The experiences of adult patients receiving treatment for femoral shaft fractures at a public referral hospital in Lilongwe, Malawi: A qualitative analysis

Abstract

Background: Malawi has a rising burden of musculoskeletal trauma, coupled with insufficient surgical capacity to manage common, debilitating injuries like femoral shaft fractures. Nonoperative treatment remains the standard of care, with surgery available only at central hospitals. We sought to understand how patients navigate the Malawian health system and the barriers they face while seeking care.

Methods: We performed in-depth, semistructured interviews of 15 adults with closed femoral shaft fractures during their hospitalization at Kamuzu Central Hospital, a public referral hospital in Lilongwe—Malawi’s capital city. We additionally interviewed 1 patient who left Kamuzu Central Hospital to seek care at a private hospital. An English-speaking investigator performed all interviews with 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 and treatment on patients and their families. Interviews were audio recorded, translated, and transcribed in English. We coded the transcripts and performed 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’ experiences and observations; frustrations with the inequitable provision of surgery; and patients’ resignation, acceptance, and resilience in the face of hardship. Many patients receiving nonoperative treatment described the devastating financial burden imposed upon them and their families by their injuries and prolonged hospitalization. These patients viewed nonoperative treatment as inferior to surgery and suspected that richer patients were receiving more timely care.

Conclusions: This qualitative study suggested a need to standardize care for femoral shaft fractures in Malawi, increase the availability and timeliness of surgery, and increase transparency and communication between providers and patients. These remedies should focus on improving the quality of care and achieving equity in access to care.