Statewide Policy to Increase Provision of Take-Home Naloxone at Emergency Department Visits for Opioid Overdose, Rhode Island, 2018‒2019.

In 2017, Rhode Island responded to rising overdose deaths by establishing statewide emergency department (ED) treatment standards for opioid overdose and opioid use disorder. One requirement of the policy is that providers prescribe or provide take-home naloxone to anyone presenting to EDs with opioid overdose. Among adults presenting to EDs with opioid overdose from 2018 to 2019, approximately half received take-home naloxone. Receipt of naloxone was associated with administration of naloxone before ED presentation, ED policy certification level, and regional overdose frequency. (Am J Public Health. 2023;113(4):372-377. https://doi.org/10.2105/AJPH.2022.307213).

Validity of Self-Report for Ascertaining HIV Status Among Circular Migrants and Permanent Residents in South Africa: A Cross-Sectional, Population-Based Analysis.

While expanded HIV testing is needed in South Africa, increasing accurate self-report of HIV status is an essential parallel goal in this highly mobile population. If self-report can ascertain true HIV-positive status, persons with HIV (PWH) could be linked to life-saving care without the existing delays required by producing medical records or undergoing confirmatory testing, which are especially burdensome for the country's high prevalence of circular migrants. We used Wave 1 data from The Migration and Health Follow-Up Study, a representative adult cohort, including circular migrants and permanent residents, randomly sampled from the Agincourt Health and Demographic Surveillance System in a rural area of Mpumalanga Province. Within the analytic sample (n = 1,918), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of self-report were calculated with dried blood spot (DBS) HIV test results as the standard. Among in-person participants (n = 2,468), 88.8% consented to DBS-HIV testing. HIV prevalence was 25.3%. Sensitivity of self-report was 43.9% (95% CI: 39.5-48.5), PPV was 93.4% (95% CI: 89.5-96.0); specificity was 99.0% (95% CI: 98.3-99.4) and NPV was 83.9% (95% CI: 82.8-84.9). Self-report of an HIV-positive status was predictive of true status for both migrants and permanent residents in this high-prevalence setting. Persons who self-reported as living with HIV were almost always truly positive, supporting a change to clinical protocol to immediately connect persons who say they are HIV-positive to ART and counselling. However, 56% of PWH did not report as HIV-positive, highlighting the imperative to address barriers to disclosure.

Coronavirus Disease 2019 Epidemic Doubling Time in the United States Before and During Stay-at-Home Restrictions.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has spread rapidly in the United States since January 2020. METHODS: We estimated mean epidemic doubling time, an important measure of epidemic growth, nationally, by state, and in association with stay-at-home orders. RESULTS: The epidemic doubling time in the United States was 2.68 days (95% confidence interval [CI], 2.30-3.24 days) before widespread mitigation efforts, increasing by 460% to 15 days (12.89-17.94 days) during the mitigation phase. Among states without stay-at-home orders, the median increase in doubling time was 60% (95% CI, 9.2-223.3), compared with 269% (95% CI, 277.0-394.0) for states with stay-at-home orders. CONCLUSIONS: Statewide mitigation strategies were strongly associated with increased epidemic doubling time.

Evaluation of Andrews' Analysis as a Predictor of Ideal Sagittal Maxillary Positioning in Orthognathic Surgery.

PURPOSE: There is no universally accepted method for determining the ideal sagittal position of the maxilla in orthognathic surgery. In "Element II" of "The Six Elements of Orofacial Harmony," Andrews used the forehead to define the goal maxillary position. The purpose of this study was to compare how well this analysis correlated with postoperative findings in patients who underwent bimaxillary orthognathic surgery planned using other guidelines. The authors hypothesized that the Andrews analysis would more consistently reflect clinical outcomes than standard angular and linear measurements. MATERIALS AND METHODS: This is a retrospective cohort study of patients who had bimaxillary orthognathic surgery and achieved an acceptable esthetic outcome. Patients with no maxillary sagittal movement, obstructive sleep apnea, cleft or craniofacial diagnoses, or who were non-Caucasian were excluded. Treatment plans were developed using photographs, radiographs, and standard cephalometric measurements. The Andrews analysis, measuring the distance from the maxillary incisor to the goal anterior limit line, and standard measurements were applied to end-treatment records. The Andrews analysis was statistically compared with standard methods. RESULTS: There were 493 patients who had orthognathic surgery from 2007 through 2014, and 60 (62% women; mean age, 22.1 ± 6.8 yr) met the criteria for inclusion in this study. The mean Andrews distances were -4.8 ± 2.9 mm for women and -8.6 ± 4.6 mm for men preoperatively and -0.6 ± 2.1 mm for women and -1.9 ± 3.4 mm for men postoperatively. For women, the Andrews analysis was closer to the goal value (0 mm) postoperatively than any standard measurement (P < .001). For men, the linear distance from the A point to a vertical line tangent to the nasion from the McNamara analysis performed best (P < .001), followed by the Andrews analysis. CONCLUSION: The Andrews analysis correlated well with the final esthetic sagittal maxillary position in the present sample, particularly for women, and could be a useful tool for orthognathic surgical planning.

Physician Courtesy and Patient Satisfaction in a Pediatric Plastic and Oral Surgery Department.

EXECUTIVE SUMMARY: Hospitals in the United States have started collecting information related to the patient experience with the objective of improving overall patient satisfaction. Between 2012 and 2015, the authors collected data from 2,875 patient satisfaction surveys. The purpose of this study was to analyze the effects of several variables-wait time, physician courtesy, administrative staff courtesy, patients' opportunity to ask questions, and patients' understanding of the answers-on a patient satisfaction score. A linear regression model was used to analyze the effects of these variables on patient satisfaction. All variables but one were significantly associated with patient satisfaction in the multivariable model. Healthcare provider courtesy was the strongest predictor of patient satisfaction; a score of "excellent" was associated with a 2.63-point (95% confidence interval [2.36, 2.90]) increase on a 5-point scale for patient satisfaction compared with a courtesy score of "poor." These findings suggest that patients had a positive experience when physicians and staff members were courteous.

A qualitative study exploring contextual challenges to surgical care provision in 21 LMICs.

BACKGROUND: Billions of people worldwide are without access to safe, affordable, and timely surgical care. The Lancet Commission on Global Surgery (LCoGS) conducted a qualitative study to understand the contextual challenges to surgical care provision in low-income and middle-income countries (LMICs), and how providers overcome them. METHODS: A semi-structured interview was administered to 143 care providers in 21 LMICs using stratified purposive sampling to include both urban and rural areas and reputational case selection to identify individual providers. Interviews were conducted in Argentina (n=5), Botswana (3), Brazil (10), Cape Verde (4), China (14), Colombia (4), Ecuador (6), Ethiopia (10), India (15), Indonesia (1), Mexico (9), Mongolia (4), Namibia (2), Pakistan (13), Peru (5), Philippines (1), Sierra Leone (11), Tanzania (5), Thailand (2), Uganda (9), and Zimbabwe (15). Local collaborators of LCoGS conducted interviews using a standardised implementation manual and interview guide. Questions revolved around challenges or barriers in the area of access to care for patients; challenges or barriers in the area of in-hospital care for patients; and challenges or barriers in the area of governance or health policy. De-identified interviews were coded and interpreted by an independent analyst. FINDINGS: Providers across continent and context noted significant geographical, financial, and educational barriers to access. Surgical care provision in the rural hospital setting was hindered by a paucity of trained workforce, and inadequacies in basic infrastructure, equipment, supplies, and access to banked blood. In urban areas, providers face high patient volumes combined with staff shortages, minimal administrative support, and poor interhospital care coordination. At a policy level, providers identified regulations that were inconsistent with the realities of low-resource care provision (eg, a requirement to provide 'free' care to certain populations but without any guarantee for funding). Regional variation did exist on some matters, particularly related to prevalence of patient-provider mistrust and supply chain failures. Everywhere, providers have created innovative workarounds to overcome some of these barriers, such as clever financing mechanisms for planned surgery (eg, raising donated farm animals for cash in Zimbabwe, Ethiopia, and India), provision in scheduling and accommodations to facilitate patients from afar, reduction of cost and waste through re-sterilisation of disposable supplies, and locally sourcing consumables (eg, hand cleaning solution made of alcohol from the local distillery in India). INTERPRETATION: Although some variation exists between countries, the challenges to surgical care provision are largely consistent and based on local resource availability; underfunded rural hospitals faced similar challenges worldwide. Global efforts to scale-up surgical services can focus on these commonalities (eg, investments in infrastructure, workforce), while local governments can tailor solutions to key contextual differences (eg, community-based outreach, supply chains, professional management, and interhospital coordination). FUNDING: None.

Focusing Quality Improvement Initiatives in Pediatric Plastic Surgery: A Descriptive Study Using the Pediatric National Surgical Quality Improvement Program.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program - Pediatrics uses a risk-adjusted, case-mix-adjusted methodology to compare quality of hospital-level surgical performance. This paper aims to focus quality improvement efforts on diagnoses that have large patient volume and high morbidity for pediatric plastic surgery. METHODS: Frequency statistics were generated for a cohort of patients under age 18 who underwent plastic surgery procedures at participating National Surgical Quality Improvement Program - Pediatrics hospitals from January 1, 2011 to December 31, 2012. RESULTS: Cleft lip and palate procedures were the leading contributor to serious adverse events (45.00%), and the second largest contributor to composite morbidity (37.73%) as well as hospital-acquired infections (21.23%). CONCLUSIONS: When focusing resources for relevant data collection and quality improvement efforts, it is important to consider procedures that are both substantial volume and result in relatively higher morbidity. A balance must be made between what is relevant to collect and what is feasible given finite resources. Cleft lip and/or palate procedures might provide an ideal opportunity for coordinated efforts that could ultimately improve care for pediatric plastic surgery patients.

Characterizing opioid overdose hotspots for place-based overdose prevention and treatment interventions: A geo-spatial analysis of Rhode Island, USA.

OBJECTIVE: Examine differences in neighborhood characteristics and services between overdose hotspot and non-hotspot neighborhoods and identify neighborhood-level population factors associated with increased overdose incidence. METHODS: We conducted a population-based retrospective analysis of Rhode Island, USA residents who had a fatal or non-fatal overdose from 2016 to 2020 using an environmental scan and data from Rhode Island emergency medical services, State Unintentional Drug Overdose Reporting System, and the American Community Survey. We conducted a spatial scan via SaTScan to identify non-fatal and fatal overdose hotspots and compared the characteristics of hotspot and non-hotspot neighborhoods. We identified associations between census block group-level characteristics using a Besag-York-Mollié model specification with a conditional autoregressive spatial random effect. RESULTS: We identified 7 non-fatal and 3 fatal overdose hotspots in Rhode Island during the study period. Hotspot neighborhoods had higher proportions of Black and Latino/a residents, renter-occupied housing, vacant housing, unemployment, and cost-burdened households. A higher proportion of hotspot neighborhoods had a religious organization, a health center, or a police station. Non-fatal overdose risk increased in a dose responsive manner with increasing proportions of residents living in poverty. There was increased relative risk of non-fatal and fatal overdoses in neighborhoods with crowded housing above the mean (RR 1.19 [95 % CI 1.05, 1.34]; RR 1.21 [95 % CI 1.18, 1.38], respectively). CONCLUSION: Neighborhoods with increased prevalence of housing instability and poverty are at highest risk of overdose. The high availability of social services in overdose hotspots presents an opportunity to work with established organizations to prevent overdose deaths.

Calculating risk and prevalence ratios and differences in R: developing intuition with a hands-on tutorial and code.

Epidemiologic research questions often focus on evaluating binary outcomes, yet curricula and scientific literature do not always provide clear guidance or examples on selecting and calculating an appropriate measure of association in these scenarios. Reporting inappropriate measures may lead to misleading statistical conclusions. We present a hands-on tutorial that includes annotated code written in an open-source statistical programming language (R) showing readers how to apply, compare, and understand four methods used to estimate a risk or prevalence ratio (or difference), rather than presenting an odds ratio. We will provide guidance on when to use each method, discussing the strengths and limitations of each approach, and compare the results obtained across them. Ultimately, we aim to help trainees, public health researchers, and interdisciplinary professionals develop an intuition for these methods and empower them to implement and interpret these methods in their own research.

Epidemiology of chronic multimorbidity and temporary migration in a rural South African community in health transition: A cross-sectional population-based analysis.

Introduction: In sub-Saharan African settings, the increasing non-communicable disease mortality is linked to migration, which disproportionately exposes sub-populations to risk factors for co-occurring HIV and NCDs. Methods: We examined the prevalence, patterns, and factors associated with two or more concurrent diagnoses of chronic diseases (i.e., multimorbidity) among temporary within-country migrants. Employing a cross-sectional design, our study sample comprised 2144 residents and non-residents 18-40 years interviewed and with measured biomarkers in 2018 in Wave 1 of the Migrant Health Follow-up Study (MHFUS), drawn from the Agincourt Health and Demographic Surveillance System (AHDSS) in rural north-eastern South Africa. We used modified Poisson regression models to estimate the association between migration status and prevalent chronic multimorbidity conditional on age, sex, education, and healthcare utilisation. Results: Overall, 301 participants (14%; 95% CI 12.6-15.6), median age 31 years had chronic multimorbidity. Multimorbidity was more prevalent among non-migrants (14.6%; 95% CI 12.8-16.4) compared to migrants (12.8%; 95% CI 10.3-15.7). Non-migrants also had the greatest burden of dual-overlapping chronic morbidities, such as HIV-obesity 5.7%. Multimorbidity was 2.6 times as prevalent (PR 2.65. 95% CI 2.07-3.39) among women compared to men. Among migrants, men, and individuals with secondary or tertiary education manifested lower prevalence of two or more conditions. Discussion: In a rural community with colliding epidemics, we found low but significant multimorbidity driven by a trio of conditions: HIV, hypertension, and obesity. Understanding the multimorbidity burden associated with early adulthood exposures, including potential protective factors (i.e., migration coupled with education), is a critical first step towards improving secondary and tertiary prevention for chronic disease among highly mobile marginalised sub-populations.

Spurious early ecological association suggesting BCG vaccination effectiveness for COVID-19.

BACKGROUND: Several ecologic studies have suggested that the bacillus Calmette-Guérin (BCG) vaccine may be protective against SARS-CoV-2 infection including a highly-cited published pre-print by Miller et al., finding that middle/high- and high-income countries that never had a universal BCG policy experienced higher COVID-19 burden compared to countries that currently have universal BCG vaccination policies. We provide a case study of the limitations of ecologic analyses by evaluating whether these early ecologic findings persisted as the pandemic progressed. METHODS: Similar to Miller et al., we employed Wilcoxon Rank Sum Tests to compare population medians in COVID-19 mortality, incidence, and mortality-to-incidence ratio between countries with universal BCG policies compared to those that never had such policies. We then computed Pearson's r correlations to evaluate the association between year of BCG vaccination policy implementation and COVID-19 outcomes. We repeated these analyses for every month in 2020 subsequent to Miller et al.'s March 2020 analysis. RESULTS: We found that the differences in COVID-19 burden associated with BCG vaccination policies in March 2020 generally diminished in magnitude and usually lost statistical significance as the pandemic progressed. While six of nine analyses were statistically significant in March, only two were significant by the end of 2020. DISCUSSION: These results underscore the need for caution in interpreting ecologic studies, given their inherent methodological limitations, which can be magnified in the context of a rapidly evolving pandemic in which there is measurement error of both exposure and outcome status.

The Macroeconomic Consequences Of Firearm-Related Fatalities In OECD Countries, 2018-30: A Value-Of-Lost-Output Analysis.

We modeled gross domestic product (GDP) losses attributable to firearm-related fatalities in each of thirty-six Organization for Economic Cooperation and Development (OECD) countries using the value-of-lost-output approach from 2018 to 2030. There are three categories of firearm-related fatalities: physical violence, self-harm, and unintentional injury. We project that the thirty-six OECD countries will lose $239.0 billion in cumulative GDP from 2018 to 2030 from firearm-related fatalities. Most of these losses ($152.5 billion) will occur as a result of fatalities in the US. In 2030 alone, the OECD countries will collectively lose $30.4 billion (0.04 percent) of their estimated annual GDP from firearm-related fatalities. The highest relative losses will occur in Mexico and the US; the lowest will occur in Japan. Firearm-related fatalities are expected to disproportionately affect the US and Mexican economies. Across the OECD, 48.5 percent of economic losses will be attributable to physical violence, 47.0 percent to self-harm, and 4.6 percent to unintentional injury. These findings provide a more complete picture of the toll of firearm-related fatalities, a global public health crisis that, without intervention, will continue to impose significant economic losses across OECD countries.

The global surgery blood drought: frontline provider data on barriers and solutions in Bihar, India.

BACKGROUND: Limited access to safe, timely banked blood is a critical barrier to providing basic surgical care in resource-limited settings globally. Contextual, locally driven data are required to elucidate country needs, develop effective interventions, and guide policy decisions. OBJECTIVE: We employ qualitative methodology to describe barriers faced and solutions proposed by front-line obstetric providers in Bihar - a poor, populous Indian state where maternal mortality exceeds the national average. We aim to make locally driven recommendations for ongoing policy work in India to strengthen the country's blood transfusion system. METHODS: From February to May 2016, two researchers conducted semi-structured interviews with 19 obstetric providers across Bihar. Snowball sampling was employed until thematic saturation was reached. Following immersion into de-identified texts and dual codebook development, a primary analyst completed topical coding, and a secondary analyst confirmed reproducibility. RESULTS: Providers report that pervasive banked blood shortages force hospitals to require replacement donation, but patients' families often cannot or will not donate. Providers wait one to six hours for blood, depending on availability of staff and supplies, blood bank proximity, and the ability of the patient being treated to navigate the system. Providers feel forced to refer their patients, often to distant, poorly equipped centers. Providers identify donor education, improved infrastructure, and improved local coordination as focus areas for intervention. CONCLUSIONS: A multi-stakeholder approach that aims to increase blood donation through community education, mitigate limited infrastructure through short-term workarounds, and improve local-level coordination through state support and policy change is required in Bihar. This study generates data to guide policy and future research aimed at generating affordable, contextually appropriate interventions to the blood drought.

Long-Term Functional Upper-Extremity Outcomes in Adults with Apert Syndrome.

BACKGROUND: The goal of this study was to determine upper-extremity function and health-related quality of life in a cohort of adults with Apert syndrome. METHODS: Twenty-two adults with Apert syndrome completed the Disabilities of the Arm, Shoulder, and Hand survey; the 36-Item Short-Form Health Survey; and a semistructured interview. One surgeon administered the Jebsen Hand Function Test and measured sensation, joint motion, and strength. RESULTS: Median Disabilities of the Arm, Shoulder, and Hand score was 16.9, which indicated slightly greater disability than the population norm of 10.1. Median 36-Item Short-Form Health Survey scores were 54.5 for mental health and 57.0 for physical health-both more favorable than population norms. Total Jebsen Hand Function Test scores for dominant hand were 69.2 seconds for men and 64.7 seconds for women versus 37.8 seconds for population norms of both sexes. More complex syndactyly resulted in worse metacarpophalangeal joint motion but no significant difference in Disabilities of the Arm, Shoulder, and Hand; 36-Item Short-Form Health Survey; or other functional results. There was no difference in self-reported outcomes between patients with four (n = 8) versus five digits (n = 14) in each hand. CONCLUSIONS: In this cohort of adults with Apert syndrome, self-reported assessment of disability was more favorable than measured functional data would suggest. Despite significant functional deficits, the participants in this study had adapted remarkably well.

'We are all serving the same Ugandans': A nationwide mixed-methods evaluation of private sector surgical capacity in Uganda.

INTRODUCTION: Half of all Ugandans (49%) turn to the private or private-not-for-profit (PNFP) sectors when faced with illness, yet little is known about the capacity of these sectors to deliver surgical services. We partnered with the Ministry of Health to conduct a nationwide mixed-methods evaluation of private and PNFP surgical capacity in Uganda. METHODS: A standardized validated facility assessment tool was utilized to assess facility infrastructure, service delivery, workforce, information management, and financing at a randomized nationally representative sample of 16 private and PNFP hospitals. Semi-structured interviews were conducted to qualitatively explore facilitating factors and barriers to surgical, obstetric and anaesthesia (SOA) care. Hospitals walk-throughs and retrospective reviews of operative logbooks were completed. RESULTS: Hospitals had a median of 177 beds and two operating rooms. Ten hospitals (62.5%) were able to perform all Bellwether procedures (cesarean section, laparotomy and open fracture treatment). Thirty-day surgical volume averaged 102 cases per facility. While most hospitals had electricity, oxygen, running water, and necessary equipment, many reported pervasive shortages of blood, surgical consumables, and anesthetic drugs. Several themes emerged from the qualitative analysis: (1) geographic distance and limited transportation options delay reaching care; (2) workforce shortages impede the delivery of surgical care; (3) emergency and obstetric volume overwhelm the surgical system; (4) medical and non-medical costs delay seeking, reaching, and receiving care; and (5) there is poor coordination of care with insufficient support systems. CONCLUSION: As in Uganda's public sector, barriers to surgery in private and PNFP hospitals in Uganda are cross-cutting and closely tied to resource availability. Critical policy and programmatic developments are essential to build and strengthen Ugandan surgical capacity across all sectors.

Latent class analysis of the social determinants of health-seeking behaviour for delivery among pregnant women in Malawi.

INTRODUCTION: In the era of Sustainable Development Goals, reducing maternal and neonatal mortality is a priority. With one of the highest maternal mortality ratios in the world, Malawi has a significant opportunity for improvement. One effort to improve maternal outcomes involves increasing access to high-quality health facilities for delivery. This study aimed to determine the role that quality plays in women's choice of delivery facility. METHODS: A revealed-preference latent class analysis was performed with data from 6625 facility births among women in Malawi from 2013 to 2014. Responses were weighted for national representativeness, and model structure and class number were selected using the Bayesian information criterion. RESULTS: Two classes of preferences exist for pregnant women in Malawi. Most of the population 65.85% (95% CI 65.847% to 65.853%) prefer closer facilities that do not charge fees. The remaining third (34.15%, 95% CI 34.147% to 34.153%) prefers central hospitals, facilities with higher basic obstetric readiness scores and locations further from home. Women in this class are more likely to be older, literate, educated and wealthier than the majority of women. CONCLUSION: For only one-third of pregnant Malawian women, structural quality of care, as measured by basic obstetric readiness score, factored into their choice of facility for delivery. Most women instead prioritise closer care and care without fees. Interventions designed to increase access to high-quality care in Malawi will need to take education, distance, fees and facility type into account, as structural quality alone is not predictive of facility type selection in this population.

Implementation of an international standardized set of outcome indicators in pregnancy and childbirth in Kenya: Utilizing mobile technology to collect patient-reported outcomes.

BACKGROUND: Limited data exist on health outcomes during pregnancy and childbirth in low- and middle-income countries. This is a pilot of an innovative data collection tool using mobile technology to collect patient-reported outcome measures (PROMs) selected from the International Consortium of Health Outcomes Measurement (ICHOM) Pregnancy and Childbirth Standard Set in Nairobi, Kenya. METHODS: Pregnant women in the third trimester were recruited at three primary care facilities in Nairobi and followed prospectively throughout delivery and until six weeks postpartum. PROMs were collected via mobile surveys at three antenatal and two postnatal time points. Outcomes included incontinence, dyspareunia, mental health, breastfeeding and satisfaction with care. Hospitals reported morbidity and mortality. Descriptive statistics on maternal and child outcomes, survey completion and follow-up rates were calculated. RESULTS: In six months, 204 women were recruited: 50% of women returned for a second ante-natal care visit, 50% delivered at referral hospitals and 51% completed the postnatal visit. The completion rates for the five PROM surveys were highest at the first antenatal care visit (92%) and lowest in the postnatal care visit (38%). Data on depression, dyspareunia, fecal and urinary incontinence were successfully collected during the antenatal and postnatal period. At six weeks postpartum, 86% of women breastfeed exclusively. Most women that completed the survey were very satisfied with antenatal care (66%), delivery care (51%), and post-natal care (60%). CONCLUSION: We have demonstrated that it is feasible to use mobile technology to follow women throughout pregnancy, track their attendance to pre-natal and post-natal care visits and obtain data on PROM. This study demonstrates the potential of mobile technology to collect PROM in a low-resource setting. The data provide insight into the quality of maternal care services provided and will be used to identify and address gaps in access and provision of high quality care to pregnant women.

Provision of surgical care in Ethiopia: Challenges and solutions.

With the lowest measured rate of surgery in the world, Ethiopia is faced with a number of challenges in providing surgical care. The aim of this study was to elucidate challenges in providing safe surgical care in Ethiopia, and solutions providers have created to overcome them. Semi-structured interviews were conducted with 10 practicing surgeons in Ethiopia. Following de-identification and immersion into field notes, topical coding was completed with an existing coding manual. Codes were adapted and expanded as necessary, and the primary data analyst confirmed reproducibility with a secondary analyst. Qualitative analysis revealed topics in access to care, in-hospital care delivery, and health policy. Patient financial constraints were identified as a challenge to accessing care. Surgeons were overwhelmed by patient volume and frustrated by lack of material resources and equipment. Numerous surgeons commented on the inadequacy of training and felt that medical education is not a government priority. They reported an insufficient number of anaesthesiologists, nurses, and support staff. Perceived inadequate financial compensation and high workload led to low morale among surgeons. Our study describes specific challenges surgeons encounter in Ethiopia and demonstrates the need for prioritisation of surgical care in the Ethiopian health agenda. ABBREVIATIONS: LCoGS: The Lancet Commission on Global Surgery; LMIC: low- and middle-income country.