Factors Affecting Parents to ‘Drop-Out’ from Ponseti Method and Children’s Clubfoot Relapse

Abstract

Background: Completed treatment of congenital clubfoot deformity using the non-surgical Ponseti method yields very good results. However, many children do not complete the treatment course, potentiating relapse of the deformity, forever compromising independent gait and quality of life. If the factors precipitating 'drop out' from treatment can be averted, more children will complete the Ponseti method of treatment which has low rate of complication and is both economical and highly effective. Children depend on parents to bring them to the clinics, hence we aimed to identify factors obstructing parents and ultimately the children's outcomes. Once identified, barriers to completing treatment may be removed. Aim:To identify the factors obstructing completion of clubfoot treatment.Method: Two of the 32 Walk for Life (WFL) clubfoot clinics in Bangladesh were utilised for participants, who were parents and children (n=72) who had dropped out from completing the clubfoot treatment course four to six years earlier. Bootstrapping was used to improve statistical power (based on 1000 random sample). Validated outcome measures included a specific context drop out questionnaire, the Oxford Ankle Foot questionnaire, the Bangla clubfoot assessment, and the Foot Posture Index. Parent's insights, experiences and recommendations were canvassed both qualitatively and quantitatively.Result: Relapse occurred in 15/72 drop out cases, predicted by problems with the initial casting process. The main reasons for drop out were difficulty with the foot abduction brace (42%), family issues (31%), and other problems with the child's clubfoot treatment (15%). Despite problems and incompletion, the parents were generally satisfied (93%), although many felt sad or ashamed for not completing the treatment course and realizing clubfoot deformity recurrence (96%). Parents who had dropped out, were noted by WFL staff to be regretful, and especially so if their now older child's clubfoot had relapsed to obviously compromise independent gait and mobility. A lack of discernment of postural clubfeet from 'true' clubfeet was identified in some clinicians, indicating variable practice methods despite uniform training, and probably lowering the overall relapse rate with inclusion of 'postural' cases. Conclusion:Relapse was predicted by problems with casting and predicted worse foot posture and reduced physical functioning. Walk for Life adopted appointment reminders, parent support groups, cost sharing, and staff updates.

A Community Audit of 300 “Drop-Out” Instances in Children Undergoing Ponseti Clubfoot Care in Bangladesh—What Do the Parents Say?

“…Whilst many parents reported no problems with the treatment, the most reported treatment phase problems were the tenotomy procedure (23.9%) and brace (37.5%) in the current audit cohort. In contrast, the previous study had identified the initial casting phase as that most difficult for parents (and predictive of drop-out [8]). BCAT was used to identify the children requiring more thorough assessment and further treatment at a WFL clinic.…”

“…We had found previously that parents reported dealing with difficult emotions, and that especially mothers reported sadness, had not told their family of their child's foot deformity, felt blamed for their child's deformity, and reported negative reactions from other people (due to their baby having visible casts or braces) [4,8].…”

“…Recently, we followed-up longer-term drop-out cases and found that problems with initial casting were predictive of drop-out, worse foot posture, and reduced physical function [8]. This study also identified a surprisingly low relapse rate, found disparity regarding typical versus postural clubfoot deformity recognition, and illuminated that many factors for drop-out were due to wider social, family, and treatment-related issues [8].…”

“…Relationships between variables were analyzed using Spearman's rho test (Foot Posture Index (FPI) and relapse signs). A comparison between this short-term community audit (n = 300) and a previous longer-term study (n = 72) in WFL clinics [8] utilized percentage differences.…”

“…Drop-out before treatment completion is a well-known and well-cited feature of clubfoot projects globally, and especially in LMICs [1,[7][8][9][10][11][12]. The Ponseti method is universally recognized as the "gold standard" treatment for congenital talipes equinovarus (CTEV) [6,[13][14][15].…”