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Culture May Affect Outcome of Ponseti Treatment for Clubfeet Due to Communication Issues

Posted on: 03/25/2009
Children who are born with a clubfoot have to receive treatment to allow their foot to grow properly and bear the body's weight as it should. One method that's used is called the Ponseti method, which seems to be effective in more than 95 percent of cases. When examining the reasons why the treatment may fail in some children, research suggests that parents may not be compliant in some cases, which could be caused by their educational level. Non compliance can be discontinuation of the treatment before it's finished or even due to the brace no longer fitting properly and the parents not wanting the child to suffer, for example. The authors of this article wanted to examine how large rural areas and economic and ethnic diversity may have an effect on how successful Ponseti treatment is.

Researchers recruited 100 infants who, among them all, had 138 clubfeet. Fifty patients (68 clubfeet) lived in an urban area and the remaining 50 patients (70 clubfeet) lived in an urban area. The researchers examined the severity of the clubfeet. The condition was mild if it was between 0.5 and 2 points on a rating scale, moderate between 2 to 4 (including 4), or severe, more than 4 points. The family provided information of how often the braces were used. They also used questionnaires such as the Pediatric Outcomes Data Collection Instrument (PODCI), measures how the parents see the child's function after treatment.

At the beginning of treatment, each family was given written instructions, in English, that described the treatment, the cast and the process, and the importance of compliance. They were also given an article that was about the success of the treatment, as well as several websites to use as resources. At every follow-up visit, the caregiver was reminded about the importance of compliance and the procedure again.

Treatment for the clubfeet was provided by one of three surgeons and the children were treated by the Ponseti guidelines. The children visited the clinic every week when the physician examined the foot while manipulating and stretching it. A new molded cast was then applied. Most of the children required surgery to loosen the Achilles tendon. After the final cast was removed, the children then received a brace to be worn full-time for three full months. After that, it was to be worn at nap and night time.

The results of the study showed that initially, 131 of the 138 feet were corrected completely. Seven weren't completely corrected by the initial cast treatment and they needed surgery to lessen the foot's stiffness. Looking at the recurrence rates among the other feet, the families of those children with recurrence were much more likely to not be compliant with the treatment, discontinuing the use of the orthotics before the doctor recommended it. The families in this group were most likely to be Native American, unmarried parents, have no insurance or rely on public insurance, have no more than a high school education, and/or have a family income of 20,000 dollars or less. However, Native Americans who lived in urban environments had rates of compliance equal to their non-Native American peers. It was only those in the rural areas who had higher non-compliance rates.

The authors of this study found a 25 percent higher rate of non-compliance than did earlier studies. They wrote, "We believe that cultural factors coupled with the distance from the site of care resulted in this difference in clinical outcome." Interestingly, they also wrote that Hispanic and non-Hispanics who lived in rural areas didn't have such a decreased compliance rate.

The findings suggest that the written material and teaching provided to the parents of children with clubfeet is not meeting the needs of certain populations, such as the Native Americans who live in rural areas. In this particular study, they lived in New Mexico, were more likely to follow their traditions, speak their language at home, and rely on native healers in addition to western medicine. Visual learning material may have been more appropriate. As well, the approach should have focused more on the positive than the negative: telling them the good that will result if they comply instead of the bad that will result if they don't comply.

References:
Frank R. Avilucea, BA, et al. Effect of Cultural Factors on Outcome of Ponseti Treatment of Clubfeet in Rural America. In The Journal of Bone & Joint Surgery. March 2009. Vol. 91. No. 3. Pp. 531 to 540.

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