Acceptability, appropriateness, and feasibility of a point-of-care ultrasound program for the diagnosis of forearm fractures in rural Nepal: a mid-level provider qualitative study

In Nepal, fractures contribute an estimated 2.5 million disability-adjusted life years annually, with upper-extremity injuries representing the most common fracture type. While radiography is the diagnostic standard, access to X-ray machines and trained technicians is limited in rural Nepal, leading to delayed diagnosis and substantial patient costs. Point-of-care ultrasound (POCUS) is a low-cost, portable imaging modality that has demonstrated high sensitivity and specificity for diagnosing upper-extremity fractures and is well suited to resource-limited settings. Seventeen health assistants and auxiliary health workers, together called mid-level providers (MLPs), who attended a two-day ultrasound training program focused on forearm fractures were selected for this study. Participants were selected based on successful completion of the training and continued practice at Bayalpata Hospital. Participants were interviewed with a semistructured guide that assessed their perceptions of the training and their implementation of ultrasound in clinical practice. Thematic analysis was conducted using NVivo. Seventeen MLPs participated, representing a combined 126 years of clinical experience. Five major themes emerged: (1) positive perceptions of the training program, (2) frequent clinical application of fracture POCUS, (3) improved diagnostic confidence and autonomy, (4) barriers, including language and duty-time constraints, and (5) strong support for expansion to additional facilities and anatomic regions. Participants reported reduced reliance on radiography, faster delivery of care, and enthusiasm for further POCUS training. Mid-level providers successfully integrated forearm fracture POCUS into routine clinical practice following ultrasound training. MLPs reported confidence using POCUS for fracture diagnosis after a two-day, hands-on training session. These findings support the acceptability, appropriateness and feasibility of the program and support the expansion of ultrasound training in rural Nepal, particularly in areas lacking X-ray access.