Exploring the Implementation of Clubfoot Treatment Services in Malawi Using Extended Normalization Process Theory: An Ethnographic Study

: 1.036_HHR A Novel Paradigm for Short-Term Medical Teams S. Draugelis; Wayne State University, Dearborn, Mi, USA Program/Project Purpose: Short-term medical aid trips have been criticized in be past for their inability to provided follow-up care, for their inability to address root causes of disease, and because they may detract from local economies. However, these types of trips are growing in popularity. Mobile electronic medical records systems have enabled these teams to collect patient-level data, even in areas with limited access to the Internet and electricity. By sharing this data with local healthcare providers, we can begin to improve the continuity of care provided to those who may rely on foreign aid as their primary mode of healthcare. Structure/Method/Design: In the village of Morne l’Hopital, Haiti, there are 2-4 American teams who volunteer once per year for one week at a time. They use fEMR, an electronic medical records system designed for use in remote locations without IT personnel in the field. This system will flag patient records of those who are pregnant, and send email notification to a local nonprofit hospital. The hospital can then dictate whether the patient should come to the hospital, if the hospital should send an outreach team to their village, or if the next American team should provide the next point of care. This is a unique dynamic between providers from a variety of institutions, but ultimately putting authority into the hands of in-country physicians. Outcome & Evaluation: We can measure number of women who deliver in a health care setting, and number of women who were monitored at each trimester of pregnancy. Going Forward: This paradigm may be applied to other areas of primary care and to other geographic locations. Source of Funding: None. Abstract #: 1.037_HHR Exploring the Implementation of Clubfoot Treatment: 1.037_HHR Exploring the Implementation of Clubfoot Treatment Services in Malawi Using Extended Normalization Process Theory: An Ethnographic Study S. Drew, P. Chidothie, C. Lavy, R. Gooberman-Hill; University of Oxford, Oxford, United Kingdom, Beit Cure International Hospital, Blantyre, Malawi, University of Bristol, Bristol, United Kingdom Background: Annually in Malawi around 800 children are born with clubfoot, where one or both feet are twisted inwards. If untreated, this limits participation in everyday life. Clubfoot may be treated using staged manipulation. This method has been adopted as the national standard and is delivered in 29 regional clinics. Implementing these services is challenging. Extended Normalization Process Theory (eNPT) specifies four constructs that may impact on service implementation: capacity, potential, capability and contribution. This study uses ethnographic methods to explore how clubfoot services can be successfully implemented, using eNPT to illuminate findings. Methods: Six observation sessions of 4-5 hours each were undertaken at Beit/CURE Hospital and two outreach clinics. Findings were used to inform 61 semi-structured interviews with professionals working at these and a further nine clinics. Follow-up interviews were then undertaken with clinic coordinators. Four interviews were conducted with professionals responsible for managing public health services to provide an understanding of the wider healthcare system. Data were analysed using an inductive thematic analysis. An abductive approach was undertaken whereby inductive codes were transposed onto the constructs of eNPT. Codes that did not fit within the theory were integrated into an additional theoretical category. Findings: Capacity or co-ordination between healthcare professionals was effective. This included cooperation with primary care and participants felt most health workers could successfully identify and refer patients. There was a desire for a closer working relationship with Beit/CURE. Motivation to enact the intervention varied and was influenced by contextual factors inherent in the healthcare system. Many professionals were committed to delivering and providing services, but some faced challenges in doing so. Implementation was also affected by staffing levels, resources and availability space. Contributions to service delivery were facilitated by proformas and monitoring systems to improve practice, although participants suggested improvements to both. A fifth construct was identified concerning strategies to facilitate patient access, including arranging patient transport and following up those that had absconded from treatment. Interpretation: Findings identify and describe elements that impact on the successful implementation of clubfoot treatment services in Malawi. It is hoped this will inform future service development in Malawi and other low income country settings. Source of Funding: Cure International UK COSECSA Oxford Orthopaedic Link (COOL). Abstract #: 1.038_HHR: 1.038_HHR

Going Forward: Lessons learned include: 1) Provide orientation in advance of initiating groups; 2) Include guidance on discussion group norms for entries, language, cases, and feedback; 3) Assign a moderator to guide the following of norms; 4) Complete one case before moving to the next. The highly positive results of this assessment indicate that text messaging discussion groups can be an effective adjunct to training courses for health workers, and in low resource settings are a low-cost platform for building health care worker competence and enhancing care. Program/Project Purpose: Short-term medical aid trips have been criticized in be past for their inability to provided follow-up care, for their inability to address root causes of disease, and because they may detract from local economies. However, these types of trips are growing in popularity. Mobile electronic medical records systems have enabled these teams to collect patient-level data, even in areas with limited access to the Internet and electricity. By sharing this data with local healthcare providers, we can begin to improve the continuity of care provided to those who may rely on foreign aid as their primary mode of healthcare.
Structure/Method/Design: In the village of Morne l'Hopital, Haiti, there are 2-4 American teams who volunteer once per year for one week at a time. They use fEMR, an electronic medical records system designed for use in remote locations without IT personnel in the field. This system will flag patient records of those who are pregnant, and send email notification to a local nonprofit hospital. The hospital can then dictate whether the patient should come to the hospital, if the hospital should send an outreach team to their village, or if the next American team should provide the next point of care. This is a unique dynamic between providers from a variety of institutions, but ultimately putting authority into the hands of in-country physicians.

Outcome & Evaluation:
We can measure number of women who deliver in a health care setting, and number of women who were monitored at each trimester of pregnancy.
Going Forward: This paradigm may be applied to other areas of primary care and to other geographic locations.
Source of Funding: None. Background: Annually in Malawi around 800 children are born with clubfoot, where one or both feet are twisted inwards. If untreated, this limits participation in everyday life. Clubfoot may be treated using staged manipulation. This method has been adopted as the national standard and is delivered in 29 regional clinics. Implementing these services is challenging. Extended Normalization Process Theory (eNPT) specifies four constructs that may impact on service implementation: capacity, potential, capability and contribution. This study uses ethnographic methods to explore how clubfoot services can be successfully implemented, using eNPT to illuminate findings.
Methods: Six observation sessions of 4-5 hours each were undertaken at Beit/CURE Hospital and two outreach clinics. Findings were used to inform 61 semi-structured interviews with professionals working at these and a further nine clinics. Follow-up interviews were then undertaken with clinic coordinators. Four interviews were conducted with professionals responsible for managing public health services to provide an understanding of the wider healthcare system. Data were analysed using an inductive thematic analysis. An abductive approach was undertaken whereby inductive codes were transposed onto the constructs of eNPT. Codes that did not fit within the theory were integrated into an additional theoretical category.
Findings: Capacity or co-ordination between healthcare professionals was effective. This included cooperation with primary care and participants felt most health workers could successfully identify and refer patients. There was a desire for a closer working relationship with Beit/CURE. Motivation to enact the intervention varied and was influenced by contextual factors inherent in the healthcare system. Many professionals were committed to delivering and providing services, but some faced challenges in doing so. Implementation was also affected by staffing levels, resources and availability space. Contributions to service delivery were facilitated by proformas and monitoring systems to improve practice, although participants suggested improvements to both. A fifth construct was identified concerning strategies to facilitate patient access, including arranging patient transport and following up those that had absconded from treatment.
Interpretation: Findings identify and describe elements that impact on the successful implementation of clubfoot treatment services in Malawi. It is hoped this will inform future service development in Malawi and other low income country settings.