This first countrywide survey of MSI in Malawi revealed that 6.5% of children, or an estimated 576,000 children are living with MSI. Of these, 112,000 children could be in need of P&O devices and 42,000 in need of mobility aids (including 37,000 in need of wheelchairs) to help with ambulation or activities of daily living; 73,000 need medication; 59,000 could benefit from physical therapy, and approximately 20,000 were estimated to benefit from surgery. Currently it is estimated to be only 14 Prosthetists & Orthotists, 200 physiotherapists and physiotherapy assistants, and 15 orthopaedic surgeons in the country.
Studies done on MSI in children in Rwanda and in the Fundong District in North-West Cameroon have shown a prevalence of MSI in children of 16 years and younger of 2.58% and 2.9% respectively [12, 19]. This is less than half the 6.5% proportion of children with MSI in Malawi. The reason of this difference remains unclear. However, extrapolated MSI treatment need estimates in our study have shown that approximately 20,000 children would benefit from surgery in Malawi against 50,000 in Rwanda. The reason for this difference could be that diagnoses and surgical indications in our survey were made by a surgeon, in contrast to the studies from Rwanda and Cameroon, where these were made by physiotherapists.
Most MSI diagnoses in our survey were due to congenital deformities (46%) or were neurological in nature (34.4%). There are few studies to compare our numbers with, but a 5-year audit of all elective orthopaedic operations performed in children at a university hospital in Nigeria showed that congenital limb deformities alone accounted for 35.2% of the diagnoses [20]. A previous study on childhood disability in two districts of Malawi showed that physical impairment (39%) was the commonest impairment type [13], which is in line with this study.
The neurological conditions identified were predominantly cerebral palsy (CP) and epilepsy, which explains the need of medication and P&O devices in those affected children. CP is the most common motor disability in children worldwide, with an estimated prevalence of more than 2 per 1000 in high-resource settings, and a higher prevalence of up to 10 per 1000 reported in low-resource settings [21-22]. CP is known to be an important and common contributor to childhood disability in low-resource settings [23], as supported by another Malawian study [13].
47.5% of children in our survey had moderate MSI, 29.2% had severe MSI and 23.3% had mild MSI. These findings support those of the World Bank where recent estimates suggest that 5% of all children – 93 million children globally – are living with moderate or severe disability as defined by the World Health Organization (WHO) [2]. Our study also showed that low education in the family was associated with more MSI among the family members. A literature review on disability has suggested that an educated individual with a disability is more likely to better cope with her/his disability than those without education and that chronic health conditions may go improperly monitored by patients who are functionally illiterate and the overall well-being of these individuals may worsen overtime [24].
In common with all population surveys, our study had some limitations. The probability proportional to size sampling, diagnostic tools were limited to history and clinical examination, which restricted the identification of conditions that needed complex investigations. Other limitations were that data on other aspects, such as previous treatment received (some participants were unable to recall their previous treatment) and locations were not collected, and our demographic data were limited. Due to long travel distances in some areas, the call back at a few households where people were unavailable at the initial visit was not achieved. Extrapolations are always associated with some uncertainty and we have been careful to give 95% confidence limits. The study also had several strengths. The response rate of over 96% is very good for a survey in our setting, with the added strength that the study was a nationwide survey with a cluster randomized design to obtain a representative sample of children aged 16 years and younger. The fact that most diagnoses and surgical indications were made by one orthopaedic surgeon, also strengthens the findings and implications in our opinion.
In Malawi, a country with limited resources for health, it is unlikely that the unmet needs for treatment among these children will be met fully in near future. However, the estimates provided in this study should be useful in development of policy and for planning of services in Malawi. With 85% of the Malawian population living in rural areas, access to health and other services may be improved through community-based rehabilitation programs in rural communities. In addition, the development of programs that serve populations at the district level, where needs can be assessed and resources identified, may improve access to preventative services and rehabilitation.
Regarding CP, being one of the most common disabilities among the children, further studies are needed with regard to causes, types, socioeconomic status, education, severity, and other associated medical conditions.