The development of a cat-II level pedorthics education programme

Fred Holtkampa, Fons Dehinga, Nguyen Hai Thanh 

Abstract
In Southeast Asia in general, there is a lack of skilled staff and (training) facilities to provide essential aid for people with foot related mobility problems, caused by serious foot deformities and diseases such as diabetes and leprosy. In rural areas in Asia, these conditions concerning training and foot care are worst. Two Dutch NGO’s, i.e., Netherlands Leprosy Relief and Liliane Foundation, focus on solving children‘s foot related mobility problems.They have funded the creation of a regional training facility in Pedorthics at VIETCOT, Hanoi, Vietnam.This facility, the ISPO cat–II awarded Vietnamese Training Centre for Orthopaedic Technologists perceived an orthopaedic shoe technology course as a completion of its training portfolio.
The Dutch Fontys University of Applied Sciences (department of orthopaedic engineering / shoe technology) in collaboration with the VIETCOT designed and implemented an 18-month curriculum in orthopaedic shoe technology to solve the identified training gap at the training facility. This curriculum has been piloted in 2014 — 2015 and after completing the course by the students the programme will be submitted for evaluation by IVO. This project has been made possible financially by a Grant of the Dutch National Postcode Lottery.

Walking! For most people a natu­ral way of moving around in the world, but for more than two million people in Southeast Asia it is a major problem [1-2]. Diseases such as diabetes and leprosy are taking their toll and a large percentage of children have to deal with serious foot deformities, in a number of cases congenital. In addressing this problem, one meets two major problems: First, suitable footwear to prevent or mitigate the problem is not generally available in the rural areas; and second, there is a lack of skilled ­pedorthists (orthopaedic shoemakers).
Although a training programme for educating prosthetics and orthotics is ­already available at the Vietnamese Training Centre for Orthopaedic Technolo­-
gists (VIETCOT) in Hanoi and at schools in other Southeast Asian countries, a specific educational programme in ­pedorthics is still missing.
To fill this gap and to address both major problems, the “Netherlands ­Leprosy Relief“ [NLR] and Liliane Foundation initiated and funded a training facility for pedorthists in cooperation with VIETCOT and Fontys University of Applied Sciences (Department of ortho­paedic engineering/shoe technology). Fontys and VIETCOT developed an educational program in pedorthics, installed a craft workshop/laboratory and trained the teachers.
As the project has a regional scope, students originate from all over Southeast Asia. After graduation, the novice orthopaedic shoemakers will go back to their home country and set up workshops in pedorthics in collaboration with local partners. In this way deployment of ­expertise will be facilitated and provide for a sustainable aid provision for rehabilitation of children and adults with foot problems. In summary, the main ­objectives of this project were: to create a training facility and to train, in a comprehensive program, students from the Southeast Asian region to become ­pedorthists. To train them in such a way that they will be able to provide the most common aid for people with foot related mobility problems in the region. In addition, to train them to become ­entrepreneurs, so they can maintain their service as self-employed professionals.
The project "These shoes are made for walking" runs from 2013-2017 and VIETCOT will continue the course thereafter.

The setting up of the training facilityProject organisation and partners
In this project, a number of partners ­collaborated. NLR and the Liliane Foundation, that focus on projects solving leprosy related foot problems and children’s foot related mobility problems, initiated this project. The project was sponsored by the Dutch National Postcode Lottery which covered the entire development costs, as well as the grants for 32 students joining this program.
VIETCOT, the Vietnamese Training Centre for Orthopaedic Technologists is part of the orthopaedic faculty of the University of Labour and Social Affairs in Hanoi, Vietnam. The VIETCOT already
offers a program in prosthetics and
orthotics which is accredited by the ­International Society for Prosthetics and Orthotics (ISPO) at the level of category II (cat II) which can be compared to a vocational + level. VIETCOT has collaborated with the NLR for several years.
Fontys University of Applied Sciences, Department of Allied Health Professions, Bachelor Program in Orthopaedic Engineering in Eindhoven, provides the ­academic and professional orthopaedic expertise for the development of a ­prosthetics educational program. This occurs in cooperation with Dutch professional organisations such as NVOS-
Orthobanda and international organisations such as IVO and ISPO.
The project partners have established a project organisation and a steering committee. The project runs from 2013 to 2017. In June 2014, June 2015 and June 2016 groups of approx. 12 students from Vietnam, Indonesia, Myanmar, Laos and Cambodia enrolled in the course. The first two groups can be perceived as pilots. The group that started in June 2016 is the first regular course.
An adequate training facility requires:
1. A sound curriculum;
2. competent staff/teachers; and
3. adequate equipment in a workshop.
In this project all three elements had to be specified, facilitated and implemented. In the next paragraphs, we describe the design of the curriculum, the recruitment and training of staff and the ­spe-cification of the equipment.

The curriculum design process
The curriculum design and development process consists of four consecutive steps:
1. Need-assessment and aim setting;
2. The actual curriculum design;
3. Selection of content and development of learning materials and
4. Preparation for piloting. In the next paragraphs the phases are shortly ­described.

Need-assessment, aim setting and requirements
The need-assessment consisted of desk research of existing national and international orthopaedic shoemaking curricula on both the vocational and professional level. It showed that most training trajectories for orthopaedic shoemaking had considerable lengths (4–8 years) as they were provided as part-time training combined with training on the job. In these rather traditional trajectories, artisanal shoemaking and ortho­paedic knowledge were interwoven. And a catalogue of existing shoe constructions for known orthopaedic cases were transferred. In addition, the international standards for orthopaedic shoemaking were assessed and these (provisional) IVO cat II criteria proved to be the best available. 
Also, a fact finding (inception) mission to VIETCOT was done to get ­acquainted with the proposed local partner, its academic staff, the workshop ­facilities and an insight into the local foot problems.Since the training-time was limited we took a different training perspective by dividing orthopaedic shoemaking in two related consecutive phases. The first phase is the training for artisanal shoemaking, resulting in the ability to produce shoes for the healthy foot. The second phase is acquiring knowledge about mobility problems that inform the design of adapted or bespoke shoes. We further decided to intensify the training into a full time 18-month training course.
We assumed that if we would train students to make shoes for the healthy foot, they would be able to understand and perceive the shoe as a “mechanical construction” with functions such as protection and support during stance and walking. In other words, a shoe as a construction defined by parameters for mobility. In addition, students would be educated in the fields of (lower limb) anatomy and (exercise) physiology. As a result of this education students were to understand the interaction of the lower limb and the shoe. A training duration of 6 months (fulltime) was regarded achievable.The next step was to train the students to apply artisanal shoemaking for the unhealthy foot. We presumed that teaching them a catalogue of a variety of existing shoe constructions for known orthopaedic cases, the “how-to“-know-ledge, is not enough. A sound understanding of the mobility problems and their related anatomical/physiological pathology is essential as the orthopaedic shoe is not just a shoe but a “mechanical construction” which has to be designed to meet the set–up requirements of the mobility solution. Sound anatomical/physiological knowledge and know-ledge of pathology is also required to ­become aware of the boundaries of the pedorthists acting.
In addition of the knowledge of ­designing and construction of shoes for the normal foot, students have to know specific constructions, materials use, production and fitting methods to make adapted or bespoke shoes. We estimated that a 6-month specific training in ­orthopaedic shoemaking could give the students a firm basis for further development.
A second project aim is that the graduates preferably become self-employed professionals and set up their own workshop, or start a new department within an existing rehabilitation centre or ­orthopaedic workshop. Consequently, during the program students have to ­develop their entrepreneurial skills.

Based on the need assessment the course aim was agreed as:
Training entrepreneurial competent shoe technologists who are competent in designing and producing mobility ­solutions (orthopaedic shoes and artefacts). In addition, competent and willing to lifelong learning and entre­preneurship.
Student characteristics: This program aims at students in the Southeast Asian region from Vietnam, Laos, Myanmar, ­Indonesia, Philippines, India and Nepal. Requirements for enrolment were:
a) Having finished at least 9 years of ­education (lower secondary school) with relevant experience in shoe­making or orthopaedic technology; or
b) having finished at least 12 years of education (higher secondary school) without previous shoe experience;
c) also a good understanding and command of English (TOEFL test level 550 if possible); as well as
d) a list of references.

Next, the students should recognize themselves having most of the following personal skills and ambitions: feature fine manual/motor skills; good spatial (2D/3D) awareness; enjoy hands-on working skills; good communication skills; entrepreneurial skills; able and willing to learn in an international environment with different nationalities. ­Finally, candidates have to be committed to work with people with disabilities and/or diseases that might be socially labelled; ambitious to become an ­orthopaedic shoe technologist and willing to study away from home in Vietnam for 18 months.

The actual curriculum design
The need-assessment and aim setting provided information for a curriculum draft outline. This outline, the educational concept, the programme, subjects and target groups was discussed and agreed with all partners.
The educational concept: Millers concept of educating for increasing professionalism has been the leading principle in the development of the curriculum. A gradual build-up in getting acquainted with, and acquiring of knowledge and skills to gain the competences in shoemaking and orthopaedic shoemaking, was used. In parallel, students learn the theoretical background, so their competence is based on understanding. Students learn to cope with authentic foot­related mobility problems in a professional way, also knowing the limitations of their competence [3-4].
The programme outline: The programme has a duration of 18 months (2400 teaching hours) and consists of equal parts of theory modules and workshop practice. The programme must provide subjects that equip the students with the skills to design, produce and evaluate mobility solutions based on a solid basis of fundamental knowledge. The student has to know how to perform and why it has to be done that way. ­Furthermore, students must recognise where problems exceed their competence. The curriculum has be fit for a future ­accreditation by IVO as a cat-II course;
The programme consists of three phases: first, becoming a artisanal handi­craft shoemaker; second, becoming ­a orthopaedic shoe technologist and third extending to a entrepreneurial ortho­paedic shoe technologist. Each phase equals a 6-month semester.

Semester 1: Artisanal handicraft shoemaker
The main objective for this first phase is that the students become competent shoemakers of shoes for healthy people and acquire knowledge of the healthy lower extremity and foot. As a result, at the end of phase 1 the student is a ­competent artisanal handicraft shoemaker who can work safely in a workshop, using both conventional tools and operating modern machines. He knows about shoes, knows how to make them, demonstrates how to make them, actually produces shoes of acceptable quality and knows how to fit the shoes to the person they have been made for.
This objective is met as students have to design and produce a number of shoes with increasing complexity and skills ­requirements. As part of the learning process, students peer reviews each ­other’s products.
Important objective of this phase is that students become skilled in communicating with colleagues and clients on clients’ requirements for shoes, shoe ­design, fit, comfort, flaws in measure taking, material use and production. To obtain this objective, the student has to make lasts of their own feet, design, ­produce and fit a pair of shoes for themselves that they actually have to use. In this way the student experiences the ­effect of his or her self-made shoes and can eventually adapt them. Next the ­students work in pairs and make bespoke shoes for each other based on an “client” requirement specification. Communication with each other becomes crucial as the shoes have to meet client’s expectations. In this way students develop a professional vocabulary and understanding of communicating with clients.
In addition, in this phase the student has acquired theoretical knowledge of the healthy lower extremity and in particular the foot in the theory modules such as Anatomy, (Bio-) Mechanics, Physiology and General Pathology.

Semester 2: Orthopaedic shoe technologist
The main objective in the second phase is to become a competent orthopaedic shoe technologist, and extend the ­acquired competence of phase 1 to the field of people with foot related mobility problems. To do so, students acquire knowledge of typical diseases resulting in mobility problems. They become ­familiar with a functional approach of designing solutions for mobility problems. Therefore, the students study gait analysis.
As a result, at the end of phase 2 the student is an orthopaedic shoe technologist who is competent in understanding, designing, producing and fitting the most common and some specialized types of orthopaedic shoes and artefacts. To apply this competence to the real world, the student can communicate with colleagues and doctors about these artefacts. Furthermore, the student is able to communicate with real clients;
The educational training will focus on the local common foot problems such as: spasticity, clog feet, polio and diseases that affect the foot such as leprosy and diabetes. In addition, also attention will be paid to traumatic foot problems of children and people with mutilations by traffic accidents, conflicts and natural disasters.
In phase 2 the student has to also ­acquire theoretical knowledge of typical diseases (Diabetics, Leprosy, Club Feet) resulting in mobility problems, in theory modules such as: Pathology, Gait analysis, Orthopaedic Technology of the lower limbs, Wound Care and Production and Materials.

Semester 3. Entrepreneurial orthopaedic shoe technologist
In phase 3 the student will apply his competence in the clinic where he/she will communicate with clients, specify, design, produce and fit orthopaedic shoes for real clients to their convenience. Furthermore a 6-week apprenticeship in practice is scheduled. In this phase, the student will extend his competence in profile/specialize in specific diseases/mobility issues of the student’s country of origin.
In addition, students will be trained in entrepreneurial skills.
In the final work (final examination assignment) the student demonstrates that he/she is a competent pedorthist who can serve clients from the intake to the aftercare. He/she is able to explicate the decision process and his/her solutions are according to professional stand­ard.
In this phase, the student acquires additional theoretical (bio-medical) knowledge and entrepreneurial skills, so the student is able to set-up a workshop after graduation.

Selection of content and production of learning materials
For the theory line of the programme we selected for semester 1 basic materials in the field of anatomy, bio-mechanics, shoe construction, materials and production.
For the second semester materials were selected in the field of advanced biomechanics, (exercise) physiology, pathology, gait analysis and functional design.
A number of the most common foot problems in this area form a starting point for further development of the ­various topic that will take place from there. This led to the description and production of a synopsis. This synopsis is the starting point for the development of teaching and learning guidelines and materials including literature references.
The practical line of the curriculum contains the description of skills that students have to have. Also, a selection of practical skills and subjects that leads to the development of learning lines and workshop assignments are described.

Preparation for piloting
Right from the start of the project, discussions between the two educational partners took place with respect to the operational necessities. This resulted in an exchange of teachers each with their own experience and knowledge.

Recruitment and training of teaching staff
The curriculum consists of two strands: the theory, knowledge line and the practice, application line. As the theory line with the fundamental subjects as ana­to­my, mechanics, biomechanics and patho­lo­gy shows a certain overlap with the orthotic course at VIETCOT, most of these subjects, with minor adaptations, can be taught by the local staff of VIETCOT.
During piloting, special and specialized subjects in mobility and shoe technology such as podiatry elements, clinical experience in combination with biomechanics etc. were covered by foreign staff and experts from the work field ­provided by Fontys University. Teaching staff from VIETCOT was appointed to ­further develop their professional scope during the pilot phase in these special­ised subjects.
For the practical line, a very experienced shoe technologist was recruited as a long term trainer and as an interme­diate between both universities with ­respect to the practice application line. Two teaching staff of VIETCOT were ­appointed to become the practice teachers in future. They participated in the ­pilot courses, first as a student, next as a teacher and will be further trained on the job until the end of the project. In a fade in/fade out process the VIETCOT teaching staff is now after 3 years ­substituting the long-term trainer.

Specification and purchase of the equipment
A site visit to VIETCOT made clear that a specific workshop for orthopaedic shoemaking was not available. Therefore, a workshop design was made and classrooms were allocated and renovated. In parallel, standard shoemaking equipment, tools and materials were selected, ordered, shipped and installed. The workshop provides for both artisanal shoemaking and more complex production of orthopaedic shoes. Provisions for (weekly) maintenance and repair were organised.

Results
The first pilot group started in June 2014 with the first batch of 12 students and the appointed 3 staff members to become teachers. The theory modules (anatomy, bio-mechanics) were provided by local staff of VIETCOT, combined with staff from Fontys which flew in twice a semester for specific subjects such as biomechanics, and OST-Design and the combination of clinical and technical problems/solutions and review and ­discussions.
The practical part as well as part of the theory on shoe technology and ­material were provided by the long-term teacher, an experienced orthopaedic shoemaker. The then trained local staff members took over the training activities in 2016 in a fade-in–fade-out-process and the local teaching staff has been in full control since January 2017.
The results of semester 1 showed that students had met all theoretical and practical objectives. The produced shoes were of acceptable quality. The results of the second semester proved also promising.
In the third semester, the apprenticeships needed some more attention. The final projects were presented to an international jury, which was impressed by the high standards of the presented ­cases and the high quality of the provided orthopaedic solution products. In June 2015, the second pilot group started and the third group started in May 2016.

Discussion / Conclusion
The training facility is up and running and the third student group is progressing well. The curriculum design proved workable and, considering the first final exam results, successful. Also the training of local teaching staff was successful.
An important goal for this project is that the training programme had to be developed in order to be sustainable. Therefore, firstly, the structure of the program had to be embedded in the ­national existing structures. Secondly, it also had to be embedded in the local systems where aspects as religion and culture play an important role. Thirdly, it must connect to locally existing techno-logies. Using local knowledge and using local materials is of great importance.
The aim of developing an international recognized curriculum needs an international framework of accreditation and acknowledgement by the profession ­represented by the Internationaler Verband der Orthopaedie Schuhtechniker (IVO). A first draft in international ­standards has been developed which can be used to the further development of an international accreditation system [4-5]. This will be of great importance in ­developing more educational programs throughout the world in this field of work.

Corresponding Author:
Ing. Fred Holtkamp M.Sc.
Associate Professor
Fontys University of Allied health Professions Postbus 347
5600 AH, Eindhoven
This email address is being protected from spambots. You need JavaScript enabled to view it.

Bibliography
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Het project [Internet]. 2014 [cited 24 June 2014]. Available from: http://www.theseshoesaremadeforwalking. org/nl/het-project.
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3. Miller GE. The assessment of clinical skills/ competence/ performance. Acad Med (1990); 65:s63-s67.
4. Pratt D. Curriculum, design and Development (1980), Wadsworth Pub, ISBN-13: 978-0155167353.
5. International Standards for Orthopedic Shoe Technology, Final report of an international working group on request of the boards of ISPO International and IVO (2011); Belgium.