title: Longstanding pain and social strain: patients' and health care providers' experiences with fracture management by skeletal traction; a qualitative study from Malawi.
abstract: The aim of the study is to contribute to a more holistic evidence based on lower limb fracture management in low-income settings, by exploring the perspectives of those actually experiencing and administering skeletal traction in Malawi.
  
  
  
  The study took place at Queen Elizabeth Central Hospital in Blantyre and Kamuzu Central Hospital in Lilongwe, the two largest public hospitals of Malawi. Qualitative data were collected by participant observation, individual interviews with eight patients, two orthopedic surgeons, one physiotherapist, and two focus group discussions with multidisciplinary teams.
  
  
  
  Patients experienced physical and psychological pain from the prolonged traction treatment in bed. Anxiety, indignity and emotional distress in the ward environment were commonly observed. Patients emphasized the negative impact on their families and the significant economic consequences due to prolonged hospitalization. Health care providers identified the major obstacles for quality treatment due to the lack of staff, equipment, specialized knowledge and skills. Rehabilitation services were nearly absent, thus little effort was made to maintain function and enhance recovery during and after long-term bed confinement.
  
  
  
  The use of long-term skeletal traction has a devastating impact on the patients and families, and causes major frustrations to health workers involved with fracture management in a low-resource setting. Implications for Rehabilitation As stated by various health care providers, there is a need to improve trauma care, strengthen rehabilitation services and educate more rehabilitation staff so they can take up the different roles and functions required in treatment and rehabilitation after injuries and other debilitating conditions. In the current situation, sufficient pain relief for patients is required. This should go hand in hand with the empowerment of patients so as to fulfill their rights to quality health services. For health care providers, multidisciplinary teamwork, enhanced specialized education and skills, improved access to adequate equipment and developing standardized procedures appear essential in order to improve fracture management. With injuries representing a growing portion of the global burden of disease, and in the changing demographic panorama with aging populations in Africa and the world at large, injury prevention, trauma care- and rehabilitation need a stronger focus in public health globally.
authors.affiliation: a Department of Occupational Therapy, Physiotherapy and Radiography , Bergen University College , Bergen , Norway.
authors.forename: Lise
authors.initials: L
authors.lastname: Haug
authors.affiliation: b Ministry of Disability and Elderly Affairs , Lilongwe , Malawi.
authors.forename: Margaret
authors.initials: M
authors.lastname: Wazakili
authors.affiliation: c Department of Surgery , Kamuzu Central Hospital , Lilongwe , Malawi.|d Department of Orthopaedic Surgery , Haukeland University Hospital , Bergen , Norway.
authors.forename: Sven
authors.initials: S
authors.lastname: Young
authors.affiliation: a Department of Occupational Therapy, Physiotherapy and Radiography , Bergen University College , Bergen , Norway.
authors.forename: Graziella
authors.initials: G
authors.lastname: Van den Bergh
mesh_terms: D000328:Adult; D000368:Aged; D001007:Anxiety / Q000523:psychology*; D005260:Female; D017144:Focus Groups; D050723:Fractures, Bone / Q000523:psychology* / Q000534:rehabilitation*; D006282:Health Personnel; D006801:Humans; D007103:Immobilization / Q000523:psychology*; D007407:Interviews as Topic; D035002:Lower Extremity / Q000601:surgery*; D008295:Malawi; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000209:etiology; D036301:Qualitative Research; D014143:Traction
keywords: Femur fractures; Malawi; hospitalization; skeletal traction