Application of the Three Delays Framework to Assess Barriers to Surgical Care in an East African Refugee Camp: A Cross-sectional Survey Among 1,135 Adults

Introduction: The three delays framework assesses barriers associated with seeking (delay 1), reaching (delay 2), and receiving (delay 3) healthcare in global health. This study applies this model to identify factors contributing to delays in surgical care among adult refugees in Tanzania. Methods: A validated surgical needs survey was administered using random cluster sampling to adults aged 19 and over living in Tanzania's Nyarugusu refugee camp. Participants with potentially surgically amenable issues were categorized by whether they sought, reached, and/or received care promptly for each concern. Multivariate logistic regressions identified factors that were significantly associated with the three delays. Results: There were 1135 participants with 2463 potentially surgically amenable concerns. Of these, 689 adults (60.1%) experienced a delay for at least one problem, with care-seeking delays being most common (n = 477, 42.2%). Illiteracy, no prior use of the camp health center, traditional healer usage, and having a burn were associated with delays in seeking care. Older age and positive self-perception of health status were associated with delays in reaching care, while lack of recent illness and Burundian nationality were correlated with delays in both seeking and reaching care. Female sex and Congolese nationality were associated with delays only in receiving care, while having a wound was correlated with delays in reaching and receiving care. Conclusions: Adults in Tanzania's Nyarugusu refugee camp experience unmet surgical needs attributable to multifactorial barriers along the surgical care continuum. Raising patient awareness of surgically treatable conditions and increasing health services accessibility may improve health outcomes for refugees in humanitarian settings.