Psychosocial Experiences of Adults With Lower Limb Fracture in Ghana: A Qualitative Study

Abstract

Patients’ psychosocial experiences vary and can influence their recovery. An insight into these experiences can facilitate patients’ perioperative care. This study explored and described the psychosocial experiences of adults aged 18 years and older with lower limb fractures. A qualitative exploratory, descriptive design was undertaken among 18 purposively sampled postoperative adults with lower limb fractures who had undergone surgery at a hospital in Ghana. Data were collected using semi-structured face-to-face individual interviews and analyzed using thematic analysis. The 2 main themes identified were altered psychological well-being and frightening experiences, and evolving social experiences among adults with lower limb fractures. The subthemes showed that the participants experienced fear, worry, and anxiety as well as social isolation, social role neglect, socioeconomic problems, and varying availability of social support. Participants’ fears, worries, and anxieties were related to the possible loss of their limbs, lives, livelihoods, and social support. Healthcare providers must incorporate holistic psychological and social care that enables adults with lower limb fractures to deal with injuries, their surgery, and the protracted recovery process postoperatively.

Introduction

Musculoskeletal disorders, including fractures, are the second leading cause of disability worldwide and the most significant burden on surgical services globally.^1,2 A fracture refers to a break in the structural continuity of a bone that may occur due to injuries or conditions that weaken the bones, such as osteoporosis. ³ Lower limb fractures (such as femur, tibia, fibula, and ankle fractures) cause severe pain and restrict patients’ movement while affecting their overall well-being. ⁴ Resuming social activities following fractures is a significant worry for patients and a key element in their recuperation. ⁵

Studies indicate that in the aftermath of a fracture, patients must deal with the psychosocial effects of the traumatic event, unexpected hospitalization, social isolation, and psychological distress spanning several months. ⁶ Lower limb fractures negatively affect the psychological and emotional well-being of affected persons and may result in mobility problems, contributing to the loss of patients’ independence.^7,8 Weimert et al, ⁹ note that these psychological, behavioral, and injury-related effects on the function of persons with lower limb fractures can span over a year postoperatively, making it an essential component of their recovery. ⁸

The healthcare costs associated with lower limb fracture treatment or healthcare may pose a financial burden to patients who can no longer work or earn an income.^10,11 Without adequate social support, affected patients may be unable to care for their significant others and fulfil their social roles. ¹² These psychosocial experiences can impair the postoperative recovery of patients living with lower limb fractures and thus must be empirically explored to inform healthcare providers’ interventions.

International qualitative studies have documented that individuals recovering from open lower limb fractures may feel emotionally fragile, experience shifts in identity, and anxiously wonder about their future.^13,14 However, research among persons with lower limb fractures in Ghana remains predominantly quantitative, focusing on outcomes such as loss to follow-up, socioeconomic predictors, and quality of life, ¹⁵ often overlooking psychosocial experiences. ¹⁶ By investigating the psychosocial experiences of adults with lower limb fractures through a qualitative lens, this study can provide additional insight into patients’ unmet psychosocial needs, such as feelings of vulnerability, social isolation, and anxiety about returning to work or fulfilling societal roles.^17,18 These insights can help healthcare providers deliver healthcare that addresses patients’ physical recovery as well as their psychological well-being and social reintegration.^19,20 This study, therefore, aimed to explore and describe the psychosocial experiences of adults with lower limb fractures at a hospital in Ghana.

Methods

A qualitative exploratory, descriptive design was used to explore and describe the experiences of adults with lower limb fractures at a hospital in Ghana.

Research Paradigm

The study adopted an interpretivist philosophical approach, which values participants’ perspectives and interpretations, and views reality as subjective, differing from person to person.^21–23 The interpretivist paradigm provided an opportunity to gain deep insight into the experiences of adults with lower limb fractures from their unique perspectives, while capturing their realities as they understand them within their contexts.

Reflexivity

The researcher is a male registered nurse tutor with a Master of Philosophy in Nursing who has previously cared for adults with fractures in the study region (Upper East Region). The researcher was supervised by a female Professor of Nursing and a male Doctor of Nursing lecturer, both of whom had previously supervised research within the Upper East Region but reside outside the study region. None of the authors had prior associations with the study participants before this research, thereby reducing the risk of courtesy bias. Nonetheless, the researcher regularly discussed the study processes and data with the supervisors to ensure the findings accurately reflected participants’ responses and experiences.

Study Population and Sampling

Adults aged 18 years and older with lower limb fractures who had received postoperative inpatient care in the orthopedic wards of Bawku Presbyterian Hospital for at least 6 months were purposively sampled for the study. Participants were excluded if they had a severe illness or injury that hindered their ability to participate in interviews or provide accurate reports of their experiences. The inclusion and exclusion criteria ensured that only adult participants who had experienced living with lower limb fractures could participate and share their experiences.

The Bawku Presbyterian Hospital was purposively sampled for the study because it has a well-established orthopedic department that manages orthopedic cases and serves as a referral center for health facilities within and around the Upper East Region of Ghana. With the support of 3 nurses working in the orthopedic unit, the nurse researcher approached eligible participants individually and explained the study to them. Participants were recruited individually until data saturation was attained, which determined the final sample size (18 participants). ²⁴

Data Collection

The researcher collected data from participants through semi-structured individual interviews using an interview guide developed by the authors in accordance with the study's objectives. The researcher was trained by his supervisors to conduct the in-depth individual interviews, take field notes, and probe participants’ responses. Three pilot interviews were conducted to identify aspects of the interview guide and data collection process that required modification before the main study. ²⁵ No revisions were required after piloting the instruments.

Section A of the study's interview guide covered the participants’ demographic data, while Section B explored their experiences. The participants’ demographic data collected included their ages, sex, and religion, which provided additional insight into the participants’ psychosocial experiences. For instance, data on participants’ religious affiliation were collected because religious beliefs may influence participants’ experiences with illness and healthcare.

During the interviews, participants were asked questions such as “Please can you share with me experiences about your recent injury?” and “Can you please tell me how you felt when you were first told you had a fracture of the lower limb?” The interviews were conducted once with each participant alone in a quiet room within the hospital, in line with their preferences to ensure privacy and confidentiality. The face-to-face interviews between the researcher and participants lasted 30 to 60 min and were audio recorded with participants’ permission to ensure accurate data collection for analysis. During interviews, the researcher took field notes of participants’ verbal and nonverbal cues, including gestures, pauses, and points of emphasis, to enhance understanding of their experiences and facilitate data analysis. ²⁶

Data Analysis

Data were analyzed using Miles and Huberman’s ²⁷ thematic analysis approach, which entailed data reduction (summarizing, coding, and categorizing the data gathered), data display (establishing a pattern of relationships in the data), drawing conclusions, and verifying data. ²⁷

The audio-recorded interviews were transcribed verbatim, anonymized, and imported into MAXQDA (version 2020) software to organize and code the data. Each participant was allowed to clarify and confirm their responses during and after the interview before verbatim transcription. After reading the transcripts repeatedly to acquaint himself with the data, the researcher identified similar or related ideas or thoughts and assigned them corresponding codes. The related codes were grouped into subthemes, related subthemes were grouped into themes or categories, and the relationship between the themes or categories was further analysed. ²⁷

Data analysis was conducted concurrently with data collection, and a table of themes, subthemes, and codes was developed and refined with each interview and data analysis. The researcher discussed the data analysis with his 2 supervisors to ensure that the findings accurately reflected the participants’ responses. Disagreements among the data analysts were resolved by consensus.

Methodological Rigor

Trustworthiness was ensured in this study through Lincoln and Guba's framework of credibility, dependability, confirmability, and transferability.^28,29 Credibility (confidence in the findings) was ensured through prolonged engagement with participants and by audio-recording interviews and transcribing them verbatim for an accurate description of the participants’ experiences. ³⁰ The researcher ensured dependability (stability of data over time) by maintaining an audit trail and documenting all decisions made during the study. ³⁰ To ensure confirmability (objectivity and data congruence), the researcher maintained an audit trail of decisions, regularly debriefed study supervisors, and used participants’ verbatim quotes during data analysis. ²⁸ To ensure transferability (the extent to which findings can be applied to other settings), participants’ characteristics and contexts were clearly described alongside their experiences. ³⁰

Ethical Consideration

This study was approved by an institutional review board in Ghana. Participants were provided clear information about the research and the option to voluntarily consent or decline participation without penalty. ²⁸ Written informed consent was obtained from each participant before participating in the study. The researcher assigned participants anonymous identification numbers (P1-P18) to ensure their anonymity. The participants’ demographic data were separated from the interview data to ensure that their details could not be linked to their interview data by third parties. Participants were encouraged to answer the questions as they saw fit and could refuse to answer any questions with which they were not comfortable. They were reminded that they could also withdraw from the study at any time without consequences.

Results

Participant Characteristics

Eighteen participants aged between 19 and 72 years participated in the study. Thirteen participants were males, and 11 were married. The participant had lived with their fracture between 3 and 22 months. Participants’ characteristics are summarized in Table 1. Two themes and 6 subthemes were identified (Table 2).

Table 1.

Participant's Characteristics.

No.	Age (Years)	Sex	Marital Status	Occupation	Level of Education	Religion	Duration of Injury	Type of Fracture
P1	45	Male	Married	Driver	SHS	Islam	6 months	Tibia and fibula
P2	61	Male	Married	Retired teacher	Tertiary	Christianity	3 months	Right femur
P3	32	Female	Single	Nurse	Tertiary	Islam	1 year, 7 months	Right ankle
P4	72	Male	Married	Trader	Intermediate school	Christianity	3 months	Right hip
P5	22	Male	Single	Tricycle driver	JHS	Islam	1 year, 3 months	Right tibia fibula
P6	50	Male	Married	Farmer	O’ level	Christianity	6 months	Bilateral tibia fibula
P7	20	Female	Married	None	SHS	Christianity	2 months	Left ankle
P8	37	Male	Married	Teacher	Tertiary	Christianity	10 weeks	Left calcaneus
P9	30	Male	Single	Electrician	SHS	Islam	I year, 10 months	Left femur
P10	31	Male	Married	Scrap dealer	None	Islam	9 months	Right tibia fibula
P11	19	Male	Married	Kebab seller	SHS	Christianity	6 months	Right ankle
P12	36	Male	Married	Trader	JHS	Christianity	1 year, 4 months	Right hip and left femur
P13	24	Male	Single	Mining	SHS	Islam	7 months	Left femur
P14	20	Male	Single	Student	SHS	Islam	1 year	Right hip
P15	28	Male	Single	Butcher	SHS	Christianity	8 months	Right tibia and fibula
P16	40	Female	Widower	Trader	SHS	Christianity	1 year, 7 months	Right tibia and fibula
P17	32	Female	Married	Nurse	Tertiary	Christianity	6 months	Right tibia, fibula, and acetabulum
P18	41	Female	Divorced	Trader	None	Christianity	11 months	Left tibia

Abbreviations: SHS, Senior High School; JHS, Junior High School.

Table 2.

Themes and Subthemes.

Themes	Subthemes
Altered psychological well-being and frightening experiences	Fear of losing life, limb, and control over pain medications
	Feelings of worry and anxiety
Evolving social experience	Social isolation
	Neglect of social role
	Socioeconomic problems
	Social support availability

Theme 1: Altered Psychological Well-Being and Frightening Experiences

This theme describes participants’ frightening experiences, which contributed to deleterious changes in their mental and emotional well-being. The subthemes generated under this theme were (1) fear of losing life, limb, and control over pain medication and (2) feelings of worry and anxiety.

Fear of Losing Life, Limb, and Control Over Pain Medications

In most interviews, participants feared losing their lives or limbs due to their fractures, yet did not express them to their healthcare providers. The participants recounted needing several units of blood transfusions perioperatively, which made them fear losing their lives. Other participants were afraid they might develop complications requiring amputation of their lower limbs. The participants expressed their fears by saying;

I was thinking I will die seriously. First, the bleeding was too much and then they asked for blood; four units of blood …, they gave me the blood … the following day, I bled again, and they said we need like four again and they brought that four and the doctor said that they can’t do the surgery because, the way the leg is, if they are to try, I will die. … I was afraid I would die and or even if I don’t die, they will amputate my leg. (P11)

The participants expressed a fear of losing control over their pain medications and becoming addicted to them. They explained that their fractures were managed mainly with opioid analgesics. Several participants’ fears could be linked to healthcare providers’ advice to patients not to depend on their analgesics for pain relief. Informed by their fear of analgesic addiction, participants resorted to enduring pain instead of taking prescribed pain relief medications.

After the surgery, I was given the pain killer, … it was not working, … the nurse was like “you just must manage the pain because I wouldn’t like you to be addicted to the pain killer.” The pain will be there, but you must endure the pain. Be a man. So, I took his advice. (P10)

Feelings of Worry and Anxiety

Participants reported being worried after sustaining lower limb fractures. Most participants felt their injuries had interrupted their plans and livelihoods. They were worried they might be unable to carry out their planned activities or start and run their businesses. One participant who was a widow with a right tibia and fibula fracture was worried that her children might starve or engage in undesirable activities because of her inability to cater for them while living with a fracture.

I have been that much worried because … I was planning on starting a new business with a colleague, but then the accident happened. (P15)

My husband died not even a year ago, and this thing happens to me, and this thing can make my daughter and son starve and do things that I might not like, so I was worried it would affect my children. (P16)

Participants mentioned feeling anxious on account of their limb fracture. Whereas some participants were anxious about their surgeries, others experienced anxiety because their recovery spanned longer than they had expected. Some participants’ delayed recovery and feelings of anxiety were occasioned by their late reporting of fractures to the hospital. Participants’ treatment delay-related anxieties were worsened by their need to discard their plans and focus on their full recovery.

I was anxious because, at the hospital, they told me three months after the surgery, I would be fine. But with the bone setter, after two, three months, the leg was still like that, there was no improvement, so I was getting anxious about getting healed. (P3)

Theme 2: Evolving Social Experience

This theme describes how participants with limb fractures interacted as social beings with others and their communities. Whereas some participants felt isolated and neglected on account of their limb fractures, others received support from their relatives. The participants reported the financial challenges they experienced due to their fractures. The subthemes identified under this theme include (1) social isolation, (2) neglect of social roles, (3) socioeconomic problems, and (4) social support availability.

Social Isolation

Participants recounted how they related very well with their family and friends before their fractures. However, they mentioned feeling isolated after their fractures because they spent most of their time alone at home, with only a few relations visiting them occasionally. One participant with a right tibia and fibula fracture described how his mother told him she was not able to fund or take care of a sick person.

Everybody just leaves you alone, they never come to my house and greet me, none of my friends after I had that accident had come to the house to come and see me. I was alone, and my mother to come and take care of me too says she can’t come to take care of a sick person. (P5)

Neglect of Social Roles

The participants reported that they were unable to perform their social activities and roles, such as engaging in their previous hobbies or going out to meet friends. They described how living with lower limb fractures affected their intimacy and sexual relations with their partners. Several participants expressed that they were not thinking about sex since their fracture was a more pressing issue for them. Some participants avoided sex because they believed such an activity might worsen their injuries. Several participants explained that traditionally, they were not supposed to have sex with a fracture because it did not promote their healing or recovery.

Our forefathers told us that if you have a fracture, you are not supposed to touch a woman (have sexual intercourse). It's our tradition that if you have a fracture or a wound, you are not supposed to sleep with a woman, and I believe in it. so, I don’t have sex. (P6)

One participant admitted that although he believed that having sex may worsen his fracture may be a myth, he was not ready to take chances with the healing process of his fracture.

Oh no, when it happened traditionally, they will tell you that if you have a sore or a fracture, you don’t have sex because it can worsen it. I know it's a myth, but at times you don’t take chances. (P8)

During the interviews, participants reported that due to their lower limb fractures, they were unable to engage in the daily activities, social engagements, and hobbies they used to enjoy with their friends. They describe this experience by saying:

I like to jog. Jogging is one of my hobbies, then riding, meeting friends. I used to jog every morning and evening, riding a bicycle, and a motorcycle for my daily activities, but now I can’t do that. (P8)

My hobbies are just football. I used to play football all the time. I have been doing it since childhood, and I enjoy playing. But after the accident, I've never tried. I feel I cannot do it any longer. (P9)

Socioeconomic Problems

Participants experienced employment, financial, and cost-of-care problems while living with lower limb fractures. Several participants were unable to work and earn income on account of their fractures. Some participants felt that their businesses had stalled and that their competitors would overtake them while they recovered. The participants regretted having to start the businesses all over again.

… so, the business is locked up, I’m hoping that when I bounce back, I will figure it out, but competitors have already taken over, so it's not easy for me. I know I must start all over. (P8)

Beyond the loss of income, the long-term cost of treatment for fractures depleted the funds of most participants. Participants specifically highlighted the high cost of their surgeries, hospitalization (bed), and medication. Other healthcare-related costs, such as radiographic scans (x-rays) and transportation to the hospital for regular wound dressing, posed a financial challenge to many participants.

I spent like five thousand and fifty-one Ghana cedis ($352) and then the surgery, you know that one too, you know and then the bed and the medicine. So, it was not easy for me to pay all that money. (P11)

Social Support Availability

Despite the myriad social problems participants experienced, a few mentioned receiving social support from their partners, friends, bosses, and colleagues at work to overcome their challenges. Participants noted that their spouses supported them in seeking healthcare, visited them daily, conducted errands while they were hospitalized, and assisted them in maintaining their hygiene. Others recounted how relations (including fathers and daughters) financed their healthcare costs, which enabled them to undergo surgery and purchase medication.

My wife was so good to me because when the thing (fracture) happened, my wife was there, even food she didn’t want to take, she was crying left and right, running up and down, especially when I was in the local hospital, she always used to come every day. (P11)

Some participants explained that they were permitted to make necessary adjustments to their work, which enabled them to continue earning income while recovering from their fractures. For instance, a nurse with a right ankle fracture described how she could continue working because her colleagues allowed her to sit and make entries (document nursing activities) instead of standing to provide direct nursing care.

It's ok, you know, with work they understand me, so I don’t stand to work, I only sit and do entries. (P3)

In contrast with informally employed participants, government employees, such as public sector teachers and drivers, felt their jobs were secure and thus had adequate time to recover and return to work. This sense of job security that employers provided some participants enabled them to maintain their salaries and afford their healthcare costs.

You know, one of the conditions for the public services is some of these things, so I can’t lose my job. Just when they see that with time I can’t really stand and teach well, maybe they can advise that I move to the office where I just sit and do the work there. (P8)

Discussion

The study showed that the sudden injury leading to lower limb fracture, surgery, and postoperative recovery disrupted the patients’ preexisting roles, relationships, and finances. As found in a qualitative systematic review of patients with ankle fractures, the adults with lower limb fractures in this study experienced anxiety regarding their recovery postoperatively. ³¹ The finding that participants were worried and anxious about their diagnosis several months after their injury supports previous observations that the psychological effects of fractures persist even during treatment. ⁶ This gap highlights the importance of open and empathetic communication in recovery. Postoperatively, patients with fractures become aware of their limitations and thus may experience mental stress or anxiety, which worsens their evaluations of their self-worth. ³² When patients feel comfortable disclosing fears, concerns, and emotional struggles, it not only alleviates psychological distress but also strengthens trust and therapeutic relationships.^33,34 If healthcare providers in Ghana fostered a more supportive environment by asking open-ended questions, validating emotions, and reassuring patients, participants’ frightening experiences might have been lessened. Nurses’ messaging about pain medication heightened patients’ anxiety. This finding underscores how communication styles can inadvertently worsen distress. Such practices are consistent with the principles of patient-centered care, where care extends beyond clinical management to include psychosocial support. ³⁵ Patient-centered approaches to pain management emphasize clear explanations, shared decision-making, and reassurance about safety. ³⁶ By adopting such strategies, healthcare providers could mitigate fears about addiction or side effects while ensuring patients feel heard and respected.

The patients’ worry about their inability to carry out planned activities on account of their fractures and hospitalization highlights the lack of control or autonomy associated with lower limb fracture recovery, despite the availability of ongoing care.^32,37 This finding suggests that healthcare providers (such as nurses) must identify effective yet individualized ways of empowering adults with lower limb fractures to exercise autonomy throughout the postoperative recovery phase. To enhance recovery experiences, healthcare providers should adopt patient-centered care frameworks that prioritize dignity, respect, emotional support, and collaborative decision-making with patients. ³⁸ Care models such as the Institute of Medicine's patient-centered care framework ³⁸ and the Ghana Health Service's Respectful Maternity Care can be adapted for trauma and orthopedic care to promote patient-provider communication and patient recovery.

The social isolation experienced by adults with lower limb fractures can lead to poorer social function and participation, which may impair their postoperative recovery.^39,40 Previous authors experiencing similar isolation have advocated integrating sociological thinking and patient experience in healthcare delivery and education. ¹⁹ Thus, it is essential for adults with lower limb fractures to actively involve their significant others in their care to enable the patient to address their social needs and play their social roles throughout their recovery. ⁴¹

The finding that the cost of surgery and treatment was a major financial challenge for adults with low-limb fractures is comparable to the results of an observational study among adults with open tibial shaft fractures in Ghana. ¹⁵ Such high costs may lead patients to seek care from relatively cheaper traditional healers, such as bone setters, who may not provide the best possible care. ¹⁵ Most of the patients in this study obtained financial support from their close relations, contrary to Okoroh and Riviello. ⁴² In Ghana, where many patients rely on out-of-pocket payments despite the National Health Insurance Scheme (NHIS), costs associated with surgery, medications, rehabilitation, and transportation exacerbate distress. ⁴³ Financial challenges can worsen anxiety, limit treatment adherence, and prolong recovery. The implication is that financial insecurity intersects with emotional well-being, suggesting the need for social protection measures, NHIS reforms, and community support systems to ease the economic burden of fractures. Health policy makers should explore alternative sources of healthcare funding, such as health insurance schemes. ⁴³ Furthermore, as relations transition into their new caregiver roles, they require relevant guidance from healthcare providers to function effectively without experiencing burnout. ⁴⁴

Limitations

The participants included only individuals enrolled at a single health institution, which may not reflect the experiences of patients with lower limb fractures in different geographic or healthcare contexts. The study focused on adults aged 18 years and older, leaving out younger patients who might have different experiences with fractures in terms of coping mechanisms, dependence, and psychological effects. Future research involving larger and more diverse samples could offer deeper and broader insights into the experiences of adults with lower limb fractures.

Conclusions

This study revealed that adults living with lower limb fractures, such as femur, tibia, fibula, and ankle fractures, have to contend with a painful experience associated with multiple mental health and social well-being issues, which may not be identified or fully addressed postoperatively. The findings emphasize the importance of patient-centered care approaches that address both the physical and psychosocial well-being of adults with lower limb fractures. Healthcare providers should be trained to communicate openly and empathetically with patients, allowing them to share their emotional, social, and financial difficulties. Additionally, integrating psychosocial assessments into routine orthopedic care can help identify hidden distress early and support timely interventions. Future research should investigate the interventions that can mitigate the psychosocial challenges faced by adults with lower limb fractures, both locally and internationally.

Supplemental Material

sj-docx-1-jpx-10.1177_23743735251400003 - Supplemental material for Psychosocial Experiences of Adults With Lower Limb Fracture in Ghana: A Qualitative Study

Supplemental material, sj-docx-1-jpx-10.1177_23743735251400003 for Psychosocial Experiences of Adults With Lower Limb Fracture in Ghana: A Qualitative Study by Umar Farouk Mohammed, Eric Tornu and Lydia Aziato in Journal of Patient Experience