Browsing by Subject "Pediatric surgery"
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Item Open Access Colonic polyposis in a 15 year-old boy: Challenges and lessons from a rural resource-poor area.(Ann Med Surg (Lond), 2016-05) Kakembo, Nasser; Kisa, Phyllis; Fitzgerald, Tamara; Ozgediz, Doruk; Sekabira, JohnINTRODUCTION: Colorectal polyps usually present with rectal bleeding and are associated with increased risk of colorectal carcinoma. Evaluation and management in resource-poor areas present unique challenges. PRESENTATION OF CASE: This 15 year-old boy presented with 9 years of painless rectal bleeding and 2 years of a prolapsing rectal mass after passing stool. He had 3 nephews with similar symptoms. On clinical assessment and initial exam under anesthesia, an impression of a polyposis syndrome was made and a biopsy taken from the mass that revealed inflammatory polyps with no dysplasia. He was identified during a pediatric surgical outreach to a rural area with no endoscopy, limited surgical services, and no genetic testing available, even at a tertiary center. He subsequently had a three-stage proctocolectomy and ileal pouch anal anastomosis with good outcome after referral to a tertiary care center. The surgical specimen showed many polyps scattered through the colon. DISCUSSION: In the absence of endoscopic surveillance and diagnostic services including advanced pathology and genetic testing, colorectal polyposis syndromes are a significant challenge if encountered in these settings. Reports from similar settings have not included this surgical treatment, often opting for partial colectomy. Nonetheless, good outcomes can be achieved even given these constraints. The case also illustrates the complexity of untreated chronic pediatric surgical disease in rural resource-poor areas with limited health care access. CONCLUSION: Polyposis syndromes in children present unique challenges in rural resource-poor settings. Good outcomes can be achieved with total proctocolectomy and ileal pouch anastomosis.Item Open Access Economic Analysis of Pediatric Surgical Financing and Universal Health Coverage in Guatemala(2020) Landrum, Kelsey RaeBackground: 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.
Item Open Access Family and Provider Perceptions of Barriers to NGO-Based Pediatric Surgical Care in Guatemala(2014) Silverberg, Benjamin AndrewBackground: 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.