Final draft

UNIVERSITY OF CAPE COAST

TRADITIONAL BONE SETTING AND ITS ASSOCIATED COMPLICATIONS AMONG TRAUMA PATIENTS IN CAPECOAST

1 PROPOSAL – Traditional Bone Setting & Complications in Cape Coast

Table of Contents EXECUTIVE SUMMARY........................................................................................................3 INTRODUCTION..................................................................................................................4 PROBLEM STATEMENT.......................................................................................................6 AIM OF STUDY....................................................................................................................7 RESEARCH DESIGN..............................................................................................................7 Research Objectives.....................................................................................................................7 Research Questions......................................................................................................................7 Population, Sampling and Sample................................................................................................8 Data Collection, Instrumentation and Analysis.............................................................................8

SIGNIFICANCE OF THE STUDY..............................................................................................9 EXPECTED OUTCOMES......................................................................................................10 ORGANISATION OF STUDY................................................................................................10 ETHICAL AND PRIVACY CONSIDERATIONS.........................................................................11 APPENDIX.........................................................................................................................14 Work Plan...................................................................................................................................14 Budget........................................................................................................................................14

QUESTIONNAIRE...............................................................................................................16

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EXECUTIVE SUMMARY Traditional bone setting is an important component of primary healthcare in Ghana.

However, the advent of allopathic medicine and its attendant benefits of fracture scans, record keeping, and effective pain management have caused Traditional Bone Setting (TBS) to appear archaic and risky. In the face of modernisation, TBS practice has generally remained conservative and unchanged, underpinned by superstition and passed on orally within the family. Meanwhile, TBS practice continues to receive patronage from bone fracture patients due to inability to afford orthopaedic care, superstition, illiteracy and lack of access to formal healthcare.

Research conducted into TBS have recommended that further studies must be conducted into TBS to better understand the differences and similarities in the practice across various settings in Ghana. Furthermore, initial research into TBS in Ghana have focused on the practice and patients' experience in rural settings, where access to orthopaedic care remains little. This trend of research further reinforces the belief that TBS is preferred where and when allopathic care is unavailable, even though TBS remains popular in urban settings also.

Other studies have also recommended the training of traditional bone setters and subsequent integration into formal healthcare systems.

The researcher thus seeks to conduct an explorative study to examine the complications, if any, TBS patients in an urban setting experience in the course of their treatment. The study shall employ a quantitative approach to providing a statistical overview on the factors that influence patients’ choice of TBS in an urban setting and the types of complications patients face.

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INTRODUCTION Bone fractures occur when a person breaks a bone. The soft tissue surrounding the bone also stands the possibility of injury. Fractures

are mostly caused by sports injuries, motor

accidents, and domestic accidents such as slips and falls (Parmet et al, 2004) [1]. Fractures are generally characterised by difficulty in using the limb, swelling, severe pain and a noticeable twist or bump at the affected area.

Bone fractures take many forms depending on the nature of the fracture. A primary classification for bone fractures is based on whether they are closed or open fractures (Parmet et al, 2004)

[1]

. Closed fractures refer to bone injuries that do not break the skin to cause a

flesh wound. Open fractures refer to bone injuries that break the skin to cause a flesh wound.

Thus, open fractures require treatment for the bone fracture as well as treatment for the flesh wound (Oryan et al, 2015) [2]. Bone fractures can also be classified as complete, displaced or partial depending on the axis of the bone along which the break occurred.

In 2019, there were an estimated 178 million cases of bone fractures, indicating that bone fractures are a huge global public health issue (Wu et al, 2019) [3]. This is evidenced by the increment in percentage of all disability adjusted life years (DALYs) lost due to musculoskeletal disorders from 4.7% to 6.8% seen from 1990 to 2010 (Lyn et al, 2013) [4].

However, despite the prevalence, there is a continued lack of research to track the incidence of bone fractures across the world, particularly in Ghana (Torgbenu et al, 2017) [5].

The most common medically prescribed methods for treating bone fractures include closed reduction and immobilisation, which are typically administered following physical examination and/or scans to fully assess the extent of the injury (McManus et al, 2008) 5 PROPOSAL – Traditional Bone Setting & Complications in Cape Coast

[6]

.

These treatment processes must be undertaken by qualified medical personnel to avoid circumstances of malunion, non-union or even worse, gangrene.

According to a study that compared the number of orthopaedic surgeons in Ghana to the United States, about 24 orthopaedic surgeons were available in Ghana, relative to 23,956 surgeons in the United States. Thus, Ghana had an appalling orthopaedic surgeon to patient ratio of 0.9 surgeons to 1 million patients, compared to the US’ 79 orthopaedic surgeons to 1 million patients (Brouilette et al, 2014) [7].

The huge gap in primary fracture care in Ghana is thus filled by traditional bone setters (TBSs) who are informally trained care givers with an untested and unlicensed expertise in providing bone fracture treatment (Wedam, Twumasi, 2017) [8]. Due to persistent factors such as inadequate bone surgeons, cost of treatment, illiteracy and superstition, the services of TBSs are widely patronised across Ghana. One hospital in Ghana reported that as high as 63% of bone fracture patients who reported to the hospital left to seek care from TBSs (Yempabe et al, 2020) [9].

It is however imperative to note that traditional bone setting is not a new phenomenon in the Ghanaian context (Wedam, Twumasi, 2017)

[8]

. Long before the advent of orthopaedic

treatment of fractures, fracture patients were seeking care form TBSs. However, the patronage of TBS care has persisted even after the institution of orthopaedic care methods. A study conducted in Techiman in 1996 discovered that up to 97% of 34 respondents preferred to seek care from a TBS for a ‘simple’ fracture. Up to 57% of the respondents reported to prefer to treat a more complex fracture with a TBS (Ventevogel 1996) [10].

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To address the service gap in providing primary fracture care, studies have recommended the formalisation of the services of TBSs to increase their capacity to provide better, safer care for fracture patients (Yempabe et al, 2020) [9] (Aries et al, 2007) [11]. TBSs have also indicated the skill areas for which they required additional training i.e., record keeping, pain management, and management of open fractures and complications (Yempabe et al, 2020) [9].

This study seeks to build upon the insights from previous studies to determine the factors that cause trauma patients in Cape Coast to patronise the services of TBSs and also explore the complications, if any, patients experience as a result of TBS care.

PROBLEM STATEMENT Bone fracture is a critical public health issue in Ghana. However, due to a lack of adequate personnel and infrastructure to provide primary fracture care for patients, TBSs fill the gap to provide orthopaedic care. There is the urgent need to either train more orthopaedic surgeons to provide care for trauma patients or formalise the activities of TBSs through capacity building and licensure.

However, in order to formalise the services of TBSs, there is the need to fully understand the quality they provide for trauma patients. A good understanding of their skill and knowledge level would guide the development of curricula and training material towards their formalisation.

This study shall therefore examine the frequency and degree of complications resulting from the primary fracture care administered by TBSs. It is the researcher’s ambition to critically

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assess the quality of care administered by TBSs to fracture patients to determine the safety of TBS care and the critical areas for which formal training is required.

AIM OF STUDY Generally, this study seeks to assess the complications, if any, fracture patients face as a result of receiving care from TBSs. Specifically, this paper shall focus on a small sample of fracture patients in Cape Coast in the Central Region of Ghana to examine the quality of TBS care for fracture patients.

RESEARCH DESIGN Research Objectives Specifically, the following objectives will help in the navigation of the study and the realization of this broad aim. They will also guide the progress of the study. i.

To explore the reasons bone fracture patients in Cape Coast, patronise TBS care

ii.

To analyse the nature of complications, if any, fracture patients face as a result of receiving care from TBSs.

Research Questions

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In furtherance of the research objectives stated above, the following are the questions that will be answered by the end of the study. i. What factors influence the decision of bone fracture patients in Cape Coast to seek TBS care? ii. What is the nature of complications, if any, fracture patients face as a result of receiving care from TBSs.?

Population, Sampling and Sample The population for the study is bone fracture patients living within Cape Coast in the Central region of Ghana. For the avoidance of doubt, Cape Coast as stated in this study is operationalised to mean the city of Cape Coast, the capital of Central Region of Ghana. Due to the difficulty in finding TBS patients in the records of any health archive, the study shall employ the non-probability method of snowball sampling to find participants for this study..

This sampling method gives the study the best chance of observing and enquiring about the complications that arise from TBS treatment.

Data Collection, Instrumentation and Analysis To achieve this quantitative study, the researcher shall employ a structured interview to collect data from the sample. The data collection instrument shall be administered to the subjects by the researcher. In the event, there is a language barrier to the effective administration of the data collection tool, a local interpreter shall be engaged to assist in the administration. The data collection tool has been annexed to this document.

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All data collection shall occur within the city of Cape Coast in the Central Region. The data collected shall be analysed manually with the assistance of a statistical data analysis software.

The findings will be presented in the form of graphs and charts.

SIGNIFICANCE OF THE STUDY Yempabe et al (2020) examined the knowledge and practices of traditional bone setters in the Northern region of Ghana, with a view to determine opportunities for formal engagement to regularise TBS practice. The study recommended further research in different contexts across the country to enable policymakers to gain a deeper insight of the practice nationally, to guide policymaking approaches regarding TBS. Aries et al (2007) explored the treatment of fractures by traditional bone setters in the then Brong Ahafo region (now Bono East region) by examining patients’ choices and experiences during the treatment. The study argued that the popularity of TBSs in rural areas and their perceived competence required policy makers to understand the practice and regulate them accordingly to ensure safe care for patients. The study recommended that further reviews of patients’ treatment results from different fracture types must be conducted to deepen the understanding of the safety of TBS care.

Wedam, Amoah (2017) studied the experiences of TBS patients and sought to understand the factors that contributed to their adoption of the decision to seek TBS care. The study revealed that quick treatment, perceived quality care and recommendations were some of the most influential factors that contributed to patients’ decision to use TBS care. The study recommended the need to integrate TBS care into formal health systems especially in areas 10 PROPOSAL – Traditional Bone Setting & Complications in Cape Coast

where there is a lack of infrastructure to support allopathic medicine. However, prerequisite to any form of effective integration is the imperative to fully understand all the complexities and nuances of TBS across Ghana.

This study therefore follows the recommendations of earlier research to understand the complications resulting from TBS care in Cape Coast, in the Central Region of Ghana. This study is unique because this is one of the very few studies that has chosen a relatively urban setting i.e., the thriving capital of one of Ghana’s more modern regions.

The insight from this study shall provide further insight into the similarities and differences of TBS treatment in different regions in Ghana as well as the efficacy of the treatment for the patients.

EXPECTED OUTCOMES By the end of the research, this study will achieve the following outcomes: 1. The factors that influence the decision of bonne fracture patients in Cape Coast to seek TBS care.

2. The complications, if any, and their degrees TBS patients experience during their treatment.

ORGANISATION OF STUDY

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The study will be organized in five chapters. Chapter one will be an introductory chapter which will espouse the framework of the study. The chapter discusses the background of the problem, problem statement, research questions, research objectives, significance of the study, scope of the study and limitations of the study.

The second chapter is themed literature review. This chapter is centred around the analyses and discussion of literature that are relevant to the problem or phenomenon under investigation. The chapter will explore the theoretical underpinnings of the study, as well as the discussion of key concepts. Lastly, the chapter reviews and discusses other related empirical studies.

Chapter three will look at the methodology to be adopted to complete a study of this nature.

The research design and orientation will be carefully explored, justification given for the selected research method, data collection method, population, and target sample. The sampling technique will aptly be explained and how data collected will be treated and analysed.

Chapter four will be dedicated to the presentation and discussion of findings in tandem with the key research questions, and also in conjunction with relevant literature in chapter two.

Chapter five which happens to be the last chapter will be focused on the summary of the study, conclusions, and recommendations.

ETHICAL AND PRIVACY CONSIDERATIONS

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The researcher will seek ethical approval from University of Cape Coast Ethics Review Committee. All the interviews shall be preceded by a disclaimer indicating that the privacy of the subject shall be protected and that all data collected shall be used strictly for academic purposes. All participants shall voluntarily sign a written informed consent form before any data collection occurs. In the event the subject is unable to sign this form, they can provide consent by stating it clearly in a video, in a language of their choice to be recorded as proof of consent. To further ensure the privacy and confidentiality of participants, data will be collected in a private environment where no third party will be present.

REFERENCES 1.

Sharon Parmet, Cassio Lynm, Richard M. Glass,

JAMA. 2004;291(17):2160.

doi:10.1001/jama.291.17.2160

2.

Ahmad Oryan, Somayeh Monazzah, Amin Bigham-Sadegh,Bone Injury and Fracture

Healing Biology, Biomedical and Environmental Sciences, Volume 28, Issue 1,2015 ISSN 0895-3988.

3.

Wu, A-M., Bisignano, C., James, S. L., Abady, G. G., Abedi, A., Abu-Gharbieh, E., Alhassan, R. K., Alipour, V., Arabloo, J., Asaad, M., Asmare, W. N., Awedew, A. F., Banach, M., Banerjee, S. K., Bijani, A., Birhanu, T. T. M., Bolla, S. R., Cámera, L. A., Chang, J-C., ... Vos, T. (2021). Global, regional, and national burden of bone fractures

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in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019. The Lancet Healthy Longevity.

4.

Lyn M, Peter B, Damien H, Rachelle B, Marita C, Emma S et al. Global and Country Specific Burden of Musculoskeletal Disorders: A report from the Global Burden of Diseases Musculoskeletal Expert Group. American College of Rheumatology 2013 Annual Meeting.2013;65(S10): S34

5.

Torgbenu, E. L., Nakua, E. K., Kyei, H., Badu, E., & Opoku, M. P. (2017). Causes, trends and severity of musculoskeletal injuries in Ghana. BMC musculoskeletal disorders, 18(1), 349. https://doi.org/10.1186/s12891-017-1709-8

6.

John G McManus, Melinda J Morton, Chad S Crystal, Todd J McArthur, Jeremy S Helphenstine, David A Masneri, Scott E Young, Michael A Miller, American Journal of Disaster Medicine 2008, 3 (4): 241-7

7.

Brouillette MA, Kaiser SP, Konadu P,Kumah-Ametepey RA,Aidoo AJ,Coughlin RC. Orthopaedic surgery in the developing world:workforce and operative volumes in Ghana compared to those in united states.World J Suerg.2014;38(4):849-57.

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8.

Wedam, Emmanuel & Amoah, Samuel. (2017). Traditional Bone Setting: Analysis of Contribution and Patronage in Northern Ghana. Ghana Journal of Development Studies. 14. 23. 10.4314/gjds.v14i2.2.

9.

Yempabe, Tolgou & Edusei, Anthony & Donkor, Peter & Buunaaim, Alexis & Mock, Charles. (2020). Traditional bonesetters in northern Ghana: opportunities for engagement with the formal health sector. Pan African Medical Journal. 37.

10.11604/pamj.2020.37.248.22420.

10.

Ventevogel P. Whiteman’s things: Training and detraining healers in Ghana.

Amsterdam: Het Spinhuis; 1996.

11.

Ariës MJ, Joosten H, Wegdam HH, van der Geest S. Fracture treatment by bonesetters in central Ghana: patients explain their choices and experiences. Trop Med Int Health.

2007 Apr;12(4):564-74. doi: 10.1111/j.1365-3156.2007.01822.x. PMID: 17445148.

12.

Eman Abu-Gharbieh et al, Department of Orthopaedics, Global Burden of Disease, The Lancet healthy Longevity, 2019 https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(21)00172

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APPENDIX Work Plan NO .

ACTIVITY

PERIOD / DEADLINE

1

Reviewing of literature

11th January – 28th February, 2022

2

Submission of proposal for approval

11th March, 2022

3

Gathering data

June – August, 2022

4

Analysis and report writing:

September – November 2022

5

Submission of drafted report

December 2023

6

Submission of final report

January 2023

.

ACTIVITY

UBDGET

1

Printing and binding IRB documents

GH¢150.00

2

Printing of questionnaire:

GH¢100.00

3

Printing and binding of final dissertation:

GH¢100.00

Budget NO

TOTAL

GH¢350.00

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QUESTIONNAIRE Read to patient: Hello, I am Rosemary Agyeiwaa Yeboah, a fifth-year medical student from the university of Cape Coast school of Medical Sciences. I am conducting a survey on management of bone fractures by traditional bone setters in Cape Coast. In order to know why you chose the service of the bone setters and help reduce complications associated with post treatment by traditional bone setters, I would like to ask you some questions. Please note that participation in this study is completely voluntary. You may refuse to answer any questions and you may stop the survey at any time. Information from this survey will be protected, your name and the date of services will not be on any published information. You are assured that your identity and all your private data will remain confidential, and shall be used strictly for academic purposes only. If at any point you would prefer to discontinue with this survey, please feel free to tell me.

Do you have any questions for me?

Do I have your permission to continue with the questionnaire?

Yes No

PERSONAL/DEMOGRAPHIC CHARACTERISTICS 1. How old are you? a) 18 – 30 years b) 30 – 40 years c) 40 – 50 years d) 50+ years

2. Patient’s sex. a) Male b) Female 3. What is your level of formal education? a) None b) Junior High 17 PROPOSAL – Traditional Bone Setting & Complications in Cape Coast

c) Senior High d) Tertiary

4. What is your religious belief? a) Christian b) Muslim c) Traditional d) Other………………………………………………………………

5. What is your ethnicity? a) Akan b) Ga-Adangbe c) Ewe d) Bono e) Dagomba f) Other………………………………………………………………

6.What is your occupation? a) Public Servant b) Private sector employee c) Self-employed d) Unemployed 7. What is your average monthly income? a) < GH¢100 b) GH¢100 – GH¢299 c) GH¢300 – GH¢599 d) GH¢599+

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FACTORS INFLUENCING PATIENT’S DECISIONS TO PATRONISE TRADITIONAL BONE SETTINN SERVICES

8. What type of fracture did you attain? a) Open fracture b) Closed fracture

9. Is this your first time seeking the service of a traditional bone setter? a) Yes b) No

10. How did you learn of TBS care? a) Self b) Friends c) Family members

11. Are you aware of any family member who has ever used TBS care? a) Yes b) No

12. Are you aware of medical personnel (orthopaedic surgeons) or healthcare facilities who treat bone fractures? a) Yes b) No

13. Did you seek any alternative medicine before using TBS care? a) Yes b) No

14. Did you go to the hospital before coming here?

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c) Yes d) No

15. Which reasons influenced your decision to use TBS care? a) Affordable cost b) Proximity c) delay in hospital d) attitude of health workers e) fear of amputation f) cultural beliefs g) religion h) influence from family/friends i) others………………………………………………………………

16. How much will this treatment cost? a) 100 – 299 b) 300 – 599 c) 600 – 1000 d) 1000+

COMPLICATIONS

ASSOCIATED

WITH

FRACTURE

MANAGEMENT

TRADITIONAL BONE SETTERS 17. How long have you been undergoing treatment? a) 1 - 2 weeks b) 3 – 4 weeks c) 5 – 6 weeks d) 6+ weeks

18. Has the treatment reduced your pain? a) Yes 20 PROPOSAL – Traditional Bone Setting & Complications in Cape Coast

BY

b) No

19. Has the treatment reduced swelling in injured area? a) Yes b) No

20. Do you feel stiffness in the injured area? a) Yes b) No

21. Which of the following conditions have you observed in the course of your treatment? a) discoloration of affected area (gangrene) b) malalignment of healed fracture (malunion) c) failure of fractured bone to heal over a period of time (non-union) d) compartment syndrome e) osteomyelitis f) immobilized g) others…………………………………………………………………….

22. Are you satisfied with the service so far? a) Yes b) No

23. Do you have trust in your TBS care giver to help you make a full recovery? a) Yes b) No

24. Will you still want to continue treatment here? a) Yes b) No 21 PROPOSAL – Traditional Bone Setting & Complications in Cape Coast

25. What reasons influence your decision to continue the treatment? a) Satisfactory treatment b) Low Cost c) Accessibility d) Delay in hospitals e) Fear of amputation f) Attitude of health workers g) Belief in traditional bone setters h) Influence from family/friends i) Cultural beliefs j) Others If no, please specify ……………………………………………………………………………

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