November 2012

Out on a Limb: The whys of compliance

By, Jordana Bieze Foster, Editor

If you think your patients have compliance issues, be glad you’re not treating clubfoot in a place like India, Egypt, Mexico, or Bangladesh.

The vast majority of children with clubfoot live in resource-poor countries, and the challenges that practitioners face in trying to provide quality care to these patients are daunting. At the International Clubfoot Symposium, held in October at the University of Iowa in Iowa City, one speaker after another told of barriers to treatment that would be unimaginable to most first-world clinicians (see Conference Coverage).

Your patient doesn’t want to stop wearing her Ferragamos? She should be happy she can afford shoes. Many clubfoot patients can’t.

And that’s a shame, because many of them can’t afford vehicular transportation either. Getting a body from point A to point B is the job of the feet, regardless of whether one or both of those feet are awkwardly inverted, adducted, and plantar flexed thanks to a birth defect.

Your patient is too busy to make time for treatment? Some parents of children with clubfoot literally spend every waking hour working to provide food and shelter for their families. Saving money is next to impossible. And even if they can scrape up enough money for transportation to a clinic, the time lost getting there and back means corners will have to be cut elsewhere.

Your patient thinks the other kids will make fun of his ankle foot orthosis? Some children have to live their whole lives with clubfoot. If a child’s clubfoot isn’t treated during infancy, that child learns to walk on the feet he was born with. An ambulatory child is a child who can contribute to a family’s welfare, a contribution that would be missed if he were to undergo treatment for his neglected clubfoot. You can understand how that treatment might not be seen as a priority. And eventually that child will be too old for treatment to be effective—although some clinicians have had positive outcomes in 19 and 21-year-old patients.

Your patient thinks the brace you’ve prescribed isn’t comfortable? At least you have a brace to prescribe. In some parts of Egypt, there aren’t enough donated abduction braces for all the clubfoot patients who need them. Local craftsmen do their best, but the results just aren’t as good as they should be.

We hear so much about patients who fail to comply for what are essentially selfish reasons. But there’s a big difference between being selfish and just trying to survive. Understanding that is an essential component of clubfoot outreach efforts.

Faced with unique factors affecting patient compliance, practitioners have had to be creative in trying to cultivate improvement. Reducing the number of casts required decreases a family’s travel burden. So do the efforts of organizations like Walk For Life, which facilitates donations of braces and other supplies and is working to make Ponseti clubfoot treatment available to younger children within 60 km of their homes. Scientists are studying the use of low-cost materials for casting and bracing clubfoot patients in cash-strapped areas.

Here’s hoping those efforts help more kids get the treatment they need—regardless of where they live.

One Response to Out on a Limb: The whys of compliance

  1. Good post. Interesting concept on the transportation methods of other countries.

    Thanks,

    Brian Meisenburg

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