of the most common congenital musculoskeletal malformations. Despite this, considerable variation exists in the measurement of deformity correction and outcome evaluation. This study aims to determine the criteria for successful clubfoot correction using the Ponseti technique in low resource settings through Africa. METHODS: Using the Delphi method, 18 experienced clubfoot practitioners and trainers from ten countries in Africa ranked the importance of 22 criteria to define an 'acceptable or good clubfoot correction' at the end of bracing with the Ponseti technique. A 10cm visual analogue scale was used. They repeated the rating with the results of the mean scores and standard deviation of the first test provided. The consistency among trainers was determined with the intra-class correlation coefficient (ICC). From the original 22 criteria, ten criteria with a mean score >7 and SD 9 and SD<1.5. RESULTS: The consensus definition of a successfully treated clubfoot includes: (1) a plantigrade foot, (2) the ability to wear a normal shoe, (3) no pain, and (4) the parent is satisfied. Participants demonstrated good consistency in rating these final criteria (ICC 0.88; 0.74,0.97). CONCLUSIONS: The consistency of Ponseti technique trainers from Africa in rating criteria for a successful outcome of clubfoot management was good. The consensus definition includes basic physical assessment, footwear use, pain and parent satisfaction

Assessment of success of the Ponseti method of clubfoot management in sub-Saharan Africa: a systematic review.

BACKGROUND: Clubfoot is one of the most common congenital deformities affecting mobility. It leads to pain and disability if untreated. The Ponseti method is widely used for the correction of clubfoot. There is variation in how the result of clubfoot management is measured and reported. This review aims to determine and evaluate how success with the Ponseti method is reported in sub-Saharan Africa. METHODS: Five databases were examined in August 2017 for studies that met the inclusion criteria of: (1) evaluation of the effect of clubfoot management; (2) use of the Ponseti method; (3) original study undertaken in sub-Saharan Africa; (4) published between 2000 and 2017. We used the PRISMA statement to report the scope of studies. The included studies were categorised according to a hierarchy of study methodologies and a 27-item quality measure identified methodological strengths and weaknesses. The definition of success was based on the primary outcome reported. RESULTS: Seventy-seven articles were identified by the search. Twenty-two articles met the inclusion criteria, of which 14 (64%) reported a primary outcome. Outcomes were predominantly reported though case series and the quality of evidence was low. Clinical assessment was the most commonly reported outcome measure and few studies reported long-term outcome. The literature available to assess success of clubfoot management is characterised by a lack of standardisation of outcomes, with different measures reporting success in 68% to 98% of cases. CONCLUSION: We found variation in the criteria used to define success resulting in a wide range of results. There is need for an agreed definition of good outcome (successful management) following both the correction and the bracing phases of the Ponseti method to establish standards to monitor and evaluate service delivery

Results of clubfoot treatment after manipulation and casting using the Ponseti method: experience in Harare, Zimbabwe.

OBJECTIVES: The objective of this study was to evaluate the outcomes of the Ponseti manipulation and casting method for clubfoot in a tertiary hospital in Zimbabwe and explore predictors of these outcomes. METHODS: A cohort study included children with idiopathic clubfoot managed from 2011 to 2013 at Parirenyatwa Hospital. Demographic data, clinical features and treatment outcomes were extracted from clinic records. The primary outcome measure was the final Pirani score (clubfoot severity measure) after manipulation and casting. Secondary outcomes included change in Pirani score (pre-treatment to end of casting), number of casts for correction, proportion receiving tenotomy and proportion lost to follow up. RESULTS: A total of 218 children (337 feet) were eligible for inclusion. The median age at treatment was 8 months; 173 children (268 feet) completed casting treatment within the study period. The mean length of time for corrective treatment was 10.2 weeks (9.5-10.9 weeks). Of the 45 children who did not complete treatment, 28 were under treatment and 17 were lost to follow up. A Pirani score of 1 or less was achieved in 85% of feet. Mean Pirani score at presentation was 3.80 (SD 1.15) and post-treatment 0.80 (SD 0.56, P-value <0.0001). Severity of deformity and being male were associated with a higher (worse) final Pirani score. Severity and age over two were associated with an increase in the number of casts required to correct deformity. CONCLUSION: This case series demonstrates that the majority (80%+) of children with clubfoot can achieve a good outcome with the Ponseti manipulation and casting method

The feasibility of a training course for clubfoot treatment in Africa: A mixed methods study.

BACKGROUND: There is no available training programme with standard elements for health workers treating clubfoot in Africa. Standardised training with continued mentorship has the potential to improve management of clubfoot. We aimed to evaluate the feasibility of such a training programme among clubfoot providers in Africa, and assess implications for training effectiveness and scale up. METHOD: We used participatory research with trainers from 18 countries in Africa over two years to devise, pilot and refine a 2-day basic and a 2-day advanced clubfoot treatment course. (The Africa Clubfoot Training or 'ACT' Course.) The pilots involved training 113 participants. Mixed methods (both qualitative and quantitative) were used for evaluation. We describe and synthesise the results using the eight elements proposed by Bowen et al (2010) to assess feasibility. All participants completed feedback questionnaires, and interviews were conducted with a subset of participants. We undertook a narrative description of themes raised in the participant questionnaires and interviews. Descriptive statistics were used to compare pre- and post-course scores for confidence and knowledge. RESULTS: 113 participants completed pre and post-course measures (response rate = 100%). Mean participant confidence increased from 64% (95%CI: 59-69%) to 88% (95%CI: 86-91%) post course. Mean participant knowledge increased from 55% (95%CI: 51-60%) to 78% (95%CI: 76-81%) post course. No difference was found in mean for either subscale of cadre or sex. The qualitative analysis generated themes under four domains: 'practical learning in groups', 'interactive learning', 'relationship with the trainer' and 'ongoing supervision and mentorship'. CONCLUSION: The Africa Clubfoot Training package to teach health care workers to manage clubfoot is likely to be feasible in Africa. Future work should evaluate its impact on short and long term treatment outcomes and a process evaluation of implementation is required

What factors impact on the implementation of clubfoot treatment services in low and middle-income countries?:a narrative synthesis of existing qualitative studies

Around 100,000 children are born annually with clubfoot worldwide and 80% live in low and middle-income counties (LMICs). Clubfoot is a condition in which children are born with one or both feet twisted inwards and if untreated it can limit participation in everyday life. Clubfoot can be corrected through staged manipulation of the limbs using the Ponseti method. Despite its efficacy and apparent availability, previous research has identified a number of challenges to service implementation. The aim of this study was to synthesise these findings to explore factors that impact on the implementation of clubfoot services in LMICs and strategies to address them. Understanding these may help practitioners in other settings develop more effective services.Five databases were searched and articles screened using six criteria. Articles were appraised using the Critical Appraisal Skills Programme (CASP) checklist. 11 studies were identified for inclusion. A thematic analysis was conducted.Thematic analysis of the included studies showed that a lack of access to resources was a challenge including a lack of casting materials and abduction braces. Difficulties within the working environment included limited space and a need to share treatment space with other clinics. A shortage of healthcare professionals was a concern and participants thought that there was a lack of time to deliver treatment. This was exacerbated by the competing demands on clinicians. Lack of training was seen to impact on standards, including the nurses and midwives attending to the child at birth that were failing to diagnose the condition. Financial constraints were seen to underlie many of these problems. Some participants identified failures in communication and cooperation within the healthcare system such as a lack of awareness of clinics. Strategies to address these issues included means of increasing resource availability and the delivery of targeted training. The use of non-governmental organisations to provide financial support and methods to disseminate best practice were discussed.This study identified factors that impact on the implementation of clubfoot services in LMIC settings.Findings may be used to improve service delivery

Macroeconomic costs of the unmet burden of surgical disease in Sierra Leone: a retrospective economic analysis.

OBJECTIVES: The Lancet Commission on Global Surgery estimated that low/middle-income countries will lose an estimated cumulative loss of US$12.3 trillion from gross domestic product (GDP) due to the unmet burden of surgical disease. However, no country-specific data currently exist. We aimed to estimate the costs to the Sierra Leone economy from death and disability which may have been averted by surgical care. DESIGN: We used estimates of total, met and unmet need from two main sources-a cluster randomised, cross-sectional, countrywide survey and a retrospective, nationwide study on surgery in Sierra Leone. We calculated estimated disability-adjusted life years from morbidity and mortality for the estimated unmet burden and modelled the likely economic impact using three different methods-gross national income per capita, lifetime earnings foregone and value of a statistical life. RESULTS: In 2012, estimated, discounted lifetime losses to the Sierra Leone economy from the unmet burden of surgical disease was between US$1.1 and US$3.8 billion, depending on the economic method used. These lifetime losses equate to between 23$360 million and US$2.9 billion. CONCLUSION: There is a large economic loss from the unmet need for surgical care in Sierra Leone. There is an immediate need for massive investment to counteract ongoing economic losses

A comparison of outcome measures used to report clubfoot treatment with the Ponseti method: results from a cohort in Harare, Zimbabwe.

BACKGROUND: There are various established scoring systems to assess the outcome of clubfoot treatment after correction with the Ponseti method. We used five measures to compare the results in a cohort of children followed up for between 3.5 to 5 years. METHODS: In January 2017 two experienced physiotherapists assessed children who had started treatment between 2011 and 2013 in one clinic in Harare, Zimbabwe. The length of time in treatment was documented. The Roye score, Bangla clubfoot assessment tool, the Assessing Clubfoot Treatment (ACT) tool, proportion of relapsed and of plantigrade feet were used to assess the outcome of treatment in the cohort. Inter-observer variation was calculated for the two physiotherapists. A comparative analysis of the entire cohort, the children who had completed casting and the children who completed more than two years of bracing was undertaken. Diagnostic accuracy was calculated for the five measures and compared to full clinical assessment (gold standard) and whether referral for further intervention was required for re-casting or surgical review. RESULTS: 31% (68/218) of the cohort attended for examination and were assessed. Of the children who were assessed, 24 (35%) had attended clinic reviews for 4-5 years, and 30 (44%) for less than 2 years. There was good inter-observer agreement between the two expert physiotherapists on all assessment tools. Overall success of treatment varied between 56 and 93% using the different outcome measures. The relapse assessment had the highest unnecessary referrals (19.1%), and the Roye score the highest proportion of missed referrals (22.7%). The ACT and Bangla score missed the fewest number of referrals (7.4%). The Bangla score demonstrated 79.2% (95%CI: 57.8-92.9%) sensitivity and 79.5% (95%CI: 64.7-90.2%) specificity and the ACT score had 79.2% (95%CI: 57.8-92.9%) sensitivity and 100% (95%CI: 92-100%) specificity in predicting the need for referral. CONCLUSION: At three to five years of follow up, the Ponseti method has a good success rate that improves if the child has completed casting and at least two years of bracing. The ACT score demonstrates good diagnostic accuracy for the need for referral for further intervention (specialist opinion or further casting). All tools demonstrated good reliability

Evaluation of a simple tool to assess the results of Ponseti treatment for use by clubfoot therapists: a diagnostic accuracy study.

BACKGROUND: We aimed to develop and evaluate a tool for clubfoot therapists in low resource settings to assess the results of Ponseti treatment of congenital talipes equinovarus, or clubfoot, in children of walking age. METHOD: A literature review and a Delphi process based on the opinions of 35 Ponseti trainers in Africa were used to develop the Assessing Clubfoot Treatment (ACT) tool and score. We followed up children with clubfoot from a cohort treated between 2011 and 2013, in 2017. A full clinical assessment was conducted to decide if treatment was successful or if further treatment was required. The ACT score was then calculated for each child. Inter-observer variation for the ACT tool was assessed. Sensitivity, specificity, positive and negative predictive values were calculated for the ACT score compared to full clinical assessment (gold standard). Predictors of a successful outcome were explored. RESULTS: The follow up rate was 31.2% (68 children). The ACT tool consisted of 4 questions; each scored from 0 to 3, giving a total from 0 to 12 where 12 is the ideal result. The 4 questions included one physical assessment and three parent reported outcome measures. It took 5 min to administer and had excellent inter-observer agreement.An ACT score of 8 or less demonstrated 79% sensitivity and 100% specificity in identifying children that required further intervention, with a positive predictive value of 100% and negative predictive value of 90%. Children who completed two or more years of bracing were four times more likely to achieve an ACT score of 9 or more compared to those who did not (OR: 4.08, 95% CI: 1.31-12.65, p = 0.02). CONCLUSIONS: The ACT tool is simple to administer, had excellent observer agreement, and good sensitivity and specificity in identifying children who need further intervention. The score can be used to identify those children who definitely need referral and further treatment (score 8 or less) and those with a definite successful outcome (score 11 or more), however further discrimination is needed to decide how to manage children with a borderline ACT score of 9 or 10. LEVEL OF EVIDENCE: Level II, Diagnostic Study

Prevalence and causes of musculoskeletal impairment in Mahabubnagar District, Telangana State, India: results of a population-based survey.

Background: Musculoskeletal impairments (MSI) are the leading contributor to global years lived with disability. Comparable epidemiological data on MSI is lacking, and are needed to inform health and rehabilitative services. This study aimed to estimate the prevalence and causes of MSI in Telangana State, India. Method: A population-based survey used probability proportionate to size and compact-segment sampling to select 51 clusters of 80 individuals (all ages). Participants were screened using seven questions and any participant who screened positive underwent standardized examination by a physiotherapist for MSI presence, severity and diagnosis. Data were also collected on vision and hearing impairment, depression and self-reported difficulties with physical functioning. Results: The prevalence of MSI was 19.6% (95% CI: 16.7-22.8%) and this increased with age. The majority (82%; 574/699) of MSI was classified as mild, 11% as moderate and 7% as severe. Over half (57%) of MSI diagnoses were acquired non-traumatic causes, with degenerative joint disease being the most common. There was a high unmet need for physiotherapy services (3% attended vs. 40% recommended). One-fifth (21%) of MSI cases also had at least one of vision (10%) or hearing (11%) impairment or depression (3%). Conclusions: MSI is common among persons living in Mahabubnagar District, particularly older adults. These estimates can inform public health initiatives for the planning of health and rehabilitation services