title: Assessing access to surgical care in Nepal via a cross-sectional, countrywide survey.
abstract: Adequate surgical care is lacking in many low- and middle-income countries because of diverse barriers preventing patients from reaching providers. We sought to assess perceived difficulties to accessing surgical care in Nepal using the Surgeons OverSeas Assessment of Surgical Need tool.
  
  
  
  Fifteen of 75 Nepali districts were selected proportionate to the population, with 1,350 households surveyed. Household heads answered questions regarding access to health facilities, and 2 household members were interviewed for medical history. Continuous and categorical variables were analyzed via Wilcoxon rank sum test and Pearson χ(2) test. Multivariable logistic regressions for independent predictors of care access were performed controlling for age, sex, location, and literacy.
  
  
  
  Of respondents with a surgical condition (n = 1,342), 650 (48.4%) accessed care and 237 (17.7%) did not. Unadjusted analyses showed greater median travel times to all facilities (P < .001) and median transport costs to secondary and tertiary centers (P < .001) for those who did not access care versus those who did. Literate respondents were more likely to access care across all facilities and access variables in adjusted models (odds ratio 1.66-1.80, P < .01). Those without transport money were less likely to access care at any facility in all analyses (P < .01).
  
  
  
  The data project that at least 2.4 million individuals lack access to needed surgical care in Nepal during their lifetimes, with those not accessing health facilities having lower literacy rates and fewer transport resources. Promoting education, outreach programs, and transportation access could lessen barriers but will require further exploration.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD. Electronic address: marissaboeckMD@gmail.com.
authors.forename: Marissa A
authors.initials: MA
authors.lastname: Boeck
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD.
authors.forename: Neeraja
authors.initials: N
authors.lastname: Nagarajan
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD.
authors.forename: Shailvi
authors.initials: S
authors.lastname: Gupta
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD.
authors.forename: Varshini
authors.initials: V
authors.lastname: Varadaraj
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD.
authors.forename: Reinou S
authors.initials: RS
authors.lastname: Groen
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD.
authors.forename: Sunil
authors.initials: S
authors.lastname: Shrestha
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD.
authors.forename: Susant
authors.initials: S
authors.lastname: Gurung
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Kushner
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD.
authors.forename: Benedict
authors.initials: B
authors.lastname: Nwomeh
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD.
authors.forename: Mamta
authors.initials: M
authors.lastname: Swaroop
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D003906:Developing Countries; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D054625:Healthcare Disparities; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009390:Nepal; D012959:Socioeconomic Factors; D013514:Surgical Procedures, Operative; D055815:Young Adult