<p>Observation schedule in community settings.</p>

Across Africa, the average age of the population is increasing, leading to a rise in health challenges such as hip fractures. Surgical fixation is the standard of care for hip fracture in older adults. In The Gambia, traditional bone setters (TBS) remain an important source of fracture care, though concerns exist regarding complications. In resource-constrained settings, system constraints may also result in post-operative complications. Currently treatment-seeking decisions are poorly understood. We aimed to map hip fracture care pathways to understand factors affecting engagement with TBS and biomedical care. Ethnographic case studies, comprising interviews with 38 patients and 37 caregivers, were complemented by contextual observations of care provision. The social ecological model informed analyses. The model distinguishes five inter-related components influencing illness behaviour: (i) intrapersonal, (ii) interpersonal, (iii) organisational or institutional, (iv) socio-cultural factors, and (v) public policies. Findings showed the complexity of hip fracture care pathways, with most patients moving between TBS, public and private healthcare facilities. Intrapersonal: patients often delayed seeking care because they did not think low-trauma injuries were serious. After visiting TBS, experiences of pain and dependency motivated biomedical care seeking. Some older people avoided surgery because they lacked the “strength” to survive an operation. Interpersonal: decisions about treatment largely rested with caregivers, strongly influenced by finances. Organisational factors favouring TBS included convenience, affordability and prolonged waiting times for operations. Ambiguous terminologies used by healthcare professionals to describe fractures were influential. Socio-cultural factors included beliefs about the causes of fractures, traditions around visiting TBS and fears of biomedical care. Public policy: healthcare financing requiring patients to pay before accessing care encouraged many to seek TBS for timely treatment. Findings highlight the need to co-develop interventions with TBS to help patients navigate complex care pathways and address organisational barriers within biomedical services, whilst respecting local perceptions of TBS.