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Identifying the Burden of Pediatric Surgical Disease in Somaliland By Identifying the Burden of Pediatric Surgical Disease in Somaliland by Tessa Leigh Concepcion Duke Global Health Institute Duke University Date: _______________________ Approved: ___________________________ Henry Rice, MD, Supervisor ___________________________ Emily Smith, PhD MSPH ___________________________ Dan Poenaru, MD PhD Thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in the Duke Global Health Institute in the Graduate School of Duke University 2018 ABSTRACT Identifying the Burden of Pediatric Surgical Disease in Somaliland by Tessa Leigh Concepcion Duke Global Health Institute Duke University Date: _______________________ Approved: ___________________________ Henry Rice, MD, Supervisor ___________________________ Emily Smith, PhD MSPH ___________________________ Dan Poenaru, MD PhD An abstract of a thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in the Duke Global Health Institute in the Graduate School of Duke University 2018 Copyright by Tessa Leigh Concepcion 2018 Abstract Background: A staggering 5 billion people worldwide lack access to safe and affordable surgery, and surgical conditions contribute to up to 32% of the global disease burden. However, precise data on the burden of surgical conditions is lacking, particularly for children. This study aims to measure the burden of pediatric surgical conditions in Somaliland using a community-based, household, nationwide survey as well as a national hospital survey to identify the types and volume of pediatric surgical care. Methods: We surveyed 1450 children, from 839 families, through national community-based sampling using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey to identify the prevalence of surgical conditions. We also performed a hospital capacity survey at 15 hospitals in Somaliland, with surgical records reviewed over a 1-year time frame to identify pediatric surgical procedures performed. Results: Using a community survey, we identified 226 surgical conditions in 191 children, yielding a surgical condition prevalence of 13.7% in the pediatric population. Only 55 of 226 conditions were treated with a surgical procedure. The most common conditions reported were congenital deformities (34.4%) and wound related injuries (23.8%). Using a hospital survey, we identified 1255 pediatric surgical procedures performed nationally over 1 year. We found that 56.7% procedures were in performed in boys and 79.8% were done at private hospitals. The most common surgical diagnoses were tonsillitis, trauma/wound/snake bite, and hydrocephalus. Conclusions: Between 91,500 – 209,000 children in Somaliland have an unmet need for pediatric surgery, highlighting the high burden of surgical disease in the country. The estimated number of performed surgical procedures represents a small fraction of the burden of pediatric surgical 1 conditions, highlighting the need for expansion of infrastructure, resources, and workforce to provide needed surgical care. 2 Dedication To Mom, for telling me I can To Dad, for telling me I should To Evan, for telling me I will 1 Content Abstract ............................................................................................................................................ 1 Dedication ........................................................................................................................................ 1 Contents ........................................................................................................................................... 2 List of Acronyms ............................................................................................................................... 6 List of Tables .................................................................................................................................... 7 List of Figures ................................................................................................................................... 8 Acknowledgements.......................................................................................................................... 9 1. Introduction ............................................................................................................................... 10 1.1. Surgical burden of disease ................................................................................................ 10 1.2. Pediatric surgical disease burden ..................................................................................... 10 1.3. Delays in surgical care ...................................................................................................... 11 1.4. Gaps in knowledge ........................................................................................................... 12 1.5. Objective........................................................................................................................... 13 2. Methods ..................................................................................................................................... 13 2.1. Setting ............................................................................................................................... 13 2.2. Participants ....................................................................................................................... 15 2.2.1. Aim 1: Community survey ........................................................................................... 15 2.2.1.1. Sample size calculation ........................................................................................ 15 2.2.1.2. Somaliland sampling strategy .............................................................................. 16 2.2.1.3. Household selection and randomization procedures .......................................... 18 2.2.2. Aim 2: Hospital survey ................................................................................................. 19 2.2.2.1. Hospital capacity assessment .............................................................................. 19 2.2.2.2. Surgical record review ......................................................................................... 20 2.3. Data Collection ................................................................................................................. 21 2.3.1. Aim 1: Community survey ........................................................................................... 21 2.3.1.1. SOSAS ................................................................................................................... 21 2.3.1.2. Enumerators ........................................................................................................ 22 2.3.2. Aim 2: Hospital survey ................................................................................................. 22 2.3.2.1. Hospital capacity assessment .............................................................................. 22 2.3.2.2. Surgical record review ......................................................................................... 22 2.4. Measures .......................................................................................................................... 23 2.4.1. Aim 1: Community survey ........................................................................................... 23 2.4.2. Aim 2: Hospital survey ................................................................................................. 24 2.4.2.1. Hospital capacity assessment .............................................................................. 24 2.4.2.2. Surgical record review ......................................................................................... 24 2.5. Analysis ............................................................................................................................. 24 2.5.1. Aim 1: Community survey ........................................................................................... 24 2.5.2. Aim 2: Hospital survey ................................................................................................. 26 2.5.2.1. Hospital capacity assessment .............................................................................. 26 2.5.2.2. Surgical record review ......................................................................................... 26 2.6. Ethical considerations ...................................................................................................... 29 3. Results ........................................................................................................................................ 29 3.1. Aim 1: Community Survey ................................................................................................ 29 3.1.1. Demographics of families and children (Table 5) ........................................................ 29 3.1.2. Characteristics of children who died (Table 6) ............................................................ 31 3.1.3. Demographics of children surveyed for surgical conditions (Tables 7 & 8) ................ 33 2 3.1.4. Demographics by surgical condition, healthcare seeking behavior, and surgical treatment status (Table 9) .................................................................................................... 36 3.1.5. Condition specifics by healthcare seeking behavior and surgical treatment status (Table 10) ..............................................................................................................................
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