Understanding Barriers to Orthopaedic and Trauma Care Delivery in The Gambia Utilizing the Social Ecological Model: A Scoping Review

The rising burdens of musculoskeletal disease and trauma have become a global public health crisis.[1] The Global Burden of Disease 2019 study estimated that 1.7 billion people live with musculoskeletal pathology.[2] However, there is a large discrepancy in access to essential orthopaedic and trauma care services for people living in high-income countries (HIC) versus low- and middle-income countries (LMICs).[3-6] Barriers to timely care, inefficient health systems, scarcity of healthcare resources, and inadequate infrastructure have each been described as significant challenges in LMICs.[7] Efforts to strengthen orthopaedic and trauma capacity—and improve access to safe, timely, and affordable care—can reduce preventable mortality and disability, as well as the associated physical, mental, and financial burdens.[7]

The Gambia is the smallest country in Mainland Africa. It has an area of 1300 km (4,363 million) with an estimated population of 2.6 million. It is also one of the most densely populated countries on the continent, with 176 individuals per square kilometer [8] (Figure 1). The country has a three-tiered healthcare system that provides primary, secondary, and tertiary services. Edward Francis Small Teaching Hospital (EFSTH) and Serrekunda General Hospital (SGH) are the only tertiary level hospitals that have the surgical capacity to manage patients with complex trauma. Of the two, EFSTH is the only one with an orthopaedic and trauma department; it was opened in 2018 following Dr. Kebba Marenah becoming the first residency-trained orthopaedic surgeon in the country.[9]

In The Gambia, rapid urbanization, industrialization, and motorization have significantly increased the burden of injury and musculoskeletal trauma while a multitude of shortcomings have plagued its trauma care system, contributing to heightened morbidity and mortality.[10] The reported deficiencies include a lack of a toll-free emergency response number, inadequate prehospital care and triage infrastructure, limited emergency and surgical clinical staff, and scarce essential supplies and medical facilities.[11] The Ministry of Health, health system leaders, and international collaborators have acknowledged these significant gaps in effective delivery of orthopaedic and trauma care.[12] Through partnerships with international organizations such as the AO Alliance, AO Trauma Foundation, and The Gambia Medical UK Partnership, concerted efforts have been made to improve orthopaedic and trauma care nationwide.[13, 14] However, a comprehensive assessment of the barriers to orthopaedic and trauma care in The Gambia has not been reported in the peer-reviewed literature to-date.

The Social Ecological Model (SEM) is a framework for understanding the multifaceted and interactive effects of personal and environmental factors on individual behaviors. It was first introduced in the 1970s as an ecological systems theory to understand the impact of different environmental systems on child development.[15, 16] It has been proposed that an individual’s development is influenced by systems ranging from the immediate family environment to broad societal institutions. Over time, this model has been applied and expanded to understand the complex interplay of factors that influence health behaviors. This expanded model considers the complex interplay among individual, interpersonal, organizational, community, and policy-level factors [17, 18] (Figure 2). The individual level domain evaluates how personal factors such as knowledge, attitudes, and beliefs influence behavior. The interpersonal level domain involves relationships and social networks that include family and peer influences. The community level domain encompasses neighborhood characteristics, as well as physical and social environments, community programming, and local resources, whereas the organizational level domain addresses institutional factors such as policies, regulations, and culture. Finally, the policy level domain includes larger-scale laws, initiatives, and systematic structures that create a broader framework for behaviors and interventions. SEM has been widely adopted as a framework within the field of public health and has been used to better conceptualize and categorize the multitude of factors that impact healthcare in LMICs.[19-23]

Because a comprehensive characterization of these variables has not been reported in the peer-reviewed literature, this study aimed to conduct a scoping literature review to identify barriers to orthopaedic and trauma care delivery in The Gambia. The identified barriers were systematically categorized into individual, interpersonal, organizational, community, and policy domains of the SEM. This study models the Technical Priorities for Orthopaedic Trauma Care Development Approach performed in Malawi to identify essential challenges and goals to advance musculoskeletal trauma care delivery in Malawi.[24] The primary goal for this study was to allow for a more nuanced understanding of potential barriers and their interactions across different levels of influence, providing foundational evidence for programmatic research aimed at implementing resultant strategies to improve orthopaedic and trauma care in The Gambia.

Design

A scoping literature review was conducted to identify the current challenges in orthopaedic and trauma care delivery in The Gambia. We followed the methodological framework outlined by Arksey, O’Malley, and Levac.[25-26]

Strategy

A search strategy consisting of keywords and index terms together with medical subject headings (MeSH) related to trauma, surgical, and orthopaedic care delivery in The Gambia was established. We conducted a comprehensive search of peer-reviewed literature from PubMed, Scopus, and Embase. Grey literature was searched using Google Scholar and internet search engines (e.g., Google). Grey literature for this review was defined as literature not subject to a peer-review process and not under the control of commercial publishing organizations. Searches were performed with no date or study design restrictions and included only articles in English.

Study Selection

Following the search, all identified citations were collated and uploaded into Covidence. The titles and abstracts were screened by two independent reviewers to assess the inclusion criteria for the review. We included all articles pertaining to orthopaedic and trauma care in The Gambia including injury prevention, prehospital care, Gambian trauma systems, health care facility infrastructures, and health policy within The Gambia. Articles were excluded if they were not relevant to orthopaedic and trauma care in The Gambia or did not present at least one clear orthopaedic and trauma care delivery challenge. Any discrepancies were discussed and resolved by consensus.

Data Extraction

A data extraction chart was devised to discern the challenges to orthopaedic and trauma care delivery in each study. This task was undertaken by two independent reviewers, who resolved any data inconsistencies through consensus. The variables incorporated included authors, title, publication year, country of origin, aims/purpose, methodology, and principal challenges. The challenges were categorized into thematic domains of Injury Prevention, Pre-Hospital Care, Trauma System and Operative Infrastructure, and Health System Policy. Challenges were organized using the SEM framework.

The search strategy yielded 450 articles that underwent title and abstract screening by two independent reviewers. Sixty-one full-text articles were reviewed. Twenty studies were extracted and used to identify the challenges. A summary of the review process is presented (Figure 3: PRISMA). The included articles were published between 2000 to 2024 and came from 3 different countries of origin (Table 1: Included articles). Nearly 65% of the articles were peer-reviewed studies, primarily retrospective cohort studies [12, 27-30] (38.5%) and cross-sectional studies [31-34] (30.7%). The remaining 4 articles included a case series,[35] systematic review,[36] prospective cohort study,[37] and an op-ed[38]. Seven of the 20 articles included were identified during the grey literature search. The seven grey literature articles included 5 news articles,[39-43] a technical report,[13] and an interview transcription[44] (Table 2: Grey Literature).

Injury Prevention

At the individual level, a key factor affecting trauma care outcomes in The Gambia was the widespread lack of awareness about when and where to seek medical attention after injuries. Tourey et al. (2018) revealed that patients’ limited understanding of severe injury warning signs resulted in critical delays in seeking emergency care, potentially compromising treatment outcomes.[33] This knowledge gap particularly affected rural communities. At the community level, analysis of 1905 trauma cases at Edward Francis Small Teaching Hospital (EFSTH) and Serrekunda General Hospital from March 1 to August 8, 2014, revealed the leading mechanisms of injury were road traffic (26.1%), struck by objects (22.1%), cut/pierce (19.2%), falls (19.2%), and burns (5.4%), with over half of emergency department trauma cases (52%) involving injuries to upper extremities or lower extremities/pelvis/hip.10 At the policy level, The Gambia was ranked as having the 8th highest rate of road traffic accidents in the world.[42, 43] The prevailing poor societal driving practices, such as failing to yield to pedestrians and the insufficient availability of designated crossing lanes for pedestrians, bicyclists, and motorcyclists, increased the risk of road traffic injuries, all of which created substantial challenges for preventing injuries and delivering trauma care.[29, 30]

Pre-Hospital Care

At the individual level, a pervasive mistrust of Western medical practices—rooted in negative historical experiences and cultural beliefs—reportedly influenced healthcare-seeking behavior, with many patients preferring traditional bone setters despite their well-documented associated complications including infection, malunion, gangrene, and possible death.[35, 37, 38] This individual hesitancy was further reinforced at the interpersonal level, where family dynamics and religious beliefs strongly influenced healthcare decisions, particularly in rural communities where traditional healers (“Marabouts”) were frequently consulted for injury treatment.[31] Bickler et al. (2000) reported in a case series that 9 children primarily from rural areas were treated for gangrene in a 29-month period after fracture management by traditional bone setters with the use of wooden sticks bound tightly with cloths. Five (56%) of these children underwent proximal extremity amputations.[35] At the community level, geographic barriers create significant access issues, with the Gambian River dividing the country and limiting access to the only 2 tertiary hospitals in Banjul, forcing most patients to rely on informal transportation methods like taxis for emergency medical transport.[33] Touray et al. (2018) found that the most common mode of transportation during medical emergencies was taxi, with 186 respondents (72%) choosing this as their preferred mode of transport.[33] The organizational infrastructure presented additional challenges, characterized by the absence of formal emergency response systems and proper trauma immobilization protocols during hospital transfers.[33, 34] Although trauma was the most common reason for referral to other hospitals in The Gambia, cervical spine and long bone fracture immobilization was rarely performed prior to referral.[33] At the organization and policy levels, the financial burden of medical care remained a significant barrier to orthopaedic and trauma care. Treatment costs at EFSTH ranging from 10,000 to 20,000 Dalasis (USD $190 to $380) represented an insurmountable barrier for many, especially considering the reported monthly incomes of 2,100 to 4,000 Dalasis (USD $43 to $82).[12] This financial disparity disproportionately affected rural communities, where 90% of respondents identified medication costs as their primary barrier to emergency care access, compared to 73% in urban areas.[33]

Orthopaedic and Trauma Care Infrastructure

At the individual level, patients faced significant barriers in accessing trauma care. It was found that 64% of individuals from rural areas, when presented with a hypothetical emergency, would have initially taken an unconscious motor vehicle trauma victim to a primary care facility.[33] These facilities in Gambia were often poorly equipped and staffed to provide care to acute trauma patients.[33] At the community and organizational level, healthcare facilities demonstrated severe infrastructural deficiencies. A study by Iddriss et al. (2011) of 18 referral healthcare facilities including 1 tertiary referral hospital (5.6%), 5 (27.8%) general hospitals, 6 (33.3%) health centers, and 6 (33.3%) private hospitals revealed 50.0% experienced interruptions in water supply and 55.6% in electricity.[32] The capability to manage various medical conditions was also limited, with only 41.2% able to manage closed fractures, 29.4% open fractures, and 44.4% amputations.[32] Notably, 3 out of the 7 tertiary hospitals (43%) lacked X-ray services entirely.[32] The availability of essential medical supplies also varied considerably, with resuscitator bags and intravenous infusion sets present in only 58.8% and 66.7% of facilities, respectively.[32] At the policy level, the uneven distribution of resources created geographical disparities in access to quality care, with rural communities particularly disadvantaged. The shortage of basic medical supplies and medications such as opioids often resulted in improvised solutions or delayed treatments, potentially compromising patient outcomes.[32, 33, 40] The country faces a severe shortage of healthcare professionals, with less than 0.5 physicians per 10,000 inhabitants.[32] This workforce crisis was noted to be particularly acute in specialized care, with only three residency-trained orthopaedic surgeons serving a population of 2.7 million.[13, 36, 37]

Gambian Orthopaedic and Trauma Care System

At the individual level, patients face significant barriers to accessing trauma care, while healthcare providers struggle with limited resources and training opportunities. The nation’s only medical school, established in 2000, has integrated surgery into its medical school curriculum to encourage students to pursue surgical careers.[33] Edward Francis Small Teaching Hospital and West African College of Surgeons have engaged in new collaborative efforts to increase the number of specialized training programs in healthcare. However, model projections indicate a potential deficit of over 5,000 physicians in The Gambia, given the anticipated exponential population growth.[33, 36] The interpersonal level reveals challenges in provider-patient communication and care coordination, time-out processes before surgeries were largely absent, used by only 29% of the respondents. Standardized consent forms for operations were present in 14% of the responding facilities.[33] The community level continues to highlight the void of critical emergency response infrastructure, including the lack of a coordinated ambulance system and emergency medical services hotline.[29, 30] At the organizational level, healthcare facilities demonstrate significant safety and management concerns, with 71% reporting major safety issues.[33] Communication about medical errors between frontline staff and management remains inconsistent, with only 58% stating that management was routinely informed about medical errors.[33] At the policy level, trauma system development in The Gambia faces significant financial constraints, as evidenced by its low health expenditure relative to the gross domestic product (GDP). In 2021, The Gambia’s general health expenditure as a percentage of GDP was only 1.62%.[45]

This scoping review of the available evidence revealed a complex interplay of factors affecting orthopaedic and trauma care in The Gambia, spanning across individual, interpersonal, community, organizational, and policy domains. The comprehensive characterization of these factors provided details on their impacts in the realms of injury prevention, pre-hospital care, orthopaedic and trauma infrastructure, and national trauma care policy. The findings highlight challenges that need to be addressed to advance orthopaedic and trauma care access and delivery in the country, while shedding light on potential opportunities for interventions that mitigate barriers to improve patient outcomes.

Barriers to Injury Prevention

In 2023, The Gambia was ranked as the 8th country with the highest rate per capita of road traffic accidents in the world.[42] Based on the prevalence of these issues throughout sub-Saharan Africa,[46] evidence-based interventions for road traffic injury prevention have primarily focused on 3 key domains: vehicle safety enhancement, driver behavior modification, and road condition improvement.[47] Successful safety measures encompass speed limit implementation, mandatory usage of safety devices and restraints, strict enforcement of blood alcohol limits, and development of alternative mass transit systems.[48] Policy initiatives targeting road safety and public transportation emphasize preventive strategies and post-incident response optimization through enhanced emergency care accessibility and first responder effectiveness.[48] However, technological advancement and infrastructure development in sub-Saharan Africa’s public transport sector face significant constraints due to regional, cultural, and socioeconomic limitations.[48] The critical nature of road traffic injury-associated mortality and morbidity in The Gambia necessitates immediate intervention strategies founded on comprehensive, integrated, and evidence-based methodologies supported by empirical research. In addition, this aligns with the United Nations Decade of Action for Road Safety 2021-2030, with the goal of preventing at least 50% of road traffic deaths and injuries by 2030.[49]

Barriers to Pre-Hospital Care

A complex interplay of cultural, financial, and educational factors creates significant barriers to accessing modern orthopaedic and trauma care. The prevalence of traditional bone setters in The Gambia remains high despite their association with high complication rates, underscoring the need for culturally sensitive healthcare interventions and public health education. Studies have reported similar rates of traditional bone setter use throughout sub-Saharan Africa, with an estimated 85% of fracture patients in Nigeria and 63% of patients in a Ghanaian hospital departing to pursue care from traditional bone setters.[50, 51, 52] To improve healthcare outcomes in these areas, several key recommendations emerge:[53]

• Expand access to modern orthopaedic facilities to reduce reliance on potentially unsafe, traditional practices while preserving cultural healing traditions.
• Implement comprehensive training programs for traditional healers to enhance their skills, introduce sterile techniques, and improve patient safety standards
• Establish formal connections between traditional practitioners and conventional healthcare systems to create referral networks for complex cases requiring specialized care
• Conduct thorough research to evaluate treatment outcomes across both approaches to identify best practices and develop evidence-based guidelines that integrate valuable traditional knowledge and values with modern medical standards.

Current initiatives in The Gambia such as the virtual fracture clinics are underway to reduce delays in care through diagnosis and treatment from colleagues based in Great Britain.[39] Financial constraints also pose a formidable obstacle to modern orthopaedic and trauma care in The Gambia. Studies across the region have illustrated a similar burden. In Ghana, approximately 10% of patients refused recommended surgery due to cost concerns.[54] Malawi reported costs of $597 for intramedullary nailing and $678 for traction in femur shaft fractures, although Malawi is a nationalized health system so these cost are borne by the hospital system, and not the patient.[55] In Cameroon, a study of 7603 injured patients presenting to emergency departments revealed that 95.7% paid out-of-pocket to finance ED care.[56] These financial constraints often lead to delayed care-seeking behavior, potentially exacerbating injuries and resulting in more complex and costly treatments that are even less accessible and affordable.

Interpersonal factors, particularly social networks and family decisions, play crucial roles in healthcare-seeking behaviors in The Gambia. The preference for traditional healers in rural areas highlights the need for community-based interventions to bridge the gap between traditional and modern medical practices. Such interventions might include community health workers who can act as liaisons, as demonstrated in Ghana, where traditional healers were trained in 5 sessions over a 9-month period with an overall orthopaedic knowledge gain of 19.7% (from 67.2% to 86.9%).[57] As an immediate result, there was a significant increase in the number of patients referred to local hospitals in the 6 months following the training. Research also indicates that patients with advantageous social connections are better able to self-advocate for orthopaedic trauma surgery in resource-constrained settings. A study of orthopaedic trauma patients in Uganda revealed that social capital was the strongest predictor of access to surgery, highlighting the importance of social capital in healthcare access and outcomes, particularly in areas with limited medical resources.[58]

At the community level, the inadequacy of local healthcare facilities equipped to handle orthopaedic and trauma cases is a major concern. The situation is particularly dire in Africa, where Emergency Management System (EMS) services exist in only a third of the countries, and merely 8.7% of the population is within EMS system coverage, significantly skewed towards urban areas.[59] The percentage of injured patients arriving at health facilities by ambulance varies widely across sub-Saharan Africa, from 59% in Ethiopia to as low as 5% in Mozambique.[60, 61] A study by Juran et al. (2018) revealed that a substantial portion of the population of Africa are not within 30 minutes of a hospital that could provide trauma surgery including only 43% in Central Africa, 33% in Eastern Africa, 40% in Southern Africa, and 34% in West Africa.[62] This underscores the urgent need for implementing community-based emergency response training, developing robust emergency medical services systems, establishing regional trauma centers, and creating standardized protocols for the assessment and transfer of trauma patients.

Barriers to Orthopaedic and Trauma Care Infrastructure

Resource constraints and shortages of healthcare professionals significantly impact quality of care. Iddriss et al. (2011) revealed alarming interruptions in basic utilities, such as water and electricity, in half of the surgical facilities in The Gambia, directly affecting the ability to provide safe and effective care.[32]  The limited availability of essential medical supplies, diagnostic equipment, and specialized personnel highlights the need for substantial investment in healthcare infrastructure and human resources. A study on healthcare facilities in East, Central, and Southern Africa revealed significant disparities in medical equipment availability, with functional mobile C-arm X-ray machines present in only 4% of district hospitals and 27% of referral facilities, and CT scan machines are even scarcer.[63] The shortage of healthcare professionals, particularly in specialized fields such as orthopaedics, is critical, with surgical workforce density in sub-Saharan Africa at about 1.7 per 100,000 population.[64] In 2014, Ghana had only 24 residency-trained orthopaedic surgeons (0.9 per million) compared to 75.2 per million in the United States, but these were largely located in an urban setting.[65] Collaborative efforts with international organizations and academic institutions could help in rapidly building capacity, while implementing recruitment and retention strategies is crucial to address high turnover rates. The inconsistency in communication and transfer protocols between healthcare facilities further complicates the delivery of effective care, highlighting the need for standardized communication protocols and a centralized coordination system investments for patient transfers to improve the continuity of care and patient outcomes.

Barriers to Gambian Orthopaedic and Trauma Care System

The low healthcare expenditure as a percentage of GDP (1.62% in 2021) indicates a critical underinvestment in the healthcare sector in The Gambia.[45] Addressing this issue requires a commitment from policymakers to prioritize healthcare spending and explore innovative financing mechanisms to increase the healthcare budget. The high out-of-pocket expenses for households create a significant barrier to accessing care and increase the risk of catastrophic health expenditure for families. A study of 1396 injured patients in Ghana who had indications for surgery at admission revealed 60% of the uninsured incurred “catastrophic” health costs (more than 10% of their household annual income) as compared with 30% among the insured.[66] Implementing universal health coverage schemes and exploring community-based health insurance models could help to alleviate this financial burden and improve access to care. The absence of a national ambulance system and an EMS hotline further exacerbates the challenges in providing timely and effective care. An expert survey investigating the jurisdiction, operations, resources, and regulation of EMS in 49 of 54 African countries showed the absence of EMS prehospital systems in 33 (61%). Only 26% had a toll-free EMS telephone number.[67] Establishing these essential services should be a priority for policymakers as they form the backbone of an effective emergency response system. Developing a national emergency medical services strategy, including training paramedics and establishing a centralized dispatch system, could significantly improve outcomes for patients with trauma. The identified issues in patient safety and healthcare management across facilities, including the lack of standardized consent forms, safety checklists, and consistent communication during care transitions, necessitate the implementation of comprehensive quality improvement initiatives. These should focus on establishing standardized protocols, improving documentation practices, and fostering a culture of safety within health care institutions. Currently in Western Africa, only Senegal and Nigeria have National Surgical Obstetrics and Anesthesia Plans[68], although current work in The Gambia is underway to develop a Gambia National Trauma and Injury Plan (GNTIP). Implementing a national patient safety strategy that includes regular audits and continuous quality improvement processes could help to address these issues systematically. The integration of surgery into the medical school curriculum and collaborative efforts to increase specialized training are positive steps. However, the projected deficit of over 5000 physicians by 2053, given the expected population growth, indicates that these efforts need to be scaled up significantly. As of 2023, Africa has 444 public and private medical schools. Medical education in Africa faces significant challenges that include underfunding, faculty shortages, inadequate infrastructure, and insufficient medical schools. These issues hinder progress and effectiveness, creating a complex problem that requires comprehensive solutions to improve education and healthcare delivery across the continent.[69] Long-term planning and investment in medical education and retention strategies for healthcare professionals are crucial to address this impending shortage.[70] This might involve expanding medical school capacity, offering scholarships and incentives for students to pursue careers in high-need specialties, and developing continuing education programs to support the professional growth of healthcare workers.

Limitations

This review had several limitations that should be considered when interpreting the findings. First, reliance on a limited number of only English language studies, many of which are cross-sectional or retrospective in nature, may not capture the full complexity and dynamism of the healthcare landscape in The Gambia. While cross-sectional studies provide valuable snapshots, they cannot establish causal relationships or track changes over time. This limitation highlights the need for more longitudinal studies, as well as national databases and registries, to better understand the evolving challenges and impacts of interventions in orthopaedic and trauma care in The Gambia. Second, the inclusion of grey literature while providing valuable insights from non-academic sources may introduce bias due to the lack of peer review. News articles, technical reports, and interview transcriptions, although informative, may not adhere to the same rigorous methodological standards as peer-reviewed academic publications. Third, the rapid changes in healthcare systems and policies mean that some of the findings may not reflect the current situation in The Gambia. The healthcare landscape, particularly in developing countries, can change rapidly owing to political climates, policy shifts, international aid interventions, or technological advancements. As such, some of the identified challenges may not be as relevant, while new challenges may have emerged that are not captured in this review. Finally, this review’s focus on published literature and official reports may not fully capture the lived experiences of patients and healthcare providers on the ground, especially in rural communities that may not be incorporated into the current literature. Qualitative studies incorporating patient narratives and healthcare workers’ perspectives could provide valuable insights into day-to-day challenges, patient-specific barriers, and pragmatic solutions that may not be reflected in more population-based research methodologies.

This review highlights the multifaceted challenges facing orthopaedic and trauma care in The Gambia, revealing a complex interplay of individual, interpersonal, community, organizational, and policy-level factors. In order to address these barriers coordinated investment in healthcare infrastructure, expansion of workforce capacity, and organized development of emergency services and referral systems will be critical. Additionally, efforts should prioritize the integration of traditional and modern care models through culturally tailored education and partnerships. Financial barriers must be addressed through innovative health financing and health coverage initiatives. Enhancing prehospital care, standardizing facility protocols, and advancing national trauma policies such as the Gambia National Trauma and Injury Plan are also critical. Lastly, sustained collaboration with global partners and academic institutions can support training, research, and capacity building to improve access, safety, and patient outcomes in orthopaedic and trauma care in The Gambia.

MeSH TERMS: Orthopaedic; Orthopedic; Fracture; Musculoskeletal; Trauma; Trauma System; Capacity; Injury; Surgery; Healthcare; The Gambia

We would like to acknowledge Edward Francis Small Teaching Hospital, The Harvard Global Orthopaedics Collaborative, and the University of Missouri Department of Orthopaedic Surgery for their support to conduct this project.