UNIVERSITY eliminating the aspect of ignorance that may








Parent’s understanding of and attitude towards their child’s clubfoot
after initial counselling in our Ponseti Clubfoot Clinic.





Author: Group 19

Kezia George, Nabila Lortan,
Karlien Moyse, Cheyanne Moodley, Moeponi Pakkies, Zane Stenning, Kiren Moodley
and Ash Butau




Contact Details:


[email protected]

084 645 8863




Supervisor: Professor A. Robertson


Date: 1 September 2017




To date, there has been no study that
has investigated whether counselling of parents during the initial correction
of their child’s clubfoot has improved the parents’ knowledge of clubfoot,
thereby eliminating the aspect of ignorance that may lead to non-compliance
when it comes to continuous application of a foot abduction brace for 4 years.
Therefore, we aim to investigate whether the initial understanding and attitude
of parents towards clubfoot changes after 6 weeks of counselling provided by a
health professional in the Ponseti Clubfoot Clinic, Charlotte Maxeke
Johannesburg Academic Hospital (CMJAH). Parents/caregivers will be asked to
complete a questionnaire on their initial visit to the clinic and again after 6
weeks. This enables the research team to determine whether counselling during
that time has had a significant impact on parents understanding and attitude
towards their child’s clubfoot, thereby decreasing the likelihood of



















Literature Review

Congenital talipes equinovarus,
better known as clubfoot, affects approximately 8 in every 1000 children born
in Africa (Dietz et al, 2009).
Clubfoot presents at birth as a complex lower limb deformity (Parker et al, 2009) consisting of four
components; equinus, varus, adductus and cavus deformities (Ballantyne &
MacNicol, 2002). The exact cause of clubfoot is unknown; however, a combination
of genetic, environmental and pre-natal factors may influence the development
of clubfoot. The genetic component has been shown to play a significant role in
clubfoot, with a positive family history being reported in 25% of cases as well
as there being a higher incidence in first-degree relatives (2%) when compared
to second-degree relatives (0.6%) (Lochmiller et al, 1998; Paton et al,
2010). Pre-natal influences have been noted as a possible cause of clubfoot,
where reduced foetal movement or muscular atrophy of the hind limb, as well as
maternal smoking during the first trimester have been linked to an increased
prevalence of neonates being born with clubfoot (Somppi, 1984; Honein et al, 2000). It seems that clubfoot is
a multifactorial process, however, there is still much to be unravelled
regarding the intricacies of the multifactorial influences driving the
development of clubfoot.

Clubfoot can be diagnosed as early as
the 12th week of gestation (Keret et al, 2002). However, in our society, the majority of clubfoot is
diagnosed at birth. The severity of the clubfoot is determined by using the
Pirani Scale (Appendix 1). A 13-point scale comprising of six items which
describe the appearance and range of movement of the foot (Dyer and Davis,
2006). The final score indicates the severity of the clubfoot. A score of zero
indicates a normal foot and a score of six indicates a severe foot deformity.
The score is able to predict the outcomes of management, by predicting the
number of casts to be used (Ponseti method) for the initial correction period
(Dyer and Davis, 2006).

Congenital Club Foot: The results of treatment was published in 1963 by Drs Ponseti and
Smoley (Ponseti and Smoley, 1963). In this paper, the Ponseti method was first
described. However, it wasn’t until The
treatment of idiopathic clubfoot was published in 1995 by Dr  Ponseti. In this paper 78% of patients
reported excellent outcomes following clubfoot correction via the Ponseti
method some 30 years earlier (Cooper and Dietz, 1995). The Ponseti technique
has significantly decreased the need for major surgery in the correction of
clubfoot, and is now the most widely used clubfoot management – particularly in
South Africa (Zionts et al, 2010;
Khan, 2005). The technique involves 6-8 weeks of serial casting with
manipulation of the foot occurring around the talo-crural joint (Ponseti et al, 2005). The use of the serial
castings is associated with an improvement in the shape and positioning of the
abnormal bone structures, and following the initial manipulation an Achilles
tenotomy is needed in up to 90% of cases (Zionts et al, 2010). Children are then required to wear a foot abduction
shoe-brace for 23 hours a day for 3 months and thereafter, during sleep until
the age of 4 (Zionts et al, 2010).
Compliance with the bracing regime is imperative to the success of the
treatment and without it there may be a relapse (Haft et al, 2007).

Relapsed or untreated clubfoot is one
of the primary causes of physical disability in the world, affecting 1 in every
750 children (Carney and Coburn, 2005). Untreated or poorly managed clubfoot is
a large contributor to poverty in developing countries, as an individual’s
potential productivity is diminished due to the pain associated with performing
activities, thus leading to dependency (Penny, 2005). Therefore, the correct
management and compliance of clubfoot is imperative to an affected individual’s
long-term well-being.

The issue of non-compliance regarding
the continued use of the foot abduction brace is the leading risk factor for
deformity recurrence (Garg and Porter, 2009). There are a number of reasons why
parents fail to comply with treatment guidelines, particularly failing in the
application of the foot brace. Parents complain that their child cries and
becomes irritable during application thereby discouraging the parents to
continue the application process (Jawadi et
al, 2015; Rashid et al, 2016). Socio-economic
reasons for poor compliance include the delay of obtaining a new foot brace
once the child has out grown their current orthosis, as parents do not have the
time or means to return to clinics to be issued with a new orthosis (Rashid et al, 2016). Other reasons include that
of parental ignorance, where parents are unsure as to why their children need
the brace for the following 4 years when they have already been “cured” (Rashid
et al, 2016).

The lack of knowledge and
understanding of parents to their child’s condition can be attributed to poor
compliance in the long-term treatment of clubfoot. Counselling of patients as
well as their caregivers has been shown to have a beneficial effect on the
clinical outcome by improving patient compliance to the intervention (Goodyer et al, 1995). A recent Nigerian study
has concluded that paying special attention to parents would improve the
emotional and parenting stress experienced by these parents during their
child’s clubfoot treatment (Esan et al,

To date, there has been no study that
has investigated whether counselling of parents during the initial correction
of their child’s clubfoot has improved the parents’ knowledge, understanding
and attitude towards clubfoot and with the correlation of ignorance and
non-compliance seen in previous literature, the assumption can be made that
counselling would improve the long-term compliance in application of the foot
abduction brace.


Therefore, the aim of this study is
to investigate whether the initial understanding and attitude of parents
towards clubfoot changes after six weeks of counselling provided by a health
professional in the Ponseti Clubfoot Clinic, Charlotte Maxeke Johannesburg
Academic Hospital (CMJAH).


the attitude of parents towards their child clubfoot both before and after 6
weeks of counselling.

the response of parents towards 6 weeks of counselling.



Study Design

data will be collected using a questionnaire. The study design is therefore a
descriptive survey.


study will take place at the Ponseti Clubfoot Clinic in Charlotte Maxeke
Johannesburg Academic Hospital (CMJAH), South Africa. It will be conducted on
Wednesdays, the day on which the clinic is run.


study population will include parents, caregivers and/or guardians of children
with clubfoot, who have been referred and are presenting to the clinic for
treatment for the first time.

Inclusion Criteria:

Parents, caregivers
and/or guardians of children with unilateral or bilateral clubfoot, that have
been referred to the clinic and who are presenting to the clinic for the first

Exclusion Criteria:

Potential participants
who choose not to sign an informed consent form.


Sampling Method

study sample will be recruited by consecutive sampling. Every subject that
meets the inclusion criteria within the study time frame, will be included in
the study.

Sample size

study will take place over six months, every subject meeting the inclusion
criteria and willing to sign informed consent in that time period will be
included in the study. A sample size of n=25 is an initial goal.

Recruitment of participants

caregivers and/or guardians of patients referred to the clinic for the first time
will be approached by a member of the research team who will explain the nature
and procedure of the study and what is expected of them to be able to
participate in the study. The individuals who have been approached will be
asked for their permission to take part in the study, and if granted, an
informed consent form (Appendix 2) will be completed.

Measurements & Data Collection

questionnaire (Appendix 3) as well as a demographic data sheet (Appendix 4)
will be used to collect data. As seen in Figure 1, eligible participants will
be seen on their first visit to the Ponseti Clubfoot Clinic. On this day, participants
will be asked to complete part one of the questionnaire, either by themselves
or with assistance from the research team members. Each research team member
will keep track of their participants from day one and follow up the same
participant when they come back in week six to do part two of the

of participants will occur after part one of the questionnaire has been
completed and will continue on every subsequent visit of the participant to the
Ponseti Clubfoot Clinic. Health care professionals will be provided with a
counselling checklist (Appendix 5) in order to standardise the counselling
giving to each participant. The checklist provides a guideline and outlines
important points that need to be covered during each counselling session.

barriers will be overcome by asking research team members as well as nurses
working in the clinic, who are fluent in African languages to interpret and
translate explanations and responses.















Figure 1. A schematic
representation of the data collection process.


Data Management and Analysis

Data Organization

Paper questionnaires and demographic
data sheets will be collected by members of the research team. Members will
then input all information gathered onto a Microsoft Excel2010 spreadsheet,
where scoring will take place.


Questions that ask for definitions/knowledge
of clubfoot will be scored according to how closely the answers resemble the
dictionary/approved scientific definition. The scoring will be carried out by
the same research team member and each answer will be scored in the following

No idea = 0

Some Idea =

A complete
idea = 2



All papers questionnaires and
demographic data sheets will be kept in a locked locker, only accessible by
research team members, in the Medical School of the University of the
Witwatersrand, Johannesburg.


The statistical analysis will be
performed using commercially available computer software (GraphPad Prism5;
Microsoft Excel 2010). Basic statistical analyses will be used, in addition to
a Student T-test to compare parts one and two of the questionnaire, where a p ?
0.05 will be considered as statistically significant.

Expected Outcomes


provided by health care professionals in the clinic over a 6-week period will
improve the outlook and attitude of parents/caregivers towards their child’s
clubfoot. Thereby, improving their willingness and compliance to treatment

parents/caregiver’s social economic and educational status will be linked to
their understanding and attitude towards their child’s clubfoot. Whereby more
affluent and educated parents will understand more about their child’s

will help address cultural and societal misnomers, relating to the possible
causes of clubfoot, thereby decreasing the likelihood of self-blame and guilt
felt by parents.


Anticipated Problems


Failure of participant to present at follow up.

Experimental Bias: Bias introduced by the research
team member, whose expectation about the outcome can be subtly communicated to
the participants.

Subject Bias: Participants consciously or
subconsciously respond in a manner that they think the research member wants
them to respond.


Ethical and Legal Considerations

Ethical clearance will be
obtained from the Wits Human Research Ethics Committee prior

to data collection. Consent
will be obtained before commencing with data collection and the

confidentiality of all
participants will be ensured throughout the study. Participants will be

able to withdraw from the
study at any point in time; this decision will make their results

inapplicable to the study.



JUL 2017

AUG 2017

SEPT 2017

OCT 2017

NOV 2017

DEC 2017

JAN 2018

FEB 2018

MAR 2018

APR 2018

MAY 2018

JUNE 2018

JUL 2018

AUG 2018

SEPT 2018

















































Final Protocol
















Data Collection
















Data Analysis
















Final write-Up
















Final report due

















10.  Funding

This study
is self-funded by the student researchers.