The development of a training course for clubfoot treatment in Africa: learning points for course development.

BACKGROUND: Clubfoot is a common congenital musculoskeletal disorder that causes mobility impairment. There is a lack of trained mid-level personnel to provide clubfoot treatment in Africa and there is no standard training course. This prospective study describes the collaborative and participatory approach to the development of a training course for the treatment of clubfoot in children in resource constrained settings. METHODS: We used a systems approach to evaluate the development of the training course. Inputs: The research strategy included a review of context and available training materials, and the collection of data on current training practices. Semi-structured interviews were conducted with seven expert clubfoot trainers. A survey of 32 international and regional trainers was undertaken to inform practical issues. The data were used to develop a framework for training with advice from two technical groups, consisting of regional and international stakeholders and experts. PROCESS: A consensus approach was undertaken during workshops, meetings and the sharing of documents. The design process for the training materials took twenty-four months and was iterative. The training materials were piloted nine times between September 2015 and February 2017. Processes and materials were reviewed and adapted according to feedback after each pilot. RESULTS: Fifty-one regional trainers from Africa (18 countries), 21 international experts (11 countries), 113 local providers of clubfoot treatment (Ethiopia, Rwanda and Kenya) and local organising teams were involved in developing the curriculum and pilot testing. The diversity of the two technical advisory groups allowed a wide range of contributions to the collaboration. Output: The resulting curriculum and content comprised a two day basic training and a two day advanced course. The basic course utilised adult learning techniques for training novice providers in the treatment of idiopathic clubfoot in children under two years old. The advanced course builds on these principles. CONCLUSION: Formative research that included mixed methods (both qualitative and quantitative) was important in the development of an appropriate training course. The process documentation from this study provides useful information to assist planning of medical training programmes and may serve as a model for the development of other courses.

Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade.

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society's role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.

Clubfoot treatment in 2015: a global perspective.

INTRODUCTION: Clubfoot affects around 174 000 children born annually, with approximately 90% of these in low-income and middle-income countries (LMIC). Untreated clubfoot causes life-long impairment, affecting individuals' ability to walk and participate in society. The minimally invasive Ponseti treatment is highly effective and has grown in acceptance globally. The objective of this cross-sectional study is to quantify the numbers of countries providing services for clubfoot and children accessing these. METHOD: In 2015-2016, expected cases of clubfoot were calculated for all countries, using an incidence rate of 1.24/1000 births. Informants were sought from all LMIC, and participants completed a standardised survey about services for clubfoot in their countries in 2015. Data collected were analysed using simple numerical analysis, country coverage levels, trends over time and by income group. Qualitative data were analysed thematically. RESULTS: Responses were received from 55 countries, in which 79% of all expected cases of clubfoot were born. More than 24 000 children with clubfoot were enrolled for Ponseti treatment in 2015. Coverage was less than 25% in the majority of countries. There were higher levels of response and coverage within the lowest income country group. 31 countries reported a national programme for clubfoot, with the majority provided through public-private partnerships. CONCLUSION: This is the first study to describe global provision of, and access to, treatment services for children with clubfoot. The numbers of children accessing Ponseti treatment for clubfoot in LMIC has risen steadily since 2005. However, coverage remains low, and we estimate that less than 15% of children born with clubfoot in LMIC start treatment. More action to promote the rollout of national clubfoot programmes, build capacity for treatment and enable access and adherence to treatment in order to radically increase coverage and effectiveness is essential and urgent in order to prevent permanent disability caused by clubfoot.

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.

A critical review of interventions for clubfoot in low and middle-income countries: effectiveness and contextual influences.

Inadequate treatment provision for clubfoot in many low and middle-income countries results in a high prevalence of neglected clubfoot, a condition causing severe impairment. This study critically reviewed evidence on surgical, conservative and mixed (Ponseti) treatment interventions for clubfoot in low and middle-income countries. Intervention effectiveness was analysed by comparing outcomes within International Classification of Functioning groupings. Contextual factors were qualitatively analysed for effect on intervention outcomes. The Ponseti method appeared to be more effective than conservative techniques but was not directly comparable with surgical techniques. Contextual factors were reported to influence outcomes; service providers using the Ponseti technique had made most intentional steps to overcome contextual barriers.

A collaborative public health approach to clubfoot intervention in 10 low-income and middle-income countries: 2-year outcomes and lessons learnt.

Untreated clubfoot has been acknowledged as a public health problem in low-income countries. In 2007-2009, a 10-country initiative was implemented by a collaboration of nongovernmental organizations and Ministries of Health to establish and strengthen national programmes for management of clubfoot using the Ponseti technique. Independent evaluation used quantitative data on programme outcomes and qualitative data from service providers and users. Overall, 110 clubfoot clinics were established, 634 practitioners were trained and 7705 children were enrolled for treatment. The public health model of establishing services for clubfoot on a national level was found to be successful in the majority of countries included.