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Barriers to surgery for in low- and middle-income countries: a cross-sectional study of cleft lip and cleft palate patients in Vietnam

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Barriers to surgery for in low- and middle-income countries: a cross-sectional study of cleft lip and cleft palate patients in Vietnam

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1
Thesis for USC Masters Degree
Clinical and Biomedical Investigation
Degree conferral date: December 2015

Barriers to Surgery for in Low- and Middle-Income Countries:
A Cross-sectional Study of Cleft Lip and Cleft Palate Patients in Vietnam

First Author:
Caroline A. Yao, MD
a,b,c,d

caroline.yao@gmail.com

Co-Authors:
Jordan Swanson, MD
a

jswans@gmail.com

Dayana Chanson
e
dchanson@usc.edu

Trisa B. Taro, MS, MPH
c

trisa.taro@gmail.com

Barrie Gura, MPH
d

blgura@yahoo.com

Jane C. Figueiredo, PhD
e

JANEFIGU@med.usc.edu

Heather Wipfli, PhD
d

hwipfli@med.usc.edu

Kristin Hatcher
Kristin.Hatcher@operationsmile.org

Erin McCrane
erin.mccrane@operationsmile.org

Richard Vanderburg, RN, BSN
f

richard.vanderburg@operationsmile.org

William P. Magee III, MD, DDS
a,b,c

WMagee@chla.usc.edu

a
Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern
California, Los Angeles, CA
b
Department of Plastic and Reconstructive Surgery, Shriners Hospital for Children, Los Angeles, CA
c
Division of Plastic and Reconstructive Surgery, Children’s Hospital Los Angeles, Los Angeles, CA
d
USC Institute of Global Health, Keck School of Medicine of the University of Southern California, Los
Angeles, CA
e
Department of Preventive Medicine, Keck School Of Medicine Of USC
f
Operation Smile International, Virginia Beach, VA

2
Table of Contents:
Structured Abstract Page 3
Introduction Page 5
Methods Page 6
Results Page 7
Discussion Page 9
Table 1 Page 13
Table 2 Page 15
Table 3 Page 16
Figure 1 Page 17
Figure 2 Page 18
References Page 19

3

Abstract:
STRUCTURED ABSTRACT
Importance: Despite health system advances, residents of low- and middle-income countries (LMICs)
continue to experience substantial barriers in accessing healthcare, particularly for specialized care such
as surgery.
Objective: To identify and describe barriers to surgical care for oral clefts and to delineate whether these
varied in single- versus multiple-intervention cases.
Design: A cross-sectional household survey of patients seeking surgical care for cleft lip and/or cleft
palate in November 2014.
Setting: Surveys were completed at five Operation Smile International mission sites throughout Vietnam.
Participants: A total of 453 households were surveyed. Households included both patients who had and
had not received cleft surgery in the past. Eligibility criteria were individuals of any age currently residing
in Vietnam with a cleft lip and/or cleft palate with or without previous surgical repair.
Main Outcomes: Cost, mistrust of medical providers, and lack of supplies and trained physicians were
cited as the most significant barriers for obtaining surgery from local hospitals. There was no significant
difference in household income or hospital access between those who had and those who had not obtained
cleft surgery in the past.
Results: Fewer households who had cleft surgery in the past were enrolled in health insurance
(p=<0.001). Of those households/patients who had surgery previously, 83% had their surgery performed
by a charity. Forty-three percent of participants did not have access to any other surgical cleft care and
41% did not have any other access to non-surgical cleft care.
Conclusion: The data highlights barriers specific to surgical care within the health systems context of a
LMIC that are not addressed in previous research. Patients rely on charitable care outside of the
centralized healthcare system. As a result, surgical treatment of congenital conditions, such as cleft lip

4
and palate, is delayed beyond the standard optimal window compared to more developed countries. Data
from this study was used to develop a more evidence-based framework designed to modify health
behaviors and perceptions regarding surgical care. The Disease State in LMIC Model accounts for
barriers specific to both surgical care and LMICs that are not addressed in previous models, including
disease state and patient perceptions.

5
Text:

INTRODUCTION
Despite recent advances in health systems strengthening, people in low- and middle-income countries
(LMICs) continue to face substantial barriers in accessing healthcare, particularly for specialized care
such as surgery.[1, 2] In 2005, access to surgical care was declared a global health priority by the World
Health Organization (WHO) Global Initiative for Emergency and Essential Surgical Care, which
promoted increased access to and improved standards for district-level surgical care in LMICs.
2
A decade
later, frameworks for understanding barriers to surgical care in LMICs are still in development.

Existing models for barriers to healthcare often combine primary care (including preventative services)
and surgical care, and fail to recognize the unique requisites of the latter – for example, the need for
specially-equipped facilities, the demand for specialized physicians, and the high level of follow-up care
for certain diseases. Surgical care must also be understood in relation to socioeconomic, cultural, and
psychosocial elements. For these reasons surgical care, and barriers to accessing it, must be analyzed and
understood within a unique context. Unfortunately, few evidence-based studies have been conducted on
barriers to surgical care in LMICs and, of those that have, the majority are specific to single-intervention
procedures.

In an effort to grow the current evidence base in this area, we investigated barriers to surgical care at
medical missions in Vietnam sponsored by Operation Smile, a non-profit organization dedicated to the
repair of cleft lip and cleft palate for children around the world. Cleft lip and cleft palate represent the
most common craniofacial congenital defect with a birth prevalence of 1/500 to 1/2,500 worldwide. The
defect not only results in physical obstacles to feeding and language development but patients are often
subjected to significant social stigma.

6

In this paper we present data from Vietnam for both single and multiple-intervention cleft repair in order
to introduce a comprehensive analysis of barriers to surgical care. Based on our evidence, in conjunction
with the existing literature, we recommend a modified framework for barriers to healthcare that addresses
the particular needs of surgical patients while also taking into account the complexities of surgical and
post-operative care. This type of evidence-based framework for the structural and behavioral determinants
of surgical care access is necessary to allow policymakers, donors, and other key stakeholders to develop
policies and programs that effectively address barriers to obtaining surgical care.

METHODS
In this cross-sectional study, surveys were administered to households who attended the Operation Smile
International 25
th
Anniversary multi-site mission in Vietnam in November 2014. Eligibility criteria were
individuals of any age currently residing in Vietnam with a cleft lip and/or cleft palate with or without
previous surgical repair. Missions were completed in the cities of Hanoi, Nghe An, Hue, Ho Chi Minh,
An Giang and Bac Lieu. Among 884 eligible patient households, 51% (453 households) were randomly
surveyed. Depending on the number of households/patients at each site, every other or every third
household/patient was approached for participation.

Through collaboration with the Vietnamese Fund for Children, local bilingual (English-Vietnamese)
medical and dental students verbally administered the survey . All volunteers underwent an eight-hour
training course led by study investigators to ensure consistent data collection, professionalism and
cultural sensitivity when surveying patients and families about their social/medical history and cleft
disease. At each mission site, a study investigator oversaw surveyors and reviewed each survey for
consistency and completeness.

7
As most orofacial cleft patients were children, surveys were administered in a confidential setting to a
member of the household age 17 or older who was deemed an authority in the household and able to
answer medical history and questions regarding familial decision processes, e.g. a parent, grandparent,
aunt/uncle or other family member/close friend.

A portion of households/patients had undergone cleft surgery previously and attended the current mission
in hopes of receiving a revision surgery to improve their results. As such, the survey was adapted into two
versions: one for individuals who had prior surgical repair of the cleft lip and/or palate and one for those
who had no previous surgery. For patients at the mission who had not received surgery previously, the
mission day was considered their date of first surgery.

Demographic and access/barriers to care questions were taken from the validated WHO Survey of Health
and Health System Responsiveness. Questions specific to medical and surgical history were adapted from
a validated survey created for the International Family Study, an epigenetic cleft study run by the
University of Southern California during similar Operation Smile International missions.[3]

Data analysis included descriptive statistics and comparisons between those who had received past cleft
surgery versus those who had not (Stata 12.0, College Station, TX, 2014).

RESULTS
A total of 453 households/patients were surveyed. Table 1 shows demographic characteristics of
household participants. The proportion of patients with cleft lip (CL), cleft palate (CP), or cleft lip and
palate (CL+CP) significantly differed by households who had received cleft surgery in the past compared
to those that did not (23%, 28% and 49%, respectively). Current patient age, patient age at the time of
first surgery, and health insurance status also differed significantly by surgical status. Median and mean

8
annual income of each household at the mission was US$1,700 and US$2,390, respectively. Mean annual
income per household member was US$530. Most household adults were farmers by trade (53% of
fathers, 52% of mothers), followed by unskilled labor workers and those who were self-employed. A
majority of mothers and fathers had finished secondary (middle) school or higher (55% and 54%,
respectively) (Table 2). Mothers and fathers were more likely to have finished secondary school for
patients who had had previous surgery (p=0.05, p=0.0020, respectively) and the mother’s occupation was
correlated with whether or not the child received cleft surgery in the past (p=0.02).

Eighty-five percent of households who had not received surgery in the past reported having insurance,
whereas only 63% of households who had surgery in the past reported having insurance (p<0.001). Of
those households/patients who had surgery previously, 83% had their surgery performed by a charity.
Most households reported having a local hospital with surgical facilities that was more accessible than the
mission site, but stated that they could not obtain surgical cleft treatment at these facilities largely due to
the cost of care (Table 1).

Each household had an average of 4.8 members, with an average of one person per household able to see
a primary care physician in the last three months. On average, one out of four people per household
needed to see a physician but did not/could not; one in five people per household saw a surgeon in the last
three months, while one in seven persons who needed to see a surgeon did not/could not (Table #). If not
given surgical care during the current mission, 43% reported that they did not have access to any other
form of surgical cleft care. If not provided non-surgical care for their cleft (e.g. general pediatric, dental
or speech therapy) at the current mission, 41% reported they did not have any other access to such care.

Structural barriers, such as the lack of trained medical personnel and lack of equipment/medicine, were
the most commonly reported obstacles to obtaining surgical cleft care for households/patients (Figure 1).

9
Financial barriers to care included treatment costs, lack of savings, and food/living expenses necessary to
travel for care. With respect to cultural barriers, most households cited family opinion/permission (68%),
lack of trust in the medical system/personnel (54%), and poor quality treatment (43%) as obstacles to
obtaining surgical cleft care.

DISCUSSION

Several important findings emerged from this patient-centric study of access to surgical care among 453
households/patients receiving care through missions operated by a large non-profit organization. First, the
total proportion of insurance coverage is high (73%) among these communities in Vietnam. Second,
despite high rates of insurance coverage, households have considerable difficulty accessing surgical care
and the vast majority (> 80%) still rely on charitable care outside of the centralized healthcare system.
Finally, as a result, surgical treatment of congenital conditions, such as cleft lip and palate, is delayed
beyond the standard optimal window compared to more developed countries.

Several models have been developed to categorize and evaluate access to healthcare. The most cited non-
surgical healthcare model is Andersen’s Behavioral Model of Utilization. Several models are derived
from Anderson’s paradigm, but few specifically address surgical intervention.[7] Irfan et al. combined
Phillips’ adaptation of Anderson’s model[8] with the WHO health systems concept to create the
Healthcare Barrier Model for both surgical and non-surgical care [7]. This model deconstructs patient-
level barriers into several variables (i.e. predisposing, enabling, and need-based) but does not clearly
identify which factors are specific to surgical versus non-surgical care. In a systematic review, Grimes et
al. presents the most commonly cited model for barriers to surgical care using three broad categories:
structural aspects, cultural beliefs and attitudes, and financial barriers.[1] However, Grimes’ model, while
compelling, has primarily been applied to short-term, single intervention surgeries such as

10
cataracts/glaucoma (ophthalmologic) and antenatal/delivery (obstetrical). While certain barriers apply to
all types of surgery (i.e., anesthesia, fear, etc.), specific classes of surgical disease present different
barriers at each level, both perceived and real.

Past models do not stratify medical or surgical care by disease state and/or level of continuing care
required. While surgical repair for cleft lip is typically a singular intervention, some patients require
several additional surgeries – for example, scar revision and rhinoplasty. In the case of cleft palate,
treatment needs parallel that of chronic disease, as patients require multiple revisions over years of care
and extensive post-operative rehabilitation through speech therapy. To this point, the majority (54%) of
households in our random sample were returning to the mission for revision surgery and follow-up
medical treatment. Thus, cleft disease and other surgical diseases that require longer term follow-up must
be addressed differently in a barriers to care framework. Furthermore, certain disease states, such as
orofacial clefts, are physically distinguishable and easily recognized by laypersons, leading to
stigmatization and community pressure for treatment. The perception or reality of external pressures to
obtain treatment is separate from what Grimes refers to as “acceptability,” which is the cultural or social
resistance towards obtaining treatment.

Past models are also limited in their capacity to address barriers specific to surgical care. In this study, the
lack of qualified surgeons and lack of surgical equipment were the most frequently cited barriers to
obtaining needed surgery. The most commonly cited cultural barrier to care was distrust of the medical
system due to both corruption and suspicion of medical providers, which was heighted by the perceived
invasiveness of surgery. Additionally, barriers for multi-stage surgeries may exacerbate existing
perceived provider-level limitations and patient factors.

11
The financial barriers identified in our population have been described in past models, i.e. treatment costs,
savings, and travel/living expenses. However, qualitative data from the study showed that the lack of
accurate information and education in this population may have led to inflated perceptions of costs and a
diminished perception of the benefits of surgical intervention. While Grimes’ model subjugates “no
perceived need” and “lack of understanding of severity of condition” as barriers related to cultural beliefs
and attitudes [1], it does not specifically address how a patient’s perception of a healthcare problem and
the corresponding solution pervasively affect care-seeking behavior. Similarly, the Healthcare Barrier
Model mentions how “perceptions, knowledge and beliefs” are barriers within patient-level predisposing
barriers but does not elaborate on the scope or definition of “perceptions”; nor does the model propose
how perceptions impact the decision to obtain surgery. No previous models clearly delineate patient
perceptions, which we define as a non-community-, culture- or religion-specific personal modifier that
may change over time.

Our data highlight barriers specific to surgical care within the health systems context of a LMIC that are
not addressed in previous research. Table 3 summarizes which factors are included in past models for
barriers to care and highlights the elements that we propose to modify and/or introduce. Our proposed
framework, “The Disease State in LMIC Model,” (Figure 2) augments current models by addressing three
key elements: barriers specific to surgical care; single versus multiple intervention diseases; and specific
LMIC challenges, e.g. perceived versus real barriers on a patient level. Factors in blue are items that are
particularly exacerbated by diseases that require multiple or a series of treatments/interventions.

The conclusions from this study and the proposed model developed as a result can be generalized for
other populations in Vietnam and similar LMICs. For Vietnam specifically, our study cohort provides a
strong representation of the national population: households surveyed were comparable in income,
occupation type, and education level to the nation’s lower-and middle-class population; the reported

12
annual household income for our study population was on par with Vietnam’s gross national income per
capita in 2013[4]; and the majority of our study population were farmers, parallel to national statistics that
report 51% of adults being employed in the agricultural sector[5].

As with most cross-sectional studies, the primary limitations of this study are the potential for selection
bias and limited generalizability. Individuals were recruited from surgical missions where households
were proactive in seeking care and had the time/means to spend several days at the mission site. While
Operation Smile reimbursed travel, food and lodging fees, those at the mission may have represented a
more economically secure and/or educated subset.

Our data help validate existing healthcare barrier models through quantitative methods and support the
development of a more evidence- and needs-based framework designed to modify health behaviors and
perceptions regarding surgical care. The Disease State in LMIC Model accounts for barriers specific to
both surgical care and LMICs that are not addressed in previous models, including disease state and
patient perceptions. It also highlights the challenges and successes for mission-based care and the need to
better understand surgical barriers in order to design more effective programs for both missions-based and
locally sustainable surgical care.

13
Table 1: Demographic characteristics of household/patient surveyed

Diagnosis
No
previous
surgery
Had previous
surgery Total P value
Cleft lip 69 (34%) 31 (13%)
100
(23%)
<0.001*
Cleft palate 79 (39%) 45 (18%)
124
(28%)
Cleft lip + Cleft palate 55 (27%) 166 (69%)
221
(49%)

Gender
Male
124
(60%) 107 (44%)
260
(57%)
0.197*
Female 83 (40%) 136 (56%)
190
(43%)

Age
Patient age (years) 2.58 6.71 4.82 <0.001**
Patient age at time of first surgery
(years) 2.61 3.78 3.24 0.004**
Income
Household income USD, annual) $2,461 $2,328 $2,390 0.586**
Household income per person $543 $518 $530 0.645**
Hospital Access
Closest Hospital (hours) 0.79 0.79 0.74 0.379**
Closest Hospital (km) 15.89 15.89 20.90 0.130**
Travel cost to closest hospital (USD) $13.84 $15.73 $14.94 0.610**
Insurance

No 24 (15%) 72 (37%) 96 (27%)
<0.001*
Yes
132
(85%)
124 (63%)
256
(73%)
Reasons for not seeing a doctor
Cost 30 (61%) 35 (49%) 65 (54%)
0.156*
Too Far 7 (14%) 15 (21%) 22 (18%)
No time 8 (16%) 10 (14%) 18 (15%)
Fear 2 (4%) 4 (6%) 6 (5%)
Other 2 (4%) 8 (11%) 10 (8%)
Reasons for not seeing a surgeon
Cost 16 (39%) 19 (56%) 35 (47%)
0.310*
Too Far 8 (20%) 8 (24%) 16 (21%)
No time 7 (17%) 6 (18%) 13 (17%)
Fear 4 (10%) 0 (0%) 4 (5%)

14
Poor health 3 (7%) 0 (0%) 3 (4%)
Lacked information 2 (5%) 0 (0%) 2 (3%)
Family disagreed 1 (2%) 1 (3%) 2 (3%)
Travel cost to nearest facility
0 to $99,999 70 (49%) 95 (48%)
165
(48%)
0.610**
100,000 to 199,999 26 (18%) 33 (17%) 59 (17%)
200,000 to 299,999 11 (8%) 23 (12%) 34 (10%)
300,000 to 399,999 12 (8%) 11 (6%) 23 (7%)
400,000 to 499,999 4 (3%) 2 (1%) 6 (2%)
Greater than 500,000 19 (13%) 35 (18%) 54 (16%)
* Chi-squared test
** Student t-test

15
Table 2: Socioeconomic demographics of household parents

Father

Mother
Occupation
No
previous
surgery
Had
previous
surgery P value

No
previous
surgery
Had
previous
surgery
P
value
Farming 108 (52%) 135 (54%)
0.181*

103 (49%) 137 (55%)
0.018
*
Government/public
employee 7 (3%) 5 (2%) 12 (5%) 10 (4%)
Housewife/unemployed 3 (1%) 1 (0%)

31 (14%) 25 (10%)
Labor worker (unskilled) 20 (9%) 24 (9%)

23 (11%) 25 (10%)
Professional employee 8 (3%) 7 (2%)

9 (4%) 3 (1%)
Self-employed 25 (12%) 23 (9%)

18 (8%) 27 (10%)
Service 19 (9%) 14 (5%)

6 (2%) 1 (0%)
Labor worker (skilled) 3 (1%) 7 (2%)

2 (0%) 4 (1%)
Military 2 (0%) 1 (0%)

0 (0%) 0 (0%)
Other 5 (2%) 19 (7%)

1 (0%) 9 (3%)
Omitted 7 (3%) 10 (4%)

2 (0%) 5 (2%)
Education

None 13 (6%) 26 (10%)
0.110*

15 (7%) 12 (4%)
0.102
*
Some primary school 16 (7%) 17 (6%)

16 (7%) 21 (8%)
Completed primary
school 44 (21%) 78 (31%) 53 (25%) 86 (35%)
Completed secondary
school 55 (26%) 63 (25%) 55 (26%) 66 (27%)
Completed high school 47 (22%) 36 (14%)

42 (20%) 36 (14%)
Completed university 24 (11%) 13 (5%)

23 (11%) 13 (5%)
Omitted 8 (3%) 12 (4%)

3 (1%) 10 (4%)

16
Table 3: Past and proposed barrier/access to healthcare frameworks. [1, 7-10]

17
Figure 1: Barriers to surgical cleft care

44%

34%

39%

4%

21%

12%

52%

59%

59%

45%

61%

59%

64%

66%

54%

57%

60%

52%

55%

50%

64%

66%

62%

67%

62%

52%

38%

68%

56%

56%

58%

60%

99%

83%

87%

43%

32%

39%

48%

37%

39%

35%

33%

34%

35%

38%

48%

39%

49%

29%

13%

27%

15%

33%

47%

62%

26%

43%

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%

Family
opinion

Family
permission

No
:me

Religion

Community
opinion

Prefer
tradi:onal
methods

Didn't
know
what
treatment
needed

Available
treatment
of
poor
quality

Fear
of
surgery/side
effects

Don't
trust
medical
system/personnel

Transport

Income
lost

Living
expenses

Food

Treatment

Lack
of
savings

Distance
to
facility

Time
to
facility

No
transporta:on

Poor
roads

Don't
know
where
to
get
care

No
doctor
to
provide
treatment

Not
told
by
doctors
there
was
treatment

No
equipment/medicine

Unfriendly
health
staff

Wait
:me

Hospital
open
hours

No
long
term
care

Paperwork/administra:ve
delays

Percentage

Agree
%

Disagree
%

Cultural Structural Financial

18
Figure 2: Proposed barriers to care framework: The Disease State LMIC model

19
References:

1. Grimes, C.E., et al., Systematic review of barriers to surgical care in low-income and middle-
income countries. World J Surg, 2011. 35(5): p. 941-50.
2. Ologunde, R., et al., Surgical care in low and middle-income countries: burden and barriers. Int
J Surg, 2014. 12(8): p. 858-63.
3. Figueiredo, J.C., et al., Genetic risk factors for orofacial clefts in Central Africans and Southeast
Asians. American Journal of Medical Genetics Part A, 2014. 164(10): p. 2572-2580.
4. GNI per capita, Atlas method (current US$). Data 2015 [cited 2015; Available from:
http://data.worldbank.org/indicator/NY.GNP.PCAP.CD.
5. Skilling up Vietnam: Preparing the workforce for a modern market economy, in Vietnam
Development Report 2014. 2014, World Bank: Washington, D.C.
6. Education in Vietnam: Develompent History, Challenges and Solutions. 2006, World Bank:
Washington, D.C.
7. Irfan, F.B., B.B. Irfan, and D.A. Spiegel, Barriers to accessing surgical care in Pakistan:
healthcare barrier model and quantitative systematic review. J Surg Res, 2012. 176(1): p. 84-94.
8. Phillips KA, M.K., Andersen R, Aday L. , Understanding the Context of Healthcare Utilization:
Assessing Environmental and Provider-Related Variables in the Behavior Model of Utilization.
Health Services Research, 1998: p. 571-596.
9. McIntyre, D., M. Thiede, and S. Birch, Access as a policy-relevant concept in low- and middle-
income countries. Health Econ Policy Law, 2009. 4(Pt 2): p. 179-93.
10. Obrist M, O.-B.E., Awuah B, Watanabe-Galloway S, Merajver SD, Schmid K, Soliman AS.,
Factors related to incomplete treatment of breast cancer in Kumasi, Ghana. Breast, 2014. 6: p.
821-8.

Abstract (if available)

Abstract Importance: Despite health system advances, residents of low- and middle-income countries (LMICs) continue to experience substantial barriers in accessing healthcare, particularly for specialized care such as surgery. ❧ Objective: To identify and describe barriers to surgical care for oral clefts and to delineate whether these varied in single- versus multiple-intervention cases. ❧ Design: A cross-sectional household survey of patients seeking surgical care for cleft lip and/or cleft palate in November 2014. ❧ Setting: Surveys were completed at five Operation Smile International mission sites throughout Vietnam. ❧ Participants: A total of 453 households were surveyed. Households included both patients who had and had not received cleft surgery in the past. Eligibility criteria were individuals of any age currently residing in Vietnam with a cleft lip and/or cleft palate with or without previous surgical repair. ❧ Main Outcomes: Cost, mistrust of medical providers, and lack of supplies and trained physicians were cited as the most significant barriers for obtaining surgery from local hospitals. There was no significant difference in household income or hospital access between those who had and those who had not obtained cleft surgery in the past. ❧ Results: Fewer households who had cleft surgery in the past were enrolled in health insurance (p=<0.001). Of those households/patients who had surgery previously, 83% had their surgery performed by a charity. Forty-three percent of participants did not have access to any other surgical cleft care and 41% did not have any other access to non-surgical cleft care. ❧ Conclusion: The data highlights barriers specific to surgical care within the health systems context of a LMIC that are not addressed in previous research. Patients rely on charitable care outside of the centralized healthcare system. As a result, surgical treatment of congenital conditions, such as cleft lip and palate, is delayed beyond the standard optimal window compared to more developed countries. Data from this study was used to develop a more evidence-based framework designed to modify health behaviors and perceptions regarding surgical care. The Disease State in LMIC Model accounts for barriers specific to both surgical care and LMICs that are not addressed in previous models, including disease state and patient perceptions.

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Asset Metadata

Creator Yao, Caroline A. (author)

Core Title Barriers to surgery for in low- and middle-income countries: a cross-sectional study of cleft lip and cleft palate patients in Vietnam

School Keck School of Medicine

Degree Master of Science

Degree Program Clinical, Biomedical and Translational Investigations

Publication Date 11/18/2015

Defense Date 11/18/2015

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag access to healthcare,access to surgical care,barriers to healthcare,barriers to surgical care,developing country access to healthcare,lower-middle income country healthcare,lower-middle income country surgical care,OAI-PMH Harvest,Vietnam healthcare

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Figueiredo, Jane (committee member), Magee, William P., III (committee member), Samet, Jonathan (committee member), Wipfli, Heather (committee member)

Creator Email caroline.yao@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-200943

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