Perceptions, practices, and gaps in osteomyelitis care in rural Rwanda: insights from patients and healthcare workers

Abstract

Background

Osteomyelitis is a chronic, debilitating bone infection that contributes substantially to morbidity and disability in low- and middle-income countries (LMICs). In Rwanda, the condition remains under-recognized due to delayed healthcare-seeking, reliance on traditional medicine, and limited diagnostic capacity at peripheral health facilities. This study explored perceptions, practices, and systemic gaps in osteomyelitis care from both patient and healthcare provider perspectives to inform strategies for early detection and improved management.

Methods

A cross-sectional qualitative study was conducted in two hospitals in Nyamasheke District, Western Province, Rwanda. Purposive sampling identified 40 patients diagnosed with osteomyelitis (March-September 2024) and 8 healthcare providers involved in osteomyelitis care. Data were collected through semi-structured interviews, transcribed verbatim, translated into English, and analyzed thematically using the constant comparison method in ATLAS.ti version 24. Credibility was ensured through member checking, peer debriefing, and triangulation of responses. Percentages are used for descriptive purposes only and do not represent population prevalence.

Results

The majority of patients (85%) reported delayed medical consultation, initially relying on traditional remedies due to financial hardship, stigma, and misconceptions about the disease. 6 out of 8 healthcare providers (75%) cited diagnostic limitations, lack of standardized treatment protocols, and poor referral feedback as major barriers. Both groups emphasized inadequate public awareness, insufficient follow-up, and limited rehabilitation support for disabled patients.

Conclusion

Osteomyelitis care in Rwanda is undermined by sociocultural beliefs, financial barriers, and systemic weaknesses across diagnostic and referral pathways. These findings suggest that interventions such as enhanced provider training for early detection, locally adapted management guidelines and strengthened referral practices, and the integration of community-based education and rehabilitation services may help reduce osteomyelitis-related morbidity in resource-limited settings; however, the effectiveness of these approaches warrants further evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14148-3.

Introduction

Osteomyelitis is a severe, progressive infection of the bone characterized by inflammation, necrosis, and new bone formation. It can arise from hematogenous spread, contiguous soft-tissue infection, or direct inoculation following trauma or surgery [1]. Globally, the annual incidence of osteomyelitis ranges between 10 and 50 cases per 100,000 population, with higher rates observed among children, trauma patients, and individuals with diabetes or vascular insufficiency [2]. Despite advances in antimicrobial therapy and surgical techniques, osteomyelitis continues to cause significant morbidity, prolonged hospitalization, and long-term disability, particularly in low- and middle-income countries (LMICs) [3].

In sub-Saharan Africa, the true burden of osteomyelitis remains poorly characterized due to limited surveillance and underreporting. Available evidence suggests that musculoskeletal infections, including osteomyelitis, account for 5–10% of orthopedic admissions in regional hospitals [4]. Contributing factors include delayed presentation, inappropriate initial management, and restricted access to imaging and microbiology services. The disease frequently affects younger populations engaged in high-risk occupations or exposed to trauma, resulting in a major socioeconomic burden for families and healthcare systems [5].

In Rwanda, osteomyelitis is a growing yet neglected public health problem. Most district hospitals lack advanced diagnostic imaging, laboratories capable of bacterial culturing, and standardized clinical guidelines for osteomyelitis management [6]. Consequently, diagnosis often relies on clinical suspicion, and treatment outcomes are inconsistent. Patients commonly seek care after months or years of chronic symptoms, often following traditional or spiritual interventions. In Rwanda, the Ubudehe classification is a community-based socioeconomic stratification system that categorizes households according to overall living conditions rather than income alone. Classification is based on multiple factors, including housing quality, land and livestock ownership, employment stability, household dependency, food security, and vulnerability to shocks. Because Ubudehe status determines eligibility for social protection programs such as subsidized community-based health insurance, households in lower categories often face compounded financial and structural barriers to healthcare access, which may contribute to delayed healthcare-seeking, particularly in rural settings [7]. Furthermore, the referral pathway from community health workers and primary care centers to district and tertiary hospitals is often fragmented, leading to gaps in continuity of care.

Existing literature in Rwanda and neighboring countries has primarily focused on the clinical and microbiological aspects of osteomyelitis, with little attention to the social, behavioral, and systemic factors influencing disease outcomes [8]. Few studies have captured the lived experiences of patients coping with chronic bone infection or the practical challenges faced by healthcare providers in resource-constrained environments [9]. Qualitative insights into these perspectives are essential for designing context-appropriate strategies to improve early detection, standardized management, and long-term rehabilitation.

This study aimed to explore patient and healthcare provider perspectives on osteomyelitis care in Rwanda. Specifically, it sought to identify sociocultural, behavioral, and health system factors influencing diagnosis and treatment, and to propose practical recommendations for strengthening osteomyelitis management within Rwanda’s decentralized healthcare system.

Materials and methods

Study design

A qualitative, cross-sectional study was conducted to explore the experiences and perceived quality of care among osteomyelitis patients and their healthcare providers in Rwanda. A thematic approach was applied to capture in-depth insights into individual and system-level factors influencing osteomyelitis care.

Study setting

The study was carried out in two district-level hospitals in Nyamasheke District, Western Province, Rwanda. These facilities provide secondary-level care and serve predominantly rural populations. The setting was selected to capture perspectives from both rural and peri-urban contexts. Rwanda operates a decentralized, tiered healthcare system overseen by the Ministry of Health, with services delivered across community, health center, district, provincial, and national referral levels. District hospitals act as the primary referral point for health centers and provide essential inpatient, surgical, and emergency services, while complex cases are referred to tertiary teaching hospitals. In rural areas, healthcare delivery is supported by government-led initiatives such as community health workers and community-based health insurance, which aim to improve access and continuity of care. This structured integration between community, district, and referral services provides important context for understanding healthcare-seeking behavior in rural settings.

Study population and sampling

Sample size was guided by qualitative research principles prioritizing thematic saturation rather than statistical representativeness. An initial target of 35–40 patients and 6–10 healthcare providers was set based on feasibility and previous qualitative studies in similar contexts. Recruitment continued until thematic saturation was reached, defined as the absence of new codes or themes in consecutive interviews. The participating district hospitals serve as referral centers for multiple health centers in Nyamasheke District and primarily manage advanced osteomyelitis cases. The study was designed to capture in-depth experiential perspectives rather than to represent service volume or population coverage.

Patients

Forty (40) patients or caregivers were eligible if they met the following criteria.

1. A confirmed clinical diagnosis of acute or chronic osteomyelitis;

2. Age 13 years or older; and.

3. Provision of informed consent.

Participants were included irrespective of time since diagnosis to enable reflection on the full course of osteomyelitis management.

Healthcare providers

Eight healthcare providers (six physicians and two nurses) from hospitals and health centers were purposively recruited based on their direct involvement in osteomyelitis care. The predominance of physicians reflects their central role in diagnosis, surgical decision-making, and referral at district hospitals, while nurses contributed perspectives on inpatient care and follow-up. The lower number of nurses reflects role distribution rather than intentional exclusion and is acknowledged as a study limitation. The provider sample was intended to capture functional roles rather than professional proportions.

Data collection

Data were collected between March and September 2024 using in-depth, semi-structured interviews. Two interview guides one for patients/caregivers and one for healthcare providers were developed by the research team through a review of contextual considerations of osteomyelitis care in Rwanda. The tools were validated through expert review by two qualitative researchers and one orthopedic specialist, and pre-tested for clarity and cultural appropriateness. Minor revisions were incorporated before field use (provided in Supplementary: Interview Guide). All interviews were conducted in Kinyarwanda by trained qualitative researchers, lasted approximately 45–60 min, and were audio-recorded with informed consent. Audio files were transcribed verbatim, translated into English, and cross-checked for accuracy prior to analysis.

Data analysis

Thematic analysis was performed using ATLAS.ti (version 24). Analysis began with repeated reading of transcripts to ensure familiarization with the data, followed by open coding of meaningful text segments. Codes were iteratively refined through a constant-comparison process, in which new data were continually assessed against existing codes and emerging themes to ensure coherence and saturation. The coding framework was developed inductively and organized into higher-order thematic families and networks. Divergences between patient and provider accounts were examined through matrix queries and comparative coding. Peer debriefing sessions were conducted to enhance interpretive validity, and discrepancies were resolved through discussion and codebook revision. Member checking with a subset of participants and maintenance of an analytic audit trail strengthened transparency and reliability. Coding was performed independently by two researchers before consensus was reached. Percentages and frequency counts are used exclusively for descriptive and narrative purposes to summarize interview responses and do not represent prevalence estimates or population-level measures.

Trustworthiness and rigor

Credibility was established through prolonged engagement, participant validation, and peer review of analytic outputs. Transferability was supported by providing detailed contextual descriptions of the study setting and participants. Dependability and confirmability were maintained through documentation of analytic decisions and independent coder verification.

Data saturation

Recruitment continued until thematic saturation was achieved, defined as the point at which no new codes or themes emerged from two consecutive interviews. Saturation was independently confirmed by two researchers reviewing coded transcripts. This approach ensured adequate depth and breadth of data to support robust thematic interpretation.

Researcher reflexivity

To minimize bias, the interviewers maintained reflexive journals throughout data collection and analysis. These journals documented personal assumptions, professional experiences, and potential influences on participant interaction or interpretation. All analysts had prior experience in qualitative research but no direct clinical responsibility for the patients involved, reducing the likelihood of social desirability or hierarchical bias during interviews.

Results

Socio-demographic characteristics of osteomyelitis patients

A total of 40 osteomyelitis patients participated; 21 (52.5%) were male and 19 (47.5%) were female. The largest age group was 19–30 years (32.5%), followed by 31–40 years (27.5%). Most respondents had completed primary education (60.0%), and 34 (85.0%) reported having health insurance coverage. The majority (65.0%) resided in rural areas. Socio-economic status was assessed using Rwanda’s national Ubudehe classification, which categorizes households into four levels from Category 1 (lowest income) to Category 4 (highest income). Seventeen participants (42.5%) belonged to Category 1, representing the lowest income group (Table 1).

Table 1.

Socio-demographic and health characteristics of osteomyelitis patients (N = 40)

Characteristics	Frequency	Percent
	(N = 40)	(%)
Gender of patient
Female	19	47.5
Male	21	52.5
Age of respondent
13–18 Years	9	22.5
19–30 Years	13	32.5
31–40 Years	11	27.5
41–60 Years	7	17.5
Education Level
No Education	11	27.5
Primary	24	60.0
Secondary	5	12.5
Health insurance
No	6	15.0
Yes	34	85.0
Family history of osteomyelitis
No	29	72.5
Yes	11	27.5
Residence
Rural	26	65.0
Urban	14	35.0
UBUDEHE Category
First Category	17	42.5
Second Category	11	27.5
Third Category	9	22.5
Fourth Category	3	7.5

Source: Primary data, 2024

Socio-demographic characteristics of healthcare providers

Eight healthcare providers were interviewed: five females (62.5%) and three males (37.5%). Half of the participants were aged 31–40 years. Physicians accounted for 75%, and 75% had more than three years of experience managing osteomyelitis cases (Table 2).

Table 2.

Socio-demographic characteristics of healthcare providers

Characteristics	Frequency	Percent
	(N = 8)	(%)
Gender of healthcare provider
Female	5	62.5
Male	3	37.5
Age of respondent
19–30 Years	2	25.0
31–40 Years	4	50.0
More than 40 Years	2	25.0
Function
Nurse	2	25.0
Physician	6	75.0
Experience
Less than 1 year	1	12.5
1–3 years	1	12.5
3–5 years	3	37.5
More than 5 years	3	37.5

Source: Rrimary data, 2024

The descriptive characteristics presented above provide context for the qualitative findings that follow. Thematic results reflect recurring patterns across interviews rather than weighted quantitative outcomes.

Thematic findings

Analysis of 48 interviews (40 patients, 8 providers) generated six overarching themes describing barriers and opportunities in osteomyelitis care. Frequencies indicate how often themes were mentioned among participants and are not intended as prevalence measures.

Theme 1: delayed Health-Seeking behavior and use of traditional medicine (34/40 patients; 85%)

Delayed presentation to formal healthcare facilities was common. Cultural beliefs, financial hardship, and limited awareness of disease severity were major contributors.

We thought it was a curse or poison, so we tried herbs and prayers for many months before going to the hospital. (Patient P12, female, rural)

I stayed home for nine years with the wound because I didn’t have money or insurance. (Patient P34, male, rural)

Theme 2: challenges in diagnosis and referral at health facilities (6/8 providers; 75%)

Providers highlighted difficulties in early identification due to non-specific symptoms, lack of imaging, and absence of diagnostic protocols. Referral feedback between facilities was inconsistent.

We suspect osteomyelitis based on swelling and wound characteristics, but there are no X-rays or laboratory tests at health centers. (Nurse HP03, district health center)

Sometimes hospitals send patients back without a clear diagnosis. (Provider HP06, health center)

Theme 3: perceived quality of care and treatment gaps (22/40 patients; 55%)

Participants described variable quality of hospital care. Some reported improvement after surgery or antibiotics, whereas others experienced persistent symptoms, inadequate follow-up, or repeat infections.

They operated on me and gave antibiotics, but the swelling came back. I have no money to go again. (Patient P17, male, rural)

Even when referrals are made early, hospitals sometimes fail to investigate properly, and patients return with unresolved problems. (Physician HP02, district hospital)

Theme 4: Socio-economic and psychosocial burden (30/40 patients; 75%)

Osteomyelitis caused substantial financial strain, stigma, and loss of productivity. Several participants reported school dropout or family neglect. People abandoned us because they think it’s a curse. My child is disabled and no longer goes to school. (Parent P08, rural)

We don’t even have food sometimes, let alone money for the hospital. (Patient P22, female, rural)

Theme 5: limited Health-Worker training and absence of clinical guidelines (7/8 providers; 88%)

Most healthcare providers reported insufficient training in osteomyelitis diagnosis and management. The absence of national or institutional guidelines contributed to inconsistent care.

We delay suspecting osteomyelitis because there is no specific training. Clear guidelines and proper tools are needed. (Nurse HP01, health center)

Theme 6: proposed interventions and community engagement (all providers and 31/40 patients; 78%)

Participants recommended strategies such as public awareness campaigns, community health worker involvement, and establishment of rehabilitation services for patients with disabilities.

Community outreach should teach early signs of osteomyelitis and the danger of waiting too long. (Healthcare provider HP05, district hospital)

Hospitals and health centers must work together for follow-up and support, and prostheses or crutches should be provided for those disabled. (Patient P31, male, rural)

Summary of key patterns

Delays in care-seeking and diagnostic limitations emerged as dominant barriers, while sociocultural beliefs, financial constraints, and inadequate professional training reinforced the persistence of poor outcomes. Participants consistently emphasized the need for standardized clinical protocols, capacity building for providers, and integration of community-based education and rehabilitation initiatives.

Discussion

This qualitative study explored patient and healthcare-provider perspectives on osteomyelitis care in Rwanda, revealing sociocultural, financial, and systemic barriers that contribute to delayed diagnosis and suboptimal management. Although osteomyelitis accounts for a modest share of orthopedic admissions, it imposes disproportionate clinical and socioeconomic burdens, including prolonged hospitalization, disability, and impoverishment. The findings corroborate global evidence that osteomyelitis remains under-recognized within health priorities of low- and middle-income countries (LMICs), particularly where diagnostic infrastructure and standardized management guidelines are lacking, as indicated by Geurts and Pande [4, 10].

Delayed presentation and sociocultural determinants

Delayed health-seeking emerged as a dominant theme, with 85% of participants reporting prior use of traditional or spiritual treatments. This mirrors findings from Ethiopia and Nigeria, where osteomyelitis is often attributed to supernatural causes, delaying biomedical intervention [11, 12, 6] similarly described the cultural interpretation of chronic osteomyelitis (inzibyi) in Rwanda as curable by traditional healers, emphasizing the influence of cultural norms and poor community awareness. Such perceptions result in progression to chronic infection, bone necrosis, and limb deformities before hospital presentation, as also observed in pediatric studies from Ethiopia by Mulualem [13].

Financial constraints further compound these delays. Even with Rwanda’s broad health-insurance coverage, indirect costs such as transportation, surgical supplies, and rehabilitation remain prohibitive, consistent with broader evidence on catastrophic expenditures for chronic infections in rural African settings.

Diagnostic and health-system barriers

Healthcare providers identified diagnostic uncertainty and referral fragmentation as key challenges. Limited access to radiological imaging and microbiological services forces reliance on clinical judgment, increasing risks of misdiagnosis and delayed initiation of therapy. Comparable obstacles have been documented in South Africa by Venter, where inadequate coordination between primary and tertiary levels undermines continuity of orthopedic infection care [14]. The absence of national or institutional clinical guidelines in Rwanda echoes the pattern seen in other LMICs and contributes to heterogeneous management practices [4]. Strengthening diagnostic capacity through decentralized imaging and laboratory services, alongside development of standard treatment protocols, is therefore crucial.

Treatment quality and emerging innovations

Patients’ dissatisfaction with care continuity manifested as recurrent infections, insufficient follow-up, and financial hardship reflects both clinical and system-level gaps. In Rwanda, innovative local solutions are emerging [6]. Gashegu demonstrated that locally manufactured calcium-sulfate antibiotic bone cement is a feasible, low-cost option that achieved favorable outcomes at the University Teaching Hospital of Butare. Such context-specific approaches align with recommendations by [15], who emphasized simplified, biologically driven treatment protocols for bone infections in low-income countries that leverage natural healing potential and affordable materials. Integrating these locally validated techniques into national orthopedic practice could enhance sustainability and reduce dependency on imported implants or prolonged systemic antibiotic regimens.

Recurrence and Long-term outcomes

The risk of recurrence after osteomyelitis treatment remains a global challenge [16]. Previous studies have reported relapse rates of 22% among adults with long-bone osteomyelitis, influenced by disease duration, surgical approach, and bone exposure. Similar determinants are likely relevant in Rwanda, where late presentation, incomplete antibiotic adherence, and limited surgical expertise predispose to persistent infection. Adopting comprehensive, multidisciplinary management including radical debridement, effective dead-space management, and extended antibiotic therapy has been shown to achieve cure rates above 90% when applied systematically [10, 14]. These insights underscore the need to integrate surgery, microbiology, and rehabilitation within an integrated national framework.

Psychosocial and economic consequences

The psychosocial impact of osteomyelitis was profound in this study, with reports of stigma, school dropout, and family neglect. These findings align with [17] reports on the global burden of musculoskeletal conditions, which emphasize social exclusion and productivity loss among affected populations. Community-based rehabilitation, prosthetic services, and targeted insurance subsidies could mitigate these adverse effects, particularly in rural Rwanda where disability support remains limited.

Policy and practice implications

The findings suggest areas that may inform future programmatic and policy discussions encompassing prevention, early detection, and multidisciplinary treatment. Key priorities include:

• Development of standardized clinical guidelines that reflect both global best practice and locally tested innovations such as antibiotic-impregnated bone cement.

• Capacity building for healthcare providers, emphasizing early recognition, debridement techniques, and post-operative care.

• Integration of community health workers into early detection and follow-up programs to reduce diagnostic delay.

• Health-system investment in diagnostic imaging and rehabilitation services, particularly in district hospitals.

• Implementing these measures could align Rwanda with successful integrated models of chronic osteomyelitis management reported from South Africa (Venter et al., 2020) and other LMICs, improving long-term outcomes and reducing disability.

Strengths and limitations

The study’s strengths include its dual perspective from patients and healthcare providers and the use of rigorous thematic analysis ensuring credibility and transferability. However, as a cross-sectional qualitative inquiry confined to two district hospitals, generalizability may be limited. Furthermore, recall bias among patients diagnosed several years prior cannot be excluded. Participants were recruited from health facilities, which may underrepresent individuals who never accessed formal care. Despite these limitations, the findings provide valuable contextual insights into barriers and opportunities for strengthening osteomyelitis care in Rwanda.

Conclusion

This study highlights how osteomyelitis care in Rwanda is influenced by sociocultural beliefs, economic constraints, and health-system limitations that delay diagnosis and treatment. Patient and provider perspectives underscore the importance of improved awareness, clearer referral pathways, and better follow-up care. Although context-specific, these insights provide a foundation for further research and locally appropriate strategies to strengthen osteomyelitis management in resource-limited settings.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

JPN conceived and designed the study, conducted interviews, and led the drafting of the manuscript. TK performed data analysis, contributed to the interpretation of findings, and critically revised the manuscript for scientific accuracy and clarity. EN and BU provided guidance for the research process and contributed to the manuscript writing. All authors read and approved the final version of the manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The qualitative interview datasets generated and analyzed during the current study are not publicly available due to participant confidentiality and ethical restrictions. De-identified transcripts or selected excerpts may be available from the corresponding author upon reasonable request and with approval from the Rwanda National Ethics Committee (contact: jnsengiyumva714@gmail.com).

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Rwanda National Ethics Committee (RNEC) (IRB No: 00001497; IORG No: 0001100), issued on 20 November 2020. Written informed consent was obtained from all participants prior to data collection. For participants under the age of 18, written consent was obtained from a parent or legal guardian, and assent was obtained from the adolescent. All study procedures were conducted in accordance with the principles of the Declaration of Helsinki and relevant local ethical regulations. Institutional authorization for data collection was granted by the management of the participating hospitals.

Consent for publication

All participants provided written consent for anonymized quotations and aggregated findings to be published in scientific journals. No identifiable personal information has been included in the manuscript.

Competing interests

The authors declare no competing interests.