Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Barriers to Surgical Care Among Children in Somaliland: An Application of the Three Delays Framework

  • 13 Accesses

Abstract

Background

There are complex barriers that increase delays to surgical care in low- and middle-income countries, particularly among the vulnerable population of children. Understanding these barriers to surgical care can result in targeted and strategic intervention efforts to improve care for children. The three-delay model is a widely used framework in global health for evaluating barriers associated with seeking (D1), reaching (D2), and receiving health care (D3). The goal of our study is to evaluate reasons for delays in the surgical care for children in Somaliland using the three-delay framework.

Methods

Data were collected in a cross-sectional study in Somaliland from 1503 children through a household survey. Among children with a surgical need, we quantified the number of children seeking, reaching, and receiving care along the surgical care continuum, according to the three-delay framework. We evaluated predictors of the three delays through a multivariate logistic regression model, including the child’s age, gender, village type, household income level, region, and household size.

Results

Of the 196 children identified with a surgical condition, 50 (27.3%) children had a delay in seeking care (D1), 28 (20.6%) children had a delay in reaching care (D2), and 84 (71.2%) children had a delay in receiving care (D3), including 10 children who also experienced D1 and D2. The main reasons cited for D1 included seeking a traditional healthcare provider, while lack of money and availability of care were main reasons cited for D2. Significant predictors for delays included household size for D1 and D3 and condition type and region for D2.

Conclusion

Children in Somaliland experience several barriers to surgical care along the entire continuum of care, allowing for policy guidance tailored to specific local challenges and resources. Since delays in surgical care for children can substantially impact the effectiveness of surgical interventions, viewing delays in surgical care under the lens of the three-delay framework can inform strategic interventions along the pediatric surgical care continuum, thereby reducing delays and improving the quality of surgical care for children.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. 1.

    Canfin P et al (2013) Our common vision for the positioning and role of health to advance the UN development agenda beyond 2015. Lancet (London England) 381:1885–1886

  2. 2.

    Kim JY, Farmer P, Porter ME (2013) Redefining global health-care delivery. Lancet (London England) 382:1060–1069

  3. 3.

    Makasa EM (2014) Letter to global health agency leaders on the importance of surgical indicators. Lancet (London England) 384:1748

  4. 4.

    Thaddeus S, Maine D (1994) Too far to walk: maternal mortality in context. Soc Sci Med (1982) 38(8):1091–1110

  5. 5.

    Kakembo N, Godier-Furnemont A, Nabirye A et al (2019) Barriers to pediatric surgical care in low-income countries: the Three Delays’ impact in Uganda. J Surg Res 242:193–199

  6. 6.

    Concepcion T et al (2019) Prevalence of pediatric surgical conditions across Somaliland. JAMA Netw Open 2:e186857. https://doi.org/10.1001/jamanetworkopen.2018.6857

  7. 7.

    Smith ER et al (2019) The contribution of pediatric surgery to poverty trajectories in Somaliland. PLoS ONE 14:e0219974. https://doi.org/10.1371/journal.pone.0219974

  8. 8.

    Concepcion TL et al (2019) Provision of surgical care for children across Somaliland: challenges and policy guidance. World J Surg 43:2934–2944. https://doi.org/10.1007/s00268-019-05079-8

  9. 9.

    New World Bank GDP and Poverty Estimates for Somaliland. World Bank. http://www.worldbank.org/en/news/press-release/2014/01/29/new-world-bank-gdp-and-poverty-estimates-for-somaliland. Accessed 16th Nov 2016

  10. 10.

    World Bank (2013) Africa development indicators 2012/2013. World Bank, Washington, DC

  11. 11.

    You D et al (2015) Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. Lancet (London) 386:2275–2286

  12. 12.

    WHO | Infant mortality. WHO. http://www.who.int/gho/child_health/mortality/neonatal_infant_text/en/. Accessed 26th Feb 2017

  13. 13.

    The World Bank (2015) SOMALILAND: poverty profile and overview of living conditions (poverty global practice: Africa region), vol 55. The World Bank, Washington, DC

  14. 14.

    Krishna A (2017) The broken ladder: the paradox and potential of India’s one-billion. Cambridge University Press, Cambridge. https://doi.org/10.1017/9781108235457

  15. 15.

    Meara JG et al (2015) Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet (London, England) 386:569–624. https://doi.org/10.1016/s0140-6736(15)60160-x

  16. 16.

    Smith ER, Concepcion T, Lim S, Sadler S, Poenaru D, Saxton AT, Shrime M, Ameh E, Rice HE (2018) Disability weights for pediatric surgical procedures: a systematic review and analysis. World J Surg 42(9):3021–3034. https://doi.org/10.1007/s00268-018-4537-6

  17. 17.

    Magee WP, Vander Burg R, Hatcher KW (2010) Cleft lip and palate as a cost-effective health care treatment in the developing world. World J Surg 34(3):420–427. https://doi.org/10.1007/s00268-009-0333-7

  18. 18.

    Wang H, Bhutta ZA, Coates MM, Coggeshall M, Dandona L, Diallo K, Franca EB, Fraser M, Fullman N, Gething PW, Hay SI (2016) Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet (London, England) 388(10053):1725–1774

  19. 19.

    Smith ER, Concepcion TL, Shrime M, Niemeier K, Mohamed M, Dahir S, Ismail EA, Poenaru D, Rice HE (2019) Waiting too long: the contribution of delayed surgical access to pediatric disease burden in Somaliland. World J Surg. https://doi.org/10.1007/s00268-019-05239-w

  20. 20.

    Abdelgadir J, Punchak M, Smith ER et al (2018) Pediatric traumatic brain injury at Mbarara Regional Referral Hospital, Uganda. J Clin Neurosci Off J Neurosurg Soc Australas 47:79–83

  21. 21.

    Abdelgadir J, Smith ER, Punchak M et al (2017) Epidemiology and characteristics of neurosurgical conditions at Mbarara regional referral hospital. World Neurosurg 102:526–532

  22. 22.

    Appenteng R, Nelp T, Abdelgadir J et al (2018) A systematic review and quality analysis of pediatric traumatic brain injury clinical practice guidelines. PLoS ONE 13(8):e0201550

  23. 23.

    Bearden A, Fuller AT, Butler EK et al (2018) Rural and urban differences in treatment status among children with surgical conditions in Uganda. PLoS ONE 13(11):e0205132

  24. 24.

    Butler EK, Tran TM, Nagarajan N et al (2017) Epidemiology of pediatric surgical needs in low-income countries. PLoS ONE 12(3):e0170968

  25. 25.

    Fuller AT, Haglund MM, Lim S et al (2016) Pediatric neurosurgical outcomes following a neurosurgery health system intervention at Mulago Hospital in Uganda. World Neurosurg 95:309–314

  26. 26.

    Smith ER, van de Water BJ, Martin A et al (2018) Availability of post-hospital services supporting community reintegration for children with identified surgical need in Uganda. BMC Health Serv Res 18(1):727

  27. 27.

    Smith ER, Vissoci JRN, Rocha TAH et al (2017) Geospatial analysis of unmet pediatric surgical need in Uganda. J Pediatr Surg 52(10):1691–1698

  28. 28.

    Butler EK, Tran TM, Fuller AT et al (2016) Quantifying the pediatric surgical need in Uganda: results of a nationwide cross-sectional, household survey. Pediatr Surg Int 32(11):1075–1085

  29. 29.

    Davé DR, Nagarjan N, Canner JK, Kushner AL, Stewart BT, SOSAS4 Research Group (2018) Rethinking burns for low & middle-income countries: differing patterns of burn epidemiology, care seeking behavior, and outcomes across four countries. Burns 44(5):1228–1234

  30. 30.

    Jolly SP, Rahman M, Afsana K, Yunus FM, Chowdhury AM (2016) Evaluation of maternal health service indicators in urban slum of Bangladesh. PLoS ONE 11(10):e0162825

  31. 31.

    Global Initiative for Children’s Surgery (2019) Optimal resources for children’s surgical care: executive summary. World J Surg 43(4):978–980. https://doi.org/10.1007/s00268-018-04888-7

  32. 32.

    Global Initiative for Children’s Surgery (2019) A model of global collaboration to advance the surgical care of children. World J Surg 43(6):1416–1425. https://doi.org/10.1007/s00268-018-04887-8

  33. 33.

    Smith ER, Concepcion TL, Niemeier KJ, Ademuyiwa AO (2019) Is global pediatric surgery a good investment? World J Surg 43:1450–1455. https://doi.org/10.1007/s00268-018-4867-4

  34. 34.

    Saxton AT et al (2016) Economic analysis of children’s surgical care in low- and middle-income countries: a systematic review and analysis. PLoS ONE 11:e0165480. https://doi.org/10.1371/journal.pone.0165480

Download references

Acknowledgements

We want to thank the Global Initiative for Children’s Surgery (GICS) for its support of this work. GICS (www.globalchildrenssurgery.org) is a network of children’s surgical and anesthesia providers from low-, middle-, and high-income countries collaborating for the purpose of improving the quality of surgical care for children globally.

Funding

Funding was provided by Duke Global Health Institute, Duke University and Baylor University.

Author information

Correspondence to Emily R. Smith.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Concepcion, T.L., Dahir, S., Mohamed, M. et al. Barriers to Surgical Care Among Children in Somaliland: An Application of the Three Delays Framework. World J Surg (2020). https://doi.org/10.1007/s00268-020-05414-4

Download citation