Burden of Surgical Diseases

Surgical need in an ageing population: a cluster-based

household survey in Nepal
Barclay T Stewart, Even Wong, Shailvi Gupta, Santosh Bastola, Sunil Shrestha, Adam L Kushner, Benedict C Nwomeh

Abstract
Background With an ageing global population comes major non-communicable disease burden, especially in low- Published Online
income and middle-income countries. An unknown proportion of this burden is treatable or palliated with surgery. April 27, 2015
This study aimed to estimate the surgical needs of individuals aged 50 years or older in Nepal. Poster 6
Department of Surgery,
Methods A two-stage, 30 randomised cluster by 30 households, community-based survey was performed in Nepal University of Washington,
Seattle, Washington DC, USA
with the validated Surgeons OverSeas Assessment of Surgical Need (SOSAS). Respondents aged older than 50 years (B T Stewart MD); Surgeons
were included. After verbal informed consent was obtained, SOSAS collected household demographics, completed a OverSeas (SOS), New York, NY,
verbal autopsy, and randomly selected household members for verbal head-to-toe examinations for surgical conditions. USA (E Wong MD); Centre for
The Nepal Health Research Council in Kathmandu and the Nationwide Children’s Hospital in Columbus, OH, USA, Global Surgery, McGill
University Health Centre,
granted ethical approval. Montreal, QC, Canada (E Wong);
Surgeons OverSeas (SOS), New
Findings The survey sampled 1350 households, totalling 2695 individuals (97% response rate); 49% were aged York, NY, USA (S Gupta MD);
50–59 years, 33% were 60–69 years, and 17% were 70 years and older. Of these, 273 surgical conditions were reported Department of International
Health, Johns Hopkins
by 507 individuals. A growth or mass (including hernias and goiters) was the most commonly reported potentially Bloomberg School of Public
surgical condition (25%), injuries and fractures were also common and had the greatest disability. Acquired deformities Health, Baltimore, MD, USA
(13%), incontinence (11%), non-injury wounds (9%), and pelvic organ prolapse were also prevalent. Together, head and (S Gupta); Manipal College of
Medical Sciences, Pokhara,
neck (24%) and back and extremity conditions (32%) were responsible for more than half of the conditions potentially
Nepal (S Bastola MBBS);
treatable with surgery. These were followed by genitourinary (28%), abdominal (14%) and chest and breast conditions Department of Surgery, Nepal
(2%). Extrapolated nationwide, roughly 1·25 million elderly individuals have a surgically treatable condition (32 150 per Medical College, Kathmandu,
100 000 people). There were 108 deaths in the year before to the survey. 20 (19%) were potentially preventable with Nepal (S Shrestha MBBS);
Surgeons OverSeas (SOS), New
surgery. Half of the deaths were due to a growth or mass, 20% to injury, 20% to abdominal pain or distension, and 10%
York, NY, USA (A L Kushner
to a non-injury wound. The age-standardised death rate of those with a potentially surgical condition was 24 per MD); Department of
1000 persons for individuals in their 6th decadte, 60 per 1000 for those in their 7th, and 44 per 1000 for those in their International Health, Johns
8th. One in five deaths were potentially treatable or palliated by surgery. Literacy and distance to secondary and tertiary Hopkins Bloomberg School of
Public Health, Baltimore, MD,
health facilities were associated with not receiving care for surgical conditions (p<0·05).
USA (A L Kushner); Department
of Surgery, Columbia
Interpretation Surgical need is largely unmet among elderly individuals in Nepal. Literacy and distance from a capable University, New York, NY, USA
health facility are the greatest barriers to care. Although verbal examination findings were used as proxies for surgical (A L Kushner); Surgeons
OverSeas (SOS), New York, NY,
conditions, the survey tool has been previously validated. Also, there is potential for recall bias with overestimation of
USA (Prof B C Nwomeh MD);
tragic deaths and underestimation of unknown or forgotten surgical causes of death and disease. However, this is the and Department of Pediatric
most comprehensive evaluation of surgical need in a developing country among the elderly. As the global population ages, Surgery, Nationwide Children’s
there is an increasing need to improve access to surgical services and strengthen health systems to care for this group. Hospital, Columbus, OH, USA
(Prof B C Nwomeh)
Correspondence to:
Funding The Association for Academic Surgery, Surgeons OverSeas, and the Fogarty International Center.
Dr Barclay T Stewart,
Contributors Department of Surgery,
SG, SB, SS, ALK, and BN conceived and designed the study. EW, SG, SB, and SS collected the data. BTS, EW, ALK, and BN interpreted the data. BTS University of Washington,
and EW wrote the Abstract. All authors approved the final version of the Abstract for publication. Seattle, WA 98195-6410, USA
stewarb@uw.edu
Declaration of interests
We declare no competing interests.
Acknowledgments
Logistical and transportation funding for the survey was provided by the 2014 Global Surgery Research Fellowship Award provided by the Association
for Academic Surgery and from Surgeons OverSeas, a US-based non-governmental organisation. This study was funded in part by a grant
(R25TW009345) from the Fogarty International Center, US National Institutes of Health. The content is solely the responsibility of the authors and
does not necessarily represent the official views of the National Institutes of Health. We thank the dedicated supervisors and enumerators for their
contribution to understanding surgical need in Nepal.

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