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

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 identied 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 nancial 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.


Background
The global burden of trauma-related death and disability is high, disproportionately affecting low-and middle-income countries (LMICs). [1][2][3][4] Trauma-related disability can push the poorest patients deeper into poverty due to associated healthcare costs and decreased economic productivity. 5,6 Signi cant injuryrelated disability can be prevented with quality trauma and surgical care. 8,13 However, surgery remains out of reach for many patients, especially in LMICs. 14,15 Malawi is a low-income country in southeastern Africa, with a population of 19 million. 20 Eighty-three percent of people live in rural areas, and half the population lives below the national poverty line. 20,21 Musculoskeletal trauma incidence is high, resulting in many trauma-related admissions at Malawian public hospitals. [22][23][24][25][26] Femoral shaft fractures (FSFs) are increasingly common and are potentially debilitating if not treated appropriately. 22 Approximately one adult with FSF presents to each district hospital -and 4 to each central hospital -every week in Malawi. 27 No public hospital nationwide has the minimum required resources to adequately treat FSF. 28 The public hospital system in Malawi has three tiers: rural health centers, providing basic medical and maternity care only; district hospitals, staffed by general doctors and clinical o cers (non-physician clinicians); and central hospitals staffed by specialists including surgeons. Operative treatment of FSFsthe international gold standard 29 -is performed only in central hospitals. 22 Orthopaedic clinical o cers (OCOs) manage up to 90% of orthopaedic workload nationally, primarily providing non-operative treatment. 20,21 However, 24 of the 25 district hospitals and all four central hospitals in Malawi reported barriers to performing skeletal traction, the non-operative treatment that remains the standard of care in Malawi. 28,30 Patients receiving skeletal traction experience prolonged hospitalization, about 20% experience complications and 9% die in hospital. 31 Patients describe longstanding pain, emotional distress, and signi cant nancial strain for themselves and their families. 32,33 It is unclear how adults with FSFs navigate these myriad challenges. In this qualitative study, we aimed to understand patients' pathways through the Malawian health system to receive care (henceforth termed "health system navigation"), and to examine patients' perceptions of their treatment. We sought to identify barriers that could be addressed to improve accessibility of essential musculoskeletal trauma care.

Study design
We performed semi-structured, in-depth interviews of 16 adults who were receiving treatment for closed FSFs. We previously found that hospitals in Malawi's central region reported fewer patients admitted with FSFs than would be expected based on population size, possibly due to barriers to hospital presentation. 27 In fact, we previously reported that adults presenting for fracture care to Kamuzu Central Hospital (KCH) -the only public referral hospital in the central region -were at an increased risk of late presentation compared to other hospitals in Malawi. This may be due to relatively de cient transportation infrastructure in the central region, perceived poor quality of care or long wait times at KCH, or increased utilization of non-governmental hospitals by patients. 37 Thus, we focused our study on the experiences of patients who had been admitted to KCH.
We interviewed patients 18 years or older; actively receiving inpatient treatment for a closed FSF; and without concomitant head, thoracic, abdominal, spine, or vascular injuries. Fifteen interviews were performed at KCH, and one interview was performed at Beit Cure International Hospital, a private mission hospital in Blantyre, Malawi. Nurses on the orthopaedic wards helped identify individuals who met study inclusion criteria. We purposefully interviewed individuals that captured a diversity of age, gender, socioeconomic status and occupation, rural versus urban living situation, and experience of FSF care in Malawi. 38

Data collection
We conducted semi-structured interviews with an interview guide, ensuring consistency of content while allowing patients to elaborate freely and raise new topics. The interview guide (Appendix 2) was designed by applying topics from the social cognitive theoretical framework including outcome expectation, 39 self and collective e cacy, 40 behavioral capability, 41 observational learning, 42 and incentive motivation. 43 A multidisciplinary team of investigators in the U.S. and Malawi reviewed and re ned the interview guide for clarity and cultural sensitivity prior to beginning the interviews.

Data analysis
The transcribed interviews underwent content analysis, which classi es textual data into themes. 44 First, two investigators (K.J.A.H. and L.A.) performed open readings of a subset of transcripts, iteratively identifying repeated concepts which were captured as codes and organized into a codebook. 45 The codebook was used to code all transcripts using the web application Dedoose (SocioCultural Research Consultants LLC, Los Angeles, CA). At regular intervals, we informally assessed agreement between coders, and reassessed the codebook to ensure it adequately captured newly emerging concepts. 46 An inductive thematic analysis was then performed, where themes were extracted from the coded text. Transcripts were interpreted through iterative cycles of reading and re ection until dominant themes were identi ed. 47 We analyzed each transcript in isolation and in comparison to others to fully appreciate the contextual richness of each patient's response and differences in experience and perception. 48 This allowed us to: 1) compare patients' pathways through the Malawian health system, 2) examine patients' frustrations and perceptions of their injuries and subsequent hospitalizations, and 3) examine patients' treatment preferences and expected outcomes. We used de-identi ed quotations from the transcripts to support themes that emerged.

Participants
Of the 16 patients, 6 were women and 10 were men. Ages ranged from 19 to 85 years. Half of patients lived in rural areas, and half lived in urban areas. The most common occupation was farmer (5 patients), followed by student (3 patients). Seven patients were injured following a fall; nine following a road tra c collision. Four were receiving skeletal traction, where a metal pin had been inserted through the proximal tibia, weight was attached to the pin with a cord and hung over the end of the bed, applying longitudinal traction on the limb and immobilizing the patient. Seven patients were in skin traction, where traction was achieved not via metal pin but via strips of cloth tape applied directly to the patients' skin. Skin traction is recommended in Malawi only for temporary stabilization. Three patients had undergone intramedullary nailing (operative treatment), and two were awaiting treatment with no form of immobilization. Five of the 16 patients had nonunions ( Table 1). The median time since injury was 12 weeks.  We identi ed six 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 surgical treatment (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 social and nancial burden of prolonged hospitalization. They felt they were receiving inferior treatment compared to surgery and suspected that richer patients were receiving more timely care.
High Variability in Health System Navigation Five patients initially presented to a local health center, four to a district hospital, three to a mission hospital or private health center, and four presented directly to KCH. For the four patients who presented to KCH initially, three were immobilized on arrival with skin traction, one patient was placed in a cast. The 12 patients who presented rst to other facilities underwent a variety of initial treatments including splinting (2 patient), skin traction (4 patients), and no immobilization (6). The patients who received splinting or no immobilization were all referred to KCH within 2 days. Four patients remained in skin traction for 1-2 months prior to referral. Total time since injury for the entire cohort varied from 6 days to 7 months. Health system navigation for each patient is summarized in Table 2, and representative patient pathways are shown in Fig. 1. Patients recognized and expressed frustration with this seeming lack of standardization of care, especially delays in receiving treatment.
"We want an explanation about the treatment and if it is being given out accordingly. Some people are here 5-6 months. Some stay here for only 6 weeks. We wonder why so many different things are happening that are unfair." -Male, age [25][26][27][28][29] Frustrations with Hospitalization Patients who had experienced prolonged hospitalizations, usually while receiving skin or skeletal traction, expressed feelings of being trapped and powerless.
"When I was at home, I was able to go to school. I've been stationary here for a month. This place is like a detention [prison]." -Male, age 18-24 Patients recognized the shortcomings of the hospital system, describing limited resources, which contributed to their frustrations.
"It was di cult. There was no PoP [plaster of Paris for casts/splints] to treat me." -Female, age 60-64 "After x-raying they referred me here because they had no equipment." -Male, age 40-44 Patients also described overcrowded and unsanitary conditions on the inpatient wards, which they felt needed to be addressed by hospital leadership. Preference for Surgery Drawing from their own experiences, experiences of family members and friends, or observations of other patients on the wards around them, patients described a strong preference for surgery over skin or skeletal traction. Many felt that surgery would lead to a better outcome and quicker return to home or work.
"When patients are operated on, they walk upright and go home to continue working." -Male, age 55-59 In contrast, patients receiving skin and skeletal traction described the pain and frustration of the prolonged treatment method. Acceptance, Resignation, and Resilience Recognizing the severity of their injury and the need for formal medical care, several patients demonstrated a sense of acceptance, and a feeling as if they had nowhere else to go.
"This is how it's supposed to go. I have to follow…. I can't go anywhere else to get treatment. This is the only place to get treatment." -Male, age 30-34 Many patients continued to show resilience in the face of tremendous hardship, frustration, and uncertainty. Even patients who described the frustrations of prolonged hospitalization also demonstrated gratitude to be in the hospital, and con dence in their providers' abilities to heal them. They described drawing their strength to persevere from their families and from God.
"I pray to God a lot. I pray for God to give my doctor strength and ideas to operate on me." -Male, age 50-54 Moreover, despite the many challenges they faced, some patients remained optimistic. This optimism seemed to be rooted in the belief that they would eventually receive surgery and return to their lives and families.
"I'm expecting that I will get a better treatment [surgery] and I will be ok. I am expecting that things will change." -Female, age 60-64

Discussion
In our interviews, adults with closed FSFs described a lack of trauma care standardization in Malawi, with limited access to surgery. Based on their own experiences and observations, many patients demonstrated a strong preference for surgical over non-operative treatment and suspected that richer patients were unfairly receiving more timely surgery. Hospitalization was fraught with challenges and frustrations as a result of limited hospital resources, unsanitary and crowded conditions, lack of participation in decisionmaking, and uncertainty about treatment course. Many patients also described the devastating nancial burden imposed upon them and their families by prolonged hospitalization.
In patients' descriptions of their journeys, we noted a high degree of variability in utilization of immobilization in the acute injury setting, time to referral for de nitive treatment, treatment method used, and duration of hospitalization. Many patients described receiving no immobilization at the health center or district hospital where they rst presented. Skin traction was being utilized not as a temporary stabilization, but inappropriately as the de nitive treatment for 7 of the 16 patients interviewed. These observations are concerning, because when care practices differ, quality of care and safety can be compromised. 49 In many healthcare facilities in Malawi, clinical o cers -non-physician clinicians -are the highest educated providers. 50 Their level of training and competence, especially with regard to basic trauma care and fracture stabilization should be investigated. Standardization of care practices that promote adherence to evidence-based guidelines may be a useful method of improving care delivery. Patients clearly recognized the bene ts of surgical treatment, which allows for early weight bearing and lower complication rates. 31 Many of the patients we interviewed perceived unfair inconsistencies in care, where richer patients preferentially received surgery. Preferential treatment can undermine healthcare delivery by worsening inequalities in access. 51,52 This issue must be investigated further in Malawi, to understand its prevalence and its root causes. Implementation of a standardized surgical waitlist, adhering to a rst-come, rst-serve policy within the constraints of clinical necessity and triage may decrease the ambiguity and frustrations with the inequitable provision of surgery.
Perceived barriers to healthcare access for rural Malawians include limited emergency services, limited healthcare capacity, poor health workers' attitudes, and perceived poor quality of health services. 53 Several patients we interviewed recognized that limitations of the health system likely contributed to delayed surgery and substandard care. Central hospitals in Malawi have reported inadequate nursing staff, too few hospital beds, and unavailability of the operating room, OCOs, and orthopaedic surgeons when needed. In fact, central hospitals face challenges in providing even skeletal traction due to broken drills, limited traction pins, and inadequate traction frames and weights. 28 Improving hospital infrastructure, bolstering surgical staff, and improving availability of material resources would all likely improve the patient experience navigating the Malawian health system. However, many of the patients' frustrations could be addressed by fostering a culture of quality improvement that is accountable to patients -a culture where patients' experiences and outcomes are noted, acknowledged, and addressed.
Increased transparency and communication between patients and providers may also help address the profound uncertainty that many patients felt with regards to their treatment plans and expected outcomes. Several patients described receiving a speci c treatment without giving consent. Informed consent helps patients understand treatment options and set outcome expectations, which can ultimately affect patient satisfaction. 55,56 This study's ndings must be interpreted with caution, recognizing that our patient population was not a representative sample of all Malawian patients with FSFs. We chose to focus on care delivery at Kamuzu Central Hospital, given the relatively high rates of delayed presentation previously observed there, 37 in an effort to examine challenges where they were perhaps the greatest. This was a qualitative study, undertaken to generate hypotheses. Thus, the experiences of the patients interviewed in this study are not representative, but rather demonstrate the breadth of experiences and common themes.
In our interviews, patients shared the many challenges they faced seeking care, enduring prolonged hospitalization, and bearing the perceived injustice of poor quality care and inequitable provision of surgery. Patients were forced to accept these myriad challenges without recourse. The remarkable resilience of Malawian patients shone through in our interviews. Their desperate hope for a good outcome seemed tragically linked to hope for receiving surgery, which for many patients may never come.

Conclusion
In this qualitative examination of health system navigation, we found that patients with FSFs who received treatment at Kamuzu Central Hospital in Malawi were frustrated by high variability in care. The negative effects of prolonged hospitalization for non-operative treatment led many patients to feel that surgery was a superior treatment that was unfairly made more available to the rich. Our ndings suggest a need to increase the equitable availability of surgery through capacity improvement and standardization of care along evidence-based guidelines. Patients may also bene t from increased transparency and communication with providers, and a culture of quality improvement and accountability led by hospital department leadership.
Declarations Figure 1 Representative patient pathways.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. Healthnavigationappendix.docx