title: Barriers to Essential Surgical Care in Low- and Middle-Income Countries: A Pilot Study of a Comprehensive Assessment Tool in Ghana.
abstract: BACKGROUND
  Beyond resource deficiencies, other barriers to care prevent patients from receiving surgery in low- and middle-income countries (LMICs). This study aimed to develop and pilot a comprehensive, generalizable tool for assessing the barriers to surgical care.
  
  
  METHODS
  Sociodemographic, clinical and 38 questions regarding potential barriers to surgical care were asked during a surgical outreach to two district and one regional hospital in Upper East Region, Ghana. Sites were selected to capture individuals with prolonged unmet surgical needs and represent geographic, socioeconomic, and healthcare development differences. Results were indexed into three dimensions of barriers to care (i.e., 'acceptability,' 'affordability,' and 'accessibility') so that communities could be compared and targeted interventions developed.
  
  
  RESULTS
  The tool was administered to 148 participants (98 % response rate): Bolgatanga 54 (37 %); Amiah 16 (11 %); and Sandema 78 (52 %). Amiah had the fewest barriers to surgical care (median index 8.3; IQR 7.6-9.3), followed by Sandema (8.2; IQR 5.3-9.2) and Bolgatanga (6.7; IQR 3.9-9.5). Individual dimension scores (i.e., acceptability, affordability, accessibility) ranged from 10.8 to 18 out of 18 possible points. Main factors contributing to low dimension scores were different between communities: Bolgatanga-cost and healthcare navigation; Amiah-social marginalization and poor medical understanding; Sandema-distance to surgically capable facility.
  
  
  CONCLUSIONS
  This study identified a number of significant barriers, as well as successes for patients' ability and willingness to access surgical care that differed between communities. The tool itself was well accepted, easy to administer and provided valuable data from which targeted interventions can be developed.
authors.affiliation: Department of Surgery, University of Washington, 1959 NE Pacific St., Suite BB-487, PO Box 356410, Seattle, WA, 98195-6410, USA. stewarb@uw.edu.|Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. stewarb@uw.edu.
authors.forename: Barclay T
authors.initials: BT
authors.lastname: Stewart
authors.affiliation: Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.|Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
authors.forename: Adam
authors.initials: A
authors.lastname: Gyedu
authors.affiliation: Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.|Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
authors.forename: Francis
authors.initials: F
authors.lastname: Abantanga
authors.affiliation: Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
authors.forename: Abdul Rashid
authors.initials: AR
authors.lastname: Abdulai
authors.affiliation: Department of Planning, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
authors.forename: Godfred
authors.initials: G
authors.lastname: Boakye
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
authors.initials: A
authors.lastname: Kushner
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D003695:Delivery of Health Care; D005260:Female; D005869:Ghana; D006801:Humans; D007182:Income; D007223:Infant; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D013514:Surgical Procedures, Operative / Q000592:standards*