title: An estimate of hernia prevalence in Nepal from a countrywide community survey.
abstract: BACKGROUND
  Herniorrhaphy is one of the most frequently performed general surgical operations worldwide. However, most low- and middle-income countries (LMICs) are unable to provide this essential surgery to the general public, resulting in considerable morbidity and mortality. This study aimed to estimate the prevalence, barriers to care and disability of untreated hernias in Nepal.
  
  
  METHODS
  Nepal is a low-income country in South Asia with rugged terrain, infrastructure deficiencies and a severely under-resourced healthcare system resulting in substantial unmet surgical need. A cluster randomized, cross-sectional household survey was performed using the validated Surgeons OverSeas Assessment of Surgical (SOSAS) tool. Fifteen randomized clusters consisting of 30 households with two randomly selected respondents each were sampled to estimate surgical need. The prevalence of and disability from groin hernias and barriers to herniorrhaphy were assessed.
  
  
  RESULTS
  The survey sampled 1350 households, totaling 2695 individuals (97% response rate). There were 1434 males (53%) with 1.5% having a mass or swelling in the groin at time of survey (95% CI 1.8-4.0). The age-standardized rate for inguinal hernias in men ranged from 1144 per 100,000 persons between age 5 and 49 years and 2941 per 100,000 persons age≥50 years. Extrapolating nationally, there are nearly 310,000 individuals with groin masses and 66,000 males with soft/reducible groin masses in need of evaluation in Nepal. Twenty-nine respondents were not able to have surgery due to lack of surgical services (31%), fear or mistrust of the surgical system (31%) and inability to afford care (21%). Twenty percent were unable to work as previous or perform self-care due to their hernia.
  
  
  CONCLUSIONS
  Despite the lower than expected prevalence of inguinal hernias, hundreds of thousands of people in Nepal are currently in need of surgical evaluation. Given that essential surgery is a necessary component in health systems, the prevalence of inguinal hernias and the cost-effectiveness of herniorrhaphy, this disease is an important target for LMICs planning surgical capacity improvements.
authors.affiliation: Department of Surgery, University of Washington, Seattle, WA, USA. Electronic address: stewarb@uw.edu.
authors.forename: Barclay T
authors.initials: BT
authors.lastname: Stewart
authors.affiliation: Kathmandu Medical College, Kathmandu, Nepal.
authors.forename: John
authors.initials: J
authors.lastname: Pathak
authors.affiliation: Surgeons OverSeas (SOS), New York, NY, USA; Department of Surgery, University of California San Francisco East Bay, Oakland, CA, USA.
authors.forename: Shailvi
authors.initials: S
authors.lastname: Gupta
authors.affiliation: Department of Surgery, Nepal Medical College, Kathmandu, Nepal.
authors.forename: Sunil
authors.initials: S
authors.lastname: Shrestha
authors.affiliation: Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Reinou S
authors.initials: RS
authors.lastname: Groen
authors.affiliation: Surgeons OverSeas (SOS), New York, NY, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Benedict C
authors.initials: BC
authors.lastname: Nwomeh
authors.affiliation: Surgeons OverSeas (SOS), New York, NY, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Surgery, Columbia University, New York, NY, USA.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Kushner
authors.affiliation: Program for Surgery and Public Health, Kings County Hospital Center, SUNY Downstate Medical School, Brooklyn, NY, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: McIntyre
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D006119:Groin; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006552:Hernia, Inguinal / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D059685:Herniorrhaphy; D006801:Humans; D008297:Male; D008875:Middle Aged; D009390:Nepal / Q000453:epidemiology; D015995:Prevalence; D055815:Young Adult
keywords: Community assessment; Hernia; Low-income; Nepal; Surgical capacity