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Original Investigation |

Self-reported Determinants of Access to Surgical Care in 3 Developing Countries

Joseph D. Forrester, MD, MSc1; Jared A. Forrester, MD1; Thaim B. Kamara, MD2,3; Reinou S. Groen, MD, MIH, PhD4,5; Sunil Shrestha, MBBS6; Shailvi Gupta, MD, MPH5,7; Patrick Kyamanywa, MMed, MPH8; Robin T. Petroze, MD9; Adam L. Kushner, MD, MPH5,10,11; Sherry M. Wren, MD1
[+] Author Affiliations
1Department of Surgery, Stanford University, Stanford, California
2Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
3College of Medicine and Allied Health Science, Freetown, Sierra Leone
4Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland
5Surgeons OverSeas, New York, New York
6Department of Surgery, Nepal Medical College, Kathmandu, Nepal
7Department of Surgery, University of California–San Francisco, East Bay, Oakland
8College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
9Department of Surgery, University of Virginia, Charlottesville
10Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
11Department of Surgery, Columbia University, New York, New York
JAMA Surg. 2016;151(3):257-263. doi:10.1001/jamasurg.2015.3431.
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Importance  Surgical care is recognized as a growing component of global public health.

Objective  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.

Results  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.

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