The Development and Inclusion of Questions on Surgery in the 2018 Zambia Demographic and Health Survey

Background: While primary data on the unmet need for surgery in low- and middle-income countries is lacking, household surveys could provide an entry point to collect such data. We describe the first development and inclusion of questions on surgery in a nationally representative Demographic and Health Survey (DHS) in Zambia. Method: Questions regarding surgical conditions were developed through an iterative consultative process and integrated into the rollout of the DHS survey in Zambia in 2018 and administered to a nationwide sample survey of eligible women aged 15-49 years and men aged 15-59 years. Results: In total, 7 questions covering 4 themes of service delivery, diagnosed burden of surgical disease, access to care, and quality of care were added. The questions were administered across 12,831 households (13,683 women aged 15-49 years and 12,132 men aged 15-59 years). Results showed that approximately 5% of women and 2% of men had undergone an operation in the past 5 years. Among women, cesarean delivery was the most common surgery; circumcision was the most common procedure among men. In the past 5 years, an estimated 0.61% of the population had been told by a health care worker that they might need surgery, and of this group, 35% had undergone the relevant procedure. Conclusion: For the first time, questions on surgery have been included in a nationwide DHS. We have shown that it is feasible to integrate these questions into a large-scale survey to provide insight into surgical needs at a national level. Based on the DHS design and implementation mechanisms, a country interested in including a set of questions like the one included in Zambia, could replicate this data collection in other settings, which provides an opportunity for systematic collection of comparable surgical data, a vital role in surgical health care system strengthening.

USAID has been implementing the DHS Program for more than 30 years, collecting and disseminating data on population and health through more than 400 surveys in over 90 countries since 1984. DHS data are gathered through nationally representative, repeated household surveys, using standardized questionnaires and enables comparison between and across countries.24 Questionnaires consist of a core module and a series of elective modules that countries select from. There are 5 standard model questionnaires; man’s, woman’s, household, fieldworker, and biomarker questionnaire, where elective modules can be added, such as the survey on maternal mortality.25 Based on matching of variables and classification systems of existing data collection mechanisms, the authors identified data sources for surgical statistics, including facility-based data as well as population-based approaches. As a population-based approach, household surveys were considered advantageous as they can reach those who otherwise would not have access to or have not tried to reach surgical care. Questions on access to surgical, anesthesia, and obstetric care were designed for addition to the female and male DHS questionnaires planned for roll out in Zambia. Questions were designed through an iterative consultation process during 2017 and 2018, involving an expert panel from the surgical research community with a research focus on global surgical data. The 13 group members (SJ, SM, VS, LR, JD, MS, TW, LH, HH, EM, JGM, JMG, DL) from Africa, Europe, North America, and South America brought together expertise from the fields of medicine, epidemiology, statistics, and demography. The expert group proposed a longer list of questions, while statisticians from the ZamStats provided guidance on the selection of the final set of questions to prioritize the inclusion of locally relevant surgical health care metrics and avoid information overload and data collection fatigue. Adhering to the DHS questionnaire format, the questions were fine-tuned for clarity, comprehensibility, and utility. The consultation process reached consensus on 5 topics representing 4 central themes: These topics were used as a basis to construct a set of nonambiguous questions with good face validity. The Lancet Commission on Global Surgery estimates an operative volume of 5,000 surgical cases per 100,000 population as a minimum threshold target. The first question aimed at generating an estimate of surgical volume and an output measure of service delivery by asking: “Have you ever undergone a surgical operation in the past 5 years?” The overall definition of surgical procedure applied in this work follows that of the Lancet Commission of Global Surgery, which is a procedure performed in an operating room under any kind of anesthesia. The timeframe of 5 years was deemed an ideal between achieving adequate power without risking substantial recall bias. To establish the met need of surgery by broad categories of procedures, the next question asked respondents that had undergone surgery in the past 5 years, “What type of operation(s) were they?” Response options were provided from a spectrum of common surgical procedures, and several responses could be recorded for each subject (Table 1). Surgery-Related Questions Added to the 2018 Zambia Demographic and Health Survey The interviewer manual provided explanations for interviewers to use if further clarification regarding procedures were necessary. These procedures were selected because they were considered as common, conceptually accessible for laypeople, and rely on the availability of a wide array of surgical services, providing additional insight about the surgical capacity in the country. Stratification by procedure was adopted as it was considered valuable in providing possible insight for projecting infrastructure and workforce development needs. The inclusion of cesarean delivery, laparotomy, and open fracture management are recognized as “Bellwether procedures,” therefore may reflect broader surgical system capacity regionally. During data collection, when looking at the open responses in the option “Other (specify),” ZamStat added and coded the following response variations not considered in the questionnaires: The third question is assessing the perceived total demand for surgical health care by asking respondents, “In the last 5 years has a doctor or another health care worker told you that you might need (an/another) operation?” We deemed this question to be a pragmatic proxy for actual need for surgery, validated by a health care worker, that owned some validity rather than simply asking if subjects themselves believed they needed surgery. Unmet need for diagnosed surgical care is defined as the number of individuals who in the last 5 years had been recommended by a doctor or another health care worker that they needed surgery and could or did not access it. Multiple response options to the question, “Why did you not undergo it [the surgery]?” were built upon social, cultural, structural, and financial dimensions as well as the patient’s beliefs, views, and expectations. Structural barriers refer to the location of health care facilities and the availability of these facilities to the population, while financial dimensions refer to medical and non-medical costs such as transport and time off work. Here, ZamStat added the response alternative that the surgery was not needed anymore. Although quality of care is multifaceted and complex to measure, perioperative mortality is considered a baseline indicator of surgical care quality.26 Due to the need for case mix and risk factor adjustment for interpretation of this indicator a specific intervention ideally should be chosen. The volume and homogeneity of the cesarean delivery make this an appropriate choice. Also, mortality after cesarean delivery has been recognized in both systematic reviews and prospective observational data27 to discriminate strongly on health system quality, with estimates that maternal mortality after cesarean deliveries are 50–100 times higher in LMICs than in high-income countries.28 Information on maternal death after cesarean delivery health care may be limited due to the overall low number of cases of maternal death in sampled households, owing to the rarity of maternal deaths. However, the expert panel felt this was an essential quality metric that should be explored in this pilot survey to measure and improve 1 component of the quality of obstetric health care. Quality of maternal health care is an essential health measure, and this may provide critical data for quality improvement.29 In the maternal mortality section of the ZDHS survey, respondents were asked about the survival of their siblings. Two questions for all women, relevant for surgical analysis, were included. In the case of sisters having died during childbirth or within 2 months after the end of a pregnancy or childbirth, respondents were asked “Did (name) receive a cesarean delivery?” A second question about that same woman, and/or those women that were pregnant when they died (all maternal deaths), was asked “Did (name) die in the hospital?” In parallel to the consultative process of question design, stakeholders within and associated with the Zambia MOH argued for the adoption of the questions regarding surgical care in the 2018 ZDHS. In 2018, questions to collect data on access to timely essential surgery and surgical volume were added to the woman’s and man’s health questionnaire and the adult and maternal mortality module of the ZDHS. While the woman’s questionnaire was used to collect information from women aged 15–49 years; the man’s questionnaire was used to collect information from men aged 15–59 years. All permanent residents of a selected household or visitors who stayed in the households the night before the survey were eligible to be interviewed. Data were collected by the implementing organization (ZamStats) and were gathered for the individual interviewed, apart from questions on maternal mortality, which were aimed at sisters of women who had passed during pregnancy, childbirth, or within 42 days of delivery or end of a pregnancy. After the questionnaires were finalized in English, they were translated into 7 major languages: Bemba, Kaonde, Lozi, Lunda, Luvale, Nyanja, and Tonga. Data collection took place from July 18, 2018, to January 24, 2019, as part of a standard DHS. The sampling frame used for the 2018 ZDHS was the 2010 Population and Housing Census of the Republic of Zambia conducted in 2010 by ZamStats. Twenty-two teams of 7 enumerators set out to gather information from sampled 13,595 households across the Zambian territory. SPSS was used to extract data from 2 datasets containing data from the men’s questionnaire and the women’s questionnaire, also holding data on adult and maternal mortality, called “men’s recode” and “individual recode,” respectively. This has been presented using descriptive frequency analysis with calculations of percentages of the survey population. Results for surgical volume were already disaggregated by sex, age, and place of residence in the ZDHS main report and are presented as such in this text. No missing values were found for the data relevant for surgical care.

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• juran, sabrina
• moren, sanna
• santhirapala, vatshalan
• roa, lina
• makasa, emmanuel
• davies, justine i.
• guzman, jose miguel
• hagander, lars
• holmer, hampus
• shrime, mark g.
• weiser, thomas g.
• meara, john g.
• klug, stefanie j.
• ljungman, david