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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 114-121

Prevalence and factors influencing the preference of traditional bone setting amongst patients attending orthopaedic clinics in Kano, Nigeria


1 Department of Community Medicine, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Faculty of Clinical Science, Bayero University Kano, Kano, Nigeria
3 Department of Surgery, Aminu Kano Teaching Hospital and Bayero University Kano, Kano, Nigeria
4 Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Submission08-Oct-2021
Date of Decision17-Oct-2021
Date of Acceptance20-Oct-2021
Date of Web Publication10-Dec-2021

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_57_21

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  Abstract 


Context: Traditional bone setting is a public health concern because of the late hospital presentation and resulting socioeconomic consequences. Aim: This study aimed to determine the prevalence and factors associated with preference of traditional bone setting among patients attending orthopedic clinics in Kano, Nigeria: Design: Descriptive cross-sectional design was used. Materials and Methods: Up to 370 patients were selected using a two-staged sampling technique. Statistical Analysis: Data were collected using interviewer administered questionnaires and analyzed using SPSS version 22.0 with P ≤ 0.05 considered statistically significant. Results: The respondents age ranged 1 − 82 years with a median age of 29 (IQR = 20, 40) years. Majority of the patients (77.6%, n = 287) were older than 24 years of age with more than one-quarter (36.2%, n = 134) engaged in trading activities. Period prevalence (Within the last one year of visiting TBS) was 60.5% (95% CI: 55.4–65.6) while the point prevalence was 2.4% (95% CI: 1.1–4.6). Main reasons highlighted for the preference of traditional bone setting include low costs (8.6%, n = 32) and accessibility (6.5%, n = 24). Patients on admission had less probability of ever visited TBS (aOR: 0.4, 95% CI: 0.2–0.7), and patients with formal education were less likely to currently visit TBS (aOR: 5.0, 95% CI: 1.2–21.7) Conclusion: The prevalence of patronizing traditional bone setters is of significant public health concern despite the reported consequences. Therefore, the stakeholders should ensure regulated practices of the bone setters by providing them with appropriate guidelines including supervision of their practices.

Keywords: Fracture, Kano, prevalence and factors, traditional bone setting


How to cite this article:
Jibo AM, Muhammad AA, Muhammad S, Usman MI, Ibrahim UM, Bashir U, Tsiga Ahmed FI, Jalo RI, Ayaba AK. Prevalence and factors influencing the preference of traditional bone setting amongst patients attending orthopaedic clinics in Kano, Nigeria. Niger J Basic Clin Sci 2021;18:114-21

How to cite this URL:
Jibo AM, Muhammad AA, Muhammad S, Usman MI, Ibrahim UM, Bashir U, Tsiga Ahmed FI, Jalo RI, Ayaba AK. Prevalence and factors influencing the preference of traditional bone setting amongst patients attending orthopaedic clinics in Kano, Nigeria. Niger J Basic Clin Sci [serial online] 2021 [cited 2022 Jun 25];18:114-21. Available from: https://www.njbcs.net/text.asp?2021/18/2/114/332197




  Introduction Top


The practice of traditional bone setting is recognized as a specialized method of traditional medicine, and the expertise is perceived to be passed within the same family. However, interested individuals outside the family can be trained through apprenticeship.[1],[2],[3],[4],[5],[6],[7],[8] Fracture can occur due to trauma, such as from road traffic accident or fall from height.[8] The utilization of traditional bonesetters (TBS) to manage fracture and other musculoskeletal diseases is common in developing countries in Africa, Asia, and some areas in Southern America.[1] The well-organized health system in many developed countries results in early diagnosis and treatment of patients with fracture, more so because the doctors-patients ratio is good enough in ensuring good coverage and accessibility of care by all. Furthermore, there is an existing functional health insurance system; therefore, all the citizens have the benefit of the specialized treatment.[6] In Nigeria for example, traditional bonesetters (TBS) manage between 70% and 90% of the fractures in some parts of the country.[2] There is existence of different choice for the care of fractures by either the traditional bonesetters or orthopedic surgeons in Nigeria both of which have a number of barriers and facilitators affecting the preference of the choice.[2]

In many developing countries where traditional bone setting is regarded as an alternative management option for fractures, many failures of the procedures have been acknowledged due to the utilization of inappropriate approaches that are not scientific. The procedures are grossly defective in terms of the existing information on human physiology, anatomy, radiology, and various principles of infection prevention, including the care of soft tissue, which often results in serious complications.[5] The complications attributable to the choice of traditional bone setting (TBS) include but are not limited to gangrene, mal-union, pain, non-union, infections, and joint stiffness.[1],[3],[4],[5],[6],[7] Evidence has shown that about half of the amputations were performed due to gangrene resulting from poor management by the TBS.[8] People have preference for this approach of treating fractures due to the inherent belief that diseases and accidents have spiritual part that require integrated approach in the management.[1],[3],[4],[5],[6],[7]

Furthermore, in Nigeria, despite the availability of orthopedic services, the practice of TBS has continued to thrive.[7] The practice is widespread and associated with significant patronage, with about 85% of patients having fractures reported first to traditional bone setters prior to the hospital visit.[4] This high level of acceptance is perhaps due to its existence before the coming of orthodox specialization, the nature of the practitioners, affordability, superstition, quick access to the services, low socioeconomic status, ignorance, pressure from family and community members, and perhaps because the modes of payment could be either in cash or in kind for the services provided coupled with the deep-rooted belief in its effectiveness and contribute to the continued patronage despite the complications.[4],[5],[7],[8]

In Kano, the situation is not different, especially due to the fact that Kano is an important city in Northern Nigeria with significant cultural heritage that may involve the practice of traditional bone setting. In addition, the commercial activities within the state are associated with increased traffic activities and perhaps more cases of trauma that may require the services of traditional bonesetters. Similarly, being one of the commercial cities in Nigeria increases the likelihood of people coming from different backgrounds from within and outside the country with commercial activities likely not limited to commodities but also various forms of traditional medication including TBS. These bonesetters may be from Kano or come from different areas to Kano for their practices as a form of gainful employment. They are usually barely educated or not educated at all and depend mainly on inheritance from the family, spiritual intuition, or experience.[9] This may be the reason for the record why 65.3% of major limb amputations reported in an orthopedic hospital in Kano were linked to traditional bone setting.[9] Therefore, this study aimed to assess the prevalence and factors associated with the choice of traditional bone setting among patients attending orthopedic clinics in Kano. The findings may provide a guide to the healthcare workers and other stakeholders for providing appropriate interventions.


  Materials and Methods Top


Study design

A descriptive cross-sectional design was used to study all the patients (in-patients and out-patients) attending orthopedic surgery clinics in government-owned hospitals within the Kano metropolis providing orthopedics services. Data were collected between August 20, 2020 and December 30, 2020 All the patients with fractures attending orthopedic clinics were included in the study while those found in critical condition during the study, those attending private facilities in Kano, and admitted patients that were found absent for any reason during the research were excluded from the study

Ethics

Ethical approval was given by the Research Ethics Committee of Ministry of Health, Kano State with approval number: (MOH/OFF/797/T.I/1994) dated March 20, 2020 and National Orthopedics Hospital Dala Kano with approval number: RET/ETHIC/60 dated August 14, 2020. Signed informed consent was obtained from all the respondents selected in this study. All the principles of the Helsinki Declaration were strictly adhered to throughout the data collection process.

Study setting

Kano is a commercial state in Northwest Nigeria (11°30 N, 8°30E) and is one of the most populous states in the country with a 2020 estimated population of 19,377,462 based on the 2006 census carried out by the National Population Commission (NPC) of the country.[10] The metropolis has some hospitals owned by both the state and federal government providing trauma care, including National Orthopedic Hospital, Dala (NOHD); Aminu Kano Teaching Hospital (AKTH); Murtala Muhammad Specialist Hospital (MMSH); Sheikh Muhammad Jeddah General Hospital (SMJSH); and Sir Muhammad Sanusi General Hospital (SMSGH). In all the hospitals, there are specialists who provide orthopedic services with significant collaboration between the specialists. Referrals are also made between the hospitals based on specific services needed.

Sample size estimation

The target sample size for the survey was determined using Fisher's formula.[11] Using a prevalence of using TBS of 31.6%,[7] 95% confidence level, desired level of precision of 0.05, and an increase of 10% to account for nonresponse, a minimum size of 370 was obtained.

Sampling procedure

A two-stage sampling technique was used to study the eligible patients. In the first stage, a list of all the hospitals providing orthopedic services was obtained from the Kano State Ministry of Health from which two hospitals were selected using balloting (Murtala Muhammad Specialist Hospital and National Orthopedics Hospital Dala). Eligible patients were equally allocated (185) to the two selected hospitals.

In the second stage, eligible participants for the study including both inpatients and outpatients in the selected hospitals were selected via systematic sampling. The outpatient and inpatient studied in each of the two selected facilities were proportionately allocated based on the clinic register and the total number of patients on admissions. The sampling frame of the two facilities was obtained from the record units and the sampling interval was estimated for each hospital.

Procedure of data collection and instrument of data collection

An adapted, pretested, interviewer-administered, semi-structured questionnaire, written in English language was used for data collection.[1],[2],[3],[4],[5],[6],[7],[8],[9] Data were collected by eight trained research assistants. The instrument had three sections seeking information on sociodemographic characteristics of the patients, history of fracture, previous and current patronage of TBS, and reasons for patronizing TBS. Up to 37 questionnaires were pretested among patients with fractures attending a facility outside Kano metropolis.

Data analysis and measurement of variables

Data collected were appropriately entered into a Microsoft Excel spreadsheet, cleaned, and analyzed using IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Numerical data were presented using mean and standard deviation or median and interquartile range (IQR) as appropriate, while categorical variables were presented using frequencies and percentages. Period prevalence was defined as the number of fracture cases involving any part of the body within the last 1 year divided by the total number of eligible respondents for this study

The period prevalence of visiting the TBS within the last 1 year and the point prevalence (at the time of interview) were estimated. The outcome variables were ever visited TBS (categorized into those that never visited or ever visited TBS) and currently visited (categorized into those that were presently visiting or were not presently visiting the TBS). Independent variables were age, sex, ethnicity, admission status, and first point of care, among others. Pearson's Chi-square or Fisher's exact test as appropriate were used for comparison of proportions at ≤5% α-level of significance. Factors ≤0.2 at bivariate level or were entered in the logistic regression analysis model to adjust for confounding variables.[10],[11],[12]


  Results Top


Sociodemographic characteristics

All the questionnaires administered were returned with a response rate of 100%. The maximum age of the respondents was 82 years and the youngest was a year old, with a median of 29 (IQR = 20, 40) years. Majority of the patients (77.6%, n = 227) were greater than 24 years of age; 77.6% (n = 287) were males, and more than one-quarter (36.2%, n = 134) engaged in trading activities. More than two-thirds (74.3%, n = 275) had formal education, and 66.5% (n = 246) resided in an urban area. Most of the patients studied (70.5%, n = 261) were on admission during the data collection. The monthly income earned ranged between 0 to 700,000 Naira with a median income of 15,000 (IQR: 5000, 4500) Naira. More than half of the respondents had an average monthly income below 35,000 Naira. About two-third of the patients (61.1%, n = 221) reported road traffic accident (RTA) as the cause of their fracture, and 62.4% (n = 231) mentioned hospital as their first point of care after sustaining the fracture as shown in [Table 1] below.
Table 1: Sociodemographic characteristics of the respondents

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Prevalence and reasons for patronizing traditional bone setters

Period prevalence (within the last one year of patronizing TBS) was 60.5% (95% CI: 55.4–65.6), while the point prevalence was 2.4% (95% CI: 1.1–4.6). More than one-quarter of the patients expressed their willingness to continue patronizing the TBS and 46.8% (n = 173) still believed positively in the role of TBS in managing various forms of fractures. Among the patients who opted for orthodox management of fractures, (13.0%, n = 48) reported that their preference is because qualified doctors are more competent in managing fracture cases while 60.0% (n = 222) agreed that hospital management is less likely to result in long term complications as shown in [Table 2]. Additionally, 8.6% (n = 32) preferred the service of TBS because it is inexpensive, 6.5% (n = 24) reported ease of access, while 8.4% (n = 31) mentioned quick management as shown in [Figure 1].
Figure 1: Reasons for choosing traditional bone setting method

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Table 2: Prevalence and reasons for the choice of the bone setting method

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Factors associated with the preference of traditional bone setting

[Table 3] and [Table 4] show the crude and adjusted estimates for the association between explanatory factors and ever visited TBS as well as currently visiting TBS, respectively. Educational status, admission status, and first point of help were independent predictors of the current visit to TBS. Male patients were twice more likely to ever visit the TBS (aOR: 1.9, 95% CI: 1.1–3.3). Similarly, respondents who sustained the fracture via domestic accident (aOR: 1.4, 95% CI: 1.1–1.8), those who fractured their arm (aOR: 1.3, 95% CI: 1.1–1.6) and those whose first point of contact was a TBS had increased odds of ever visiting a TBS (aOR: 53.8, 95% CI: 19.2–150.7). Odds of ever visiting a TBS were lower among respondents currently on admission (aOR: 0.4, 95% CI: 0.1–0.3) and among those who had sustained a fracture for less than six months (aOR: 0.5, 95% CI: 0.3–0.8).
Table 3: Factors associated with ever visited traditional bone setters

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Table 4: Factors associated with currently visiting traditional bone setters

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Respondents who were not formally educated were five times more likely to currently visit a TBS (aOR: 5.0, 95% CI: 1.2–21.7); however, admitted patients (aOR: 0.4, 95% CI: 0.005–0.3) and respondents whose first point of contact after the fracture was the TBS (aOR: 14.0, 95% CI: 1.7–113.5) had less probability of visiting the TBS currently.


  Discussion Top


In this study, we assessed the prevalence and factors associated with the choice of traditional bone setting among patients attending orthopedic clinics in Kano state. We found that almost six in ten of the study participants had visited a TBS in the last 1 year. Respondents' gender, cause of fracture, duration of fracture, admission status, first point of contact after fracture, and part of the body fractured were independently associated with ever visited TBS, whereas educational status, admission status, and first point of help were predictors of current visit to TBS.

In keeping with the findings of a record review conducted in Kano that found up to 65.3%[9] of major limb amputation to be linked to traditional bone setting and evidence from other studies,[9],[13],[14],[15] we found a period prevalence of 60.5%, indicating high turnover of patients fractures at the TBS workshops, though the finding of lower point prevalence may be attributable to the good efforts of discouraging the practice of combined orthodox and TBS services by the healthcare workers in the study facilities. More so, it may be due to progressive lack of trust in the TBS interventions, which are known over the years to be associated with long and lifelong complications. In addition, the number still practicing the two approaches concurrently is not surprising considering our study setting is one where many cultural practices are still held in high esteem. In many Sub-Saharan African countries, including Nigeria, traditional, complementary, and alternative medicine is common. A significant portion of the population rely on local herbal medicines or products and indigenous healthcare practices, including traditional bone setting, to maintain their health or prevent and treat various diseases.[16],[17]

The findings of an association between visiting a TBS and being male in this study are in line with a study from the south-eastern part of Nigeria where males utilized CAM more than their female counterparts.[18] Although studies have suggested that women are more health conscious and have higher utilization of health services than men,[17] an African man's belief in traditional medicine cannot be underestimated. They are regarded as the chief custodians of customs and would want to be seen maintaining this culture. Additionally, the ease with which TBS services are accessed may have contributed, considering males may be less prone to engaging in time-wasting activities. Bearing in mind that eight in every 10 participants in this study were males, this may also have contributed to a higher prevalence of visiting TBS among males.

The results of our research noted that patients whose fractures were less than 6 months old utilized the services of a TBS more. Many of these new cases were still on admission at the time of this study and could not have had access to a TBS while being on a hospital bed. This, explains the reason why being on admission was also found to be associated with TBS. A fractured arm may not be as complicated as fractures of other parts of the body, a reason why respondents with this type of fracture seek help from the TBS rather than the hospitals where more severe cases would be taken.

Education is a well-established determinant of health.[18],[19] Sound education has been shown to improve a population's healthcare utilization and other health-seeking behaviors. It is no surprise that this study found a relationship between education and visiting TBS. A study conducted in south-western Nigeria reported that formal education, higher average monthly income, and urban residence were positively associated with the utilization of hospital services in the management of fracture.[13],[14] This can be explained by the ability of the educated patients to read the possible consequences of failed traditional bone setting methods, which can influence the decision of seeking care from specialists in the hospitals. Similarly, higher monthly income and residing in the urban settings increase both the financial and geographical accessibility among the patients. This is in disagreement with the finding of a study conducted in Tanzania that reported that patients who were financially buoyant, educated formally, and geographically within the reach of orthopedic services were among the adherents of TBS.[15] The patients who do not have any form of formal education were found to be combining the TBS and hospital management, probably due to limited trust in the orthodox medication that is not unconnected with ignorance. This underscores the need for regular health education programs, especially mass media, that are within the reach of even the rural population. In a situation where the traditional bone setters were the first contact by the patient studied, that also likely resulted in continued follow-up by our study participants.

When we consider the average monthly income of our study participants, it signifies that a good number of them have their monthly income below the minimum wage in Nigeria. That could explain the expression of willingness to continue patronizing the TBS by some patients because of the financial need for managing fracture in the hospital, which is comparable with what was reported by a study conducted in Ethiopia that reported 29.9% of the study participants to have a preference for the traditional bone setting.[8] In addition, a review of TBS practice in Nigeria[14] is in keeping with our findings of the drivers for patronizing the practices of TBS, including accessibility, pressure from the family and community members, and timely commencement of traditional intervention among others, all of which are linked to the deep rooted cultural belief despite several noticeable complications of TBS care.[14] The fear of amputation, use of Plaster of Paris (POP), internal and external wires, and long duration of hospital treatment were the reported reason in another study conducted in Tanzania;[15] these can all be linked to the high cost of care in addition to other reasons.


  Conclusion and Recommendations Top


Traditional bone setting is still significantly patronized despite the reported complications especially related to late hospital presentation. Formal education and first point of contact after sustaining the fracture were significant factors influencing the patronage of traditional bonesetters. The government should regulate the services of TBS through regular training and supervision of their practices.

Acknowledgements

The authors are thankful to the patients for participating in the research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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