Addressing Barriers to the Ponseti
Method of Clubfoot Treatment
in Guatemala
Developing an Educational Solution
By Rhonda Endecott
MHIRT Intern Summer 2010
Project Overview
At Home…
◦ Project Advisors: Dr. Jose Morcuende and Dr.
Laurence Fuortes
On Location…
◦ Quetzaltenango, Guatemala
 2 Wks at San Juan de Dios Hospital
 Preceptor: Dr. Jorge Escalante
◦ Guatemala City, Guatemala
 8 Wks at IGSS Hospital
 Preceptor: Dr. Ana Zambrano
What do these people
have in common?
Young Bangladeshi girl
Mia Hamm
Kristi
Yamaguchi
Troy Aikman
Clubfoot
What is Clubfoot?

Talipes Equinovarus: the most
common birth deformity of the
lower limbs1
◦ Occurs, on average, 1.1 in every
1000 live births2

The foot is turned inward and
downward3
◦ One or both feet affected3
◦ Presents en utero at week 16-18 of
the pregnancy4

Cause?
◦ Most cases are Idiopathic (the cause
is unknown)3
◦ Genetics play a role in some cases5
SIGNIFICANCE
Every 3 minutes a child
with clubfoot is born.
Incidence in the
6
Developing World
The Cost

Child
◦
◦
◦
◦
Abortion7 or abandonment8,9
Physical disability3
Social stigma  Marginalization4,6
Limited future prospects…
 Education, Jobs, and Marriage10

Family/Community: high financial burden4,6
Results of Treatment:
Ponseti Method
Without
Treatment
Operations
The Ponseti Method of
Clubfoot Treatment11
The Problem…
• Untreated clubfoot poses significant
disability
• Traditional surgical treatments are…
1 to 8 clubfoot cases
• High Cost unattainable for many
• Low success rate undesirable for
per 1000 live births
nearly ALL
• Gold Standard: Ponseti Method
• Over 90% success rate
• Non-invasive
450 Guatemalan children • Collaboration with caregivers is key to
success
born with clubfoot yearly
• Poor compliance in bracing is the
most common cause for relapse.
(minimum)
• When given additional support,
including educational materials,
they were more likely to comply
with the treatment.15
The Project…
Goal 1 Enhance the
educational support materials
available to caregivers of
children with clubfoot
undergoing the Ponseti
method of treatment.
Goal 2 Enhance the
educational materials available
to referral and treatment
healthcare providers on
clubfoot and the non-invasive
Ponseti method of treatment.
Goal 3 Implement a public awareness poster campaign on
clubfoot and the non-invasive Ponseti method of treatment.
Summer 2010…
target audiences were provided with the following
developed education and awareness materials.
Caregiver
Education Module
Awareness Poster
Healthcare Provider
Tri-fold
For 10 Weeks at 2 Clinics…

Caregivers were…
◦ Walked through the information step-by-step.
◦ Given Q & A time.
◦ Provided with a hardcopy to take home.
Caregiver Education Module
•
•
They were encouraged to share the
information with the child’s other
caregivers.
They were informally asked about...
• Any commentary on the materials.
• Their treatment compliance.
• Their self-efficacy regarding sharing treatment
information.
Healthcare
Provider Tri-fold

Presentation on
clubfoot and the
Ponseti method
◦ Given to the heads of
nursing department at
IGSS.
◦ Informational Tri-folds
handed out
Awareness
Posters

Copies given to
preceptors and
posted at each clinic
◦ Also including San Juan
de Dios at the capital.
Both: Dr. Ana Zambrano distributed copies at her
presentation to local pediatric doctors.
Lessons Learned

For proper referral…
A list of treatment sites and/or providers needs
to be included the tri-fold and posters.

For better understanding in a low literacy
setting…
Even more of the text in the caregiver
information could be pictorially represented.

For greater tailoring…
Pictures in the materials could be altered to
those in traditional dress, and text to include
local jargon.
Future Direction





Revise the materials to tailor to this population.
OR
Keep it general enough to implement on a broad
scope.
Increase accessibility to scientific literature on the
topic to help build clinician advocates.
Move the poster campaign beyond the clinic
setting and into the community.
Give the healthcare provider information out to a
broader range of professionals (including
midwives).
At the Hospital…
Off the
Clock…
Special Thanks to…
Project Advisors and
Site Preceptors
 Medical staff at each
hospital
 MHIRT staff
 Host families

References
1.
Kromber, J., Jenkins, T., (1982) Common Birth Defects in South African Blacks. South African Medical Journal 16;62 (17) 599-602.
2.
Barker, S., Chesney, D., Miedzynbrodzka, Z., Mafulli, N., (2003) Genetics and Epidemiology of Idiopathic Congential Talipes
Equinovarus. Journal of Pediatric Orthopedics 23:265-227.
3.
Ponseti I., Congenital Clubfoot: Fundamentals of Treatment (1996) Oxford University Press Inc., New York.
4.
Pirani, S., Naddumba, E., Mathias, R., Konde-Lule, J., Norgrove, P. J., Beyeza, T., et al. (2009). Towards Effective Ponseti Clubfoot
Care: The Uganda Sustainable Clubfoot Care Project. Clinical Orthopaedics and Related Research , 467 (5), 1154-1163.
5.
Deitz, F., (2002). The Genetics of Idiopathic Clubfoot. Clinical Orthopaedics & Related Research. 401:39-48.
6.
E.A. Mayo, A. J. (2007). Creating a Countrywide Program Model for Implementation of a Ponseti Method Clubfoot Treatment Program in
Developing Countries. Retrieved from CURE International: http://www.helpcurenow.org/atf/cf/%7BB2D46E45-F4A9-4FA7-A241DBFC8297818A%7D/ccw-creating_a_countrywide_program_model.pdf
7.
Barnes, E. (2008). MP bids to outlaw abortions for clubfoot or cleft palate. Retrieved from:
http://news.scotsman.com/abortion/MP-bids-to-outlaw-abortions.4260541.jp
8.
China Abandoned and Orphaned Children. (2010). Retrieved from:
http://www.jubileeaction.co.uk/projects_china_abandoned_and_orphaned_children
9.
Lohan, I. (2009) Treatment of Congenital Clubfoot Using the Ponseti Method: Workshop Manual. Retrieved from Global-Help:
http://www.global-help.org/publications/books/help_clubfoottreatmentmanual.pdf
10.
USAID: Facts on the Disabled in Africa and the Developing World (2007) . Retrieved from USAID:
http://www.usaid.gov/locations/sub-saharan_africa/features/disabilities.html
11.
Staheli L, ed. (2003). Clubfoot: Ponseti Management. Seattle: Global-HELP Publications. Retrieved from: http://www.globalhelp.org/publications/ponseti-cf.html.
12.
Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am. 1980;62:23-31.
13.
Dobbs MB, Nunley R, Schoenecker PL. (2006). Long-term follow-up of patients with clubfeet treated with extensive soft-tissue
release. J Bone Joint Surg Am. (88). 986-96.
14.
Scher, David M. (2006) The Ponseti Method for Treatment of Congenital Clubfoot, Current Opinion in Pediatrics, 18(1):22-25,
15.
McElroy T, Konde-Lule J, Neema S, Gitta S; Uganda Sustainable Clubfoot Care (2007) Understanding the barriers to clubfoot
treatment adherence in Uganda: a rapid ethnographic study. Disabil Rehabil 29: 845-855