Background
In Nigeria and many developing countries, the treatment of diseases and injuries using traditional and cultural methods remain popular among the populace in spite of the availability of modern health care services [
1,
2]. Traditional bonesetting is an age-long practice and has remained a part of health care delivery in many low- and middle-income countries (LMICs).
Traditional bonesetters receive no formal training in modern orthopaedic care, but mostly acquire informal training from family members as a part of ancestral heritage [
3,
4]. Their practice of bonesetting is unregulated and lacks the basic scientific principles of fracture management as well as infection prevention and control [
5]. Subsequently, the treatment of bone and joint injuries by the TBS has been reported to be associated with some complications such as mal-union, non-union, gangrene, chronic osteomyelitis, Volkmann’s ischaemic contracture and joint stiffness [
6‐
8].
Despite the shortcomings in the training and outcomes of fracture treatment by the TBS, they enjoy high patronage and confidence in their communities [
1,
5]. About 70–90% of primary fracture care is provided by the TBS in many rural communities in Nigeria [
9,
10]. It is therefore of public health importance that this method of fracture treatment be recognized, formalized and regulated. The bonesetters appear to have met the fracture care needs of our rural communities for many decades prior to the advent of orthodox fracture treatment. Some of the reasons why they are widely patronized despite the availability of modern orthopaedic services include the following: socio-cultural beliefs, easy accessibility, relatively cheaper cost of treatment and perceived quicker services [
1,
5,
11].
In Nigeria, both the traditional and orthodox fracture care methods have existed parallel to each for many decades. However, the relationship between the orthopaedists and TBS has been characterized by distrust and a sense of rivalry. While many TBS believe that the informal training they receive from their ancestors is superior to orthodox medicine, many orthopaedic surgeons in Nigeria believe that the TBS are untrainable [
12]. Consequently, with the huge patronage enjoyed by the TBS in Nigeria and many LMICs, complications of fracture care ranging from limb- to life-threatening conditions have persisted and have remained a challenge to the orthopaedic surgeons practicing in these regions [
6,
8].
Some studies suggest that TBS can be trained in safe methods of fracture treatment as a means of controlling these preventable complications [
8,
12,
13]. However, the method and feasibility of this training has remained unclear with a paucity of reports on formal training of TBS. The aim of this study was to establish the feasibility and acceptability of formal training of TBS by the orthopaedic surgeons in Nigeria. It is believed that this training is the first step towards the regulation and integration of the TBS into the healthcare system as orthopaedic technicians. This will help to improve the collaboration between the orthodox and traditional fracture caregivers and bridge the gap between the two groups of practitioners with the ultimate goal of improving the outcomes of fracture treatment in Nigeria. This study may provide the template for the formalization and regulation of TBS practice in other LMICs where there are similar challenges with TBS practice.
Methods
Study setting
The study setting is Enugu State, located in the southeastern part of Nigeria. The state has a population of 3.2 million people [
14], estimated at over 3.8 million in 2012. There are three tertiary hospitals that provide trauma care, all located in the capital city of the state, serving the state and other neighbouring states.
Study design and data collection
This was a qualitative study, which collected data using focus group discussions. Focus group discussion (FGD) was appropriate because it is best suited for sharing experiences and perceptions among a similar group of participants. Furthermore, it allows for a richer and more flexible data collection that is not usually achieved with individual interviews while permitting spontaneity of interaction among the participants [
15].
Two focus group discussions were conducted—one for traditional bonesetters (TBS) and one for orthopaedists on separate days. The TBS were recruited from their association, with the help of the Director of Public Health, State Ministry of Health. The FGD was held at the office of the Director of Public Health at the Ministry of Health, Enugu State. The orthopaedists were recruited from the three tertiary hospitals in Enugu namely: the National Orthopaedic Hospital Enugu, University of Nigeria Teaching Hospital Ituku-Ozalla and Enugu State University Teaching Hospital Enugu. The participants comprised both residents and specialists. A public health practitioner, trained in qualitative research methods facilitated the discussions as the moderator using a topic guide, developed from the research questions while a trained research assistant took notes. The sessions lasted between 60 and 75 min respectively. Written consent was obtained from all participants and the sessions were audio-recorded with participants’ permission. Identifiers were not used during the discussions to maintain confidentiality of the participants.
Ethics approval
Ethical approval for the study was obtained from the Health Research Ethics Committee of the College of Medicine, University of Nigeria Ituku-Ozalla.
Data analysis
The focus group discussion audio-recordings and notes were transcribed verbatim. Responses given in Pidgin English were translated into the English language. The anonymized transcripts were edited for clarity, grammatical errors and quality assurance. Data was analysed by thematic analysis. First, the transcripts were read at least twice to familiarize the researchers with the data. Then the research team collaboratively developed a coding scheme by sorting the data into categories and sub-categories. Sub-themes of related categories were grouped into central themes. Central themes, sub-themes and emerging themes were generated from the data and the topic guides. The data were analysed according to themes generated from the transcripts and by relating outstanding points in the responses and analytic concepts to the objectives of the study. Phrases with special connotations and keywords were noted in the transcripts and presented as illustrative quotes. The rationale for adopting a step by step approach was to ensure we did not miss out any concept in the data.
Discussion
All the traditional bonesetters acquired their skills through informal training by apprenticeship mostly from relatives and family members. One of the major shortcomings of the practice of the traditional bonesetters in Nigeria and other LMICs is their process of skills acquisition in bonesetting. Our study corroborates previous reports that the training of the TBS is informal, undocumented and non-standardized [
1,
3]. The training process is also associated with secrecy and hoarding of information from non-family members because it is seen as part of an ancestral heritage [
16,
17]. Consequently, this may be associated with a decrease in the quality of information and skills passed on to learners over many generations.
Additionally, the training is passed on by verbal communication, and there are no peer-review mechanisms, continuing education programs or any regulations. The quality of the training cannot be guaranteed, thus making the practice non-standardized and prone to complications [
8,
18]. It is imperative to have a formalized, standardized and regulated training of TBS. A potential solution is a competency-based training method with certification in the form of micro-credentials. This will guarantee safe, satisfactory and predictable outcomes of fracture treatment by TBS in many LMICs where a majority of primary fracture treatment is provided by them.
Bridging the gap between the orthodox practitioners and TBS will ensure a more effective fracture treatment in developing countries. Therefore, the perceptions of both practitioners of each other are critical. All the participants (orthopaedists) in our study recognized that the bonesetters play a vital role in filling the gap created by the shortage of orthopaedic surgeons in Nigeria and need to be equipped to render safer services. With a population of over 180 million people, Nigeria has approximately 400 orthopaedic surgeons. The density of orthopaedic surgeons in Nigeria is 0.22 per 100,000 population. This is very low compared to 9.2 per 100,000 population in USA [
19] and 6.9 per 100,000 population in UK [
20]. The majority of the orthopaedic surgeons practise in the tertiary hospitals in the cities and urban areas with little or no presence in the rural communities. This dearth of orthopaedic surgeons particularly in the rural communities in Nigeria may be contributing significantly to the huge patronage of TBS in Nigeria.
All the orthopaedists recognized the huge patronage of TBS compared to orthodox fracture treatment among the populace which cuts across educational and socio-economics status. This is not surprising because, with the gross shortage of orthopaedists, the only alternative is the TBS who are more accessible to the rural dwellers. The reasons cited for the huge patronage of TBS in this study are similar to reports from other studies [
1,
5,
11]. Notably, the complications associated with TBS practice were considered a major problem by the orthopaedists. The exact complication rates of TBS practice are not known because only the patients with complications present to the orthopaedists for treatment. Since not all the patients treated by TBS present to the orthopaedists, it is believed that many patients with undisplaced or minimally displaced fractures may have been successfully treated by them. It was noteworthy that the orthopaedists did not express concern about the TBS taking over their work; rather, they were mostly concerned about the safety and risks associated with TBS practice. Overall, the collaboration between the orthodox and traditional fracture caregivers will bridge the age-long rivalry and distrust that has existed between these two groups of practitioners.
Interestingly, majority of the TBS participants felt their practice was superior to orthodox practice. They claimed that their practice is natural, predates orthodox practice and was originally made by God. Traditional medicine practitioners were in practice long before orthodox medicine was introduced to developing countries [
21]. The first orthodox hospital in Nigeria was built in 1873 [
22]. However, prior to this time, traditional medicine was the only available healthcare service in Nigeria. This long-standing history and the deep cultural acceptance of traditional medicine in Nigeria and other developing countries seem to have given the TBS the feeling of superiority over modern medicine. Consistent with the findings in this study, communities perceive traditional medical practitioners as members of their communities, see them as more accessible and trust them more than orthodox practitioners.
We noted that the bonesetters recognized the need to formalize their training and skill acquisition process. According to them, this will enhance their recognition by Government and the populace. Their request for a training school and for seminars to be organized for them express their desire for formal training in modern medicine to improve their knowledge and skills. This observation is critical in the bid to formalize the training and skill acquisition by TBS. One of the TBS expressed willingness to accept training support from orthopaedists, which was passively supported by the others. He recognized the possibility of a deficiency in knowledge and skills among the TBS which could be addressed by training by orthodox practitioners. This observation is in contrast to opinions expressed in previous reports that the TBS are untrainable and should not be offered any opportunity to improve their knowledge and skills [
12]. It was remarkable that the TBS were interested in seeking formal recognition by government. This provides a great opportunity for micro-credentialing of all the TBS practitioners who complete the proposed competency-based training.
All the orthopaedists in this study believed that the TBS are trainable and require further training. The need for training is to improve the knowledge and skills of the bonesetters. They were also willing to offering this training to the TBS. On the basis of the type of complications from TBS practice that present to them, the orthopaedists recommended specific areas that the training should address. These areas included patient selection, splinting techniques and a referral system. It is believed that the most dreaded complications from TBS practice such as limb gangrene, septicemia, tetanus, chronic osteomyelitis and Volkmann’s ischaemic contracture could be controlled by these interventions. The proposed method of education is instructional training using pictures and practical demonstrations. This was considered appropriate because of the level of education of most bonesetters. The majority of the orthopaedists support the integration of TBS into the primary healthcare system after formal training and registration by a regulatory board. This observation corroborates the recommendations of previous authors that training of bonesetters was a means of improving the outcome fracture treatment in developing countries [
8,
12,
13]. The findings from this study may be potentially applicable to other areas of traditional medical practice. For instance, the traditional birth attendants (TBAs) may be formally trained to provide skilled obstetric care in the rural communities, thereby improving maternal and neonatal outcomes.
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