Tropical Medicine and International Health
doi:10.1111/tmi.12215
volume 19 no 1 pp 107–116 january 2014
Individual and community perceptions of surgical care in Sierra Leone Reinou S. Groen1,2, Veena M. Sriram3, Thaim B. Kamara4, Adam L. Kushner2,3,5 and Lucie Blok6 1 2 3 4 5 6
Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA Surgeons OverSeas, New York, NY, USA Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA Department of Surgery, Connaught Hospital, Freetown, Sierra Leone Department of Surgery, Columbia University, New York, NY, USA Royal Tropical Institute, Amsterdam, The Netherlands
Abstract
objectives To determine themes and beliefs that influence health-seeking behaviour and barriers to accessing surgical care. methods In January 2012 in Western Area Province of Sierra Leone, six Focus Group Discussions (FGDs) were conducted. The FDGs consisted of three male only and three female only groups in an urban, a slum and a rural setting. Researchers investigated a wide range of topics including definitions of surgery, types of surgical procedures, trust, quality of care, human resources, postoperative care, permission-seeking and traditional beliefs. results Although many individual beliefs were expressed, common fears were as follows: becoming half human after surgery; complications from procedures; stigma from having a scar; and financial burdens resulting from the cost of care. Participants also expressed concern about the quality of the care available in Sierra Leone. conclusions The concept of being half human after surgery, previously not documented in the literature, is noteworthy and should be explored more fully. Qualitative research in other parts of Sierra Leone and other LMICs into beliefs of the local population could improve programmes for access and delivery of surgical care. keywords barriers to care, focus group discussion, half human, healthcare seeking behaviour, surgery, Sierra Leone
Introduction An estimated 11% of the global burden of disease can be treated with surgery (Debas et al. 2012) and recent studies from Sierra Leone and Rwanda document a high prevalence of surgically treatable conditions and deaths that could possibly have been averted with timely access to surgical care (Groen et al. 2012; Petroze et al. 2013). Although data exist on the lack of surgical capacity in numerous LMICs (Kingham et al. 2009; Choo et al. 2010; Kushner et al. 2010; Iddriss et al. 2011; Sherman et al. 2011), few studies have evaluated access to surgical care, and those that did are quantitative (Mock et al. 1997; Hang & Byass 2009; Grimes et al. 2011). In Vietnam, 60% of patients with a disability lasting for more than 29 days are likely to seek health care (Hang & Byass 2009). In Ghana, healthcare usage was more likely in cases of serious trauma (Mock et al. 1997).
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Little is known about the beliefs of populations in low- and middle-income countries about barriers to access surgical care. The goal of this study was to explore perceptions of surgical care in Sierra Leone. Methods The objectives of this research in Sierra Leone were to (i) understand the population’s perception of surgery in general and (ii) explore feelings towards local surgical care delivery to determine perceived barriers to accessing surgical care. Data for this qualitative study were collected through focus group discussions (FGDs). Three male and three female FGDs were held in different parts of Western-Area Province of Sierra Leone. The locations were randomly chosen from a list of enumerating areas, defined as rural, urban and slum for census and demographic health survey purposes. The participants were recruited based on expressed interest or upon 107
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recommendation of community leaders. The two moderators (one male, one female) were provided with a topic sheet to start the discussion on the ideas of surgery and operations and to elicit information on specific topics not raised by participants. All discussions took around one hour and were held in Krio, the local language in Western-Area, and the mother tongue of trained focus group moderators and participants. The moderator of the discussion was the same sex as the respondents. However, tape recordings and notes were taken by a moderator of the opposite sex. The two moderators who participated in all FDGs transcribed them into English. All six transcriptions of the various groups were discussed during a feedback session, which included the two moderators, their supervisor, the Chief of Surgery of Connaught Hospital, the principal investigator and four other interested medical persons. The principle investigator (RG) grouped the six transcripts into themes and subthemes to provide a useful overview. Ethical approval was obtained from the Sierra Leone Ethics and Scientific Review Committee, the Sierra Leone Ministry of Health and Sanitation and the Research Ethics Committee of the Royal Tropical Institute (KIT) in Amsterdam, the Netherlands. Funding was provided by Surgeons OverSeas (SOS). Results The main discussion themes are displayed in Table 1. All focus groups could be held, although one male group consisted of only four rather than the anticipated ten participants. Respondents in both the female and male groups were asked to list various types of operations. The most commonly mentioned were as follows: appendectomy, hernia repair, caesarean section, trauma care and abscess drainage. Respondents were encouraged to provide detailed explanations of the reason for and their understanding of the technical aspects of each procedure. For example, respondents believed appendicitis could result in death due to the appendix bursting in the abdomen, and caesarean sections were procedures that occur when the foetus is in the ‘wrong position’ and vaginal delivery is not possible. Misconceptions were also present, such as that a testicle will always be removed during a hernia repair, as stated in one discussion with male participants. All focus groups began with an open-ended question about associations with surgery and an operation. Primary reactions were fear of death and concern about the cost. One participant expressed fear about to the poor quality of hospitals in Sierra Leone. A recurrent theme in 108
several discussions and closely linked to the fear of surgery was the concept that one becomes a ‘half human’ or incomplete after an operation. Numerous participants referred to even an injection or incision as a process that resulted in becoming incomplete. However, variations of this concept were present, as seen in Table 2. It appeared that this concept is not strictly defined. Some individuals had the idea that after an appendectomy or hernia repair one was ‘half human’ where as others disputed this idea. Wound healing and a visible scar were also closely linked to the ‘half human’ concept. One respondent made a neutral statement regarding scarring, simply stating that the scar gives him a memory. However, most participants had a negative perception of scars and related them to bad feelings, fear and stigmatisation. Participants expressed that once a scar was visible, other people would investigate what went wrong with you. From the male focus group discussions came multiple negative comments on women with a scar (Table 1). The female group discussion in the urban area confirmed those statements, indicating that men stayed away from women with scars. Other negative perceptions towards people who have undergone surgery were that they are difficult to deal with and not strong enough for hard work. However, some positive remarks were also heard. Some respondents stated that people who underwent surgery are strong and should therefore given sympathy. One male participant from the rural area noted that scars from Sierra Leone are worse than scars than from surgeries abroad, while showing a barely visible scar from his laparoscopic operation performed in London. All groups talked about the need for qualified/certified medical doctors to practice surgery. Gender of the surgeon was of no importance. Subspecialties and their importance were also mentioned, although participants had difficulty accessing information on qualifications and certifications of a doctor and felt that this information should be publicly available. The quality of the doctor was intertwined with the discussion on the quality of the hospitals. Some participants stated that the quality depends more on the provider than on the hospital. However, others conversely stated that a good hospital made sure that only good trained, certified nurses and doctors were employed. The participants judged the quality of the hospitals from positive stories within their social networks. Availability of equipment and drugs were mentioned as being a factor in judging the quality of a hospital; the limited surgical capacity of Sierra Leone was mentioned several times. It was known that certain procedures, specifically laparoscopic procedures, are not available in Sierra Leone.
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Table 1 Main discussed themes and subthemes in different focus group discussion. (Numbers refer to how many times this was mentioned in the group) Men Main themes
Subthemes
Rural
Definitions and indications for surgery
Cut something from the body Remove a disease Remove a foreign body Removing unwanted material (…) To correct something that is wrong Cut and Stitch, cut and sew Operation to deliver a baby Split my stomach …take you to theatre and give (..) anaesthetic’ Death Fear Money/the cost of the operation Half human (See Table 2) Become an incomplete human being’ Definitions of surgery I will pray ..(get a) well body’ …it is either die or live’ Hernia C-section Appendix Eye Bozie’ (red: Hydrocele) Boil’ (red: Abscess) Amputation (Breast) cancer lump, growth Elephantiasis Heart operation Fracture/bones Operation and stitches for somebody involved in a motor accident’ ..that baby had something on its navel, it was operated and the child is oke..’ …there are various kinds of operations, some we do not know their names’ Doctor/medical doctor Doctor needs to be qualified for an operation Doctor who is specialised to do an operation Doctors with success stories Doctors who care also for the poor and do not ask money upfront Traditional healer I will pray to God and be operated by a God-fearing person’ We are not well informed to know if (..) (a) doctor is qualified’ Gender of the surgeon: ‘Even if that surgeon is a male or female as long as he/she is qualified’ The eye is not to be operated in Sierra Leone. They will not replace it in the right position. It is untouchable’
1 1 1
First thing to think of while talking about surgery
Known type of operations
Who do you trust to do an operation?
Women Slum
1 1 1
Urban
1 1
1
2 1 1 1
2
Rural
Slum
1
1
1
1
Urban
1 1
1
1 1 1
2 1
1 1
1
1 1 1
1 1 1 1 1 1 1
1 2 1 1
1 1
1 1 1
1 1 1
1 1 1 1 1
1
2 1 1 1
1 1
1 1 1
1 1 1 1
1 1 1 1
2 2 1 3
1 1 2
1 1 2
1 1
1 1 1 1
1 1 3
1 1 2
1
1
(continued)
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Table 1 (Continued) Men Main themes
Subthemes
Rural
Different mentioned surgical specialists
Surgeon/General surgeon Bone specialist Gynecologist, ‘gyne’ Eye surgeon Dentist For good quality, a hospital should be well equipped Not good if unsuccessful operations are carried out–people die or have complications Some surgical care is not available in Sierra Leone It is a government hospital and well known’ Because Chinese are there (…) they provide good drugs’ If they have (well qualified and trained) nurses and doctors available The quality depends more on the doctor than the hospital From success stories Logistics and drugs need to be available There is no good hospital/the facilities are not good in Sierra Leone Good quality is imported equipment and only used on one person There are no bad hospitals as far as operations are concerned/they will refer you if you are in the wrong hospital …is a good hospital (…) because it is a big hospital with many doctors (…) with different operation background (…) and share ideas in order to save life’ ..we do not have any bad hospital because there (are) death case(s) in all hospitals. (…) it (might be) destiny to die one day’ Numb a body part - I want to see what is done Numb a body part - ‘Sometimes people don’t come back from sleep’, ‘it is the anaesthetic that kills majority of the patients under surgery’ Sleep - I don’t want to see what is done - I’m afraid Sleep - I don’t want to irritate the doctor I let the doctor decide Not to do hard work/carry heavy load ‘ …like gardening or chopping fire wood’ ‘They (people after surgery) are not (to) do hard work because the wound reopens from the inside’ Not to eat that much to belly full’ (‘if intestine been removed’) Not to eat: pepper and solid food Drink alcohol (after liver and kidney operations) Avoid bright light and dust (use sunglasses), not bow down and chew hard substances (after eye surgery) … for the eye’s you should not concentrate for a long time…. (take) your drugs properly and eat(..) good food, (..)follow up with your doctor (…) (do not) get close(..) to fire or light..’ Women stop bearing children
1 1 1 1 1 1 2
Hospital quality
Anaesthesia
Limitations after surgery
Women Slum
Urban
Rural 1 1
1
1
2
1 2
Slum
Urban 1 1
1
1
1
1
1 1 1 2 1 1 1 1
1
1
2
1 2
1
4
1 1 1
1
1
1
2
2 1
2
2
1 1
3 1
2
3 1
4
3
1
4
1
1
1
1 3
2
1
1 1
1 2
1
1 1
1
(continued)
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Table 1 (Continued) Men Main themes
Wound healing
Complications of operations
What to do in case of a complication Taboos/spiritual or traditional beliefs on surgery
Subthemes (some) would say you wouldn’t be able to deliver on your own (..) but that is not true’ …Women who undergo C-Section operation are advised not to get pregnant’ I have heard that men after a hernia operation are unable to pregnant a woman’ Sex (after Appendix) (after Hernia) Soak towel in hot water and apply that on the scar/apply warm water Coconut oil Groundnut Krowbombo (country tree) grinded and applied Palm oil (for hot water burns) Raw egg (for burns) Mud (for burns) Honey (on burns) Traditional herbs (…) really helps especially in the area of fracture’ Cold and hot ointment (for broken bones) Kroo woman applied chalk and commanded the guy to walk (after a sport injury) No idea Reaction Being dizzy Death (‘…stomach, chest and throat. Once you have been operated in these you will not live long. With the feet it is oke’) Stomach ache Pain Fistula (after C-section) Bleeding (after a heart operation) the area (scar/operated area) becomes loosed’/‘the operated area will open’ waiting for like one month for her stomach to get a bowel sound’ (unhealed) sore’ (medical) ‘Checkup’ with your doctor Repeat the treatment to find out what was wrong (take) back to the hospital’ There are no body parts, which should not be operated on Taboo to be injected for Limba (tribe in SL) People belonging to cults (of witch craft) believe that there are some body parts not to be operated on/(…) a member of a secret society, will say that: no knife can be able to pierce through his body/those that joined poro hunting people with witch craft (…) may manipulate on the doctors so that when they are doing the operation, the person might die. (…) the patients normally die if the parent use force in order to carry out the operation’
Rural
Women Slum
Urban
Rural
Slum
Urban
1 1 1 1 1
1
1 1 1
2 1
1 1 1 1
1 1 1 1
1 1 1 1 1 1
1 1
1
2
1 1 1 1
1
1
1
1
1 1 1
1
1 1 1
1
1
1 1
1
1
1
(continued)
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Table 1 (Continued) Men Main themes
Permission/ authorisation for operation
Reason for delay or cancelation of surgery
Perceptions of scars
Subthemes I will not allow someone to touch my penis (for an operation)’ An old woman with a growth refused to be operated on’ (…) she believed it was God that placed it there’ Even an old person can undergo operation, as far as he/ she is living’ .. An old age like ninety years (seventy) need not to undergo operation in order not to die during the process. ‘ Ideal age for operation: ‘people in their eighties (….) they are mentally strong for an operation’ (for a nephew the doctor) asked us to wait until the child is four months before he can be operated’ No age limit for operation My wife I take the discussion My children My parents (mother or father) My husband God Money/Financial constraints Find the right doctor/qualified Find someone to accompany you to the hospital Fear/panic Unavailability of drugs Unavailability of equipment Based on doctors’ advice Nurses who want to bribe you before an operation witch craft manipulation’ ..with the free medical facility pregnant women can go for C-Section (…) (but) there are some drugs that are not available (..) the patient (needs) to buy the drugs (…) (and) the family (needs) to donate blood … at first my father did not agree for the surgery to carry on except that he has to be convinced that after the surgery I will survive and will still be a complete human being…’ (appendectomy) Age : ‘in case of babies, the age can make you wait to undergo an operation’ … (in case of fear you can) pray to God and deliver safely without doing a C-Section’ Gives me a memory the scar of my wife/friend/spouse scares me’, fear …whenever somebody sees the scar, they will shout at you and ask you what is that.’ (when I see her scar) ‘she makes me feel bad’, ‘I do not feel good’ (when I saw her scar) ‘I lost taste for her’ I’m not interested in any women that has a scar on her body..’ I just believe there is something wrong with her’
Rural
Women Slum
Urban
Rural
Slum
Urban
1
1 1
1
1 1 2 1 1 1 1
2 1 1
1 2
1
1 1
1
1 1
3 1
2 2
2 1 1
1
3
1 2 1 2
1 1 1 2
2
2
1
2
1 1
1 1 1
1
1 1 1 1
1
1
1 1
1
1
1
1
1
1 1 1
(continued)
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Table 1 (Continued) Men Main themes
Subthemes ..some men do stay away from women with operation scar by that you lost opportunity’ I do not like seeing even my own (scar) because it is a very big scar’ It makes the stomach (abdomen) big (…)and you will be ashamed to expose it to friends’ and ‘I cannot wear any fashion dress that expose my stomach’ Scars from Sierra Leone are worse than scars from operations abroad Half human/Incomplete human …I will rushed to give a helping hand because he/she is an incomplete human’ The people are not normal again (…) they are not strong as us (…) some are very difficult to handle after they (have) undergone operation’ …they are not strong enough and normal to do hard work’ I will congratulate them, because that person loves his/her life’ My friend did an operation (…) we play football together (…) I believe he is fit. ‘ I sympathise with them (…) they are sympathetic’ …I will feel so much for him/her and think of the pains he/she must have gone through’
Perceptions of people who have undergone surgery
Table 2 Definitions of ‘half human’ concept Definitions of ‘half human’
When are you NOT half human
Rural
(people with) ‘removed part of body’ ‘The one amputated is half human’/ amputation Hernia Appendix Operation on the stomach Tooth extraction ‘With my 50 years of experience all my friends who have undergone surgery will not tell me they are 100% human’ When you are given ‘incomplete treatment’ Once you are operated/‘once they have used knife or scissor on your body’ ‘People that are operated here (Sierra Leone) are left half human’ ‘When they do hernia operations, one ball is removed’ AND ‘God gave us men two balls’ Incomplete human (being) If after the operation the location was sown Hernia Appendix (if)’they are given some time to rest so that the saw will heal up’
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Women Slum
Urban
Rural
Slum
Urban 1
1 2
1 1
1 1
1
2 1
3
1
1 1 1 1
1 1
There were discrepancies in the perceptions around availability of good surgical care in Sierra Leone. Some participants felt that there is no good hospital in Sierra Leone for surgical care, while others proudly mentioned the names of good hospitals and surgeons. In the rural male focus group, one participant explicitly stated that the Sierra Leonean doctors and surgeons are good, but that lack of resources limits their capabilities to undertake successful operations. The use of traditional healers was mentioned once in the discussion regarding those that participants trust for an operation. Respondents indicated that they took injured relatives to traditional healers for surgical consultations, particularly for broken bones. One participant from the slum area mentioned spontaneously the use of anaesthesia when talking about the definition of surgery. In all other groups, the moderator elicited responses towards anaesthesia and the desire to be sleeping during an operation or having local anaesthetic. Respondents favoured local and general anaesthesia equally. Fear of anaesthesia was also expressed in three groups with respondents feeling that anaesthesia was the main factor in surgical deaths. 113
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For a good recovery from a surgical procedure, several measures were mentioned. Pepper or solid food should be limited after abdominal surgery, and almost all groups mentioned that one should not do hard work or carry heavy loads immediately after a procedure. Some groups discussed that these measures were temporary (lasting three months), while others believed that an operation made exertion in labour permanently impossible. Multiple comments were made relating reproductive health. Respondents stated that those who undergo an appendectomy or herniorrhaphy should not have sex for 3 months and that males can become infertile after a hernia operation. For wound healing, several substances, such as coconut oil, groundnut (peanut), and ground country tree, were mentioned as useful. For burn injuries, palm-oil, raw egg, mud and honey were discussed as prehospital treatment. Fractures and sports injuries were mainly treated with cold and hot ointment, traditional herbs and chalk application. In Sierra Leone, it is taboo for members of the Limba tribe to receive an injection. Also members of certain cults and secret societies are believed not to be able to be ‘touched by a knife’. It is thought that such persons possess powers that would kill a doctor who tried to operate on them. Permission for an operation was granted by close relations within the family. Females would ask their husbands and males their wives. Secondly, parents, mothers or fathers were also mentioned. Older participants mentioned their children. It seemed that decision-making was linked with payment for the surgery. Also permission needed to be granted by the caretaker after the surgery. Reasons to delay or cancel a surgery were most often financial or fear, but also searching for a qualified doctor, unavailability of drugs or equipment, age, doctors’ advice or not having the permission from a family member. It was also mentioned that nurses can delay the surgery if informal payments are not provided. Different amounts were mentioned for the cost of operations and these varied by provider. Financial constraints were commonly mentioned as a reason to delay surgery. One urban woman said that she was totally dependent on others to provide funds or loans if she needed to undergo a procedure. She also indicated that in some cases, doctors conduct procedures without payment for those who are unable to pay. The government programme of free care for pregnant women was noted as a positive development. However, challenges with drugs and blood donations were raised, with respondents stating that patients were frequently asked to buy drugs even though the surgery was free and that families had to donate blood when necessary. Therefore, free care for 114
pregnant women was not completely free. All participants indicated that they would be pleased if surgery became truly free of charge. Discussion The results of the focus group discussions present a number of important findings regarding the perception of surgical care and health-seeking behaviours in Sierra Leone. The results highlight the major themes of availability, accessibility and quality of surgical services and some of the sociocultural perceptions of surgery. The cost associated with surgery is seen as a major barrier to accessing care: participants indicated the need to borrow money from social networks or lending agencies. Participants also identified the breakdown of supply chains, resulting in patients bearing the delay as well as added costs of drugs, blood and equipment. The cost aspect of surgical care was similarly seen in research conducted in Vietnam that found an increase in cost with the increasing severity of injury. Interestingly, the study also pointed to a higher indirect cost placed on low-income patients than high-income patients (Hang & Byass 2009). Closely related to costs is the issue of permission. Studies exploring questions of decision-making and utilisation of health services have found that increased autonomy of a household member in terms of decision-making leads to increased utilisation of services (Mistry et al. 2009). Given that permission for surgery is related to the party responsible for payment of the surgery, our study raises a number of interesting questions about equity. How does this presumed financial power affect access to care? What steps are taken to ‘convince’ family members of the importance of the surgical service? Future research could also look into the age and sex stratification of costs. For example, does the collection of funds for surgery differ for children and the elderly, males or females, or maybe by procedure type? Another consideration is the impact of the type of surgery on direct and indirect costs associated with care. Laparoscopic surgery requires more resources and is therefore often more expensive than open surgery. However, it can potentially reduce costs by minimising hospital stay (Lagoe & Milliren 1986; Guller et al. 2004). In Bangladesh, laparoscopic surgery reduced post-operative hospitalisation time (Hannan et al. 2012). Quicker recovery and therefore fewer indirect costs and a faster return to work add to the benefit of expanding access to laparoscopic surgery. Laparoscopic procedures use smaller incisions and therefore might help address some of the concerns regarding post-operative scars. Misconceptions about surgical procedures and risks of anaesthesia were
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also identified in the current study and give direction for patient counselling and community education (Eyelade et al. 2010). The results also highlight several key sociocultural perceptions about surgery. The concept of becoming ‘half human’ after surgery was one of the main themes identified, which is not previously mentioned in the literature. Although this concept was not completely clear and not always perceived as negative, it is likely that such beliefs contribute to fear and stigma. It is also important to realise that the expression ‘half human’ might not relate directly to disability or physical impairment, but rather to a state of mind or a state of being. The western/contemporary concept of the ‘plumbing model’ of the body, where broken parts can be replaced, is likely not conceptualised in West-African societies (Helman 2007). Earlier exploration of cultural concepts of the Mende tribe in Sierra Leone revealed that replacing body parts or body components, as with a blood transfusion, was not imaginable (Bledsoe & Goubaud 1988). The topic of blood transfusion was not specifically explored in the current discussions; however, it is possible that this cultural concept is related to the fear of undergoing surgery. More in-depth anthropological and ethological research is indicated for further understanding of this potential barrier to acceptability of surgery in Sierra Leone. The discussion of injuries was limited in our FGDs, but it would be interesting to explore more fully given the negative opinion about scars. The findings highlight a number of contextual factors that influence perceptions of surgical care. The role of traditional healers in surgical and post-operative care mentioned in the FDGs highlights the importance of engaging these networks. Potential benefits might be expected when traditional healers are trained about the benefits or harm associated with popular topical and ingested treatments. Previous studies on the role of traditional healers in access to health care have shown the widespread availability and acceptance of traditional healers in low-resource communities (Addis et al. 2004). Given their proximity to communities, health organisations can potentially engage these networks in referral services for surgery, as has been successfully implemented with traditional birth attendants and providers of emergency obstetric care (Byrne & Morgan 2011). An important area for further research will be perceptions within the community about the skill level of health workers providing services. This is particularly important given the growing push for non-physician clinicians to provide high-skilled health services, such as surgical procedures. As demonstrated in Malawi and Tanzania, Clinical Officers (COs) or Assistant Medical
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Officers (AMOs) provide obstetric surgical services comparable to medical officers in terms of post-operative outcomes (Chilopora et al. 2007; McCord et al. 2009). In view of the limited availability of skilled providers of surgical procedures in many poor countries, task shifting to non-physician clinicians could be a promising strategy. It would be important to conduct qualitative research to understand how patients perceive non-physician clinicians providing services compared with specialist surgeons. As our current FGDs showed, a certification procedure for trained COs or AMOs might be beneficial from both patient and provider perspective. Information on qualifications needs to be disseminated to the public. A major limitation of this study is that the FGDs were conducted in Krio. This official language in Sierra Leone sounds like English but has its own distinct grammar and expressions as well as words not intelligible to an English speaker. It is distinct from the 15 other local ethnic groups, which have their own language. Therefore, it might be difficult to generalise the findings throughout the entire country or even regionally. FGDs were only conducted in Western-Area of Sierra Leone, close to the capital city Freetown. There is the possibility that more remote locations away from an urban centre with less access to surgical care and lower literacy and education rates might produce differing findings. The FGD guidelines were developed using Western academic standards. A deeper anthropologic and ethnological exploration of the identified themes might allow for differing conclusions. Lastly, there was no compensation for participation. Potentially, participants who were unavailable for the FDGs but might have participated if their time had been compensated would have provided other useful insights, which were not covered in the present discussions. Conclusion Focus group discussions conducted in Western-Area Province of Sierra Leone provided insights into the Krio population’s beliefs and perceptions of surgery. The previously unpublished concept that persons who undergo surgery become ‘half human’ was identified. Concerns were expressed over the availability and quality of surgical services as well as financial barriers and stigma. These results can be useful in planning programmes to increase access to surgical care for the population of Sierra Leone. References Addis G, Abebe D, Genebo T & Urga K (2004) Perceptions and practices of modern and traditional health practitioners about
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traditional medicine in Shirka District, Arsi Zone, Ethiopia. Ethiopian Journal of Health Development 16, 19–29. Bledsoe CH & Goubaud MF (1988) The reinterpretation and distribution of Western pharmaceuticals: an example from the Mende of Sierra Leone. In: The Context of Medicines in Developing Countries (eds S Van Der Geest & SR Whyte) Kluwer, Dordrecht, pp. 253–276. Byrne A & Morgan A (2011) How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance. International Journal of Gynecology & Obstetrics 115, 127–134. Chilopora G, Pereira C, Kamwendo F, Chimbiri A, Malunga E & Bergstr€ om S (2007) Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi. Human Resources for Health 14, 5–17. Choo S, Perry H, Hesse AAJ et al. (2010) Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool. Tropical Medicine & International Health 15, 1109–1115. Debas HT, Gosselin R, McCord C, Thind A (2006) Surgery. In: Disease Control Priorities in Developing Countries , (eds DT Jamison, JG Breman, AR Measham, G Alleyne, M Claeson, DB Evans, P Jha, A Mills & P Musgrove). 2nd edn, Chapter 67, World Bank, Washington (DC). Available at: http:// www.dcp2.org/pubs/DCP/67/FullText. (accessed 14 May 2012). Eyelade OR, Akinyemi JO & Adewole IF (2010) Patients’ perception and knowledge of anaesthesia and anaesthetists – a questionnaire survey. Southern African Journal of Anaesthesia and Analgesia 16, 28–31. Grimes CE, Bowman KG, Dodgion CM & Lavy CBD (2011) Systematic review of barriers to surgical care in low-income and middle-income countries. World Journal of Surgery 35, 941–950. Groen RS, Samai M, Stewart KA et al. (2012) Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet 380, 1082–1087. Guller U, Hervey S, Purves H et al. (2004) Laparoscopic versus open appendectomy outcomes comparison based on a large administrative database. Annals of Surgery 239, 43–52.
Hang HM & Byass P (2009) Difficulties in getting treatment for injuries in rural Vietnam. Public Health 123, 58–65. Hannan MJ, Hoque MM & Begum LN (2012) Laparoscopic appendectomy in pregnant women: experience in Chittagong, Bangladesh. World Journal of Surgery 36, 767–770. Helman CG (2007) The body: cultural definitions of anatomy and physiology. In: Culture, Health and Illness (eds. J Koster & S Purdy). 5th edn, London, UK, pp. 30–32, 50 Iddriss A, Shivute N & Bickler S (2011) Emergency, anaesthetic and essential surgical capacity in the Gambia. Bulletin of the World Health Organization 89, 565–572. Kingham TP, Kamara TB, Cherian MN et al. (2009) Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care. Archives of Surgery 144, 122–127. Kushner AL, Cherian MN, Noel L et al. (2010) Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Archives of Surgery 145, 154–159. Lagoe RJ & Milliren JW (1986) A community-based analysis of ambulatory surgery utilization. American Journal of Public Health 76, 150–153. McCord C, Mbaruku G, Pereira C, Nzabuhakwa C & Bergstrom S (2009) The quality of emergency obstetrical surgery by assistant medical officers in Tanzanian district hospitals. Health Affairs 28, 876–885. Mistry R, Galal O & Lu M (2009) Women’s autonomy and pregnancy care in rural India: a contextual analysis. Social Science and Medicine 69, 926–933. Mock CN, Nii-Amon-Kotei D & Maier RV (1997) Low utilisation of formal medical services by injured persons in a developing nation: health service data underestimate the importance of trauma. Journal of Trauma 42, 504–511. Petroze RT, Groen RS, Niyonkuru F, et al. (2013) Estimating operative disease prevalence in a low-income country: Results of a nationwide population survey in Rwanda. Surgery 153, 457–464. Sherman L, Clement PT, Cherian MN et al. (2011) Implementing liberia’s poverty reduction strategy: an assessment of emergency and essential surgical care. Archives of Surgery 146, 35–39.
Corresponding Author Reinou S. Groen, 1111 Light Street, Apt 309, Baltimore, MD, USA. Tel.: +1 919 599 0577; E-mail: [email protected]
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Individual and community perceptions of surgical care in Sierra Leone Reinou S. Groen1,2, Veena M. Sriram3, Thaim B. Kamara4, Adam L. Kushner2,3,5 and Lucie Blok6 1 2 3 4 5 6
Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA Surgeons OverSeas, New York, NY, USA Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA Department of Surgery, Connaught Hospital, Freetown, Sierra Leone Department of Surgery, Columbia University, New York, NY, USA Royal Tropical Institute, Amsterdam, The Netherlands
Abstract
objectives To determine themes and beliefs that influence health-seeking behaviour and barriers to accessing surgical care. methods In January 2012 in Western Area Province of Sierra Leone, six Focus Group Discussions (FGDs) were conducted. The FDGs consisted of three male only and three female only groups in an urban, a slum and a rural setting. Researchers investigated a wide range of topics including definitions of surgery, types of surgical procedures, trust, quality of care, human resources, postoperative care, permission-seeking and traditional beliefs. results Although many individual beliefs were expressed, common fears were as follows: becoming half human after surgery; complications from procedures; stigma from having a scar; and financial burdens resulting from the cost of care. Participants also expressed concern about the quality of the care available in Sierra Leone. conclusions The concept of being half human after surgery, previously not documented in the literature, is noteworthy and should be explored more fully. Qualitative research in other parts of Sierra Leone and other LMICs into beliefs of the local population could improve programmes for access and delivery of surgical care. keywords barriers to care, focus group discussion, half human, healthcare seeking behaviour, surgery, Sierra Leone
Introduction An estimated 11% of the global burden of disease can be treated with surgery (Debas et al. 2012) and recent studies from Sierra Leone and Rwanda document a high prevalence of surgically treatable conditions and deaths that could possibly have been averted with timely access to surgical care (Groen et al. 2012; Petroze et al. 2013). Although data exist on the lack of surgical capacity in numerous LMICs (Kingham et al. 2009; Choo et al. 2010; Kushner et al. 2010; Iddriss et al. 2011; Sherman et al. 2011), few studies have evaluated access to surgical care, and those that did are quantitative (Mock et al. 1997; Hang & Byass 2009; Grimes et al. 2011). In Vietnam, 60% of patients with a disability lasting for more than 29 days are likely to seek health care (Hang & Byass 2009). In Ghana, healthcare usage was more likely in cases of serious trauma (Mock et al. 1997).
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Little is known about the beliefs of populations in low- and middle-income countries about barriers to access surgical care. The goal of this study was to explore perceptions of surgical care in Sierra Leone. Methods The objectives of this research in Sierra Leone were to (i) understand the population’s perception of surgery in general and (ii) explore feelings towards local surgical care delivery to determine perceived barriers to accessing surgical care. Data for this qualitative study were collected through focus group discussions (FGDs). Three male and three female FGDs were held in different parts of Western-Area Province of Sierra Leone. The locations were randomly chosen from a list of enumerating areas, defined as rural, urban and slum for census and demographic health survey purposes. The participants were recruited based on expressed interest or upon 107
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recommendation of community leaders. The two moderators (one male, one female) were provided with a topic sheet to start the discussion on the ideas of surgery and operations and to elicit information on specific topics not raised by participants. All discussions took around one hour and were held in Krio, the local language in Western-Area, and the mother tongue of trained focus group moderators and participants. The moderator of the discussion was the same sex as the respondents. However, tape recordings and notes were taken by a moderator of the opposite sex. The two moderators who participated in all FDGs transcribed them into English. All six transcriptions of the various groups were discussed during a feedback session, which included the two moderators, their supervisor, the Chief of Surgery of Connaught Hospital, the principal investigator and four other interested medical persons. The principle investigator (RG) grouped the six transcripts into themes and subthemes to provide a useful overview. Ethical approval was obtained from the Sierra Leone Ethics and Scientific Review Committee, the Sierra Leone Ministry of Health and Sanitation and the Research Ethics Committee of the Royal Tropical Institute (KIT) in Amsterdam, the Netherlands. Funding was provided by Surgeons OverSeas (SOS). Results The main discussion themes are displayed in Table 1. All focus groups could be held, although one male group consisted of only four rather than the anticipated ten participants. Respondents in both the female and male groups were asked to list various types of operations. The most commonly mentioned were as follows: appendectomy, hernia repair, caesarean section, trauma care and abscess drainage. Respondents were encouraged to provide detailed explanations of the reason for and their understanding of the technical aspects of each procedure. For example, respondents believed appendicitis could result in death due to the appendix bursting in the abdomen, and caesarean sections were procedures that occur when the foetus is in the ‘wrong position’ and vaginal delivery is not possible. Misconceptions were also present, such as that a testicle will always be removed during a hernia repair, as stated in one discussion with male participants. All focus groups began with an open-ended question about associations with surgery and an operation. Primary reactions were fear of death and concern about the cost. One participant expressed fear about to the poor quality of hospitals in Sierra Leone. A recurrent theme in 108
several discussions and closely linked to the fear of surgery was the concept that one becomes a ‘half human’ or incomplete after an operation. Numerous participants referred to even an injection or incision as a process that resulted in becoming incomplete. However, variations of this concept were present, as seen in Table 2. It appeared that this concept is not strictly defined. Some individuals had the idea that after an appendectomy or hernia repair one was ‘half human’ where as others disputed this idea. Wound healing and a visible scar were also closely linked to the ‘half human’ concept. One respondent made a neutral statement regarding scarring, simply stating that the scar gives him a memory. However, most participants had a negative perception of scars and related them to bad feelings, fear and stigmatisation. Participants expressed that once a scar was visible, other people would investigate what went wrong with you. From the male focus group discussions came multiple negative comments on women with a scar (Table 1). The female group discussion in the urban area confirmed those statements, indicating that men stayed away from women with scars. Other negative perceptions towards people who have undergone surgery were that they are difficult to deal with and not strong enough for hard work. However, some positive remarks were also heard. Some respondents stated that people who underwent surgery are strong and should therefore given sympathy. One male participant from the rural area noted that scars from Sierra Leone are worse than scars than from surgeries abroad, while showing a barely visible scar from his laparoscopic operation performed in London. All groups talked about the need for qualified/certified medical doctors to practice surgery. Gender of the surgeon was of no importance. Subspecialties and their importance were also mentioned, although participants had difficulty accessing information on qualifications and certifications of a doctor and felt that this information should be publicly available. The quality of the doctor was intertwined with the discussion on the quality of the hospitals. Some participants stated that the quality depends more on the provider than on the hospital. However, others conversely stated that a good hospital made sure that only good trained, certified nurses and doctors were employed. The participants judged the quality of the hospitals from positive stories within their social networks. Availability of equipment and drugs were mentioned as being a factor in judging the quality of a hospital; the limited surgical capacity of Sierra Leone was mentioned several times. It was known that certain procedures, specifically laparoscopic procedures, are not available in Sierra Leone.
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Table 1 Main discussed themes and subthemes in different focus group discussion. (Numbers refer to how many times this was mentioned in the group) Men Main themes
Subthemes
Rural
Definitions and indications for surgery
Cut something from the body Remove a disease Remove a foreign body Removing unwanted material (…) To correct something that is wrong Cut and Stitch, cut and sew Operation to deliver a baby Split my stomach …take you to theatre and give (..) anaesthetic’ Death Fear Money/the cost of the operation Half human (See Table 2) Become an incomplete human being’ Definitions of surgery I will pray ..(get a) well body’ …it is either die or live’ Hernia C-section Appendix Eye Bozie’ (red: Hydrocele) Boil’ (red: Abscess) Amputation (Breast) cancer lump, growth Elephantiasis Heart operation Fracture/bones Operation and stitches for somebody involved in a motor accident’ ..that baby had something on its navel, it was operated and the child is oke..’ …there are various kinds of operations, some we do not know their names’ Doctor/medical doctor Doctor needs to be qualified for an operation Doctor who is specialised to do an operation Doctors with success stories Doctors who care also for the poor and do not ask money upfront Traditional healer I will pray to God and be operated by a God-fearing person’ We are not well informed to know if (..) (a) doctor is qualified’ Gender of the surgeon: ‘Even if that surgeon is a male or female as long as he/she is qualified’ The eye is not to be operated in Sierra Leone. They will not replace it in the right position. It is untouchable’
1 1 1
First thing to think of while talking about surgery
Known type of operations
Who do you trust to do an operation?
Women Slum
1 1 1
Urban
1 1
1
2 1 1 1
2
Rural
Slum
1
1
1
1
Urban
1 1
1
1 1 1
2 1
1 1
1
1 1 1
1 1 1 1 1 1 1
1 2 1 1
1 1
1 1 1
1 1 1
1 1 1 1 1
1
2 1 1 1
1 1
1 1 1
1 1 1 1
1 1 1 1
2 2 1 3
1 1 2
1 1 2
1 1
1 1 1 1
1 1 3
1 1 2
1
1
(continued)
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Table 1 (Continued) Men Main themes
Subthemes
Rural
Different mentioned surgical specialists
Surgeon/General surgeon Bone specialist Gynecologist, ‘gyne’ Eye surgeon Dentist For good quality, a hospital should be well equipped Not good if unsuccessful operations are carried out–people die or have complications Some surgical care is not available in Sierra Leone It is a government hospital and well known’ Because Chinese are there (…) they provide good drugs’ If they have (well qualified and trained) nurses and doctors available The quality depends more on the doctor than the hospital From success stories Logistics and drugs need to be available There is no good hospital/the facilities are not good in Sierra Leone Good quality is imported equipment and only used on one person There are no bad hospitals as far as operations are concerned/they will refer you if you are in the wrong hospital …is a good hospital (…) because it is a big hospital with many doctors (…) with different operation background (…) and share ideas in order to save life’ ..we do not have any bad hospital because there (are) death case(s) in all hospitals. (…) it (might be) destiny to die one day’ Numb a body part - I want to see what is done Numb a body part - ‘Sometimes people don’t come back from sleep’, ‘it is the anaesthetic that kills majority of the patients under surgery’ Sleep - I don’t want to see what is done - I’m afraid Sleep - I don’t want to irritate the doctor I let the doctor decide Not to do hard work/carry heavy load ‘ …like gardening or chopping fire wood’ ‘They (people after surgery) are not (to) do hard work because the wound reopens from the inside’ Not to eat that much to belly full’ (‘if intestine been removed’) Not to eat: pepper and solid food Drink alcohol (after liver and kidney operations) Avoid bright light and dust (use sunglasses), not bow down and chew hard substances (after eye surgery) … for the eye’s you should not concentrate for a long time…. (take) your drugs properly and eat(..) good food, (..)follow up with your doctor (…) (do not) get close(..) to fire or light..’ Women stop bearing children
1 1 1 1 1 1 2
Hospital quality
Anaesthesia
Limitations after surgery
Women Slum
Urban
Rural 1 1
1
1
2
1 2
Slum
Urban 1 1
1
1
1
1
1 1 1 2 1 1 1 1
1
1
2
1 2
1
4
1 1 1
1
1
1
2
2 1
2
2
1 1
3 1
2
3 1
4
3
1
4
1
1
1
1 3
2
1
1 1
1 2
1
1 1
1
(continued)
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Table 1 (Continued) Men Main themes
Wound healing
Complications of operations
What to do in case of a complication Taboos/spiritual or traditional beliefs on surgery
Subthemes (some) would say you wouldn’t be able to deliver on your own (..) but that is not true’ …Women who undergo C-Section operation are advised not to get pregnant’ I have heard that men after a hernia operation are unable to pregnant a woman’ Sex (after Appendix) (after Hernia) Soak towel in hot water and apply that on the scar/apply warm water Coconut oil Groundnut Krowbombo (country tree) grinded and applied Palm oil (for hot water burns) Raw egg (for burns) Mud (for burns) Honey (on burns) Traditional herbs (…) really helps especially in the area of fracture’ Cold and hot ointment (for broken bones) Kroo woman applied chalk and commanded the guy to walk (after a sport injury) No idea Reaction Being dizzy Death (‘…stomach, chest and throat. Once you have been operated in these you will not live long. With the feet it is oke’) Stomach ache Pain Fistula (after C-section) Bleeding (after a heart operation) the area (scar/operated area) becomes loosed’/‘the operated area will open’ waiting for like one month for her stomach to get a bowel sound’ (unhealed) sore’ (medical) ‘Checkup’ with your doctor Repeat the treatment to find out what was wrong (take) back to the hospital’ There are no body parts, which should not be operated on Taboo to be injected for Limba (tribe in SL) People belonging to cults (of witch craft) believe that there are some body parts not to be operated on/(…) a member of a secret society, will say that: no knife can be able to pierce through his body/those that joined poro hunting people with witch craft (…) may manipulate on the doctors so that when they are doing the operation, the person might die. (…) the patients normally die if the parent use force in order to carry out the operation’
Rural
Women Slum
Urban
Rural
Slum
Urban
1 1 1 1 1
1
1 1 1
2 1
1 1 1 1
1 1 1 1
1 1 1 1 1 1
1 1
1
2
1 1 1 1
1
1
1
1
1 1 1
1
1 1 1
1
1
1 1
1
1
1
(continued)
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Table 1 (Continued) Men Main themes
Permission/ authorisation for operation
Reason for delay or cancelation of surgery
Perceptions of scars
Subthemes I will not allow someone to touch my penis (for an operation)’ An old woman with a growth refused to be operated on’ (…) she believed it was God that placed it there’ Even an old person can undergo operation, as far as he/ she is living’ .. An old age like ninety years (seventy) need not to undergo operation in order not to die during the process. ‘ Ideal age for operation: ‘people in their eighties (….) they are mentally strong for an operation’ (for a nephew the doctor) asked us to wait until the child is four months before he can be operated’ No age limit for operation My wife I take the discussion My children My parents (mother or father) My husband God Money/Financial constraints Find the right doctor/qualified Find someone to accompany you to the hospital Fear/panic Unavailability of drugs Unavailability of equipment Based on doctors’ advice Nurses who want to bribe you before an operation witch craft manipulation’ ..with the free medical facility pregnant women can go for C-Section (…) (but) there are some drugs that are not available (..) the patient (needs) to buy the drugs (…) (and) the family (needs) to donate blood … at first my father did not agree for the surgery to carry on except that he has to be convinced that after the surgery I will survive and will still be a complete human being…’ (appendectomy) Age : ‘in case of babies, the age can make you wait to undergo an operation’ … (in case of fear you can) pray to God and deliver safely without doing a C-Section’ Gives me a memory the scar of my wife/friend/spouse scares me’, fear …whenever somebody sees the scar, they will shout at you and ask you what is that.’ (when I see her scar) ‘she makes me feel bad’, ‘I do not feel good’ (when I saw her scar) ‘I lost taste for her’ I’m not interested in any women that has a scar on her body..’ I just believe there is something wrong with her’
Rural
Women Slum
Urban
Rural
Slum
Urban
1
1 1
1
1 1 2 1 1 1 1
2 1 1
1 2
1
1 1
1
1 1
3 1
2 2
2 1 1
1
3
1 2 1 2
1 1 1 2
2
2
1
2
1 1
1 1 1
1
1 1 1 1
1
1
1 1
1
1
1
1
1
1 1 1
(continued)
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Table 1 (Continued) Men Main themes
Subthemes ..some men do stay away from women with operation scar by that you lost opportunity’ I do not like seeing even my own (scar) because it is a very big scar’ It makes the stomach (abdomen) big (…)and you will be ashamed to expose it to friends’ and ‘I cannot wear any fashion dress that expose my stomach’ Scars from Sierra Leone are worse than scars from operations abroad Half human/Incomplete human …I will rushed to give a helping hand because he/she is an incomplete human’ The people are not normal again (…) they are not strong as us (…) some are very difficult to handle after they (have) undergone operation’ …they are not strong enough and normal to do hard work’ I will congratulate them, because that person loves his/her life’ My friend did an operation (…) we play football together (…) I believe he is fit. ‘ I sympathise with them (…) they are sympathetic’ …I will feel so much for him/her and think of the pains he/she must have gone through’
Perceptions of people who have undergone surgery
Table 2 Definitions of ‘half human’ concept Definitions of ‘half human’
When are you NOT half human
Rural
(people with) ‘removed part of body’ ‘The one amputated is half human’/ amputation Hernia Appendix Operation on the stomach Tooth extraction ‘With my 50 years of experience all my friends who have undergone surgery will not tell me they are 100% human’ When you are given ‘incomplete treatment’ Once you are operated/‘once they have used knife or scissor on your body’ ‘People that are operated here (Sierra Leone) are left half human’ ‘When they do hernia operations, one ball is removed’ AND ‘God gave us men two balls’ Incomplete human (being) If after the operation the location was sown Hernia Appendix (if)’they are given some time to rest so that the saw will heal up’
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Women Slum
Urban
Rural
Slum
Urban 1
1 2
1 1
1 1
1
2 1
3
1
1 1 1 1
1 1
There were discrepancies in the perceptions around availability of good surgical care in Sierra Leone. Some participants felt that there is no good hospital in Sierra Leone for surgical care, while others proudly mentioned the names of good hospitals and surgeons. In the rural male focus group, one participant explicitly stated that the Sierra Leonean doctors and surgeons are good, but that lack of resources limits their capabilities to undertake successful operations. The use of traditional healers was mentioned once in the discussion regarding those that participants trust for an operation. Respondents indicated that they took injured relatives to traditional healers for surgical consultations, particularly for broken bones. One participant from the slum area mentioned spontaneously the use of anaesthesia when talking about the definition of surgery. In all other groups, the moderator elicited responses towards anaesthesia and the desire to be sleeping during an operation or having local anaesthetic. Respondents favoured local and general anaesthesia equally. Fear of anaesthesia was also expressed in three groups with respondents feeling that anaesthesia was the main factor in surgical deaths. 113
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For a good recovery from a surgical procedure, several measures were mentioned. Pepper or solid food should be limited after abdominal surgery, and almost all groups mentioned that one should not do hard work or carry heavy loads immediately after a procedure. Some groups discussed that these measures were temporary (lasting three months), while others believed that an operation made exertion in labour permanently impossible. Multiple comments were made relating reproductive health. Respondents stated that those who undergo an appendectomy or herniorrhaphy should not have sex for 3 months and that males can become infertile after a hernia operation. For wound healing, several substances, such as coconut oil, groundnut (peanut), and ground country tree, were mentioned as useful. For burn injuries, palm-oil, raw egg, mud and honey were discussed as prehospital treatment. Fractures and sports injuries were mainly treated with cold and hot ointment, traditional herbs and chalk application. In Sierra Leone, it is taboo for members of the Limba tribe to receive an injection. Also members of certain cults and secret societies are believed not to be able to be ‘touched by a knife’. It is thought that such persons possess powers that would kill a doctor who tried to operate on them. Permission for an operation was granted by close relations within the family. Females would ask their husbands and males their wives. Secondly, parents, mothers or fathers were also mentioned. Older participants mentioned their children. It seemed that decision-making was linked with payment for the surgery. Also permission needed to be granted by the caretaker after the surgery. Reasons to delay or cancel a surgery were most often financial or fear, but also searching for a qualified doctor, unavailability of drugs or equipment, age, doctors’ advice or not having the permission from a family member. It was also mentioned that nurses can delay the surgery if informal payments are not provided. Different amounts were mentioned for the cost of operations and these varied by provider. Financial constraints were commonly mentioned as a reason to delay surgery. One urban woman said that she was totally dependent on others to provide funds or loans if she needed to undergo a procedure. She also indicated that in some cases, doctors conduct procedures without payment for those who are unable to pay. The government programme of free care for pregnant women was noted as a positive development. However, challenges with drugs and blood donations were raised, with respondents stating that patients were frequently asked to buy drugs even though the surgery was free and that families had to donate blood when necessary. Therefore, free care for 114
pregnant women was not completely free. All participants indicated that they would be pleased if surgery became truly free of charge. Discussion The results of the focus group discussions present a number of important findings regarding the perception of surgical care and health-seeking behaviours in Sierra Leone. The results highlight the major themes of availability, accessibility and quality of surgical services and some of the sociocultural perceptions of surgery. The cost associated with surgery is seen as a major barrier to accessing care: participants indicated the need to borrow money from social networks or lending agencies. Participants also identified the breakdown of supply chains, resulting in patients bearing the delay as well as added costs of drugs, blood and equipment. The cost aspect of surgical care was similarly seen in research conducted in Vietnam that found an increase in cost with the increasing severity of injury. Interestingly, the study also pointed to a higher indirect cost placed on low-income patients than high-income patients (Hang & Byass 2009). Closely related to costs is the issue of permission. Studies exploring questions of decision-making and utilisation of health services have found that increased autonomy of a household member in terms of decision-making leads to increased utilisation of services (Mistry et al. 2009). Given that permission for surgery is related to the party responsible for payment of the surgery, our study raises a number of interesting questions about equity. How does this presumed financial power affect access to care? What steps are taken to ‘convince’ family members of the importance of the surgical service? Future research could also look into the age and sex stratification of costs. For example, does the collection of funds for surgery differ for children and the elderly, males or females, or maybe by procedure type? Another consideration is the impact of the type of surgery on direct and indirect costs associated with care. Laparoscopic surgery requires more resources and is therefore often more expensive than open surgery. However, it can potentially reduce costs by minimising hospital stay (Lagoe & Milliren 1986; Guller et al. 2004). In Bangladesh, laparoscopic surgery reduced post-operative hospitalisation time (Hannan et al. 2012). Quicker recovery and therefore fewer indirect costs and a faster return to work add to the benefit of expanding access to laparoscopic surgery. Laparoscopic procedures use smaller incisions and therefore might help address some of the concerns regarding post-operative scars. Misconceptions about surgical procedures and risks of anaesthesia were
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also identified in the current study and give direction for patient counselling and community education (Eyelade et al. 2010). The results also highlight several key sociocultural perceptions about surgery. The concept of becoming ‘half human’ after surgery was one of the main themes identified, which is not previously mentioned in the literature. Although this concept was not completely clear and not always perceived as negative, it is likely that such beliefs contribute to fear and stigma. It is also important to realise that the expression ‘half human’ might not relate directly to disability or physical impairment, but rather to a state of mind or a state of being. The western/contemporary concept of the ‘plumbing model’ of the body, where broken parts can be replaced, is likely not conceptualised in West-African societies (Helman 2007). Earlier exploration of cultural concepts of the Mende tribe in Sierra Leone revealed that replacing body parts or body components, as with a blood transfusion, was not imaginable (Bledsoe & Goubaud 1988). The topic of blood transfusion was not specifically explored in the current discussions; however, it is possible that this cultural concept is related to the fear of undergoing surgery. More in-depth anthropological and ethological research is indicated for further understanding of this potential barrier to acceptability of surgery in Sierra Leone. The discussion of injuries was limited in our FGDs, but it would be interesting to explore more fully given the negative opinion about scars. The findings highlight a number of contextual factors that influence perceptions of surgical care. The role of traditional healers in surgical and post-operative care mentioned in the FDGs highlights the importance of engaging these networks. Potential benefits might be expected when traditional healers are trained about the benefits or harm associated with popular topical and ingested treatments. Previous studies on the role of traditional healers in access to health care have shown the widespread availability and acceptance of traditional healers in low-resource communities (Addis et al. 2004). Given their proximity to communities, health organisations can potentially engage these networks in referral services for surgery, as has been successfully implemented with traditional birth attendants and providers of emergency obstetric care (Byrne & Morgan 2011). An important area for further research will be perceptions within the community about the skill level of health workers providing services. This is particularly important given the growing push for non-physician clinicians to provide high-skilled health services, such as surgical procedures. As demonstrated in Malawi and Tanzania, Clinical Officers (COs) or Assistant Medical
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Officers (AMOs) provide obstetric surgical services comparable to medical officers in terms of post-operative outcomes (Chilopora et al. 2007; McCord et al. 2009). In view of the limited availability of skilled providers of surgical procedures in many poor countries, task shifting to non-physician clinicians could be a promising strategy. It would be important to conduct qualitative research to understand how patients perceive non-physician clinicians providing services compared with specialist surgeons. As our current FGDs showed, a certification procedure for trained COs or AMOs might be beneficial from both patient and provider perspective. Information on qualifications needs to be disseminated to the public. A major limitation of this study is that the FGDs were conducted in Krio. This official language in Sierra Leone sounds like English but has its own distinct grammar and expressions as well as words not intelligible to an English speaker. It is distinct from the 15 other local ethnic groups, which have their own language. Therefore, it might be difficult to generalise the findings throughout the entire country or even regionally. FGDs were only conducted in Western-Area of Sierra Leone, close to the capital city Freetown. There is the possibility that more remote locations away from an urban centre with less access to surgical care and lower literacy and education rates might produce differing findings. The FGD guidelines were developed using Western academic standards. A deeper anthropologic and ethnological exploration of the identified themes might allow for differing conclusions. Lastly, there was no compensation for participation. Potentially, participants who were unavailable for the FDGs but might have participated if their time had been compensated would have provided other useful insights, which were not covered in the present discussions. Conclusion Focus group discussions conducted in Western-Area Province of Sierra Leone provided insights into the Krio population’s beliefs and perceptions of surgery. The previously unpublished concept that persons who undergo surgery become ‘half human’ was identified. Concerns were expressed over the availability and quality of surgical services as well as financial barriers and stigma. These results can be useful in planning programmes to increase access to surgical care for the population of Sierra Leone. References Addis G, Abebe D, Genebo T & Urga K (2004) Perceptions and practices of modern and traditional health practitioners about
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traditional medicine in Shirka District, Arsi Zone, Ethiopia. Ethiopian Journal of Health Development 16, 19–29. Bledsoe CH & Goubaud MF (1988) The reinterpretation and distribution of Western pharmaceuticals: an example from the Mende of Sierra Leone. In: The Context of Medicines in Developing Countries (eds S Van Der Geest & SR Whyte) Kluwer, Dordrecht, pp. 253–276. Byrne A & Morgan A (2011) How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance. International Journal of Gynecology & Obstetrics 115, 127–134. Chilopora G, Pereira C, Kamwendo F, Chimbiri A, Malunga E & Bergstr€ om S (2007) Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi. Human Resources for Health 14, 5–17. Choo S, Perry H, Hesse AAJ et al. (2010) Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool. Tropical Medicine & International Health 15, 1109–1115. Debas HT, Gosselin R, McCord C, Thind A (2006) Surgery. In: Disease Control Priorities in Developing Countries , (eds DT Jamison, JG Breman, AR Measham, G Alleyne, M Claeson, DB Evans, P Jha, A Mills & P Musgrove). 2nd edn, Chapter 67, World Bank, Washington (DC). Available at: http:// www.dcp2.org/pubs/DCP/67/FullText. (accessed 14 May 2012). Eyelade OR, Akinyemi JO & Adewole IF (2010) Patients’ perception and knowledge of anaesthesia and anaesthetists – a questionnaire survey. Southern African Journal of Anaesthesia and Analgesia 16, 28–31. Grimes CE, Bowman KG, Dodgion CM & Lavy CBD (2011) Systematic review of barriers to surgical care in low-income and middle-income countries. World Journal of Surgery 35, 941–950. Groen RS, Samai M, Stewart KA et al. (2012) Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet 380, 1082–1087. Guller U, Hervey S, Purves H et al. (2004) Laparoscopic versus open appendectomy outcomes comparison based on a large administrative database. Annals of Surgery 239, 43–52.
Hang HM & Byass P (2009) Difficulties in getting treatment for injuries in rural Vietnam. Public Health 123, 58–65. Hannan MJ, Hoque MM & Begum LN (2012) Laparoscopic appendectomy in pregnant women: experience in Chittagong, Bangladesh. World Journal of Surgery 36, 767–770. Helman CG (2007) The body: cultural definitions of anatomy and physiology. In: Culture, Health and Illness (eds. J Koster & S Purdy). 5th edn, London, UK, pp. 30–32, 50 Iddriss A, Shivute N & Bickler S (2011) Emergency, anaesthetic and essential surgical capacity in the Gambia. Bulletin of the World Health Organization 89, 565–572. Kingham TP, Kamara TB, Cherian MN et al. (2009) Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care. Archives of Surgery 144, 122–127. Kushner AL, Cherian MN, Noel L et al. (2010) Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Archives of Surgery 145, 154–159. Lagoe RJ & Milliren JW (1986) A community-based analysis of ambulatory surgery utilization. American Journal of Public Health 76, 150–153. McCord C, Mbaruku G, Pereira C, Nzabuhakwa C & Bergstrom S (2009) The quality of emergency obstetrical surgery by assistant medical officers in Tanzanian district hospitals. Health Affairs 28, 876–885. Mistry R, Galal O & Lu M (2009) Women’s autonomy and pregnancy care in rural India: a contextual analysis. Social Science and Medicine 69, 926–933. Mock CN, Nii-Amon-Kotei D & Maier RV (1997) Low utilisation of formal medical services by injured persons in a developing nation: health service data underestimate the importance of trauma. Journal of Trauma 42, 504–511. Petroze RT, Groen RS, Niyonkuru F, et al. (2013) Estimating operative disease prevalence in a low-income country: Results of a nationwide population survey in Rwanda. Surgery 153, 457–464. Sherman L, Clement PT, Cherian MN et al. (2011) Implementing liberia’s poverty reduction strategy: an assessment of emergency and essential surgical care. Archives of Surgery 146, 35–39.
Corresponding Author Reinou S. Groen, 1111 Light Street, Apt 309, Baltimore, MD, USA. Tel.: +1 919 599 0577; E-mail: [email protected]
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