Assessing awareness and knowledge level of clubfoot among a rural city population in Saudi Arabixsa: A cross-sectional study

ABSTRACT

Purpose:

Clubfoot is among the most common musculoskeletal congenital anomalies. Poor understanding of clubfoot can cause lack of awareness that leads to complications in treating this condition because of late medical intervention. This is considered as a significant public health problem, especially in communities where the burden of clubfoot deformity remains unrecognized. We assessed the level of awareness and knowledge on clubfoot among residents of rural areas and determined the knowledge and attitudes of the public toward the risk factors and general consequences of clubfoot.

Methods:

This cross-sectional study, conducted from January to July 2021, included the general population of small city and rural area residents. The participants completed a self-administered survey on the web. The questionnaire was pre-tested in a pilot study to ensure comprehension and ease of administration.

Results:

Altogether, 41.6% of the participants recognized the scientific name of clubfoot in their native language, whereas 38.9% identified the disorder after they were shown a photograph of it. The most recognized risk factors of clubfoot according to the participants were family history (52.2%), complicated pregnancy (46.5%), and medications (43.4%). Only 8.8% of the participants considered casting the initial treatment of clubfoot.

Conclusion:

An individual’s residential area plays a role in their level of awareness concerning clubfoot. Our results suggest that many educational interventions for clubfoot must be provided in rural areas, particularly regarding therapeutic options and plans of care.

Introduction

Clubfoot or congenital talipes equinovarus is one of the most common musculoskeletal congenital anomalies; it includes four main deformities: forefoot adduction, cavus foot, hindfoot varus, and equinus.[1,2] It is known that genetic predisposition plays a role in the development of the deformity; however, the exact etiology remains unclear.[2] Annually, 174,000 newborns are affected by clubfoot worldwide, and most children (91%) with clubfoot are from low- and middle-income countries.[3] Clubfoot is diagnosed at birth on typical clinical examination, but it can be identified on ultrasonography in the third trimester.[4] The risk factors of clubfoot include primiparous mothers, male gender, maternal smoking during pregnancy, and family history.[2] Family history is a notable risk factor, and the chances of having a second baby with clubfoot deformity increase 20-fold if the first baby is affected.[5]

The burden of clubfoot deformity as a public health problem in rural areas remains unknown.[6] The term “neglected clubfoot” refers to lack of treatment or incorrect treatment of clubfoot, which results in physical impairments, such as difficulty in wearing shoes, severe pain in growing children, and inability to walk in some cases.[7] Therefore, early recognition and treatment of clubfoot are considered cornerstones in ensuring excellent clinical outcomes by preventing permanent late disabilities.[2,8]

Saudi Arabia has an excellent health care system. However, there are regional differences in resource availability, service delivery, and access to treatment and follow-up, particularly in individuals living in border and remote areas.[9] Despite the large percentage of children with clubfoot, only 15% are started on a treatment program.[3] Adherence to the management plan is as important as the initiation of treatment. Therefore, factors affecting adherence to the regimen make it difficult for health providers and planners to determine the impact of the treatments on the health status of the individuals affected.[10] Transportation is a major obstacle to adherence because even though the treatment is free, weekly transport costs can become a barrier to treatment adherence.[11]

Clubfoot in Saudi Arabia is considered as a public health issue, and 70% of individuals living in Saudi Arabia have never heard of or read about clubfoot deformity. Lack of public knowledge on clubfoot may be a barrier to early intervention and successful management of this condition.[12] Hence, the present study aims to assess the awareness and knowledge among residents of rural areas regarding clubfoot and to determine the knowledge and attitude of the public toward the risk factors and general consequences related to clubfoot. This study is one of few that exclusively target a specific group in the population that are at high risk of neglected clubfoot and evaluates their level of awareness and knowledge on the condition. Based on previous studies, we hypothesized that residents of rural areas have limited knowledge and awareness about club foot deformity. Because the majority of health care providers that serve our target population are limited to primary care physicians, the findings from this study may increase the knowledge and awareness of general primary care providers and family physicians as well as the importance of early treatment and the general consequences of neglected clubfoot deformity. We believe that the findings will help families with children suffering from clubfoot to consider seeking early medical attention.

Methods

Ethics statements

This study was approved by the local ethics committee, and informed consent was obtained from the participants after explaining the study objectives to them. All the data collected in this study were treated as confidential, and to ensure their privacy, no personal information was obtained from the participants. We obtained consent from a family member for use of the photograph [Figure 1] in this study.

Figure 1.

Clinical photograph of a baby diagnosed with bilateral congenital talipesequinovarus

Study design and population

This cross-sectional study was conducted from January to July 2021. Participants living in major cities and in cities in which the Ponseti method was performed in Saudi Arabia were excluded from the study (n = 546). Only residents of rural areas were enrolled in this study. We recruited participants via various social media platforms, targeting individuals of all age groups and socioeconomic statuses. After recruitment, we applied the inclusion and exclusion criteria as mentioned.

Data collection

Data were collected using a self-administered web-based survey. Participants were asked to complete a self-reported questionnaire that included demographic factors (age, gender, marital status, education, and career) in its first section. The second section included questions assessing their awareness of clubfoot by displaying a photograph of clubfoot [Figure 1]. Without naming the condition, we asked the participants to identify the condition in the photograph. Other questions were asked in this section to assess their knowledge on the therapeutic options, the consequences of leaving this condition untreated, and the specialty responsible for managing such cases. The last section focused on evaluating the participants’ knowledge on clubfoot and whether they had heard or read about the condition. The risk factors, appropriate method of treatment, and appropriate age of commencing treatment were also assessed. The questionnaire was validated via a pilot study involving 15 random participants, to identify any issues with content and language, and their answers were excluded from the study.

The knowledge level was subcategorized into low, moderate, and high according to the participants’ answers to the seven questions. Participants who correctly answered two or fewer questions were placed in the low-level group; those who answered three to five questions correctly were placed in the moderate-level group; and those who answered six to seven questions correctly were placed in the high-level group.

Data analysis

Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 23. Frequency and percentages are used to display categorical variables. Mean and standard deviation are used to present continuous variables. Chi-square and ANOVA tests were used to test for association. Level of significance was set at 0.05.

Results

Demographic of the participants

A total of 772 participants were screened for this study; only 226 of them who were from rural areas were included in the study, whereas 546 (70.7%) who were from major cities were excluded.

Table 1 shows the sociodemographic data of the participants. Thirty-three (14.6%) were men and 193 (85.4%) were women, with 72 (32.3%) between 20 and 29 years of age, 40 (17.7%) between 30 and 39 years of age, 107 (47.3%) between 40 and 59 years of age, and six (2.7%) aged 60 years and older. In terms of occupation, 54 (23.9%) were students, four (1.8%) were entrepreneurs/business owners, 93 (41.2%) were office workers, two (0.9%) were laborers/craftsmen, two (0.9%) were military, 39 (17.3%) were unemployed, and 32 (14.2%) were retired.

Table 1.

Socio-demographic profile of the participants (n=226)

Demographic characteristic	n	%
Age (years)
20-29	73	32.30
30-39	40	17.70
40-59	107	47.30
≥60	6	2.70
Gender
Male	33	14.60
Female	193	85.40
Nationality
Saudi	221	97.80
Non-Saudi	5	2.20
Education
High school	48	21.20
Diploma/bachelor’s degree	162	71.60
Higher education (Masters/PhD)	16	7.20
Occupation
Student	54	23.90
Entrepreneur/business owner	4	1.80
Office worker	93	41.20
Laborer/craftsman	2	0.90
Military member	2	0.90
Unemployed	39	17.30
Retired	32	14.20
Marital status
Married	151	66.80
Single	63	27.90
Divorced	5	2.20
Widowed	7	3.10
Parental status
Have children	150	66.40
Do not have children	76	33.60
Monthly income
≤5,000 SR	37	16.40
5,000-10,000 SR	77	34.10
10,000-20,000 SR	68	30.10
>20,000 SR	44	19.50
Presence of health care centers in participants’ residential areas
Private practice clinics	158	69.90
Primary health care centers	115	50.90
Public hospitals	208	92.00
Tertiary hospitals	32	14.20

Awareness and knowledge of the participants about clubfoot

Participants’ previous knowledge on clubfoot was assessed by presenting a photograph of clubfoot, and only 88 (38.9%) participants were able to recognize the condition by a photograph. When asked if they had heard or read about clubfoot, only 94 (41.6%) participants answered in the affirmative.

Table 2 illustrates the participants’ awareness of clubfoot. In total, 184 (81.4%) participants thought that early medical intervention would improve the outcome, four (1.8%) believed it would worsen the outcome, and 38 (16.8%) said they did not know. When participants were asked what specialty managed clubfoot, only 74 (32.7%) correctly identified orthopedic surgery. The respondents’ answers to the question “what would happen if the condition was left untreated” were abnormal gait, 152 (67.3%); loss of motor function, 101 (44.7%); and shoe fitting issues, 92 (40.7%). Forty-nine (21.7%) participants knew a person affected with clubfoot, 68 (30.1%) correctly knew that the incidence of clubfoot increased when a family member was affected, whereas 137 (60.6%) did not know. Only 20 (8.8%) participants correctly identified casting as the first treatment option for clubfoot. When participants were asked about the proper age to start treatment of clubfoot, only 71 (31.4%) correctly identified the appropriate age, which is from birth to the first 6 months of life.

Table 2.

Assessment of participants’ knowledge and awareness of clubfoot (n=226)

Question	n	%
1. Do you know a person diagnosed with clubfoot deformity?
Yes	49	21.7
No	177	78.3
2. Does the incidence rate increase if a family member suffers from the same condition?
Yes	68	30.1
No	21	9.3
I am not aware	137	60.6
3. What is the first treatment for clubfoot?
Cast	20	8.8
Physiotherapy	46	20.4
Surgery	24	10.6
Splint	19	8.4
Shoes	27	11.9
I don’t know	90	39.8
4. What is the proper age to start treatment for clubfoot?
Birth-6 months	71	31.4
6-12 months	45	19.9
1-4 years	23	10.2
>4 years	2	0.9
I don’t know	85	37.6
5. How do you think early medical intervention will affect the outcome?
Improve the outcome	184	81.4
Worsen the outcome	4	1.8
I don’t know	38	16.8
6. Which medical specialty manages this condition?
Pediatric medicine	29	12.8
Pediatric surgery	20	8.8
Orthopedic surgery	74	32.7
Plastic surgery	1	0.4
Physical medicine and rehabilitation	71	31.4
I don’t know	31	13.7
7. If left untreated, this condition can lead to which of the following conditions? (more than one answer can be chosen)
Normal foot	6	2.7
Painful foot	70	31
Abnormal gait	152	67.3
Loss of motor function	101	44.7
Skin issues and ulcers	18	8
Shoe-fitting issues	92	40.7
I don’t know	30	13.3
8. Do you think that this condition is an isolated phenomenon or is accompanied by other conditions?
Isolated	78	34.5
Accompanied by other conditions	50	22.1
I don’t know	98	43.4

Participants knowledge about certain treatment and complication of clubfoot

Figure 2 displays the complementary therapeutic techniques preferred or used by the participants before visiting a physician. About 77 (34.1%) stated that they did not prefer any complementary/alternative medicine. The most sought complementary therapeutic techniques were as follows: physical therapy/massage, 101 (44.7%); specific shoes, 59 (26.1%); and cupping therapy, 17 (7.5%).

Figure 2.

The complementary therapeutic techniques preferred or used by the participants before visiting a physician

Figure 3 demonstrates the participants’ thoughts regarding the risk factors of clubfoot. The most common clubfoot risk factors were as follows: family history, 118 (52.2%); complicated pregnancy, 105 (46.5%); medications, 98 (43.4%); and maternal age, 36 (15.9%).

Figure 3.

Participants’ thoughts on the risk factors of clubfoot

Table 3 shows the relationship between clubfoot risk factor recognition and clubfoot awareness. Participants who recognized the photograph and correctly identified clubfoot were categorized aware (n = 62), whereas those who could not recognize the condition were considered unaware (n = 164). Most participants in the aware group identified complicated pregnancy as a risk factor for clubfoot (36, 58.1%), whereas majority of the participants in the unaware group did not acknowledge this risk factor (95, 57.9%).

Table 3.

Relationship between recognition of risk factors for clubfoot and previous knowledge about clubfoot (n=226)

Factor	Recognition and awareness of risk factors for clubfoot n (%)		P
	Not aware (n=164)	Aware (n=62)
Family history			0.192
Yes	90 (54.9)	28 (45.2)
No	74 (45.1)	34 (54.8)
Complicated Pregnancy			0.032*
Yes	69 (42.1)	36 (58.1)
No	95 (57.9)	26 (41.9)
Medications			0.018*
Yes	79 (48.2)	19 (30.6)
No	85 (51.8)	43 (69.4
Maternal age			0.114
Yes	30 (18.3)	6 (9.7)
No	134 (81.7)	56 (90.3
Maternal smoking during pregnancy			0.319
Yes	21 (12.8)	5 (8.1)
No	143 (87.2)	57 (91.9
“Evil eye” and witchcraft			0.192
Yes	17 (10.4)	3 (4.8)
No	147 (89.6)	59 (95.2
Twin pregnancy			0.559
Yes	12 (7.3)	6 (9.7)
No	152 (92.7)	56 (90.3
Maternal gestational diabetes			0.875
Yes	6 (3.7)	2 (3.2)
No	158 (96.3)	60 (96.8
Gender			0.005*
Yes	0 (0)	3 (4.8)
No	164 (100)	59 (95.2)

*Statistically significant

Demographic factors that affect the knowledge level toward clubfoot

Table 4 displays the factors associated with participants’ knowledge level of clubfoot. Age was significantly associated with the knowledge level of clubfoot (P < 0.001), and it was noted that the higher the age, the higher the knowledge level. Similarly, occupation was associated with knowledge level. For instance, most students (75.9%) and entrepreneurs/business owners (75%) belonged to the low knowledge level group, whereas retired participants had the highest percentage of respondents in the high knowledge level group (31.3%).

Table 4.

Factors associated with participants’ knowledge level regarding clubfoot

Factor	Knowledge level n (%)			P
	Low	Moderate	High
Age (years)				<0.001*
20-29	53 (72.6)	20 (27.4)	0 (0)
30-39	20 (50)	19 (47.5)	1 (2.5)
40-59	45 (42.1)	47 (43.9)	15 (14)
≥60	4 (66.7)	1 (16.7)	1 (16.7)
Gender				0.708
Male	20 (60.6)	11 (33.3)	2 (6.1)
Female	102 (52.8)	76 (39.4)	15 (7.8)
Nationality				0.251
Saudi	121 (54.8)	84 (38)	16 (7.2)
Non-Saudi	1 (20)	3 (60)	1 (20)
Education				0.074
High school	35 (72.9)	13 (27.1)	0 (0)
Diploma/bachelor’s degree	80 (49.4)	67 (41.4)	15 (9.3)
Higher education (Masters/PhD)	7 (43.8)	7 (43.8)	2 (12.5)
Occupation				<0.001*
Student	41 (75.9)	13 (24.1)	0 (0)
Entrepreneur/business owner	3 (75)	1 (25)	0 (0)
Office worker	41 (44.1)	45 (48.4)	7 (7.5)
Laborer/craftsman	1 (50)	1 (50)	0 (0)
Military member	1 (50)	1 (50)	0 (0)
Unemployed	23 (59)	16 (41)	0 (0)
Retired	12 (37.4)	10 (31.3)	10 (31.3)
Marital status				<0.001*
Married	74 (49)	63 (41.7)	14 (9.3)
Single	44 (69.8)	19 (30.2)	0 (0)
Divorced	2 (40)	3 (60)	0 (0)
Widowed	2 (28.6)	2 (28.6)	3 (42.9)
Parental status				0.018*
Have children	72 (48)	63 (42)	15 (10)
Do not have children	50 (65.8)	24 (31.6)	2 (2.6)
Monthly Income				0.012*
≤5,000 SR	26 (70.3)	11 (29.7)	0 (0)
5,000-10,000 SR	41 (53.2)	34 (44.2)	2 (2.6)
10,000-20,000 SR	31 (45.6)	29 (42.6)	8 (11.8)
>20,000 SR	24 (54.5)	13 (29.5)	7 (15.9)
Number of children (mean + standard deviation)	3+2.9	3.3+2.2	4.6+2.3	0.061
Classification of participants’ knowledge	n		%
Low level of knowledge (score of≤2)	122		54.00
Moderate level of knowledge (score between 3 and 5)	87		38.50
High level of knowledge (score of 6-7)	17		7.50

*Statistically significant.

Discussion

Awareness of clubfoot must begin with the recognition of the disorder. Many names have been used to describe clubfoot in the rural areas of Saudi Arabia. This was apparent when the study participants were shown a photograph of clubfoot and asked to name this disorder in Arabic. Despite the various names used to describe the photograph of the condition, 41.6% recognized the scientific name of clubfoot in Arabic, whereas 38.9% identified the disorder when shown a clear photograph of a baby diagnosed with bilateral congenital talipes equinovarus. Alsiddiky et al.[12] found that 30.3% of the participants in their study had either heard or read about clubfoot. This disparity may be because of differences in study selection because only 23.6% of their study population was from small cities in Saudi Arabia.

Early intervention is the key to successful and effective therapeutic outcomes of clubfoot treatment.[3] The Ponseti method is the gold standard for treating clubfoot and can be initiated soon after birth.[13,14] Fortunately, 81.4% of our participants in rural areas agreed with the statement that early medical intervention improves the outcome of clubfoot. Neglected clubfoot can be defined as clubfoot that has been left untreated for 2 years[15]; it has various consequences that affect the child’s quality of life and daily activities.[7,16] Hence, it is important to explore the individual’s viewpoint regarding the consequences of untreated clubfoot. More than half (67.3%) of our participants considered abnormal gait a consequence. Medical professionals are also greatly concerned about abnormal gait, as it may worsen the condition by the weight-bearing forces on the dorsum of the foot, causing more contractures of the medial soft tissues and plastic deformation of the bones.[17]

Limited health care is provided to residents in rural areas in Saudi Arabia,[9] especially complex and long medical interventions, such as the Ponseti method. This explains the logic of more than half (65.9%) of the participants who considered alternative medicine as the first option before seeking treatment at a proper medical center. Physical therapy/massage was the most common alternative treatment modality. Interestingly, a previous study in India found that doctors in rural areas used massage as the sole treatment for managing clubfoot.[18] Only 8.8% of the respondents selected casting as the first intervention. Unexpectedly, 10.6% of participants preferred surgery. These findings can explain the knowledge gap in therapeutic options for clubfoot in rural areas.

Family history has a clear and strong association with clubfoot.[19] Awareness status did not affect participants’ judgment in selecting family history as a known risk factor. Multiple studies have shown a well-established link between maternal smoking during pregnancy and the prevalence of clubfoot.[20] Male gender and multiple gestations are also considered risk factors.[21] However, the knowledge gap concerning the risk factors of clubfoot is evident in our results because a limited number of participants linked maternal smoking (11.5%), gender (1.3%), and twin pregnancy (8%) to clubfoot.

Respondents’ knowledge level revealed that occupation plays a role in the individual’s knowledge on clubfoot. About one-third of the retired group (31.3%) was categorized in the high knowledge level group, whereas some other occupations lacked participants in the high-level group. Our findings suggest that parents have a higher knowledge on clubfoot than non-parents, as more than half (52%) of the parents in this study belonged to the moderate and high knowledge level groups.There is a positive correlation between the number of children and the level of knowledge, as parents’ knowledge level increased with the mean number of children (three children in the low-level category, 3.3 the in moderate-level category, and 4.6 in the high-level category).

Limitation

The sample population was a major limitation in this study, as we only targeted residents of rural areas in Saudi Arabia. However, reasonable explanations for this outcome are that individuals living in rural areas are difficult to recruit in such studies and the collection method was carried out via the web. Therefore, we advise the use of different methods of data collection in addition to web self-reported surveys in future studies.

Conclusions

Our findings showed that an individual’s living area plays a role in their awareness of clubfoot. Information regarding therapeutic options for clubfoot in rural areas is unclear, considering that more participants thought the first treatment for clubfoot was surgery (10.6%) rather than simple casting (8.8%). In general, these findings suggest that many educational interventions for clubfoot are needed in rural areas, particularly regarding therapeutic options and plans for clubfoot care. We recommend that other national studies in developing countries be carried out to explore their rural community populations and assess their awareness of such disabling yet manageable conditions.

Consent for publication

Informed consent was obtained from all individual participants included in the study.We obtained consent from a family member for use of the photograph [Figure 1] in this study.

Declaration of informed consent

Informed consent was obtained from all individual participants included in the study.

Declaration of ethical approval for study

The Institutional Review Board of Imam Mohammad ibn Saud Islamic University has approved the current study on the 16 of March 2021, Project number: 53-2021.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.