Fractures in Sub-Saharan Africa: Epidemiology, Economic Impact and Ethnography; The FRACTURES-E3 Study


Full study website: 

Funder: Collaborator Award funded by the NIHR-Wellcome Partnership for Global Health Research

PI: Prof Celia Gregson (University of Bristol, UK)


Prof Bilkish Cassim (University of Kwa-Zulu Natal, South Africa)

Prof Matt Costa (University of Oxford, UK)

Prof Rashida Ferrand  (Biomedical Research and Training Institute, Zimbabwe / London School of Hygiene and Tropical Medicine, UK)

Prof Rachael Gooberman Hill (University of Bristol, UK)

Dr Sian Noble (University of Bristol, UK) 

Prof Kate Ward (University of Southampton, UK / MRC Gambia, The Gambia)

Dates: 1st October 2020–30th September 2025


Life expectancy is rising more rapidly in Africa than any other continent globally. As countries in sub-Saharan Africa (SSA) transition due to rapid urbanisation, their changing demographics are giving rise to an increasing burden of non-communicable diseases (NCDs) of ageing, this includes fractures, often as a consequence of skeletal fragility. Fractures can be devastating, causing pain, disability, loss of productivity and sometimes death. Such fractures may occur in the context of multimorbidity (e.g. obesity and osteoarthritis). At the same time in SSA, communicable diseases (e.g. HIV), with both short- and longer-term sequelae, continue to affect millions of people every year. In high-income countries fractures place significant strain on healthcare services and budgets. For countries in Africa to plan future healthcare services we need to understand the epidemiology of key fracture types, their costs both monetarily and for the patient themselves, and what healthcare resources are currently in place to provide for those who fracture, and that might be amenable to future development 1.


In South Africa, Zimbabwe, and The Gambia we will establish how frequently two key age-related fractures occur: vertebral fractures (the commonest) and hip fractures (the most life-challenging), and the associated risk factors for these fracture types. We will assess recovery, disability and death rates following hip fracture, and identify factors that improve outcomes for patients. We will calculate how much fractures cost health services now and in the future. By talking with patients and healthcare workers we will learn of their experiences and gain insights into how fracture care can be improved in the future.

Aims and Approach

This study is an international mixed-methods study using cross-sectional and longitudinal study designs together with ethnographic study to investigate the epidemiology, economic impact, and ethnography of fractures in The Gambia, Zimbabwe, and SA. Within four workpackages (WP) we aim to address the following objectives:

WP1. Determine the epidemiology of vertebral fractures

a)       Quantify vertebral fracture prevalence amongst men and women aged 40 years and older by community-based population surveys across urban, peri-urban, and rural settings.

b)      Determine clinical risk factors for vertebral fractures, particularly the role of HIV and HIV-related factors, the role of traditional osteoporosis risk factors, and other co-morbidities, between individuals with and without fracture. We will further determine the prevalence of wider musculoskeletal morbidities, including osteoarthritis, sarcopenia and injurious falls, and associations with functional impairment in terms of activities of daily living (ADLs), and health-related quality-of-life (HR-QOL).  Individuals surveyed in WP1(a) without a history of hip fracture, will provide an age and sex frequency-matched comparator group for the incident hip fracture population, identified in 2(b) below.

WP2. Determine the epidemiology of hip fractures

a)       Determine hip fracture incidence in men and women aged 40 years and older. Understand risk factors, fracture mechanisms (determining the burden due to fragility relative to trauma), and management received (Zimbabwe and The Gambia only, as data recently published from South Africa 2)

b)      Establish hip fracture outcomes over 12 months, including hospital length-of-stay, readmission, mortality, function in terms of ADLs, disability, and HR-QOL, and predictors of adverse outcomes.

WP3. Determine the health costs attributable to incident hip fractures and model future fracture burdens

a)       Using high-quality patient and site-level cost data on healthcare in the year following hip fracture we will perform health economic analyses to determine the direct and indirect health costs and budget impact attributable to hip fracture care, informing decision makers on affordability of different care models.

b)      We will establish the main predictors of healthcare costs using risk factors and outcomes recorded in WP2.

c)       We will determine the cost-effectiveness of different pathways of care and cost-effectiveness-based intervention thresholds for the treatment of osteoporosis within these settings.

d)      Combining data from WP1, WP2 and population projection data, we will model future fracture burdens and health costs predicted to be attributable to hip fracture within the region.

WP4. Quantify current hip fracture services for each country (WP4)

We will quantify current hip fracture services for each country, including types of facilities, fracture services, referral patterns, drug supplies/costs, staffing, equipment, and radiology using the modified WHO Service Availability & Readiness Assessment (SARA) survey framework.

WP5. Understand and characterise care pathways for hip fracture and identify factors that help and hinder set-up and implementation of fracture services (WP5)

If ultimately this research is to impact health policy and the configuration of fracture services in SSA, it is crucial to understand current health services and management practices to inform healthcare improvement strategies. We will characterise hip fracture services by ethnographic study in both urban and rural environments, aiming to understand:

a)      Pathways to and through fracture care, including how people with fractures do or do not make it into and through current services.

b)      Factors that help or hinder the implementation of fracture treatment services. We will explore and characterise decision rationales and barriers and facilitators to care delivery.

Expected impact

Greater understanding of fracture care will be able to inform health service policy and planning in SSA, for example it is intended that our findings will influence essential medicines availability, calibrate risk assessment tools for generalised clinical use, inform national clinical guidelines and advise health service development for the future.

Figure 1: Overview of Study Design & Co-investigators FE3 overview of study design and co-investigators

Presentations by Celia Gregson and Kate Ward providing background and introduction to this project available here:



1. Gregson CL, Cassim B, Micklesfield LK, et al. Fragility fractures in sub-Saharan Africa: time to break the myth. Lancet Global Health 2019;7(1):E26-E27.

2. Dela SS, Paruk F, Brown SL, et al. Ethnic and gender-specific incidence rates for hip fractures in South Africa: A multi-centre study. Bone 2020;133:115253. doi: 10.1016/j.bone.2020.115253


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