The experiences of adult patients receiving treatment for femoral shaft fractures at Kamuzu Central Hospital, Malawi: a qualitative analysis

Abstract

Background: There is a growing burden of musculoskeletal trauma in Malawi, and a lack of surgical capacity to manage common, debilitating injuries like femoral shaft fractures (FSFs). Non-operative treatment with skeletal traction remains the standard of care, with surgery available only at central hospitals. Patients experience myriad barriers to care, which can result in delayed treatment and complications. We sought to understand how patients navigate the Malawian health system and the barriers they face while seeking care. Methods: We performed in-depth, semi-structured interviews of 15 adults with closed FSFs during their inpatient hospitalization at Kamuzu Central Hospital (KCH), a public referral hospital in Lilongwe, Malawi. We additionally interviewed one patient who left KCH to seek care at a private hospital. An English-speaking study investigator performed all interviews accompanied by a Chichewa-speaking medical interpreter. Interviews focused on patients’ pathways from injury to present treatment (health system navigation); impressions of the hospital and care received; and the effects of injury/treatment on patients and their families. Interviews were audio-recorded, translated, and transcribed in English. We coded the transcripts and performed a thematic analysis. Results: We identified 6 themes: high variability in health system navigation; frustrations with the biopsychosocial effects of hospitalization; lack of participation in decision-making and uncertainty about treatment course; preference for surgery (vs. traction) based on patients’ own experiences and observations; frustrations with the inequitable provision of surgery ; and patients’ resignation, acceptance, and resilience in the face of hardship. Many patients receiving non-operative treatment described the devastating financial burden imposed upon them and their families by their injury and prolonged hospitalization. They felt they were receiving inferior treatment compared to surgery and suspected that richer patients were receiving more timely care. Conclusion: This qualitative study suggests a need to standardize care for FSF in Malawi, increase availability and timeliness of surgery, and increase transparency and communication between providers and patients. These remedies should focus on improving quality of care and achieving equity in access to care.

The Socioeconomic consequences of femoral shaft fracture for patients in Malawi

“…In some instances, patients were forced to unenroll schoolaged children from school. Agarwal-Harding et al similarly found that patients with femoral shaft fracture in Malawi face numerous social and financial challenges following injury 16 . This is consistent with previous studies demonstrating the potential multigenerational repercussions of trauma that can push patients into vicious cycles of poverty and hardship 6 .…”

“…While the gold standard treatment of femoral shaft fracture worldwide is surgical fixation with an intramedullary nail, this treatment is only feasible in Malawian CHs, where https://dx.doi.org/10.4314/mmj.v35i3.2 inadequate supply of implants, limited operating theatre (OT) time, lack of anesthesia staff, and insufficient surgical staff can limit its availability to all patients. Due to a lack of surgeons, inadequate surgical infrastructure, and limited resources, many femoral shaft fractures in Malawi are treated nonoperatively with skeletal traction, requiring prolonged hospitalization 5,11,16,17 . Unfortunately, no district or central hospital in Malawi has the minimum required resources to safely treat femoral shaft fractures and all hospitals reported some barriers to providing skeletal traction as a result of resource, staffing, and infrastructure limitations 5 .…”

“…Unfortunately, no district or central hospital in Malawi has the minimum required resources to safely treat femoral shaft fractures and all hospitals reported some barriers to providing skeletal traction as a result of resource, staffing, and infrastructure limitations 5 . Inadequate treatment results in poor outcomes, high complication rates, long-term disability, and patient frustration with the quality of care 11,14,16,18 . This imposes considerable functional, biopsychosocial, and economic challenges upon patients with femoral shaft fractures.…”