Prevalence of Surgically Untreated Face, Head, and Neck Conditions in Uganda: A Cross-Sectional Nationwide Household Survey

Prevalence of Surgically Untreated Face, Head, and Neck Conditions in Uganda: A Cross-Sectional Nationwide Household Survey

Original Article Prevalence of Surgically Untreated Face, Head, and Neck Conditions in Uganda: A Cross-Sectional Nationwide Household Survey Anthony ...

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Original Article

Prevalence of Surgically Untreated Face, Head, and Neck Conditions in Uganda: A Cross-Sectional Nationwide Household Survey Anthony T. Fuller1,2, Jacquelyn Corley1,3, Tu M. Tran1, Elissa K. Butler4, Joao Ricardo Vissoci1,5, Luciano Andrade6,7, Fredrick Makumbi8, Samuel Luboga9, Christine Muhumuza1,8, Vincent F. Ssennono10, Jeffrey G. Chipman11, Moses Galukande12, Michael M. Haglund1-3, Emily R. Smith1,5

BACKGROUND: The Surgeons OverSeas Assessment of Surgical Need tool (SOSAS) was created to evaluate the burden of surgically treatable conditions in low- and middle-income countries. The goal of our study is to describe the face, head, and neck (FHN) conditions that need surgical care in Uganda, along with barriers to that care and disability from these conditions.

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METHODS: A 2-stage cluster randomized SOSAS survey was administered in a cross-sectional manner between August and September 2014. Participants included randomly selected persons in 105 enumeration areas in 74 districts throughout Uganda with 24 households in each cluster. The SOSAS survey collected demographic and clinical data on all respondents. Univariate and multivariate logistic models evaluated associations of demographic characteristics and clinical characteristics of the FHN conditions and outcomes of whether health care was sought or surgical care was received.

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RESULTS: Of the 4428 respondents, 331 (7.8%) reported having FHN conditions. The most common types of conditions were injury-related wounds. Of those who reported an FHN condition, 36% reported receiving no surgical care whereas 82.5% reported seeking health care. In the multivariate model, literacy and type of

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Abbreviations and Acronyms ENT: Ear, nose, and throat FHN: Face, head, and neck LMICs: Low- and middle-income countries OOP: Out-of-pocket OR: Odds ratio SOSAS: Surgeons Overseas Assessment of Surgical Need

INTRODUCTION

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lthough there has been an increase in global health efforts over the past few decades, surgery has not commonly been viewed as an essential part of health care in low- and middle-income countries (LMICs). The lack of proper surgical care results in high morbidity and mortality from common conditions among the world’s poorest regions.1-3 An estimated 143 million inpatient surgical procedures are needed to tackle the global burden of disease.4 The greatest surgical needs per population exist in sub-Saharan Africa, with an estimated 80% of the population having an unmet surgical need.4

To whom correspondence should be addressed: Michael M. Haglund, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2017). https://doi.org/10.1016/j.wneu.2017.11.099 Journal homepage: www.WORLDNEUROSURGERY.org 2

From the Duke University Division of Global Neurosurgery and Neuroscience, Duke University School of Medicine, Durham, North Carolina, USA; 3Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA; 4Department of Surgery,

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CONCLUSIONS: Many individuals in Uganda are not receiving surgical care and barriers include costs, rural residency, and literacy. Our study highlights the need for targeted interventions in various parts of Uganda to increase human resources for surgery and expand surgical capacity.

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University of Washington, Seattle, Washington, USA; 5Duke University Global Health Institute, Duke University Medical Center, Durham, North Carolina, USA; 6State University of West of Parana, Unioeste, Foz do Iguaçu, Brazil; 7Public Health Research Group, Unioeste, Toledo, Brazil; 8Makerere University School of Public Health, Kampala, Uganda; 9Department of Anatomy, Makerere University School of Medicine, Kampala, Uganda; 10Ministry of Health, Government of Uganda, Kampala, Uganda; 11Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA; and 12Department of Surgery, Makerere University College of Health Sciences, Kampala, Uganda

Key words - Disease burden - Global surgery - Head and neck injury - Low- and middle-income countries

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condition were significant predictors of seeking health care whereas village type, literacy, and type of condition remained significant predictors of receiving surgical care.

Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.

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ORIGINAL ARTICLE ANTHONY T. FULLER ET AL.

SURGICALLY UNTREATED FHN CONDITIONS IN UGANDA

Quantifying the surgical disease burden at national and community levels is essential for government officials and agencies, as well as for various nonprofits and outreach programs, to guide resource allocation. However, few formal projects have been undertaken to explore the surgical needs of individual countries and their diverse populations.5 Although hospital registries have been paramount in quantifying surgical outcomes, they fail to assess broader population needs within the local population because they reflect only those seen and evaluated at hospitals.6 Data are lacking about those with a surgical need who do not have access to medical facilities, transportation, or required funding needed for hospital admission. To overcome this obstacle, the Surgeons OverSeas group created the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool, a structured, cross-sectional, and clusterbased population survey developed for application in LMICs that can evaluate the burden of surgically treatable conditions.5-7 Surgery involving the face, head, and neck (FHN) is one area of particular concern, because there is a dearth of surgeons trained in this specific field of expertise. Noneinjury-related FHN conditions are common; infections, congenital defects, and cancers require highly trained surgeons to avoid complications and high mortality.8 Likewise, injury-related FHN conditions from road traffic incidents or trauma resulting in head fractures and brain hemorrhages are common in LMICs and pose an even greater need for highly trained surgical personnel.9 Furthermore, it has been proved that for head and neck injuries, treatment by surgeons with increased experience improves these outcomes10,11; however, within much of sub-Saharan Africa, head and neck specialty training is rare. The literature describing the prevalence, treatment, and outcomes of FHN conditions as well as barriers to surgical care in sub-Saharan Africa is sparse. One study in Sierra Leone found a prevalence of 11.8% of untreated surgical FHN conditions, with as many as 700,000 people in potential need of surgical treatment.6 Uganda is a low-income country that allocates <10% of its gross domestic product toward public health care, a rate that has been declining in recent years.12 Uganda has a population of 34.9 million people, with almost 4 million people located centrally in the capital area, Kampala, and the adjacent Wakiso district. Health care is provided within a tiered system with levels of health centers, district hospitals, regional referral hospitals, and national referral hospitals.13 The goal of our study was to describe the FHN conditions that need surgical care, along with barriers to care and disability from those untreated conditions within Uganda. METHODS Research ethics approval was obtained from the Makerere University School of Medicine research and ethics committee, Duke University Health System institutional review board, and University of Minnesota institutional review board. Data Collection The 2-stage cluster sampling method of the study was designed similarly to the Uganda Demographic Health Survey. The sampling framework and country-specific adapted survey instrument

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are detailed elsewhere.14 SOSAS is a tool used to evaluate the burden of untreated surgical conditions that is administered in 2 parts: 1) a head of household demographic survey and 2) an individual head-to-toe questionnaire about surgical conditions taken by up to 2 randomly selected individuals in the household. For Uganda, we adapted the survey to fit the country’s needs, and specifically used mobile technology, more than 100 trained researchers, and a detailed data management structure for data collection. Data regarding FHN surgical conditions, including whether the condition was treated, treatment modality, reasons for not seeking care or receiving treatment, and demographic data were captured using the SOSAS instrument. The SOSAS instrument is designed to capture obvious surgically treatable conditions as codified in Disease Control Priorities second and third editions.15-17 The head of household and each individual participant before initiating the survey provided informed consent. A parent or guardian provided consent for all participants younger than 18 years, and children ages 8e18 years provided consent. Parents assisted children in answering survey questions when necessary. Statistical Analysis We analyzed the data using SAS 9.4 (SAS Institute Inc., Cary, North Carolina, USA) and stored the data in Microsoft Excel 2010 (Microsoft Corp., Redmond, Washington, USA). Weighting of household and individual cases was achieved using design weights for each enumeration area, household-level, and individual-level response rates, and known population counts of gender and age groupings from the Uganda Census 2014 data. FHN conditions included conditions of the head, forehead, neck, eye, mouth, lips, cheek, teeth, ear, nose, or throat. Demographic data of all respondents were compared with respondents with FHN conditions. Prevalence of FHN surgical conditions was mapped by district using QGIS version 2.8.18 Univariate associations of demographic characteristics and clinical characteristics of FHN conditions and outcomes of whether health care was sought or surgical care was received were determined by c2 tests for categorical data and t tests for normally distributed continuous data. A backward elimination approach was used to determine the final multivariate models. Variables in the initial multivariate model included whether the condition was present, education, village type, timing of onset, literacy, occupation, and condition specifics. Education was stratified into no education, primary, or more than primary. Timing of onset was stratified into <12 months or 12 months. Occupation type was stratified into none, domestic helper, farmer, self-employed, government or nongovernment employee, homemaker, or student. Variables were excluded from the multivariate model if significance was >0.20 according to the P value. Variables were excluded in a step-by-step fashion according to least significance (i.e., higher P values) for each iteration. The final model included variables with P values <0.10 for either outcome (i.e., health care sought or surgical care received). RESULTS SOSAS Uganda interviewed 4248 individuals (97.1% response rate) in 2315 households (95.4% response rate) with a total of 11,148

WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.11.099

ORIGINAL ARTICLE ANTHONY T. FULLER ET AL.

SURGICALLY UNTREATED FHN CONDITIONS IN UGANDA

Table 1. Demographics Characteristics of Survey Respondents (N ¼ 4248) All Respondents (N [ 4248)

Respondents with FHN Condition (N [ 331) P Value*

19.6 (0.37)

27.8 (1.2)

<0.0001

Male

2076/4248 (48.6)

157/331 (47.0)

0.54

Female

2172/4248 (51.4)

174/331 (53.0)

Rural

3457/4248 (81.2)

278/331 (82.9)

Urban

791/4248 (18.8)

53/331 (17.1)

Mean age, years (standard deviation) Gender

Village type 0.4 Figure 1. Prevalence of untreated surgical need (USN) for face, head, and neck conditions in Uganda.

Health status in past 12 months Healthy

3568/4248 (84.2)

232/331 (69.5)

<0.0001

Education levely None

962/2437 (39.5)

106/231 (45.9)

Primary

844/2437 (34.6)

65/231 (28.1)

Secondary

470/2437 (19.3)

48/231 (20.8)

Tertiary

72/2437 (2.9)

6/231 (2.6)

Graduate

4/2437 (0.2)

1/231 (0.4)

0.07

University

85/2437 (3.5)

5/231 (2.2)

Literate (yes)y

1549/2437 (63.6)

150/231 (64.9)

0.57

None

241/2437 (9.5)

19/231 (7.1)

0.007

Homemaker

295/2437 (10.8)

29/231 (10.9)

Occupationy

Domestic helper

101/2437 (3.7)

10/231 (3.9)

Farmer

919/2437 (39.3)

92/231 (42.1)

Self-employed

375/2437 (16.4)

44/231 (20.6)

Government employee

50/2437 (1.8)

7/231 (2.8)

Nongovernment employee

114/2437 (4.3)

13/231 (5.8)

Student

342/2437 (14.2)

17/231 (6.8)

Values are number/total number (%) except where indicated otherwise. Inclusion was at least 1 FHN condition. If >1 were reported, the observation was deleted for demographic reporting purposes. This strategy ensured only distinct persons were counted. FHN, face, head, and neck. *P value comparing respondents with FHN conditions with overall study population. yAmong individuals older than 14 years.

household members. Of the 4428 respondents, 331 (7.8%) reported having FHN conditions (Table 1). Respondents with FHN conditions were statistically older than the entire respondent cohort (P < 0.0001), were less likely to report being healthy within the past 12 months, (P < 0.0001), and were more likely

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to report having an occupation of a farmer or government or nongovernment employee or being self-employed (P ¼ 0.007). No statistically significant differences were found between those reporting FHN conditions and the entire cohort when comparing gender, village type, education level, or literacy. The geographic distribution of FHN conditions varied by location (Figure 1), with the highest concentrations in the northern and southern regions. Twenty-two respondents reported 2 FHN conditions and 1 respondent reported 3 FHN conditions, for a total of 358 FHN conditions among 331 individuals. Most FHN conditions were located on the head or forehead (45.1%), followed by conditions located on the mouth, lips, teeth, or cheek (Table 2). More than half of the 331 individuals reported that the condition was present currently (56.2%), reported the timing of onset as more than a year before the survey (68.1%), and reported no disability associated with the condition (60.5%). The most common types of conditions were injury-related wounds (28.9%), noneinjuryrelated wounds (19.3%), mass or goiters (16.4%), and acquired deformities (15.7%). Most respondents reporting FHN conditions sought health care (82.5%), whereas 14.5% sought a traditional healer. Among those who received formal health care, 56.9% received a minor surgical procedure and 6.0% received a major surgical procedure, whereas 19.3% reported receiving no surgical care or being referred. Of those who sought care and did not receive any, reasons for not receiving surgical care included no money (52.4%), followed by no need or time (30.2%). For those who did not seek care, the major reasons were no money (67.2%), no need or time (21.3%), and lack of social support (18.0%). Predictors of seeking health care or receiving surgical care were evaluated in univariate analyses (Table 3). Respondents older than 49 years were 1.6 times more likely to seek health care compared with their younger counterparts (P ¼ 0.02). Respondents living in urban areas were 1.7 times more likely to seek health care (P ¼ 0.11) and 2.2 times more likely to receive surgical care (P ¼ 0.01) than were their counterparts residing in rural areas. Respondents with primary or secondary levels of education and those who were literate were more likely to seek health care (P < 0.0001) and receive surgical care (P < 0.0001) compared with respondents with no education or who were illiterate.

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Table 2. Continued

Table 2. Clinical Characteristics and Health Care Seeking Among Those With Head and Neck Conditions* Frequency

%

Characteristics of condition

%

41

67.2

Reason for no carez No money

Location

Frequency

9

14.8

153

45.1

No need/time

10

16.4

Mouth/lips/dental/cheek

81

22.1

No transport

13

21.3

Eye

64

17.7

No facility/personnel/equipment

Neck

50

12.9

Lack of social support

Head/forehead

Fear

6

9.8

11

18.0

33

52.4

5

7.9

Ear/nose/throat

10

2.2

Present now (yes)

205

56.2

<1

33

9.8

No need/time

19

30.2

1e12

78

22.1

No transport

9

14.3

>12

247

68.1

No facility/personnel/equipment

9

14.3

Lack of social support

9

14.3

Timing of onset (months)

212

60.5

Unable to work like before

67

16.9

I feel ashamed

45

12.3

Need help with daily living

28

8.5

6

1.8

Injury-related wound

93

28.9

Noneinjury-related wound

71

19.3

Need help with transportation

No money Fear

Disability None

Reason for no carex

*There were 22 respondents who reported 2 conditions and 1 respondent who reported 3 conditions for a total of 358 total conditions among 331 respondents. yOf individuals who sought formal health care. zAmong individuals who did not seek formal health care. Multiple responses allowed. xAmong individuals who sought formal health care but did not receive care. Multiple responses allowed.

Type of condition

Mass or goiter

62

16.4

Acquired deformity

65

15.7

Keloid

26

7.0

Burn

16

5.3

Congenital deformity

15

4.7

Hearing problem

10

2.7

Yes

276

82.5

No

55

17.5

Yes

51

14.5

No

279

85.5

None/no surgical care

42

13.5

Major procedure

27

6.0

Minor procedure

207

56.9

21

5.8

Health care sought and care received Formal health care sought

Traditional healer sought

Type of care receivedy

Referred

Continues

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Patients with an occupation of a farmer (odds ratio [OR], 4.1), student (OR, 4.1), government or nongovernment position or who were self-employed (OR, 4.3) were more likely to receive surgical care compared with respondents who reported no occupation, although no significant statistical difference was found for seeking health care. Respondents who reported having the condition at the time of the interview were less likely to receive surgical care (OR, 0.5; P ¼ 0.0001) than were their counterparts who reported not having the condition at the time of the interview. Persons who reported conditions other than injury-related wounds were significantly less likely to seek health care (P ¼ 0.002) and receive surgical care (P ¼ 0.02) than were those with injury-related wounds. Respondents who reported a longer timing of their FHN condition (>12 months) were less likely to seek health care (OR, 0.4; P ¼ 0.02) or receive surgical care (OR, 0.5; P ¼ 0.05) compared with those reporting a timing of onset of <12 months. In the multivariate model, literacy and type of condition remained significant predictors of seeking health care, whereas village type, literacy, and type of condition remained significant predictors of receiving surgical care (Table 4). The odds of seeking health care or receiving surgical care were 1.9 times and 2.7 times, respectively, higher for literate respondents with FHN conditions than among illiterate respondents with FHN conditions (P ¼ 0.03 and 0.004, respectively). Respondents with FHN conditions were 2.0 times more likely to receive surgical care if the onset of the condition was less than 12 months from the time of the interview (P ¼ 0.07). The odds of seeking health care (P ¼ 0.0002) or receiving surgical care (P ¼ 0.006) were significantly less among persons with

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SURGICALLY UNTREATED FHN CONDITIONS IN UGANDA

Table 3. Univariate Analysis of Predictors for Seeking Health Care or Receiving Surgical Care Health Care Sought Yes

No

OR (95% CI)

Age (years)

P Value

Yes

No

OR (95% CI)

P Value

0.02

<15

81

19

146

22

49

14

Male

130

27

Female

146

28

Rural

236

42

Urban

40

13

84

22

15e49

Surgical Care Received

>49

0.27 66

34

0.6 (0.3e1.5)

125

43

0.7 (0.4e1.1)

1.6 (0.8e2.8)

45

18

0.8 (0.4e1.7)

112

45

124

50

205

73

31

31

69

37

Gender 0.93 0.9 (0.5e1.9)

0.57 1.2 (0.7e1.9)

Village type 0.11 1.7 (0.9e3.4)

0.01 2.2 (1.2e3.9)

Education None

<0.0001

<0.0001

Primary

57

8

2.5 (1.2e5.3)

51

14

1.9 (0.9e3.9)

Secondary

42

6

2.3 (0.9e6.0)

38

10

2.0 (0.9e4.5)

>Secondary*

12

0

NA

12

0

NA

No

64

17

51

30

Yes

131

19

119

31

Literate 0.02 2.3 (1.2e4.6)

Occupation

0.02 2.5 (1.2e5.3)

0.94

None

15

4

Homemaker

24

5

8

2

Farmer

79

13

Self-employed/governmental/nongovernmental

55

9

Student

14

3

0.9 (0.1e8.3)

55

9

Domestic helper

0.18 9

10

0.7 (0.1e4.9)

22

7

3.5 (0.7e17.8)

0.5 (0.05e5.2)

7

3

3.3 (0.5e21.0)

0.8 (0.1e4.0)

71

21

4.1 (1.3e13.0)

1.1 (0.2e6.3)

48

16

4.3 (1.6e11.2)

13

4

4.1 (1.1e16.7)

50

14

Location Eye Neck

0.37

0.71

39

6

1.4 (0.3e5.7)

29

16

0.6 (0.2e1.9)

108

28

0.8 (0.3e2.3)

93

43

0.7 (0.3e1.5)

Mouth/lips/dental/cheek

64

12

1.0 (0.4e2.7)

55

21

0.9 (0.3e2.1)

Ear/nose/throat

10

0

N/A

9

1

N/A

Head/forehead

Present now

<0.0001

0.19

No

122

18

Yes

154

37

0.6 (0.3e1.3)

Type of condition Injury-related wound

125

66

111

29

0.5 (0.3e0.8)

0.002 76

7

0.002 72

11

OR, odds ratio; CI, confidence interval. *>Secondary: tertiary, graduate, university. y<12 months includes those <1 month and 1e12 months because of small sample sizes. Continues

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Table 3. Continued Health Care Sought Yes

No

OR (95% CI)

Surgical Care Received P Value

Yes

No

OR (95% CI)

Burn

12

4

0.3 (0.07e1.1)

9

7

0.2 (0.05e0.6)

Acquired deformity

51

6

0.8 (0.3e2.5)

47

10

0.6 (0.2e1.5)

Congenital deformity

10

5

0.2 (0.05e0.7)

7

8

0.1 (0.03e0.4)

Hearing problem

7

3

0.2 (0.04e1.0)

5

5

0.09 (0.02e0.3)

13

10

0.1 (0.3e0.4)

11

12

0.1 (0.05e0.4)

Mass or goiter

44

13

0.3 (0.1e0.8)

36

21

0.2 (0.1e0.5)

Noneinjury-related wound

63

7

0.8 (0.3e2.5)

48

22

0.3 (0.1e0.7)

Keloid

Health status

0.86

Yes

192

15

No

84

40

1.1 (0.6e1.8)

Timing of onset (months)

0.69 164

68

72

27

1.1 (0.6e1.9)

0.02

<12y

95

12

>12

181

43

0.4 (0.2e0.9)

P Value

0.05 84

23

152

72

0.5 (0.3e1.1)

OR, odds ratio; CI, confidence interval. *>Secondary: tertiary, graduate, university. y<12 months includes those <1 month and 1e12 months because of small sample sizes.

congenital deformities, hearing problems, keloids, masses or goiters, and noneinjury-related wounds compared with respondents with injury-related wounds. DISCUSSION The results of the SOSAS survey suggest that nearly 8% of Uganda’s population have surgically amenable FHN conditions and 36% of these individuals did not receive the surgical care they require. Extrapolating these estimates to the current population using the 2015 Uganda Census data19 would result in 2,792,000 individuals with an FHN condition and 1,005,120 of those individuals in need of surgical treatment. Main Findings The most significant predictor to seeking health care or receiving surgical care for FHN conditions was the type of condition, specifically injury-related wounds, which are similar findings to the Sierra Leone study.6 In our data, nearly 30% of the FHN conditions were related to injury, and head injuries made up most of these cases. Injuries account for 10% of the current global burden of disease, with nearly 30% of injuries being caused by road traffic accidents and a disproportionate amount (90%) of injuries occurring in LMICs.20 Although we were unable to assess the cause of injury in our data, head injuries caused by road traffic accidents are a major cause of morbidity and mortality, especially in Uganda, which is ranked seventh in the world for death from road traffic accidents.15,21 Consequently, FHN injury-related wounds contribute to high mortality and significant losses in economic output for LMICs.22,23 Our data suggest interventions targeted to

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reducing injury-related wounds, such as improving road conditions or prevention measures, should be implemented. Despite a large percentage of FHN respondents seeking health care in our data, many individuals did not receive surgical care regardless of if health care was sought (36%). In our study and in the previous SOSAS study in Sierra Leone,6 cost was the major prohibitive factor for respondents who were unable to receive care and also a major consideration for those who did not seek care for their FHN conditions. This situation is further exemplified by the disparity between the rural and urban populations; urban populations were more likely to receive care because urban areas have a greater density of medical facilities with surgical capacity, and thus a decreased cost of transport, compared with rural areas.13 In our study, we identified the specific regions within Uganda with the greatest need (Figure 1). Based on the geographic distribution of FHN conditions, the greatest need for FHN surgical expansion exists in the northern and southern regions. The number of surgeons with training specific to FHN conditions, such as neurosurgeons or ear, nose and throat (ENT) surgeons, in sub-Saharan Africa is low. A study from 2009 showed that the average ENT physician ratio across most of sub-Saharan Africa is less than 0.01 per 100,000 people, with Uganda having only 16 providers for a ratio of 0.04 per 100,000.24 As for neurosurgeons in Uganda, the numbers are even bleaker, with only 7 providers for a ratio of 0.02 per 100,000.25,26 In areas without surgical access, interventions can be targeted to increase infrastructure and human resources, similar to the current efforts to expand ENT trainees via a Ugandan ENT Society, and a residency program for neurosurgical trainees in Uganda.25

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ORIGINAL ARTICLE ANTHONY T. FULLER ET AL.

SURGICALLY UNTREATED FHN CONDITIONS IN UGANDA

Table 4. Multivariate Analysis Examining Socioeconomic and Face, Head, and Neck Condition Variables Health Care Sought Adjusted OR (95% CI) Village type

P Value

Surgical Care Received Adjusted OR (95% CI)

0.1

P Value 0.02

Rural Urban

1.8 (0.8e4.4)

Literacy

2.1 (1.2e3.8) 0.03

0.004

No Yes

1.9 (1.1e3.4)

Timing of onset (months)

2.7 (1.4e5.2) 0.2

0.07

>12 <12

1.6 (0.7e3.6)

Type of condition

2.0 (0.9e4.3) 0.002

0.006

Wound (injury) Burn

0.3 (0.07e1.4)

0.2 (0.04e0.8)

Acquired deformity

0.7 (0.2e2.3)

0.6 (0.2e1.8)

Congenital deformity

0.2 (0.04e0.7)

0.2 (0.03e0.6)

Hearing problem

0.2 (0.04e0.9)

0.09 (0.02e0.4)

Keloid

0.1 (0.03e0.3)

0.2 (0.05e0.5)

Mass or goiter

0.2 (0.07e0.5)

0.2 (0.08e0.4)

Wound (noninjury)

0.6 (0.2e1.8)

0.3 (0.1e0.7)

OR, odds ratio; CI, confidence interval.

Paradoxically, regions near Kampala, an area with the highest density of health facilities, was a location with high unmet surgical needs. Perhaps for this region, the issue is not availability of surgical staff but rather cost of receiving care beyond the free surgery. This claim is further backed by a recent study of healthseeking behavior of residents of a district near Kampala (Wakiso district).27 Although residents in this study knew about health facilities near them, they did not seek care because of the knowledge of high out-of-pocket (OOP) costs of receiving care. This issue of high OOP costs of receiving surgical care has also been explored in other countries, supporting the claim that OOP costs greatly affect individuals’ health-seeking behavior.28,29 To address this cost issue, studies must be performed at Uganda’s government-run public hospitals to evaluate the true OOP costs for patients to develop solutions for reducing the impact of catastrophic expenditures, thereby improving health-seeking behavior. Beyond increases in infrastructure and human resource training, efforts in the area of prevention must also be undertaken. Road traffic accident prevention programs linked with proper

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helmet usage would be an effective mechanism to decrease incidence and severity of head injuries. For example, in a systematic review of road traffic injury prevention initiatives, legislation paired with a multifaceted approach focused on patient outcomes was deemed the most effective approach for injury reduction.30 Uganda has begun implementing this initiative through the Uganda Helmet Vaccine Initiative, which was informed by baseline data gathered from motorcycle taxi drivers.31 Evaluation of the impact that the Uganda Helmet Vaccine Initiative has had on head injury incidence and overall injury prevalence is under way, but anecdotal evidence suggests an increase in the use of helmets. Increased support of road improvement projects, establishment and enforcement of helmet safety regulations, creation of safe roadside walkways, and improved monitoring would further help address road traffic injury prevention. Limitations The main purpose of our adapted SOSAS survey was to provide a population estimate of the burden of surgical disease within Uganda. We added additional questions and prompts to further elucidate FHN conditions, but several limitations of our study must be acknowledged. Respondents to our survey were asked to discuss all conditions that they perceived to be surgically related, which increases the likelihood of missed surgical conditions. Furthermore, our researchers in the field were trained in research methods and all underwent an intensive surgical conditions workshop, but none was a medical professional. We addressed this concern by having researchers collect detailed verbal statements of each condition reported and our medical staff then evaluated each to determine which were surgical and which were not. A physical examination after the survey performed by a welltrained medical professional with experience in FHN conditions would have been ideal. This issue of self-reported conditions has been a common criticism of the SOSAS methodology, although recently, SOSAS was performed in Nepal with a visual examination that agreed with participant self-reporting in 94.6% of cases.32 We were also unable to assess the direct causes of surgical conditions, such as road traffic accidents, and these warrant further investigation. CONCLUSIONS Based on our results, many individuals in Uganda are not receiving surgical care for the FHN conditions and barriers include costs, rural residency, and illiteracy. Our study highlights the need for targeted interventions in various parts of Uganda to increase human resources for surgery, inclusive of specialized ENT and neurosurgeons, and expand surgical capacity. Likewise, expansion of injury prevention efforts specifically targeted to prevent head injuries and provision of programs to reduce catastrophic medical expenditures are critical to address the need. ACKNOWLEDGMENTS We thank the Uganda Bureau of Statistics for methodological advice and for providing randomized enumeration areas and the Uganda Ministry of Health and Makerere College of Health Sciences for institutional support. We thank the following enumerators and field supervisors for their dedication to data

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ORIGINAL ARTICLE ANTHONY T. FULLER ET AL.

SURGICALLY UNTREATED FHN CONDITIONS IN UGANDA

quality and the field supervisors for their leadership of implementation: Samuel Kagongwe, Mark Kashaija, Sheila Kisakye, Mable Luzze, and Hassard Sempeera. We benefitted from the generous collaboration of the Gates Institute for Population and Reproductive Health at Johns Hopkins Bloomberg School of Public Health, specifically Professors Scott Radloff and Amy Tsui. We are grateful to the Surgeons OverSeas organization, and in particular Dr. Reinou Groen, Dr. Shailvi Gupta, and Dr. Adam

REFERENCES 1. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386: 569-624. 2. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372:139-144. 3. Rose J, Chang DC, Weiser TG, Kassebaum NJ, Bickler SW. The role of surgery in global health: analysis of United States inpatient procedure frequency by condition using the Global Burden of Disease 2010 framework. PLoS One. 2014;9:e89693. 4. Rose J, Weiser TG, Hider P, Wilson L, Gruen RL, Bickler SW. Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate. Lancet Glob Health. 2015;3(suppl 2):S13-20. 5. Zogg CK, Kamara TB, Groen RS, Mungo B, Kushner AL, Molena D. Prevalence of thoracic surgical care need in a developing country: results of a cluster-randomized, cross-sectional nationwide survey. Int J Surg. 2015;13:1-7. 6. Van Buren NC, Groen RS, Kushner AL, Samai M, Kamara TB, Ying J, et al. Untreated head and neck surgical disease in Sierra Leone: a cross-sectional, countrywide survey. Otolaryngol Head Neck Surg. 2014;151:638-645. 7. Elliott IS, Groen RS, Kamara TB, Ertl A, Cassidy LD, Kushner AL, et al. The burden of musculoskeletal disease in Sierra Leone. Clin Orthop Relat Res. 2015;473:380-389. 8. Bhattacharyya N, Fried MP. Benchmarks for mortality, morbidity, and length of stay for head and neck surgical procedures. Arch Otolaryngol Head Neck Surg. 2001;127:127-132. 9. Onywera VO, Blanchard C. Road accidents: a third burden of ’disease’ in sub-Saharan Africa. Glob Health Promot. 2013;20:52-55. 10. Eskander A, Goldstein DP, Irish JC. Health services research and regionalization of care-from policy to practice: the Ontario Experience in Head and Neck Cancer. Curr Oncol Rep. 2016;18:19. 11. Pulte D, Brenner H. Changes in survival in head and neck cancers in the late 20th and early 21st century: a period analysis. Oncologist. 2010;15:994-1001. 12. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation

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www.SCIENCEDIRECT.com

Kushner, for guidance from initial design to analysis of SOSAS and this specific report. Author contributions: A.T.F., J.C., T.M.T., E.K.B., J.R.V., and L.A., analysis and interpretation of findings; A.T.F., T.M.T., E.K.B., J.C., F.M., S.L., C.M., V.F.S., J.G.C., M.G., and M.M.H., conception and design; A.T.F., T.M.T., E.K.B., J.C., S.L., J.G.C., M.G., and M.M.H. drafting and editing final version; E.R.S., analysis, interpretation of data, and drafting and editing the final manuscript.

from the provider perspective. Lancet Glob Health. 2015;3(suppl 2):S8-9. 13. Fitzmaurice C, Dicker D, Pain A, Hamavid H, Moradi-Lakeh M, MacIntyre MF, et al. The global burden of cancer 2013. JAMA Oncol. 2015;1:505-527. 14. Fuller AT, Butler EK, Tran TM, Makumbi F, Luboga S, Muhumza C, et al. Surgeons OverSeas Assessment of Surgical Need (SOSAS) Uganda: update for household survey. World J Surg. 2015;39: 2900-2907. 15. Verguet S, Alkire BC, Bickler SW, Lauer JA, UribeLeitz T, Molina G, et al. Timing and cost of scaling up surgical services in low-income and middleincome countries from 2012 to 2030: a modelling study. Lancet Glob Health. 2015;3(Suppl 2):S28-37. 16. Groen RS, Samai M, Stewart KA, Cassidy LD, Kamara TB, Yambasu SE, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet. 2012; 380:1082-1087. 17. Petroze RT, Groen RS, Niyonkuru F, Mallory M, Ntaganda E, Joharifard S, et al. Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda. Surgery. 2013;153:457-464. 18. Team QD. QGIS geographic information system. Open Source Geospatial Foundation Project. Available at: http://qgis.orgeo.org; Accessed January 3, 2017. 19. Shrime MG, Dare AJ, Alkire BC, O’Neill K, Meara JG. Catastrophic expenditure to pay for surgery worldwide: a modelling study. Lancet Glob Health. 2015;3(suppl 2):S38-44. 20. Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev. 2016;22:3-18. 21. Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G, Kobusingye OC. The impact of traumatic brain injuries: a global perspective. NeuroRehabilitation. 2007;22:341-353. 22. Tran TM, Fuller AT, Kiryabwire J, Mukasa J, Muhumuza M, Ssenyojo H, et al. Distribution and characteristics of severe traumatic brain injury at Mulago National Referral Hospital in Uganda. World Neurosurg. 2015;83:269-277. 23. Humphreys I, Wood RL, Phillips CJ, Macey S. The costs of traumatic brain injury: a literature review. Clinicoecon Outcomes Res. 2013;5:281-287.

24. Fagan JJ, Jacobs M. Survey of ENT services in Africa: need for a comprehensive intervention. Glob Health Action. 2009;2. 25. Anthony Fuller TT, Michael M, Haglund MM. Building neurosurgical capacity in low and middle income countries. eNeurologicalSci. 2016;3:1-6. 26. El Khamlichi A. African neurosurgery: current situation, priorities, and needs. Neurosurgery. 2001; 48:1344-1347. 27. Musoke D, Boynton P, Butler C, Musoke MB. Health seeking behaviour and challenges in utilising health facilities in Wakiso district, Uganda. Afr Health Sci. 2014;14:1046-1055. 28. Hamid SA, Ahsan SM, Begum A. Disease-specific impoverishment impact of out-of-pocket payments for health care: evidence from rural Bangladesh. Appl Health Econ Health Policy. 2014;12: 421-433. 29. Brinda EM, Andres AR, Enemark U. Correlates of out-of-pocket and catastrophic health expenditures in Tanzania: results from a national household survey. BMC Int Health Hum Rights. 2014;14:5. 30. Staton C, Vissoci J, Gong E, Toomey N, Wafula R, Abdelgadir J, et al. Correction: road traffic injury prevention initiatives: a systematic review and metasummary of effectiveness in low and middle income countries. PLoS One. 2016;11:e0150150. 31. Roehler DR, Naumann RB, Mutatina B, Nakitto M, Mwanje B, Brondum L, et al. Using baseline and formative evaluation data to inform the Uganda Helmet Vaccine Initiative. Glob Health Promot. 2013;20(4 suppl):37-44. 32. Gupta S, Shrestha S, Ranjit A, Nagarajan N, Groen RS, Kushner AL, et al. Conditions, preventable deaths, procedures and validation of a countrywide survey of surgical care in Nepal. Br J Surg. 2015;102:700-707. Conflict of interest statement: Funding was provided by the Duke Global Health Institute, Duke University Department of Neurosurgery, University of Minnesota Department of Surgery, Makerere College of Health Sciences, and Johnson and Johnson Family of Companies. Received 13 September 2017; accepted 18 November 2017 Citation: World Neurosurg. (2017). https://doi.org/10.1016/j.wneu.2017.11.099 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.

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