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Access to Surgical Care in Rural Ecuador and the Role of Cinterandes Mobile Surgery in Addressing Barriers and Delays: a Qualitative and Biosocial Research Analysis

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Access to Surgical Care in Rural Ecuador and the Role of Cinterandes Mobile Surgery in Addressing Barriers and Delays: a Qualitative and Biosocial Research Analysis Access to Surgical Care in Rural Ecuador and the Role of Cinterandes Mobile Surgery in Addressing Barriers and Delays: A Qualitative and Biosocial Research Analysis The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Vega, Martha Paola. 2018. Access to Surgical Care in Rural Ecuador and the Role of Cinterandes Mobile Surgery in Addressing Barriers and Delays: A Qualitative and Biosocial Research Analysis. Master's thesis, Harvard Medical School. Citable link https://nrs.harvard.edu/URN-3:HUL.INSTREPOS:37365178 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA ACCESS TO SURGICAL CARE IN RURAL ECUADOR AND THE ROLE OF CINTERANDES MOBILE SURGERY IN ADDRESSING BARRIERS AND DELAYS: A QUALITATIVE AND BIOSOCIAL RESEARCH ANALYSIS MARTHA PAOLA VEGA, MD A Thesis Submitted to the Faculty of The Harvard Medical School in Partial Fulfillment of the Requirements for the Degree of Master of Medical Sciences in Global Health Delivery in the Department of Global Health and Social Medicine Harvard University Boston, Massachusetts. August 23, 2017 Thesis Advisors: Martha P. Vega Molly F. Franke, ScD Hannah N. Gilbert, PhD, Robert Riviello MD MPH Access to Surgical Care in Rural Ecuador & The Role of Cinterandes Mobile Surgery in Addressing Barriers and Delays: A Qualitative & Biosocial Research Analysis Abstract Timely access to surgical care is crucial to the development of resilient healthcare systems, society and economic growth (Meara et al., 2015). Using a biosocial approach, this study aimed to (1) identify and understand barriers, delays and facilitators affecting rural patients’ surgical care access; and (2) investigate the role that Cinterandes mobile surgery plays in surgical care in five rural Ecuadorian communities. This qualitative assessment employed an inductive, content analytic approach to document experiences and opinions on accessing surgical services in rural Ecuador. We sought to understand the perspectives on surgical access from a variety of informants including rural patients, healthcare providers, healthcare workers, healthcare leaders and rural community leaders. We conducted 36 multi-vocal semi-structured interviews to include participants from five rural communities within Azuay and Cañar provinces in the Andean highlands, Morona-Santiago province in the Amazon rainforest, and Santa Elena province in the coastal region; and also interviewed members of the Cinterandes Foundation, an Ecuadorian mobile surgery program. We found nine barriers and delays in the care seeking process of rural patients. These include unfamiliarity with hospitals, doctors and urban settings; the responsibility of the family unit, distrust in the public healthcare system, health system inefficiencies, displacement of ii decision-making power, strong regulations on non-governmental organizations, unique remoteness of the Amazon, the negative impact that lack of supplies has on delivery of surgical care, and the conflict between the assumptions and practices about rural patient’s use of traditional medicine. In addition, we found three facilitators including (1) the benefit of the family unit; (2) Socialización (an educational process that brings together rural patients and physicians to deepen patients’ understandings of surgical illness, surgical care and break biosocial barriers); and (3) the importance of surgeons or physicians visiting patients’ homes. In analyzing biosocial issues, we found that structural violence embedded in historical, social, political and healthcare system structures hindered rural patient’s ability to access surgical care. We described how Cinterandes mobile surgery addresses the three delays in surgical care and described the Cinterandes mobile surgery model of care. Moreover, we redefined Cinterandes mobile surgery as a Community-Based Surgical Care Accompaniment Model. Based on this analysis we offer recommendations that we hope will inform and guide future decisions to optimize the surgical care delivery system and help decrease barriers to surgical care for rural patients. iii Table of Contents ACKNOWLEDGMENTS ............................................................................................................ vii INTRODUCTION .......................................................................................................................... 1 Access to Surgical Care .......................................................................................................... 1 Why Study Access to Surgical Care in Rural Ecuador? ..................................................... 2 Healthcare System Structure ................................................................................................. 4 Biosocial Context ..................................................................................................................... 5 Structural Violence .................................................................................................................. 5 Socio-Political Context Affecting Rural Populations .............................................................. 6 Cinterandes Mobile Surgery Program: ................................................................................ 8 METHODOLOGY ....................................................................................................................... 11 Study Design .......................................................................................................................... 11 Ethics statement .................................................................................................................... 11 Study Setting: ........................................................................................................................ 11 Inclusion Criteria: ................................................................................................................. 13 Exclusion Criteria: ................................................................................................................ 13 Data Collection ...................................................................................................................... 13 Data Preparation and Analysis: .......................................................................................... 15 RESULTS ..................................................................................................................................... 16 Barriers and Delays: ............................................................................................................. 16 Unfamiliarity with hospitals, doctors and the urban setting create fear and dissuade rural patients from going to hospitals............................................................................................. 16 The Responsibility to the Family Unit .................................................................................. 17 Distrust in Public Health System ........................................................................................... 19 Health System Inefficiencies ................................................................................................. 22 Displacement of Decision-making Power .......................................................................... 25 Strong Regulations on Non-Governmental Organizations:............................................. 27 Unique Remoteness of the Amazon ...................................................................................... 30 Lack of Supplies Negatively Impacts the Delivery of Surgical Care .................................... 32 The Conflict Between Assumptions and Practices About Rural Patient’s Use of Traditional Medicine ................................................................................................................................ 35 iv Facilitators ............................................................................................................................. 37 The Benefit of the Family Unit.............................................................................................. 37 “Socialización” ...................................................................................................................... 38 Home Visits by Surgeons or Physicians ................................................................................ 40 How Cinterandes Mobile Surgery Overcomes Surgical Access Barriers and Delays: ... 43 Understanding the Cinterandes Mobile Surgery Model of Care ..................................... 47 Types of Surgical Missions: .................................................................................................. 47 Preparation before Surgical Mission: .................................................................................... 48 DISCUSSION ............................................................................................................................... 55 Analysis for Barriers, Delays and Facilitators ................................................................... 55 Unfamiliarity with Hospitals, Doctors and the Urban Setting Create Dear and Dissuade Rural Patients from Going to Hospitals ................................................................................
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