Ranking and Rating Analyses of Barriers to Surgical Care for Children in Guatemala

C l i n M e d International Library Citation: Gulack BC, Heydari S, Figueroa L, Tew S, Taicher BM, et al. (2015) Ranking and Rating Analyses of Barriers to Surgical Care for Children in Guatemala. Int J Surg Res Pract 2:032 Received: October 28, 2015: Accepted: November 18, 2015: Published: November 20, 2015 Copyright: © 2015 Gulack BC. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Gulack et al. Int J Surg Res Pract 2015, 2:2 ISSN: 2378-3397


Introduction
Barriers to surgical care in low and middle-income countries (LMICs) remain poorly understood.This is particularly true of surgical care for children, where families are required to make complex decisions amidst multiple obstacles.Unmet surgical care contributes choose between each variable, although they do not determine how significant the difference is between variables [11,12].Each of these analytic tools offers complementary information to understand how people view different variables that impact decision making.The purpose of this study was to compare the significance of different barriers to surgical care for children in Guatemala using rating and ranking surveys.Understanding which barriers are most important for families may assist in the development of policies to increase access to surgical care for children.

Study recruitment
Study subjects included one parent or guardian (hereafter referred to as parent) of children receiving care during April 2013 at the Moore Pediatric Surgical Center (Centro QuirúrgicoPediatrico Moore), which is a NGO based surgical center in Guatemala City.Previous studies have confirmed that families choose to seek care at this clinic when they are not able to access care in the public health sector or other part of the health system [10].Children of the respondents were undergoing a range of general surgical and urology procedures, performed by a U.S. team working alongside with Guatemalan staff.Using convenience sampling, 51 parents were invited to participate by a clinical social worker or health promoter of a total of 85 families being considered for surgical intervention.Of these 51 families, 46 parents enrolled in the study, and five declined study enrollment.All interviews were conducted in Spanish or the interviewee's primary indigenous language with the use of a trained interpreter during the child's hospital stay.
The Duke University Medical Center Institutional Review Board determined this study exempt from review.Families were enrolled in this study after reviewing the risks and benefits with the interviewer and having an opportunity to ask questions.All parents signed an informed consent document with the help of a trained interpreter.All collected information was de-identified, with no protected health information recorded.

Questionnaire instrument
Following study enrollment, each respondent completed a structured questionnaire (Appendix A) designed to collect their opinions about issues which affected their own access to surgical care in Guatemala.We collected demographic data, including child age, gender, distance the patient lived from the clinic, and yearly family income as well as operative data including the type of operation.The questionnaires contained two separate sections, one in which barriers to surgical care were rated for significance, and the other in which they were ranked.
For the rating portion, each parent was asked to rate the importance of eight barriers to care in Guatemala which led to them seeking care at this center.These barriers were chosen based on our previous research as well as other studies of surgical barriers in LMICs, and included the cost of surgery, distance to hospital, waiting time for surgery, language barriers, transportation issues, ability to take time off of work, quality of care at an available institution, and lack of local surgical health center [7,9,13].We used a Likert scale to assess the significance of each barrier, which were rated from 1 (least significant) to 5 (most significant) [14].For the ranking portion, we asked each parent to rank the same eight barriers in order of significance, using a scale from 1 (most significant) to 8 (least significant).Questionnaires were available in English and Spanish, and translators worked individually with each parent to ensure each question was fully understood.

Statistical analysis
We summarized parametric continuous datausing means and standard deviation, and non-parametric continuous datausing medians and interquartile ranges (IQR).All categorical data were summarized in count and percentage form.We determined the median rating and ranking along with interquartile range for each barrier to surgical care.Barriers to care were ranked from most to least significant for both types of analyses, and compared.All data analysis was performed using R version 3.1.0(Vienna, Austria).
Rating assessment demonstrated that the cost of surgery (median rating: 5, IQR: 5, 5) and the perceived quality of care (median rating: 5, IQR: 3, 5) were the most significant barriers to surgical care, with language differences the least significant barrier (median rating: 1.5, IQR: 1, 3, Figure 1).Ranking analysis of these same barriers demonstrated that the cost of surgery was the most significant barrier to care (median ranking: 1, IQR: 1, 7.8), however waiting time for surgery was also of significance to families (median ranking: 3, IQR: 2.2, 4, Figure 2).A lack of local surgical health centerwas the least significant barrier (median ranking: 5, IQR: 4, 7).
Comparison of rating and ranking results demonstrated several differences between the two methods (Figure 3).The cost of surgery was the most significant barrier to surgical care in both the rating and ranking analyses.However, the perceived quality of care was the second most significant barrier based on the rating scale, but was the third highest using the ranking scale.Furthermore, the waiting time for surgery was the fifth most significant barrier in the rating results,  although it was the second most significant barriers in the ranking results.

Discussion
Inadequate access to surgical care in LMICs remains a significant global health concern, particularly for children [8].In this study, we used two decision-analysis tools, rating and ranking scales, to measure how parents view different barriers to surgical care for children in Guatemala.We found those financial barriers and the perceived quality of care are the most significant obstacles to surgical care in Guatemala using rating and ranking analyses.Language barriers and ability to take time away from work were the least significant barriers.There was some variation between the two analyses with regards to other barriers.For example, the significance of the lack of a local surgical health center was the fourth most significant barrier in the rating analysis, but the eighth in the ranking analysis.
Our findings confirm most studies using other research methods that have shown that financial barriers as well as the quality of care are the dominant barriers to accessing surgical care in many LMICs [7,13,15].Our results also align with case studies of NGOs providing care in Guatemala, which have shown the importance of quality of care and trust in this health system during decisions to seek care [5,6].As Guatemala has a public health care system which offers free or reduced cost surgical care for children, the significance of cost as the most important barrier suggests that financial issues other than the direct cost of care, such as lost wages, drug costs or other financial strains, impact how families access surgical care.As the perceived quality of care was of great important to most families, this suggests that trust in existing health systems affect how families access surgical care for their children, and outweighs the importance of other barriers such as language or transportation.
The ability to receive surgical care depends on many factors, which are commonly framed as issues of accessibility, affordability, and availability [9,10].These concepts and have been described as a Three Delays framework, including delays in seeking care, delays in reaching care, and delays in receiving care [8].Our current study support the role of all of these delays in Guatemala, particularly delays in seeking care due to financial and geographic restrictions as well as low confidence in public health services.
In contrast to previous studies in Guatemala which have shown the importance of distance on access to primary care services, we have demonstrated that distance to a hospital and the lack of a local hospital are among the least significant barriers to surgical care [16][17][18].Although this finding may be related to our specific patient population, it is unlikely as many of our subjects waited a significant time for surgery, and therefore was likely dealing with other issues unrelated to the actual distance to a surgical center.
The use of two complementary analysis tools demonstrates some discrepancies in results, and is of importance to interpretation of our findings.Rating systems, which assign a value for each barrier, can be used to determine the order of importance of a list of variables to an individual [11].However they do not force a respondent to choose between two barriers, which can lead to multiple barriers being ranked at the same level [11].Ranking scales force a respondent to choose between each variable, however they do not determine how significant the difference is between two variables [11,12].Although rating systems are relatively simple and can easily indicate which of two variables is of greater importance, it can be difficult to determine the actual difference between variables when many variables are of similar significance [11].Ranking methods forces a respondent to determine the order of the significance of a list of variables, but it does not allow them to suggest that two variables are more similar in importance than two others [11].Ranking is also more conceptually taxing than simple rating, which can limit its accuracy and may be of concern in a setting with language barriers or where participants may have limited education [11].Researchers who use these analytic tools should be aware of the inherent limitations of each approach.
There are several limitations in our study.Most importantly, we examined the views of families who chose to access surgicalcare at a single site NGO-based site, and their experiences may not be generalizable to those who use the public sector or those who cannot access care.However, all of our respondents had previous experiences with the public sector, which impacted their decision to seek care outside of that system.Second, our study population was primarily ladino and Spanish-speaking, and under-representative of the indigenous Mayan population in Guatemala [7].This sampling  bias may explain why language barriers and the ability to take time off of work were the least significant barriers to care in our study, which contrasts with other studies which demonstrate the importance of language barriers on healthcare access in Guatemala [5,19].Third, the rating portion of the survey was asked before the ranking portion, and therefore mental exhaustion may have reduced accuracy of the ranking portion.Future studies should vary the order of testing to control for these confounders.
In conclusion, using rating and ranking analyses, we have demonstrated that the cost of care and the perceived quality of care at an available hospital are the most significant barriers for children receiving NGO-based surgical care in Guatemala.Language barriers and the ability to take time off of work are among the least significant.Efforts to decrease barriers to pediatric surgical care should focus on decreasing the cost of surgery as well as to increase the quality of care at available institutions.However, the interplay between barriers as families access surgical care systems is still not completely understood, and further study of these processes is critical to assist policy makers in developing programs to enhance access to surgical care for children.

Figure 1 :
Figure 1: Median rating for each barrier to surgical care along with interquartile range.Variables are ordered from highest median rating (5) to lowest (1).

Figure 2 :
Figure 2: Median ranking for each barrier to surgical care along with interquartile range.Variables are ordered from most significant median ranking (1) to least (8).

Figure 3 :
Figure 3: Comparison between rating and ranking analyses of barriers to care.Barriers were listed in order from most to least significant by median/ interquartile range for rating and ranking analyses.Arrows were drawn to demonstrate the differences in the findings of the two types of analyses.

Table 1 :
Demographics of children undergoing surgical procedures.