Native American children who live in rural areas are at greater risk of clubfoot recurrence following treatment than other rural populations, and researchers are beginning to understand why. According to a study published in the March 2009 issue of The Journal of Bone and Joint Surgery (JBJS), cultural differences and communication barriers are factors that appear to contribute to this increased risk.
In the Ponseti technique, after repetitive casting, a brace is used to treat the affected foot. The success of the technique relies heavily on the participation of the caregiver to make sure the brace is used properly. When the brace protocol, as outlined by the physician, is not followed, or when the use of the brace is discontinued before treatment is completed, the condition is much more likely to recur. Caregivers are more likely to stop using the brace if they do not fully understand its importance, and the researchers found the failure to effectively communicate the importance of bracing was a key contributor to recurrence.
“The challenge of the Ponseti treatment regimen lies not in the initial cast correction, but in the success of educating the parents and family regarding their role in the bracing process, and in the provision of a brace that is acceptable to the child and family alike,” said Elizabeth Szalay, MD, pediatric orthopaedic surgeon and chief of the Division of Pediatric Orthopaedics at the University of New Mexico, Carrie Tingley Medical Center, Albuquerque. “When physicians are unable to effectively communicate the treatment program to the parents or other caregivers, the Ponseti method is not as successful…. The physician’s skill as an educator is pivotal to a positive outcome of the Ponseti technique, as it is in many other treatments. An ability to communicate across cultural divides is essential to providing the best health care possible.”
Recurrence levels are generally higher in a rural population than in an urban setting, Szalay noted, and are highest in patients whose families have a yearly income of less than $20,000, have public or no insurance, are unmarried, or have an educational level of high school or less.
But the level of recurrence is significantly higher in the rural Native American group than in any other group studied. Szalay noted that this indicates a lack of effective communication between the parent and the physician.
“Basically, we are not communicating well with the rural Native American population. Our message is not geared to their specific and unique culture,” said Szalay. “We are not communicating effectively because we do not have a complete understanding and awareness of the cultural differences that exist. As orthopaedic surgeons, we need to educate ourselves about the cultural biases existing in all our patient populations.”
Several cultural factors may contribute to the breakdown in communication. According to Szalay, Native American families who live a considerable distance from a large metropolitan area are more likely to speak their native language, follow native traditions, use native healers in addition to modern medicine, and use members of a extended family for childcare.
In addition, Native Americans are generally more reluctant to ask questions of physicians. Szalay noted many Native American cultures consider questioning an authority to be a sign of disrespect. As a result, she said physicians must anticipate possible questions and be sure their instructions are especially thorough. Many Native American cultures also view potentially negative statements as bad luck, so the physician must be sure to emphasize the positive aspects of the treatment in order to reinforce its benefits, she added.
“I grew up in New Mexico, and thought I was fairly culturally savvy,” Szalay said in an interview with Reuters Health. “However, when we took a second look at our ‘educational materials,’ my Native American consultants thought that they were basically inappropriate for many traditional families. An example is offering Internet sites where the family may obtain more information. Some of the rural Native Americans living in the traditional way do not have electricity, much less Internet access.
“It became clear that our program for parent and family education basically left out the rural Native Americans,” Szalay said.
“I have made a clear change in how I try to stress the importance of brace wear,” she told Reuters Health, explaining, “Native Americans often do not respond well to negatives, which bring bad luck. ‘If you don’t use the brace, the foot will go bad again and your child will need surgery.’ My new message is, ‘The foot is doing so well-using the brace every day will preserve the excellent results we are seeing.'”