title: Barriers to Surgical Care and Health Outcomes: A Prospective Study on the Relation Between Wealth, Sex, and Postoperative Complications in the Republic of Congo.
abstract: Approximately thirty percent of the global burden of disease is comprised of surgical conditions. However, five billion people lack access to surgery, with complex factors acting as barriers. We examined whether patient demographics predict barriers to care, and the relation between these factors and postoperative complications in a prospective cohort.
  
  
  
  Participants included people presenting to a global charity in Republic of Congo with a surgical condition between August 2013 and May 2014. The outcomes were self-reported barrier to care and postoperative complications documented by medical record. Logistic regression was used to adjust for covariates.
  
  
  
  Of 1237 patients in our study, 1190 (96.2 %) experienced a barrier to care and 126 (10.2 %) experienced a postoperative complication. The most frequently reported barrier was cost (73 %), followed by lack of provider (8.2 %). Greater wealth was associated with decreased odds of cost as a barrier (OR 0.72 [0.57, 0.90]). Greater wealth (OR 1.52 [1.03, 2.25]) and rural home location (OR 3.35 [1.16, 9.62]) were associated with increased odds of no surgeon being available. Cost as a barrier (OR 2.82 [1.02, 7.77]), female sex (OR 3.45 [1.62, 7.33]), and lack of surgeon (OR 5.62 [1.68, 18.77]) were associated with increased odds of postoperative complication. Patient wealth was not associated with odds of postoperative complication.
  
  
  
  Barriers to surgery were common in Republic of Congo. Patient wealth and home location may predict barriers to surgery. Addressing gender disparities, access to providers, and patient perception of barriers in addition to removal of barriers may help maximize patient health benefits.
authors.affiliation: Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA. brian_lin@meei.harvard.edu.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Lin
authors.affiliation: Mercy Ships, Tyler, TX, 75704, USA.|Mercy Ships, Toamasina, Madagascar.
authors.forename: Michelle
authors.initials: M
authors.lastname: White
authors.affiliation: Mercy Ships, Tyler, TX, 75704, USA.|Mercy Ships, Toamasina, Madagascar.
authors.forename: Ana
authors.initials: A
authors.lastname: Glover
authors.affiliation: Mercy Ships, Tyler, TX, 75704, USA.|Mercy Ships, Toamasina, Madagascar.
authors.forename: Greta Peterson
authors.initials: GP
authors.lastname: Wamah
authors.affiliation: Mercy Ships, Tyler, TX, 75704, USA.|Mercy Ships, Toamasina, Madagascar.
authors.forename: Davi L
authors.initials: DL
authors.lastname: Trotti
authors.affiliation: Mercy Ships, Tyler, TX, 75704, USA.|Mercy Ships, Toamasina, Madagascar.
authors.forename: Kirstie
authors.initials: K
authors.lastname: Randall
authors.affiliation: Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA.
authors.forename: Blake C
authors.initials: BC
authors.lastname: Alkire
authors.affiliation: Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA.
authors.forename: Mack L
authors.initials: ML
authors.lastname: Cheney
authors.affiliation: Mercy Ships, Tyler, TX, 75704, USA.|Mercy Ships, Toamasina, Madagascar.
authors.forename: Gary
authors.initials: G
authors.lastname: Parker
authors.affiliation: Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA.|Mercy Ships, Tyler, TX, 75704, USA.|Mercy Ships, Toamasina, Madagascar.|Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, 02115, USA.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Shrime
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D003223:Congo; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D016015:Logistic Models; D008297:Male; D011183:Postoperative Complications / Q000209:etiology*; D011446:Prospective Studies; D013503:Surgery Department, Hospital; D055815:Young Adult