1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
There some research which are done to identify the barriers e.g. (Shayo, M.J. and Van den Bergh, G., 2015. Physiotherapy management of idiopathic clubfoot in Tanzania: experiences and challenges. Physiotherapy, 101, pp.e1374-e1375), which identified barriers in different levels including individual level lack of awareness and poor knowledge regarding clubfoot was a barrier to treatment, due to poor individual knowledge some family conflict existed and caused separation, at the level of institution few were trained on Ponsati methods of clubfoot management therefore treatment was inconsistent and varied from one institution to another; at the community level we found that stigma was a problem (clubfoot was associated with being cursed and in some tribes as a blessing that the family will have more cattle therefore they preferred not to take the child for treatment. Women and children had less rights in some society especially in rural society women would have been blamed for bringing a lame child to the family and led to less priority in rehabilitation services
2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
As a follow up of the same study in no 1 above effort was made to educate physiotherapists in the use of Ponseti methode for clubfoot management, as a physiotherapist and trainer I contacted the TCCO team which was receiving support from Miracle feet who provide training to staff and support clinics in Tanzania to provide Ponseti treatment. Now the clinics providing Ponseti treatment in Tanzania are many, and the supervision is led by MDH, I am a Ponseti trainer and a supervisor of clinics supported by Miracle feet in Northern Zone of Tanzania. What is provided is by Ponseti clinics is parental education (to affect the individual and house hold level), training to Ponseti providers and peripheral health centres(to build capacity a the institution level), creating awareness in the society (schools, religious gatherings and local government meetings). We are working close with the govement to include Ponseti method of clubfoot management in the curricula and in the implementation og the National Rehabilitation Action Plan.
3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
Currently we need to evaluate the impact of the existing program and do and explorative research to identify the need in this particular group, because the country large and the whole country is not covered. Some areas are covered yet we have a large area which is not covered
4. When considering potential interventions, what factors related to implementation do I need to consider?
For the evaluation mentioned in no. 3 above we will explore the following, acceptability of the treatment, commitment of the ministry of health to absorb the implementation into the system and budget if at all it is acceptable to the society, the intervention is carried out successfully and there is a training program which exists and it is used for African countries which ensures fidelity, however the extent that we can reach all children born with clubfoot in Tanzania need more evidence as we haven’t yest ensured sustainability in case the donor withdraws.
5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
Social economical groups and women