title: Early effects of a 'train the trainer' approach to Ponseti method dissemination: a case study of Sri Lanka.
abstract: BACKGROUND
  The Ponseti method has been established as the standard of care for the treatment of clubfoot in many developed countries for its utility, cost-effectiveness, and efficiency. However, despite its being described as the gold-standard for clubfoot treatment, there are still many areas of the world bereft in formal training in the Ponseti method. This is especially important since 80% of patients with clubfoot are born in developing countries where the need is the greater for experienced providers. This study analyzes a 'Train the Trainer' approach, specifically in the island nation of Sri Lanka, as a model for future dissemination of the Ponseti method throughout the developing world.
  
  
  METHODS
  A rapid ethnographic study design that included interviews, focus groups, and direct observation of 162 patients and healthcare practitioners directly involved with clubfoot care was conducted.
  
  
  RESULTS
  The average age of the patients at the time of the interview was 75.4 weeks old (SD = 149.2), traveled 45.2 kilometers (SD = 49.8) to receive their care, and received 4 casts (SD = 2.2) for correction of the deformity. Since the initiation of the 'Train the Trainer' educational program, clubfoot clinics reportedly grew from 6-7 patients per week to over 60 patients per week. The majority of this patient population growth was attributed to word of mouth. Major barriers to the method included casting materials, bracing materials, and a lack of a dedicated area of the clinic to conduct tenotomies under local anesthesia. Of note, cost was not cited as a major barrier.
  
  
  CONCLUSIONS
  Early evaluation suggests great utility of the 'Train the Trainer' method - especially regarding an increased patient demand for treatment. However, further studies are necessary to understand the long-term utility of this training methodology.
authors.affiliation: Department of Orthopaedics and Rehabilitation Carver College of Medicine University of Iowa.
authors.forename: Asitha
authors.initials: A
authors.lastname: Jayawardena
authors.forename: Sunil R
authors.initials: SR
authors.lastname: Wijayasinghe
authors.forename: Dimuthu
authors.initials: D
authors.lastname: Tennakoon
authors.forename: Thomas
authors.initials: T
authors.lastname: Cook
authors.forename: Jose A
authors.initials: JA
authors.lastname: Morcuende
mesh_terms: D000328:Adult; D001915:Braces; D002370:Casts, Surgical; D003025:Clubfoot / Q000601:surgery / Q000628:therapy*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007223:Infant; D008297:Male; D008349:Manipulation, Orthopedic / Q000379:methods*; D019637:Orthopedic Procedures / Q000193:education*; D013188:Sri Lanka; D058971:Tenotomy; D016896:Treatment Outcome
references.citation: J Pediatr Orthop B. 2012 Jan;21(1):59-67
references.pmid: 21811182
references.citation: Int Orthop. 2009 Apr;33(2):521-6
references.pmid: 18196240
references.citation: J Child Orthop. 2010 Dec;4(6):553-9
references.pmid: 22132033
references.citation: Ethiop J Health Sci. 2012 Jul;22(2):77-84
references.pmid: 22876070
references.citation: Clin Orthop Relat Res. 2009 May;467(5):1154-63
references.pmid: 19308648
references.citation: Pediatr Ann. 2006 Feb;35(2):128-30, 132-6
references.pmid: 16493919
references.citation: Iowa Orthop J. 2011;31:43-8
references.pmid: 22096418
references.citation: Clin Orthop Relat Res. 2009 May;467(5):1164-70
references.pmid: 18987922
references.citation: Foot Ankle Int. 2000 Dec;21(12):1037-9
references.pmid: 11139034
references.citation: J Bone Joint Surg Br. 2011 Sep;93(9):1160-4
references.pmid: 21911524
references.citation: N Engl J Med. 2013 Jan 3;368(1):78-9
references.pmid: 23281981
references.citation: J Bone Joint Surg Br. 2005 Jun;87(6):759-61
references.pmid: 15911654
references.citation: Iowa Orthop J. 2010;30:1-6
references.pmid: 21045964
references.citation: Curr Opin Pediatr. 2011 Feb;23(1):41-5
references.pmid: 21150445
references.citation: Iowa Orthop J. 2011;31:49-51
references.pmid: 22096419
references.citation: Trop Doct. 2011 Apr;41(2):65-7
references.pmid: 21262955
references.citation: Clin Orthop Relat Res. 2009 May;467(5):1171-9
references.pmid: 19172369
references.citation: Disabil Rehabil. 2007 Jun 15-30;29(11-12):857-62
references.pmid: 17577720
references.citation: Disabil Rehabil. 2007 Jun 15-30;29(11-12):845-55
references.pmid: 17577719
references.citation: J Foot Ankle Surg. 2006 May-Jun;45(3):177-81
references.pmid: 16651198
references.citation: J Bone Joint Surg Br. 2007 Mar;89(3):378-81
references.pmid: 17356154
references.citation: Iowa Orthop J. 2011;31:30-5
references.pmid: 22096416
references.citation: J Pediatr Orthop B. 2012 Jul;21(4):361-5
references.pmid: 22240485
references.citation: Clin Orthop Relat Res. 2009 May;467(5):1133-45
references.pmid: 19219519
references.citation: Int Orthop. 2008 Feb;32(1):75-9
references.pmid: 17115153
references.citation: J Pediatr Orthop. 2005 Sep-Oct;25(5):627-9
references.pmid: 16199944