title: Beyond Infrastructure: Understanding Why Patients Decline Surgery in the Developing World: An Observational Study in Cameroon.
abstract: The aim of this study was to quantify and describe a population of patients in rural Cameroon who present with a surgically treatable illness but ultimately decline surgery, and to understand the patient decision-making process and identify key socioeconomic factors that result in barriers to care.
  
  
  
  An estimated 5 billion people lack access to safe, affordable surgical care and anesthesia when needed, and this unmet need resides disproportionally in low-income countries (LICs). An understanding of the socioeconomic factors underlying decision-making is key to future efforts to expand surgical care delivery in this population. We assessed patient decision-making in a LIC with a cash-based health care economy.
  
  
  
  Standardized interviews were conducted of a random sample of adult patients with treatable surgical conditions over a 7-week period in a tertiary referral hospital in rural Cameroon. Main outcome measures included participant's decision to accept or decline surgery, source of funding, and the relative importance of various factors in the decision-making process.
  
  
  
  Thirty-four of 175 participants (19.4%) declined surgery recommended by their physician. Twenty-six of 34 participants declining surgery (76.4%) cited procedure cost, which on average equaled 6.4 months' income, as their primary decision factor. Multivariate analysis revealed female gender [odds ratio (OR) 3.35, 95% confidence interval (95% CI) 2.14-5.25], monthly earnings (OR 0.83, 95% CI, 0.77-0.89), supporting children in school (OR 1.22, 95% CI 1.13-1.31), and inability to borrow funds from family or the community (OR 6.49, 95% CI 4.10-10.28) as factors associated with declining surgery.
  
  
  
  Nearly one-fifth of patients presenting to a surgical clinic with a treatable condition did not ultimately receive needed surgery. Both financial and sociocultural factors contribute to the decision to decline care.
authors.affiliation: *Stanford University School of Medicine, Stanford, CA †Center for Health Policy/Primary Care Outcomes Research, Stanford, CA ‡Mbingo Baptist Hospital, Cameroon, West Africa §Palo Alto Veterans Healthcare System, Palo Alto, CA.
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Lerman
authors.forename: Marcella
authors.initials: M
authors.lastname: Alsan
authors.forename: Ngew J
authors.initials: NJ
authors.lastname: Chia
authors.forename: James A
authors.initials: JA
authors.lastname: Brown
authors.forename: Sherry M
authors.initials: SM
authors.lastname: Wren
mesh_terms: D000328:Adult; D002163:Cameroon; D003657:Decision Making; D003906:Developing Countries; D005260:Female; D017048:Health Care Costs; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D010361:Patients / Q000523:psychology*; D011203:Poverty; D012737:Sex Factors; D012959:Socioeconomic Factors; D013514:Surgical Procedures, Operative / Q000191:economics / Q000523:psychology; D016312:Treatment Refusal