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Iowa Orthop J. 2011; 31: 30–35.
PMCID: PMC3215110

THE PONSETI METHOD IN LATIN AMERICA: INITIAL IMPACT AND BARRIERS TO ITS DIFFUSION AND IMPLEMENTATION

Abstract

The Ponseti method for correcting clubfoot is a safe, effective, and minimally invasive treatment that has recently been implemented in Latin America. This study evaluates the initial impact and unique barriers to the diffusion of the Ponseti method throughout this region. Structured interviews were conducted with 30 physicians practicing the Ponseti method in three socioeconomically diverse countries: Chile, Peru and Guatemala. Since learning the Ponseti method, these physicians have treated approximately 1,740 clubfoot patients, with an estimated 1,705 (98%) patients treated using the Ponseti method, and 35 (2%) patients treated using surgical techniques. The barriers were classified into the following themes: physician education, health care system of the country, culture and beliefs of patients, physical distance and transport, financial barriers for patients, and parental compliance with the method. The results yielded several common barriers throughout Latin America including lack of physician education, physical distance to the treatment centers, and financial barriers for patients. Information from this study can be used to inform, and to implement and evaluate specific strategies to improve the diffusion of the Ponseti method for treating clubfoot throughout Latin America.

INTRODUCTION

Clubfoot, the most common musculoskeletal birth defect, is a deformity that results in complete inward-turning of the foot Clubfoot can be idiopathic or occur in conjunction with other disorders, such as myelome ningocele or arthrogryposis. It is estimated that the incidence for congenital clubfoot worldwide is about 1.6-1.8/1000 live births.1

The traditional treatment for clubfoot has been casting shortly after birth, followed by surgical intervention, usually a posteromedial soft-tissue release. Surgical procedures are expensive, and in developing countries the cost of surgery can be prohibitive. Untreated clubfoot is both a physical and social deformity, as babies with this defect are often abandoned, and older individuals are often ostracized from their communities.

The Ponseti method for correcting clubfoot was created in the 1940's by Dr. Ignacio Ponseti, and has started to become the gold standard around the world for treating this deformity.2 The Ponseti method uses a combination of manipulations and casting to correct the deformity, requiring a minimal, office-based procedure -an Achilles tenotomy. After the casting period, the child wears a foot abduction brace until the age of four to prevent relapse.2,3 The Ponseti method has been shown to achieve complete correction in as little as 16 days in >95% of patients. Additional surgical release is required in as few as 1% of patients.4,5

Within the last 10 years, the Ponseti method has been diffused throughout Latin America and has begun to be implemented there. Latin America contains a diverse group of countries and has a population estimated at 577 million people. This study looked at three socioeconomically diverse countries in the region: Chile (population 16.6 million; GDP per capita of $16,600); Peru (population of 29.5 million; GDP per capita of $8,500) and Guatemala (population of 13.3 million; GDP per capita of $5,100) to identify the challenges faced in the diffusion and implementation of the Ponseti method.6 By identifying those barriers, specific strategies can be employed to improve the diffusion of the method throughout these and other countries in this region. Furthermore, awareness of countries' knowledge about and attitudes toward the Ponseti method will allow evidence-based and culturally appropriate strategies to be developed, evaluated and implemented.

MATERIALS AND METHODS

Face-to-face semi-structured interviews were conducted in Spanish with physicians practicing the Ponseti method in Chile, Peru and Guatemala. These providers were chosen both from lists of those attending Ponseti training workshops and from referrals made to Ponseti providers in each country. Thirty physicians were interviewed, 22 of whom had attended Ponseti training workshops and six of whom trained on their own. Two of the physicians interviewed were practicing a modified version of the Ponseti method, and were not included in this study. These 28 interviewed physicians were the final group for this study. In addition, observations of health care practices in both hospital and clinical settings were recorded, providing an in-depth look at the health care system of each country and the initial impact of and barriers to diffusion of the Ponseti method.

Interviews were conducted by a medical student fluent in both Spanish and English. Responses were collected in Spanish over a period of ten weeks, and the results were translated into English and sorted into themes. Participant's names were removed from the data and the data was stored in a secure location. Informed consent was obtained by having participants review a consent letter. The study methodology was approved by the University of Iowa Institutional Review Board.

RESULTS

Ponseti workshops were first held in Santiago, Chile in 2005; in Lima, Peru in 2007; and in Guatemala City, Guatemala in 2009. Courses consisted of a two-day workshop with lectures and hands-on practice on models and patients, and case presentations with discussion. Today, it is estimated that Ponseti training has educated 23 physicians in Chile, 75 physicians in Peru, and 25 physicians in Guatemala. The majority of participants in Chile work in Santiago, but one physician has been trained per region (totaling 10 regions). In Guatemala, participants came from several regions, but in Peru all were concentrated in Lima.

Twenty-eight physicians from the three countries were interviewed, including nine in Chile, 11 in Peru and eight in Guatemala. In Chile, all nine physicians interviewed were practicing in Santiago. In Peru, all 11 physicians interviewed were practicing in Lima. In Guatemala, six physicians were interviewed in Guatemala City and two in Quetzaltenango. Since implementation of the Ponseti method in these countries, the majority of physicians responded that after their training they treated patients with the Ponseti method, whereas prior to that they performed surgery. There were, however, a few physicians who still did some surgery for complicated cases. They had treated approximately 1,740 clubfoot patients since learning the Ponseti method. More importantly, of these patients, an estimated 1,705 (98%) were treated using the Ponseti method, and 35

(2%) were treated using surgical techniques, most often a posteromedial soft-tissue release.

Physicians were asked to identify which of the following themes were barriers to the diffusion and implementation of the Ponseti method in their country: Physician education, the health care system of the country, the culture and beliefs of patients, physical distance and transport, patient financial barriers and/or parental compliance with the method.

Physician education

Nine of nine physicians in Chile, nine of 11 physicians in Peru and five of eight physicians in Guatemala identified physician education as a barrier to the diffusion and implementation of the Ponseti method. In Chile and Peru, for example, the Ponseti method is not currently being taught as a method of treating clubfoot in medical schools and residency programs. In order to attend a Ponseti training session, physicians must take time off of work and pay a nominal fee (approximately $100 US) to attend; therefore, there is little financial incentive for physicians to learn the Ponseti method. Additionally, some physicians that have attended training sessions may see only a few clubfoot patients each year. They may have enough training, but lack an adequate volume of patients to sustain their experience and successfully treat patients using the Ponseti method. Six of the physicians interviewed had not attended formal training sessions, but had learned the method from other physicians or over the Internet. Several physicians interviewed expressed distrust in those who had not been formally trained in the Ponseti method because they have seen unsatisfactory results mostly due to modification of the techniques and protocols.

Implementation of the Ponseti method is relatively new in Guatemala, as the first training course took place in 2009. Some of the physicians there cited a widespread lack of knowledge about and trust in the Ponseti method, as well as a lack of incentives for continuing education, as their primary reasons for physicians not receiving Ponseti training in Guatemala.

Health care system of the country

Eight of nine physicians in Chile, nine of 11 physicians in Peru and six of eight physicians in Guatemala cited their nation's health care system as a barrier to the Ponseti method. In each country, the Ministry of Health has not yet accepted the Ponseti method as a treatment for clubfoot In Chile, this means that there has been little publicity about the benefits of the method. In Peru, several physicians explained that though many people have some form of insurance, some insurance companies will not pay for treatments related to congenital problems. Private hospitals may cover all treatment costs, while in public hospitals the patient assumes the entire cost of treatment. Several physicians also described a deficit of knowledge or providers of the Ponseti method outside of Lima. In Guatemala, there is little knowledge of the benefits of the method, though CURE International, a non-governmental organization, is currently leading a widespread publicity campaign. In the public sector of the health care system in Guatemala, several physicians identified the poor quality of available casting materials as a barrier. The poor quality of materials makes the casts more uncomfortable for the children and also means the treatment is more difficult for physicians to perform. Many Guatemalans are uninsured, therefore all treatment costs would be paid out of pocket.

Culture and beliefs of patients

Zero of nine physicians in Chile, three of 11 physicians in Peru and seven of eight physicians in Guatemala described the culture and beliefs of patients as being a barrier to the Ponseti method. In Chile, some parents initially reject using the abduction brace because of the social stigma they associate with children in orthotics braces. However, this does not appear to be a long-term issue with compliance with or acceptance of the method. Several physicians in Chile have structured appointments so that all their clubfoot patients are treated on the same days of the week. This provides an opportunity for parents and children undergoing the different stages of the Ponseti method to interact with one another, and has made a positive difference in compliance and the attitudes of the parents. Parents not only hold one another accountable for consistent use of the brace, but parents of children in the casting phase of treatment can see the corrected feet of children in the later bracing phase, giving them hope that that the Ponseti method will fix their child's feet.

In Peru as in Chile, some parents initially rejected the use of the abduction brace because of the social stigma. However, most parents tended to comply after the physician explained that the brace was required to prevent regression of the clubfoot

In Guatemala, one of the largest cultural barriers that the Ponseti method faces is the language barrier. Besides Spanish, there are many different dialects and languages spoken throughout Guatemala, especially in the indigenous populations. With few translators available, it is difficult for physicians and patients to communicate effectively with one another. Several of the physicians interviewed stated that it was especially difficult to explain the bracing schedule to parents, and that this is one of the major barriers they face when using the Ponseti method. Another social issue in Guatemala is that of child abandonment Many children in rural Guatemala are born in family homes with midwives or other relatives present and children born with birth defects are often abandoned shortly after birth. This may be due to a number of factors, including lack of midwife education about clubfoot treatments and the social stigma surrounding people with disabilities. If parents have no knowledge of available clubfoot treatment methods, they may not want to raise a child with a disability who may be ostracized from their community and unable to work later in life.

Physical distance and transport

Four of nine physicians in Chile, nine of 11 physicians in Peru, and eight of eight physicians in Guatemala identified physical distance and transport as a barrier to the Ponseti method. In all three countries, the frequency of appointments the patient is required to attend (during the casting portion of Ponseti treatment) pose a significant barrier for implementation. In all three countries, the majority of Ponseti physicians are located in the capital cities. For families living outside of the capital city, this means they must travel a great distance each week for their child to receive treatment This creates many issues for parents; many of them have to request time off work in order to make the journey into the city, or find alternate childcare for their other children remaining at home. Many families are reliant on public transportation, which may not be reliable. In Peru, for example, the Andes Mountains, which traverse the majority of the country, make it very difficult and time consuming for people to reach Lima, where the only Ponseti physicians are located. Some families elect to stay in the capital city for the entirety of the casting portion of the Ponseti treatment. However, this option, while convenient, is not financially feasible for many patients. Physicians in all three countries identified physical distance and transport as a major reason for patients abandoning the treatment regimen, or choosing surgical procedures, which require only one physician visit.

Financial barriers for patients

Nine of nine physicians in Chile, seven of 11 physicians in Peru and seven of eight physicians in Guatemala described finances as being a barrier to the Ponseti method. In all three countries, cost of the treatment can have a large impact on initiation of treatment and compliance. The most expensive portion of the treatment universally, is the bracing portion. As a child grows, they will need approximately four abduction braces to complete the treatment course. Physicians in all three countries stressed that the cost of the braces is the biggest factor in patient non-compliance to the treatment, as many families cannot afford to keep buying braces through the duration of the treatment.

In Chile, the costs of treatment depend on the patient's insurance and whether or not they are receiving care in the public or private system. One physician estimated the total cost of treatment, including transportation and several abduction braces, to be approximately $1,000 US. Another physician has started a program of collecting and reusing shoes to defray treatment costs. Parents donate the shoes used on the abduction brace when their child has outgrown them, and the shoes are attached to a new bar to be used by another child. This program allows patients to complete their treatment using the Ponseti method without their parents assuming the entire cost of several new braces, each estimated to cost about $120 US.

In Peru, there is currently only one orthotics company producing the abduction braces, and each costs around $200 US. As previously discussed, some insurance companies will pay for treatment costs, while others will not because clubfoot is a congenital birth problem. No insurance company will pay for the cost of the braces, so families must assume those costs on their own.

In Guatemala, there is no cost for the casting portion of the treatment, but families must pay out of pocket for the abduction braces, each of which costs about $90 US. Families must also pay out of pocket for the transportation costs of getting to the treatment facility.

Parental compliance to the Ponseti method

Three of nine physicians in Chile, six of 11 physicians in Peru, and three of eight physicians in Guatemala identified parental compliance as a barrier to the Ponseti method. In all three countries, many of the physicians stated that once a child is in the bracing portion of the treatment, and parents see a corrected foot, they think the child is “cured,” and discontinue bracing before the child has completed treatment Parents may also stop coming to the treatment center because they cannot afford the braces or the transportation costs. Both of these lead to regression of the clubfoot in the majority of cases. In Peru, two physicians estimated that 10% of parents abandon the treatment program after they see the corrected feet.

DISCUSSION

Latin America, with a population of 577 million people and an estimated 15,400 children born each year with clubfoot, represents a world region in which the development of effective clubfoot treatment programs has the potential for a vast impact on the lives of many children and families.7 Each of the 20 countries that make up Latin America is unique; however, they share a common cultural heritage and values. Therefore, evaluation of the three countries chosen in this study was considered to be representative for the region and could provide information on the impact of and barriers to the diffusion and implementation of the Ponseti method.

Interestingly, when one considers the Ponseti method as an innovation in health care, the framework for how innovation disseminates could be applied and lessons learned in other fields could be used to improve it. In “Diffusion of Innovations,” EM Rogers discusses three basic clusters of influence that correlate with the rapid spread of a change: Perceptions of the innovation, characteristics of the people who adopt the innovation or fail to do so, and contextual factors.8 When considering successful diffusion and implementation of the Ponseti method, these concepts can be applied to the data collected in this study as well as others done previously in China, Uganda, Malawi, and rural areas of the United States.

The first influence on the rapid spread of change by an innovation is the perception of the innovation itself. Rogers discusses the perceived benefit of the change—people are more likely to adopt an innovation if they think it will help them.8 In Latin America as a whole, there is a widespread lack of knowledge about the Ponseti method. As the first training sessions took place just a few years ago, many physicians and patients have not heard of the benefits of the Ponseti method. In rural areas, many families may not even know that there is a treatment for clubfoot. These results are comparable to those initially found in both Uganda and Malawi, however, national clubfoot treatment programs have been initiated in each of these countries. In Uganda and Malawi, hundreds of healthcare workers, including orthopaedic officers, and midwife and immunization teams have been trained in the early detection and referral of patients. This has resulted in increased access to care for hundreds of children born with clubfoot in these countries, but the treatment is concentrated in specialized clinics where clinical experience and materials are more available.9-11

The second influence on the rapid spread of change of an innovation is the characteristics of the individuals who adopt the innovation or fail to do so. Rogers classifies several groups of people based on how they adopt an innovation: the “innovators,” first to adopt a new innovation, followed by “early adopters,” “early majority,” “late majority,” and last, the “laggards.” Typically, “innovators” and “early adopters” are often leaders within their hospitals or communities—in Latin America, these are the physicians who heard about the Ponseti method over the Internet or at a conference and sought out a training session. The “early majority” of the physicians are those who have heard about or learned the method from the “innovators” and “early adopters.” These three groups of people represent the physicians interviewed for this study. These are the physicians who took the incentive to learn about the Ponseti method on their own. The other two groups of physicians, the “late majority” and “laggards,” will likely not adopt the Ponseti method until it is being taught at a national level in medical schools and residency programs. Because there are many physicians who have not yet even heard of the Ponseti method, and because there are still countries where no training sessions have even been held, it is necessary to increase the number of Ponseti training sessions available in Latin America. But most importantly, these courses should be targeted first to those individuals that are very interested and willing to practice the method rather than as a mass teaching program. Unless the courses build capacity for successful treatment, there is a high risk for deterioration of the results over time. A potential mechanism to help resolve this issue is the use of virtual videoconferencing for continual medical education. This mechanism would enable a Ponseti physician to discuss and present cases to any other physician in Latin America, even those using a low-bandwidth (dial-up) internet connection. Potentially, physicians in cities and rural areas could be trained in the Ponseti method, decreasing the transportation barriers that many patients and families face. The feasibility and impact of training physicians using Eluminate Live! is currently being studied.

The third influence on the rapid spread of change of an innovation is represented by the contextual factors surrounding the innovation. Things such as poverty and communication within the social system of these countries may improve or impede the spread of the innovation. In the countries where the Ponseti method has been evaluated, many patients face financial hardship, and the frequency of required physician visits during the casting phase of the treatment, combined with the out-of-pocket costs of the braces, can result in discontinuation or decreased use of the method.12 Though China and Latin America have different health care systems and insurance standards, the cost of transport and the abduction braces seems to be the most financially constraining factors for parents.

Communication between physicians and parents of children undergoing Ponseti treatment has also been shown to be a barrier to the diffusion of the method. In countries in Latin America and even in the rural United States (where different languages and dialects are spoken) it can be difficult for parents to understand the bracing schedule for their child.13 Lack of understanding of the bracing protocol can lead to early termination of bracing and regression of the corrected feet.

The Ponseti program in Latin America can benefit greatly from the findings of the programs in China, Uganda, Malawi, and the rural United States. In order to increase the diffusion of the Ponseti method throughout this region, the Ponseti method must achieve national recognition in each country, as has been done in Uganda and Malawi.9-11 This would involve gaining approval from the Ministry of Health, training large numbers of healthcare providers throughout the countries, and integrating the Ponseti method into the medical school and residency program curricula. Increasing the number of Ponseti providers by implementing more training opportunities would also ensure that rural providers would have the chance to be trained, possibly decreasing the transportation barriers for patients living in rural areas. As previously discussed, these programs should first be targeted toward individuals who are very interested in and willing to practice the method. Additionally, nationwide publicity campaigns to educate the public that clubfoot is treatable without surgery, mirroring current campaigns by the Sustainable Clubfoot Program in Uganda and CURE International in Guatemala, would be of great assistance.

Finally, studies in Uganda have shown that an effective, low cost brace can be produced for as little as $10 US.14 By streamlining a brace production program in Latin America (in each country or centrally), effective and low-cost braces could be produced, eliminating the financial burden that the current bracing system places on families. Also, to facilitate increased communication between physicians and parents, informational pamphlets with photos and directions - translated into as many native dialects as possible - could be distributed. This would give families something tangible to take home when questions arise about treatment protocol. Increasing parental understanding of the method could go a long way toward reducing the rates of regression of corrected clubfoot.

CONCLUSION

This study identified several potential barriers to the diffusion and implementation of the Ponseti method in Latin America. Three diverse countries were studied, but many of the barriers faced by the Ponseti method were common regardless of socioeconomic differences. Overcoming these educational, social, and financial barriers will allow the continued diffusion of the Ponseti method throughout Latin America, resulting in better access and patient care.

Acknowledgments

This project was supported by the Arnold P. Gold Foundation and the University of Iowa Carver College of Medicine's Summer Student Research Fellowship.

The authors would like to thank Centro Ann Sullivan del Peru for their specific assistance with the forums and Dra. Ana Zambrano, Dr. Alejandro Bermudez, Dra. Dalia Sepulveda, and Dr. Gaston Terrazas for their specific roles organizing this project.

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