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Title: The organisation and delivery of clubfoot treatment services in Malawi : an ethnographic study
Author: Drew, Sarah
ISNI:       0000 0004 7653 7613
Awarding Body: University of Oxford
Current Institution: University of Oxford
Date of Award: 2018
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Background Clubfoot is a congenital condition in which one or both feet are twisted inwards and if left untreated or 'neglected', can have a profound impact on the wellbeing of children and their families. Clubfoot can be treated through staged manipulation of the limb and treatment is delivered by Beit CURE Hospital in Malawi which coordinates 29 outreach clinics. However, implementing these services is complex; a high proportion do not present; and adherence to treatment is low. This study had three aims: 1) identify factors that impact on the implementation of services and develop a theoretical framework to inform findings; 2) understand the impact of accessing services on carers of children with clubfoot; and 3) explore the experiences of those who had not fully accessed treatment. Methods Ethnographic data collection comprised three elements. Element 1: Observation sessions were conducted at three clinics (totalling 90 hours) and interviews conducted with staff at an additional nine sites and members of the CURE management team. Key informants helped place findings within the wider health context (n = 58). Element 2: Fieldwork was conducted at three sites and involved single, dyad or triad interviews and focus groups with those currently accessing treatment, those who had been discharged and clubfoot counsellors (n = 57). Element 3: In-depth case studies were conducted with those that had not fully accessed treatment (n = 4). Results Factors impacting on service implementation were interpreted using an implementation science theory known as extended Normalization Process Theory. Factors identified included cooperation, commitment to delivery, workability and strategies to facilitate delivery over time. An additional construct identified concerned work done to facilitate patient access. How families and the community responded on finding out the child's feet were different varied. Whilst some mothers received love and support from others, it could also be a source of conflict and division. Families were overwhelmingly satisfied with treatment although challenges were identified. Those that had been discharged described joy and were happy to be relieved of the financial burden of treatment. Factors that influenced treatment-seeking for those who had not fully accessed treatment included the anticipated outcomes of living with clubfoot, availability of social support networks, healthcare experiences and a lack of referral pathways for treatment. Challenges took place in a web of competing concerns such as poverty. Conclusions The study provides insights to help organisations in Malawi deliver more effective patient care. Future research should explore processes of identification and referral of children with neglected clubfoot.
Supervisor: Gooberman-Hill, Rachael ; Lavy, Christopher Sponsor: CURE International UK
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available