Insight into clubfoot awareness: A Cross- sectional survey in Al-Baha Region, Saudi Arabia

Introduction

Congenital talipes equinovarus (CTEV) is a congenital disability characterized by leg deformities in the cavus, adducts, varus, and equinus 1. Clubfoot is one of the most prevalent congenital deformities in the pediatric population, estimated to affect 0.5 to 2.0 cases per 1,000 live births 2. However, recent study in Saudi Arabia showed a prevalence of 5.3 per 1,000 live births 3. Clubfoot occurs bilaterally in 50% of cases and is twice as common in males as in females. In unilateral cases, the right side is most frequently impacted 4.

Several environmental risk factors have been linked to the incidence of congenital clubfoot, most notably maternal smoking and family history 5. Ultrasound imaging can detect clubfoot between the 18th and the 24th week of pregnancy 6.7. However, the primary method of detection is usually clinical 8. Clubfoot can be managed using a variety of techniques, which can be classified into surgical and non-surgical approaches 9. A child with an early diagnosis of clubfoot can usually be managed with the Ponseti method along with achilles tendon tenotomy, which is considered the gold standard and reported to have a high success rate10. Another nonsurgical approach to treating clubfoot is the French method, often known as the functional therapy 11. In some cases, tibialis tendon transfer may be needed to correct residual deformity 12.13. Management of cases with late detection may be challenging as it may include more complex surgical intervention including posteromedial release, corrective osteotomy, and arthrodesis 14. Parental awareness plays a crucial role in the early diagnosis and treatment, as neglected clubfoot can result in foot deformity, abnormal gait, painful feet, difficulty wearing shoes, and reduced mobility, often significantly restricting daily activities and negatively impacting the quality of life 15.16. Despite the high incidence rate of clubfoot, there is a notable deficiency in public knowledge and awareness, particularly among parents and caregivers 17. Understanding parental awareness and knowledge regarding clubfoot is essential for early recognition and appropriate management.

A study conducted in several cities in Saudi Arabia found that 69.7% of participants had never heard about clubfoot 8. Another study found that only 38.9% of rural city population had recognized this condition 18, while about 43.8% had fair knowledge about the disorder in Al-Qassim region19. A recent study in the Makkah region revealed that a significant portion of the population lacks sufficient knowledge about clubfoot, with only 41.8% of participants having prior awareness of the condition. For instance, more than half of the respondents were unaware of clubfoot, and many were unfamiliar with the available treatment options17.

To our knowledge, no previous study has evaluated the level of awareness among parents in Al-Baha region. Therefore, the objective of this study is to evaluate their level of knowledge about clubfoot.

Methodology

This cross-sectional study was conducted among Al-Baha region population, Saudi Arabia. The inclusion criteria involved individuals living in Al-Baha region, who are older than 18 years and willing to participate. The exclusion criteria include those who are not willing to participate, residing outside Al-Baha region, and healthcare professionals (HCPs). Data collected with a previously validated questionnaire in Arabic language 18. Ethical approval was obtained from the Institutional Research Board of Al-Baha University under the approval number REC/SUR/BU-FM/204/2. Consent was obtained from all participants prior to the distribution of the questionnaire, and they were assured of the confidentiality of their information.

The questionnaire was distributed via Google Forms to the participants through social media platforms. The consent was obtained from the participants at the beginning of the questionnaire, and they were assured of the confidentiality of the information provided. The questionnaire consists two sections, the first section included sociodemographic questions, the second section contained questions to assess population’s knowledge and awareness about clubfoot and its management.

The scoring system was used for evaluating awareness and knowledge regarding clubfoot is binary scoring method (0 or 1) for most questions allows for a straightforward assessment of correct and incorrect responses while assigning different weights (3 points and 4 points) to questions 3, 5, and 6 appropriately reflects their relative importance. By summing the scores obtained for each question, we calculated the knowledge score, which provides a quantitative measure of participants' knowledge level. Categorizing participants as having adequate or inadequate knowledge based on their scores above or below the mean score.

The research study employed descriptive statistics to summarize the data, including counts, proportions (%), median, and mean values with standard deviations, as appropriate. To examine the relationship between knowledge, awareness, and attitude and participants' socio-demographic characteristics, statistical analyses were conducted using the Mann-Whitney U test and Kruskal-Wallis test. These non-parametric tests were chosen to assess potential differences between groups, considering the nature of the variables and the sample size. A significance level of less than 0.05 (p < 0.05) was considered statistically significant, indicating a meaningful association between the variables. Additionally, statistical collinearity was assessed using the Shapiro-Wilk test and Kolmogorov-Smirnov test. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS), version 28.

Results

A total of 538 individuals included in our study. However, 64 individuals were excluded from the study, resulting in a final sample size of 474 participants. The main reasons for exclusion were that 60 individuals were identified as HCPs or already enrolled in health colleges, four participants chose not to participate and were thus excluded from the study (Figure 1).

The participants were mainly female 74.9% (n=355) and they showed better level of knowledge than male with statistical significance (p = .037). The largest age group being 40-49 years old (34.0%). The majority of participants had a bachelor's degree (63.1%), and approximately half of them were employed (50.8%). Most participants were married (76.8%) and had children (74.9%). The income distribution showed that the majority earned between 10,001 and 20,000 S.R (41.8%), without any statistically significant difference across these demographical data (Table 1).

The assessment of the level of knowledge among the Al-Baha population regarding clubfoot revealed that the participants had a mean score of 7.06 out of 16 points, with a median of 7 ± 2.19. The results indicated a relatively low overall knowledge level, with 58.2% of the participants classified as having inadequate knowledge, (Figure 2).

In our study we found that 74.5% of participants were not familiar with the condition, while only 13.3% correctly identified the condition as "Clubfoot." Regarding the consequences of leaving clubfoot untreated, 65% recognized the development of an abnormal gait, and smaller proportions identified skin issues and ulcers (14.8%), and shoe-fitting issues (39.7%).

Concerning risk factors, 27.8% believed that having a family member with clubfoot increased the likelihood of developing the condition. Also, maternal smoking during pregnancy (13.1%) was recognized as a potential risk factor, while factors like gender (2.1%) and the evil eye (5.7%) were less commonly acknowledged. A majority of participants (75.1%) considered that clubfoot is treatable. However, when asked about the appropriate age to start treatment, 42.8% recognized birth to six months as the optimal time (Table 2).

Our data shows that most of the participants (82.5%) have not heard or read about clubfoot. Among those who have received information (n=83), internet sites were the most common source (50.6%), followed by printed media (29.1%), and relatives and friends (36.7%). Furthermore, 14.3% reported knowing someone with Clubfoot. A significant number (77%) expressed a desire to know more about clubfoot (Table 3).

Discussion

Early diagnosis and treatment of clubfoot in infancy can significantly improve long-term outcomes and reduce the need for more invasive surgeries21.22. Therefore, community awareness is crucial to ensure these children receive proper early treatment. In our study, we found that 58.2% of the population in Al-Baha region had an inadequate level of knowledge about clubfoot. Our results are consistent with previous studies conducted locally in Saudi Arabia, such as in Makkah (58%) 17 and Al-Qassim (60%) 19 , as well as internationally, with Pakistan (69.7%) 24 and India (57%) 24 reporting similar findings. The low level of knowledge can be attributed to several factors, including limited public health education initiatives focused on clubfoot, lack of awareness campaigns, and possibly cultural beliefs that may hinder seeking early medical advice.

When participants were shown a photograph of clubfoot, only 25% were able to correctly identify the condition. Additionally, only 18% of participants reported having heard about clubfoot. This low level of awareness aligns with a study conducted in rural communities of Saudi Arabia, where 38.9% of participants were able to recognize the condition from a photograph. When asked if they had heard or read about clubfoot, only 41.6% of participants responded affirmatively. The low level of knowledge may be attributed to the rarity of the condition and the specific characteristics of the pathology, which can make it difficult for the general population to recognize and understand.

In our study, we found that females were more knowledgeable about clubfoot than their male counterparts, with statistical significance (p = 0.037). These results are consistent with findings from previous studies conducted in Makkah and Al-Qassim 17.19. This disparity may be attributed to the active roles often played by females in family health education. However, it is important to consider the possibility of self-selection bias, meaning that males may not be well-represented in this study. To address this, we recommend developing targeted educational programs to increase clubfoot knowledge among males, using inclusive sampling methods in future studies to ensure balanced representation, engaging community leaders in outreach efforts to promote awareness of clubfoot among males, and conducting further research to explore the underlying reasons for gender differences in knowledge about clubfoot.

Regarding the source of information in Saudi Arabia, social media has become an important part of the everyday lifestyle. Around 92% of individuals use the internet, and approximately 25 million individuals are actively using social media 25. It was predicted that 50% of participants would use social media to learn about clubfoot and 37% heard about it from Relative or friend. In contrast AL-Qassim study found that Relative and friends 43% is more commonly used then Internet used by 30% of participants 19. While a Study involved multiple Saudi Arabia cities concluded that Social media source used by 38% Relative and friend in 20% 6. Moreover, a study, conducted in Makkah Region found that 27% of the participants reported using websites and the internet as their sources of information about club foot. Social media were reported by 23% of the participants as their source of information 17.

Concerning treatment The best initial treatment of clubfoot is non-surgical 11. The most common method worldwide for correcting clubfoot is the Ponseti method 10. In our study a majority of participants 75% believed that clubfoot is treatable. This result is in line with study conducted in Middle East where All respondents prefer to start treatment soon after birth when this is possible 26. While in the study conducted in Nigeria 54% mothers felt that this problem could be treated 24. Moreover, 43% of participant in our study recognized birth to six months as the optimal time to start treatment which is concordant with a study conducted in several cities in Saudi Arabia found 42% of the participants believe the proper age for treatment is from birth - 6 months 8. While in Al-Qassim study 52% recognized optimal time correctly 19. However, in study conducted in India only 25% of the participants believed that any kind of treatment should be started immediately after birth 24.

The study has some limitations, firstly, our study’s design cannot demonstrate cause-and-effect relationship. Secondly, the focus on a single region in Saudi Arabia limits the generalizability of the results. Finally, the study had a higher response rate from female participants, which may lead to self-selection bias. Future research perspective could be considered in order to understand the global awareness of clubfoot among Saudi population.

Conclusion

There was low awareness among Al-Baha region population regarding clubfoot and its management; this low awareness may be a barrier to early intervention and successful management of this condition. Public awareness campaigns, particularly through social media and in collaboration with reliable sources, could effectively educate the community on risk factors, the benefits of early intervention, and available treatment options. Enhancing public knowledge could facilitate timely care for affected children, improving their prognosis.

References:

1. Mustari MN, Faruk M, Bausat A, Fikry A. Congenital talipes equinovarus: A literature review. Ann Med Surg (Lond). 2022;81:104394.

2. Smythe T, Kuper H, Macleod D, Foster A, Lavy C. Birth prevalence of congenital talipes equinovarus in low- and middle-income countries: a systematic review and meta-analysis. Trop Med Int Health. 2017;22(3):269-85.

3. Alomran AK, Alzahrani BA, Alanazi BS, Alharbi MA, Bojubara LM, Alyaseen EM. Prevalence and associated factors of clubfoot in the eastern province of Saudi Arabia: A hospital-based study. World J Orthop. 2024;15(7):635-41.

4. Esbjörnsson AC, Johansson A, Andriesse H, Wallander H. Epidemiology of clubfoot in Sweden from 2016 to 2019: A national register study. PLoS One. 2021;16(12):e0260336.

5. Dodwell E, Risoe P, Wright J. Factors associated with increased risk of clubfoot: A Norwegian national cohort analysis. J Pediatr Orthop. 2015;35(8):e104-9.

6. Kim YM, Seong JS, Kim JH, Lee NM, Choi IH, Jo Y, et al. Improving prenatal diagnosis precision for congenital clubfoot by using three-dimensional ultrasonography. Diagnostics (Basel). 2024;14(1):117.

7. Faldini C, Fenga D, Sanzarello I, Nanni M, Traina F, Rosa MAA. Prenatal diagnosis of clubfoot: A review of current available methodology. Folia Med (Plovdiv). 2017;59(3):247-53.

8. Alsiddiky A, Alrwibaah S, Alqahtani A, Alnujidi A, Alhomaidhi A, Almasoud A, et al. Assessing public awareness of clubfoot and knowledge about the importance of early childhood treatment: A cross-sectional survey. BMC Pediatr. 2019;19(1):358.

9. Cady R, Hennessey TA, Schwend RM. Diagnosis and treatment of idiopathic congenital clubfoot. Pediatrics. 2022;149(2):e2021055555.

10. López-Carrero E, Castillo-López JM, Medina-Alcantara M, Domínguez-Maldonado G, Garcia-Paya I, Jiménez-Cebrián AM. Effectiveness of the Ponseti method in the treatment of clubfoot: A systematic review. Int J Environ Res Public Health. 2023;20(4):3714.

11. Souchet P, Delaby JP, Campana M, Chinnappa J, Ilharreborde B, Simon AL. The functional method: Experience from the Robert Debré Hospital. Ann Transl Med. 2021;9(13):1098.

12. Boble M, Samargandi R. Functional, clinical, and radiological outcomes of split anterior tibial tendon transfers in patients with sequelae of congenital talipes equinovarus. Eur J Orthop Surg Traumatol. 2024 May 21.

13. Agarwal A, Jandial G, Gupta N. Comparison of three different methods of anterior tibial tendon transfer for relapsed clubfoot: A pilot study. J Clin Orthop Trauma. 2020;11(2):240-4.

14. Pigeolet M, Imam S, Ninulescu GC, Kabir S, Smeesters PR, Mahmud H. Evaluation of a surgical treatment algorithm for neglected clubfoot in low-resource settings. Int Orthop. 2022;46(1):61-70.

15. Rasheed N, Itaat Hussain Zaidi NR. Awareness regarding clubfoot in parents. J Pak Orthop Assoc. 2017;29(3):90-4.

16. O’Shea RM, Sabatini CS. What is new in idiopathic clubfoot? Curr Rev Musculoskelet Med. 2016;9(4):470-7.

17. Alosaimi MA, Jawhari AM, Amin OA, Alzahrani ES, Alomar MO, Nouri MT, et al. Community awareness of congenital talipes equinovarus (clubfoot) in Makkah region, Saudi Arabia: A cross-sectional study. Cureus. 2022;14(10):e30602.

18. Alasbali MS, Altammami AF, Alharbi AA, Aljurfi MM, Alhumaidan AI, AlKhudhair MR, et al. Assessing awareness and knowledge level of clubfoot among a rural city population in Saudi Arabia: A cross-sectional study. J Family Med Prim Care. 2023;12(1):55-61.

19. Almogbil I, Albaker A, Alrabai H, Alhasson M, Alwhaid M, Alkadi S, et al. The level of public awareness about clubfoot in the Al-Qassim region and importance of early childhood intervention: A cross-sectional study. Pak J Med Health Sci. 2021;15:3463-8.

20. Oliveira CLDT, Gonçalves Filho GM, Volpon JB. Evaluation of early treatment of idiopathic clubfoot using the Ponseti method. Acta Ortop Bras. 2023;31:e259899.

21. Zionts LE, Sangiorgio SN, Cooper SD, Ebramzadeh E. Does clubfoot treatment need to begin as soon as possible? J Pediatr Orthop. 2016;36(6):558-64.

22. Sadiq BS, Khan A, Hassan M. Assessing public awareness of the knowledge and clubfoot about the importance of the treatment of early childhood. Pak J Med Health Sci. 2023;17(6):301-1.

23. Iqbal MS, Dubey R, Thakur K, Katiyar S, Prasad M. Assessment of awareness and barriers to clubfoot treatment in the Indian scenario. J Family Med Prim Care. 2021;10(11):4229-35.

24. Alalwan AA, Baabdullah AM, Rana NP, Tamilmani K, Dwivedi YK. Examining adoption of mobile internet in Saudi Arabia: Extending TAM with perceived enjoyment, innovativeness, and trust. Technol Soc. 2018;55:100-10.

25. Ghanem I, Rizkallah M. Clubfoot management in the Middle East: A survey-based review. Ann Transl Med. 2021;9(13):1106.

26. Ndukwu CU, Ndukwu CI, Eleje GU, Nze IN, Obiegbu HO, Chukwuemeka C. Aetiology and management of congenital club foot: Evaluation of perception of mothers in Nnewi. Orient J Med. 2024;36(1-2):35-40.

Figures legends and tables captions:

Table 1: Sociodemographic Characteristics of Study Participants and the level of knowledge

Table 2: Evaluation of the awareness, knowledge, and attitudes of Al-Baha population regarding Club Foot.

Table 3: Exploring Clubfoot: Familiarity, Sources, Personal Connections, and Curiosity.

Figure 1: Flowchart of the participants

Figure 2: Distribution of knowledge levels regarding clubfoot among the Al-Baha population.