Jared A. Forrester

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

IMPORTANCE Surgical care is recognized as a growing component of global public health. OBJECTIVE To assess self-reported barriers to access of surgical care in Sierra Leone, Rwanda, and Nepal using the validated Surgeons OverSeas Assessment of Surgical Need tool. DESIGN, SETTING, AND PARTICIPANTS Data for this cross-sectional, cluster-based population survey were collected from households in Rwanda (October 2011), Sierra Leone (January 2012), and Nepal (May and June 2014) using the Surgeons OverSeas Assessment of Surgical Need tool. MAIN OUTCOMES AND MEASURES Basic demographic information, cost and mode of transportation to health care facilities, and barriers to access to surgical care of persons dying within the past year were analyzed. RESULTS A total of 4822 households were surveyed in Nepal, Rwanda, and Sierra Leone. Primary health care facilities were commonly reached rapidly by foot (>70%), transportation to secondary facilities differed by country, and public transportation was ubiquitously required for access to a tertiary care facility (46%-82% of respondents). Reasons for not seeking surgical care when needed included no money for health care (Sierra Leone: n = 103; 55%), a person dying before health care could be arranged (all countries: 32%-43%), no health care facility available (Nepal: n = 11; 42%), and a lack of trust in health care (Rwanda: n = 6; 26%). CONCLUSIONS AND RELEVANCE Self-reported determinants of access to surgical care vary widely among Sierra Leone, Rwanda, and Nepal, although commonalities exist. Understanding the epidemiology of barriers to surgical care is essential to effectively provide surgical service as a public health commodity in developing countries.

Surgical Mesh Should Be Made Affordable to Low- and Middle-Income Countries

Surgical innovation uses technology to improve patient outcomes. Two examples of highly prevalent diseases positively affected by applied technology have been inguinal hernias, for which the use of mesh has cut recurrence rates from more than 10% to less than 2%, and cholecystectomy, for which laparoscopy significantly reduced recovery times. Although these advances are now standard of care in high-income countries, they remain unobtainable in most lowand middleincome countries (LMICs) despite recent analyses that show surgical conditions have as great an effect on global health as infectious disease.1 Sterilized mosquito net mesh (MNM) for tensionfree open inguinal hernia repairs is an ingenious solution to a common problem driven by necessity in many LMICs. In resource-poor settings, commercially available mesh for open inguinal hernia repairs is often either cost-prohibitive or unavailable. Several studies, including a recent randomized clinical trial, have described equivalent outcomes and noninferiority to commercial surgical mesh for patients undergoing hernia repair with MNM.2-4 One organization dedicated to performing and teaching hernia repairs in LMICs, Operation Hernia, announced the organization would prefer to use MNM, citing a cost of

Developing Process Maps as a Tool for a Surgical Infection Prevention Quality Improvement Initiative in Resource-Constrained Settings

2 per piece of sterilized and packaged MNM, compared with surgical mesh, which costs

Impact of Surgical Lighting on Intraoperative Safety in Low-Resource Settings: A Cross-Sectional Survey of Surgical Providers

40 to

Trends in Country-Specific Surgical Randomized Clinical Trial Publications

50 per unit. With the current focus on efficient health care spending and quality, we hypothesized that the potential financial effect of using sterilized MNM for open inguinal hernia repairs in the Veterans Administration (VA) might be substantial. During 2014, 11 446 hernias were repaired nationally in the VA. At

First case of mesh infection due to Coccidioides spp. and literature review of fungal mesh infections after hernia repair

40 to

Sex disparities among persons receiving operative care during armed conflicts

50 per unit, the cost of mesh in 2014 across the VA was an estimated

Using the WHO Surgical Safety Checklist to Direct Perioperative Quality Improvement at a Surgical Hospital in Cambodia: The Importance of Objective Confirmation of Process Completion

457 840 to

Developing Operating System Process Maps for Surgical Infection Prevention: A Tool to Improve Perioperative Standards in Low- and Middle-Income Countries

572 300. Using MNM (

Twelve Tips for Improving the General Surgery Resident Night Float Experience.

2 each) would have saved the VA an estimated