Patient perceptions about laparoscopy at Komfo Anokye Teaching Hospital, Ghana

Introduction Laparoscopy has become the gold standard for many surgical cases in the developed world. It however, remains a rarity in developing countries for several reasons, a major one being cost. This study aimed to determine the knowledge and attitude of patients attending Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana toward laparoscopic surgery and their willingness to pay for it. Methods A cross-sectional survey was conducted among patients attending specialist clinics at KATH. Results 1070 patients participated. Mean age was 40±15years. 54% were city-dwellers. 14% had salary-paying jobs. None had undergone prior laparoscopic surgery. 3% had knowledge of laparoscopy. 95% preferred laparoscopy to open surgery mainly because of faster recovery and less post-op pain. Age >45years (AOR = 0.53, p = 0.03) and higher education (AOR = 2.00, p = 0.04) were significant predictors of patient choice. Among those preferring laparoscopy, 78% were willing to pay more than the baseline cost of open surgery for laparoscopy. A history of previous abdominal surgery (AOR = 0.67, p = 0.02), having a salaried job compared with being unemployed (AOR = 2.36, p < 0.01) and living in the city compared with the village (AOR = 1.78, p = 0.04) were significant predictors of patients’ willingness to pay more for laparoscopy. Conclusion Knowledge about laparoscopy and its benefits are severely lacking among patients at KATH. Once educated about its benefits, most people prefer laparoscopy even if they needed to pay more for it even in resource-limited countries like Ghana.


Introduction
Minimally invasive surgery (MIS) revolutionized the surgical world 20 years ago and changed the approach of surgical procedures forever.
Currently, MIS procedures are the standard of care for many operations such as laparoscopic appendectomy and cholecystectomy in developed countries [1]. However, laparoscopic surgery and other forms of minimally invasive surgery are not routinely found in resource-restricted countries including Ghana. The reasons include increased operative cost of minimally invasive procedures as well as the lack of local training opportunities in laparoscopic techniques [2]. Some successful laparoscopic programs have been established in resource-restricted countries [3][4][5]. The advancement of MIS has largely been a patient-driven process. The rapid introduction and spread of laparoscopic cholecystectomy in the developed world was driven mostly by public demand as the benefits of decreased pain and suffering became known [6]. Reports in the English literature,

Methods
A cross-sectional study was carried out between July and August 2013 at the surgical specialist outpatient clinics of Komfo Anokye Teaching Hospital (KATH), Ghana. The KATH serves most of the northern sector of Ghana and records an average of 123 visits to surgical specialist outpatient clinics per day. By assuming that 50% of the population knew about laparoscopy, with a 95% confidence interval (CI) and 6% margin of error, a sample size of 1 069 was calculated. The study population included all patients attending surgical specialist outpatient clinics. Data were collected on every weekday within the period. Participants were selected systematically based on how they were seated at the clinic. Starting from the first patient in the first row of seats every third patient was approached and after explaining the study and seeking consent, the questionnaire was administered through a face-to-face interview.
The participants were interviewed using a structured questionnaire  Table 1 summarizes the characteristics of the participants. One thousand and seventy patients participated in the study. The mean age was 40±15 years. Fifty-four percent lived in the city while 38% lived in a town [7]. Sixty percent of them had completed basic education (nine years of education including junior high school) or less. The majority (86%) were either engaged in hourly-paying jobs

Discussion
There are many studies in the literature that have focused on the feasibility of implementing laparoscopic procedures in resource-poor countries and how to overcome the challenges involved [9][10][11].
Literature focused on how patients in resource-poor countries perceive laparoscopy is however limited [12]. This study was done to assess the knowledge and perception of patients attending specialist outpatient clinics in KATH toward laparoscopic surgery. were more likely to pay for laparoscopy. City dwellers were also better educated than town-dwellers and village-dwellers respectively (53% vs 28% vs 7%) and were more engaged in salaried jobs (19% vs 10% vs 2%). Contrary to expectations, patients who had previously undergone abdominal surgery were less likely to prefer laparoscopy. They were also less likely pay for it. The disinterest in laparoscopy in patients who previously had abdominal surgery, in fact, may be due to skepticism that minimally invasive procedures could actually accomplish such complex surgeries [15]. From the data, patients who had undergone previous abdominal surgery were 67% more likely to be older (>45 years) (p=0.001). This older age group was less likely to prefer laparoscopy and also less likely to pay for it. There are several limitations of the study. Many of the questions restricted participants to yes/no answers. This could limit the open comment opportunity to elicit patients' true preferences and to illustrate the sociocultural aspects of the study population [13]. We may also have introduced a bias towards patients' preference for laparoscopy by giving detailed descriptions about the possible risks and benefits of laparoscopy, which are not well known by our patient population in comparison with the open approach.
Despite these limitations, this study gives important insights into how patients in a resource-restricted country perceive laparoscopy.

Conclusion
The

Competing interests
The authors have no conflicts of interest or financial ties to disclose.

Authors' contributions
AG designed the study, performed data analysis and prepared the manuscript; SF was involved with data collection and management and manuscript revision; JB and RP were involved in study design, data analysis and manuscript revision. All authors have critically appraised and approved the final manuscript.