I believe India with a vast population, youth, geo-political importance, ease of obtaining IRB and field testing should be a site. However, there are huge disparities within the country as shown in our work with surgical unmet need. As you can see below, we have carefully defined the households for our sampling and data analysis. We published the first study arising from this proposal which consisted of urban slum, who were predominantly day laborers. Eventually, we hope to establish a digital platform to educate (courses for patients and community workers), ensure adherence with follow up and analyse data in real time.
Briefly, in our study of surgical unmet need, our aims are following:
a. Percentage of women and men who have undergone a surgical operation in the past.
b. Percent distribution of women and men who have undergone a surgical operation in the past and by type of operation.
a. Percentage of women and men who have been told by a doctor or another healthcare worker that they might need (another) operation.
Surgical Unmet Need
a. Percentage of women and men who have been told by a doctor or another healthcare worker that they might need an operation and were not able to access it?
b. Percent distribution of women and men who were not able to access an operation by reason for no access.
To assess the gaps in availability of surgical care at resource constraint health facilities.
Methods: There will be 3 cohorts, which have been identified and several international projects are being implemented under the auspices of the Indian Institute of Public Health, Gandhinagar, India (http://iiphg.edu.in/). This community-based panel study is nested within a larger project studying institutional childbirth in India. In Gujarat, the project was implemented in three purposely selected districts (Dahod, Sabarkantha, and Surendranagar) . The districts were selected because they cover diverse geographic and socioeconomic areas of the state . House to house detailed survey by case worker or surgical resident who has basic understanding of surgical conditions. Case worker will be trained in using the survey instruments and assessing surgical conditions. Secondary examination and confirmation by a surgeon in the local tertiary care Hospital.
Setting: Gujarat state (population of 60.4 million, 57.4% rural, 79% literate and 31.6% below poverty line, 21% tribal) is located in western India . The state is divided into 33 administrative districts, each with a population of between 1-2 million. Districts are further divided into 10–20 blocks (sub-districts) of approximately 100,000 to 200,000 people. These districts have varying human development indices and different population compositions. The population is divided into socio-economic sub groups. Government of India uses the terms ‘Schedule Tribe (ST)’ to denote these traditionally marginalized populations.
Sampling procedure: In brief, in each of the 3 districts, 3–5 blocks will be selected purposely. A list of all the villages in these blocks have already been compiled using the criteria: village population more than 1,000 and less than 2,500, greater than 40% below poverty level (BPL) population and scattered all over the block. From the list, 142 villages have been selected randomly to cover approximately 300,000 populations in 20,000 households. This selection is from the population of 6.25 million people living in the 3 districts of Gujarat described above. The sampling methodology of MATIND survey has been described elsewhere .
Analysis: Data will be double-entered and validated in REDCap. The database for this study will be imported to EpiData version v220.127.116.11 for descriptive and bivariate inferential analysis (EpiData Association, Odense, Denmark). STATA (version 12.1, copyright 1985–2011 StataCorp LP USA, serial number: 30120504773) was used for regression (Poisson) analysis (enter method). Frequencies and proportions (categorical variable) will be used to summarize utilization of surgical services. The median and interquartile ranges (IQR) will be used to summarize surgical volume, surgical need and unmet surgical need. Unadjusted analyses will be performed to assess the association (relative risk, RR) of factors with demographics and surgical volume, surgical need and unmet surgical need. Variables with p-value of <0.2 in the unadjusted analysis were included in the regression model. Adjusted RRs will be reported with 95% confidence intervals (CI).