Original Research—International Health
Untreated Head and Neck Surgical Disease in Sierra Leone: A Crosssectional, Countrywide Survey
Otolaryngology– Head and Neck Surgery 2014, Vol. 151(4) 638–645 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814542587 http://otojournal.org
Nicholas C. Van Buren, MD1, Reinou S. Groen, MD2,3, Adam L. Kushner, MD2,4,5, Mohamed Samai, PhD6, Thaim B. Kamara, MD7, Jian Ying, PhD8, and Jeremy D. Meier, MD1
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Keywords
Abstract
Received September 24, 2013; revised March 25, 2014; accepted June 17, 2014.
Objectives. Demonstrate how the Surgeons OverSeas Assessment of Surgical Need (SOSAS) can be used to determine the burden of head and neck (H&N) surgical disease in developing countries and identify reasons for untreated disease. Study Design. Cluster randomized, cross-sectional, countrywide survey. Setting. Sierra Leone. Subjects and Methods. The survey was administered to 75 of 9671 enumeration areas in Sierra Leone between January 9 and February 3, 2012, with 25 households in each cluster randomly selected for the survey. A household representative and 2 randomly selected household members were interviewed. Need for surgical care was based on participants’ responses to whether they had an H&N condition that they believed needed surgical care. Results. Of 1875 households, data were analyzed for 1843 (98%), with 3645 total respondents. Seven hundred and one H&N surgical conditions were reported as occurring during the lifetime of the 3645 respondents (19.2%).The current prevalence of H&N conditions in need of a surgical consultation was 11.8%. No money (60.1%) was the most common reason respondents reported for not receiving medical care. A bivariate analysis demonstrated that age, village type, education, and type of condition may be predictors for seeking health care and/or receiving surgical care. Conclusions. These results show limited access for patients to be evaluated for a potential H&N surgical condition in Sierra Leone. The true incidence of untreated surgical disease is unknown as most respondents were not evaluated by a surgeon. This survey could be used in other countries as health care professionals assess surgical needs throughout the world.
global health, developing countries
Introduction Global health efforts have strengthened in recent years. However, many initiatives have focused primarily on medically treated disease, neglecting surgical conditions.1,2 The decreased emphasis on surgical disease is often due to cost and inadequate infrastructure in developing countries. The actual burden of surgical disease in low-income and middleincome countries has been difficult to determine, but many studies have attempted to estimate the disability and costs associated with unrepaired surgical conditions such as cleft lip and palate.3,4 Some have estimated that operative disease accounts for 11% of global disease, but no studies have correlated this number to a community level.2,5 Even less understood is the impact of untreated otolaryngic conditions in the developing world. 1
Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA 2 Surgeon OverSeas, New York, New York, USA 3 Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland, USA 4 Department of Surgery, Columbia University, New York, New York, USA 5 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA 6 College of Medicine and Allied Health Science, Freetown, Sierra Leone 7 Department of Surgery, Connaught Hospital, Freetown, Sierra Leone 8 Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA This paper was presented as a poster at the 16th Annual Meeting at COSM; April 12-13, 2013; Orlando, Florida. Corresponding Author: Jeremy D. Meier, MD, Assistant Professor, University of Utah, Division of Otolaryngology–Head and Neck Surgery, 50 North Medical Drive, Room 3C120, Salt Lake City, UT 84132, USA. Email: [email protected]
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
Van Buren et al
639
Approximating the surgical disease burden in third world countries has relied on physician surveys, data extrapolation from well-developed countries, or hospital registries.6,7 However, these estimations are limited. Relying on hospital registries misses a significant portion of the population that never presents to the hospital. This would be particularly true with many otolaryngic conditions that are often treated in the outpatient setting. In sub-Saharan Africa, the number of otolaryngologists is estimated to be 0.01 to 0.4:100,000 compared to 2.5:100,000 in the United States, 10:100,000 in Japan, and 1:100,000 in the United Kingdom.8,9 The amount of untreated otolaryngic disease is immense but truly not known. The Surgeon OverSeas Assessment of Surgical Need (SOSAS) is a survey tool developed to measure the prevalence of surgical disease and potentially treated deaths related to surgical conditions in lowincome and middle-income countries. This population-based household survey was developed by an international group of experts. Pilot studies were performed in Sierra Leone, a small West African country with a population of 6 million.10 The purpose of this study is to demonstrate how the SOSAS can be used to estimate the prevalence of untreated head and neck (H&N) conditions in a developing country. This paper is part of a series of articles discussing the findings of the SOSAS in Sierra Leone.11-14 Results pertaining specifically to H&N conditions from this nationwide study in Sierra Leone will be described. The reasons identified through this survey for why these conditions were untreated will be discussed. Understanding the utility of the SOSAS will allow for implementation in other countries to identify needs for global surgical health initiatives.
Methods The study methods for this survey have been described in full previously.11 Baseline demographic information on Sierra Leone’s total population was obtained and the country divided into 9671 clusters or enumeration areas. Of these 9671 enumeration areas, 75 were randomly selected, with stratification for rural and urban settings and districts. Between January 9 and February 3, 2012, surveys were performed in the 75 enumeration areas. In each cluster, 25 households were randomly selected for the survey. Students from the Sierra Leone Faculty of Nursing and Sierra Leone College of Medicine and Allied Health Sciences and staff from Statistics Sierra Leone collected the data with handheld tablets. The SOSAS has been previously described in detail as well.10,11 Briefly, there are 2 parts to the survey. First, a household representative was interviewed to identify the number of household members, record deaths in the household during the previous year, and determine whether the deceased household members had any conditions in the week before their death including abdominal distention or pain; bleeding or illness during childbirth; injury; mass, growth, or swelling; acquired deformity; or a wound not due to injury or congenital deformity. Two randomly selected household members then underwent a head-to-toe verbal examination. Each selected household member was
asked whether they had a wound, burn, mass, deformity, or other condition needing surgical assessment or care for 6 different anatomical regions: (1) face, head, and neck; (2) chest and breast; (3) abdomen; (4) groin, genitals, and buttocks; (5) back; (6) arms, hands, legs, and feet. Scores are recorded for each anatomical domain, and multiple conditions could be recorded in each subsite. This paper focuses on the conditions in the survey specifically related to the face, head, and neck region. The need for surgical care was based on participants’ responses to whether they had a face, head, or neck condition that they believed needed surgical assessment or care. A surgical procedure included providing wound care, suturing, incising, excising, or manipulating tissue in a safe and painless way.15 Major procedures were defined as procedures requiring general or regional anesthesia, whereas minor procedures required either local or no anesthesia. The survey instrument was not validated but was piloted in Sierra Leone in 2011 with 100 respondents.10 The survey has also been implemented in Rwanda.16 An overview of the results from this survey has been previously published.11 In that article, all 6 anatomic regions were pooled together in the analysis. For this manuscript, we describe in detail the results from specific subsites (head, neck, eye, ear/nose/throat, and mouse/lips/dental). We also explore deeper into the reasons for untreated surgical disease by examining factors that influence whether surgical care was sought and if surgical care was received. Demographic data of all respondents were compared to respondents with H&N conditions. Characteristics of the condition including location, timing of onset, severity, and whether health care was sought and the type of care received was recorded. The summary statistics and their confidence limits were estimated with stratification defined by districts and urban and rural population distribution and clustering within enumeration area being taken into account. Separate survey logistic regression analyses were performed to relate the odds of seeking health care and of receiving surgery, respectively, to each of the following individual factors: age, gender, village type (rural vs urban), ethnicity, education level, literacy, occupation, location of condition, and type of condition. When analyzing the variables of education level, literacy, and occupation, only subjects 14 years or older were included in the analysis. Odds ratios for education, literacy, and occupation were then estimated using separate multivariable logistic regression models adjusted for age, gender, village type, location of condition, and type of condition. An additional multivariable regression analysis using the entire cohort was performed for village type while controlling for education, literacy, and occupation. Statistical significance was determined with P values less than or equal to .05, without adjustment for multiple comparisons. All analysis was performed using SAS 9.3. The study was performed with collaboration between Surgeons OverSeas, Sierra Leone Ministry of Health and Sanitation, Connaught Hospital Department of Surgery, and Statistics Sierra Leone. The Ethics and Scientific Review Committee of Sierra Leone and the Research Ethics
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
640
Otolaryngology–Head and Neck Surgery 151(4)
Table 1. Demographics.
Number Mean age (years) Gender Male Female Village type Rural Urban Education level None Primary Secondary Tertiary Graduate Missing Literate (yes) Missing Occupation None Homemaker Domestic helper Farmer Self-employed Government employee Non–government employee Missing
All Respondents n/N (%)
Respondents with H&N Condition n/N (%)
3645 25.0 (95% CI, 24.4-25.7)
666 31.3 (95% CI, 29.3-32.8)
1669/3645 (45.8) 1976/3645 (54.2)
312/666 (46.8) 354/666 (53.2)
2231/3645 (61.2) 1314/3645 (38.8)
391/666 (58.7) 275/666 (41.3)
1225/2303 (53.2) 225/2303 (9.8) 728/2303 (31.6) 114/2303 (5.0) 11/2303 (0.5) 8 1056/2294 (46.0) 15
263/482 (54.6) 47/482 (2.0) 142/482 (29.5) 28/482 (5.8) 2/482 (0.4) 2 212/481 (44.1) 2
649/2304 (28.2) 103/2304 (4.5) 94/2304 (4.1) 827/2304 (35.9) 446/2304 (19.4) 123/2304 (5.4) 61/2304 (2.6) 13
116/481 (24.1) 31/481 (6.4) 17/481 (3.5) 185/481 (38.5) 86/481 (17.9) 28/481 (5.8) 18/481 (3.7) 2
P Value
\.001 .54
.15
.73
.34 .03
Abbreviations: H&N, head and neck; CI, confidence intervals.
Committee of the Royal Tropical Institute in Amsterdam both granted ethical approval. Respondents provided written informed consent. If the respondent was illiterate, a thumbprint with a signature from a literate witness was obtained. For subjects younger than 18 years, a parent or guardian provided written consent. For respondents less than 12 years old, a parent/guardian either assisted with the interview or responded for the child.
Results Data were collected and analyzed from 1843 households (of 1875 targeted households, response rate of 98%), with 3645 total respondents. Respondents reporting an H&N condition were statistically older than the entire cohort. No statistically significant difference was found between those with an H&N condition and the entire cohort when comparing gender, village type, education level, and literacy. H&N surgical conditions occurring over the respondents’ lifetime was reported in 666 of the 3645 respondents (18.3%) (Table 1). Thirty-one respondents reported 2 conditions, and 2 respondents reported 3 conditions for a total of 701 H&N conditions reported. The most common H&N sites reported were head (34.7%), eyes (22.3%), lips/mouth/ dental (21.3%), neck (12.1%), and ears/nose/throat (9.6%)
(Table 2). Of the 701 head and neck conditions reported, 480 (69.4%) were currently present. A total of 60.8% of the injuries had been present longer than 12 months. The most common type of condition was acquired deformity (31.6%), followed by wound, not injury related (23.2%), and injuryrelated wound (21.4%). Of reported H&N conditions, 264 (41.8%) were disabling, including 135 (21.4%) conditions affecting respondents ability to work. Of the respondents with an H&N condition, 420 (60.2%) sought health care at a clinic staffed by nurses or doctors for their H&N condition while 240 (34.9%) sought care from a traditional healer, bone setter, or witch doctor. A major procedure was performed in 31 respondents (7.4%), and a minor procedure was performed in 219 respondents (52.3%) of those who sought medical care. The most common reasons respondents provided for not obtaining medical care included: no money (60.7%), no need (24.5%), and no doctor/nurse available (6.5%) (Table 3). The prevalence of H&N surgical conditions currently requiring surgical consultation of all respondents was 11.8%. An active H&N surgical condition included conditions respondents reported as current and requiring surgical care but excluded conditions that health providers or the respondent felt that did not require surgical care.
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
Van Buren et al
641
Table 2. Characteristics of Head and Neck Condition.
Location Eye Ear/nose/throat Mouth/lips/dental Neck Head Missing Present now Yes No Missing Timing of onset \1 month 1-12 months .12 months Missing Disability None I feel ashamed Unable to work like before Need help with transportation Need help with daily living Missing Type of condition Injury-related wound Non–injury-related wound Burn Mass or growth/goiter Congenital deformity Acquired deformity Missing
Table 3. Health Care Sought and Care Received.
Frequency
Percentage
156 67 149 85 243 1
22.3 9.6 21.3 12.1 34.7
480 212 9
69.4 30.6
135 136 421 9
19.5 19.7 60.8
367 87 135 10 32 70
58.2 13.8 21.4 1.6 5.1
149 162 33 103 30 220 4
21.4 23.2 4.7 14.8 4.3 31.6
Health care sought Yes No Missing Traditional healer sought Yes No Missing Type of care received None/no surgical care Major procedure Minor procedure Missing Reason for no care No money for health care No money for transportation No time No trust in health facility No skilled doctor/nurse available No need Missing
Frequency
Percentage
420 278 3
60.2 39.8
240 447 12
34.9 65.1
169 31 219 1
40.3 7.4 52.3
270 2 10 25 29 109 2
60.7 0.5 2.3 5.6 6.5 24.5
significant variable for those seeking health care, as those with a primary education were more likely to seek care than those without any education. Even after controlling for education, literacy, and occupation, subjects living in urban areas were statistically more likely to seek health care (Table 5).
Discussion
Univariate analysis to evaluate predictors for seeking health care and for receiving surgical care is shown in Table 4. Respondents older than 65 years demonstrated a trend of being less likely to seek health care and obtain surgical care compared to younger respondents. Respondents from urban clusters were 2.6 times more likely to seek health care compared to respondents from rural areas. Lips/mouth/dental conditions were the most likely H&N location to obtain surgical care, followed by conditions located on the head. Injuryrelated wounds were more likely to be brought to medical attention and obtain surgical care compared to wounds not injury related, burns, masses, congenital deformities, and acquired deformities. Respondents who were literate and had some level of education were more likely to seek medical care. Farmers were less likely to seek medical care compared to other occupations, though no significant statistical difference was seen in surgical care received (Table 4). After controlling for age, gender, village type, location of condition, and type of condition, education remained a
Access to otolaryngologists in developing countries remains limited. Particularly in sub-Saharan Africa, where many countries do not have a single otolaryngologist, H&N conditions are either treated by other medical providers or left untreated. This study suggests a high prevalence (11.8%) of untreated surgical H&N conditions in Sierra Leone, or at least a significant portion of the population needing a surgical consultation. Random selection of households within several enumeration areas of Sierra Leone was performed to obtain the best representation of the entire country. We assumed that surgical conditions are not very clustered. Extrapolating these data to the entire 6 million people of the country would suggest that 700,000 people may be in need of H&N surgical treatment. In addition, our analysis demonstrated that many lifetime H&N conditions were potentially undertreated. A majority of respondents who sought treatment for their H&N condition had either a minor procedure (52.3%) or no surgical care (40.3%) compared to small minority who underwent a major procedure (7.4%) (Table 2). The World Health Organization estimates that 42.8% of men and 35.5% of women drank alcohol in the past year, with alcohol use disorders of 2.10% and 0.24% in people 15 and over.17
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
642
Otolaryngology–Head and Neck Surgery 151(4)
Table 4. Univariate Analysis of Predictors for Seeking Health Care and Obtaining Surgical Care. Health Care Sought
Age (yrs) \14 14-65 .65 Sex Male Female Village type Rural Urban Location Eye ENT Dental/mouth Neck Head Type Wound, injury related Wound, non-injury Burn Mass Deformity, congenital Deformity, acquired Educationa None Primary Secondary Tertiary Graduate Literacya No Yes Occupationa None Homemaker Domestic helper Farmer Self-employed Government employee Non–government employee
No
Yes
76 162 39
110 275 34
132 145
197 222
OR (95% CI)
Surgical Care Received P Value
No
Yes
50 97 21
60 168 12
82 86
114 136
99 69
107 143
54 20 22 29 43
39 16 76 19 100
15 40 4 41 11 56
93 77 18 12 2 48
61 17 31 7 1
80 21 71 17 1
64 54
90 99
32 7 5 37 23 8 5
43 18 7 52 39 17 14
OR (95% CI)
.05 0.9 (0.6-1.2) 1.7 (0.95-2.9)
.006 1.5 (0.9-2.6) 0.5 (0.2-1.2)
.87 1 (0.7-1.4)
.48 1.1 (0.8-1.6)
\.001 199 78
207 212
2.6 (1.7-4.0)
.05 1.9 (1.0-3.7) \.001
.78 62 29 51 36 99
94 36 98 48 143
41 44 11 47 17 115
108 117 22 54 13 104
137 13 45 6 0
142 38 102 24 2
129 70
155 153
0.8 1.3 0.9 1.0
(0.4-1.6) (0.7-2.5) (0.5-1.6) (0.6-1.5)
1.1 (0.5-2.5) 4.8 (1.9-11.7) 0.9 (0.4-2.1) 3.2 (1.7-6.2)
\.001 1.0 0.8 0.4 0.3 0.3
(0.5-1.9) (0.3-1.9) (0.2-0.8) (0.1-0.7) (0.2-0.6)
\.001 0.3 (0.1-0.7) 0.7 (0.2-2.8) 0.05 (0.02-0.13) 0.03 (0.01-0.18) 0.14 (0.07-0.3)
\.001 2.8 (1.3-6.0) 2.2 (1.5-3.3) 3.9 (1.9-7.7) N/A
.08 0.9 (0.4-2.5) 1.7 (1.0-3.1) 1.9 (0.6-5.7) 0.8 (0.05-13)
.002 1.8 (1.2-2.7)
.28 1.3 (0.8-2.1)
\.001 47 7 7 99 28 7 4
75 25 12 90 62 25 19
2.2 1.1 0.6 1.4 2.2 3.0
(0.8-6.5) (0.4-3.2) (0.3-0.9) (0.8-2.5) (1.2-4.3) (1.1-7.9)
P Value
.73 1.9 (0.5-6.7) 1.0 (0.2-5.6) 1.0 (0.4-2.5) 1.3 (0.6-4.4) 1.6 (0.6-4.4) 2.1 (0.8-5.6)
Abbreviations: OR, odds ratio; CI, confidence interval. a Only subjects with age 14 years old were included in analysis.
Current tobacco smoking estimates in adults are 43.1% in males and 10.5% in females (25.8% total).18 With such a high prevalence of risk factors for H&N cancer and only 2 otolaryngologists in the country, surely the unmet needs will not be satisfied with the current system. Demographic data were analyzed to determine why some respondents were receiving H&N surgical care and not others. We noticed a trend in respondents younger than 65
years that were more likely to seek medical care and receive surgical care compared to elderly adults (Table 4). A recent health care initiative in Sierra Leone was implemented to improve maternal and children health by providing free care for pregnant women and children less than 5 years old. Regional hospitals have seen an increase in overall pediatric surgical cases since the initiative.19 Our data did not show a significant difference in health care sought or surgical care
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
Van Buren et al
643
Table 5. Multivariate Analysis Examining Socioeconomic Variables. Health Care Sought Surgical Care Received
Educationa None Primary Secondary Tertiary Graduate Literacya No Yes Occupationa None Homemaker Domestic helper Farmer Self-employed Government employee Non–government employee Village typeb Rural Urban
Adjusted OR (95% CI)
Adjusted OR (95% CI)
P \.001 Reference 2.3 (1.1-4.6) 1.6 (1.0-2.4) 1.9 (0.8-4.5) NA P = .33 Reference 1.2 (0.8-1.9) P = .44 Reference 1.9 (0.6-5.4) 1.3 (0.4-3.9) 0.8 (0.5-1.4) 1.2 (0.6-2.4) 1.7 (0.9-3.4) 1.5 (0.6-4.1)
P = .5 Reference 0.56 (0.22-1.44) 1.2 (0.5-2.4) 1.1 (0.3-4.0) 0.8 (0.07-9.4) P = .52 Reference 0.8 (0.4-1.5) P = .87 Reference 0.9 (0.2-3.6) 1.1 (0.2-6.0) 1.8 (0.7-4.5) 1.3 (0.5-3.3) 1.5 (0.4-5.5) 1.2 (0.4-4.3)
P = .01 Reference 1.9 (1.2-3.0)
P = .06 Reference 2.0 (0.98-4.1)
Abbreviations: OR, odds ratio; CI, confidence intervals. a OR was adjusted for age, gender, village type, location of condition, and type of condition. Only subjects 14 years old were included in the analysis. b OR was adjusted for education, literacy, and occupation. All subjects in the cohort were included in the analysis.
received for H&N conditions in children less than 5 years old compared to older children and middle-aged adults (data not shown). Higher education level, literacy, and employment were all significantly associated with an increased likelihood of seeking health care on univariate analysis. These variables are likely correlated and suggest that socioeconomic factors significantly impact the likelihood of seeking health care. To determine the patient demographic factors that most significantly impact the likelihood of seeking and receiving care, a multivariate analysis examining the socioeconomic variables of education, literacy, employment, and village type was performed. After controlling for village type and other variables, the impact of literacy and employment become insignificant. However, village type (rural vs urban) remains significant even after controlling for education, literacy, and occupation. This suggests that rural communities, likely due to proximity to available health care, may be a primary barrier to seeking and even receiving care. Respondents with burns, masses, or acquired and congenital deformities sought and obtained less surgical care compared to wounds related to an injury. The acute symptomatic aspect of an injury, such as a face laceration, appears to urge respondents to overcome health access
barriers and seek treatment. Alternatively, more local providers may be equipped to deal with minor wound injuries of the H&N compared to specialty training that other more complex deformities and masses require. We predict the high ratio of minor (87.6%) compared to major procedures (12.4%) may in part be due to the incidence of treated wound-related injuries. The most common reason reported for not seeking consultation for an H&N condition was related to lack of money. This is not surprising as 70% of the population lives in poverty.20 Remarkably, only 6% of respondents cited their reason for not seeking consultation because of no doctor or nurse. While this may suggest that the problem with untreated H&N conditions is not related to a shortage of adequately trained medical professionals, this is unlikely the case. The respondents may be unaware of current available medical expertise in their area. While many of these conditions could be adequately treated with local medical professionals, it is possible that several problems would require a more highly trained provider than what is currently available in Sierra Leone. In this survey, the most common H&N site needing a surgical consultation was the head. One limitation to this study is the generalized sites (ie, head, eyes, lips/mouth/dental, neck, and ears/nose/throat) that were asked in the survey. No specifics can be obtained from the survey results to determine the actual problem associated with each of these anatomic locations. The severity and acuity of the problem cannot be determined, so we are unable to estimate the level of medical training that might be required to adequately treat the reported problem. Although otolaryngologists in developed countries do not treat many dental or eye problems, these sites were included because of their proximity to the remainder of the head and neck and the scope of an otolaryngologist’s practice in a developing country may differ. Hearing impairment is a common H&N condition often requiring services from otolaryngologists, audiologists, and speech therapists and is a significant problem in developing countries that affects millions of people.21 Hearing loss is often the leading symptom toward many surgical ear-related conditions, and it was not addressed in the SOSAS questions. The SOSAS instrument is a tool yielding an excellent overview of untreated conditions in developing countries. However, as a screening survey for H&N disease, the information obtained is somewhat nonspecific. The self-reporting survey results will likely be biased toward acute injuries or chronic infections. Many asymptomatic masses, hearing loss, or early stage aerodigestive tract neoplasms are likely underreported. A physical examination to confirm a surgical need or identify an unreported need would improve the reliability of this tool’s results. To limit overreporting, we excluded conditions where a medical provider had evaluated a condition and stated that the condition was not surgically correctable or if the patient felt surgery was unnecessary. Estimating the prevalence of underreported H&N surgical conditions from this survey is difficult. However, only 67(1.8%) of the respondents identified a condition of the ear, nose, or throat area. This area is likely underreported,
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
644
Otolaryngology–Head and Neck Surgery 151(4)
as a community screening program in Sierra Leonean children identified 9.1% with at least mild hearing loss.22 The primary risk factor was a otorrhea lasting more than a month. Many of these patients may benefit from surgical intervention, and the number would be higher than the 1.8% of ear conditions identified in this survey. Perhaps many respondents felt that hearing loss was not surgically correctable. Overall, the true percentage of reported pathology that is surgically treatable is unknown. This survey highlights the immense amount of untreated H&N conditions in Sierra Leone. Other sub-Saharan countries face similar disease burdens with a significant lack of otolaryngic services.23 Our study provides evidence of a great opportunity that otolaryngologists from developed countries have to decrease the overall burden of H&N disease in the global community by helping advance otolaryngic services in the developing world. Otolaryngologists involved in global surgery might find the greatest needs in the rural, elderly, and illiterate populations. Additionally, creating educational programs for caregivers of indigenous populations in developing countries covering basic otolaryngic problems would be helpful. A future prospective study incorporating a basic physical examination by a trained medical provider to confirm the need for surgical intervention or identify nonreported conditions would be helpful. Also, more specific questions regarding common disorders or associated symptoms of the H&N may provide more precise results for otolaryngic conditions.
Conclusion The results of this countrywide survey reveal populationbased estimates of significantly limited patient access for head and neck conditions in Sierra Leone. Because these conditions were self-reported and not evaluated by a surgeon, the true incidence of surgically correctable conditions is unknown. The findings also provide insight into why people with these conditions were not seeking medical care. This survey could be used in other developing countries as health care professionals assess surgical needs throughout the world and shape global health initiatives. Author Contributions Nicholas C. Van Buren, conception, design, analysis, and interpretation of data; drafting paper; editing final version; Reinou S. Groen, supervised data collection; design, analysis, and interpretation of data; drafting paper; editing final version; Adam L. Kushner, design, analysis, and interpretation of data; drafting paper; editing final version; Mohamed Samai, analysis and interpretation of data, drafting paper, editing final version; Thaim B. Kamara, analysis and interpretation of data, drafting paper, editing final version; Jian Ying, analysis and interpretation of data, drafting paper, editing final version; Jeremy D. Meier, conception, design, analysis, and interpretation of data; drafting paper; editing final version.
Disclosures Competing interests: None. Sponsorships: None.
Funding source: Surgeons OverSeas with a donation from the Thompson Family Foundation, support for the survey execution and data collection. University of Utah Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 8UL1TR000105 (formerly UL1RR025764), support for the data analysis and interpretation of the data.
References 1. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32:533-536. 2. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet. 2008;372:139-144. 3. Magee WP Jr, Vander Burg R, Hatcher KW. Cleft lip and palate as a cost-effective health care treatment in the developing world. World J Surg. 2010;34:420-427. 4. Muntz HR, Meier JD. The financial impact of unrepaired cleft lip and palate in the Philippines. Int J Pediatr Otorhinolaryngol. 2013;77:1925-1928. 5. Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet. 2010;376:1055-1061. 6. Debas HT, Gosselin R, McCord C, Thind A. Surgery. Disease Control Priorities in Developing Countries. New York: Oxford University Press; 2006. 7. Walker IA, Obua AD, Mouton F, Ttendod S, Wilson IH. Paediatric surgery and anaesthesia in south-western Uganda: a cross-sectional survey. Bull World Health Organ. 2010;88: 897-906. 8. Kim JKC, Cooper RA, Kennedy DW. Otolaryngology-head and neck surgery physician work force issues: an analysis for future specialty training. Otolaryngol Head Neck Surg. 2012; 146:196-204. 9. Fagan JJ, Jacobs M. Survey of ENT services in Africa: need for comprehensive intervention. Global Health Action. 2009;2: 10.3402/gha.v2i0.1932. 10. Groen RS, Samai M, Petroze RT, et al. Pilot testing of a population-based surgical survey tool in Sierra Leone. World J Surg. 2012;36:771-774. 11. Groen R, Samai M, Stewart K, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet. 2012;380:1082-1087. 12. Kwon S, Groen RS, Kamara TB, et al. Nationally Representative Household Survey of Surgery and Mortality in Sierra Leone. World J Surg. 2013;37(8):1829-1835. 13. Groen RS, Samai M, Petroze RT, et al. Household Survey in Sierra Leone Reveals High Prevalence of Surgical Conditions in Children. World J Surg. 2013:37:1220-1226. 14. Stewart KA, Groen RS, Kamara TB, et al. Traumatic injuries in developing countries: report from a nationwide cross sectional survey of Sierral Leone. JAMA Surg. 2013;148:463-469. 15. Bickler S, Ozgediz D, Gosselin R, et al. Key concepts for estimating the burden of surgical conditions and the unmet need for surgical care. World J Surg. 2010;34:374-380.
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
Van Buren et al
645
16. Petroze RT, Groen RS, Niyonkuru F, et al. Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda. Surgery. 2013;153:457-464. 17. Sierra Leone. http://www.who.int/substance_abuse/publications/global_alcohol_report/profiles/sle.pdf. Accessed January 4, 2014. 18. WHO report on the Global Tobacco Epidemic. http://www. who.int/tobacco/surveillance/policy/country_profile/sle.pdf. Accessed January 4, 2014. 19. Kushner A, Kallon C, Kamara T. Free health care in Sierra Leone: the effect on pediatric surgery. J Pediatr Surg. 2012;47: 628-629.
20. Statistics Sierra Leone and ICF Macro. Sierra Leone Demographic and Health Survey 2008. Calverton, MD: Statistics Sierra Leone and ICF Macro; 2009. 21. Tucci D, Merson MH, Wilson BS. A summary of the literature on global hearing impairment: current status and priorities for action. Otol Neurotol. 2010;31:31-41. 22. Seely DR, Gloyd SS, Wright AD, Norton SJ. Hearing loss prevalence and risk factors among Sierra Leonean children. Arch Otolaryngol Head Neck Surg. 1995;121:853-858. 23. Fagan JJ. Developing world ENT: a global responsibility. J Laryngol Otol. 2012;126:544-547.
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
Untreated Head and Neck Surgical Disease in Sierra Leone: A Crosssectional, Countrywide Survey
Otolaryngology– Head and Neck Surgery 2014, Vol. 151(4) 638–645 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814542587 http://otojournal.org
Nicholas C. Van Buren, MD1, Reinou S. Groen, MD2,3, Adam L. Kushner, MD2,4,5, Mohamed Samai, PhD6, Thaim B. Kamara, MD7, Jian Ying, PhD8, and Jeremy D. Meier, MD1
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Keywords
Abstract
Received September 24, 2013; revised March 25, 2014; accepted June 17, 2014.
Objectives. Demonstrate how the Surgeons OverSeas Assessment of Surgical Need (SOSAS) can be used to determine the burden of head and neck (H&N) surgical disease in developing countries and identify reasons for untreated disease. Study Design. Cluster randomized, cross-sectional, countrywide survey. Setting. Sierra Leone. Subjects and Methods. The survey was administered to 75 of 9671 enumeration areas in Sierra Leone between January 9 and February 3, 2012, with 25 households in each cluster randomly selected for the survey. A household representative and 2 randomly selected household members were interviewed. Need for surgical care was based on participants’ responses to whether they had an H&N condition that they believed needed surgical care. Results. Of 1875 households, data were analyzed for 1843 (98%), with 3645 total respondents. Seven hundred and one H&N surgical conditions were reported as occurring during the lifetime of the 3645 respondents (19.2%).The current prevalence of H&N conditions in need of a surgical consultation was 11.8%. No money (60.1%) was the most common reason respondents reported for not receiving medical care. A bivariate analysis demonstrated that age, village type, education, and type of condition may be predictors for seeking health care and/or receiving surgical care. Conclusions. These results show limited access for patients to be evaluated for a potential H&N surgical condition in Sierra Leone. The true incidence of untreated surgical disease is unknown as most respondents were not evaluated by a surgeon. This survey could be used in other countries as health care professionals assess surgical needs throughout the world.
global health, developing countries
Introduction Global health efforts have strengthened in recent years. However, many initiatives have focused primarily on medically treated disease, neglecting surgical conditions.1,2 The decreased emphasis on surgical disease is often due to cost and inadequate infrastructure in developing countries. The actual burden of surgical disease in low-income and middleincome countries has been difficult to determine, but many studies have attempted to estimate the disability and costs associated with unrepaired surgical conditions such as cleft lip and palate.3,4 Some have estimated that operative disease accounts for 11% of global disease, but no studies have correlated this number to a community level.2,5 Even less understood is the impact of untreated otolaryngic conditions in the developing world. 1
Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA 2 Surgeon OverSeas, New York, New York, USA 3 Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland, USA 4 Department of Surgery, Columbia University, New York, New York, USA 5 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA 6 College of Medicine and Allied Health Science, Freetown, Sierra Leone 7 Department of Surgery, Connaught Hospital, Freetown, Sierra Leone 8 Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA This paper was presented as a poster at the 16th Annual Meeting at COSM; April 12-13, 2013; Orlando, Florida. Corresponding Author: Jeremy D. Meier, MD, Assistant Professor, University of Utah, Division of Otolaryngology–Head and Neck Surgery, 50 North Medical Drive, Room 3C120, Salt Lake City, UT 84132, USA. Email: [email protected]
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
Van Buren et al
639
Approximating the surgical disease burden in third world countries has relied on physician surveys, data extrapolation from well-developed countries, or hospital registries.6,7 However, these estimations are limited. Relying on hospital registries misses a significant portion of the population that never presents to the hospital. This would be particularly true with many otolaryngic conditions that are often treated in the outpatient setting. In sub-Saharan Africa, the number of otolaryngologists is estimated to be 0.01 to 0.4:100,000 compared to 2.5:100,000 in the United States, 10:100,000 in Japan, and 1:100,000 in the United Kingdom.8,9 The amount of untreated otolaryngic disease is immense but truly not known. The Surgeon OverSeas Assessment of Surgical Need (SOSAS) is a survey tool developed to measure the prevalence of surgical disease and potentially treated deaths related to surgical conditions in lowincome and middle-income countries. This population-based household survey was developed by an international group of experts. Pilot studies were performed in Sierra Leone, a small West African country with a population of 6 million.10 The purpose of this study is to demonstrate how the SOSAS can be used to estimate the prevalence of untreated head and neck (H&N) conditions in a developing country. This paper is part of a series of articles discussing the findings of the SOSAS in Sierra Leone.11-14 Results pertaining specifically to H&N conditions from this nationwide study in Sierra Leone will be described. The reasons identified through this survey for why these conditions were untreated will be discussed. Understanding the utility of the SOSAS will allow for implementation in other countries to identify needs for global surgical health initiatives.
Methods The study methods for this survey have been described in full previously.11 Baseline demographic information on Sierra Leone’s total population was obtained and the country divided into 9671 clusters or enumeration areas. Of these 9671 enumeration areas, 75 were randomly selected, with stratification for rural and urban settings and districts. Between January 9 and February 3, 2012, surveys were performed in the 75 enumeration areas. In each cluster, 25 households were randomly selected for the survey. Students from the Sierra Leone Faculty of Nursing and Sierra Leone College of Medicine and Allied Health Sciences and staff from Statistics Sierra Leone collected the data with handheld tablets. The SOSAS has been previously described in detail as well.10,11 Briefly, there are 2 parts to the survey. First, a household representative was interviewed to identify the number of household members, record deaths in the household during the previous year, and determine whether the deceased household members had any conditions in the week before their death including abdominal distention or pain; bleeding or illness during childbirth; injury; mass, growth, or swelling; acquired deformity; or a wound not due to injury or congenital deformity. Two randomly selected household members then underwent a head-to-toe verbal examination. Each selected household member was
asked whether they had a wound, burn, mass, deformity, or other condition needing surgical assessment or care for 6 different anatomical regions: (1) face, head, and neck; (2) chest and breast; (3) abdomen; (4) groin, genitals, and buttocks; (5) back; (6) arms, hands, legs, and feet. Scores are recorded for each anatomical domain, and multiple conditions could be recorded in each subsite. This paper focuses on the conditions in the survey specifically related to the face, head, and neck region. The need for surgical care was based on participants’ responses to whether they had a face, head, or neck condition that they believed needed surgical assessment or care. A surgical procedure included providing wound care, suturing, incising, excising, or manipulating tissue in a safe and painless way.15 Major procedures were defined as procedures requiring general or regional anesthesia, whereas minor procedures required either local or no anesthesia. The survey instrument was not validated but was piloted in Sierra Leone in 2011 with 100 respondents.10 The survey has also been implemented in Rwanda.16 An overview of the results from this survey has been previously published.11 In that article, all 6 anatomic regions were pooled together in the analysis. For this manuscript, we describe in detail the results from specific subsites (head, neck, eye, ear/nose/throat, and mouse/lips/dental). We also explore deeper into the reasons for untreated surgical disease by examining factors that influence whether surgical care was sought and if surgical care was received. Demographic data of all respondents were compared to respondents with H&N conditions. Characteristics of the condition including location, timing of onset, severity, and whether health care was sought and the type of care received was recorded. The summary statistics and their confidence limits were estimated with stratification defined by districts and urban and rural population distribution and clustering within enumeration area being taken into account. Separate survey logistic regression analyses were performed to relate the odds of seeking health care and of receiving surgery, respectively, to each of the following individual factors: age, gender, village type (rural vs urban), ethnicity, education level, literacy, occupation, location of condition, and type of condition. When analyzing the variables of education level, literacy, and occupation, only subjects 14 years or older were included in the analysis. Odds ratios for education, literacy, and occupation were then estimated using separate multivariable logistic regression models adjusted for age, gender, village type, location of condition, and type of condition. An additional multivariable regression analysis using the entire cohort was performed for village type while controlling for education, literacy, and occupation. Statistical significance was determined with P values less than or equal to .05, without adjustment for multiple comparisons. All analysis was performed using SAS 9.3. The study was performed with collaboration between Surgeons OverSeas, Sierra Leone Ministry of Health and Sanitation, Connaught Hospital Department of Surgery, and Statistics Sierra Leone. The Ethics and Scientific Review Committee of Sierra Leone and the Research Ethics
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
640
Otolaryngology–Head and Neck Surgery 151(4)
Table 1. Demographics.
Number Mean age (years) Gender Male Female Village type Rural Urban Education level None Primary Secondary Tertiary Graduate Missing Literate (yes) Missing Occupation None Homemaker Domestic helper Farmer Self-employed Government employee Non–government employee Missing
All Respondents n/N (%)
Respondents with H&N Condition n/N (%)
3645 25.0 (95% CI, 24.4-25.7)
666 31.3 (95% CI, 29.3-32.8)
1669/3645 (45.8) 1976/3645 (54.2)
312/666 (46.8) 354/666 (53.2)
2231/3645 (61.2) 1314/3645 (38.8)
391/666 (58.7) 275/666 (41.3)
1225/2303 (53.2) 225/2303 (9.8) 728/2303 (31.6) 114/2303 (5.0) 11/2303 (0.5) 8 1056/2294 (46.0) 15
263/482 (54.6) 47/482 (2.0) 142/482 (29.5) 28/482 (5.8) 2/482 (0.4) 2 212/481 (44.1) 2
649/2304 (28.2) 103/2304 (4.5) 94/2304 (4.1) 827/2304 (35.9) 446/2304 (19.4) 123/2304 (5.4) 61/2304 (2.6) 13
116/481 (24.1) 31/481 (6.4) 17/481 (3.5) 185/481 (38.5) 86/481 (17.9) 28/481 (5.8) 18/481 (3.7) 2
P Value
\.001 .54
.15
.73
.34 .03
Abbreviations: H&N, head and neck; CI, confidence intervals.
Committee of the Royal Tropical Institute in Amsterdam both granted ethical approval. Respondents provided written informed consent. If the respondent was illiterate, a thumbprint with a signature from a literate witness was obtained. For subjects younger than 18 years, a parent or guardian provided written consent. For respondents less than 12 years old, a parent/guardian either assisted with the interview or responded for the child.
Results Data were collected and analyzed from 1843 households (of 1875 targeted households, response rate of 98%), with 3645 total respondents. Respondents reporting an H&N condition were statistically older than the entire cohort. No statistically significant difference was found between those with an H&N condition and the entire cohort when comparing gender, village type, education level, and literacy. H&N surgical conditions occurring over the respondents’ lifetime was reported in 666 of the 3645 respondents (18.3%) (Table 1). Thirty-one respondents reported 2 conditions, and 2 respondents reported 3 conditions for a total of 701 H&N conditions reported. The most common H&N sites reported were head (34.7%), eyes (22.3%), lips/mouth/ dental (21.3%), neck (12.1%), and ears/nose/throat (9.6%)
(Table 2). Of the 701 head and neck conditions reported, 480 (69.4%) were currently present. A total of 60.8% of the injuries had been present longer than 12 months. The most common type of condition was acquired deformity (31.6%), followed by wound, not injury related (23.2%), and injuryrelated wound (21.4%). Of reported H&N conditions, 264 (41.8%) were disabling, including 135 (21.4%) conditions affecting respondents ability to work. Of the respondents with an H&N condition, 420 (60.2%) sought health care at a clinic staffed by nurses or doctors for their H&N condition while 240 (34.9%) sought care from a traditional healer, bone setter, or witch doctor. A major procedure was performed in 31 respondents (7.4%), and a minor procedure was performed in 219 respondents (52.3%) of those who sought medical care. The most common reasons respondents provided for not obtaining medical care included: no money (60.7%), no need (24.5%), and no doctor/nurse available (6.5%) (Table 3). The prevalence of H&N surgical conditions currently requiring surgical consultation of all respondents was 11.8%. An active H&N surgical condition included conditions respondents reported as current and requiring surgical care but excluded conditions that health providers or the respondent felt that did not require surgical care.
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
Van Buren et al
641
Table 2. Characteristics of Head and Neck Condition.
Location Eye Ear/nose/throat Mouth/lips/dental Neck Head Missing Present now Yes No Missing Timing of onset \1 month 1-12 months .12 months Missing Disability None I feel ashamed Unable to work like before Need help with transportation Need help with daily living Missing Type of condition Injury-related wound Non–injury-related wound Burn Mass or growth/goiter Congenital deformity Acquired deformity Missing
Table 3. Health Care Sought and Care Received.
Frequency
Percentage
156 67 149 85 243 1
22.3 9.6 21.3 12.1 34.7
480 212 9
69.4 30.6
135 136 421 9
19.5 19.7 60.8
367 87 135 10 32 70
58.2 13.8 21.4 1.6 5.1
149 162 33 103 30 220 4
21.4 23.2 4.7 14.8 4.3 31.6
Health care sought Yes No Missing Traditional healer sought Yes No Missing Type of care received None/no surgical care Major procedure Minor procedure Missing Reason for no care No money for health care No money for transportation No time No trust in health facility No skilled doctor/nurse available No need Missing
Frequency
Percentage
420 278 3
60.2 39.8
240 447 12
34.9 65.1
169 31 219 1
40.3 7.4 52.3
270 2 10 25 29 109 2
60.7 0.5 2.3 5.6 6.5 24.5
significant variable for those seeking health care, as those with a primary education were more likely to seek care than those without any education. Even after controlling for education, literacy, and occupation, subjects living in urban areas were statistically more likely to seek health care (Table 5).
Discussion
Univariate analysis to evaluate predictors for seeking health care and for receiving surgical care is shown in Table 4. Respondents older than 65 years demonstrated a trend of being less likely to seek health care and obtain surgical care compared to younger respondents. Respondents from urban clusters were 2.6 times more likely to seek health care compared to respondents from rural areas. Lips/mouth/dental conditions were the most likely H&N location to obtain surgical care, followed by conditions located on the head. Injuryrelated wounds were more likely to be brought to medical attention and obtain surgical care compared to wounds not injury related, burns, masses, congenital deformities, and acquired deformities. Respondents who were literate and had some level of education were more likely to seek medical care. Farmers were less likely to seek medical care compared to other occupations, though no significant statistical difference was seen in surgical care received (Table 4). After controlling for age, gender, village type, location of condition, and type of condition, education remained a
Access to otolaryngologists in developing countries remains limited. Particularly in sub-Saharan Africa, where many countries do not have a single otolaryngologist, H&N conditions are either treated by other medical providers or left untreated. This study suggests a high prevalence (11.8%) of untreated surgical H&N conditions in Sierra Leone, or at least a significant portion of the population needing a surgical consultation. Random selection of households within several enumeration areas of Sierra Leone was performed to obtain the best representation of the entire country. We assumed that surgical conditions are not very clustered. Extrapolating these data to the entire 6 million people of the country would suggest that 700,000 people may be in need of H&N surgical treatment. In addition, our analysis demonstrated that many lifetime H&N conditions were potentially undertreated. A majority of respondents who sought treatment for their H&N condition had either a minor procedure (52.3%) or no surgical care (40.3%) compared to small minority who underwent a major procedure (7.4%) (Table 2). The World Health Organization estimates that 42.8% of men and 35.5% of women drank alcohol in the past year, with alcohol use disorders of 2.10% and 0.24% in people 15 and over.17
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
642
Otolaryngology–Head and Neck Surgery 151(4)
Table 4. Univariate Analysis of Predictors for Seeking Health Care and Obtaining Surgical Care. Health Care Sought
Age (yrs) \14 14-65 .65 Sex Male Female Village type Rural Urban Location Eye ENT Dental/mouth Neck Head Type Wound, injury related Wound, non-injury Burn Mass Deformity, congenital Deformity, acquired Educationa None Primary Secondary Tertiary Graduate Literacya No Yes Occupationa None Homemaker Domestic helper Farmer Self-employed Government employee Non–government employee
No
Yes
76 162 39
110 275 34
132 145
197 222
OR (95% CI)
Surgical Care Received P Value
No
Yes
50 97 21
60 168 12
82 86
114 136
99 69
107 143
54 20 22 29 43
39 16 76 19 100
15 40 4 41 11 56
93 77 18 12 2 48
61 17 31 7 1
80 21 71 17 1
64 54
90 99
32 7 5 37 23 8 5
43 18 7 52 39 17 14
OR (95% CI)
.05 0.9 (0.6-1.2) 1.7 (0.95-2.9)
.006 1.5 (0.9-2.6) 0.5 (0.2-1.2)
.87 1 (0.7-1.4)
.48 1.1 (0.8-1.6)
\.001 199 78
207 212
2.6 (1.7-4.0)
.05 1.9 (1.0-3.7) \.001
.78 62 29 51 36 99
94 36 98 48 143
41 44 11 47 17 115
108 117 22 54 13 104
137 13 45 6 0
142 38 102 24 2
129 70
155 153
0.8 1.3 0.9 1.0
(0.4-1.6) (0.7-2.5) (0.5-1.6) (0.6-1.5)
1.1 (0.5-2.5) 4.8 (1.9-11.7) 0.9 (0.4-2.1) 3.2 (1.7-6.2)
\.001 1.0 0.8 0.4 0.3 0.3
(0.5-1.9) (0.3-1.9) (0.2-0.8) (0.1-0.7) (0.2-0.6)
\.001 0.3 (0.1-0.7) 0.7 (0.2-2.8) 0.05 (0.02-0.13) 0.03 (0.01-0.18) 0.14 (0.07-0.3)
\.001 2.8 (1.3-6.0) 2.2 (1.5-3.3) 3.9 (1.9-7.7) N/A
.08 0.9 (0.4-2.5) 1.7 (1.0-3.1) 1.9 (0.6-5.7) 0.8 (0.05-13)
.002 1.8 (1.2-2.7)
.28 1.3 (0.8-2.1)
\.001 47 7 7 99 28 7 4
75 25 12 90 62 25 19
2.2 1.1 0.6 1.4 2.2 3.0
(0.8-6.5) (0.4-3.2) (0.3-0.9) (0.8-2.5) (1.2-4.3) (1.1-7.9)
P Value
.73 1.9 (0.5-6.7) 1.0 (0.2-5.6) 1.0 (0.4-2.5) 1.3 (0.6-4.4) 1.6 (0.6-4.4) 2.1 (0.8-5.6)
Abbreviations: OR, odds ratio; CI, confidence interval. a Only subjects with age 14 years old were included in analysis.
Current tobacco smoking estimates in adults are 43.1% in males and 10.5% in females (25.8% total).18 With such a high prevalence of risk factors for H&N cancer and only 2 otolaryngologists in the country, surely the unmet needs will not be satisfied with the current system. Demographic data were analyzed to determine why some respondents were receiving H&N surgical care and not others. We noticed a trend in respondents younger than 65
years that were more likely to seek medical care and receive surgical care compared to elderly adults (Table 4). A recent health care initiative in Sierra Leone was implemented to improve maternal and children health by providing free care for pregnant women and children less than 5 years old. Regional hospitals have seen an increase in overall pediatric surgical cases since the initiative.19 Our data did not show a significant difference in health care sought or surgical care
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
Van Buren et al
643
Table 5. Multivariate Analysis Examining Socioeconomic Variables. Health Care Sought Surgical Care Received
Educationa None Primary Secondary Tertiary Graduate Literacya No Yes Occupationa None Homemaker Domestic helper Farmer Self-employed Government employee Non–government employee Village typeb Rural Urban
Adjusted OR (95% CI)
Adjusted OR (95% CI)
P \.001 Reference 2.3 (1.1-4.6) 1.6 (1.0-2.4) 1.9 (0.8-4.5) NA P = .33 Reference 1.2 (0.8-1.9) P = .44 Reference 1.9 (0.6-5.4) 1.3 (0.4-3.9) 0.8 (0.5-1.4) 1.2 (0.6-2.4) 1.7 (0.9-3.4) 1.5 (0.6-4.1)
P = .5 Reference 0.56 (0.22-1.44) 1.2 (0.5-2.4) 1.1 (0.3-4.0) 0.8 (0.07-9.4) P = .52 Reference 0.8 (0.4-1.5) P = .87 Reference 0.9 (0.2-3.6) 1.1 (0.2-6.0) 1.8 (0.7-4.5) 1.3 (0.5-3.3) 1.5 (0.4-5.5) 1.2 (0.4-4.3)
P = .01 Reference 1.9 (1.2-3.0)
P = .06 Reference 2.0 (0.98-4.1)
Abbreviations: OR, odds ratio; CI, confidence intervals. a OR was adjusted for age, gender, village type, location of condition, and type of condition. Only subjects 14 years old were included in the analysis. b OR was adjusted for education, literacy, and occupation. All subjects in the cohort were included in the analysis.
received for H&N conditions in children less than 5 years old compared to older children and middle-aged adults (data not shown). Higher education level, literacy, and employment were all significantly associated with an increased likelihood of seeking health care on univariate analysis. These variables are likely correlated and suggest that socioeconomic factors significantly impact the likelihood of seeking health care. To determine the patient demographic factors that most significantly impact the likelihood of seeking and receiving care, a multivariate analysis examining the socioeconomic variables of education, literacy, employment, and village type was performed. After controlling for village type and other variables, the impact of literacy and employment become insignificant. However, village type (rural vs urban) remains significant even after controlling for education, literacy, and occupation. This suggests that rural communities, likely due to proximity to available health care, may be a primary barrier to seeking and even receiving care. Respondents with burns, masses, or acquired and congenital deformities sought and obtained less surgical care compared to wounds related to an injury. The acute symptomatic aspect of an injury, such as a face laceration, appears to urge respondents to overcome health access
barriers and seek treatment. Alternatively, more local providers may be equipped to deal with minor wound injuries of the H&N compared to specialty training that other more complex deformities and masses require. We predict the high ratio of minor (87.6%) compared to major procedures (12.4%) may in part be due to the incidence of treated wound-related injuries. The most common reason reported for not seeking consultation for an H&N condition was related to lack of money. This is not surprising as 70% of the population lives in poverty.20 Remarkably, only 6% of respondents cited their reason for not seeking consultation because of no doctor or nurse. While this may suggest that the problem with untreated H&N conditions is not related to a shortage of adequately trained medical professionals, this is unlikely the case. The respondents may be unaware of current available medical expertise in their area. While many of these conditions could be adequately treated with local medical professionals, it is possible that several problems would require a more highly trained provider than what is currently available in Sierra Leone. In this survey, the most common H&N site needing a surgical consultation was the head. One limitation to this study is the generalized sites (ie, head, eyes, lips/mouth/dental, neck, and ears/nose/throat) that were asked in the survey. No specifics can be obtained from the survey results to determine the actual problem associated with each of these anatomic locations. The severity and acuity of the problem cannot be determined, so we are unable to estimate the level of medical training that might be required to adequately treat the reported problem. Although otolaryngologists in developed countries do not treat many dental or eye problems, these sites were included because of their proximity to the remainder of the head and neck and the scope of an otolaryngologist’s practice in a developing country may differ. Hearing impairment is a common H&N condition often requiring services from otolaryngologists, audiologists, and speech therapists and is a significant problem in developing countries that affects millions of people.21 Hearing loss is often the leading symptom toward many surgical ear-related conditions, and it was not addressed in the SOSAS questions. The SOSAS instrument is a tool yielding an excellent overview of untreated conditions in developing countries. However, as a screening survey for H&N disease, the information obtained is somewhat nonspecific. The self-reporting survey results will likely be biased toward acute injuries or chronic infections. Many asymptomatic masses, hearing loss, or early stage aerodigestive tract neoplasms are likely underreported. A physical examination to confirm a surgical need or identify an unreported need would improve the reliability of this tool’s results. To limit overreporting, we excluded conditions where a medical provider had evaluated a condition and stated that the condition was not surgically correctable or if the patient felt surgery was unnecessary. Estimating the prevalence of underreported H&N surgical conditions from this survey is difficult. However, only 67(1.8%) of the respondents identified a condition of the ear, nose, or throat area. This area is likely underreported,
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
644
Otolaryngology–Head and Neck Surgery 151(4)
as a community screening program in Sierra Leonean children identified 9.1% with at least mild hearing loss.22 The primary risk factor was a otorrhea lasting more than a month. Many of these patients may benefit from surgical intervention, and the number would be higher than the 1.8% of ear conditions identified in this survey. Perhaps many respondents felt that hearing loss was not surgically correctable. Overall, the true percentage of reported pathology that is surgically treatable is unknown. This survey highlights the immense amount of untreated H&N conditions in Sierra Leone. Other sub-Saharan countries face similar disease burdens with a significant lack of otolaryngic services.23 Our study provides evidence of a great opportunity that otolaryngologists from developed countries have to decrease the overall burden of H&N disease in the global community by helping advance otolaryngic services in the developing world. Otolaryngologists involved in global surgery might find the greatest needs in the rural, elderly, and illiterate populations. Additionally, creating educational programs for caregivers of indigenous populations in developing countries covering basic otolaryngic problems would be helpful. A future prospective study incorporating a basic physical examination by a trained medical provider to confirm the need for surgical intervention or identify nonreported conditions would be helpful. Also, more specific questions regarding common disorders or associated symptoms of the H&N may provide more precise results for otolaryngic conditions.
Conclusion The results of this countrywide survey reveal populationbased estimates of significantly limited patient access for head and neck conditions in Sierra Leone. Because these conditions were self-reported and not evaluated by a surgeon, the true incidence of surgically correctable conditions is unknown. The findings also provide insight into why people with these conditions were not seeking medical care. This survey could be used in other developing countries as health care professionals assess surgical needs throughout the world and shape global health initiatives. Author Contributions Nicholas C. Van Buren, conception, design, analysis, and interpretation of data; drafting paper; editing final version; Reinou S. Groen, supervised data collection; design, analysis, and interpretation of data; drafting paper; editing final version; Adam L. Kushner, design, analysis, and interpretation of data; drafting paper; editing final version; Mohamed Samai, analysis and interpretation of data, drafting paper, editing final version; Thaim B. Kamara, analysis and interpretation of data, drafting paper, editing final version; Jian Ying, analysis and interpretation of data, drafting paper, editing final version; Jeremy D. Meier, conception, design, analysis, and interpretation of data; drafting paper; editing final version.
Disclosures Competing interests: None. Sponsorships: None.
Funding source: Surgeons OverSeas with a donation from the Thompson Family Foundation, support for the survey execution and data collection. University of Utah Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 8UL1TR000105 (formerly UL1RR025764), support for the data analysis and interpretation of the data.
References 1. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32:533-536. 2. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet. 2008;372:139-144. 3. Magee WP Jr, Vander Burg R, Hatcher KW. Cleft lip and palate as a cost-effective health care treatment in the developing world. World J Surg. 2010;34:420-427. 4. Muntz HR, Meier JD. The financial impact of unrepaired cleft lip and palate in the Philippines. Int J Pediatr Otorhinolaryngol. 2013;77:1925-1928. 5. Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet. 2010;376:1055-1061. 6. Debas HT, Gosselin R, McCord C, Thind A. Surgery. Disease Control Priorities in Developing Countries. New York: Oxford University Press; 2006. 7. Walker IA, Obua AD, Mouton F, Ttendod S, Wilson IH. Paediatric surgery and anaesthesia in south-western Uganda: a cross-sectional survey. Bull World Health Organ. 2010;88: 897-906. 8. Kim JKC, Cooper RA, Kennedy DW. Otolaryngology-head and neck surgery physician work force issues: an analysis for future specialty training. Otolaryngol Head Neck Surg. 2012; 146:196-204. 9. Fagan JJ, Jacobs M. Survey of ENT services in Africa: need for comprehensive intervention. Global Health Action. 2009;2: 10.3402/gha.v2i0.1932. 10. Groen RS, Samai M, Petroze RT, et al. Pilot testing of a population-based surgical survey tool in Sierra Leone. World J Surg. 2012;36:771-774. 11. Groen R, Samai M, Stewart K, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet. 2012;380:1082-1087. 12. Kwon S, Groen RS, Kamara TB, et al. Nationally Representative Household Survey of Surgery and Mortality in Sierra Leone. World J Surg. 2013;37(8):1829-1835. 13. Groen RS, Samai M, Petroze RT, et al. Household Survey in Sierra Leone Reveals High Prevalence of Surgical Conditions in Children. World J Surg. 2013:37:1220-1226. 14. Stewart KA, Groen RS, Kamara TB, et al. Traumatic injuries in developing countries: report from a nationwide cross sectional survey of Sierral Leone. JAMA Surg. 2013;148:463-469. 15. Bickler S, Ozgediz D, Gosselin R, et al. Key concepts for estimating the burden of surgical conditions and the unmet need for surgical care. World J Surg. 2010;34:374-380.
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
Van Buren et al
645
16. Petroze RT, Groen RS, Niyonkuru F, et al. Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda. Surgery. 2013;153:457-464. 17. Sierra Leone. http://www.who.int/substance_abuse/publications/global_alcohol_report/profiles/sle.pdf. Accessed January 4, 2014. 18. WHO report on the Global Tobacco Epidemic. http://www. who.int/tobacco/surveillance/policy/country_profile/sle.pdf. Accessed January 4, 2014. 19. Kushner A, Kallon C, Kamara T. Free health care in Sierra Leone: the effect on pediatric surgery. J Pediatr Surg. 2012;47: 628-629.
20. Statistics Sierra Leone and ICF Macro. Sierra Leone Demographic and Health Survey 2008. Calverton, MD: Statistics Sierra Leone and ICF Macro; 2009. 21. Tucci D, Merson MH, Wilson BS. A summary of the literature on global hearing impairment: current status and priorities for action. Otol Neurotol. 2010;31:31-41. 22. Seely DR, Gloyd SS, Wright AD, Norton SJ. Hearing loss prevalence and risk factors among Sierra Leonean children. Arch Otolaryngol Head Neck Surg. 1995;121:853-858. 23. Fagan JJ. Developing world ENT: a global responsibility. J Laryngol Otol. 2012;126:544-547.
Downloaded from oto.sagepub.com at CORNELL UNIV on June 25, 2015
