Browsing by Author "Rice, Henry E"

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Background: Robeson County, North Carolina was ranked as the least healthy county in the state, in 2020. In Robeson, accessing surgical care is a health challenge, and two known risk factors are its rural location and high proportion of racial minority groups. Applying the three-delays model, the aim of this study was to identify and assess the perceived barriers to surgical care. Methods: To obtain a diverse perspective of how access to surgical care in Robeson County is perceived, interviews were conducted with surgical patients, surgical providers, and community leaders. Duke healthcare personnel, who work in Robeson County, assisted with identifying appropriate stakeholders and surgical patients to interview initially. Additional interviewees were identified through snowball sampling, until saturation was reached. Two researchers independently examined and categorized the responses using the constant comparative method, categorizing quotes from participants in an iterative fashion to identify recurring themes. Results: A total of eleven participants were interviewed (2 nurses, 7 patients, and 2 community leaders). Themes identified included: comfort level with the health system, transportation, logistics of the health system, health system capacity, alternative medicine, community beliefs, county’s historical and cultural context, financing, and suggestions from the participants. Conclusions: This preliminary study suggests that along with Robeson’s rural geography and high proportion of minority groups, the county’s historical and cultural context, the stigmatization of surgical diseases, and the knowledge gap in resource availability also contribute to barriers to accessing surgical care in the county.

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Background: Financing of surgical care in low- and middle-income countries remains challenging and poses challenges for implementation of Universal Health Coverage (UHC). This study is an exploration of financing of surgical care for children and alignment of surgical financing within UHC schemes in Guatemala. Our hypothesis is that current financing mechanisms do not address key barriers to provision of surgical care for children within current UHC schemes. Methods: We performed a qualitative analysis of the financing of surgical care for children in the public health system in Guatemala. We surveyed key informants (n=20) in medical, financial, and political sectors to assess mechanisms and operations of financing for pediatric surgical coverage. Qualitative results were triangulated with national financing data and health system reports, with a set of recommendations generated to improve financing of surgical care for children. Results: We found several macro-level challenges to financing for surgical care in Guatemala, including complex political contexts, health finance system fragmentation, and lack of earmarked funding for surgical care. Dominant micro-level challenges include lack of provider agency in financing and patients functioning as financing agents and beneficiaries. Although formal user fees are not used in Guatemala, informal fees for surgical services are common barriers to care. Conclusions: Pediatric surgical financing in Guatemala remains challenging, with little inclusion of surgical care within existing UHC schemes. Recommendations to improve surgical financing include evidence-based financing with provider technical input, strengthening organizational structure for surgical financing, and quantification and reduction of informal user fees through resource pooling between health system actors.

Background: Globally, there is often a gap between medical need and access to care, and this is particularly true for surgical care for children. In Guatemala, for instance, families frequently pursue care outside of the government health system. Using a structured anthropologic approach, we sought to explore the barriers to surgical care for children in Guatemala, suspecting both financial and cultural barriers were the primary obstacles families had to face.

Study design: Twenty-nine parents/guardians of children receiving surgical care at two non-governmental organizations (NGOs) in Guatemala and 7 health care providers participated in semi-structured interviews to explore what they believed to be the impediments to care. Transcripts were analyzed using a grounded theory approach. Current models for barriers to care were critiqued and a novel Framework for Barriers to Pediatric Surgery in Guatemala (FBPSG) was developed, which highlights both the existence, and centrality, of fear and mistrust in families' experience.

Results: Families and providers identified financial costs, geography, and systems limitations as the primary barriers to care. Mistrust and fear were also voiced. In addition, health literacy and cultural issues were also thought to be relevant by providers.

Conclusions: Due to biases inherent in this sample, parents/guardians did not necessarily report the same perceived barriers as healthcare providers - e.g., education/health literacy and language - and may have represented a "best case" scenario compared to more disadvantaged populations in this specific Central American context. Nonetheless, financial concerns were some of the most salient barriers for families seeking pediatric surgical care in Guatemala, with systems limitations (waiting time) and geographic factors (distance/transit) also being highlighted. Fear and mistrust were found to be deeper barriers to care and warrant reevaluation of organizational heuristics to date. NGOs can address these worries by working with individuals and organizations already known by and trusted in target communities and by providing good quality medical treatment and interpersonal care.

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Background: A staggering 5 billion people worldwide lack access to safe and affordable surgery, and surgical conditions contribute to up to 32% of the global disease burden. However, precise data on the burden of surgical conditions is lacking, particularly for children. This study aims to measure the burden of pediatric surgical conditions in Somaliland using a community-based, household, nationwide survey as well as a national hospital survey to identify the types and volume of pediatric surgical care.

Methods: We surveyed 1450 children, from 839 families, through national community-based sampling using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey to identify the prevalence of surgical conditions. We also performed a hospital capacity survey at 15 hospitals in Somaliland, with surgical records reviewed over a 1-year time frame to identify pediatric surgical procedures performed.

Results: Using a community survey, we identified 226 surgical conditions in 191 children, yielding a surgical condition prevalence of 13.7% in the pediatric population. Only 55 of 226 conditions were treated with a surgical procedure. The most common conditions reported were congenital deformities (34.4%) and wound related injuries (23.8%). Using a hospital survey, we identified 1255 pediatric surgical procedures performed nationally over 1 year. We found that 56.7% procedures were in performed in boys and 79.8% were done at private hospitals. The most common surgical diagnoses were tonsillitis, trauma/wound/snake bite, and hydrocephalus.

Conclusions: Between 91,500 – 209,000 children in Somaliland have an unmet need for pediatric surgery, highlighting the high burden of surgical disease in the country. The estimated number of performed surgical procedures represents a small fraction of the burden of pediatric surgical conditions, highlighting the need for expansion of infrastructure, resources, and workforce to provide needed surgical care.

Background: Patient safety is critical to prevent medical errors and to improve clinical outcomes. The need to implement programs in patient safety is increasingly recognized as a prime component of healthcare delivery in low- and middle- income countries (LMICs). The goal for our study is to assess the implementation of a patient safety program in Guatemala.

Methods: We used a mixed-methods approach to assess implementation of a patient safety program in the pediatric perioperative unit in Hospital Roosevelt, Guatemala. We collected data from unit staff respondents (n=16) using a qualitative de novo survey, the Evidence-Based Practice Attitude Scale-36 (EBPAS-36) survey, and a semi-structured interview. Interviews and surveys were conducted in Spanish, translated, and analyzed in English using NVivo v12. Quantitative data were analyzed to compare group means across survey domains. Data were triangulated, with final analysis guided by the Consolidated Framework for Implementation Research (CFIR). Data were collected over a 10-day period in July 2018.

Results: Responses underscored several emergent thematic determinants representing the Inner Setting and Characteristics of Individuals CFIR domains, indicating a gap in knowledge of patient safety programs and attitude towards the use of evidence-based patient safety programs. Though respondents expressed an openness and willingness to adopt patient safety practices, few existing practices are in place to prevent medical errors.

Conclusions: The main determinants which affect the implementation of an evidence-based patient safety program in the pediatric perioperative unit in Guatemala are related to the internal structure and culture of the unit, and not to external factors or the intervention itself. Positive attitudes and knowledge of patient safety practices are insufficient to overcome the challenges towards implementation. A framework for future implementation should include education and communication programs, adaptation of existing practices to increase leadership engagement, and use of tools to create a strong culture of safety.

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