Wednesday, January 14, 2009


Taylor, L.1 and Harding, K.2
The Crippled Children’s Association of South Australia1,
Majuro Hospital, The Republic of the Marshall Islands2

The Republic of the Marshall Islands (RMI) is located in the Central Pacific. It consists of 29 coral atolls and 5 low lying islands scattered over almost 2 million square kilometres of ocean. The population is approximately 60,000 people, with half living on the capital atoll, Majuro.
The Majuro Hospital is the primary health care facilty in the RMI. Since early 2001, rehabilitation has experienced a significant period of advancement. Staffing numbers have increased to five, including an Occupational Therapist, Physiotherapist, Prosthetic Technologist, Prosthetic Assistant and a Therapy Assistant.

Diabetes Mellitus (DM) is a huge challenge facing the health of the Marshallese people. It is thought that more than 50% of the population over fifty years of age has DM. In light of the DM rate and disabilities observed within the Rehabilitation Service, Orthotic Management was identified as an essential addition to the service.

The International Society for Prosthetics and Orthotics (ISPO) Australian National Member Society (ANMS) and the Majuro Hospital Rehabilitation Service developed an eight-week in country training model to teach Marshallese prosthetics staff basic concepts of lower limb orthotic prescription and manufacturing techniques. After several months of preparation, the training program was conducted in August/September 2003.

The training program resulted in a viable and sustainable orthotics service in the RMI. Patient presentations varied, however 18 of the 36 patients assessed were diagnosed with DM. Other presenting conditions included cerebral palsy, stroke and poliomyelitis. The trainees learned to independently manufacture foot orthoses, ankle-foot orthoses and knee-ankle-foot orthoses for their client population.

Other results included; improved workshop organisation, education of medical staff, development of referral systems, trial of a ‘high risk foot’ screening clinic, development of O&P assessment and measurement forms, production of patient education materials, and improved time management and communication within the rehabilitation team.

To the authors’ knowledge, this is the first time an in-country Orthotics training program has been conducted in the Pacific. The success of this training approach suggests that there is scope for tailored, shorter term training strategies that consider prior learning and flexible learning techniques.

This approach has the added advantage of allowing training in the local professionals own environment, which is likely to facilitate more satisfactory learning outcomes. It also allows the professional to continue to service their community during the training. This is important in small nations, as the professional may be the only person able to provide a clinical service.

Many obstacles and hurdles were encountered throughout the training program, including geographical isolation, the variation and severity of patient presentations, cultural differences, lack of prior education experiences and language difficulties. Many lessons were learned from the experience and several recommendations were made for future training in the RMI and for future ISPO ANMS training programs in the Pacific.

Notwithstanding these challenges, this program has demonstrated that National Member Societies have sufficient resources to improve clinical services in regions with less-developed prosthetics and orthotics services. This model was not intended to be a substitute for appropriate tertiary training, but rather an augmentation to such training where an immediate need was identified.

It is hoped that the lessons learned from this program can be applied in similar situations, and that the work in the RMI can be consolidated with increased networking between Australian and Marshallese professionals.

The authors of this work acknowledge the assistance of AESOP Business Volunteers, The Majuro Hospital and the ISPO ANMS for supporting this project.

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