Giving the rising number of musculoskeletal injuries in Sudan, and the continued use of traditional bone setters (TBS) even though modern orthopedic care is available, it is important to understand why many patients use both systems. This study helps explain how cultural beliefs and treatment outcomes are connected, and gives insight into why people rely on both traditional and modern healthcare.

This study shows that traditional healing in White Nile State, Sudan, can play both a complement and barrier role in modern orthopedic care. Many patients, especially those in rural areas, prefer traditional methods like massage and splinting because they are cheaper, easier to reach, and match their cultural beliefs (Table 1). These methods are often used as the first treatment for bone and joint problems. While some patients felt they were helpful, many experienced complications like poor healing or delays, which later led them to seek hospital treatment (Table 2). This means traditional healing can support modern care if used early and safely, but it can also be a problem when it causes delays in proper medical treatment.

In our study, it was obvious that demographic factors like age, gender, education level, residency, and occupation were not strongly linked to whether people used traditional healers. This result is different from some international studies that found higher use of traditional medicine among women or people with lower education ⁽⁷⁾. However, it supports other research showing that cultural beliefs and social traditions often have a stronger impact on healthcare choices than income or education level, especially in low- and middle-income countries (LMICs) ⁽⁸⁾. The higher number of male (71.1%) and rural (60.0%) participants who used traditional healing in our study (Table 4) matches a common pattern in the region, where these practices remain common regardless of background ⁽⁹⁾.

Although we didn’t find a big difference between rural and urban participants, studies from other areas like West Africa show more use of traditional healing in rural communities, likely because modern healthcare is harder to access. In our study, most participants said they turned to traditional healers because of cultural trust and spiritual beliefs (Table 2). This is different from findings in where people often choose traditional bone-setting because they believe it leads to faster recovery ⁽¹⁰⁾.

We also found no strong link between patient backgrounds and the perceived effectiveness of the traditional healers (Table 3). This supports other studies in LMICs, showing that people rely on traditional healing mainly because of belief and trust, not their age, income, or education ⁽¹¹⁾.

Modern orthopedic treatment was rated as “very effective” by 59.9% of participants, which is similar to findings in other countries that show success with surgical and evidence-based treatments. However, some patients were not fully satisfied—25.1% said it was “somewhat effective” and 6.8% said it was “not effective” (Table 4). This matches reports from LMICs where long waiting times, high costs, and lack of personal care make people less satisfied. In Sudan as seen in Ghana these challenges often lead patients to try traditional care first, only going to hospitals after problems appear (^{12, 13}).

Satisfaction with traditional bone setters (TBS) remains high in Sudan, despite that traditional medicine users in our study reporting inefficacy by 40%. Similar studies in Turkey show over 70% satisfaction, often because the care feels more personal, familiar, and spiritually meaningful. In Nigeria, 85% of people with fractures first visit a TBS, leading to many avoidable problems when they finally go to the hospital. This same trend appears in Sudan and shows the need to reduce risks (^{14, 15}).

We also found that fractures (45.6%) and arthritis (23.1%) were the most common conditions among participants (Table 2), reflecting a high burden of musculoskeletal diseases. This is similar to patterns across Africa, where older people face more fragility fractures and younger people suffer trauma-related injuries, especially from road traffic accidents ⁽¹⁶⁾. About 30.6% of our participants used traditional healing—mostly massage or splinting (91.1%)—while all participants also used modern orthopedic care (Table 1). This shows a clear dual reliance on both systems, which is common in many African countries ⁽¹⁷⁾. In Sudan, this is made worse by shortages of healthcare workers, unequal access to services, and the high cost or low quality of modern care.

One of the main issues found in this study is the poor connection between traditional healers and orthopedic doctors. None of the four doctors had worked with traditional healers and said that cultural differences (25.0%), different ways of treating patients (50.0%), and poor communication (25.0%) were the main reasons (Table 6). On the other hand, most of the traditional healers (85.7%) were open to working together, through better communication and shared training (Table 5), which is similar to what has been seen in other low- and middle-income countries ⁽¹⁸⁾. Doctors were more cautious because they were concerned about patient safety, lack of clear rules, and the use of methods not based on science ⁽¹⁹⁾. Still, the willingness of traditional healers to cooperate—like in successful programs in Burkina Faso and Mozambique—shows that working together is possible. Many traditional healers said that for good teamwork to happen, there needs to be mutual respect, proper training, and a clear system for referring patients ⁽²⁰⁾. If these steps are taken, traditional healing could be safely included to help improve orthopedic care in Sudan.