Elsevier

World Neurosurgery

Volume 110, February 2018, Pages e747-e754
World Neurosurgery

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

https://doi.org/10.1016/j.wneu.2017.11.099Get rights and content

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.

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.

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

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.

Introduction

Although 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, 2, 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

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 cluster-based population survey developed for application in LMICs that can evaluate the burden of surgically treatable conditions.5, 6, 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. Non–injury-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.

Section snippets

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.

Results

SOSAS Uganda interviewed 4248 individuals (97.1% response rate) in 2315 households (95.4% response rate) with a total of 11,148 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 to report having an occupation of a farmer or government or

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.

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

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 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

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  • 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.

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