THE ROLE OF SIGNIFICANT OTHERS IN THE UTILIZATION OF TRADITIONAL
ORTHOPAEDIC SERVICES IN KWARA STATE, NIGERIA
By
Owumi, B.EI, Kolo, v.r' and Taiwo, P. A3
Department of sociology, Faculty of the Social Sciences, University of Ibadan
1. bowumi@yahoo:com.2 vikol033@gmail.com 3. pataiwo@gmail.com
ABSTRACT
Orthopaedic injuries contribute to most musculo-skeletal health challenges in developing
societies partly due to increasing rate of technological advancement and its associated
consequences. Despite the little recognition experienced, traditional orthopaedic service
due to the 'severity of most orthopaedic injuries which sometimes 'left patients
incapacitated, decision making regarding treatment is sometimes determined by
significant others and has implication for patients well being. This forms the focuss of
this paper which is hinged on the health belief model as framework for explanation. Both
qualitative and quantitative methods were used to elicit data. Questionnaire was
administered to 357 randomly selected orthopaedic patients, while In-depth Interview
(IDI) was conducted with 7patients and 14 practitioners. Findings revealed that majority
of the patients (73.1%) belonged to the active age group (21-60 years); were males
(74.5%) who engaged in occupations that predisposed them to orthopaedic injuries.
Referral was mainly effected by family members (43:2%), former TOSP's patients
(35.4%), friends (13.0%), and members of practitioners' ethnic groups (8.0%) who made
these decisions because they were privy to effective treatment offered by the TOSPs.
Intensive capacity building and collaboration with western practitioners was
recommended for improved deliveryof orthopaedic care.
Word count: 192
Key words: Traditional, significant others, utilization, orthopaedic injury
BACKGROUND TO THE STUDY
Orthopaedic injuries affect the vertebrae, joint, bone, ligament, cartilage and muscle. It
includes bone fracture, dislocation, sprain and stress of bodily tissues and other infections and
damages that occur to the musculo-skeletal system of the human body (Hurst, 2014). Although
they date to time immemorial, the occurrence of orthopaedic injuries is on the increase, probably
due to industrialization and high rate of socio-economic activities that characterize the complex
modern society. This has broadened the myriad of factors responsible for orthopaedic injuries.
According to Olaitan (2001), both direct and indirect violence (including severe contusion or
. impact, such as a blow or fall) to any part of the musculo-skeletal system results in orthopaedic
injuries. Scholars have identified the causes of orthopaedic injuries to include sporting activities,
fall, gunshot, occupational hazard, blow and Road Traffic Accidents (RTAs) ((Olaitan, 2001;
1
,
Dada, Yunusa and Giwa, 2011 and Aderibigbe, Agaja and Bamidele, (2013). Onyemaechi,
Onwuasoigwe, Nwankwo, Schuh, and Popoola (2014) however observed that RTAs are the
· leading causes of orthopaedic injuries.
Owumi, Taiwo and Olorunnisola (2013) reported that the high rate of RTAs can be
attributed to the poor state of roads in Nigeria, poor motor vehicle maintenance culture, flouting
of highway codes, over-speeding and armed robbery activities on the highway. Ngim, Udosen,
and Ikpeme (2006) further gave an analysis of RTAs in their review of 'seventy consecutive
cases of Limb Injuries in Calabar'. According to them, Car/Bus accounted for 22.6%,
Motorcycle, 52.8%, Bicycle, 1.9%, Lorry 1.9% and Pedestrian 20.8%. This implies that motor
cycles play a major role in RTA-induced o.rthopaedic injuries than any other factor. Thus,"
motorcycle injuries constitute a major but neglected emerging public health problem in
developing countries. There is therefore an urgent need to regulate orban the use of motorcycles
for commercial purposes. This is because in their bid to make more profits within the shortest
possible time, commercial motorcyclists ride with great recklessness than other motorcyclists.
However, there is a general belief in Africa that associates the causes of orthopaedic injuries to
underlying spiritual factors such as witchcraft, breaking of taboos and wrath of the gods
(Owumiet al, 2013). These influence, patients' perception of their case as well as their choice and
utilization of orthopaedic care.
Before the emergence of modern healthcare system and the consequent advancements
· experienced in medical science and technology, traditional medicine was the sole source of care
available all over the world. This included traditional orthopaedic services, a specialty in
traditional medicine which provided care for orthopaedic injuries. Practitioners of traditional
orthopaedic care are popularly called Traditional Orthopaedic Service Providers (TOSP).
Although the development of modern orthopaedic care which is based on biomedical and
scientific principles can be perceived as a threat to traditional orthopaedic practice, Aderibigbeet
al (2013) reported that majority of populations in developing countries including those in urban
areas still utilize the services of TOSP. Thus, .orthopaedic patients believe that TOSP are not an"
alternative but a preferred source of care even when modern hospitals are available.
Orthopaedic injuries are accidental, sudden and unplanned, so that patients' immediate
family members are. not usually present at the site of occurrence. Due to the" severe, life
threatening nature of orthopaedic injuries, patients are often left incapacitated and dependent on
other people (family members, 'good Samaritans', eye-witnesses and law enforcement agents
such as Police and road safety officials). These individuals, groups and organizations play
enormous roles in the pathway to the, utilization of care by patients. It is against this background
that the paper seeks to examine the role of significant others in the utilization of traditional
orthopaedic services in Ilorin. This is done with a view to specifically discuss the role of
· significant others in the utilization of traditional orthopaedic services and investigate the referral
practices in the utilization of traditional orthopaedic services
2
SIGNIFICANT OTHERS AND THE UTILIZATION OF TRADITIONAL
OR,THOPAEDIC SERVICES
According to Scott and Marshall (2005), 'significant others' refer to those who have an
important influence or playa formative role in shaping the behaviour of another. For the purpose
of this paper, significant others include any person or social actors who are in a position to offer
support to victims of orthopaedic injuries or influence their health seeking behaviour in any way.
These include passers-by, family members, employers, law enforcement agents, co-workers, and
eye-witnesses, who may be well known or even total strangers to a victim of orthopaedic injury,
but exert enormous influence on health decision making and consequent pathway to the
utilization of care by patients. Thus, an holistic understanding of the utilization of TOSP by
orthopaedic patients among other things requires proper analysis of the role of significant others
who do not only influence health seeking behaviour but further mediate contact between patient
and practitioners.Hence, significant others form an indispensible nexus of social relationship that
contributes to the healing process. As noted byUmberson and 110ntez (2010),the quantity and
quality of social relationships affect health behaviour and utilization of health services. This is
congruent with the views of Olaosebikan, Owoaje and Asuzu (2012) who noted that health
behaviour and utilization of health care facilities is highly influenced by the social relationships at
the disposal of an individual patient. This is most typical of the orthopaedic patient because he is
often rendered incapacitated, sometimes unconscious and often times dependent on other people,
- depending on the severity of his case. Thus, social relationships determine the extent of social
capital available to a patient. It also determines his or her social support - the emotionally
sustaining qualities of relationships, for example the belief that one is loved, cared for, and
listened to (Umberson and Montez, 2010). Corroborating this view, Thoits (1995) and Cohen
(2004) noted that social support which derives from social relationships reduces the impact of
stress by fostering a sense of meaning and purpose in life. It is the family, friends, relations and
significant others that harness the opportunities for and seek help on behalf of the patient as well
as serve as caregivers throughout hislher Illness career. This is why Owumi et al (2013) posited
that friends and families remain an important group in the choice of the type of treatment an
injured or sick relative will receive. They not only make choices from possible alternatives but
also take necessary decisions, contact the TOSP and enter into relevant agreement on behalf of
the patient.
According to Solagberu (2005), the initial idea of visiting TOSP is mooted by an external
person in 75% of cases. The study conducted by Ogunlusi, Okem and Ogini (2006) also revealed
that only 13.8% of patients had direct contact with the TOSP while others are through old
patients (44.8%) and middle men (41.4%) either of whom have some relationship with either the
patient or his family and friends. According to them, the middlemen are said to be always around
- the hospital premises to introduce the TOSP's treatment as soon as the opportunity arises. Most
of the middlemen are hospital attendants who initiate the idea of utilizing TOSP once they notice
delay in response to treatment, relapse or despair in any patient.
3
In their study, Berkman and Breslow (1983) found that greater overall involvement with
formal (religious organizations) and informal (friends and relatives), social ties were associated
with more positive health-seeking behaviour. Being married (Waite, 1995), having children
· (Denny, 2010), and ties to religious organizations (Musick, House and Williams, 2004) have all
been linked to positive health care utilization. This may be attributed to the fact that these factors
potentially improve the quantity and quality of relationships to which a person belongs, which
further has serious implications for the choice and utilization of health care services, by
influencing the type of information available to patients with regards to healthcare utilization.
Significant others therefore determine whether or not a patient will accept or patronize TOSP's
service, as some religious sects actually discourage the utilization of traditional medicine of any
kind. .
As implied by Dada, Yinusa, Giwa (2011), significant others consider their perceived
advantages in making preferred choice' for the utilization of traditional orthopaedic service.
These include ease of accessibility, low cost of treatment, natural approach to treatment and use
of incantations and concoctions which are believed to address the spiritual dimensions to
orthopaedic injuries while treating the physical aspects of. the injury. Although education
produces a tendency towards preference for modern care, Aderibigbe et al (2013) found out that
there is no significant relationship between level of education and utilization of TOSP. This may
be attributed to the overwhelming influence of the significant others who are already products of
and participants in cultures which asserts the efficacy of traditional medical systems over modern
·medicine, and have been socialized along such line. They are therefore, able to exert so much
influence due to the communal character of family, kinship and social relationships in Africa
generally. As a result of this significant others play enormous roles not only as care-givers but
also in defraying patients' treatment costs, which further reinforces their influence in the choice
·and utilization of traditional orthopaedic service.
In the view of Omololu, Ogunlade and Alonge (2002), there is an erroneous belief that
the application of plaster of Paris (P.O.P.) and the belief among the people especially those far
away from the cities that fracture cases presented in the hospital mostly ends up in amputation.
Based on this, Alongeet al (1980), Agarwalet al (2010) and Aderibigbeet al (2013) further noted
that the fear of impending surgical terror" an~ its potentially high costs are factors considered by
patients' care givers in the decision-making process. These reasons, coupled with the fact that
significant others as well as patients are participants in a wider culture which considers modern
healthcare as alien. and is therefore biased against it on that ground. This account for why
significant others constitute a major influence on the pathway to the utilization of traditional
orthopaedic services by orthopaedic patients.
REFERRAL PRACTICES IN THE UTILIZATION OF TRADITIONAL
ORTHOPAEDIC SERVICES
Referral is the process by which a health worker transfers the responsibility of care
temporarily or permanently to another health professional or social worker or the community
4
(Ransome-Kuti, Sorungbe and Oyegbite; 1998). The referral' process can involve two major
dimensions: horizontal and vertical referral. Horizontal referral occurs when a patient transfers
from one health care practitioner or level of care to another within the same health care system,
-modem or traditional. On the other hand, vertical is a situation where the transfer is between
modem and traditional healthcare.systems or vice-versa. Erinosho (1998) distinguished between
voluntary and involuntary referral. According to him, voluntary referral occurs when the patient
changes from one source of care to another out of his own volition. Involuntary referral on the
other hand is a situation where a health practitioner or facility at which a patient has been
receiving care formally transfers the patient from one to another. In the case of traditional
.orthopaedic service, referral practices is largely horizontal, that is either from one TOSP to
another TOSP, or from a TOSP to another traditional medical practitioner (such as Diviners or
Sorcerers) other than a TOSP. There are different factors that can necessitate the transfer of
patients from one practitioner or health facility to another. These include inadequate diagnostic
and treatment facilities, cost of treatment, lack of personnel and proximity to patients' place of
residence.
According to Omololu, et al (2002), bone healing occurs naturally. It is the anatomical
union which is required for the healing to take place effectively that the bone setter does. Hence,
Owumiet al (2013) argued that certification is not a prerequisite to set bones: Rather, their
utilization and prevalence of traditional orthopaedic service is determined by societal norms and
values. However modem medical scholars (Dada et al, 2011; Ekere, 2011 and Aderibigbeet al,
. 2013) maintained that traditional orthopaedic practitioners do not have adequate training and
resources to manage orthopaedic injuries. This in their view accounts for the high rate of
treatment failure, complications and mortality associated with TOSP's intervention in
orthopaedic cases. Thus, western practitioners 'believe that TOSP should regularly refer
orthopaedic cases to the modem hospital, especially those in which the patient had suffered
serious (complex) injuries and shock which are often characterized by open wounds or even
unconsciousness.
In a study by Ejima (2014), it was revealed that referral practice among TOSP was poor
as only 37.5% of bone setters did refer serious cases to the modernhospital. It was also reported
that all (100%) practitioners claimed that they do not refer cases to other traditional bone setting
setters but that other practitioners refer patients to them. Similarly, Bassey, Aquaisua, Edagha,
Peters and Bassey (2009) also reported that-TO'Sl' did not see any reason to refer cases to the
modem hospital. According to them, practitioners were contented with the state of their practice
and therefore believ.ed that they possessed all that it takes to .,diagnose and treat any type of
orthopaedic injury. Although practitioners have never officially received any direct referral from
modem hospital, they claimed that friends and family members bring patients who have not been
successfully managed in hospitals to them. This implies that poor referral among traditional
. orthopaedic practitioners contravenes best practices in health care delivery. Even modem
medical practitioners refer patients from one practitioner to another, as no single professional is
infinitely good asto not consult another practitioner on certain issues. Poor referral practices
5
might be responsible for the high rate of complications and disability (Dada et al, 2011;
Aderibigbeet al, 2013, Onyemaechi et al, 2014) attributed to the intervention of TOSP in
orthopaedic cases as had been highlighted by scholars. This can however be blamed on the non-
· existence of integration between modern medical practitioners and their traditional counterpart.
Bridging this gap would reduce treatment failure and mortality due to traditional orthopaedic
service which is the most acceptable to the people in Nigeria.
Health belief Model (HBM)
HBM is a psychological model that attempts to explain and predict health behaviours. It focuses
on the perception and beliefs of people as it affects their health seeking behaviour. Developed in
the 1950s by Hochbaum, Rosenstock and Kegels who are social psychologists working in the
U.S.Public Health Service, HBM uses six major concepts to explain health behaviour. These are:
perceived susceptibility, perceived severity, perceived benefit, perceived barriers, cue to action
and self-efficacy. The concepts are briefly defined below:
Perceived Susceptibility: This has to do with an individual's assessment of their risk of being
affected by a particular ill-health condition. For example ~ person who per.ceives himself
susceptible to a disease may get himself vaccinated against such disease.
Perceived Severity: This refers to an individual's assessment of the seriousness (severity) of his
· ill-health condition, and its potential consequences.' Individual differences influence perceived
severity which varies greatly between people.
Perceived Barriers: This describes an individual's assessment of the influences that enable or
incapacitate his adoption of particular health behaviour. Perceived barriers are a person's own
thoughts about the obstacles in the way of utilizing a health service. The perceived barriers are
the most influential construct because they determine whether someone will adopt a treatment
·type or not.
Perceived Benefits: This concept has to do with one's belief in the efficacy of a potential action
to reduce risk or seriousness of impact. Perceived benefit is based on an individual's assessment
of the positive consequ.e.nces of adopting behaviour or utilizing a health service .
Cues to Action: This refers to strategies to activate readiness, by way of providing
information, raising awareness or even facilitating links toward a particular
Health behavior or treatment service.
Self-Efficacy: This refers to confidence in one's ability to actually perform a particular Health
action.
As presented above, HBM not onlyaccounts for the pathway to the utilization ofTOSP treatment
vis-a-vis the roles of significant others, but further explains the continued patronage of
·practitioners despite the massive advances in western orthopaedic practice. Due to the attribution
of orthopaedic problems to spiritual causes (Owumi et al 2013), the theory argues that patients'
perceived severity of orthopaedic' conditions is very high. Hence their belief that only TOSPs
6
possess effective approaches (such as use of sacrifice, incantations and other spiritual regimen)
for addressing their problem holistically. Such perceived efficacy influences significant others'
"decision making processes and eventual choice of TOSPs treatment over its western
counterpart.Significant others also believe that perceived barriers such as cost, distance and
bureaucratic bottlenecks which characterise the hospital are absent in rasps settings. Thesedo
not only enhance their perceived benefits with regards to the utilization of practitioner services,
but further prornetes their cue to action by activating readiness and making them harness relevant
social relationships to facilitate contact with practitioners (Onyemaechi, 2014). Thus, the
preference for, and persistent utilization of traditional orthopaedic treatment can be attributed to
factors such as lack of access to modem orthopaedic services in terms of cost, proximity and
availability which constitute 'perceived barriers' and naturally makes patients or resort to
TOSPs. Patients' and more importantly, significant others' assessment of and belief in the
efficacy of practitioners' treatment constitute 'perceived benefits' which motivates their
utilization of TOSP~ .services, Thus, TOSPs play huge roles in the provision of orthopaedic
services especially in developing countries in spite of civilization and existence of modem
healthcare services (Dada et al, 2011') and this partly explains their persistent utilization.
Although misconceptions about the aetiology of health problems which patients often attribute to
spiritual factors has led to low acceptance of modem orthopaedic services, HBM argues that the
utilization of TOSP is due to patients' perception of their situation and the belief that
"practitioners offer the most effective treatment.
METHODOLOGY
The location for this study, was Ilorin in Kwara state, North-central Nigeria. Communities
where TOSP resided and offered orthopaedic services were both urban and semi-urban in nature.
This included Okelele, Odota, Oko-olowo, Ganmo, Oja-Gboro, Adangba, Sango, Oke-Ose,
Jimba-Oja, Aboto, Ote, Afon and Alore areas. Although the number of TOSP that existed in
these communities was not well documented due to lack of proper record by the relevant
government agencies, it is widely known that traditional orthopaedic service is well utilized in
the area (Aderibigbeet al, 2013). Both quantitative and qualitative, methods were adopted in the
study.
Multi-stage sampling technique was used to select participants (orthopaedic patients)
from the study area. In the first stage, all' the four (4) LGAs (Ilorin west, Ilorin East, Ilorin South
and Asa) constituting "norin in Kwara state were purposively selected since they compose the
study area. In the second stage, snow-balling method was used to identify 18 TOSPclinicsacross
the study area while the third stage involved the selection of respondents from each of the clinics
based on their relative size. Finally, simple random sampling was used to select respondents
from each location.
Quantitative data was collected using ques~ionnaire, while qualitative data was collected
using in-depth Interviews and observation. A total of 357 questionnaires were administered on
7
patients who were selected using Lemeshow· and Lwanga's (1991) formula for determining
sample size in descriptive health studies. This is presented below:
~ [PO ~ P)]
n=Z·--E-·-
Where: n= sample size
z= standard normal score corresponding to 95% confidence level=1.96
P= the es!imated proportion of the factor to be studied (or P= the prevalence rate of
Medical research studies) assumed 50%
E= Sampling error that can be tolerated 5% or 0.05
The questionnaires were distributed across the TOSP centres based on their relative size.
The qualitative data involved 14 IDls that were conducted with practitioners aged 40 years and
above, and 7 IDIs that were conducted with patients who had received traditional orthopaedic
treatment for a periodnot less than two months.The researcher believed that practitioners and
patients who met above criteria would have garnered indepth experiences relevant to the
objectives of the research. Quantitative data were analysed at the Univariate and bivariate levels
using SPSS and findings were presented using frequencies. For the qualitative data, IDI
responses were content-analysed. In recognition and adherence to ethical considerations for the
research, participants' consent were sought and permitted to withdraw their participation
allowed. Respondents' privacy was respected and confidentiality ensured as no information was
traced to any respondents .
.-
8
FINDINGS
Socio-Demographic ·_Chflracteristics of Respondents
Table 1. shows the socio-demographic characteristics. It is reveals that most (73.1%) of
patients fell within the socially active groups of the population, a time when they were agile and
geographically mobile; were males (74.5%) who unlike their female counterparts have
instrumental gender roles, and single (58.8%), which also makes them geographically mobile.
Table 1: Socio-demographic Characteristics of patients (N=357)
Variables Categories FREQUENCY PERCENTAGE
~
Age 20years and below 77 21.7
21-30years 98 25.0
31-40years 70 19.7
41-50years 49 13.9
51-60years 20 14.7
61years and above 7 5.2
Sex Male 266 74.5
Female 91 25.5
Ethnic Affiliation Yo.ruba 224 62.7
Rausa 84 23.5
Igbo · 21 5.9Others . 28 7.8
Marital Status Single 196 54.9
Married J47 41.2
. SeparatedlDivorcedlWidowed 14 3.9
Religious Christianity 112 31.4
Affiliation Islam 224 62.7
Traditional/others 21 5.9
Level of Education Non-formal 49 13.8
Primary 35 9.8
~ ISecondary 147 41.2
Tertiary 126 35.3
Residence Urban 189 52.7
Semi-Urban 98 27.5
Rural 70 19.8
Occupation Civil Servant 63 35.3
Business 70 33.3
Farmer 63 19.6
Artisan 77 5.9
Student/ Apprentice/Unemployed 84 5.9
Income below #10,000 126 35.3
#10,001-#50,000 · . 119 33.3
#51,001-#100,000 70 19.6
#100,001-#150,000 21 5.9
Above #150,000 21 5.9
9
.;- Furthermore, only 19.8% of the respondents resided in rural areas compared to urban and
semi-urban areas where there are higher exposures to the leading causes of orthopaedic injuries
such as RTAs. Findings reveled that respondents were involved in some other form of
occupation that predisposed them to physical dangers, accidents and other hazards that led to
occurrence of their injury, yet most of them belonged to low income groups. Similar to the
findings by Owumi .et at (2013), these imply that majority of the patients possessed socio-
demographic characteristics that exposes them to the causes .of orthopaedic injuries, whereas
they had low incomes, which affects their capacity to access modem orthopaedic service. Thus,
there is a social class dimension to vulnerability as well as ability to cope with orthopaedic
mjunes,
SIGNIFICANT OTHERS AND THE UTILIZATION OF TRADITIONAL
ORTHOPAEDIC SERVICES
Participants revealed that they experienced a feeling of helplessness and were sometimes
unconscious at the time of the accident. They therefore relied on humanitarian assistance and
support of significant others such as 'good-samaritans', or family members (depending on where
such injury occurred). For injuries that occurred around victim's residence, family members and
friends constituted the bulk of rescuers and exerted high influence in determining the first point
of call in seeking help, .as well as subsequent pathway to patients' utilization of care. In any case,
patients had little or no say in the decision about their choice of care until their conditions were
relatively stabilized. Factors such as nature an,d severity of injury as well as nearness of health
facilities to the location/site of injury were taken into account in determining the first point of
call for treatment. Injuries that involved open wounds leading to enormous loss of blood and
those that involved serious internal injury or rendered patients unconscious were first presented
to the modem hospital. This was because of the perception that western medicine is highly
effective in stabilizing such patients. However, injuries that occurred in urban areas were more
likely to have higher geographical access (proximity) to western health facilities than those that
occurred in rural areas. This is because of the relatively higher presence of public and private
e
hospitals in the former than the latter.
Findings revealed that 27.4% of patients had hospital as their first point of call, while the
larger majority went straight to the TOSP (see table 2 below). It was further found that patients
who went straight to the hospital in the first instance presented did so either because their
condition needed to be first stabilised or because they were victims of highway accidents rescued
by 'good Samaritans' who decided that the best place to seek first aid and temporary abode
pending the arrival of victim's kith and kin was the hospital. A respondent who is resident in the
study area but went for trading in another state where her injury occurred shared experience:
... I was unconscious ... and was rushed to the hospital where I
received first aid before ~y, people came the next day •.•my
husband then decided that I should be moved to Ilorin where we
live, so that I can receive adequate care from my family members,
since I·don't have anybody in Oshogbo and it will be difficult to be
10
corning to see me there from Ilorin. (Female
patient/50NorubalIDI/ Ilorin West LGAI September 16, 2014) .
.
This confirmed the report by Onyemaechiet al (2014) that the opinion of relatives and
friends is an important factor in many African societies because of the existing social system.
The communal lifestyle often required that relatives and friends contributed to defraying the cost
of treatment as well as suggesting where treatment for ailments and injuries may be sought. This
decision process was however influenced by social factors which determined the nature and
extent of information available to patients and their family members regarding alternative
sources of care based on the relative advantage of one traditional over modem sources of care.
Table 2 shows the rationale behind patients' presenting at modem hospitals before the going to
the traditional orthopaedic centre.
TABLE 2: Rationale for presenting orthopaedic cases to hospital before TOSP
(N=357)
Reasons for going to Frequency Percentage
hospital
Nearness of hospital 71 27.4
Rushed to hospital by
rescuers .. 59 22.7
Unconscious 51 19.7
Loss of blood . 32 12.4
Unaware of TOSP 46 17.7
competence
(Source: Survey, 2014)
As presented in table 2, nearness of hospital which was patients' leading reason for
presenting in the hospital can be understood from the viewpoint that majority of the patients
resided in urban and semi-urban areas where the injuries were likely to have occurred. Such
areas are also likely to have more h,ospitals than the rural areas. Fu.rthermore, modem hospitals
are likely to have better publicity (such as sign posts which shows direction for easy location of
the hospital) than TOSP centres. This had implications for the awareness ofTOSP's service as an
alternative under such emergency situations. Patients (22.7%)who consulted the hospital first
related that they were rushed there due to the intervention of eye witnesses of the incidence that
led to the injury, as well as law enforcement agents such as Police and Road safety Officials.
These constituted the bulk of rescuers especially where the kith and kin of the victim were
nowhere in sight. These 'good Samaritans' who were responsible for taking patients to the
hospital did so out of humanitarian concerns. They played further roles by informing the families
and friends of the patients about the incidence. Apart from the extent of severity which might
have been perceived as requiring western ·tre~tment, another factor considered by such rescuers
was the fact that modem hospitals had better legal backing than TOSP's clinic and therefore
11
should be the first point of call so as to avoid unnecessary litigations afterwards. This is more so
when the patient was unconscious as was the case with 19.7% of patients who utilized hospital
services first because they (modern hospitals) were perceived to be the best place to resuscitate
and stabilize patients especially those in critical conditions. Therefore, patients harnessed their
social relationships to identify possible alternatives, which they eventually found in TOSP. Apart
from high treatment cost, western treatmen.t further subject patients to surgical terror in the long
run.
The availability of blood banks and safer blood transfusion schemes enabled patients who
had lost blood to be easily stabilised in the hospital. This was another reason why some (12.4%)
patients presented first to the hospital. Compared to the modem hospital, TOSP did not have the
capacity to transfuse blood, and even when they did, it was done under very risky conditions.
This general awareness might have accounted for why patients who had lost blood were first
taken to the hospital by rescuers and not TOSP centres. The widespread emphasis by modern
medical practition-ers about TOSP's treatment failures tend to undermine the credibility of
TOSP's treatment especially among the majority of the highly educated orthopaedic patients
(17.7%) who among other patients attributed their presenting at the hospital to the fact that they
were unaware ofTOSP's competence when their injury occurred. However, majority of patients
who had presented to modern hospitals opted out due to various disadvantages of the hospital
. which were absent in traditional orthopaedic practice and therefore accounted for preference for
TOSP. Thus, significant others,· especially patients' family members, friends, neighbours,
colleagues and members ofTOSP's ethnic group exerted enormous influences on the withdrawal
of patients from the hospital. Such factors played further roles in facilitating contact between
practitioners and patients. Table 3 presents !he various links though which patients and their
significant others established contact with practitioners.
TABLE 3: Links th~ough which patients established contact ,:ith TOSP (N=357)
Links to contact with TOSP Frequency Percentage
Family 147 43.2
TOSP former patients 126 35.4
Friends 49,~ 13.0
Members of practitioners'
ethnic group 35 8.0
(Source: Survey, 2014)
From Table 3, it can be observed that contact between orthopaedic patients and TOSP was
. mediated by family members (43.2%) followed by former patients (35.4%), Patients' friends
(13.0%), and people from the practitioners' ethnic group (8.0%).This contradicts the report by
Ogunlusiet al (2006) that contact between patients and TOSP is often mediated by middle men
who facilitate such links for a fee. On t~e contrary, contact between patients and TOSP was
mediated free of charge by significant others. As a result of patients' incapacitation, their
12
immediate family and friends not only harnessed existing social relationships but further enacted
newer ones, weighing the costs against the benefits of modem orthopaedic care and TOSP in a
- rational decision process. This probably accounted for why former TOSP's patients (35.4%) who
may not be primarily part of patients' significant others later played major roles in linking new
patients with practitioners. Hence, the quantity and quality of social network determined the
extent of social capita.l. and economic/coping resources that are available to patients, which
enormously influence decisions about their choice of health care (Berkman and Breslow, 1983).
One respondent narrated how she got to loeate the TOSP:
...my husband contacted one of his co-workers who once had bone
fracture. It was that man that introduced us to this place ...his two
legs ~ere broken but after receiving treatment in t?is place for two
months, he started using crutches and four months later, he started
walking by himself. Today, if you see him walking, you will not
know that he once had a serious fracture ...and there are different
cases like that. 'Erilopinariyanjiyan' (evidence is the end of
argument). (Female' patientlY oruba/29/IDII university graduate/
Ilorin west LGAI September 19, 2014).
Due to high perceived severity, the choice of TOSP was one that involved serious rationalization
by significant others who often considered patients' interest in decision making. The attitude that
- significant others have towards traditional orthopaedic service is very important. If the people
who linked patients with TOSP did not have a positive attitude towards the practice, they would
not have encouraged or facilitated the contact in. the first place. However, people in African
societies generally fav.o.ur the practice of bone settingwhich accounted for their preference for
TOSP as an indigenous practice,over modem orthopaedic practice (Aderibigbeet al, 2013). This
can however be attributed to the fact that societal members have been socialized into having
positive attitude towards traditional orthopaedic practice, since it is viewed as part of their
culture, an ethno-medicine for orthopaedic injury.
Furthermore, bone setting clinics were community-based and operated in a home-like natural
environment, unlike the modem hospital that is run as a total institution. Traditional orthopaedic
service is therefore more patient-friendly as patients, practitioners and host community interacted
in a very cordial manner (Researcher's observation, 2014). This might be due to the absence of
strict rules and infermal principles 'in traditional orthopaedic service. There was also free access
to in-patients by their family members, friends and significant others who played major roles in
introducing patients to practitioners. Infact, significant others who linked patients with their
healers often mediated the interaction between the two parties especially on sensitive issues such
. as having to do with spiritual treatment challenges as well as monetary matters.
'!.I'
13
REFERRAL PRACTICES IN THE UTILIZATION OF TRADITIONAL
ORTHOPAEDIC SERVICES
The referral practices associated with the utilization of traditional orthopaedic services were
mostly voluntary in nature. In many cases, patients opted out of the hospital to utilize
practitioners' treatment. This was due toa number-of attributes of traditiorial orthopaedic service
including affordability, easy accessibility, non-surgical healing methods, and spiritual dimension
to healing and cultural acceptance all of which were advantages (benefits) which the practice was
perceived to possess over the modem hospital. These factors greatly influenced the decision
making process of patients and their significant others towards the utilization of traditional
orthopaedic service. Many of the patients who had been rushed to the hospital voluntarily opted
out to utilize traditional orthopaedic service. The response of one former TOSP's patient who
had come for check-up corroborated this:
.. .1 was admitted at the teaching hospital and after spending two
months, the doctors said my leg had 'died' and that they will have
to cut it, so that it does not affect other parts of my body. It was at
this stage that my ,family began to look for alternative when
somebody advised us to come here. I didn't spend up to 6 months
here before I was discharged and today, I have even stopped using
crutches. (Male patientlY oruba/42/IDII Asa LGAI September 19,
2014).
TABLE 4: Patients' perception of the need for referral by TOSP (N=357)
Opinion on referral Frequency Percentage
Patients who believed some cases be referred to the hospital 126 35.3
Patients who believed TOSP should handle all cases 217 60.8
0
I don't know . 14 3.9
(Source: Survey, 2014)
From Table 4 above, majority (60.8%) of the patients believed jhat practitioners needed not to
refer any orthopaedic case to the modem hospital, regardless of haw severe the case might be.
Such patients believed that orthopaedicconditions can never get beyond the capacity of
practitioners since the practice predated modem medicine in the first place, and has accumulated
experiences over time. Hence, there was no need for referral from TOSP to modem hospital, but
VIce-versa. Qualitative data however suggested otherwise. Some respondents believed that
whenever orthopaedic injuries like those emanating from road traffic accident rendered victims
unconscious due to shock, internal injury or loss of blood, the modem hospital was the best place
. where patients can be resuscitated and stabilized before further treatments by traditional
; orthopaedic practitioners. A TOSP's patient who voluntarily withdrew from the hospital
expressed his view as thus:
14
·..The Alaanu (good samaritans) who came to the accident scene
promptly rushed me to the hospital where I was stabilised. I
shuttled between different hospitals for 7months ... I was treated of
the wounds and internal injury ...but I opted out of the hospital
when I was not getting the improvement that I expected in my
broken arm.(Male Patient/52years/IDII Asa LGA/ September 23,
2014).
As expressed above, the view that hospitals were better at stabilizing patients, managing sores
and internal injury was shared by majority o.f the patients. This is because complex fractures-
which involved sore and open wound increases the possibility of infections (Dada et ai, 2011),
hence the need for more competent hands in their management such as obtain under the modem
methods. This belief. was based on patients' understanding that TOSP did not have adequate
training in the dynamics of open wounds/ulcers given the high risk of infection associated with
it. Hence, their in-patients also practiced self-medication through the use of western medicines
(antibiotics, blood tonic, analgesic, water disinfectant and antiseptic soaps) which they purchased
from vendors, as a guide against infection and complication (Researcher's Observation, 2014).
e
Practitioners themselves believed that they possessed the capacity to address both physical and
. spiritual factors that affect the cause, course and consequent outcomes of orthopaedic injuries.
This included the use of 'ojuinu' (insight), herbal concoctions, ointment, medicinal powders as
well as incantations and other spiritual resources 'utilized in the diagnosis and treatment of
orthopaedic injuries. They argued that most, if hot all of these are non-existent in western
practice, which they believed makes traditional practice superior to its modem counterpart. The
opinion of one practitio-ne.r is captured below:
There are some things that. we do that doctors cannot do. A good
example is the treatment of spinal and neck fracture which we treat
easily but doctors cannot. In February last year (2013), a former
patient of mine introduced me to some people whose friend
sustaihed a neck fracture in China. He had spent close to one year
in the hospital with no improvement. It was when I got there that
he began to see changes, and he is now perfectly okay. Even
recently, I treated a white man here ... (Male TOSP N oruba/32/IDII
Ilorin west LGAI September 16,2014)
Another practitioner believed that TOSP are the best experts in orthopaedic injuries just the
same way that modem practitioners provide the best treatment for diseases. In his view:
... the body is naturally created by God, and the medicines that we
(TOSP) use for treating injuries are also sourced from nature (as
revealed by God), not from any man-made chemical.. .. Hospital
treatments often result in complications due to P.O.P and the iron
15
that they normally put inside broken bone (implant), and which
makes the treatment'unnatural. (Male TOSP Noruba/38/IDII Ilorin
South LGAI September 16,2014).
However, practitioners recognized that some modern methods can be very useful in the treatment
of complex orthopaedic injuries such as those involving open wound, loss of blood or requiring
surgical suturing. Hence, they favoured the combination of both methods in the management of
such injuries. This is supportive of WHO's vision of integrating traditional with modern
hea1thcare systems which has proven in countries like china. However, they noted that modern
practitioners showed po- o- r disposition towards them and as well as their practice. This has serious
implications for cooperation and referral between modern and traditional orthopaedic systems.
According to one TOSP:
Doctors know that we treat bones better than they do ...because I
have personally treated 2 or 3 medical doctors. However, many of
them look at us as Animals who don't know what they are doing.
They are hostile towards us ...especially those in government
hospitals. I often have open confrontation with them whenever
relatives of an admitted patient invite me to work while the patient
is still on hospital admission ...but a particular private hospital
actually hires me to treat any orthopaedic case presented to them ....
while I also send some of my patients to see them whenever there
is need (Male TOSP /32Noruba/IDII Ilorin West LGAI September
16,2014).
As a result of this, majority of the practitioners themselves resorted carrying out minor surgeries
and other western procedures including wound dressing. Fig 1 shows a TOSP dressing a
patient's wound using w- -estern materials.
16
FIG 1: Practitioner dressing a patient's wound using modern medicinal substances
(Hand gloves, cotton wool, Gentian Violet and procaine penicillin powder and
hydrogen peroxide)
Practitioners also engaged the services of auxiliary nurses (popularly called 'doctors') who
performed treatment procedures such as surgical suturing, blood transfusion, anesthesia
administration, wound dressing and prescription of drugs. Fig 2 shows an Auxiliary nurse
(standing) wool during a clinic session.
FIG 2: Practitioners, patients and an Auxiliary Nurse (standing) during a clinic
session
With the auxiliary nurse meeting most of practitioners' needs with regard to complementary
modem procedures, it was believed that no need arose for the referral of patients to modem
hospitals except on patients' own voluntary decisions which according to practitioners, was a
very rare occurrence: However, the quality of intervention provided by the auxiliary nurses is
questionable. This is because, by virtue of their training, auxiliary nurses are too ill-equipped to
provide competent interventions in such sensitive health problems as orthopaedic injuries .
. Hence, their services are likely to be ridden with high level of malpractice which is worsened by
the unhygienic conditions under which traditional orthopaedic services are provided. This
probably contributes to the complications attributed to traditional orthopaedic service by the
modem practitioners (Dada eta ai, 2011, Aderibigbeet al, 2013 and Onyemaechi et ai, 2014).
17
TABLE 5: Respondents' place of Residence and whether they still went to the Hospital in
addition to TOSPs' treatment.
Place of Residence Do you still go to the hospital in addition toTOSP's Total
0 (%)
YES (%) NO(%)
URBAN 71.4 50.0 52.9
SEMI URBAN 14.3 29.5 27.5
RURAL 14.3 20.5 19.6
..
TOTAL 13.7 86.3 100.0
0
.
N=357; Pearson Chi-Square=1.562; Df=2; Significant level =0.05; P-Value=0.562
_Table 5 shows the relationship between respondents' place of residence (urban, semi-urban and
rural) and whether they still attended modem hospitals in 'addition to seeking TOSP's
treatment.With P-Value (0.562) greater than 0.05 level of significance,the table implies that
majority of the patients (86.3%) still did not go to the hospital. This shows that although modem
hospital services are likely to be more accessible in the urban and semi-urban areas, it did not
determine whether a patient will go to the hospital or not. If there is the need for a patient to seek
western treatment, he will do all that is within his power to do so, even if it means travelling over
many kilometres from the rural area where the patient resides or receives TOSPs' treatment to
wherever hospital can be located. Similarly, a patient that resides or receives TOSPs' treatment
in an urban area may not utilize modem hospital in addition to TOSP treatment if he does not see
the need to do so; regardless of whether or not the hospital is just behind his/her place of
residence. Patient's perceived efficacy ofTOSP's treatment which is very high may account for
why majority of respondents did not go to modem hospitals in addition to TOSPs' treatment.
Furthermore, the role of patent medicine sellers and auxiliary nurses who were popularly referred
to as 'doctors' by patients went a long way in bringing the 'modem hospital' to the TOSPs'
clinic. Table 6 below shows the test of relationship between Respondents' religious affiliation
and whether their religious beliefs encouraged the utilization of TOSP.
,
TABLE 6: Test of relationship between respondents' religious affiliation and whether their
religious belief encouraged the utilization of TOSP's treatment.
18
Religious Affliation My religious affiliation encourage the utilization of Total
TOSP's treatment
(%)
Yes (%) No(%)
Christianity . 25.6 71.4 3.2
Islam 69.8 14.3 62
Traditional 2.3 14.3 4.0
Others 2.3 0.0 2.0
Total 86.0 14.0 100.0..
N=357; Pearson Chi-Square=P.Zfi; Df=3; Slpmficant level =0.05; P-Value=0.26
As can be observed, majority (86.0%)of the respondents believed that their religious affiliation
'. encouraged the utilization of TOSP. The P-Value of 0.26 which is greater than 0.05 level of
significance implies that there is no significant relationship between respondents' religious
affiliation and the belief that their religious affiliation encouraged them to utilize TOSP. This
means that Respondents' religions affirmed the adequacy as well as propriety of TOSP in the
treatment of orthopaedic injuries. This can be attributed to thebeliefby practitioners and patients
that traditional medicine generally and bone setting in particular are divinely established by God
for the purpose of resolving infirmities such as orthopaedic injuries that may arise in the course
of life. In line with the biblical verse: 'I am the Lord that healeth thee' (Exodus 15:26), it is
generally believed that God himself is a healer who carries out his healing through human
instruments such as the bone setters. This is why most respondents who were adherents of one
religion or the other agreed that their religious affiliation encouraged the utilization ofTOSP.
CONCLUSION
Traditional orthopaedic .s.ervice plays a huge role in the delivery of orthopaedic services in,
developing countries like Nigeria. This is because people believed that the practice produces
better outcomes than its modern counterpart, hence the persistent utilization of the former.
However, significant others played major roles in the utilization of traditional orthopaedic
service by orthopaedic patients. Since patients were usually incapacitated, the role of significant
others began right from the onset of the injury and spans throughout its course. Apart from the
immediate actors who usually ensure the initial first aid, patient's family members, social
relations and friends are significant others who decided on the choice of care. However, they
often enlisted newer actors into the network in their bid to mobilize social and economic
resources for patients' treatment. Practitioners' former patients and members of their ethnic
group who may not- constitute significant others initially were some of the leading actors that
were enlisted. As established by HBM, the utilization of traditional orthopaedic service can be
19
explained from based on perception of patients condition and belief about the potential benefits
of TOSP's treatment which spurred significant others to action. However, the strategic situation
of TOSPs in providing orthopaedic services to patients should be optimized through intensified
support and training by government and various health care institutions, as well as better
disposition by modem practitioners towards the integration project as had been advocated for by
WHO.
RECOMMENDATION
1. The study recommends that better education and enlightenment be carried out regarding
health-seeking behaviour and healthcare delivery generally in developing countries. This
will aid informed decision-making by members of society who are often part ofpatients'
significant others, whose inputs could be needed in the rational process of choosing
source of health care.
2. Given the dearth of personnel in the health sector of most developing countries, there is
the need to enhance capacity building for traditional medical practitioners and auxiliary
nurses who are providing the deficit manpower especially at the level of primary care.
3. Modem medical institutions and practitioners should show more disposition and
acceptance towards their traditional counterparts who on their part are willing to adopt
modem innovation in their diagnosis and treatment. This will not only improve referral
practices, reduce complications and mortality due to treatment failure but also provide
Proper Avenue for quality orthopaedic care to the people through the traditional
practitioners who are more culturally acceptable.
20
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