title: Clubfoot care in low-income and middle-income countries: from clinical innovation to a public health program.
abstract: BACKGROUND
  Clubfoot occurs in nearly 1 in every 1,000 live births worldwide, representing a significant burden of disease. In high-income countries, an evidence-based treatment protocol utilizing sequential casting was pioneered by Ponseti and has resulted in excellent outcomes among children treated for this condition. However, treatment methods and results of treatment vary greatly across low- and middle-income countries (LMICs). Our goal was to create a framework for understanding how effective programs that treat clubfoot in LMICs choose and organize their activities.
  
  
  METHODS
  A systematic literature review was conducted using the keywords "developing countries" and "clubfoot." A public health analysis model known as the Care Delivery Value Chain (CDVC) was applied to discover public health practices that would optimize value over the entire course of a patient's life.
  
  
  RESULTS
  The literature review yielded 32 unique results, seven of which met our inclusion and exclusion criteria. Review of the bibliographies yielded two additional papers for a total of nine papers. We identified seven vital steps in the clubfoot cycle of care and constructed a CDVC.
  
  
  CONCLUSIONS
  The analysis of this CDVC model suggests six best practices that are essential to successfully scaling up clubfoot treatment programs and ensuring excellent clinical outcomes: (1) diagnosing clubfoot early; (2) organizing high-volume Ponseti casting centers; (3) using nonphysician health workers; (4) engaging families in care; (5) addressing barriers to access; (6) providing follow-up in the patient's community. These practices must be adapted to each context. Applying them will optimize outcomes when designing public health programs that deliver clubfoot care in LMICs.
authors.affiliation: Section of Orthopedic Surgery, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada, lsharmer@ucalgary.ca.
authors.forename: Luke
authors.initials: L
authors.lastname: Harmer
authors.forename: Joseph
authors.initials: J
authors.lastname: Rhatigan
mesh_terms: D002370:Casts, Surgical; D003025:Clubfoot / Q000175:diagnosis / Q000628:therapy*; D003695:Delivery of Health Care / Q000458:organization & administration*; D003906:Developing Countries; D006801:Humans; D007103:Immobilization / Q000295:instrumentation*