Adherence with treatment
Parents may find adhering to the treatment process difficult. Many Ponseti treatment programmes have found that bracing is the most difficult phase of treatment for parents to adhere to. Non-adherence and drop-out rates can also be high in the manipulation and casting phases of treatment too. Failure to adhere means that recurrence of the clubfoot deformity is highly likely to occur; this is frustrating both for parents and clinicians. It also results in considerable waste of parents’ and service providers’ resources. A study in New Zealand showed that the Ponseti method is far less cost-effective when adherence rates are low; this is due to the expense of managing recurrences (43).
In programmes where adherence is particularly problematic the causes for this should be investigated. It is important to understand what the barriers to adherence are so that parents do not get blamed for lack of adherence as it can be due to circumstances outside their control. Previous studies have shown that most parents do want to adhere with treatment instructions but that outside circumstances and influences can prevent them being able to do so. Two studies conducted in Uganda and one in Malawi with parents of children receiving Ponseti treatment investigated barriers and facilitators to adherence with treatment. These are summarised below and may be helpful in understanding potential causes for lack of adherence.
Barriers and Facilitators to adherence with treatment in Uganda and Malawi (16,17, 40) (facilitators do not necessarily relate directly to barriers)
|Cost of treatment (if parents are asked to pay)||Treatment provided free of charge|
|Cost of transportation||Reimbursement for travel expenses|
|Distance travelled and long journeys||Decentralisation of services|
|Unreliable resource provision (for example, attending clinics, finding there are no braces available and being asked to come back the following week.)||Receiving good quality care|
|Lack of paternal and family support||Family solidarity and harmony|
|Parents’ other responsibilities: e.g. employment, caring for their other children, domestic tasks||Clubfoot treatment counsellors and positive relationship with practitioners|
|Lengthy treatment process with many visits required|
|Difficulty applying braces|
|Prevailing beliefs in society that clubfoot is a result of supernatural forces and is not curable|
|Corruption and inconsistencies in health services|
The list of barriers and facilitators shows that there are many factors that can make adhering with treatment difficult for parents. These are likely to depend on the local context and are unique to their settings. Understanding these challenges and how they can be overcome may be crucial to the success of national or regional clubfoot programmes.
The information provided by GCI is based on publications in scientific journals (references indicated by numbers within the text). To see the full reference list click here.