title: Care seeking pathways of older adults with hip fracture in India: exploratory study protocol.
abstract: BACKGROUND
  The incidence of hip fractures in older adults in India is likely to increase dramatically in the coming decades as a result of an aging population and increasing life expectancy. Currently, more than 600,000 adults over 60 years of age suffer a hip fracture annually in India. This paper outlines a protocol for a qualitative study investigating the care seeking behavior of older adults with hip fractures: to determine the processes in decision making, identify causes for delay in obtaining care, and identify potential barriers and facilitators to seeking appropriate care in time.
  
  
  METHODS
  The planned study will consider Odisha, an eastern state in India with limited health care facility, as a suitable case study. It is proposed to conduct 30 in-depth interviews in two administrative districts of Odisha. The participants will be patient and their carers in seven health facilities- four public hospitals, two private hospitals and one traditional bone-setting facility. The study relies on a purposive sampling strategy. Ethics permission will be sought from each participating institution and participants. The participants will be adults aged 50 years or older of both sexes arriving at the recruiting centers with a history of fall or injury, pain in the hip region and inability to walk and X-ray confirmed diagnosis of proximal femoral fracture and their primary carer. Trained qualitative research team will conduct these interviews. A thematic framework approach will be used to analyze the data using NVivo 9 software. The data collected from the interviews will be analysed to explore the cause of the hip fracture, events following the injury, the experiences of patients from the time of sustaining the injury, pain relief measures, decision to seek care, understanding of the urgency for treatment, causes for delay in receiving treatment, funding sources, cost liabilities for the family, financing mechanisms for out of pocket expenditure and the burden for caring.
  
  
  CONCLUSIONS
  The findings of this study will provide an increased understanding of the care seeking behaviors of older adults with hip fracture, and inform contextually appropriate changes in healthcare program and policy aimed at improving health outcomes.
authors.affiliation: The George Institute for Global Health, New Delhi, India. atewari@georgeinstitute.org.in.
authors.forename: Abha
authors.initials: A
authors.lastname: Tewari
authors.affiliation: The George Institute for Global Health, New Delhi, India. kirtisundar@gmail.com.
authors.forename: Kirti Sundar
authors.initials: KS
authors.lastname: Sahu
authors.affiliation: The George Institute for Global Health, New Delhi, India. lyadav@georgeinstitute.org.in.
authors.forename: Lalit
authors.initials: L
authors.lastname: Yadav
authors.affiliation: Indian Institute of Public Health, Public Health Foundation of India, Bhubaneshwar, India. Sanghamitra.pati@iiphb.org.
authors.forename: Sanghamitra
authors.initials: S
authors.lastname: Pati
authors.affiliation: Indian Institute of Public Health, Public Health Foundation of India, Bhubaneshwar, India. srinivas.n@iiphb.org.
authors.forename: Srinivas
authors.initials: S
authors.lastname: Nallala
authors.affiliation: Nuffield Department of Population Health, University of Oxford, Oxford, UK. premila.webster@dph.ox.ac.uk.
authors.forename: Premilla
authors.initials: P
authors.lastname: Webster
authors.affiliation: Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK. rnorton@georgeinstitute.org.|The George Institute for Global Health, Sydney Medical School, University of Sydney, 34 Broad Street, Sydney, OX1 3BD, Australia. rnorton@georgeinstitute.org.
authors.forename: Robyn
authors.initials: R
authors.lastname: Norton
authors.affiliation: Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK. santosh.rath@georgeinstitute.ox.ac.uk.
authors.forename: Santosh
authors.initials: S
authors.lastname: Rath
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D016330:Frail Elderly; D015438:Health Behavior; D006297:Health Services Accessibility; D006620:Hip Fractures / Q000191:economics / Q000628:therapy*; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research