Duurzame ontwikkelingshulp in ruraal Tanzania

J.J. Binnerts, T.C.C. Hendriks, M.J. Meijer, J. Okoth, N.W. Harun, P.S. Teyha, G. Njambilo, I.L. Akaro, B.R. Mkinze, E. Staal, M. Botman, N. Bempong-Ahun, G. Ibbotson, W. Harrison, C. Martin Jr., E. Hermans, M.J.R. Edwards & B.M. Chirangi. https://doi.org/10.1002/wjs.12503 

Binnerts, J.J., Hendriks, T.C.C., Hussein, S., Bempong-Ahun, N., Ibbotson, G.C., Harrison, W.J., Martin, C., Ranganathan, K., Ehsan, A.N., Chirangi, B.M., Edwards, M.J.R. and Hermans, E. https://doi.org/10.1002/wjs.12503

Abstract

Background
Bone fractures in low- and middle-income countries are commonly managed by traditional bonesetters (TBSs). Past studies emphasize the potential for improved fracture care through intersectoral cooperation. This review gauged support among stakeholders for intersectoral collaboration and the results of previous initiatives.

Methods
Five medical databases were reviewed. Studies focusing on stakeholder perspectives and articles detailing collaborative initiatives were included. Data extraction and synthesis were carried out using the Cochrane Consumers and Communication Review Group’s template. Additionally, all studies underwent quality assessment.

Results
Of the 3821 identified articles, 16 were included after full-text screening. Twelve articles presented stakeholder perspectives, whereas four discussed collaborative initiatives. The overall article quality was low: articles on stakeholder perspectives scored on average 1.42 out of 4 points, whereas articles on collaborative initiatives scored a mean 1.25 points. In total, 62% of stakeholders (75% of TBSs, 92% of hospital staff, and 52% of patients) expressed support for intersectoral collaboration. The ratio between stakeholders expressing support versus those opposing was 4.4:1. No articles presented data on governmental perspectives. The most mentioned collaborative forms were TBS training (24% of stakeholders) and an integrative model (16% of stakeholders). Interventional studies all consisted of TBS training, reporting improved clinical outcomes and increased practice integration.

Conclusion
Despite the limited and low-quality evidence on collaboration initiatives and perspectives, most stakeholders seem supportive of intersectoral collaboration, with training and integration being commonly suggested. Future research efforts exploring the feasibility of embedding TBSs into current primary care systems should ensure the involvement of local and national government.

Binnerts, J.J., Hendriks, T.C.C., Okoth, J., Gill-Wiehl, A., Ranganathan, K., Ehsan, A.N., Harun, N.W., Ogoya, S., Bempong-Ahun, N., Ibbotson, G., Harrison, W.J., Martin, C., Jr., Edwards, M.J.R., Hermans, E. and Chirangi, B.M. https://doi.org/10.1002/wjs.12540

Abstract

Background
Limited research exists on the burden of extremity fractures in Sub-Saharan Africa. Underreporting is likely, as patients often seek out traditional bonesetters (TBSs). This study aims to determine the annual incidence and impact of extremity fractures, alongside health-seeking behavior of patients in rural Tanzania.

Methods
We conducted a cross-sectional household survey in Rorya district, Tanzania, enrolling 497 households with 2667 members, using spatial random sampling. We surveyed household heads regarding access to fracture care and fracture occurrence among household members. We then randomly selected up to three members per household to survey, using the 1448 responses to calculate extremity fracture incidence. Any (self-)reported fractures were questioned on healthcare-seeking behavior and assessed through radiological evaluation. Confirmed cases completed a survey on disability and financial impact.

Results
We radiologically confirmed 11 extremity fractures among 1448 randomly selected respondents, yielding an annual incidence of 0.76%. Five additional fractures were identified among nonrandomized individuals totaling 16 confirmed cases. TBS attendance among patients suspecting fracture was significantly higher than hospital attendance (95% vs. 32%, p < 0.0005). Primary reasons for choosing TBSs were lower cost (62%) and perceived faster healing (29%). Sixty-two percent of patients reported reduced work capacity or requiring help with transport and 50% experienced a decrease in income.

Conclusions
The annual incidence of extremity fractures in this study was 0.76%. TBSs were largely preferred over hospitals due to lower cost and perceived faster healing. Over half of patients experienced reduced ability to work and income loss. Improved communication between TBSs and hospitals, along with better access to hospital care, could reduce complications.

Binnerts J.J., Hendriks T.C.C., Buzugbe N., et al. doi:10.1177/00469580251325031

Abstract

Extremity fractures are increasingly common in Sub-Saharan Africa. In many resource-limited settings, patients with fractures have historically sought out traditional bonesetters (TBSs) and continue to do so, in part due to the undercapacity of existing orthopedic facilities. This qualitative study investigates key stakeholder perspectives on intersectoral collaboration between the formal healthcare system and TBSs in treating extremity fractures in the Rorya district, Tanzania. We combined focus group discussions and semi-structured interviews with four key stakeholder groups: patients with previous fractures, TBSs, hospital staff, and local government representatives. Questions concerned stakeholder experience, advantages of TBS and hospital care, perspectives on collaboration, and potential facilitators and/or barriers. Transcripts were analyzed using thematic analysis and inductive coding. Between June 2022 and August 2023, 35 TBSs, 9 patients with previous fractures, 5 hospital staff members, and 2 government representatives were interviewed. Participants unanimously recognized the need for collaboration between TBSs and hospitals. 

Identified barriers included TBSs’ motivation for hospital referral, poor customer care at hospitals, and limited understanding of fracture management in hospitals by TBSs and patients. Implementation of a collaborative triage and referral system was most commonly suggested. This study summarized all relevant perspectives on intersectoral collaboration. A combined approach of a joint triage and referral system, augmented by community education and TBS training, may enhance the quality and accessibility of fracture care and potentially serve as a model for regions facing similar challenges. Further research is needed to evaluate the feasibility and effectiveness of such initiatives in practice.