|Year : 2021 | Volume
| Issue : 1 | Page : 6-10
Epidemiological determinants of children's orthopedic care in rural central India
Deeptiman James1, Manjulata Gajendran2, Tapan Kumar Paraseth1
1 Department of Pediatric Orthopedic, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Physiotherapy and Occupational Therapy, Christian Hospital Mungeli, Mungeli, Chhattisgarh, India
|Date of Submission||13-May-2020|
|Date of Acceptance||11-Apr-2021|
|Date of Web Publication||16-Jun-2021|
Dr. Deeptiman James
Department of Pediatric Orthopedic, Christian Medical College, Ida Scudder Road, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Musculoskeletal disorders of children in rural India are often highlighted through anecdotal reports of delayed presentations. This study was conducted to identify prevalence and factors that influenced children's orthopedic care in a secondary hospital in rural Central India. Methodology: A retrospective survey was conducted to identify the prevalence of musculoskeletal disorders and delayed presentation among children at our institution from July 2011 to June 2016. Actionable epidemiological determinants were identified with the Delphi method and a prospective cohort was analyzed for delayed presentation. Results: Among 2281 children 71% presented with trauma. The incidence of delayed presentation among the trauma cases was 28%. Remaining had neuromuscular (17%), infectious (3.75%), metabolic (1.5%), congenital (3.25%), and miscellaneous (3.5%) disorders. Delayed presentation in 19 children from a prospective cohort of 100 patients showed significant association with distance traveled to reach the clinic and poor transport infrastructure in rural areas (P = 0.025) but did not differ by socioeconomic scale (SES) (P = 0.085), lack of health insurance coverage (P = 0.348) or primary indigenous treatment (P = 0.535). In this cohort, 84% belonged to middle and low-SES families, 33% had insurance coverage, 79% received primary traditional remedies and 68% traveled from distant rural locations. Conclusions: Trauma care and neuromuscular diseases constituted the bulk of musculoskeletal disorders in children in this survey from rural India. Poor transport infrastructure led to delayed presentation in the prospective cohort but lower SES, lack of health insurance, and rampant primary indigenous treatment in rural areas are likely contributory factors.
Keywords: Children's musculoskeletal disorders, delayed presentations, epidemiological determinants, orthopedic care in low-middle income countries
|How to cite this article:|
James D, Gajendran M, Paraseth TK. Epidemiological determinants of children's orthopedic care in rural central India. J Orthop Traumatol Rehabil 2021;13:6-10
|How to cite this URL:|
James D, Gajendran M, Paraseth TK. Epidemiological determinants of children's orthopedic care in rural central India. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2021 Sep 20];13:6-10. Available from: https://www.jotr.in/text.asp?2021/13/1/6/318408
| Introduction|| |
More than two billion children worldwide do not have access to safe and affordable surgical and orthopedic healthcare., India is home to nearly 500 million such children, of which an overwhelming majority (73%) lives in rural India., The Global initiative for children's surgery has given recommendations to strengthen the delivery of surgical and orthopedic care to low-middle-income countries (LMICs) areas, but we lack specific national and regional goals., Existing government flagship schemes, research, and national policies are focused on control and eradication of communicable, preventable medical conditions but no streamlined policy exists to target children's musculoskeletal conditions. This vulnerable group is exposed to high risk of trauma, congenital musculoskeletal conditions, and a host of orthopedic conditions ranging from infections to acquired neuromuscular and metabolic disorders., Few reports have highlighted delayed presentations and complications due to poor orthopedic surgeon to patient ratio in our country, the prevalence of indigenous treatment, poverty, and inadequate infrastructure and training for children's orthopedic care are in rural areas.,,
This study was conducted to determine the prevalence of musculoskeletal disorders, the incidence of delayed presentations, and identify actionable epidemiological determinants leading to delayed presentation among children at a secondary hospital in rural Central India.
| Methodology|| |
A retrospective survey and descriptive statistics were performed to determine the prevalence of musculoskeletal conditions among children at a secondary hospital (with a dedicated orthopedic clinic) located in rural Central India. Demographic data and clinical profile of children below 18 years, with musculoskeletal disorders treated at this institution from July 2011 to June 2016 were audited.
A subsequent qualitative analysis was conducted with one-on-one interviews and focused group discussion among healthcare providers and parents. Actionable epidemiological determinants contributing to delayed presentation to the hospital were identified using the Delphi method.
A prospective cohort was audited from January 2016 to June 2016, to determine the association of these epidemiological determinants with the delayed presentation to the hospital. A sample size of 92 was calculated to provide a confidence level of 95% and a confidence interval of 10. Family's Socioeconomic scale (SES), health insurance coverage, initial treatment history, and distance from and transport facility to the hospital were audited for 100 children with musculoskeletal conditions. Udai Pareek's SES scale for rural areas was calculated based on the parent's interview. Correlation between delayed presentation to the hospital and SES, indigenous treatment, insurance coverage, and transport infrastructure was analyzed with Chi-square test of independence.
| Results|| |
Prevalence of musculoskeletal disorders
The survey audited 2281 children with musculoskeletal disorders. They constituted 16.6% of the total outpatient attendance at the orthopedic clinic. Six hundred and eighty-five (30%) were girls and rest were boys. Mean age was 9.32 years (range: 0–18 years), (standard deviation: 5.47). Seventy-one percent (1619) of children presented with trauma. Nine hundred and thirty-nine children (58%) sustained injury to the lower limb, remaining sustained injury to the upper limb, and few sustained injuries to the pelvis and thorax. Two children presented with polytrauma. In this subset, 1328 (82%) children sustained closed injuries. Fall from height and bicycle and play-related injuries were the commonest mechanisms of injury. All children who presented with native splinting, massage, branding with hot metals, deformity secondary to malunions, infections, or more than 1 month after the incident was categorized as delayed presentation. Four hundred and fifty-three children (28%) had delayed presentation in this group [Table 1].
|Table 1: Baseline characteristics of children with musculoskeletal conditions evaluated at the hospital in rural central India|
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Three hundred and eighty-four children (17%) presented with neuromuscular disorders including spastic nonprogressive central motor disorders, postpolio residual paralysis, myelomeningocele, postinjection nerve palsy, obstetric brachial plexopathy, brain injury sequelae, and progressive undiagnosed conditions. Patients with neuromuscular disorders were referred to the institution for physiotherapy and occupational therapy interventions. Eighty-five (3.75%) children presented with musculoskeletal infections and 74 (3.25%) had congenital deformity of upper or lower limbs. Thirty-four (1.5%) children had deformities secondary to metabolic disorders including rickets. Few children with Volkman's ischemic contracture burns contracture, muscular dystrophy, skeletal dysplasias, and inflammatory polyarthralgia, Perthe's disease, benign and malignant tumors were also evaluated at the orthopedic clinic [Table 1].
Epidemiological determinants of delayed presentation to the hospital
In the prospective cohort of 100 children, sixty-seven were girls. Eighty-four children hailed from middle and lower SES families' and the remaining 16 belonged to the upper SES category. Thirty-three children had insurance coverage, 79 children received primary indigenous treatment with traditional remedies and 68 traveled from remote locations with poor transport infrastructure to reach the hospital [Table 2].
Nineteen children had delayed presentation in this group. Among them 4 belonged to high SES family, 5 belonged to middle SES family and 10 belonged to low SES family (P = 0.085), 11 children did not have health insurance (P = 0.348) and 16 children received primary indigenous treatment before coming to the hospital (P = 0.535). Of these nineteen children, seventeen had to travel from a rural location on dry-weather unpaved roads to reach the hospital. A Chi-square test of independence showed that there was a significant association between delay in presentation and distance from and poor transport infrastructure to the hospital (P = 0.025) [Table 3].
|Table 3: Analysis of epidemiological determinants of children's musculoskeletal health-seeking behaviour in the prospective cohort|
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| Discussion|| |
Schwend has attributed the burden of pediatric orthopedic diseases in LMICs to trauma, musculoskeletal infections, congenital and acquired deformities, and neuromuscular disorders. Early surgical treatment is essential to avoid prolonged disability and improve quality of life. Road traffic injury and orthopedic injury accounts for a quarter of all hospital admissions in children and up to 15% of all childhood deaths worldwide., Proportion of injury-related mortality is higher among Indian children from rural areas, of which at least half are avoidable with efficient trauma care systems. However, trauma care systems in LMICs are suboptimal. Reynolds et al. reported a poor and inadequate trauma care system after reviewing 71 reports from 32 LMICs including India. The pediatric orthopedic resources are heavily skewed toward urban centers. This is further compounded by the abysmal ratio of one orthopedic surgeon per million rural population and even fewer pediatric orthopedic specialists.
A recent meta-analysis of eighty-odd urban hospital-reported congenital anomalies by Bhide et al. estimated the number of congenital anomalies at 185 for every 10,000 births of which a whopping 25% to 35% were musculoskeletal anomalies. Pabbati et al. reported 4.08% prevalence of congenital anomalies in a survey of 4628 newborns in a rural medical college, of which 37.6% were congenital musculoskeletal anomalies. Taksande et al. reported a slightly lower 1.91% prevalence of congenital anomalies among 9386 births and reported 0.21 to 1.3 spinal and musculoskeletal anomalies per 1000 births. A prospective survey of 188 children with musculoskeletal conditions at a tertiary level hospital reported 51% prevalence of trauma and 10.9% prevalence of congenital deformities and suggested larger community-based cross-sectional studies to guide training modules. Gogi and Khan have listed the spectrum of musculoskeletal disorders in Indian children that includes both acute and sub-acute or chronic disorders. However, we lack comprehensive data on the prevalence of children's musculoskeletal disorders in rural India. The prevalence of trauma, congenital and neuromuscular disorders in rural area continues to be under-reported and under-surveyed.
To the best of our knowledge, this survey is the first such exercise that reports the prevalence of musculoskeletal disorders in a large cohort of 2281 children from rural India. We found that nearly one in every five patients attending the orthopedic clinic was a child and 71% of them presented with trauma. A large proportion of the survey population had neuromuscular disorders, both acquired as well as congenital. This group included children with nonprogressive central motor disorders, postpolio residual paralysis, myelomeningocele, postinjection nerve palsy, obstetric brachial plexopathy, brain injury sequelae, and progressive undiagnosed genetic conditions. The highlight of this survey is the high prevalence of neuromuscular disorders reported from rural areas. These findings must be taken into consideration for planning training modules as well as health and insurance policies. The prevalence of bone and joint infections and congenital deformities in our series is similar to reports from urban and tertiary care centers. Few uncommon conditions such as muscle dystrophy, syndromic hip dislocations, Volkmann's ischemic contractures and burn contractures, Perth's disease and benign and malignant tumors were diagnosed but referral to distant specialty centers proved challenging due to parents' reluctance and prior referrals from multiple centers.
In our survey, 453 (28%) children with musculoskeletal trauma presented with either native splinting, history of massage or branding with hot metals or with deformity secondary to malunions and infections or more than 1 month after the incident. Actionable epidemiological determinants including lower SES (poverty and poor literacy), lack of universal health insurance coverage, reliance on indigenous treatment, and poor transport infrastructure were identified. Curran et al. surveyed 83 countries and concluded that lower SES in LMICs adversely affects surgical management of femoral fractures in children and adolescents. Jain and Murlimanju et al. have attributed delayed presentation to poor access to children's orthopedic care in rural areas, lack of adequately trained personnel, and inequitable resource distribution.,, In our prospective analysis of 100 children, we found a higher proportion of children from low SES (28.5%) presented late compared to high (25%) and middle (11%) SES. Even though this difference was not statistically significant, this trend indicates early health-seeking behavior with higher SES. The four children from high SES families who presented late received initial treatment from local dispensaries.
Cost of treatment is an essential determinant for health care in LMICs. In India, the cost of treatment is often borne ”out-of-pocket” and the health expenditure adversely affects the patients' family. Hence, choice of treatment is often made to avoid “costly” hospital care wherever possible. Several reports have demonstrated the effect of family income over orthopedic treatment choices.,,, The past decade has witnessed the focus shift to providing universal health insurance. Rural populations are beneficiaries of government-sponsored health insurance programs but the sheer magnitude of the population is a logistical challenge to provide affordable healthcare for every citizen. We found only a third of our prospective sample population had insurance coverage. We did not find any correlation between health insurance and early health-seeking behavior in this cohort. In fact, a higher proportion (24%) of children covered under insurance had delayed presentation compared to those (16.4%) without health insurance.
Lack of qualified healthcare professionals and specialists has perpetually plagued our nations' rural health sector. The effect of this skewed urban-rural healthcare divide is well recognized. Unqualified indigenous practitioners and poorly trained healthcare workers fill in the vacuum in rural healthcare and provide unchecked and often disastrous treatment with life-long disabilities in children., Poor awareness and traditional beliefs have sustained abhorrent age-old practices of native splinting, vigorous and painful manipulations, and branding with hot-iron beads in rural areas. Among the 19 children in the prospective cohort with delayed presentation, 13 had native splinting with bamboo sticks, plaster of Paris splints, leaf paste, cloth pieces and even, jute ropes; 13 gave a history of manipulation, massage or hot fomentation and 3 had multiple, regular, linear scars over the affected limb suggestive of branding with hot iron rods. Primary indigenous healthcare and reliance on home therapy can delay in seeking appropriate healthcare. In the prospective cohort 79 children, equally distributed across all SES categories received primary indigenous care including home remedies, treatment by local bone-setters and even witchcraft. Of the 19 children who presented more than 1 month after the onset of symptoms, 16 received primary indigenous treatment.
Accessible health care is as essential as affordable health care. More than 30% of India's villages still do not have all-weather paved roads., Road connectivity has a direct impact on maternal and child health care in rural India. At 55.1 km/100 km2, Chhattisgarh lags far behind the national average road density of 125 km/100 km2. This hospital is located within a 70 km radius of a rural area characterized by rugged rural terrain, dry-weather unpaved village roads, and poor transport infrastructure. Access to the hospital is through infrequent, privately-owned day-time bus services. Surrounding villages are connected to the main highway through single-lane kutcha, unpaved roads. Night-time transfer to hospital is restricted to privately owned vehicles on-rent payment basis and is expensive. In the prospective cohort, we found patients from distant villages with poor transport infrastructure presented late to the hospital.
Hence, robust regional and global orthopedic healthcare initiatives are needed to overcome challenges in providing quality orthopedic care to children in rural areas. Government's flagship programs such as the National Rural Health Mission and Rashtriya Bal Swasthya Karyakram initiatives have focussed on screening and prevention of disabilities but have not been able to ensure treatment for musculoskeletal disorders in children. Hence, to create more “generalists” with specialist training, novel rural fellowship initiative and global cooperation for training district surgical teams is the first right step in this direction.,,
This is a single-center, hospital-based survey and findings cannot be generalized to represent the entire rural population. Multiple factors such as nonrandomized samples and proximity to local bone-setter colonies may have resulted in a higher proportion of delayed presentation in our survey.
| Conclusions|| |
Children with musculoskeletal disorders constituted a significant proportion of the orthopedic practice in our survey. They presented with a wide spectrum of musculoskeletal disorders. Trauma and neuromuscular disorders were the most common complaints. The high prevalence of delayed presentation is a cause of concern.
Distance traveled to reach the hospital from a distant location with poor transport infrastructure was the primary factor for delayed presentation. Lower SES, lack of universal health insurance coverage, and primary indigenous treatment may adversely affect the children's access to orthopedic care in rural areas. A national survey is the next logical step to determine actionable epidemiological determinants of children's orthopedic care in rural India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]