The Persistent Preference for Traditional Bonesetting in Ethiopia: Risk Factors and Missed Opportunities.

Introduction: Many patients in Ethiopia prefer traditional bonesetting (TBS) over formal health services for musculoskeletal injuries, despite well-documented complications. We analyzed risk factors for initial and persistent TBS preference among patients who patronized TBS and subsequently presented to a tertiary hospital for definitive treatment. Methods: Over 15 months, we prospectively enrolled patients with musculoskeletal injuries who presented to 8 Ethiopian tertiary hospitals after patronizing TBS for the same injury. Multivariable regression evaluated associations between TBS preference and covariates including demographics, injury characteristics, reasons for seeking TBS, and hospitalization outcomes. Results: We enrolled 1,243 patients (mean age 27 ± 18.4 years; 67.6% male). Elbow (307, 24.7%) and leg/ankle/foot (245, 19.7%) injuries were most common; 978 (78.7%) were closed fractures/dislocations. At study enrollment, 1,003 (80.7%) patients had complications, most commonly stiffness/contracture (671, 54.0%) and malunion (346, 27.8%). Prolonged hospitalization (>7 days) occurred for 223 (17.9%) patients; 37 (3.0%) underwent amputation. TBS was initially preferred after injury by 808 (65.0%) patients, although 298 (24.0%) visited a health facility before TBS. Initial TBS preference was lower among patients with formal education (primary school: adjusted odds ratio [AOR] 0.64, [95% confidence interval [CI]: 0.41-0.99]; secondary school or above: AOR 0.56 [0.36-0.87]) and open fractures (AOR 0.41 [0.22-0.77]). For future injuries, 455 (36.6%) patients/guardians preferred TBS over health facility-based care. Controlling for initial TBS preference, future preference was associated with poverty (AOR 1.66, 95% CI 1.10-2.49, p = 0.015) and visiting a health facility before TBS (AOR 2.04, 95% CI 1.34-3.10, p < 0.001). Neither prolonged hospitalization (p = 0.734) nor amputation (p = 0.946) influenced future preference. Conclusion: More than one-third of patients preferred TBS for future injuries. Among patients in poverty, persistent TBS preference after reaching a tertiary hospital may reflect entrenched structural barriers to formal orthopaedic care. Initial health facility visits before TBS were associated with greater future TBS preference even after definitive hospital care, suggesting missed opportunities to build trust in formal care. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.