Improving intersectoral collaboration between formal healthcare workers and traditional bonesetters in resource-limited settings: evaluation of a pilot collaborative orthopaedic trauma course in rural Tanzania

Abstract

Background

High trauma rates and limited orthopaedic care services in low- and middle-income countries (LMICs) have led to reliance on traditional bonesetters (TBSs). Previous studies have set up formal training for TBSs to promote integration in the primary healthcare sector. However, the hierarchic structure of these initiatives poses the risk of alienating TBSs instead. Therefore, this study piloted a novel training strategy, by assessing the feasibility of an orthopaedic trauma course, involving bilateral knowledge exchange between both formal healthcare workers (FHWs) and TBSs.

Methods

In November 2024, TBSs and FHWs from Rorya district, rural Tanzania, attended a three-day basic trauma course, aimed at teaching basic extremity fracture care and enhancing collaboration. Data on demographics, pre- and post-course knowledge, changes in daily practice, and perspectives were collected through tests and interviews.

Results

Fifteen FHWs and three TBSs participated in the training. Test results revealed a significant average increase in knowledge, from 79.1% pre-course to 86.5% directly post-course, which was maintained at 89.2% after 1 year post-course. In the interviews, most FHWs and TBSs noted changes in daily fracture care practice, the establishment of mutual understanding and respect, and supported expansion of the training course.

Conclusions

The results support the notion that merged training of FHWs and TBSs can improve fracture care-related knowledge of trainees. Wide support was observed for increased collaboration between FHWs and TBSs, indicating that this type of training is feasible and could be expanded into more extensive, formalized programs. Future programs could benefit from performing follow-up practical examination for objective verification of practice changes, referral monitoring and larger sample sizes.

Clinical relevance

Involvement of TBSs in orthopaedic trauma courses for FHWs could enhance training effectiveness and intersectoral collaboration in LMICs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07737-z.

Highlights

• The first orthopedic trauma course worldwide that is inclusive for both formal healthcare workers and traditional bonesetters.

• Fracture care-related knowledge increased and was sustained for up to 1 year post-course.

• A majority of trainees reported practice changes following the course.

• All trainees supported the bilateral exchange of knowledge and recommended expansion of the program.

• Study findings suggest that a collaborative orthopaedic trauma course for FHWs and TBSs leads to increased intersectoral collaboration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07737-z.

Introduction

Road traffic injuries (RTIs) are estimated to result in fifty million injuries annually worldwide, with over 90% occurring in low-and middle-income countries (LMICs) [1]. Sub-Saharan African countries are especially burdened, as RTIs contribute to approximately 32% of trauma injuries in these countries, with the younger population commonly affected. In LMICs, rapid motorization, rapid urbanization, and underdeveloped road infrastructure exacerbate this issue, and the morbidity of RTIs is expected to increase further [1].

The high rates of traumatic injuries in Sub-Saharan African countries do not correlate with availability of safe, available, and affordable orthopaedic trauma care services, especially in rural areas, contributing to high utilisation of traditional bonesetters (TBSs) [2, 3]. TBSs are historically trusted community members, and are deeply ingrained in cultural practices, offering holistic care and custom pricing. Most employ methods such as massage and manual traction for reduction of fractures, use animal hide and pieces of wood for fixation, tight circumferential bandages, and may attempt wound care, with varying levels of hygiene [4].

For various African countries, utilization of TBSs is estimated at 40–85% of the population [4–6]. Several factors drive individuals to seek treatment from TBSs, including geographical proximity, lower costs, personal or spiritual guidance, fear of surgery and metal implants, and negative experiences with hospital staff. Patients range from the entire spectrum of societal, educational and professional backgrounds [2, 7].

Studies on TBSs from various LMICs tend to focus on complications associated with TBS treatment [8–10], raising questions as to whether TBS practices should be discouraged [11, 12]. In contrast, others advocate for collaboration with TBSs, recognizing their societal significance and accessibility and suggest integration of TBSs into community-based health systems through formal training, referral systems or professional regulations [2, 13].

Several previous training programs for TBSs have shown promising results, but often lack comprehensive documentation and subsequent verification of their impact [14, 15]. Additionally, the unilateral approach risks alienation of TBSs, who may find the method paternalistic, without regard for their added value to the healing process.

In prior studies, mutual respect was often suggested as an important facilitator of successful collaboration [16–19], as there is historic mistrust and lack of communication. In an educational setting, fostering mutual respect may be supported through a joint training model that enables bilateral learning: formal healthcare workers (FHWs) learning from and about TBSs, and vice versa. Thus far, this has not been described in academic literature.

Therefore, we piloted a novel training strategy by developing a course program that attempts to train both FHWs and TBSs through bilateral knowledge exchange. By facilitating mutual respect and collaboration, the program aims to improve orthopaedic trauma care in communities where TBS practices are prevalent. This study aims to evaluate the feasibility and effectiveness of such a strategy, assessing participants’ basic fracture care knowledge, practice changes, perspectives on the course and determining the level of support for increased collaboration.

Methods

Study design & participants

This prospective multi-method cohort study was conducted at Shirati Kanisa la Mennonite (KMT) Hospital, Rorya district, rural Tanzania.

The strategy of the course was to be inclusive for both TBSs and a variety of FHWs. Thirty-five TBSs, who had been interviewed for a separate qualitative study on TBS perspectives two months before the training, were eligible. Inclusion criteria for this pilot study focused on ‘high impact’ TBSs, and included the use of basic surgical principles, practice in Rorya district, no potentially harmful practice (e.g. witchcraft, oral herb consumption), fluency in Kiswahili, registration through the local government and an average patient load of at least five new patients per month.

Additionally, various FHWs from the Rorya district were invited, including clinical officers, who are licensed primary healthcare providers with a medical training of three years, as well as nurses and physiotherapists. Participants that completed the trauma course were included in the study. The trainees were pre-approved by the district medical officer. As this was a pilot study, a power analysis was not performed.

Study procedure

The goals of the course were to assess the collaborative training’s potential to improve collaboration and knowledge exchange between both formal and informal healthcare participants, while simultaneously enhancing orthopedic fracture care knowledge for both parties. In November 2024, a three-day basic orthopaedic trauma course was hosted. Global Surgery Amsterdam [20] and AO Alliance [21] developed course material, which was modified by the faculty to the level of attending participants. Faculty consisted of three Tanzanian orthopaedic trauma surgeons, two Dutch orthopaedic trauma surgeons, one Tanzanian clinical officer, and was chaired by the hospital director of Shirati KMT Hospital.

Presentations were held by pairs of Tanzanian and Dutch specialists. Lectures were given in an interactive fashion, the primary language being Kiswahili.

The course covered various aspects of basic trauma care through lectures, group case discussions, demonstrations, and hands-on workshops. Course subjects aligned with the recommendations set by Omololu et al. in his study [4], and included:

• General principles of bone healing.

• Fracture examination and x-ray interpretation.

• Indications for referral from TBS practices or primary healthcare centres to hospitals, such as open fractures and peri-articular fractures.

• Fracture-related complications such as compartment syndrome, neurovascular injuries, and non- and malunion.

• Pre-hospital management, including wound care, splinting, and pain management.

• Surgical management at the hospital, which was explained and demonstrated, emphasizing that surgical procedures should only be performed by trained FHWs.

Additionally, guest lectures were held by two of the TBSs, providing insight into their practices and experiences, followed by a Q&A session, allowing FHWs to ask questions to the TBSs. Subsequently, the TBSs were given room to demonstrate their techniques for splinting and traditional massage.

Data collection and analysis

Demographic characteristics of all participants were collected before the course. Change in fracture care-related knowledge was assessed through written tests composed of twenty questions relating to basic extremity fracture care. Tests were taken before, directly after, and two months after the course. Answers to the questions were not shared with the trainees in the meantime. Differences between the tests pre-course, directly post-course, 2-month post-course and 1-year post-course were calculated with 2-sided paired t-tests, by using RStudio 2023 software [22].

The qualitative section consisted of a ‘case study’, postpositivist approach. Immediately after the course, semi-structured interviews with both participants and orthopaedic faculty members were conducted to evaluate both perspectives on the course and on collaboration between TBSs and FHWs. Interviews were held in a separate hospital office and led by JO and MM in Kiswahili or English, depending on interviewee preference. Two months after the course, a second series of semi-structured interviews was conducted, to evaluate changes in daily work in the months following the course. Orthopaedic faculty members were not included in this round of interviews, as they worked in other regions and would not have directly experienced changes due to the course themselves. This series of interviews was conducted by JO, NH and MM and took place at the interviewee’s workplace (e.g. dispensary, TBS practice). We employed a mixed inductive-deductive strategy, using an interview guide, which left room for new themes to emerge. Interviews were recorded, anonymized, and transcribed per verbatim by two transcribers, working separately. The consensus transcripts were segmented and coded, using MAXQDA 2022 Pro software by two researchers (MM and JB), working separately, followed by consensus-seeking. No member checking or audit trail was done in this study. Triangulation occurred at the level of the methodology, the interviewee and the data analyst.

Ethical considerations

Ethical approval was obtained by the Tanzanian National Institute for Medical Research under reference NIMR/HQ/R.8a/Vol.IX/4775. Written informed consent was obtained from all participants. Per diems for the training were provided as per government standard. No additional stipend was given for participation in this study.

Results

Demographics

In total, fifteen FHWs and three TBSs were trained for three days in the basic trauma course. These three TBSs matched inclusion criteria, out of the 35 TBSs screened for eligibility. The FHWs included six clinical officers, six nurses and three physiotherapists, of whom eight worked in health centres or dispensaries and seven in a district hospital, all in rural settings. The mean age of FHW trainees was 35 years. The three TBSs were older, averaging 62 years. Additionally, three organizing Tanzanian orthopaedic surgeons were included for post-course interviews, to evaluate their experience teaching in this new mixed format. Two surgeons worked in regional referral hospitals and one in a national hospital (Table 1).

Table 1.

Overview of participant characteristics

Variable	Number (%)
Formal healthcare workers	15 (100%)
Age (mean)	34.9 years
Sex
Male	10 (66.7%)
Female	5 (33.3%)
Occupation
Nurse	6 (40%)
Clinical officer	6 (40%)
Physical therapist	2 (20%)
Place of work
Dispensary	4 (26.7%)
Health centre	7 (46.7%)
District hospital	4 (26.7%)
Traditional bonesetters	3 (100%)
Age	62 years
Sex
Male	3 (100%)
Place of work
Home practice	3 (100%)
Orthopaedic surgeons	3 (100%)
Age	37.3 years
Sex
Male	3 (100%)
Place of work
Regional hospital	2 (66.7%)
National hospital	1 (33.3%)

Knowledge test results

The pre-course test was filled out by 17 participants, lacking one TBS. Post-course tests were completed by all 18 participants. The test scores across time are shown in Fig. 1. The overall average score on the pre-course test was 79.1% (SD 10.3, range: 65.0–95.0). The average score of the two TBSs was 65.0% (SD 0, range: 65.0–65.0). The average FHW score was 81% (SD 9.49, range: 65.0–95.0).

Fig. 1.

Knowledge test scores over time

The overall average score on the direct post-course test was 86.5% (SD 11.6, range: 65.0-100), a mean difference increase of 7.4% points (p = 0.001), according to the paired t-test. The average FHW score was 88.7% (SD 10.3, range: 65.0-100), a mean difference increase of 7.7% points (p = 0.002). The average TBS score was 71.7% (SD 5.77, range: 65.0–75.0), an average absolute mean score increase of 7.0% points, compared to the pre-course test. Paired t-tests were not done for TBS sub-group analysis, due to the limited sample size.

The average 1-year post-course test score among all participants was 89.2% (SD 7.91, range: 70.0-100), similar to the direct post-course test results. Compared to the pre-course test, the mean difference increased with 9.7% points (p = 0.0007). The average FHW score was 89.7% (SD 6.67, range: 75.0-100). Compared to the pre-course test, this meant a mean difference increase of 7.3% points (p = 0.002). The average TBS score was 86.7% (SD 14.4, range: 70.0–95.0), an absolute mean score increase of 15% and 21.7%, compared to the direct post-course test and pre-course test respectively (Table 2).

Table 2.

Knowledge test score analysis

Group		N	Min-max	Mean	SD
Total	Pre-test	17	65.0-95.0	79.1%	10.3
	Direct post-test	18	65.0-100	86.5%	11.6
	1-year post-test	18	70.0-100	89.2%	7.91
	Paired t-test (2-tailed)	Mean difference	T-statistic	95% CI interval	P-value
	Pre-test – direct post-test	−0.0735	−3.92	−0.113 to −0.034	0.0012
	Pre-test – 1-year post-test	−0.097	−4.17	−0.146 to −0.048	0.0007
		N	Min-max	Mean	SD
FHWs	Pre-test	15	65.0-95.0	81.0%	9.49
	Direct post-test	15	65.0-100	88.7%	10.3
	1-year post-test	15	75.0-100	89.7%	6.67
	Paired t-test (2-tailed)	Mean difference	T-statistic	95% CI interval	P-value
	Pre-test – direct post-test	−0.0767	−3.72	−0.121 to −0.032	0.0023
	Pre-test – 1-year post-test	−0.0733	−3.21	−0.122 to −0.024	0.0015
		N	Min-max	Mean	SD
TBSs	Pre-test	2	65.0-65.0	65.0%	0.00
	Direct post-test	3	65.0-75.0	71.7%	5.77
	1-year post-test	3	70.0–95.0	86.7%	14.4

Interview post-course: perspectives on the collaborative orthopaedics trauma course

Semi-structured interviews were conducted with ten participants, consisting of three orthopaedic surgeons, three TBSs, two clinical officers, one nurse, and one physiotherapist.

Two TBSs highlighted learning about the importance of first aid and wound cleaning before any other intervention. A third TBS recognized the use of x-ray imaging, as well as learning more about pain management. All agreed that the demonstrations of cast and external fixation application by FHWs had led to better understanding of how FHWs treat fractures, which helped to demystify hospital care for them.

“The most important thing I learned was, when a patient with a broken bone comes to me, I give first aid immediately, reduce the fracture and take the patient to the hospital for x-ray” – Participant 9 (TBS)

All three FHWs answered that the course had refreshed and expanded their knowledge on basic trauma and fracture care, highlighting the prioritization of the primary trauma survey and improved knowledge on pre-referral care. Additionally, the three FHWs emphasized their enhanced understanding of open fracture care, rehabilitation and applying POP.

Two of the faculty orthopaedic surgeons mentioned realizing during the interactive session that TBSs are preferred for their customer care and enjoy higher patient trust than FHWs, mentioning they are close to their patients, spend more time with them and deliver more psychological support.

“I realised that they are well equipped with knowledge, not the formal knowledge you get in schools, but the one which patients need. Patients are not interested in your PhD or master’s degree, but they are interested in good words, encouragement, knowing what will happen tomorrow.” – Orthopaedic surgeon 3

All ten interviewees expressed positive remarks about hosting the course with both FHWs and TBSs. The three orthopaedic surgeons acknowledged the course created a platform for mutual understanding and respect, and for understanding the role and practices of TBSs in Tanzania, through the demonstrations and Q&A session with the TBSs.

“I think this is building some trust between us, each of us used to fear the other… And now… if you are able to sit together on the same table and talk the same language… Then that is progress.” – Orthopaedic surgeon 2

When asked how to proceed from here regarding collaboration, one surgeon suggested the creation of an accessible referral system for TBSs. Three FHWs suggested a more integrated or intensified fracture management collaboration.

“I have seen that some of them are really positive towards collaboration, I think in a way we need to join hands… We cannot really eliminate them, and right now, there are not enough hospitals, so at least they provide some support.” – Orthopaedic surgeon 1

Regarding the future, participants and orthopaedic surgeons all agreed on the importance of scaling up, proposing increased duration and number of participants, as well as expansion to other regions.

“You know what it means… the problem is nationwide, yeah? Many countries in Africa have this kind of practice. So, I take this as a beginning.” – Orthopaedic surgeon 3

A common concern among the faculty orthopaedic surgeons was about TBSs potentially misrepresenting their capabilities following the course. They emphasized the importance of strictly reminding TBSs about their limitations, especially concerning surgical treatments, and continue monitoring their practices.

Interview after 2 months: changes in daily practice

Eleven participants were interviewed, including three TBSs, four clinical officers, three nurses and one physiotherapist.

Improvements in wound cleaning and recognizing the need for hospital referral was actively mentioned by two of the three TBSs. The third TBS stated he did not manage wounds differently than before the training.

“Now I know that bones without soft tissue die, and whenever I receive such patients, I must rush to a hospital, so the patient can have first aid and care to avoid the bones from dying.” – Participant 10 (TBS)

All FHWs highlighted improvements in wound treatment and pre-referral care. Four FHWs and one TBS reported improvements in diagnostics, pain management, and rehabilitation following the trauma course. Two TBSs mentioned that sending patients for X-rays improved their ability to splint fractures effectively. Finally, increased complication awareness was observed, with two TBSs and one nurse recognizing the risks of tight splints or casts. Furthermore, five FHWs mentioned the training had improved their understanding of hospital care, enabling adequate counselling of patients before referral.

All FHWs mentioned that they gave their feedback and shared their skills from the training with their colleagues. Two TBSs mentioned they told or will tell other TBSs about the advantages of collaboration and eliminate myths about hospital care.

All TBSs mentioned that the trauma course has increased closeness between them and FHWs. Two clinical officers noted the training improved the relationship between their dispensary and TBSs in prescription of pain medication.

“After the training I understood that we are all one in serving the community and now we are collaborating in one way or another.” – Participant 15 (Clinical Officer)

Discussion

This study piloted a novel training strategy for a basic orthopaedic trauma course, aiming to foster collaboration and subsequently promote collaboration and stimulate bilateral knowledge exchange between formal healthcare workers and traditional bonesetters. The results showed that the course significantly improved trainees’ fracture care-related knowledge, which was retained one-year post-course, and led to reported changes in clincial practice. All trainees supported the bilateral exchange of knowledge and recommended expanding the program.

Firstly, the findings of this study suggest that the course was effective in increasing the knowledge test scores, averaging a significant 7.4% point among all participants directly post-course. The 2-month and 1-year post-course tests yielded comparable results, indicating a positive and lasting impact of the training. A Ghanaian study by Konadu et al., which evaluated a trauma course that solely included TBSs [23], showed an average increase of 19.7% points (from 67.2 to 86.9% post-course), with sustained knowledge retention after six months. However, direct comparison between that study and the present paper cannot be reliably made, as the study methodologies and trainees involved differed in many aspects.

Furthermore, the qualitative data from participant interviews in our multi-method design indicate that all participants had improved understanding of basic trauma care, and that many had brought this knowledge into practice. A similar classroom-to-practice translation was noted by Shah et al. in their Nepalese study, which followed 367 ‘village health workers’ for 6 years post-training, monitoring practice changes with annual visits [24].

Most importantly, all interviewed participants expressed their approval of the study’s strategy of creating a training and platform for both FHWs and TBSs to discuss fracture care, acknowledging each other’s role in the healthcare system and proposing expansion of the program. This suggests our approach to orthopaedic educational programs, which has not been described in academic literature before, stimulates intersectoral collaboration, potentially reducing fracture-related complications for patients.

A final novel finding in this study was the vocal support for TBS-inclusive interventions from Tanzanian orthopaedic specialists, of which no documentation was available prior to this study. Although the sample of specialists represented is limited, this adds to the growing call for intersectoral collaboration and integration in Tanzania, which was first described by Card et al., in their qualitative study among TBSs [17]. Studies assessing perspectives among orthopaedic surgeons in other African countries have found similar levels of support, ranging between 86.7% and 100% [18, 25, 26]. However, faculty members raised valid concerns regarding the potential for trained TBSs overstating their new expertise, leading to advanced procedures in unsafe settings. Subsequent internal discussion offered continued hospital-TBS linkage as a solution, involving a patient registry and weekly monitoring of referrals at the TBS practice, to prevent such behaviour.

We believe our findings to be generalizable to other countries as well, as the reasons for TBS patronage and level of stakeholder support for intersectoral collaboration appear to be similar across studied nations [27]. In addition, this training strategy builds on ubiquitous values such as trust and respect, meaning it could even aid in building bridges between the formal healthcare sector and other areas of traditional medicine, such as traditional birth attendants, as well.

Limitations

Given that the main aim of this pilot study was to assess the feasibility of collaborative training, the number of TBSs included in this study was inadequate for statistical analysis. It would therefore require further study with sufficient TBS participants to support the observed trends among TBSs as a group.

In this study, practice changes were evaluated through semi-structured interviews of participants by study investigators involved in the organization of the training. These findings should be interpreted with caution, as this mode could have introduced social desirability bias. In addition, the selection criteria used for choosing participant TBSs may have reduced generalizability to other TBSs. Also, member checking or audit trail were not part of this study’s methodology, reducing the reliability of the qualitative part. Finally, the heterogeneity of the training participants may have reduced the usefulness of a single knowledge test, as baseline fracture-related knowledge levels of FHWs and TBSs differed and thus may have led to a ceiling effect of the average test scores.

Conclusions

A collaborative orthopaedic trauma course for formal healthcare workers and traditional bonesetters, as a platform for bilateral knowledge exchange, is a novel training strategy that may improve knowledge of fracture care sustainably, lead to subjective practice changes and promote intersectoral collaboration. This form of training could be expanded into a more extensive, formalized program to involve more traditional bonesetters, who remain the primary point of contact for fracture patients in many rural areas. Therefore, it is likely that increased linkage and education will improve referral rates to hospitals, which could reduce fracture-related complications.

Recommendations for future research

Future studies on this topic should aim for a collaborative setup on a larger scale and across multiple centres, involving more FHWs and TBSs to enhance generalizability. Implementing individual practice audits and tracking TBS-to-hospital referrals is recommended to objectively verify practice changes post-course. Developing separate knowledge tests for FHWs and TBSs could be considered to ensure appropriate challenge levels for all participants. Inclusion of TBSs in the faculty staff of the course is advisable to further improve equal representation within the course. Addressing these recommendations can further enhance the effectiveness of training programs for TBSs and FHWs, leading to better healthcare outcomes in communities with high TBS patronage.

Authors’ contributions

JB was involved in the conceptualization, methodology, formal analysis, investigation, data curation, manuscript review & editing and visualization. TH was involved in the conceptualization, methodology, investigation, manuscript review & editing. MM was involved in the conceptualization, methodology, formal analysis, investigation, and original draft writing. JO and NW were involved in the methodology and investigation. PS, GN, IA, BM and ES were involved in the methodology, investigation and manuscript review & editing. MB was involved with the software and manuscript review & editing. NB, GI, WH were involved in supervision, project administration, funding acquisition and manuscript review & editing. EH and ME were involved in supervision, project administration and manuscript review & editing. BC was involved in conceptualization, supervision and project administration.

Funding

The AO Alliance has provided funding to cover the costs of the collaborative orthopaedic trauma course.

Data availability

All data generated or analysed during this study are included in this published article and its supplementary information files.

Declarations

Ethics approval and consent to participate

Ethical clearance was obtained through the National Institute for Medical Research Tanzania (reference NIMR/HQ/R.8a/Vol.IX/4775). This study adhered to the principles set out in the Declaration of Helsinki. Written consent was obtained from all participants prior to study inclusion.

Consent for publication

Not applicable, as no identifying images or information are submitted.

Competing interests

The authors declare no competing interests.