Surgeon perspectives on musculoskeletal injury and trauma system gaps in The Gambia: a qualitative analysis

Background: In The Gambia, Edward Francis Small Teaching Hospital (EFSTH) is unique in being the only tertiary hospital with a dedicated orthopaedic and trauma department, providing critical insights into the challenges of delivering trauma and orthopaedic care in the country. This qualitative study explored surgeon perspectives on musculoskeletal injury and barriers to trauma care delivery in The Gambia using the socioecological model. Methods: The study was conducted in January 2025 at EFSTH. Structured interviews were conducted, audio-recorded, and transcribed verbatim. Data were analyzed using inductive and deductive thematic analysis by two independent reviewers. Results: Five EFSTH surgeons participated in the study, representing multiple surgical specialties involved in musculoskeletal trauma, including orthopaedic surgery (n=2), urology (n=1), general surgery (n=1), and neurosurgery (n=1). Barriers to trauma and orthopaedic care were identified across socioecological levels. At the individual level, gaps in trauma and emergency training were noted. Interpersonal and community-level barriers included limited prehospital care and the absence of trained first responders. Institutional barriers involved weak referral pathways, poor inter-facility communication, and inadequate infrastructure, particularly in rural settings. At the policy level, participants highlighted misalignment between national priorities, funding, and implementation mechanisms. Conclusions: This study demonstrates that the burden of musculoskeletal injury in The Gambia is driven not only by injury mechanisms but by interconnected barriers spanning individual knowledge, interpersonal connections, community norms, institutional capacity, and national policy. Addressing these challenges will require deliberate investment in trauma systems, workforce development, and injury prevention strategies grounded in the Gambian context.