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Year : 2022  |  Volume : 25  |  Issue : 7  |  Page : 1180-1188

Health Worker (HW) Factors in Delayed Access to Pediatric Surgery in Low- and Middle-Income Countries (LMICs)

1 Department of Pediatric Surgery, College of Medicine, University of Nigeria Nsukka, Enugu State, Nigeria
2 Department of Community Medicine, College of Medicine, University of Nigeria Nsukka, Enugu State, Nigeria

Date of Submission11-Apr-2022
Date of Acceptance03-Jun-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Dr. E P Nwankwo
Department of Pediatric Surgery, College of Medicine, University of Nigeria Nsukka, Enugu State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_257_22

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Background: In the developing world, access to pediatric surgery has been associated with sociocultural factors and healthcare funding challenges. Aim: This study aims to evaluate health worker (HW) factors in delayed access to appropriate care for children with surgical problems in South East Nigeria. Subjects and Methods: A cross-sectional analysis of the awareness of children's surgery and ability for appropriate referral among 503 HWs of various cadres in South East Nigeria was carried out using a structured questionnaire. Data was analyzed using IBM SPSS 21. Results: Of 419 (83.3%) respondents, 211 (50.4%) were doctors, 217 (51.8%) were aged 26–35 years, 261 (62.3%) indicated awareness of pediatric surgical conditions, 114 (27.2%) knew of sites to examine on the newborn at birth, and 147 (35.1%) inclined to timely referral to experts. Predictors of early referral include age <35 years, (P = 0.001) and cadre: doctors (P = 0.006). Female HWs (P = 0.013) and doctors (P = 0.008) displayed better knowledge of pediatric surgical cases. Delayed referral was mostly HW-related and included inaccurate diagnosis and wrong assumption of competence. Conditions commonly misdiagnosed were intussusception and posterior urethral valve. Conclusion: Awareness of surgical needs of children is poor among HWs in our setting. To address this and improve access to care, there may be a need to incorporate basic training in common pediatric surgical conditions in the training curriculum for HWs at various levels.

Keywords: Health worker, access to care, pediatric surgery, delayed referral, developing country

How to cite this article:
Nwankwo E P, Aniwada E C, Ekenze S O. Health Worker (HW) Factors in Delayed Access to Pediatric Surgery in Low- and Middle-Income Countries (LMICs). Niger J Clin Pract 2022;25:1180-8

How to cite this URL:
Nwankwo E P, Aniwada E C, Ekenze S O. Health Worker (HW) Factors in Delayed Access to Pediatric Surgery in Low- and Middle-Income Countries (LMICs). Niger J Clin Pract [serial online] 2022 [cited 2022 Nov 28];25:1180-8. Available from:

   Introduction Top

There is no doubt that the burden of surgical pathologies among African children is enormous.[1] In many African countries, scarce healthcare resources are concentrated on the provision of immunization, HIV control, malaria eradication, and other public health concerns. As a result, diseases for which surgical intervention offers the only hope for prevention, palliation, or cure usually do not come within the radar of health policymakers.[2]

In developing countries, including Nigeria, many children who require pediatric surgical care present late to the mainstream surgeon for treatment. Factors affecting access to pediatric surgical services in Africa have been reported to include poverty, ignorance even among health workers (HWs), shortage of manpower, poor facilities, and lack of support services such as pediatric anesthesia and neonatal intensive care unit.[3] However, in our setting, many children with congenital problems present early to the hospital or maternity care, where the child was delivered or to the health facility nearest to them as most patients with surgical conditions in low- and middle-income countries (LMICs) live quite far from healthcare institutions offering specialized surgical services.[4] Despite early presentation to these health facilities, referral to the pediatric surgeon is often late with unacceptably high morbidity and mortality.

The healthcare workforce in many general hospitals and private clinics where most children, including those who require specialized care present first is mostly made up of medical officers or non-physician HWs. Early diagnosis at these health facilities and prompt referral to the pediatric surgeon is key to appropriate management of children with surgical problems, especially with congenital malformations. In addition to a possible gap in knowledge, other indices related to this category of HWs could contribute to the delay in the referral of pediatric surgical patients in their care. In our setting, the role of medical officers and non-physician HWs in delayed access to care among children with surgical needs has not been vastly studied, and there is a paucity of data on the topic. This study is targeted at this cadre of HWs to assess their contribution to delayed access to pediatric surgical care.

   Materials and Methods Top

This was a cross-sectional study assessing the awareness of pediatric surgical conditions and the ability for appropriate referral among various cadres of HWs in urban cities of South East Nigeria. Doctors excluding pediatricians and pediatric surgeons as well as non-physician healthcare workers including nurses, midwives, community health extension workers, laboratory scientists, and nurse assistants working in both public and private hospitals in Aba, Enugu, Abakaliki, Owerri, Nnewi, and Orlu were included in the study. A random sampling method was used to recruit respondents. Those who indicated willingness to participate were involved in the study. The minimum sample size required was 385 derived from the formula n = (Z2PQ)/d2, where n is the minimum sample size, Z is the standard normal variate (1.96 at 5% type 1 error), P = expected proportion in population (set at 50%), Q = 1 − P, and d = absolute error or precision (set at 5%).

A self-administered semi-structured questionnaire developed by the researchers was completed by the respondents [Appendix 1]. This was validated by inputs from senior medical research fellows. Age, gender, duration of practice, and cadre were evaluated as possible factors influencing timely referral. Appropriate action refers to recognition of the need for referral to a pediatric surgeon. Knowledge of common pediatric surgical conditions and parts of the newborn to be examined at birth (head and neck—aniridia, macroglossia, hydrocephalous; chest—pectus excavatum and carinatum; abdomen—umbilical discharge and anterior abdominal wall defects; upper and lower limbs—polydactyly/syndactyly and club foot; back—spina bifida; genital region—disorders of sexual differentiation, undescended testes, recto, and anovestibula fistulae; anorectum—absent anus and perineal fistulae) was scored using a cutoff <50% as incorrect and 50% and above as correct. Knowledge of conditions requiring referral was scored using the same cutoff. Ethical clearance for this study was obtained from the Health Research and Ethics Committee of the University of Nigeria Teaching Hospital, Ituku-Ozalla. (NHREC/05/01/2008B/-FWA00002458-1RB00002323). This covered all areas involved in the study. Data was analyzed using IBM SPSS version 23. The Chi-square test and binary logistic regression were carried out. Findings were summarized using proportion and percentages and presented in tables. Level of significance was set at P < 0.05.

   Results Top

A total of 419 respondents were involved in the study with almost equal number of males and females. There were more doctors than other HWs, and a majority of the respondents were still young in their profession [Table 1].
Table 1: Characteristics of respondents

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Two hundred and sixty-one (62.3%) respondents demonstrated awareness to common pediatric surgical conditions. One hundred and fourteen (27.2%) including doctors and other healthcare workers could identify parts of the newborn to be examined at birth, to rule out congenital abnormalities, and one hundred and forty-seven (35.1%) of them were inclined to refer children with surgical problems appropriately [Table 2].
Table 2: Awareness to Pediatric conditions

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There was a significant association between gender (P = 0.013) and cadre (P < 0.001) with knowledge of sites to examine the newborn to detect congenital abnormalities. However, there was no significant association with age in groups (P = 0.329) and duration of practice (P = 0.932). Females were about 1.4 times (AOR 1.39; 95% CI 0.85–2.27) more likely to identify congenital anomalies requiring surgery in a newborn than males. Doctors were about 2 times more likely (AOR 2.11; 95% CI 0.99–4.48), and nurses were about 1.3 times (AOR 1.26; 95% CI 0.63–2.55) more likely than other HWs [Table 3].
Table 3: Socio-demographic factors of respondents influencing knowledge on regions of the body to examine

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There was a significant association between the ability for appropriate action with age in groups (P = 0.004), cadre (P < 0.001), years of practice (P = 0.006), knowledge of areas to examine at birth (P < 0.001), and knowledge of pediatric conditions requiring referral (P < 0.001) but none with gender (P = 0.182). Those aged < 26 years were about 3.3 times (AOR 3.27; 95% CI 1.22–8.77), those aged 26–35 years about 3.0 times (AOR 2.90; 95% CI 1.34–16.31), and those aged 36–45 years about 2.0 times (AOR 2.22; 95% CI 0.98–5.01) more likely to take appropriate action than those aged >45 years. Females were about 1.2 times (AOR 1.19; 95% CI 0.75–1.90) more likely to take appropriate action than males. Doctors were about 3 times (AOR 2.65; 95% CI 1.66–6.06) more likely, and nurses about 2 times (AOR 1.81; 95% CI 0.80–4.08) more likely to take appropriate action than other HWs. Those who had worked for ≤1 year were about 0.7 times (AOR 0.72; 95% CI 0.29–1.77) and those who had worked for 2–5 years about 0.50 times (AOR 0.49; 95% CI 0.21–1.15) more likely to refer surgical children appropriately than those that had worked for >5 years. Those with correct knowledge of areas to examine at birth were about 12.6 times (AOR 12.56; 95% CI 6.28–28.35) more likely to refer appropriately than those with incorrect knowledge [Table 4].
Table 4: Socio-demographic factors of respondents influencing inclination to appropriate referral

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The most common reasons for delayed referral among the respondents included inaccurate diagnosis 164 (39.1%) as well as cultural and financial constraints 97 (23.1%). This is shown in [Table 5].
Table 5: Reasons for delay

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   Discussion Top

The study shows a slight female preponderance among HWs, especially in the nursing profession. This compares with other studies that show that the public health workforce in developing countries is predominantly female.[5] Obembe et al.[6] in looking at the staffing of the primary healthcare centers in the Federal capital territory in Nigeria noted that females constituted more than half of their study group. Globally, the health workforce is seeing more female dominance and women now comprise approximately 75% of the global health workforce, and over 90% of nursing and midwifery professions.[7],[8] However, more males were seen among doctors and this compares with the results of a previous report by the World Health Organization. The World Health Reports (2006) noted that men continue to dominate the medical profession, while other health service providers remain predominantly female although with some exceptions.[9]

The doctors and nurses form the bulk of HWs studied in this work. This is probably because the study was conducted in urban cities where better-skilled HWs are likely to be found. The low status often conferred on those working in rural and remote areas contributes to health professionals' preference for settling in urban areas, where positions are perceived as more prestigious.[10] The study also shows a younger health workforce mean age of (34.8) years. A comparative assessment of HWs' performance and performance factors in another part of Nigeria showed a similar finding with an average age of 37 years among the HWs.[11]

A striking finding from the study was that although many of the respondents were aware of pediatric surgical conditions, only few had the clinical skills to assess a newborn and identify congenital malformation. Well-baby examination at birth is not routinely practiced in our environment; consequently, children with surgically correctable congenital problems present late to the pediatric surgeon, sometimes with poor outcomes. Ekwunife et al.[12] in a study of late presentation of undescended testes found that more than four-fifths of the children were delivered in private hospitals manned by few well-trained staff and that less than one-fifth of the patients were examined in detail at birth and even lesser at 6 weeks of postpartum visit.

In the present study, females demonstrated a greater ability to identify congenital malformations requiring surgery in the newborn than their male counterparts. This might suggest that females paid more attention to details in clinical evaluation. In a meta-analysis of physician gender effects in medical communication, female physicians were noted to spend more time with their patients and were described as more patient-centered.[13],[14] Another metanalysis on the impact of physician's sex/gender on processes of care and clinical outcomes in cardiac operative care found that patients treated by female surgeons compared with male surgeons had lower 30-day mortality in one study, while another study found no differences in patient outcomes based on the surgeon's sex.[15]

We found that younger HWs and doctors who had a lesser practice were more inclined to refer children with surgical problems to the specialist. Such early referral often follows correct diagnosis and facilitates timely appropriate intervention that no doubt impacts the outcome positively. In their work on the impact of a physician's age on patient outcomes in the US, Tsugawa et al.[16] noted that patients treated by older internists had higher mortality rates than those treated by younger ones. They had earlier found that older physicians had higher patient mortality rates than younger physicians who saw the same number of patients. On the one hand, skills and knowledge are accumulated through experience and can improve the quality of care. However, scientific knowledge, technology, and clinical guidelines change so regularly that keeping up with them and incorporating them into clinical practice can be overwhelming. In the present study, however, age of practice did not relate to any superior knowledge or awareness of the children's conditions. The inclination to early referral by younger HWs observed in this work may require a future larger-scale study for validation.

The reasons for delayed referral and therefore delayed access to care that were identified were mostly HW-related, notably inaccurate diagnosis. Those who had better knowledge of the conditions were more likely to refer. Delayed or no referral by HWs has been identified by other authors as a major factor in delayed access to care, and inaccurate diagnosis has been noted as a key factor responsible for late referrals.[17],[18] Bode, in a study of the presentation and management outcome of childhood intussusception in Lagos, Nigeria, recorded a notable departure from the pattern of delayed access to care caused by parents who presented the patients late in the hospitals and found that over 75% of patients with intussusceptions had presented early to primary healthcare facilities but were misdiagnosed and wrongly given ambulatory therapy for suspected infective gastroenteritis.[19] This is similar to the finding in the present study where the most misdiagnosed condition was intussusception.

In India, Shandip Kumar Sinha similarly found that the most common cause of delayed presentation of anorectal malformation is wrong advice given by the healthcare providers, followed by inadequate treatment elsewhere.[20] Also, in a study of maternal death and delays in accessing emergency obstetric care in Mozambique, delayed referral from peripheral facilities contributed to the highest form of delays, leading to maternal morbidity and mortality, and this agrees with the findings in the present study.[21] However, Pilkington et al.[22] contrary to our results found that care-seeking delays constituted the highest barrier to timely access to pediatric surgery in Uganda.

Other reasons given for delayed or no referral in the present study include lack of awareness of the implications of late treatment, wrong assumption of competence, confusion as to which specialist the referral should be sent, and unavailability of pediatric surgeons. All these point to a faulty referral system with no clear guidelines and compares with a previous report on referral systems. In a study of surgical referral systems in LMICs, Pittalis et al.[23] noted among other factors that gaps in surgical and decision-making skills of clinicians at sending hospitals to act as obstacles to safe and appropriate referrals. They observed that comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different levels of facilities may enhance the efficiency of referral pathways.

The scarcity of specialist pediatric surgeons to cater for the large number of children with surgical needs in the sub-region has similarly been noted in other studies.[24]

Some cultural beliefs unhelpful to the health of African children and lack of finances as identified in this study contribute significantly to delayed access to care. In some cultures, children are denied surgical treatments as parents are reluctant to commit funds to children's surgery because some surgical conditions in children are believed not to be amenable to orthodox medicine and surgery, parental embarrassment, fear that the child would die, and other superstitious beliefs.[25]

Limitations of the study

  1. The study design did not allow a thorough investigation and analysis of the inclination of younger doctors to early referral of pediatric surgical patients. A comparative analysis of the referral threshold for pediatric surgical conditions among clinicians is planned as a follow-up to the present study. It is hoped that a more robust analysis of the subject will be achieved in the future study.
  2. Scope of the study: The study was restricted to HWs in urban areas.

Including rural areas may have affected the results. However, this was to eliminate transportation barriers to access to care, which is an important factor in rural communities.[26]

   Conclusion Top

The level of knowledge of pediatric surgical conditions among HWs in our setting is low. There is equally a low tendency to referral to the pediatric surgeon as a result of lack of awareness. Female gender and medical profession were predictors of both good knowledge and appropriate referral. To address the current information gap, there may be a need to incorporate basic training in common pediatric surgical conditions in the training curriculum for HWs at various levels. Governments, policymakers, the international community, and donor agencies have to consider pediatric surgical care and capacity building in the specialty a priority in developing countries.


The authors express their profound gratitude to the following colleagues for their assistance in collecting data from various parts of South East Nigeria:

  1. Dr. Sylvester Obiechina—Nnewi
  2. Dr. Anthony Ariom—Abakiliki
  3. Dr. Isaac Chukwu—Umuahia, Owerri, Orlu, and Enugu
  4. Dr. Kevin Chukwubuike—Enugu

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Ethical approval

Ethical approval was obtained from the University of Nigeria Ethics Committee.

Appendix 1

Evaluating factors affecting access to pediatric surgical services in a developing country

Dear Respondent,

We are conducting a survey of the awareness to pediatric surgical conditions among Health Workers in urban cities. It is aimed at improving services to children requiring pediatric surgical intervention in our sub region. Kindly respond to the following questions as honestly as you can. Thank you

A. General Questions

1. Age

2. Sex

3. Occupation RN RM RN/M CHEW Medical Officer Other

4. Address of practice

5. Years of practice <5 5-10 10-15 15-20 >20

B. Knowledge And Awareness of Pediatric Surgical conditions

C. AT birth which parts of the newborn should be examined to ensure that there is no abnormality? List at least one disease or condition to exclude.

1. head and neck………… 2. chest ………. 3. Abdomen…….

4. back…… 5. genital region…. 6. anorectum

7. Upper and lower limbs…….

D. Appropriate Action

E. What do you consider the major causes of delay in referring pediatric surgical cases? List







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Mshelbwala PM, Nwomeh BC. Paediatric surgery specialty and its relevance to Africa. In: Ameh EA, Bickler SW, Lakhoo K, et al. editors. Paediatric Surgery: A Comprehensive Text for Africa. 1st ed. Seattle: Global Help; 2011. p. 3-6.  Back to cited text no. 2
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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