Pediatr Surg Int DOI 10.1007/s00383-015-3684-1
ORIGINAL ARTICLE
Unmet surgical needs in children: a household survey in Nepal Neeraja Nagarajan • Shailvi Gupta • Sunil Shresthra Varshini Varadaraj • Sagar Devkota • Anju Ranjit • Adam L. Kushner • Benedict C. Nwomeh
•
Accepted: 10 February 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose While an estimated two billion people lack access to surgical care, little data are available on surgical conditions for pediatric populations in low- and middleincome countries. Our study aims to assess pediatric surgical needs in Nepal. Methods A countrywide cross-sectional study was performed in 15 randomly chosen districts; 3 clusters (2 rural; 1 urban) per district were selected. The prevalence of surgical conditions, unmet surgical needs, and barriers to care were analyzed among children (0–18 years of age). Results Overall, 1,350 households and 2,695 individuals were surveyed (response rate: 97 %); 800 respondents (29.7 %, 95 % CI 27.9–31.4 %) were pediatric; 59.8 % (95 % CI 56.3–63.2 %) were male; median age was 10 years (IQR 5–15). Of them, 84 (10.5 %, 95 % CI 8.5–12.8 %) had a surgical condition; 48 (6.0 %, 95 % CI
N. Nagarajan Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] S. Gupta A. L. Kushner B. C. Nwomeh Surgeons OverSeas, New York, NY, USA S. Gupta Department of Surgery, University of California San Francisco, East Bay, San Francisco, CA, USA S. Shresthra Department of Surgery, Nepal Medical College, Kathmandu, Nepal
4.5–7.9 %) reported an unmet need for surgical care. Based on this, we estimate that 706,076 (95 % CI 529,557– 929,666) children live with untreated surgical conditions. Barriers to care included limited availability of services (31.3 %), funds (22.9 %), time (4.2 %), and fear/mistrust of medical services (16.7 %). Conclusion Close to 700,000 children in Nepal are estimated to need surgical consultation. Programs to address this should be developed alongside efforts by policy makers and donors to rectify the lack of care, bolster limited funds, and strengthen healthcare systems. Keywords Global surgery International pediatric surgery Surgery in developing countries Surgical health systems Public health
S. Devkota Om Saibaba Memorial Hospital, Kathmandu, Nepal A. Ranjit Department of Surgery, Harvard Medical School, Boston, MA, USA A. L. Kushner Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA B. C. Nwomeh (&) Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH, USA e-mail: [email protected]
V. Varadaraj Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Pediatr Surg Int
Introduction It is estimated that two to three billion people in the world do not have access to basic surgical care [1]. A projected 234.2 million surgical procedures were performed worldwide, but this number is heavily influenced by procedures performed in countries with higher incomes [2]. The poorest countries, with 34.8 % of the global population, only account for 3.5 % of the procedures performed [2]. This points to a large burden of unmet surgical needs in these countries. While data are scarce for enumerating unmet surgical needs in low-income countries, recent studies point to prevalence up to 25 % [3, 4]. The WHOs global burden of disease (GBD) estimates that 11 % of GBD can be treated with surgical care; with the highest surgically modifiable DALYs in Asia [5]. While research on quantifying the burden of global diseases amenable to surgery is expanding, there is a dearth of studies that examine this burden in the pediatric age group but for a few exceptions [6–9]. While child health is in the forefront of public health, as represented by their presence at number 4 in the millennium development goals (MDG), there is very little recognition of surgery as a tool in improving child mortality and morbidity [10]. This is despite children making up around 50 % of the population in lowincome countries, and having a reported cumulative risk of 85.4 % for having a surgical condition by age 15 [11]. In this scenario, it becomes imperative to collect highquality data to improve the accuracy of the burden of surgical disease estimates from low-income settings, with special provisions made to measure the burden in the pediatric population. The publication of countrywide surveys of the prevalence of surgical conditions in countries in Africa [4, 6] has helped to define a denominator that guides the development of strategies to improve access and quality of surgical care in different populations. The ability to assess the burden overall, but also within different demographics, including women, children and the elderly, is pivotal to engaging relevant stakeholders to target special populations. We decided to adopt a similar methodology in a part of the world that we expect to find a high burden of unmet surgical needs—South Asia [2, 5, 11]. The South Asian country of Nepal, in the foothills of the Himalayas, faces many of the health challenges ubiquitous to LMIC (low and middle-income countries). This includes a high fertility rate (3.1 births per woman), maternal mortality ratio (281/100,000 live births), infant mortality rate (48 per 1000 live births) and under-5 mortality rate (61 per 1000 live births) [12]. This is despite impressive development in recent times and being on target with the MDGs [13]. Nepal ranks 157th of the 187 countries in the human development index [14]; and falls in the category of low-income country with a gross national income per
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capita of $561 [12]. Nepal has a young demographic with 34.6 % of its population under the age of 15 [12, 15]. The low resource setting in conjunction with the difficult terrain and lack of transportation, make access to surgical care challenging [13, 16]. Specifically in the pediatric population, hospital-based studies show that delay in seeking surgical care contributed to increased mortality and morbidity [17]. This, as well as strong local support, served as the background for our choice to carry out an assessment of the burden of unmet surgical needs in Nepal. The surgeons overseas assessment of surgical need (SOSAS) survey tool was used for this assessment. The SOSAS survey is available as an open source document [18] and was developed to be a population-based measure of the prevalence of surgically treatable conditions. The survey was specifically developed for use in LMICs, where traditionally data was sparse, and when available, was hospitalbased data only [19]. The objective of this study was to assess the prevalence of unmet surgical needs in the children of Nepal and describe the population characteristics, geographic distribution and causes of the prevalent surgical conditions. These data will help develop strategies to improve access and reduce the mortality and morbidity associated with untreated surgical conditions among children in Nepal.
Methods A countrywide population based survey was performed in Nepal from May 25 to June 12, 2014 using the SOSAS survey tool. Institutional review board (IRB) approval was obtained from Nepal Health Research Council in Kathmandu, Nepal and Nationwide Children’s Hospital in Columbus, Ohio. Study setting Nepal is a small (147,181 km2), land-locked country in South Asia, and lies between China and India as seen in Fig. 1 [12]. The country is diverse, both in terms of geographic characteristics and the demographic composition. The almost 30 million population remains mostly rural, despite a move towards urbanization [12]. Nepal has been the center of both internal and geopolitical unrest, which contributes to it being the least developed country in South Asia [14]. Study design The study was a cross-sectional, two-staged clusterbased household and individual survey. A pilot study was
Pediatr Surg Int Fig. 1 Map of Nepal with the selected districts
performed in Pokhara, Nepal in January 2014 and revealed a preliminary unmet surgical need of 5 % [20]. This percentage was used to calculate a required sample size of at least 2,373 individuals for the countrywide survey to demonstrate power. With provision for a non-respondent rate of 5 %, our study aimed for 2700 individuals. Fifteen of Nepal’s 75 districts were randomly selected proportional to population (Fig. 1). Village development committees (VDCs) were enumerated in each district and stratified according to rural or urban settings. Based on the DHS sampling methodologies, 3 clusters were chosen per district, 2 rural and 1 urban, with a total of 45 clusters sampled countrywide. In each cluster, 30 households were chosen, and 2 individuals from each household were surveyed. A total of 1350 households were surveyed.
unavailable, the person was excluded from the analysis. The structured interview elicited symptoms from 6 anatomical regions, [1] face, head and neck, [2] chest and breast, [3] abdomen, [4] groin and genitalia, [5] back and [6] the extremities. The individual respondents were asked if they perceived a need for surgical care for any condition that they reported symptoms for. The survey also recorded their responses for the length or duration of the condition, the perceived barriers to receiving care, their general health status and access to care. Novel to the SOSAS study in Nepal was a visual physical examination performed by a trained physician. The visual physical examination provided a measure of validation for the SOSAS tool [21]. The visual physical examination excluded a breast or genital exam.
Survey design
Data collection, management and analysis
The first stage of the survey collected data at the household level with an interview of the head of household or a surrogate. The information gathered were demographical information, including age, sex of all members, and information about the time and distance to the closest health facility. Household members were defined as members who slept in the same structure the night before the survey. The head of the household was asked questions about deaths in the household in the last year, as well as perceived cause of death. The head of the household also identified members of the household who were cognitively or mentally disabled and they were excluded from the second stage of the study. The second stage of the survey, the structured individual interview, was performed on two randomly selected household members. Appropriate consent was obtained, including those of guardians for children. All children below age 18 were included in our analysis for assessing the burden in the pediatric population. For children under 12 years of age, parents or guardians, helped to answer the questions. If the household member selected was not available during the time of the survey, three attempts were made to meet with them. If the individual was still
The questions were asked in Nepali, the national language of Nepal [12], by the enumerators and were then were recorded via paper surveys in English. Children were defined as those between 0 and 18 years of age, for those below 12 the parent/guardian was interviewed. Daily debriefing was held with the enumerators to discuss any urgent issues. Feedback was provided in these meetings to the enumerators regarding adequacy of the data, and any questions with the collected data itself. Data were entered into an Excel spreadsheet. STATA 13 (Stata Statistical Software: Release 13. College Station, TX: StataCorp LP) was used for all statistical analysis. Prevalence rates were calculated, along with the 95 % CI, using a weighted model.
Results Demographic data Overall, 1350 households were surveyed, in which 2695 individuals were interviewed. The response rate for the survey was 97 %. Among those who were interviewed, 800
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Pediatr Surg Int
Current and unmet surgical needs
Table 1 Demographic characteristics Number (%)
95 % CI
Age (years) \1
62 (7.8)
1–5
169 (21.1)
18.3–24.1
6–9
143 (17.9)
15.3–20.7
10–14
204 (25.5)
22.5–28.7
15–18
222 (27.8)
24.7–30.9
Male
478 (59.8)
56.3–63.2
Female
322 (40.2)
36.8–43.7
568 (71.0) 232 (29.0)
67.7–74.1 25.9–32.3
5.9–9.8
Sex
Location Rural Urban Number in HH (median, IQR)
14
13–15
15
6–20
A total of 84 (10.5 %, 95 % CI 8.5–12.8) children reported a current surgical need (Table 2). Among them, 48 (6.0 %, 95 % CI 4.6–7.9 %) reported an unmet surgical need (Table 2). The highest unmet need was in the age group 10–14 years of age (37.5 %), and in males (58.3 %) (Table 2). The time to health centers and the mode of transport are summarized in Table 2. The commonest anatomical area with unmet need was the face/neck (39.6 %), commonest conditions were growth/mass (29.2 %) and congenital deformities (29.2 %), and the commonest type of injury was due to hot liquids (41.7 %) (Table 3). Barriers to care
Time (median, IQR) Primary care Secondary care
60
20–240
Tertiary care
120
45–360
Type of transport to primary Motorized
141 (17.7)
15.1–20.5
Non-motorized
656 (82.3)
79.5–84.9
Motorized
589 (73.9)
70.8–77.0
Non-motorized
207 (26.1)
22.9–29.2
Motorized
738 (92.8)
90.8–94.5
Non-motorized
57 (7.2)
5.5–9.2
98 (12.3) 25 (3.1)
10.1–14.7 2.0–4.6
79 (9.9)
7.9–12.2
Type of transport to secondary
Type of transport to tertiary
Total lifetime procedures Major Minor Total
800
HH household, IQR interquartile range
respondents (29.7 %, 95 % CI 27.9–31.4 %) were less than 18 years of age. The median age of the children interviewed was 10 (IQR 5–15) years, with the highest numbers in the 15–18 age group (27.8 %) (Table 1). Among the children interviewed, 478 (59.8 %, 95 % CI 56.3–63.2 %) were males (Table 1). The majority of the children were in rural areas (71 %, 95 % CI 67.7–74.1), and lived in households with a median of 14 (IQR 13–15) inhabitants (Table 1). The children lived a median of 15 (IQR 6–20) min away from a primary, 60 (IQR 20–240) min from a secondary and 120 (IQR 45–360) min from the tertiary health care center (Table 1). The common mode of transport was nonmotorized to primary and motorized to secondary and tertiary health care centers (Table 1). A total of 98 children reported having a procedure done in their lifetimes, with 25 major and 79 minor procedures performed (Table 1).
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Among children who reported an unmet surgical need, most cited non-availability of services (31.3 %) as the barrier to seeking care. The other barriers to care that were reported included lack of money (22.9 %), fear/distrust of providers (16.7 %), lack of time (4.2 %) and unknown reasons (25.0 %) (Table 3). Death and disability Head of households reported that seven children below the age of 18 had died within the last year, the youngest being 8 days old and the oldest being 17 years of age. Four of the seven children were female (57.1 %). The head of households reported abdominal distention/pain as general cause of death in three out of the seven children (42.9 %). Among the children who reported a current surgical need, 53 did not report any disability (63.1 %), 13 (15.5 %) said that they were unable to work, 8 (9.5 %) said that they felt ashamed as a result of the disability, 8 (9.5 %) said that they needed help with daily activities, while 2 (2.4 %) said that they needed help with transportation.
Discussion The results of our survey show 6.0 % (95 % CI 4.6–7.9 %) of children in Nepal live with an unmet surgical need, with 10.5 % (95 % CI 8.5–12.8) having a current surgical condition. Using the 2011 Nepal census data [22], we can extrapolate that 706,076 (95 % CI 529,557–929,667) children in Nepal have an unmet surgical need. Using the same survey tool, Sierra Leone showed that 17.6 % of children there had a potentially surgically modifiable condition; while among children in Rwanda, the percentage was at 11.2 % [3, 4].
Pediatr Surg Int Table 2 Surgical need by demographics
Current surgical need (%)
Unmet surgical need (%)
\1
4 (4.8)
1 (2.1)
1–5
20 (23.8)
10 (20.8)
6–9
12 (14.3)
4 (8.3)
10–14
23 (27.4)
18 (37.5)
15–18
25 (29.8)
15 (31.3)
Age (years)
Sex Male
49 (58.3)
28 (58.3)
Female
35 (41.7)
20 (41.7)
Rural
62 (73.8)
35 (72.9)
Urban
22 (26.2)
13 (27.1)
13 (13–15)
13 (13–15)
Primary care Secondary care
15 (5–20) 60 (30–270)
15 (7.5–30) 90 (27.5–360)
Tertiary care
150 (60–360)
165 (60–360)
Motorized
12 (14.3)
1 (14.6)
Non-motorized
72 (85.7)
41 (85.4)
Motorized
68 (80.9)
40 (83.3)
Non-motorized
16 (19.1)
8 (16.7)
Motorized
82 (97.6)
47 (97.9)
Non-motorized
2 (2.4)
1 (2.1)
84
48
Location
Number in HH (median, IQR) Time (median, IQR)
Type of transport to primary
Type of transport to secondary
Type of transport to tertiary
HH household, IQR interquartile range
Total
Nepal’s health infrastructure consists of 10 regional/ teaching hospitals, 67 district hospitals and 13,700 primary health care outreach clinics [23, 24]. Despite this, large parts of the country, especially remote rural areas, have no access to health care. This situation is exacerbated by difficult weather, terrain and the fact that only 43 % of the population have access to all weather roads [23]. In addition to the lack of physical health infrastructure, there is also a huge lack of skilled staff. As of 2008, the ratio of doctor per population was 1:15,800 (well below the WHO recommendation of 1:1000) [25]. Furthermore most of the doctors are concentrated in urban areas with very few serving in the under-developed regions of Nepal [25]. This contributes to a widespread lack of access to pediatric care, and especially surgical care. This situation hinders the country’s ability to further reduce maternal, infant and child mortality [26]. The training of community health workers (CHW) in early detection and referral of common pediatric surgical conditions, as well as utilizing mid-level providers for simple surgical triage and care are all issues that need to be
addressed [27, 28]. Nepal is on track to fulfill its MDGs, and it would be very advantageous to continue with that momentum and create sustainable systems changes that include better access to surgical care, especially for pregnant women and children. There are several limitations of this study. The survey uses self-reporting for measuring the outcome of interest, which makes it prone to bias. We included a visual physical examination portion to this survey that helped to validate self-reported symptoms. The physical examination was only visual, and was not extended to genital exam; the prevalence of hernias and other genital conditions could therefore not be verified. While this could produce an overestimation of these conditions, there are some other conditions that are asymptomatic or not apparent to the subjects (abdominal masses, undescended testis) and may be missed by this survey. Another limitation was that the patients were interviewed in Nepali, which was then translated into English. To mitigate this, all our enumerators were either physicians or medical students who were fluent in both English and Nepali. Overall, this
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Pediatr Surg Int Table 3 Surgical need by location and type of injury
Current surgical need (%)
Unmet surgical need (%)
Face/neck
37 (44.1)
19 (39.6)
Chest
4 (4.8)
4 (8.3)
Back
1 (1.2)
1 (2.1)
Abdomen
9 (10.7)
7 (14.6)
Anatomical area
Groin
4 (4.8)
3 (6.3)
Extremity
29 (34.5)
14 (29.2)
Wound by Injury
18 (21.4)
6 (12.5)
Wound not by injury
5 (5.9)
1 (2.1)
Growth/mass
22 (27. 2)
14 (29.2)
Congenital deformity
20 (23.8)
14 (29.2)
Type of condition
Acquired deformity
12 (14.3)
8 (16.7)
Other
7 (8.3)
5 (10.4)
3 (3.6)
1 (2.1)
Type of injury Motor vehicle House/work injury
2 (2.4)
1 (2.1)
Stab/slash
3 (3.6)
1 (2.1)
Fall
3 (3.6)
Nil
Hot liquids
29 (34.5)
20 (41.7)
Not an injury
36 (42.9)
22 (45.8)
Other
8 (9.5)
3 (6.3)
No money
11 (13.1)
11 (22.9)
No time
2 (2.4)
2 (4.2)
Fear/distrust
8 (9.5)
8 (16.7)
Non-availability
15 (17.9)
15 (31.3)
No need
15 (17.9)
NA
Other
33 (39.3)
12 (25.0)
84
48
Barriers to access
Total
population survey was able to frame and provide a measure of burden of surgical disease in the pediatric population in Nepal, which can help to develop better strategies for their management. Further research in unmet surgical needs, in general and in specific populations, need to be carried out in middle-income countries that have a large population base and hence carry an extensive burden despite comparatively better health systems and indices.
to reduce mortality and morbidity associated with untreated surgical conditions. Maternal, infant and under-5 mortality all have a component that requires surgical intervention, and needs to be addressed if we are to look beyond the MDGs. Acknowledgments This study was financially supported by the Association for Academic Surgery Global Surgery Research Fellowship Award and Surgeons OverSeas Conflict of interest
Authors have none to disclose.
Conclusion There is 6.0 % unmet surgical need in the pediatric population of Nepal, and we project that close to 700,000 children live in Nepal with an unmet surgical need. With the enumeration of burden, there can be focus on strengthening health systems in the country to provide basic surgical care, especially for vulnerable populations,
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ORIGINAL ARTICLE
Unmet surgical needs in children: a household survey in Nepal Neeraja Nagarajan • Shailvi Gupta • Sunil Shresthra Varshini Varadaraj • Sagar Devkota • Anju Ranjit • Adam L. Kushner • Benedict C. Nwomeh
•
Accepted: 10 February 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose While an estimated two billion people lack access to surgical care, little data are available on surgical conditions for pediatric populations in low- and middleincome countries. Our study aims to assess pediatric surgical needs in Nepal. Methods A countrywide cross-sectional study was performed in 15 randomly chosen districts; 3 clusters (2 rural; 1 urban) per district were selected. The prevalence of surgical conditions, unmet surgical needs, and barriers to care were analyzed among children (0–18 years of age). Results Overall, 1,350 households and 2,695 individuals were surveyed (response rate: 97 %); 800 respondents (29.7 %, 95 % CI 27.9–31.4 %) were pediatric; 59.8 % (95 % CI 56.3–63.2 %) were male; median age was 10 years (IQR 5–15). Of them, 84 (10.5 %, 95 % CI 8.5–12.8 %) had a surgical condition; 48 (6.0 %, 95 % CI
N. Nagarajan Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] S. Gupta A. L. Kushner B. C. Nwomeh Surgeons OverSeas, New York, NY, USA S. Gupta Department of Surgery, University of California San Francisco, East Bay, San Francisco, CA, USA S. Shresthra Department of Surgery, Nepal Medical College, Kathmandu, Nepal
4.5–7.9 %) reported an unmet need for surgical care. Based on this, we estimate that 706,076 (95 % CI 529,557– 929,666) children live with untreated surgical conditions. Barriers to care included limited availability of services (31.3 %), funds (22.9 %), time (4.2 %), and fear/mistrust of medical services (16.7 %). Conclusion Close to 700,000 children in Nepal are estimated to need surgical consultation. Programs to address this should be developed alongside efforts by policy makers and donors to rectify the lack of care, bolster limited funds, and strengthen healthcare systems. Keywords Global surgery International pediatric surgery Surgery in developing countries Surgical health systems Public health
S. Devkota Om Saibaba Memorial Hospital, Kathmandu, Nepal A. Ranjit Department of Surgery, Harvard Medical School, Boston, MA, USA A. L. Kushner Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA B. C. Nwomeh (&) Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH, USA e-mail: [email protected]
V. Varadaraj Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Introduction It is estimated that two to three billion people in the world do not have access to basic surgical care [1]. A projected 234.2 million surgical procedures were performed worldwide, but this number is heavily influenced by procedures performed in countries with higher incomes [2]. The poorest countries, with 34.8 % of the global population, only account for 3.5 % of the procedures performed [2]. This points to a large burden of unmet surgical needs in these countries. While data are scarce for enumerating unmet surgical needs in low-income countries, recent studies point to prevalence up to 25 % [3, 4]. The WHOs global burden of disease (GBD) estimates that 11 % of GBD can be treated with surgical care; with the highest surgically modifiable DALYs in Asia [5]. While research on quantifying the burden of global diseases amenable to surgery is expanding, there is a dearth of studies that examine this burden in the pediatric age group but for a few exceptions [6–9]. While child health is in the forefront of public health, as represented by their presence at number 4 in the millennium development goals (MDG), there is very little recognition of surgery as a tool in improving child mortality and morbidity [10]. This is despite children making up around 50 % of the population in lowincome countries, and having a reported cumulative risk of 85.4 % for having a surgical condition by age 15 [11]. In this scenario, it becomes imperative to collect highquality data to improve the accuracy of the burden of surgical disease estimates from low-income settings, with special provisions made to measure the burden in the pediatric population. The publication of countrywide surveys of the prevalence of surgical conditions in countries in Africa [4, 6] has helped to define a denominator that guides the development of strategies to improve access and quality of surgical care in different populations. The ability to assess the burden overall, but also within different demographics, including women, children and the elderly, is pivotal to engaging relevant stakeholders to target special populations. We decided to adopt a similar methodology in a part of the world that we expect to find a high burden of unmet surgical needs—South Asia [2, 5, 11]. The South Asian country of Nepal, in the foothills of the Himalayas, faces many of the health challenges ubiquitous to LMIC (low and middle-income countries). This includes a high fertility rate (3.1 births per woman), maternal mortality ratio (281/100,000 live births), infant mortality rate (48 per 1000 live births) and under-5 mortality rate (61 per 1000 live births) [12]. This is despite impressive development in recent times and being on target with the MDGs [13]. Nepal ranks 157th of the 187 countries in the human development index [14]; and falls in the category of low-income country with a gross national income per
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capita of $561 [12]. Nepal has a young demographic with 34.6 % of its population under the age of 15 [12, 15]. The low resource setting in conjunction with the difficult terrain and lack of transportation, make access to surgical care challenging [13, 16]. Specifically in the pediatric population, hospital-based studies show that delay in seeking surgical care contributed to increased mortality and morbidity [17]. This, as well as strong local support, served as the background for our choice to carry out an assessment of the burden of unmet surgical needs in Nepal. The surgeons overseas assessment of surgical need (SOSAS) survey tool was used for this assessment. The SOSAS survey is available as an open source document [18] and was developed to be a population-based measure of the prevalence of surgically treatable conditions. The survey was specifically developed for use in LMICs, where traditionally data was sparse, and when available, was hospitalbased data only [19]. The objective of this study was to assess the prevalence of unmet surgical needs in the children of Nepal and describe the population characteristics, geographic distribution and causes of the prevalent surgical conditions. These data will help develop strategies to improve access and reduce the mortality and morbidity associated with untreated surgical conditions among children in Nepal.
Methods A countrywide population based survey was performed in Nepal from May 25 to June 12, 2014 using the SOSAS survey tool. Institutional review board (IRB) approval was obtained from Nepal Health Research Council in Kathmandu, Nepal and Nationwide Children’s Hospital in Columbus, Ohio. Study setting Nepal is a small (147,181 km2), land-locked country in South Asia, and lies between China and India as seen in Fig. 1 [12]. The country is diverse, both in terms of geographic characteristics and the demographic composition. The almost 30 million population remains mostly rural, despite a move towards urbanization [12]. Nepal has been the center of both internal and geopolitical unrest, which contributes to it being the least developed country in South Asia [14]. Study design The study was a cross-sectional, two-staged clusterbased household and individual survey. A pilot study was
Pediatr Surg Int Fig. 1 Map of Nepal with the selected districts
performed in Pokhara, Nepal in January 2014 and revealed a preliminary unmet surgical need of 5 % [20]. This percentage was used to calculate a required sample size of at least 2,373 individuals for the countrywide survey to demonstrate power. With provision for a non-respondent rate of 5 %, our study aimed for 2700 individuals. Fifteen of Nepal’s 75 districts were randomly selected proportional to population (Fig. 1). Village development committees (VDCs) were enumerated in each district and stratified according to rural or urban settings. Based on the DHS sampling methodologies, 3 clusters were chosen per district, 2 rural and 1 urban, with a total of 45 clusters sampled countrywide. In each cluster, 30 households were chosen, and 2 individuals from each household were surveyed. A total of 1350 households were surveyed.
unavailable, the person was excluded from the analysis. The structured interview elicited symptoms from 6 anatomical regions, [1] face, head and neck, [2] chest and breast, [3] abdomen, [4] groin and genitalia, [5] back and [6] the extremities. The individual respondents were asked if they perceived a need for surgical care for any condition that they reported symptoms for. The survey also recorded their responses for the length or duration of the condition, the perceived barriers to receiving care, their general health status and access to care. Novel to the SOSAS study in Nepal was a visual physical examination performed by a trained physician. The visual physical examination provided a measure of validation for the SOSAS tool [21]. The visual physical examination excluded a breast or genital exam.
Survey design
Data collection, management and analysis
The first stage of the survey collected data at the household level with an interview of the head of household or a surrogate. The information gathered were demographical information, including age, sex of all members, and information about the time and distance to the closest health facility. Household members were defined as members who slept in the same structure the night before the survey. The head of the household was asked questions about deaths in the household in the last year, as well as perceived cause of death. The head of the household also identified members of the household who were cognitively or mentally disabled and they were excluded from the second stage of the study. The second stage of the survey, the structured individual interview, was performed on two randomly selected household members. Appropriate consent was obtained, including those of guardians for children. All children below age 18 were included in our analysis for assessing the burden in the pediatric population. For children under 12 years of age, parents or guardians, helped to answer the questions. If the household member selected was not available during the time of the survey, three attempts were made to meet with them. If the individual was still
The questions were asked in Nepali, the national language of Nepal [12], by the enumerators and were then were recorded via paper surveys in English. Children were defined as those between 0 and 18 years of age, for those below 12 the parent/guardian was interviewed. Daily debriefing was held with the enumerators to discuss any urgent issues. Feedback was provided in these meetings to the enumerators regarding adequacy of the data, and any questions with the collected data itself. Data were entered into an Excel spreadsheet. STATA 13 (Stata Statistical Software: Release 13. College Station, TX: StataCorp LP) was used for all statistical analysis. Prevalence rates were calculated, along with the 95 % CI, using a weighted model.
Results Demographic data Overall, 1350 households were surveyed, in which 2695 individuals were interviewed. The response rate for the survey was 97 %. Among those who were interviewed, 800
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Current and unmet surgical needs
Table 1 Demographic characteristics Number (%)
95 % CI
Age (years) \1
62 (7.8)
1–5
169 (21.1)
18.3–24.1
6–9
143 (17.9)
15.3–20.7
10–14
204 (25.5)
22.5–28.7
15–18
222 (27.8)
24.7–30.9
Male
478 (59.8)
56.3–63.2
Female
322 (40.2)
36.8–43.7
568 (71.0) 232 (29.0)
67.7–74.1 25.9–32.3
5.9–9.8
Sex
Location Rural Urban Number in HH (median, IQR)
14
13–15
15
6–20
A total of 84 (10.5 %, 95 % CI 8.5–12.8) children reported a current surgical need (Table 2). Among them, 48 (6.0 %, 95 % CI 4.6–7.9 %) reported an unmet surgical need (Table 2). The highest unmet need was in the age group 10–14 years of age (37.5 %), and in males (58.3 %) (Table 2). The time to health centers and the mode of transport are summarized in Table 2. The commonest anatomical area with unmet need was the face/neck (39.6 %), commonest conditions were growth/mass (29.2 %) and congenital deformities (29.2 %), and the commonest type of injury was due to hot liquids (41.7 %) (Table 3). Barriers to care
Time (median, IQR) Primary care Secondary care
60
20–240
Tertiary care
120
45–360
Type of transport to primary Motorized
141 (17.7)
15.1–20.5
Non-motorized
656 (82.3)
79.5–84.9
Motorized
589 (73.9)
70.8–77.0
Non-motorized
207 (26.1)
22.9–29.2
Motorized
738 (92.8)
90.8–94.5
Non-motorized
57 (7.2)
5.5–9.2
98 (12.3) 25 (3.1)
10.1–14.7 2.0–4.6
79 (9.9)
7.9–12.2
Type of transport to secondary
Type of transport to tertiary
Total lifetime procedures Major Minor Total
800
HH household, IQR interquartile range
respondents (29.7 %, 95 % CI 27.9–31.4 %) were less than 18 years of age. The median age of the children interviewed was 10 (IQR 5–15) years, with the highest numbers in the 15–18 age group (27.8 %) (Table 1). Among the children interviewed, 478 (59.8 %, 95 % CI 56.3–63.2 %) were males (Table 1). The majority of the children were in rural areas (71 %, 95 % CI 67.7–74.1), and lived in households with a median of 14 (IQR 13–15) inhabitants (Table 1). The children lived a median of 15 (IQR 6–20) min away from a primary, 60 (IQR 20–240) min from a secondary and 120 (IQR 45–360) min from the tertiary health care center (Table 1). The common mode of transport was nonmotorized to primary and motorized to secondary and tertiary health care centers (Table 1). A total of 98 children reported having a procedure done in their lifetimes, with 25 major and 79 minor procedures performed (Table 1).
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Among children who reported an unmet surgical need, most cited non-availability of services (31.3 %) as the barrier to seeking care. The other barriers to care that were reported included lack of money (22.9 %), fear/distrust of providers (16.7 %), lack of time (4.2 %) and unknown reasons (25.0 %) (Table 3). Death and disability Head of households reported that seven children below the age of 18 had died within the last year, the youngest being 8 days old and the oldest being 17 years of age. Four of the seven children were female (57.1 %). The head of households reported abdominal distention/pain as general cause of death in three out of the seven children (42.9 %). Among the children who reported a current surgical need, 53 did not report any disability (63.1 %), 13 (15.5 %) said that they were unable to work, 8 (9.5 %) said that they felt ashamed as a result of the disability, 8 (9.5 %) said that they needed help with daily activities, while 2 (2.4 %) said that they needed help with transportation.
Discussion The results of our survey show 6.0 % (95 % CI 4.6–7.9 %) of children in Nepal live with an unmet surgical need, with 10.5 % (95 % CI 8.5–12.8) having a current surgical condition. Using the 2011 Nepal census data [22], we can extrapolate that 706,076 (95 % CI 529,557–929,667) children in Nepal have an unmet surgical need. Using the same survey tool, Sierra Leone showed that 17.6 % of children there had a potentially surgically modifiable condition; while among children in Rwanda, the percentage was at 11.2 % [3, 4].
Pediatr Surg Int Table 2 Surgical need by demographics
Current surgical need (%)
Unmet surgical need (%)
\1
4 (4.8)
1 (2.1)
1–5
20 (23.8)
10 (20.8)
6–9
12 (14.3)
4 (8.3)
10–14
23 (27.4)
18 (37.5)
15–18
25 (29.8)
15 (31.3)
Age (years)
Sex Male
49 (58.3)
28 (58.3)
Female
35 (41.7)
20 (41.7)
Rural
62 (73.8)
35 (72.9)
Urban
22 (26.2)
13 (27.1)
13 (13–15)
13 (13–15)
Primary care Secondary care
15 (5–20) 60 (30–270)
15 (7.5–30) 90 (27.5–360)
Tertiary care
150 (60–360)
165 (60–360)
Motorized
12 (14.3)
1 (14.6)
Non-motorized
72 (85.7)
41 (85.4)
Motorized
68 (80.9)
40 (83.3)
Non-motorized
16 (19.1)
8 (16.7)
Motorized
82 (97.6)
47 (97.9)
Non-motorized
2 (2.4)
1 (2.1)
84
48
Location
Number in HH (median, IQR) Time (median, IQR)
Type of transport to primary
Type of transport to secondary
Type of transport to tertiary
HH household, IQR interquartile range
Total
Nepal’s health infrastructure consists of 10 regional/ teaching hospitals, 67 district hospitals and 13,700 primary health care outreach clinics [23, 24]. Despite this, large parts of the country, especially remote rural areas, have no access to health care. This situation is exacerbated by difficult weather, terrain and the fact that only 43 % of the population have access to all weather roads [23]. In addition to the lack of physical health infrastructure, there is also a huge lack of skilled staff. As of 2008, the ratio of doctor per population was 1:15,800 (well below the WHO recommendation of 1:1000) [25]. Furthermore most of the doctors are concentrated in urban areas with very few serving in the under-developed regions of Nepal [25]. This contributes to a widespread lack of access to pediatric care, and especially surgical care. This situation hinders the country’s ability to further reduce maternal, infant and child mortality [26]. The training of community health workers (CHW) in early detection and referral of common pediatric surgical conditions, as well as utilizing mid-level providers for simple surgical triage and care are all issues that need to be
addressed [27, 28]. Nepal is on track to fulfill its MDGs, and it would be very advantageous to continue with that momentum and create sustainable systems changes that include better access to surgical care, especially for pregnant women and children. There are several limitations of this study. The survey uses self-reporting for measuring the outcome of interest, which makes it prone to bias. We included a visual physical examination portion to this survey that helped to validate self-reported symptoms. The physical examination was only visual, and was not extended to genital exam; the prevalence of hernias and other genital conditions could therefore not be verified. While this could produce an overestimation of these conditions, there are some other conditions that are asymptomatic or not apparent to the subjects (abdominal masses, undescended testis) and may be missed by this survey. Another limitation was that the patients were interviewed in Nepali, which was then translated into English. To mitigate this, all our enumerators were either physicians or medical students who were fluent in both English and Nepali. Overall, this
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Pediatr Surg Int Table 3 Surgical need by location and type of injury
Current surgical need (%)
Unmet surgical need (%)
Face/neck
37 (44.1)
19 (39.6)
Chest
4 (4.8)
4 (8.3)
Back
1 (1.2)
1 (2.1)
Abdomen
9 (10.7)
7 (14.6)
Anatomical area
Groin
4 (4.8)
3 (6.3)
Extremity
29 (34.5)
14 (29.2)
Wound by Injury
18 (21.4)
6 (12.5)
Wound not by injury
5 (5.9)
1 (2.1)
Growth/mass
22 (27. 2)
14 (29.2)
Congenital deformity
20 (23.8)
14 (29.2)
Type of condition
Acquired deformity
12 (14.3)
8 (16.7)
Other
7 (8.3)
5 (10.4)
3 (3.6)
1 (2.1)
Type of injury Motor vehicle House/work injury
2 (2.4)
1 (2.1)
Stab/slash
3 (3.6)
1 (2.1)
Fall
3 (3.6)
Nil
Hot liquids
29 (34.5)
20 (41.7)
Not an injury
36 (42.9)
22 (45.8)
Other
8 (9.5)
3 (6.3)
No money
11 (13.1)
11 (22.9)
No time
2 (2.4)
2 (4.2)
Fear/distrust
8 (9.5)
8 (16.7)
Non-availability
15 (17.9)
15 (31.3)
No need
15 (17.9)
NA
Other
33 (39.3)
12 (25.0)
84
48
Barriers to access
Total
population survey was able to frame and provide a measure of burden of surgical disease in the pediatric population in Nepal, which can help to develop better strategies for their management. Further research in unmet surgical needs, in general and in specific populations, need to be carried out in middle-income countries that have a large population base and hence carry an extensive burden despite comparatively better health systems and indices.
to reduce mortality and morbidity associated with untreated surgical conditions. Maternal, infant and under-5 mortality all have a component that requires surgical intervention, and needs to be addressed if we are to look beyond the MDGs. Acknowledgments This study was financially supported by the Association for Academic Surgery Global Surgery Research Fellowship Award and Surgeons OverSeas Conflict of interest
Authors have none to disclose.
Conclusion There is 6.0 % unmet surgical need in the pediatric population of Nepal, and we project that close to 700,000 children live in Nepal with an unmet surgical need. With the enumeration of burden, there can be focus on strengthening health systems in the country to provide basic surgical care, especially for vulnerable populations,
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