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Forrester JD, Forrester JA, Kamara TB, et al. Self-reported Determinants of Access to Surgical Care in 3 Developing Countries. JAMA Surg. 2016;151(3):257–263. doi:10.1001/jamasurg.2015.3431
Surgical care is recognized as a growing component of global public health.
To assess self-reported barriers to access of surgical care in Sierra Leone, Rwanda, and Nepal using the validated Surgeons OverSeas Assessment of Surgical Need tool.
Design, Setting, and Participants
Data for this cross-sectional, cluster-based population survey were collected from households in Rwanda (October 2011), Sierra Leone (January 2012), and Nepal (May and June 2014) using the Surgeons OverSeas Assessment of Surgical Need tool.
Main Outcomes and Measures
Basic demographic information, cost and mode of transportation to health care facilities, and barriers to access to surgical care of persons dying within the past year were analyzed.
A total of 4822 households were surveyed in Nepal, Rwanda, and Sierra Leone. Primary health care facilities were commonly reached rapidly by foot (>70%), transportation to secondary facilities differed by country, and public transportation was ubiquitously required for access to a tertiary care facility (46%-82% of respondents). Reasons for not seeking surgical care when needed included no money for health care (Sierra Leone: n = 103; 55%), a person dying before health care could be arranged (all countries: 32%-43%), no health care facility available (Nepal: n = 11; 42%), and a lack of trust in health care (Rwanda: n = 6; 26%).
Conclusions and Relevance
Self-reported determinants of access to surgical care vary widely among Sierra Leone, Rwanda, and Nepal, although commonalities exist. Understanding the epidemiology of barriers to surgical care is essential to effectively provide surgical service as a public health commodity in developing countries.
Surgical care is increasingly recognized as an integral component of any functional public health system in the developing world; however, until recently, programs designed to provide surgical care as a public health commodity have not been as robust as similar pediatric or medical programs.1 Improved access to surgical service has the potential to bolster public health by decreasing morbidity and mortality from traumatic injuries, fetal and maternal conditions, cancer, and abdominal and extra-abdominal conditions.2,3 The burden of these surgically treated diseases can be substantial, contributing at least 7% to 18% of the total nonavertable burden of disease in developing countries.4 The Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool is a validated population-based household survey that was designed to assess the prevalence of surgically treatable conditions in developing countries and identify deaths potentially preventable with surgical care. Additionally, respondents provided information about barriers to accessing surgical care.5-7 Public health programs intending to ensure adequate provision of surgical care must be founded on solid public health principles, understanding both the surgical burden of disease and the existing barriers to accessing care. While the burden of surgical disease in developing countries is increasingly described, barriers to accessing surgical care remain ill-defined.8 To improve understanding of existing barriers to surgical care, data from 3 cross-sectional, cluster-based population SOSAS surveys in Nepal, Rwanda, and Sierra Leone were evaluated.
Data were collected and aggregated from respondents as identified by the SOSAS survey in Nepal, Rwanda, and Sierra Leone.5-7 The SOSAS tool is a validated cross-sectional, cluster-based population survey designed to identify self-reported surgical conditions. This survey was administered in Nepal in May and June 2014, in Rwanda in October 2011, and in Sierra Leone in January 2012.5-7 Changes were minimal between the 3 versions, with the exception of local modifications for language and the addition of a visual physical examination in the Nepal survey.7
Sample size was calculated using the Cochran formula; estimated prevalence was previously established in pilot studies.5,9,10 Clusters were randomly selected in 2 stages with a probability adjusted for population size and geographic stratification into rural and urban populations. Physicians, interns, and medical and nursing students were recruited and trained according to previously described protocols in each of the 3 countries.5-7 Separate households in each cluster were randomly assigned for investigation.5-7 During the study periods, collected data were screened after data collection by field supervisors to identify inconsistencies and errors in data collection. For the present study, data from sections A, B, C, and D were used.11
A primary health care facility was defined as a facility without a functioning operating room. A secondary health care facility was defined as a facility with a functioning operating room. A tertiary health care facility was defined as a facility with a functioning operating room and a minimum of 1 surgical specialist (general surgeon, orthopedic surgeon, gynecologist, or urologist). Modern health care was defined as care provided at a health facility or by a physician or nurse. A major surgical procedure was defined as a procedure that required regional or general anesthesia. A minor surgical procedure was defined as a procedure that did not require regional or general anesthesia including dressing changes, wound care, puncture care, suturing or incision, and drainage. The cost of transport in Nepalese rupees, Rwandan francs, and Sierra Leonean leones were converted to US dollars using the conversion rate on December 23, 2014.
Statistical evaluation of the data was performed using Epi Info version 188.8.131.52 (Centers for Disease Control and Prevention). Ethical approval for this study was obtained from the ethical and scientific review committee of each country, as well as the institutional review boards of each of the collaborating institutions (Stanford University, Stanford, California; Connaught Hospital, Freetown, Sierra Leone; College of Medicine and Allied Health Science, Freetown, Sierra Leone; Johns Hopkins Hospital, Baltimore, Maryland; Nepal Medical College, Kathmandu, Nepal; University of California–San Francisco, East Bay, Oakland; University of Rwanda, Kigali, Rwanda; University of Virginia, Charlottesville; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and Columbia University, New York, New York). Permission to perform the study was obtained from each of the countries’ national health ministries prior to survey administration. Informed written and oral consent was obtained from all survey respondents and respondents did not receive a stipend.
A total of 4822 households were surveyed in Nepal (1352 of 1397 eligible households responded, 96.8%), Rwanda (1627 of 1629, 99.9%), and Sierra Leone (1843 of 1875, 98.3%); the demographic variables of the surveyed households are reported in Table 1. The median number of household members ranged from 4 in Rwanda to 6 in Sierra Leone, although the ranges of household members in each country were broad. The median age of household members and the sex distribution of members of the household were similar in all 3 countries. Approximately 30% of households surveyed in Nepal and Sierra Leone were urban and less than 10% were urban in Rwanda, consistent with the respective countries’ population distribution.
In all 3 countries, primary health care facilities were most commonly (>70%) reached by persons walking to the facilities. The median travel time to the primary facilities was brief (≤1 hour), the median waiting time for transport was short (<1 hour), and the cost of transport was low (<US$1). Funds for transport to a primary health care facility were available more often than not in all 3 countries, although respondents in Sierra Leone also frequently reported that funds were not available.
Unlike transport to a primary health care facility, transport mechanisms to a secondary health care facility were heterogeneous among the 3 countries. Most Nepalese respondents used public transportation (64%), the Rwandan respondents traveled on foot (35%), and Sierra Leonean respondents traveled by motorcycle (35%). Similarly, a wider range of travel times to secondary facilities were reported, from 1 hour in Nepal and Sierra Leone to 3 hours in Rwanda. Waiting time for transport to a secondary facility remained less than 1 hour, and the cost of transport to a secondary facility remained less than US$1. However, a greater proportion of respondents in both Sierra Leone and Rwanda reported that the funds were not available for transport to secondary health facilities.
Respondents in all 3 countries noted that public transportation was required for travel to a tertiary health care facility. Transport times to tertiary care facilities varied markedly among the 3 countries, ranging from a median of 2 hours in Nepal to 12 hours in Rwanda. The cost of transport to a tertiary care facility was greater than that to either a primary or secondary facility but was similar between the 3 countries, ranging from a median of US$2.50 in Nepal and Rwanda to US$3.50 in Sierra Leone. Similar to the response to secondary health facilities, both Rwanda and Sierra Leone respondents reported not having funds available for transport to a tertiary facility, while Nepalese respondents reported that funds were available.
Epidemiologic variables of persons dying in the year prior to the survey were included in Table 2. Approximately 70% of decedents in all 3 countries sought modern health care prior to their death. Among the 852 decedents from all 3 countries who were reported as having a condition requiring surgical consultation prior to death, the cause was reported as other (not defined) for 564 decedents (66%). Reasons for not seeking surgical care when surgical care was needed were disparate among the countries. In Nepal, an absence of facilities where surgical health care was available and the person dying before health care could be obtained were commonly described. Both of these reasons for not obtaining surgical care were also described in Rwanda, although no trust in health care or fear in health care were also common causes for not seeking surgical care. Finally, in Sierra Leone, no money for health care and the person dying before health care could be obtained were the most common reasons for not obtaining surgical care.
Self-reported determinants of surgical health care–seeking behavior varied widely among the 3 developing countries assessed; these health care–seeking trends are dependent on the unique sociocultural context of each country. As suggested for other public health commodities, such as maternal and child health, barriers to access to surgical care are likely multifactorial.12 This study provides tangible evidence that any program designed to offer surgery as a public health commodity must identify and accommodate these country- or regional-level challenges; these results parallel existing reviews of access to care extrapolated to surgical disease.8 Additionally, programs should consider acknowledging health care determinants, such as transportation and point-of-need care, that transcend all 3 countries that might be useful in guiding surgical public health provision.
Access to primary health care facilities located in all 3 countries was reported to be quick, low-cost, and accomplished by travel on foot. However, by definition, these facilities did not have an operating room. Protocols for providing basic fracture management, wound care, and emergency obstetric care at primary health care facilities, as suggested by the World Health Organization for sudden-onset disasters, could provide access to urgent care at primary facilities for persons who would otherwise be unable to obtain this basic care.13 In contrast, developing novel ways to provide access to a wider range of outpatient urgent surgical care at a primary health center is more complex because of infrastructure needs such as trained personnel, supplies, anesthesia, and sterilization capabilities. Two potential scenarios for developing surgical capacity at these primary health care facilities include the following. First, domestic and international resources could be devoted to these primary health care facilities, providing permanent operative capacity and personnel. However, given financial constraints faced by developing countries, this option appears unlikely to be financially sustainable. A second option requires offering temporary surgical services with temporary operative theaters and surgeons (either national or international) providing preventive surgical care, with follow-up care provided by trained, permanent health facility staff or local community health workers. These programs might serve to train future local health care professionals and develop surgical capacity and infrastructure. This model has been used successfully for hernias(http://www.operationhernia.org.uk/), cleft lip or palate repair (http://www.operationsmile.org/), and cataract surgery (http://www.cureblindness.org/). Task shifting of surgical services to nonphysician clinicians might further increase the pool of potential surgical professionals.14 A challenge that remains unmet is how to expand these models to more complex surgical care such as oncologic screening or curative or preventive oncologic surgery.
In the 3 countries surveyed, access to secondary facilities was more expensive than primary facilities and required different modes of transportation. While respondents in Rwanda still primarily accessed secondary facilities by foot, the time required to reach these facilities was greater. For respondents in Nepal and Sierra Leone, mechanical transportation was reported as necessary. Similarly, public transportation was frequently reported as being required for transport to a tertiary health care facility in all 3 countries. Importantly, these secondary and tertiary facilities are where most higher-acuity surgical care is provided. The observation that Rwanda had the longest transport times may be a reflection of the rural population distribution; in Rwanda, only 10% of the survey was an urban-based group compared with 30% in the other countries. Urban populations have greater access to higher-level health facilities because health centers tend to be clustered in areas with greater population density.
Access to higher-level facilities also showed reliance on mechanical transportation. This is associated with an increased cost to the patients (which may take time for patients or families to mobilize) and reliant on either a functional public transportation system or a robust private transportation market, both of which are dependent on a stable political environment. Supporting this is the 30% to 40% of decedents in all 3 countries who died before access to surgical care could be arranged and the 10% to 40% of decedents for whom there was no accessible facility where surgical care was provided. Additionally, the increased transport time to get to these facilities may decrease the number of persons willing to seek surgical care early for conditions that are not perceived as life-threatening or urgent.15 It is likely that public investment in emergency transport services, such as ambulances, may improve access to these secondary and tertiary facilities provided that the full cost of transport is not completely passed on to the end user.
Low levels of understanding about surgical conditions might be another determinant that negatively impacts access to surgical care. Of the conditions requiring surgical consultation that persons experienced prior to death, most respondents reported the condition as other, despite a broad list of presented surgical conditions. This could be attributed to either insufficient descriptions of these conditions by enumerators or a poor understanding by the general population of what conditions can or should receive surgical consultation. Enumerators were trained and closely supervised to ensure quality data collection so poor enumeration seems less likely.5-7 Previous studies in these 3 countries have demonstrated that between 50% and 80% of respondents either received no education or education stopped at primary school; the literacy rate ranged from 60% to 70%.5-7 Even when educated, there is no guarantee that a person without formal medical training will understand which conditions need to be evaluated by a surgeon, underscoring the importance of accessible local surgical consultation.
Ill persons, particularly those who do not have surgical consulting services within close proximity, might instead present to traditional care professionals, an observation supported by the approximately 10% to 30% of decedents who sought care at a traditional healer prior to death. Education of, and collaboration with, traditional healers or other substitute health workers may be beneficial to improve referral and follow-up of patients with surgical conditions, a tactic used with other diseases.16-18 Investment in the education of surgical disorders for local first responders might further speed diagnosis, particularly for surgical emergencies. Additionally, public health messaging regarding treatable surgical conditions, such as hernias, obstetric fistulas, and oncologic conditions, are infrequent in many developing countries, and advertisement might represent an underrecognized opportunity to increase public awareness of surgical conditions.
There were several limitations to this study. Because the SOSAS survey instrument depends on self-reporting, the completeness and accuracy of reported conditions depends on the knowledge of the respondents and the probing of the enumerators. The 3 surveys occurred sequentially in these countries and it is likely that lessons learned in administering the first survey in Rwanda impacted the survey performed in Sierra Leone and subsequently Nepal. However, it is unlikely that this would substantially influence the responses regarding transit time, cost, and availability in these countries. Another limitation was that each of these surveys represents a point-in-time assessment and, as such, are highly dependent on the existing socio-politico-economic environs in the country. Nevertheless, these surveys do provide important snapshots of existing barriers to persons seeking surgical care in these 3 countries. Finally, recall bias may have been present in the respondents who described the health care–seeking trends of decedents within the past year. However, recall of injuries or death has been demonstrated to be adequate up to 12 months.19 Additional limitations, including that of language and translation, have been described previously.5-7
The limitations of this point-in-time survey underscore the importance of further robust analysis of determinants of surgical care. To assess these determinants of care-seeking behavior, traditionally considered to be outside of the realm of surgical provision, surgeons interested in developing robust programs in resource-limited settings will benefit from a multidisciplinary approach.20 Social scientists and anthropologists will be critical in determining how to convince those who might benefit from surgery to seek available surgical care. Logisticians can help to provide expertise in supply chain management and transportation. Epidemiologists can help surgeons develop durable, objective surgical disease surveillance systems that use verified clinical or pathologic evidence of disease to more accurately describe disease burden. By using these subject-matter experts, surgeons can work to develop programs that offer surgical services to those who need it in a way that will promote the use of these services.
Successful provision of surgical care as a public health commodity will require both an understanding of the burden of disease in a country and existing barriers to accessing surgical care in a country. There will not be a 1-size-fits-all public health option suitable for providing and sustaining surgical care in the developing world. A rational public health approach to understanding delivery of surgical care is essential, understanding that preventive surgical interventions at the local level may have a substantial impact on deliverability. Additionally, establishing surgery as a preventive intervention in local areas might allow for the repair of surgical conditions before they result in morbidity or mortality requiring specialized care at distant treatment centers. Further studies are required to delineate other barriers to surgical care in developing countries. Understanding these barriers is essential if surgery is to take its place among the list of essential global public health commodities.
Corresponding Author: Joseph D. Forrester, MD, MSc, Department of Surgery, Stanford University, 300 Pasteur Dr H3591, Stanford, CA 94305-5641 (email@example.com).
Published Online: November 4, 2015. doi:10.1001/jamasurg.2015.3431.
Author Contributions: Drs J. D. Forrester and Wren had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Groen, Shrestha, Gupta, Kyamanywa, Petroze, Kushner.
Acquisition, analysis, or interpretation of data: J. D. Forrester, J. A. Forrester, Kamara, Groen, Petroze, Kushner, Wren.
Drafting of the manuscript: J. D. Forrester, J. A. Forrester, Shrestha.
Critical revision of the manuscript for important intellectual content: J. D. Forrester, Kamara, Groen, Gupta, Kyamanywa, Petroze, Kushner, Wren.
Statistical analysis: J. D. Forrester, J. A. Forrester, Gupta.
Obtained funding: Gupta, Petroze.
Administrative, technical, or material support: J. A. Forrester, Gupta, Petroze, Kushner, Wren.
Study supervision: Kamara, Groen, Kyamanywa, Kushner, Wren.
Conflict of Interest Disclosures: None reported.
Funding/Support:Surgeons OverSeas, a non-profit organization, provided funding for this study.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the affiliated institutions. Dr Wren is on the Editorial Board of JAMA Surgery but was not involved in the editorial review or the decision to accept the manuscript for publication.
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