Evidence to improve clubfoot services in Africa with Zimbabwe as a case study

Background: Clubfoot is one of the most common congenital musculoskeletal birth defects. Untreated it leads to physical impairment and deformity, resulting in loss of mobility and function. The cause in most cases is unknown. With early diagnosis and appropriate treatment functional impairment from clubfoot is avoidable. A minimally invasive technique as described in the Ponseti method is recommended for the treatment of the clubfoot deformity. In some resource-constrained settings, this treatment is being provided by nonspecialised health workers, ‘clubfoot therapists’, trained to treat children with clubfoot. This PhD thesis seeks to provide evidence to improve services for children with clubfoot in Africa using data from Zimbabwe as a case study. Methods: Two systematic reviews were undertaken; first to investigate the birth prevalence of clubfoot in low-and middle-income countries, and second to determine and evaluate how results of clubfoot management in sub-Saharan Africa are reported. A Delphi process with 35 experts (Ponseti technique trainers) from across Africa was used to determine (a) the criteria to assess clubfoot treatment and (b) to identify the indicators to evaluate the functionality of clubfoot clinics. In a retrospective case series of 218 children with idiopathic clubfoot in Harare, Zimbabwe, the results of corrective treatment and the factors that affect outcome were analysed. Using the results of the first Delphi exercise, a tool (the Assessing Clubfoot Treatment (ACT) score) was developed for clubfoot therapists to assess the results of Ponseti treatment in children of walking age in low resource settings. The tool was evaluated prospectively using the cohort from Harare, and also compared with other existing assessment methods. Tracey H. Smythe PhD Thesis Page | 4 From the second Delphi study - to obtain a consensus definition on indicators to assess the functionality of a clubfoot clinic in Africa - a questionnaire was developed (Functionality Assessment clubfoot Clinic Tool, FACT) and piloted in a cross-sectional study of service provision in 12 clubfoot clinics in Zimbabwe. A prospective mixed methods (both quantitative and qualitative) evaluation was used to assess the feasibility of a training programme (delivered through the Africa Clubfoot Training project from 2015 - 2017) for clubfoot therapists in Africa. Results: There is similarity of pooled estimates of birth prevalence of clubfoot in Africa, Eastern Mediterranean region, India and South East Asia (between 1.11 (95%CI 0.96 – 1.26)/1,000 live births and 1.21 (95%CI 0.73 -1.68)/1,000 live births). Of 22 studies that report results of the Ponseti method in sub-Saharan Africa only 14 (64%) described a primary outcome. Clinical assessment was the most commonly reported outcome measure and the Pirani score was the most frequent tool used to assess clubfoot severity. Results were predominantly reported though case series. The case series from Parirenyatwa Hospital demonstrated that the Ponseti method was successful in the majority (85%) of feet (defined as a Pirani score of 1 or less) up to completion of the corrective phase, with a relatively low loss to follow-up (8.9%). The ACT score, which was developed as a result of the first Delphi exercise, included one simple clinical assessment and three parent reported outcomes. In the children who were followed up (n=68) in the cohort from Harare, 72% (49/68) achieved an acceptable outcome (defined as an ACT score of 9 or more). The ‘success’ of treatment defined by five different assessment tools varied between 56% and 93% in the cohort. Using the FACT score, developed from the second Delphi exercise, the most common needs identified in the 12 clubfoot clinics in Zimbabwe were (a) a Tracey H. Smythe PhD Thesis Page | 5 standard treatment protocol, (b) a process for surgical referrals, and (c) a process to monitor drop out of patients. Fifty-one regional trainers from 18 countries in Africa were trained over the two years of the Africa Clubfoot Training project. These regional trainers delivered the basic and advanced course to 113 participants in 3 countries (Ethiopia, Rwanda and Kenya). The mean participant confidence and the mean participant knowledge both increased substantially following the training. Participants expressed high acceptability of the training, which they attributed to its clear purpose and guidance, and the interpersonal interaction with the trainers. Conclusion: Clubfoot services can be improved in Zimbabwe and probably the wider Africa region. It requires a health system-oriented approach. The evidence presented indicates that children with clubfoot can be effectively treated by trained clubfoot therapists (using the Ponseti method). To enable this there is a need to ensure that clubfoot clinics are appropriately equipped and clubfoot therapists are appropriately trained. Two tools have been developed to assist clubfoot therapists monitor their results (ACT score) and to enable programme managers to monitor the national clubfoot service provision (FACT). Studies to refine and test the ACT and FACT scores in other settings in Africa are required.