Introduction

Fragility fractures are fractures resulting from low-energy trauma such as falls from standing height or less [1]. Patients who sustained fragility fractures often have underlying osteoporosis and are at risk of subsequent falls or fractures [2]. While fragility fractures are associated with significant morbidity and mortality, there remains a gap in the delivery of secondary fracture prevention [3, 4]. A Fracture Liaison Service (FLS) is a coordinator-based model developed to reduce subsequent fractures and mortality by increasing the diagnosis of osteoporosis and improving the treatment of osteoporosis [5, 6]. FLS was first introduced in Glasgow, Scotland in 1999 [6, 7]. Generally, FLS involves proactive identification of fragility fracture patients, bone health investigations, osteoporosis treatment initiation where necessary, and follow-up to improve treatment adherence [6].

Despite the known benefits of a FLS, its uptake and implementation have not been universal. A review of the secondary fracture prevention service in Singapore highlighted insufficient resources and a lack of knowledge on the importance of FLS as a barrier to its implementation [8]. Secondary fracture prevention is not a top priority for policymakers; hence, osteoporosis is not included in Singapore’s chronic disease management program [8].

Several qualitative studies regarding the implementation of a FLS have been conducted in Canada and the United Kingdom [9–12]. Some were done post-implementation [9, 11, 12], whilst one was conducted both at baseline and post-implementation to gauge how views changed over time [10]. Most studies addressed challenges and facilitators of a successful FLS implementation [10–12], whilst one study reported on strategies needed to develop a business case for the implementation of a FLS [9]. Interviews with healthcare professionals (HCPs) and members of the FLS implementation steering committee, such as managers and social workers, revealed that fracture prevention coordinators were the key to successful implementation as they helped in coordinating and promoting multidisciplinary teamwork [11, 12]. In addition, demonstrating the need for a FLS, providing resources and selecting an appropriate site for a FLS were reported as facilitators for FLS implementation [10].

In Malaysia, the delivery of secondary fracture prevention care has been reported to be lacking [4, 13]. Lack of clarity regarding the team responsible for managing osteoporosis was one of the osteoporosis treatment care gaps [14]. FLS can help address this problem as it improves coordination between departments [6]. Although a previous qualitative study was done to identify strategies for implementing a FLS [10], findings from this study may not be applicable as their healthcare system differs from Malaysia. To date, there is a paucity of data regarding the views of relevant stakeholders on the current delivery of secondary fracture prevention and their willingness to participate in or implement a FLS from a middle-income developing country in Asia. Therefore, this study aimed to explore the views of healthcare professionals regarding the barriers and facilitators for a FLS in Malaysia, especially to facilitate its implementation in this tertiary hospital.

Materials and methods

Theory

The theory of planned behaviour (TPB) was selected as the conceptual framework in this study as it could help predict stakeholders’ intention to set up a FLS and understand factors that either encourage or hinder them from implementing a FLS [15] (Fig 1). The theory proposes that an individual’s intention and behaviour (the setting up of a FLS) are driven by three major constructs: attitude, subjective norms, and perceived behavioural control. Attitude refers to an individual’s positive or negative evaluation of performing a behaviour. In our study, we assessed stakeholders’ attitudes by exploring their opinions on the current delivery of secondary fracture prevention and the perceived importance of implementing an FLS. Subjective norm involves the perceived social pressure to perform or not perform a behaviour. We investigated this construct by understanding stakeholders’ perceptions of whether significant others (such as family, friends, and colleagues) support or oppose the implementation of the FLS model. Perceived behavioural control is the perceived ease or difficulty of performing a behaviour, reflecting past experiences and anticipated obstacles. We identified this by examining the barriers and facilitators stakeholders perceive in implementing and sustaining the FLS model. These constructs together shape stakeholders’ intentions, indicating their willingness and readiness to implement and sustain the FLS model.

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Fig 1. Conceptual framework based on the Theory of Planned Behaviour.

https://doi.org/10.1371/journal.pone.0307919.g001

Instruments used

Participants’ basic information was collected using a baseline demographic questionnaire. A topic guide (Table 1) was used to guide interviews. The same topic guide was modified to cater for the different stakeholders (S1 Appendix). For policymakers, questions that might influence their decision-making process regarding a new service implementation were included. If the participants had never heard of the term “FLS” or secondary fracture prevention, it would be explained to them during the interviews.

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Table 1. Topic guide for semi-structured in-depth interviews.

https://doi.org/10.1371/journal.pone.0307919.t001

Results

A total of 13/20 doctors, 8/10 nurses, 8/10 pharmacists and 1/11 policymakers agreed to participate (response rate = 58.8%) (Table 2).

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Table 2. Baseline demographic characteristics of study participants.

https://doi.org/10.1371/journal.pone.0307919.t002

Three themes emerged from our data (Table 3). Themes and subthemes are presented in detail below (S2 Appendix).

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Table 3. Themes emerged from qualitative data analysis.

https://doi.org/10.1371/journal.pone.0307919.t003

Discussion

This study contributes to the existing body of work by identifying the best way to implement FLS in a middle-income developing country in Asia by exploring the local stakeholders’ perceptions of FLS implementation. The use of qualitative methods and the TPB was suitable as it helped identify the various perceptions of the stakeholders regarding FLS implementation and their willingness to participate in FLS.

Some participants deemed that the delivery of secondary fracture prevention was adequate for hip fracture patients, as they were co-managed by members of the orthopaedics and geriatric medicine team. However, patients with non-hip fragility fractures were not included, potentially resulting in a disparity in care. Despite a higher proportion of hip fracture patients being initiated on antiosteoporosis medications compared to wrist fracture patients, previous studies have shown a secondary fracture prevention gap in Malaysia [4, 13, 17, 18]. Our participants were unaware of this gap, especially the gap among patients with non-hip fractures. This lack of awareness could be a barrier to FLS implementation as participants did not perceive an urgent need for it. FLS was needed to help close the gap as it aims to cover all patients with fragility fractures.

The policymaker expressed that while FLS was important, it was not considered urgent. Our findings were similar to Singapore, where secondary fracture care prevention is also not a priority with policymakers, and therefore not included in their national policy [8]. In contrast, Canada’s FLS is part of their health services network and receives good support as the fragility fracture population had been made a priority [10]. The lack of focus on FLS in our country may impose challenges in obtaining resources to run FLS.

Our participants thought that FLS had many benefits, and therefore supported the need for a FLS. Our findings concurred with previous studies that reported that FLS could improve treatment initiation and bone health investigations, reduce refracture rates and mortality [5]. The perceived importance and benefits of FLS would encourage the participants to set up and implement a FLS [15]. Communicating the benefits of FLS to patients and providers would facilitate its implementation [10].

FLS was perceived as cost-effective by our participants. Previous studies have also proven the cost-effectiveness of FLS regardless of the site of fractures [19–21]. Given the long-term reduction of re-fracture rates by FLS, the initial cost of implementation was considered negligible. Demonstrating cost-effectiveness data could help support FLS implementation in Malaysia.

Additionally, our participants emphasised the need for support from relevant stakeholders to ensure successful FLS implementation. A multidisciplinary team including doctors, nurses, pharmacists, dietitians, physiotherapists, occupational therapists, social workers and administrative staff should be involved, as supported by findings from other studies [10, 11]. A study in Alberta, Canada reported that establishing a provincial steering committee to facilitate learning and monitor FLS implementation was effective, providing a platform for experience sharing, discussion and decision-making [10]. In addition, regular multidisciplinary team meetings helped ensure service sustainability. Successful FLS stories from other facilities could further facilitate implementation. However, FLS should be tailored to the local context, and the involvement of local champions is essential [10, 12]. Nevertheless, our participants felt that the FLS should not be too champion-driven, but instead should be incorporated into routine clinical service.

Based on a previous study, orthopaedic surgeons were identified as key implementation stakeholders, given their primary role in managing fragility fracture patients. They could positively influence the perception of the orthopaedic team and other relevant stakeholders [12]. However, an orthopaedic surgeon mentioned that competing priorities among orthopaedic doctors led to a lack of focus on secondary fracture prevention. Efforts were needed to change the mindset of the orthopaedic doctors and subsequently improve awareness of the importance of secondary fracture prevention.

To ensure the sustainability of a FLS, our participants agreed on the need for a coordinator to help identify fragility fracture patients, refer them for bone health investigations, initiate treatment and provide follow-up care [22, 23]. However, In resource-limited countries, there is a need to implement the service with available resources, which is true to our situation. Therefore, job reallocation among the currently available manpower may be required to help with the implementation of the service.

Most doctors believed that nurses were the most suitable candidates to be FLS coordinators, consistent with previous findings [22]. However, our nurses lacked the confidence to take up this role as they felt that this role required a person with leadership qualities to effectively coordinate the team. At present, the majority of the registered nurses in Malaysia are diploma graduates and may perceive themselves as not being on par with other healthcare professional graduates. More training and supervision are needed to empower nurses to take on the role of FLS coordinator. Incentives may help encourage participation [11].

Pharmacists were included in this study due to their potential to become a FLS coordinator, as seen in other countries [24]. Pharmacists believed they were capable of assuming this role due to their expertise in medication knowledge. However, they were very short-staffed.

Particularly in our setting, doctors in primary care are unable to prescribe antiosteoporosis medications, posing a challenge for the transition of patients from secondary care to primary care [25]. Consequently, the majority of the fragility fracture patients were treated at the tertiary hospitals and their management was not decentralised. Moreover, the cost of the antiosteoporosis medications was often borne by these tertiary centres. This discrepancy was not reported in other FLS studies as there were no prescribing restrictions on antiosteoporosis medications for primary care doctors. Future studies may explore other general practitioners’ views on secondary fracture prevention management and FLS, providing valuable insights to support policy changes facilitating treatment transition and continuation.

One of the limitations of our study was that it was performed in a tertiary teaching hospital. Given the diverse healthcare systems in Malaysia, the findings may not be generalised to institutions with different healthcare settings. Further work may be needed to explore barriers, especially in rural settings where bone mineral density machines may be lacking. We were only able to recruit one policymaker despite two rounds of emails. This may be because COVID-19 was still the main priority of the policymakers during the study period. Several pharmacists and nurses were not aware of FLS, and although the definition was provided during the interview, input from these participants was more limited due to the lack of understanding regarding this service. Our study only involved policymakers at the hospital level as they were the decision-makers for service implementation at the hospital. Nevertheless, future studies may explore stakeholders’ views at a national level as it may help promote service implementation on a larger scale. Finally, our study mainly focused on the initial phases of FLS implementation, it would be beneficial to explore the barriers and facilitators of running FLS long-term in future studies.

Conclusion

Our participants highlighted the necessity of a FLS to enhance secondary fracture prevention in Malaysia. However, they identified several challenges, including the lack of confidence among nurses in taking up the role of FLS coordinator, the need to implement the service within the constraints of limited resources, and the lack of prescribing rights for antiosteoporosis medications among primary care physicians. Support from relevant stakeholders, improved FLS awareness, the presence of FLS coordinator and national policy were required to improve the sustainability of FLS. Providing training for nurses can help boost their confidence and encourage the uptake of the FLS coordinator role.

Supporting information