Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey

[Analysis of burden and equality of lower extremity peripheral artery disease in people aged 40 and above in the Belt and Road partner countries from 1990 to 2021]

OBJECTIVES

To analyze the disease burden and inequalities of lower extremity peripheral artery disease (LEPAD) among people aged 40 and above in the Belt and Road partner countries from 1990 to 2021.

METHODS

Data were retrieved from the Global Burden of Disease 2021 database. The age-standardized prevalence rates, mortality rates, and the annual rate of years lived with disability (YLDs) of LEPAD were analyzed. Trends were measured using the estimated annual percentage change (EAPC), and the slope index of inequality (SII) and concentration index were used to quantify the absolute and relative inequalities.

RESULTS

In 2021, the age-standardized prevalence and mortality rates of LEPAD were 3168.26/105 and 3.09/105, increasing by 4.30% and 19.31% compared to 1990, while YLDs rates decreased by 4.00%. Females had higher age-standardized prevalence and YLDs rates, while males had higher mortality rates. The EAPC for prevalence rates was slightly higher in males (0.22%) than in females (0.17%); while the EAPC of age-standardized mortality rate was 2.02% for females, compared to 1.45% for males. From 1990 to 2021, the age-standardized YLDs rates decreased from 16.23/105 to 15.58/105, with a faster decline in females (－0.12%) than in males (－0.06%). LEPAD prevalence varied across countries, with higher burden in Europe and faster growth in Gulf states. Higher socio-demographic index countries had higher prevalence. Inequity improved, with the SII at 52.90/105 and concentration index at 0.038 in 2021. Gender disparities persisted, with concentration index increased to 0.058 in females and reduced to －0.026 in males.

CONCLUSIONS

LEPAD prevalence and mortality among people aged 40 and above in the Belt and Road partner countries increased, while YLDs rates decreased from 1990 to 2021. Significant differences among people exist depending on gender and country, highlighting the need for enhanced screening, health education, and shared public health strategies across the Belt and Road partner countries.

Incidence and prevalence of traumatic and non-traumatic wounds and burns and access to wound care in Sierra Leone; data from a nationwide household survey (PRESSCO) 2020

Objectives

This wound section of the PREvalence Study on Surgical COnditions (PRESSCO) determines the incidence and prevalence of wounds and burns in Sierra Leone. It further describes access to wound care and wound-related healthcare-seeking behaviour.

Methods

Between October 2019 and March 2020, a nationwide cross-sectional household survey was performed. The survey was based on Surgeons OverSeas Assessment of Surgical Need (SOSAS). Additional questions relating to wounds and burns were added. Following randomization, 25 households in 75 clusters were sampled. Severe wounds were clinically examined.

Results

Of the 3600 individuals included, 143 had developed 151 wounds, including burns (15.2 %) during the year preceding the interview (incidence 4.2 %). A total of 77 people had 83 wounds and burns at the time of the survey (prevalence 2.3 %), of which 23 were severe (prevalence 0.6 %). Burn incidence and prevalence were 0.6 % and 0.1 %, respectively. Most wounds were on extremities (73.5 %), often resulting from cuts (32.8 %), falls (22.4 %), or road traffic accidents (RTA; 16.4 %). Risk factors for developing a wound were male sex (p = 0.004), older age (p = 0.037) and smoking (p = 0.001). Severe wounds had a median duration of 18 months. For 70.2 % of wounds, care at a health facility was sought. Only 49.9 % of households reported financial capacity to visit a secondary health facility. For 56 (37.1 %) of wounds, the desired care was not obtainable. An estimated 44,000 (95 % CI 29,760-67,410) people in Sierra Leone suffer from a severe wound. An estimated 11,000 (95 % CI 6,416-18,268) annual deaths occur due to wounds, predominantly due to RTA's (66.7 %) and accidental injuries (20.0 %).

Conclusions

Wounds and burns account for an extensive burden on the health and economics of the individual, the household, and the Sierra Leonean society. For over one-third of wounds, the desired surgical care was not obtainable.

Structures, processes and outcomes between first referral and referral hospitals in low-income and middle-income countries: a secondary preplanned analysis of the FALCON and ChEETAh randomised trials

First referral hospitals, often known as district hospitals, are neglected in the discourse on universal health coverage in low-income and middle-income countries (LMICs). However, these hospitals are important for delivering safe surgery for 313 million people. This study aims to understand the structures, processes and outcomes of patients undergoing surgery in these centres in LMICs. This is a preplanned secondary analysis using data from two high-quality randomised controlled trials undergoing major abdominal surgery across six LMICs. Type of hospital was the main explanatory variable, defined according to the WHO taxonomy as first referral (ie, district or rural) and referral (ie, secondary or tertiary). Of the included 15 657 patients across 80 hospitals from 6 countries, 3562 patients underwent surgery in first referral and 12 149 patients underwent surgery in referral centres. First referral centres have lower full-time surgeons (median: 1 vs 20, p<0.001) and medically trained anaesthetists (28.6% vs 87.1%, p<0.001) compared with referral centres. Patients undergoing surgery in first referral centres were more likely to have lower rates of American Society of Anaesthesiologist (ASA) grades III-V (8.1% vs 22.7%, p<0.001), but higher rates of emergency procedures (65.1% vs 56.6%, p<0.001). In first referral centres, there was a significantly higher use of WHO surgical safety checklist (99.4% vs 93.3%, p<0.001) compared with referral centres. In adjusted analyses, there were no differences in 30-day mortality (OR 1.09, 95% CI 0.73 to 1.62) and surgical site infection (OR 1.30, 95% CI 0.89 to 1.90) between first referral and referral centres. Postoperative mortality and surgical site infection remain similar between first referral and referral centres in LMICs. There may be a clear need to upscale surgical volume safely in first referral centres to meet global surgical needs. High-quality research is needed to drive safe expansion of surgical workforce and strengthen referral pathways within these surgical health systems in LMICs.

The economic burden associated with unmet surgical needs in Liberia: a retrospective macroeconomic analysis based on a nationwide enumeration of surgical procedures

OBJECTIVES

The economic consequences of untreated surgical disease are potentially large. The aim of this study was to estimate the economic burden associated with unmet surgical needs in Liberia.

DESIGN

A nationwide enumeration of surgical procedures and providers was conducted in Liberia in 2018. We estimated the number of disability-adjusted life years (DALYs) saved by operative activities and converted these into economic losses averted using gross national income per capita and value of a statistical life (VSL) approaches. The total, the met and the unmet needs for surgery were determined, and economic losses caused by unmet surgical needs were estimated. Finally, we valued the economic losses avoided by various surgical provider groups.

RESULTS

A total of 55 890 DALYs were averted by surgical activities in 2018; these activities prevented an economic loss of between US$35 and US$141 million. About half of these values were generated by the non-specialist physician workforce. Furthermore, a non-specialist physician working a full-time position for 1 year prevented an economic loss of US$717 069 using the VSL approach, while a specialist resident and a certified specialist saved US$726 606 and US$698 877, respectively. The burden of unmet surgical need was associated with productivity losses of between US$388 million and US$1.6 billion; these losses equate to 11% and 46% of the annual gross domestic product for Liberia.

CONCLUSION

The economic burden of untreated surgical disease is large in Liberia. There is a need to strengthen the surgical system to reduce ongoing economic losses; a framework where specialist and non-specialist physicians collaborate may result in better economic return than a narrower focus on training specialists alone.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Determinants of Access to Essential Surgery in the Democratic Republic of Congo

INTRODUCTION

In the Democratic Republic of Congo (DRC), the determinants and barriers of essential surgical care are not well described, hindering efforts to improve national surgical programs and access.

METHODS

A cross-sectional study evaluated access to essential surgery in the Butembo and Katwa health zones in the North Kivu province of DRC. A double-clustered random sample of community members was surveyed using questions derived from the Surgeons OverSeas Surgical Needs Assessment Survey, a validated tool to determine the reasons for not seeking, reaching, or receiving a Bellwether surgery (i.e., caesarean delivery, laparotomy, and external fixation of a fracture) when needed.

RESULTS

Overall, 887 households comprising 5944 community members were surveyed from April to August 2022. Six percent (n = 363/5944) of the study population involving 35% (n = 309/887) households needed a Bellwether surgery in the previous year, 30% (n = 108/363) of whom died. Of those who needed surgery, 25% (n = 78) did not go to the hospital to seek care and were more likely to find transportation unaffordable (P = 0.042). The most common reasons for not seeking care were lack of funds for hospitalization, prior poor hospital experience, and fear of hospital care.

CONCLUSIONS

Access and delivery of essential surgery are drastically limited in the North Kivu province of the DRC, such that a quarter of households needing surgery fails to seek surgical care. Poor access was predominantly driven by households' inability to pay for surgery and community distrust of the hospital system.

Physical injuries and burns among refugees in Lebanon: implications for programs and policies

BACKGROUND

Refugees are prone to higher risks of injury due to often austere living conditions, social and economic disadvantages, and limited access to health care services in host countries. This study aims to systematically quantify the prevalence of physical injuries and burns among the refugee community in Western Lebanon and to examine injury characteristics, risk factors, and outcomes.

METHODS

We conducted a cluster-based population survey across 21 camps in the Beqaa region of Lebanon from February to April 2019. A modified version of the 'Surgeons Overseas Assessment of Surgical Need (SOSAS)' tool (Version 3.0) was administered to the head of the refugee households and documented all injuries sustained by family members over the last 12 months. Descriptive and univariate regression analyses were performed to understand the association between variables.

RESULTS

750 heads of households were surveyed. 112 (14.9%) households sustained injuries in the past 12 months, 39 of which (34.9%) reported disabling injuries that affected their work and daily living. Injuries primarily occurred inside the tent (29.9%). Burns were sustained by at least one household member in 136 (18.1%) households in total. The majority (63.7%) of burns affected children under 5 years and were mainly due to boiling liquid (50%). Significantly more burns were reported in households where caregivers cannot lock children outside the kitchen while cooking (25.6% vs 14.9%, p-value = 0.001). Similarly, households with unemployed heads had significantly more reported burns (19.7% vs. 13.3%, p value = 0.05). Nearly 16.1% of the injured refugees were unable to seek health care due to the lack of health insurance coverage and financial liability.

CONCLUSIONS

Refugees severely suffer from injuries and burns, causing substantial human and economic repercussions on the affected individuals, their families, and the host healthcare system. Resources should be allocated toward designing safe camps as well as implementing educational awareness campaigns specifically focusing on teaching about heating and cooking safety practices.

Picture Cards Versus Physical Examination: A Proof-of-Concept Study to Improve the SOSAS Survey Tool

INTRODUCTION

The Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool is used to determine the unmet surgical needs in the community and has been validated in several countries. A major weakness is the absence of an objective assessment to verify patient-reported surgically treatable conditions. The goal of this study was to determine whether a picture portfolio, a tool previously shown to improve parental recognition of their child's congenital deformity, could improve the accuracy of the SOSAS tool by how it compares with physical examination. This study focused on children as many surgical conditions in them require prompt treatment but are often not promptly diagnosed.

METHODS

We conducted a descriptive cross-sectional community-based study to determine the prevalence of congenital and acquired surgical conditions among children and adults in a mixed rural-urban area of Lagos, Southwest Nigeria. The picture portfolio was administered only to children and the surgical conditions to be assessed were predetermined using an e-Delphi process among pediatric surgeons. The modified The Surgeons OverSeas Assessment of Surgical Needs-Nigeria Survey Tool (SOSAS-NST) was administered to household members to collect other relevant data. Data were analyzed using the REDCap analytic tool.

RESULTS

Eight hundred and fifty-six households were surveyed. There were 1984 adults (49.5%) and 2027 children (50.5%). Thirty-six children met the predetermined criteria for the picture portfolio-hydrocephalus (n = 1); lymphatic malformation (n = 1); umbilical hernia (n = 14); Hydrocele (n = 5); inguinal hernia (n = 10) and undescended testes (n = 5). The picture portfolio predicted all correctly except a case of undescended testis that was mistaken for a hernia. The sensitivity of the picture portfolio was therefore 35/36 or 97.2%.

CONCLUSIONS

The SOSAS-NST has improved on the original SOSAS tool and within the limits of the small numbers, the picture portfolio has a high accuracy in predicting diagnosis in children in lieu of physical examination.

There is a great variety of orthopaedic conditions presenting to a large hospital in Sierra Leone: a 3-year prospective study

PURPOSE

In Sierra Leone there is a large void in orthopaedic research into the type of orthopaedic injuries, both acute and chronic. Improved data collection is essential in providing insight to guide health care planning and research. This study aims to outline the types of orthopaedic injury sustained.

METHOD

Data were prospectively collected by local surgeons in the Orthopaedic outpatient department at a large hospital between January 2016 and January 2019.

RESULTS

The orthopaedic department saw a mean 728 patients per year, with mean age 24.0 years. The workload comprised of 64.92% acute orthopaedic conditions or their complications, with 35.08% elective orthopaedics. Fractures made up the largest proportion of clinical appointments, annually 244.33 fractures; however there was a high incidence of osteomyelitis.

CONCLUSION

The study gives an important insight into the types and distribution of elective and trauma orthopaedic injuries sustained in Sierra Leone, which has not been previously reported, and highlights key areas where resources may be focused in order to improve clinical outcomes.

Specialty preferences of studying-abroad medical students from low- and middle-income countries

BACKGROUND

This study explored the specialty preferences of China-educated international medical students (IMSs), who are mainly from low- and middle-income countries (LMICs) and constitute a potential medical workforce both for their home countries and foreign countries, and the influence of migration intentions on their specialty preferences.

METHODS

A cross-sectional, questionnaire-based survey was conducted at 5 universities in China. The questionnaire link was distributed electronically among the IMSs at the 5 universities via emails. The questionnaire enquired IMSs' demographic information, migration intentions and their specialty preferences. The Chi-square test was applied to determine the influence of the respondent's gender, intention to practise in the home country and intention to practise in a high-income country on their specialty choices. The Chi-square test was also applied to determine the influence of the respondent's gender, year of study and country of origin on their preferences for generalist-orientated or non-generalist orientated specialties.

RESULTS

Altogether, 452 IMSs returned their responses, yielding a response rate of 64.1%. Approximately half of the IMSs planned to not return to their home country. The most selected specialty was general surgery and the least selected specialty was physical medicine and rehabilitation. No significant differences were evident in most specialty preferences between those who intended to return home and those who intended to stay abroad. Among the IMSs having intentions of returning to their home country, male students tended to choose a generalist-orientated specialty, while female students tended to choose a non-generalist-orientated specialty.

CONCLUSION

China-educated IMSs could play important roles in the primary care services as well as other shortage specialties both for their home countries or foreign countries. Therefore, it is recommended that governments in these countries plan migration and recruitment policies that cater for these studying-abroad medical students from LMICs, especially in this challenging time during the COVID-19 pandemic.

Pathways to effective surgical coverage in a lower-middle-income country: A multiple methods study of the family physician-led generalist surgical team in rural Nepal

The Lancet Commission on Global Surgery (LCoGS) recommends using specialist surgical workforce density as one of 6 core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care. Using Nepal as a case study, we explored the capacity of a generalist workforce (led by a family physician or MD general practitioner and non-physician anaesthetist) to enable effective surgical delivery through task-shifting. Using a multiple-methods approach, we retrospectively mapped essential surgical care and the enabling environment for surgery in 39 hospitals in 25 remote districts in Nepal and compared it with LCoGS indicators. All 25 districts performed surgery, 21 performed Caesarean section (CS), and 5 met at least 50% of district CS needs. Generalist surgical teams performed CS, the essential major operation at the district level, and very few laparotomies, but no operative orthopaedics. The density of specialist Surgeon/Anaesthesiologist/Obstetrician (SAO) was 0·4/100,000; that of Generalist teams (gSAO) led by a family physician (MD General Practitioners-MDGP) supported by non-physician anaesthetists was eight times higher at 3·1/100,000. gSAO presence was positively associated with a two-fold increase in CS availability. All surgical rates were well below LCoGS targets. 46% of hospitals had adequate enabling environments for surgery, 28% had functioning anaesthesia machines, and 75% had blood transfusion services. Despite very low SAO density, and often inadequate enabling environment, surgery can be done in remote districts. gSAO teams led by family physicians are providing essential surgery, with CS the commonest major operation. gSAO density is eight times higher than specialists and they can undertake more complex operations than just CS alone. These family physician-led functional teams are providing a pathway to effective surgical coverage in remote Nepal.

Prevalence and Severity of Burn Scars in Rural Mozambique

BACKGROUND

Burn injuries are common in low- and middle-income countries (LMICs) and their associated disability is tragic. This study is the first to explore burn scars in rural communities in Mozambique. This work also validated an innovate burn assessment tool, the Morphological African Scar Contractures Classification (MASCC), used to determine surgical need.

METHODS

Using a stratified, population-weighted survey, the team interviewed randomly selected households from September 2012 to June 2013. Three rural districts (Chókwè, Nhamatanda, and Ribáuè) were selected to represent the southern, central and northern regions of the country. Injuries were recorded, documented with photographs, and approach to care was gathered. A panel of residents and surgeons reviewed the burn scar images using both the Vancouver Scar Scale and the MASCC, a validated visual scale that categorizes patients into four categories corresponding to levels of surgical intervention.

RESULTS

Of the 6104 survey participants, 6% (n = 370) reported one or more burn injuries. Burn injuries were more common in females (57%) and most often occurred on the extremities. Individuals less than 25 years old had a significantly higher odds of reporting a burn scar compared to people older than 45 years. Based on the MASCC, 12% (n = 42) would benefit from surgery to treat contractures.

CONCLUSION

Untreated burn injuries are prevalent in rural Mozambique. Our study reveals a lack of access to surgical care in rural communities and demonstrates how the MASCC scale can be used to extend the reach of surgical assessment beyond the hospital through community health workers.

Strengthening rural surgery in the Philippines: Essential in achieving universal health care

The Lancet Commission on Global Surgery (LCoGS) launched Global Surgery 2030 to address the surgical services inequities with a bias toward low-income and middle-income countries like the Philippines. The same inequity is observed particularly when it comes to the urban-rural divide. With more than half of the population living in rural areas, access to surgery becomes a major challenge that further impedes the much-needed health of an economically productive workforce. The Universal Health Care [UHC] Act (RA 11332) of 2019 ensures that all Filipinos have access to quality, cost-effective, promotive, preventive, curative, rehabilitative, and palliative health services without causing a financial burden. Recognizing the provision of essential surgery, in the context of primary healthcare is important. It should be accessible, continuous, comprehensive, and coordinated at the time of need - parallel to the principle of primary health care. Driven by this concept and experiences, the authors conceptualized and presented the Philippine Rural Surgery model for future development and implementation. This is envisioned to provide essential surgery among local rural primary health care settings that is universal, accessible, cost-effective and safe. As this is still new in the Philippines, we proposed tenets and recommendations based on WHO Health System Strengthening building blocks to guide stakeholders in creating formal plans towards institutionalization under the principles of UHC. Such access to surgical service in the context of a unique socio-demography of the Philippines would be essential in attaining the parameters and provisions set by the UHC Act.

General Surgery: Requirements, Rationale, and Robust Results

Safe, timely, and affordable surgical care is desirable worldwide, but is largely an unmet need. Surgical care is recognized as an important component of public health. Vision for sustainable surgical development is desirable, and general surgeons can contribute substantially toward this mission. In the absence of surgical care, case-fatality rates are high for common and easily treatable conditions. These include congenital anomalies, hernia, fractures, appendicitis, etc. Solution is surgical care. Results of surgery on time are rewarding. General surgeons, as per the Medical Council of India, are required to (1) recognize the health needs of the community and carry out professional obligations, (2) be competent, and (3) be aware of the contemporary advances and developments in the discipline concerned. All this ensures that the general surgeon should be able to treat almost all surgical conditions effectively. With timely, cautious, careful, and tactful surgeries, general surgeons should be able to deliver robust results both electively and in emergency. All this in the true spirit of "Vayam Sevaamahe - We are for service" the motto of the Association of Surgeons of India. General surgeons should boost the best what was termed " Professional patriotism " in the historic Flexner report.

Global economic burden of unmet surgical need for appendicitis

BACKGROUND

There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis.

METHODS

Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism.

RESULTS

Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and $73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and $75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality.

CONCLUSION

For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially.

PREvalence Study on Surgical COnditions (PRESSCO) 2020: A Population-Based Cross-Sectional Countrywide Survey on Surgical Conditions in Post-Ebola Outbreak Sierra Leone

Background

Understanding the burden of diseases requiring surgical care at national levels is essential to advance universal health coverage. The PREvalence Study on Surgical COnditions (PRESSCO) 2020 is a cross-sectional household survey to estimate the prevalence of physical conditions needing surgical consultation, to investigate healthcare-seeking behavior, and to assess changes from before the West African Ebola epidemic.

Methods

This study (ISRCTN: 12353489) was built upon the Surgeons Overseas Surgical Needs Assessment (SOSAS) tool, including expansions. Seventy-five enumeration areas from 9671 nationwide clusters were sampled proportional to population size. In each cluster, 25 households were randomly assigned and visited. Need for surgical consultations was based on verbal responses and physical examination of selected household members.

Results

A total of 3,618 individuals from 1,854 households were surveyed. Compared to 2012, the prevalence of individuals reporting one or more relevant physical conditions was reduced from 25 to 6.2% (95% CI 5.4–7.0%) of the population. One-in-five conditions rendered respondents unemployed, disabled, or stigmatized. Adult males were predominantly prone to untreated surgical conditions (9.7 vs. 5.9% women; p < 0.001). Financial constraints were the predominant reason for not seeking care. Among those seeking professional health care, 86.7% underwent surgery.

Conclusion

PRESSCO 2020 is the first surgical needs household survey which compares against earlier study data. Despite the 2013–2016 Ebola outbreak, which profoundly disrupted the national healthcare system, a substantial reduction in reported surgical conditions was observed. Compared to one-time measurements, repeated household surveys yield finer granular data on the characteristics and situations of populations in need of surgical treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06695-7.

Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society's role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.

The Development and Inclusion of Questions on Surgery in the 2018 Zambia Demographic and Health Survey

Data from household surveys serve as the backbone to sustainable development planning. For the first time, questions on surgery have been included in a nationwide Demographic and Health Survey, showing that it is feasible to integrate these questions into a large-scale survey.

Background:

While primary data on the unmet need for surgery in low- and middle-income countries is lacking, household surveys could provide an entry point to collect such data. We describe the first development and inclusion of questions on surgery in a nationally representative Demographic and Health Survey (DHS) in Zambia.

Method:

Questions regarding surgical conditions were developed through an iterative consultative process and integrated into the rollout of the DHS survey in Zambia in 2018 and administered to a nationwide sample survey of eligible women aged 15–49 years and men aged 15–59 years.

Results:

In total, 7 questions covering 4 themes of service delivery, diagnosed burden of surgical disease, access to care, and quality of care were added. The questions were administered across 12,831 households (13,683 women aged 15–49 years and 12,132 men aged 15–59 years). Results showed that approximately 5% of women and 2% of men had undergone an operation in the past 5 years. Among women, cesarean delivery was the most common surgery; circumcision was the most common procedure among men. In the past 5 years, an estimated 0.61% of the population had been told by a health care worker that they might need surgery, and of this group, 35% had undergone the relevant procedure.

Conclusion:

For the first time, questions on surgery have been included in a nationwide DHS. We have shown that it is feasible to integrate these questions into a large-scale survey to provide insight into surgical needs at a national level. Based on the DHS design and implementation mechanisms, a country interested in including a set of questions like the one included in Zambia, could replicate this data collection in other settings, which provides an opportunity for systematic collection of comparable surgical data, a vital role in surgical health care system strengthening.

Knowledge, awareness, attitudes and screening practices towards breast and cervical cancer among women in Nepal: a scoping review

Aim

Breast and cervical cancers have emerged as major global health challenges and disproportionately affect women in low- and middle-income countries, including Nepal. This scoping review aimed to map the knowledge, attitudes and screening practices for these cancers among Nepali women to improve cancer outcomes and reduce inequality.

Methods

Five electronic databases (CINAHL, Embase, Global Health, PsycINFO and PubMed), grey literature, and reference and citation lists were searched for articles published in English up to June 2021. Articles were screened against inclusion/exclusion criteria, and data from eligible studies were extracted. Results were summarised narratively.

Results

The search yielded 615 articles, 38 of which were included in this scoping review (27 cervical cancer, 10 breast cancer, 1 both cancers). Levels of knowledge regarding breast and cervical varied widely. The main knowledge gaps were misconceptions about symptoms and risk factors, and poor understanding of screening behaviours. Screening practices were mostly inadequate due to socio-cultural, geographical or financial barriers. Positive attitudes towards cervical screening were associated with higher education and increased knowledge of screening modalities. Higher levels of knowledge, (health) literacy and participation in awareness campaigns facilitated breast cancer screening.

Conclusion

Knowledge and screening practices for breast and cervical cancer among Nepali women were poor and highlight the need for awareness and education programmes. Future research should explore community health worker-led awareness and screening interventions for cervical cancer, and programmes to increase the practice of breast self-examination and clinical breast examinations to support early diagnosis of breast cancer.

Humanitarian surgical service utilization by a host country population: comparing surgery patterns between refugees and Tanzanians using an interrupted time-series analysis

Background

While current estimates suggest that up to three million additional surgical procedures are needed to meet the needs of forcibly displaced populations, literature on surgical care for refugee or forced migrant populations has often focused on acute phase and war-related trauma or violence with insufficient attention to non-war related pathologies. To our knowledge, no study has compared refugee versus host population utilization of surgical services in a refugee camp-based hospital over such an extended period of twenty years. The aim of this paper is to first describe the patterns of surgical care by comparing refugee and host population utilization of surgical services in Nyarugusu refugee camp between 2000 and 2020, then evaluate the impact of a large influx of refugees in 2015 on refugee and host population utilization.

Methods

The study was based on a retrospective review of surgical logbooks in Nyarugusu refugee camp (Kigoma, Tanzania) between 2000 and 2020. We utilized descriptive statistics and multiple group, interrupted time series methodology to assess baseline utilization of surgical services by a host population (Tanzanians) compared to refugees and trends in utilization before and after a large influx of Burundian refugees in 2015.

Results

A total of 10,489 operations were performed in Nyarugusu refugee camp between 2000 and 2020. Refugees underwent the majority of procedures in this dataset (n = 7,767, 74.0%) versus Tanzanians (n = 2,722, 26.0%). The number of surgeries increased over time for both groups. The top five procedures for both groups included caesarean section, bilateral tubal ligation, herniorrhaphy, exploratory laparotomy and hysterectomy. In our time series model, refugees had 3.21 times the number of surgeries per quarter at baseline when compared to Tanzanians. The large influx of Burundian refugees in 2015 impacted surgical output significantly with a 38% decrease (IRR = 0.62, 95% CI 0.46–0.84) in surgeries in the Tanzanian group and a non-significant 20% increase in the refugee group (IRR = 1.20, 95% CI 0.99–1.46). The IRR for the difference-in-difference (ratio of ratios of post versus pre-intervention slopes between refugees and Tanzanians) was 1.04 (95% CI 1.00–1.07), and this result was significant (p=0.028).

Conclusions

Surgical care in conflict and post-conflict settings is not limited to war or violence related trauma but instead includes a large burden of obstetrical and general surgical pathology. Host population utilization of surgical services in Nyarugusu camp accounted for over 25% of all surgeries performed, suggesting some host population benefit of the protracted refugee situation in western Tanzania. Host population utilization of surgical services was apparently different after a large influx of refugees from Burundi in 2015.

Paediatric surgical conditions in Malawi - A cross-sectional nationwide household survey

Background

Untreated surgical conditions may lead to lifelong disability in children. Treating children with surgical conditions may reduce long-term effects of morbidity and disability. Unfortunately, low- and middle-income countries have limited resources for paediatric surgical care. Malawi, for example, has very few paediatric surgeons. There are also significantly inadequate infrastructures and personnel to treat these children. In order to strengthen resources that could provide such services, we need to begin by quantifying the need.

Aim

To estimate the approximate prevalence of surgical conditions among children in Malawi, to describe the anatomical locations and diagnoses of the conditions and the presence of injuries.

Methods

A cross-sectional, nationwide survey of surgical needs was performed in 28 of 29 districts of Malawi. Villages, households and household members were randomly selected. A total of 1487 households were visited and 2960 persons were interviewed. This paper is a sub analysis of the children in the dataset. Information was obtained from 255 living children and inquiry from household respondents for the 255 children who had died in the past year. The interviews were conducted by medical students over a 60-day period, and the validated SOSAS tool was used for data collection.

Results

There were 67 out of 255 (26.3%) total children living with a surgical condition at the time of the study, with most of the conditions located in the extremities. Half of the children lived with problems due to injuries. Traffic accidents were the most common cause. Two-thirds of the children living with a surgical condition had some kind of disability, and one-third of them were grossly disabled. There were 255 total deceased children, with 34 who died from a surgical condition. The most prevalent causes of death were congenital anomalies of the abdomen, groin and genital region.

Conclusion

An extrapolation of the 26% of children found to be living with a surgical condition indicates that there could be 2 million children living with a condition that needs surgical consultation or treatment in Malawi. Congenital anomalies cause significant numbers of deaths among Malawian children. Children living with surgical conditions had disorders in their extremities, causing severe disability. Many of these disorders could have been corrected by surgical care.

Early evaluation of the transition from an analog to an electronic surgical logbook system in Sierra Leone

BACKGROUND

Surgical logbooks are a commonly used tool for quality assurance of surgical training. Electronic logbooks are increasingly applied in low-resource settings, but there is limited research on their quality. The aim of this study is to evaluate the quality of an app-based surgical e-logbook system shortly after its implementation in a low-income country and to identify potential areas of improvement for the system.

METHODS

Entries in the e-logbook system were cross-checked with hospital records and categorized as matched or overreported. Moreover, the hospital records were checked for underreported procedures. Additionally, semi-structured interviews were conducted with users of the e-logbook system.

RESULTS

A total of 278 e-logbook database entries and 379 procedures in the hospital records from 14 users were analyzed. Matches were found in the hospital records for 67.3% of the database entries. Moreover, 32.7% of the database entries were overreported and 50.7% of the procedures in the hospital records were underreported. A previous study of an analog surgical logbook system in the same setting estimated that 73.1% of the entries were matches or close matches. Interviews with 12 e-logbook users found overall satisfaction but also identified potential areas of improvement, including the need for more training in the use of the system, modifications to improve user-friendliness, and better access to the necessary technology.

CONCLUSIONS

A reliable documentation system is necessary to evaluate the quality of health workforce training. The early evaluation of a surgical e-logbook system in a low-income country showed that the collected data should be approached with caution. The quantitative analysis suggests that the e-logbook system needs to be improved in terms of accuracy. In interviews, users reported that digitalization of the logbook system was a much-needed innovation but also identified important areas of improvement. Recognition of these aspects at an early stage facilitates guidance and adjustment of further implementation and might improve the accuracy of the system.

Nationwide enumeration of emergency operations performed in Ghana

PURPOSE

To determine the population-based rate of emergency surgery performed in Ghana, categorized by hospital level.

METHODS

Data on operations performed from June 2014 to May 2015 were obtained from a nationally representative sample of hospitals and scaled up to nationwide estimates. Operations were categorized as to: "emergency" or "elective" and as to "essential" (most cost-effective, highest population impact) or "other" according to the World Bank's Disease Control Priorities project.

RESULTS

Of 232,776 (95% UI 178,004-287,549) total operations performed nationally, 48% were emergencies. 112,036 emergency operations (95% UI 92,105-131,967) were performed and the annual national rate was 416 per 100,000 population (95% UI 342-489). Most emergency operations (87%) were in the essential category. Of essential emergency procedures, 47% were obstetric and gynecologic, 22% were general surgery, and 31% were trauma. District (first-level) hospitals performed 54%, regional hospitals 10%, and tertiary hospitals 36% of all emergency operations. About half (54%) of district hospitals did not have a fully trained surgeon, however, these hospitals performed 36% of district hospital emergency operations and 20% of all emergency operations.

CONCLUSIONS

Emergency operations make up nearly half of all operations performed in Ghana. Most are performed at district hospitals, many of which do not have fully trained surgeons. Obstetric procedures make up a large portion of emergency operations, indicating a need for improved provision of non-obstetric emergency surgical care. These data are useful for future benchmarking efforts to improve availability of emergency surgical care in Ghana and other low- and middle-income countries.

The Burden of Surgical Disease and Access to Care in a Vulnerable Syrian Refugee Population in Lebanon

Background

The Syrian conflict has produced one of the largest refugee crises in modern times. Lebanon has taken in more Syrian refugees per capita than any other nation. We aimed to study the burden of surgical disease and access to surgical care among Syrian refugees in Lebanon.

Methods

This study was designed as a convenient cross-sectional cluster-based population survey of all refugee camps throughout the Bekaa region of Lebanon. We used a modified version of the Surgeons OverSeas Assessment of Surgical Need to identify surgical conditions and barriers to care access. The head of household of each informal tented settlement provided demographic information after which two household members were randomly chosen and administered the survey.

Results

A total of 1,500 individuals from 750 households representing 21 camps were surveyed. Respondents had a mean age of 36.6 (15.0) years, 54.6% were female, and 59% were illiterate. Nearly 25% of respondents reported at least one surgical condition within the past year, most commonly involving the face, head, and neck region (32%) and extremities (22%). Less than 20% of patients with a surgical condition reported seeing any healthcare provider, > 75% due to financial hardship.

Conclusions

The prevalence of surgical disease among Syrian refugees is very high with a fourth of refugees suffering from one or more surgical conditions over the past year. The surgical needs of this vulnerable population are largely unmet as financial reasons prevent patients from seeking care. Local and humanitarian efforts need to include increased access to surgical care.

Incidence of childhood injuries and modifiable household risk factors in rural Ghana: a multistage, cluster-randomised, population-based, household survey

OBJECTIVE

We aimed to describe the incidence of childhood household injuries and prevalence of modifiable household risk factors in rural Ghana to inform prevention initiatives.

SETTING

357 randomly selected households in rural Ghana.

PARTICIPANTS

Caregivers of children aged <5 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Childhood injuries that occurred within 6 months and 200 metres of the home that resulted in missed school/work, hospitalisation and/or death. Sampling weights were applied, injuries were described and multilevel regression was used to identify risk factors.

RESULTS

Caregivers from 357 households had a mean age of 35 years (SD 12.8) and often supervised ≥2 children (51%). Households typically used biomass fuels (84%) on a cookstove outside the home (79%). Cookstoves were commonly <1 metre of the ground (95%). Weighted incidence of childhood injury was 542 per 1000 child-years. Falls (37%), lacerations (24%), burns (12%) and violence (12%) were common mechanisms. There were differences in mechanism across age groups (p<0.01), but no gender differences (p=0.25). Presence of older children in the home (OR 0.15, 95% CI 0.09 to 0.24; adjusted OR (aOR) 0.26, 95% CI 0.13 to 0.54) and cooking outside the home (OR 0.28, 95% CI 0.19 to 0.42; aOR 0.25, 95% CI 0.13 to 0.49) were protective against injury, but other common modifiable risk factors (eg, stove height, fuel type, secured cabinets) were not.

CONCLUSIONS

Childhood injuries occurred frequently in rural Ghana. Several common modifiable household risk factors were not associated with an increase in household injuries. Presence of older children was a protective factor, suggesting that efforts to improve supervision of younger children might be effective prevention strategies.

Geospatial analysis of pediatric surgical need and geographical access to care in Somaliland: a cross-sectional study

BACKGROUND

The global burden of disease in children is large and disproportionally affects low-income and middle-income countries (LMICs). Geospatial analysis offers powerful tools to quantify and visualise disparities in surgical care in LMICs. Our study aims to analyse the geographical distribution of paediatric surgical conditions and to evaluate the geographical access to surgical care in Somaliland.

METHODS

Using the Surgeons OverSeas Assessment of Surgical Need survey and a combined survey from the WHO's (WHO) Surgical Assessment Tool-Hospital Walkthrough and the Global Initiative for Children's Surgery Global Assessment in Paediatric Surgery, we collected data on surgical burden and access from 1503 children and 15 hospitals across Somaliland. We used several geospatial tools, including hotspot analysis, service area analysis, Voronoi diagrams, and Inverse Distance Weighted interpolation to estimate the geographical distribution of paediatric surgical conditions and access to care across Somaliland.

RESULTS

Our analysis suggests less than 10% of children have timely access to care across Somaliland. Patients could travel up to 12 hours by public transportation and more than 2 days by foot to reach surgical care. There are wide geographical disparities in the prevalence of paediatric surgical conditions and access to surgical care across regions. Disparities are greater among children travelling by foot and living in rural areas, where the delay to receive surgery often exceeds 3 years. Overall, Sahil and Sool were the regions that combined the highest need and the poorest surgical care coverage.

CONCLUSION

Our study demonstrated wide disparities in the distribution of surgical disease and access to surgical care for children across Somaliland. Geospatial analysis offers powerful tools to identify critical areas and strategically allocate resources and interventions to efficiently scale-up surgical care for children in Somaliland.

Identifying knowledge needed to improve surgical care in Southern Africa using a theory of change approach

Surgical healthcare has been prioritised in the Southern African Development Community (SADC), a regional intergovernmental entity promoting equitable and sustainable economic growth and socioeconomic development. However, challenges remain in translating political prioritisation into effective and equitable surgical healthcare. The AfroSurg Collaborative (AfroSurg) includes clinicians, public health professionals and social scientists from six SADC countries; it was created to identify context-specific, critical areas where research is needed to inform evidence-grounded policy and implementation. In January 2020, 38 AfroSurg members participated in a theory of change (ToC) workshop to agree on a vision: ‘An African-led, regional network to enable evidence-based, context-specific, safe surgical care, which is accessible, timely, and affordable for all, capturing the spirit of Ubuntu[1]’ and to identify necessary policy and service-delivery knowledge needs to achieve this vision. A unified ToC map was created, and a Delphi survey was conducted to rank the top five priority knowledge needs. In total, 45 knowledge needs were identified; the top five priority areas included (1) mapping of available surgical services, resources and providers; (2) quantifying the burden of surgical disease; (3) identifying the appropriate number of trainees; (4) identifying the type of information that should be collected to inform service planning; and (5) identifying effective strategies that encourage geographical retention of practitioners. Of the top five knowledge needs, four were policy-related, suggesting a dearth of much-needed information to develop regional, evidenced-based surgical policies. The findings from this workshop provide a roadmap to drive locally led research and create a collaborative network for implementing research and interventions. This process could inform discussions in other low-resource settings and enable more evidenced-based surgical policy and service delivery across the SADC countries and beyond.

People with amputations in rural Sierra Leone: the impact of 3D-printed prostheses

We report the case of a man with a transhumeral amputation in a rural area of Sierra Leone. The patient had fractured his humerus during a football match. Due to lack of transportation and medical centres nearby, the patient was seen by a traditional healer. Although the traditional healer expected the fractured bone to heal within 3 days, the open fracture became infected. This finally resulted in a transhumeral amputation. The patient began to have a lack of self-confidence and felt excluded from society. He could not afford a conventionally fabricated prosthesis. Fourteen years later, the patient received a lightweight three-dimensional-printed arm prosthesis developed at the Masanga Hospital. The patient was very satisfied because the prosthesis met his criteria of aesthetics and functionality. His story highlights the socioeconomic hardship of being a person with an amputation in Sierra Leone and the need for affordable technological solutions.

Geospatial Mapping of Pediatric Surgical Capacity in North Kivu, Democratic Republic of Congo

BACKGROUND

Despite recent attention to the provision of healthcare in low- and middle-income countries, improvements in access to surgical services have been disproportionately lagging.

METHODS

This study analyzes the geographic variability in access to pediatric surgical services in the province of North Kivu, Democratic Republic of Congo (DRC). On-site data collection was conducted using the Global Assessment of Pediatric Surgery tool. Spatial distribution of providers was mapped using the Geographical Information System and open-sourced spatial data to determine distances traveled to access surgical care.

RESULTS

Forty facilities were evaluated across 32 health zones; 68.9% of the provincial population was within 15 km of these facilities. Eleven facilities met a minimum World Health Organization safety score of 8; 48.1% of the population was within 15 km of corresponding facilities. The majority of children were treated by someone with specific pediatric surgery training in only 4 facilities; one facility had a trained pediatric anesthesia provider. Fifty-seven percent of the population was within 15 km of a facility with critical care and emergency medicine (EM) capabilities. There was one pediatric critical care provider and no pediatric EM providers identified within the province. Location-allocation assessment is needed to combine geographic area with potential for greatest impact and facility assessment.

CONCLUSIONS

Limitations in access to surgical care in the DRC are multifactorial with poor resources, few formally trained surgical providers, and near-absent access to pediatric anesthesiologists. The study highlights the deficits in the capacity for surgical care while demonstrating a reproducible model for assessment and identification of ways to improve access to care.

Economic impact of surgery on households and individuals in low income countries: A systematic review

BACKGROUND

Surgical disease in Low Income Countries (LIC) is common, and overall provision of surgical care is poor. A key component of surgical health systems as part of universal health coverage (UHC) is financial risk protection (FRP) - the need to protect individuals from financial hardship due to accessing healthcare. We performed a systematic review to amalgamate current understanding of the economic impact of surgery on the individual and household. Our study was registered on Research registry (www.researchregistry.com).

METHODS

We searched Pubmed and Medline for articles addressing economic aspects of surgical disease/care in low income countries. Data analysis was descriptive in light of a wide range of methodologies and reporting measures. Quality assessment and risk of bias analysis was performed using study design specific Joanna-Briggs Institute checklists. This study has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines.

RESULTS

31 full text papers were identified for inclusion; 22 descriptive cross-sectional studies, 4 qualitative studies and 5 economic analysis studies of varying quality. Direct medical, direct non-medical and indirect costs were variably reported but were substantial, resulting in catastrophic expenditure. Costs had far reaching economic impacts on individuals and households, who used entire savings, took out loans, reduced essential expenditure and removed children from school to meet costs.

CONCLUSION

Seeking healthcare for surgical disease is economically devastating for individuals and households in LICs. Policies directed at strengthening surgical health systems must seek ways to reduce financial hardship on individuals and households from both direct and indirect costs and these should be monitored and measured using defined instruments from the patient perspective.

What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure

OBJECTIVES

To measure the financial burden associated with accessing surgical care in Sierra Leone.

DESIGN

A cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical and indirect costs for surgical care, and summary household assets. Missing data were imputed.

SETTING

The main tertiary-level hospital in Freetown, Sierra Leone.

PARTICIPANTS

335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards.

OUTCOME MEASURES

Rates of catastrophic expenditure (a cost >10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs and means used to meet these costs were derived.

RESULTS

Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10%) was spent prehospital. Of costs incurred during the hospital admission, direct medical costs were US$138 (63%) and US$34 (16%) were direct non-medical costs. US$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (six patients) had health insurance.

CONCLUSION

Obtaining surgical care has substantial economic impacts on households that pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.

Staff recognition and its importance for surgical service delivery: a qualitative study in Freetown, Sierra Leone

We examined the views of providers and users of the surgical system in Freetown, Sierra Leone on processes of care, job and service satisfaction and barriers to achieving quality and accessible care, focusing particularly on the main public tertiary hospital in Freetown and two secondary and six primary sites from which patients are referred to it. We conducted interviews with health care providers (N = 66), service users (n = 24) and people with a surgical condition who had chosen not to use the public surgical system (N = 13), plus two focus groups with health providers in primary care (N = 10 and N = 10). The overall purpose of the study was to understand perceptions on processes of and barriers to care from a variety of perspectives, to recommend interventions to improve access and quality of care as part of a larger study. Our research suggests that providers perceive their relationships with patients to be positive, while the majority of patients see the opposite: that many health workers are unapproachable and uncaring, particularly towards poorer patients who are unable or unwilling to pay staff extra in the form of informal payments for their care. Many health care providers note the importance of lack of recognition shown to them by their superiors and the health system in general. We suggest that this lack of recognition underlies poor morale, leading to poor care. Any intervention to improve the system should therefore consider staff-patient relations as a key element in its design and implementation, and ideally be led and supported by frontline healthcare workers.

What factors shape surgical access in West Africa? A qualitative study exploring patient and provider experiences of managing injuries in Sierra Leone

INTRODUCTION

Surgical access is central to universalising health coverage, yet 5 billion people lack timely access to safe surgical services. Surgical need is particularly acute in post conflict settings like Sierra Leone. There is limited understanding of the barriers and opportunities at the service delivery and community levels. Focusing on fractures and wound care which constitute an enormous disease burden in Sierra Leone as a proxy for general surgical need, we examine provider and patient perceived factors impeding or facilitating surgical care in the post-Ebola context of a weakened health system.

METHODS

Across Western Area Urban (Freetown), Bo and Tonkolili districts, 60 participants were involved in 38 semistructured interviews and 22 participants in 5 focus group discussions. Respondents included surgical providers, district-level policy-makers, traditional healers and patients. Data were thematically analysed, combining deductive and inductive techniques to generate codes.

RESULTS

Interacting demand-side and supply-side issues affected user access to surgical services. On the demand side, high cost of care at medical facilities combined with the affordability and convenient mode of payment to the traditional health practitioners hindered access to the medical facilities. On the supply side, capacity shortages and staff motivation were challenges at facilities. Problems were compounded by patients' delaying care mainly spurred by sociocultural beliefs in traditional practice and economic factors, thereby impeding early intervention for patients with surgical need. In the absence of formal support services, the onus of first aid and frontline trauma care is borne by lay citizens.

CONCLUSION

Within a resource-constrained context, supply-side strengthening need accompanying by demand-side measures involving community and traditional actors. On the supply side, non-specialists could be effectively utilised in surgical delivery. Existing human resource capacity can be enhanced through better incentives for non-physicians. Traditional provider networks can be deployed for community outreach. Developing a lay responder system for first-aid and front-line support could be a useful mechanism for prompt clinical intervention.

Burn scar contracture release surgery effectively improves functional range of motion, disability and quality of life: A pre/post cohort study with long-term follow-up in a Low- and Middle-Income Country

OBJECTIVE

Burn scar contractures limit range of motion (ROM) of joints and have substantial impact on disability and the quality of life (QoL) of patients, particularly in a Low- and Middle-Income Country (LMIC) setting. Studies on the long-term outcome are lacking globally; this study describes the long-term impact of contracture release surgery performed in an LMIC.

METHODS

This is a pre-post cohort study, conducted in a referral hospital in Tanzania. Patients who underwent burn scar contracture release surgery in 2017-2018 were eligible. ROM (goniometry), disability (WHODAS 2.0) and QoL (EQ-5D) were assessed. The ROM data were compared to the ROM that is required to perform activities of daily living without compensation, i.e. functional ROM. Assessments were performed preoperatively and at 1, 3, 6 and 12 months postoperatively.

RESULTS

In total, 44 patients underwent surgery on 115 affected joints. At 12 months, the follow-up rate was 86%. The mean preoperative ROM was 37.3% of functional ROM (SD 31.2). This improved up to 108.7% at 12 months postoperatively (SD 42.0, p < 0.001). Disability-free survival improved from 55% preoperatively to 97% at 12 months (p < 0.001) postoperatively. QoL improved from 0.69 preoperatively, to 0.93 (max 1.0) at 12 months postoperatively (p < 0.001). Patients who regained functional ROM in all affected joints reported significantly less disability (p < 0.001) and higher QoL (p < 0.001) compared to patients without functional ROM.

CONCLUSIONS

Contracture release surgery performed in an LMIC significantly improved functional ROM, disability and QoL. Results showed that regaining a functional joint is associated with less disability and higher QoL.

Deaths from surgical conditions in Malawi - a randomised cross-sectional Nationwide household survey

Background

Relatively little is known about deaths from surgical conditions in low- and middle- income African countries. The prevalence of untreated surgical conditions in Malawi has previously been estimated at 35%, with 24% of the total deaths associated with untreated surgical conditions. In this study, we wished to analyse the causes of deaths related to surgical disease in Malawi and where the deaths took place; at or outside a health facility.

Methods

The study is based on data collected in a randomised multi-stage cross-sectional national household survey, which was carried out using the Surgeons Overseas Assessment of Surgical Need (SOSAS) tool. Randomisation was done on 48,233 settlements, using 55 villages from each district as data collection sites. Two to four households were randomly selected from each village. Two members from each household were interviewed. A total of 1479 households (2909 interviewees) across the whole country were visited as part of the survey.

Results

The survey data showed that in 2016, the total number of reported deaths from all causes was 616 in the 1479 households visited. Data related to cause of death were available for 558 persons (52.7% male). Surgical conditions accounted for 26.9% of these deaths. The conditions mostly associated with the 150 surgical deaths were body masses, injuries, and acute abdominal distension (24.3, 21.5 and 18.0% respectively). 12 women died from child delivery complications. Significantly more deaths from surgical conditions or injuries (55.3%) occurred outside a health facility compared to 43.6% of deaths from other medical conditions, (p = 0.0047). 82.3% of people that died sought formal health care and 12.9% visited a traditional healer additionally prior to their death. 17.7% received no health care at all. Of 150 deaths from potentially treatable surgical conditions, only 21.3% received surgical care.

Conclusion

In Malawi, a large proportion of deaths from possible surgical conditions occur outside a health facility. Conditions associated with surgical death were body masses, acute abdominal distention and injuries. These findings indicate an urgent need for scale up of surgical services at all health care levels in Malawi.

The role of the University of Cape Town, South Africa in the training and retention of surgeons in Sub-Saharan Africa

BACKGROUND

Sub-Saharan Africa (SSA) has a shortage of surgeon specialists. Many SSA countries lack specialty training programs but South Africa, an upper middle-income country, has several post-graduate surgical training programs. The primary objective of this study was to describe the retention rates of non-South African SSA surgical trainees from the University of Cape Town (UCT) on the African sub-continent. The secondary objective was to describe advantages and disadvantages of foreign surgical trainees on the UCT surgical training programs.

METHODS

This was a two-part cross-sectional survey administered via email between June 1, 2018 and March 1, 2019 to UCT 1) surgical residents and fellows who graduated between 2007 and 2017 and whose country of origin was in SSA but outside South Africa, and 2) UCT surgical division heads.

RESULTS

Thirty out of 78 (38%) trainees responded; 83% (n = 25) were male. There was a 96% retention rate of surgical trainees in SSA, 80% (n = 24) returned to their country of origin after training, 83% (n = 25) worked in the public sector, and 90% (n = 27) in teaching hospitals. Seven out of ten surgical division heads responded. Reported advantages of SSA trainees included more junior staff (n = 5, 71%) and the establishment of SSA networks (n = 4, 57%). Disadvantages included increased training responsibilities for educators (n = 2, 29%) and fewer cases for South African trainees (n = 2, 29%).

DISCUSSION

Retention on the African sub-continent of surgeons who trained at UCT was high. SSA doctors can utilize South African post-graduate surgical training programs until their own countries increase their training capacity. The majority of trainees returned to their countries of origin, utilizing their skills in the public and academic sectors, and contributing to the teaching of more trainees. These training partnerships also contribute to knowledge-sharing and facilitate a regional network of African surgeons. Active recruitment of more female trainees is needed to ensure gender equity.

Surgical Needs of Internally Displaced Persons in Kerenik, West Darfur, Sudan

BACKGROUND

The burden of surgical disease in refugee and internally displaced person (IDP) populations has not been well defined. Populations fleeing conflict are mobile, limiting the effectiveness of traditional sampling methods. We employed novel sampling and survey techniques to conduct a population-based surgical needs assessment amongst IDPs in Kerenik, West Darfur, Sudan, over 4 weeks in 2008.

METHODS

Satellite imagery was used to identify man-made structures. Ground teams were guided by GPS to randomly selected households. A newly created surgical needs survey was administered by surgeons to household members. One randomly selected individual answered demographic and medical history questions pertaining to themselves and first-degree blood relatives. All household members were offered a physical examination looking for surgical disease.

FINDINGS

There were 780 study participants; 82% were IDPs. A history since displacement of surgical and potentially surgical conditions was reported in 38% of respondents and by 73% of respondents in first-degree blood relatives. Surgical histories included trauma (gunshots, stabbings, assaults) (5% respondents; 27% relatives), burns (6% respondents; 14% relatives), and obstetrical problems (5% female respondents; 11% relatives). 1485 individuals agreed to physical examinations. Untreated surgical and potentially surgical disease was identified in 25% of participants.

INTERPRETATION

We identified and characterized a high burden of surgical and potentially surgical disease in an IDP population in West Darfur. Our study is unique in its direct assessment of a traumatized, mobile, vulnerable population. Health officials and agencies charged with the care of IDP and refugee populations should be aware of the high prevalence of surgical and potentially surgical conditions in these communities. This study adds to the growing body of evidence that investment in surgical resources may address a significant portion of the overall burden of disease in marginalized populations.

Does insurance protect individuals from catastrophic payments for surgical care? An analysis of Ghana's National Health Insurance Scheme at Korle-Bu teaching Hospital

BACKGROUND

According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe.

METHODS

We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017 - October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual's income.

RESULTS

Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58-87% of insured patients would face financial catastrophe, versus 83-98% of uninsured patients (all comparisons by definition were significant, p < .05).

CONCLUSION

This study-the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana-found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana's national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care.

TRIAL REGISTRATION

Registered at www.clinical trials.gov identifier NCT03604458.

The burden of urological disease in Zomba, Malawi: A needs assessment in a sub-Saharan tertiary care center

INTRODUCTION

A large part of the developing world continues to lack access to surgical care. Urology remains one of the least represented surgical subspecialties in global health. To begin understanding the burden of urological illness in sub-Saharan Africa, we sought to characterize all patients presenting to a tertiary care hospital in Malawi with a urological diagnosis or related complaint in the past year.

METHODS

Retrospective review of the surgical clinic and surgical theater record books at Zomba Central Hospital (ZCH) was performed over a one-year time span. Patients presenting with urological diagnoses or undergoing a urological procedure under local or general anesthetic in the operating theater were identified and entered into a database.

RESULTS

We reviewed 440 clinical patients. The most common clinical presentations were for urinary retention (34.7%) and lower urinary tract symptoms (15.5%). A total of 182 surgical cases were reviewed. The most common diagnoses for surgical patients were urethral stricture disease (22%), bladder masses (17%), and benign prostatic hyperplasia (BPH) symptoms (14.8%). Urethral stricture-related procedures, including direct visual internal urethrotomy and urethral dilatation, were the most common (14.2% and 7.7%, respectively). BPH-related procedures, including simple prostatectomy and transurethral resection of the prostate were the second most common (6.7% and 8.2%, respectively).

CONCLUSIONS

Urethral stricture disease, BPH, and urinary retention represent the clinical diagnoses with the highest burden of visits. Despite these numbers, few definitive procedures are performed annually. Further focus on urological training in sub-Saharan Africa should focus on these conditions and their surgical management.

The Prevalence and Characteristics of Untreated Hernias in Southwest Cameroon

BACKGROUND

Hernias are one of the most commonly encountered surgical conditions, and every year, more than 20 million hernia repairs are performed worldwide. The surgical management of hernia, however, is largely neglected as a public health priority in developing countries, despite its cost-effectiveness. To date, the prevalence and impact of hernia have not been formally studied in a community setting in Cameroon. The aim of this study was to determine the prevalence and characteristics of untreated hernia in the Southwest region of Cameroon.

METHODS

This study was a subanalysis of a cross-sectional community-based survey on injury in Southwest Cameroon. Households were sampled using a three-stage cluster sampling method. Household representatives reported all untreated hernias occurring in the past year. Data on socioeconomic factors, hernia symptoms, including the presence of hernia incarceration, and treatment attempts were collected between January 2017 and March 2017.

RESULTS

Among 8065 participants, 73 persons reported symptoms of untreated hernia, resulting in an overall prevalence of 7.4 cases per 1000 persons (95% confidence limit 4.98-11.11). Groin hernias were most commonly reported (n = 49, 67.1%) and predominant in young adult males. More than half of persons with untreated hernia (56.7%) reported having symptoms of incarceration, yet 42.1% (n = 16) of these participants did not receive any surgical treatment. Moreover, 21.9% of participants with untreated hernias never presented to formal medical care, primarily because of the high-perceived cost of care. Untreated hernias caused considerable disability, as 21.9% of participants were unable to work because of their symptoms, and 15.1% of households earned less money.

CONCLUSIONS

Hernia is a significant surgical problem in Southwest Cameroon. Despite over half of those with unrepaired hernias reporting symptoms of incarceration, home treatment and nonsurgical management were common. Costs associated with formal medical services are a major barrier to obtaining consultation and repair. Greater awareness of hernia complications and cost restructuring should be considered to prevent disability and mortality due to hernia.

Prevalence of surgically correctable conditions among children in a mixed urban-rural community in Nigeria using the SOSAS survey tool: Implications for paediatric surgical capacity-building

Background

In many low- and middle-income countries, data on the prevalence of surgical diseases have been derived primarily from hospital-based studies, which may lead to an underestimation of disease burden within the community. Community-based prevalence studies may provide better estimates of surgical need to enable proper resource allocation and prioritization of needs. This study aims to assess the prevalence of common surgical conditions among children in a diverse rural and urban population in Nigeria.

Methods

Descriptive cross-sectional, community-based study to determine the prevalence of congenital and acquired surgical conditions among children in a diverse rural-urban area of Nigeria was conducted. Households, defined as one or more persons ‘who eat from the same pot’ or slept under the same roof the night before the interview, were randomized for inclusion in the study. Data was collected using an adapted and modified version of the interviewer-administered questionnaire—Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool and analysed using the REDCap web-based analytic application.

Main results

Eight-hundred-and-fifty-six households were surveyed, comprising 1,883 children. Eighty-one conditions were identified, the most common being umbilical hernias (20), inguinal hernias (13), and wound injuries to the extremities (9). The prevalence per 10,000 children was 85 for umbilical hernias (95% CI: 47, 123), and 61 for inguinal hernias (95% CI: 34, 88). The prevalence of hydroceles and undescended testes was comparable at 22 and 26 per 10,000 children, respectively. Children with surgical conditions had similar sociodemographic characteristics to healthy children in the study population.

Conclusion

The most common congenital surgical conditions in our setting were umbilical hernias, while injuries were the most common acquired conditions. From our study, it is estimated that there will be about 2.9 million children with surgically correctable conditions in the nation. This suggests an acute need for training more paediatric surgeons.

Directions for surgical capacity developments in Nepal: a population-based assessment

Objectives

Lack of access to safe surgery is seen as a major issue that needs to be addressed. The aim of this study was to understand which combinations of factors relate to high occurrences of unmet needs and disability in Nepal, and consequently, how to focus future work to maximise impact in this country.

Methods

A large population‐based survey was conducted in Nepal in 2014 to evaluate the unmet surgical needs that result in disability. Recorded factors included diseased anatomical areas, disease specifics, disease locations, injury types, reasons for having an unmet need and the types of disability.

Results

Included in the study were 2695 individuals. The anatomical areas facing the highest disabling unmet surgical need were Head (3.9% of population), Groin/Genitalia (2.2% of population) and Extremities (3.6% of population). Four focus areas could be defined. Increase affordability, availability and acceptability of surgical care to non‐traumatic disabling conditions of (i) the eye, and (ii) extremities, and (iii) to traumatic disabling conditions of extremities and finally (iv) increase acceptability of having surgical care for non‐traumatic conditions in the groin and genital area. For the latter, fear/no trust was the main reason for receiving no surgical care despite the resulting shame.

Conclusions

This study defined four focus areas that showed the largest unmet needs that resulted in a perceived disability. For those areas, affordability, availability and acceptability of surgical need to be addressed through technical developments, capacity building and raising awareness.

The contribution of pediatric surgery to poverty trajectories in Somaliland

BACKGROUND

The provision of health care in low-income and middle-income countries (LMICs) is recognized as a significant contributor to economic growth and also impacts individual families at a microeconomic level. The primary goal of our study was to examine the relationship between surgical conditions in children and the poverty trajectories of either falling into or coming out of poverty of families across Somaliland.

METHODS

This work used the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool, a validated household, cross-sectional survey designed to determine the burden of surgical conditions within a community. We collected information on household demographic characteristics, including financial information, and surgical condition history on children younger than 16 years of age. To assess poverty trajectories over time, we measured household assets using the Stages of Progress framework.

RESULTS

We found there were substantial fluxes in poverty across Somaliland over the study period. We confirmed our study hypothesis and found that the presence of a surgical condition in a child itself, regardless of whether surgical care was provided, either reduced the chances of moving out of poverty or increased the chances of moving towards poverty.

CONCLUSION

Our study shows that the presence of a surgical condition in a child is a strong singular predictor of poverty descent rather than upward mobility, suggesting that this stressor can limit the capacity of a family to improve its economic status. Our findings further support many existing macroeconomic and microeconomic analyses that surgical care in LMICs offers financial risk protection against impoverishment.

Out-of-pocket payments and catastrophic household expenditure to access essential surgery in Malawi - A cross-sectional patient survey

BACKGROUND

Having to pay out-of-pocket for health care can be prohibitive and even cause financial catastrophe for patients, especially those with low and irregular incomes. Health services at Government-owned hospitals in Malawi are provided free of charge but patients do incur costs when they access facilities and some of them forego income. This research paper presents findings on the direct and indirect expenditure incurred by patients who underwent hernia surgery at district and central hospitals in Malawi. It reports the main cost drivers, how costs relate to patients' household incomes, the financial burden of undergoing surgery and the extent to which hernia patients had recovered and restored their capacity to work and earn an income.

MATERIALS AND METHODS

Using a cross-sectional study design, surveys were held with patients who had undergone hernia surgery in four district and two central hospitals in Malawi. Interviews were conducted by surgically trained clinical officers, trained in survey administration, and included, inter alia, questions about patients' hospital stay, the direct and indirect cost they incurred in accessing surgery, and how they financed the expenditure. Follow-up interviews by telephone were held 8-10 weeks after discharge.

RESULTS

The sample included 137 patients from district and 86 patients from central hospitals. The main direct cost drivers were transport and food & groceries. More than three quarters of patients who had their surgery at a district hospital incurred indirect costs, because of income lost due to hospital admission, compared with just over a third among central hospital patients. Median reported income losses were US$ 90 and US$ 71, respectively. Catastrophic expenditure for surgery occurred in 94% of district and 87% of central hospital patients. When indirect costs are added to the out-of-pocket expenditure, it constituted more than 10% of the monthly per capita income for 97% and 90% of the district and central hospital patients, respectively.

CONCLUSION

Out-of-pocket household expenditure associated with essential surgery in Malawi is high and in many instances catastrophic, putting households, especially those who are already poor, at risk of further impoverishment. The much needed scaling-up of surgical services in rural areas of Malawi needs to be accompanied by financial risk protection measures.

Evaluation of a surgical task sharing training programme's logbook system in Sierra Leone

BACKGROUND

Personal logbooks are universally applied for monitoring and evaluation of surgical trainees; however, the quality and accuracy of such logbooks in low income countries (LICs) are poorly examined. Logbooks are kept by the individual trainee and detail every surgical procedure they perform and their role during the procedure. The aim of this study was to evaluate the quality of such a logbook system in Sierra Leone and to identify areas of improvement.

METHODS

The last 100 logbook entries for students and graduates participating in a surgical task sharing training programme were compared with hospital records (HRs). The logbook entries were categorized as matching, close matching or over-reported. Moreover, HRs were checked for under-reported procedures. Semi-structured interviews were conducted with the study participants on logbook recording routines. The results were analysed using mixed effects logistic regression models.

RESULTS

Three thousand one hundred sixty-nine database entries from 35 participants were analysed. Of that amount, 62.2% of the entries matched the HRs, 10.4% were close matches and 26.9% were over-reported. 20.7% of the investigated HRs were under-reported.

CONCLUSIONS

Information gathered from surgical logbook systems must be applied with care, and great efforts must be made to ensure that the logbook systems used provide reliable data. Based on analysis of the logbook data and interviews, focus areas are suggested to ensure reliable logbook data in LICs. Clear instructions and proper training should be provided when introducing the logbook system to the users. The importance of logging all procedures, including minor ones, should be emphasized. The logbook system should be user friendly and only as extensive as necessary. Lastly, keeping the logbooks exclusively digital is recommended, combined with sufficient IT equipment and training.