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Table of Contents    
Year : 2021  |  Volume : 69  |  Issue : 1  |  Page : 12-20

Patient Attitudes toward Neurosurgery in Low- and Middle-Income Countries: A Systematic Review

1 Research Department, Association of Future African Neurosurgeons, Yaounde; Neurosurgery Department, Faculty of Medicine, Bel Campus University of Technology, Kinshasa, Democratic Republic of Congo, Cameroon
2 Research Department, Association of Future African Neurosurgeons, Yaounde; Faculty of Medicine, Higher Institute of Health Sciences, Université des Montagnes, Bangangte, Cameroon
3 Research Department, Association of Future African Neurosurgeons, Yaounde; Faculty of Medicine, Higher Institute of Medical Technology, Nkolondom, Cameroon
4 Research Department, Association of Future African Neurosurgeons, Yaounde; Faculty of Health Sciences, University of Buea, Buea, Cameroon
5 Research Department, Association of Future African Neurosurgeons, Yaounde; Neurosurgery Department, Felix Houphouet Boigny University, Abidjan, Côte d'Ivoire, Cameroon
6 Research Department, Association of Future African Neurosurgeons, Yaounde; Neurosurgery Unit, Department of Surgery, Yaounde Central Hospital, Yaounde, Cameroon
7 Neurosurgery Unit, Department of Surgery, Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon

Date of Web Publication24-Feb-2021

Correspondence Address:
Ulrick S Kanmounye
Kanmounye Sidney, 20 Cameron Street, Brookline, MA
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.310098

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 » Abstract 

Background: Low- and middle-income countries (LMICs) bear the majority of the neurosurgical burden of diseases but lack the resources to meet these needs.
Objective: As we increase access to neurosurgical care in LMICs, we must understand patient attitudes toward neurosurgery.
Methods and Material: PubMed, LILACS, and African Journals Online databases were searched systematically from inception to January 4, 2020, for studies on neurosurgical patient perceptions in LMICs. The articles found were blindly reviewed with Rayyan by two authors. The two authors resolved conflicts between themselves, and when this was not possible, a third reviewer was consulted. All the articles included were then appraised, and the results were summarized.
Results: Six of the 1,175 articles met the inclusion criteria. The studies were set in Brazil, Ethiopia, India, Nigeria, South Korea, and Sub-Saharan Africa. Four of the studies (50%) were phenomenological studies, and the other two were grounded theory and narrative. The studies identified patient attitudes toward neurosurgical practitioners, diseases, and interventions. Ethiopian and Nigerian patients believed cranial diseases to be otherworldly and resorted to traditional medicine or spiritual healing first, whereas Brazilian patients were more comfortable with cranial diseases and even more so if they had had a previous craniotomy. The Indian paper was a recount of a neurosurgeon's experience as a spine patient.
Conclusions: There are few studies on neurosurgery patient perception in LMICs. LMIC neurosurgeons should be encouraged to study their patient beliefs concerning neurosurgical diseases and interventions, as this can explain health-seeking behaviors.

Keywords: Attitude, low- and middle-income countries, neurosurgery, patient, qualitative study, systematic review
Key Message: The attitudes of patients in low- and middle-income countries toward neurosurgery are greatly influenced by their sociocultural characteristics

How to cite this article:
Kanmounye US, Nguembu S, Djiofack D, Zolo Y, Tétinou F, Ghomsi N, Figuim B, Esene I. Patient Attitudes toward Neurosurgery in Low- and Middle-Income Countries: A Systematic Review. Neurol India 2021;69:12-20

How to cite this URL:
Kanmounye US, Nguembu S, Djiofack D, Zolo Y, Tétinou F, Ghomsi N, Figuim B, Esene I. Patient Attitudes toward Neurosurgery in Low- and Middle-Income Countries: A Systematic Review. Neurol India [serial online] 2021 [cited 2021 Apr 11];69:12-20. Available from:

Patients in low- and middle-income countries (LMICs) lack access to safe, timely, and affordable neurosurgical care.[1] Governments have been urged to strengthen their surgical systems to increase access to care and reduce the burden of neurosurgical diseases.[2] It remains unclear how health attitudes toward neurosurgery in LMICs affect and are affected by access to neurosurgeons and neurosurgical care. We decided to review and synthesize information from existing literature on the perceptions of LMIC patients toward neurosurgery (personnel, procedures, and diseases) to collate contingent and experiential knowledge from non-randomized studies of patients in LMICs.

 » Methods Top

Literature search strategy

The authors developed and submitted review protocol No164295 a priori to PROSPERO ( for a systematic review of qualitative evidence on LMIC patient attitudes toward neurosurgery. One of the authors (U.S.K.) developed a comprehensive search strategy that was tested and adjusted through a pilot search. The authors searched the PubMed, Google scholar, African journals online, Latin American & Caribbean Health Sciences Literature (LILACS), ShodhGangotri, and Shodhganga databases for keywords related to LMIC patient health attitudes in neurosurgery on January 4, 2020. The search specifically targeted patient beliefs, expectations, and perceptions toward neurosurgical personnel, procedures, and diseases. The search strategy included title/abstract and controlled vocabulary terms for LMICs and neurosurgical procedures/diseases. To be considered an LMIC, a country had to be in the World Bank low-income, lower-middle-income, and upper-middle-income class as of January 2020. All databases were searched from their inception without language and date restrictions. An author performed (U.S.K) supplemental hand search to identify additional publications. The complete search strategies, including research terms, are available in Appendix 1.[Additional file 1]

Data extraction and selection criteria

Results were exported to an open-source reference management software, Zotero v 4.0 (Arlington, USA), for multipass deduplication. Unique records were then uploaded to an online screening system, Rayyan QCRI (Doha, Qatar), and independently reviewed by two authors (S.N. and D.D.). Included citations had to meet the following criteria: 1) studies describing neurosurgical procedures/diseases/personnel; 2) studies describing the health attitudes/perceptions of patients in LMICs; and 3) qualitative study design. The two author reviewers resolved conflicts by discussion and consensus between themselves, and when this was not possible, a third reviewer (U.S.K.) was consulted.

Authors and their affiliations, subject of the study (disease, procedure, or personnel), sample size, qualitative research approaches, data collection methods, publication year, and country of the study was extracted by D.D., N.S., and U.S.K. from eligible studies. The data extracted were input into a Microsoft Excel spreadsheet (Microsoft, WA, U.S.A.), and the results were presented in a “Summary of findings” table.

Data appraisal

Qualitative studies were appraised using a checklist by Consolidated criteria for reporting qualitative studies framework and the Critical appraisal skills programme checklist.[3],[4] We evaluated the rigour (validity, reliability, and transferability were appropriate) of each study. Furthermore, the authors reverified that all studies met all inclusion criteria and did not meet any exclusion criteria.

 » Results Top

Search results

Our search yielded 1,175 articles, of which 924 were found through database searching and 251 through other sources. We excluded 47 duplicates then screened the titles and abstracts of the 1,128 studies left. After the initial title and abstract screening, 1,120 articles did not meet inclusion criteria, most often because they were not from an LMIC, or they did not describe patient health attitudes toward neurosurgical personnel, procedures, or diseases. The full text of one article was not available, so it was excluded.[5] The remaining seven articles were thoroughly reviewed. Following the full-text review, 1 article was excluded because it was done in the U.S.A.[6] Supplemental hand searching did not result in additional articles. Six qualitative studies, reported in six separate journals, were included in this qualitative review [Figure 1].
Figure 1: PRISMA Flow Diagram. The diagram illustrates the different phases citation evaluation: inclusions and exclusions

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Among the six citations included, 66.7% were phenomenological qualitative studies, 16.7% were grounded theory, and 16.7% were narrative. Three of the studies used semi-structured data collection tools; one used structured data collection and one retrieved information from document analysis. Three studies (50.0%) were done in Africa, one (16.7%) was done in the Indian subcontinent, South America, and Asia each. Neurosurgical diseases (3 studies) and neurosurgical procedures (3 studies) were the most popular themes followed by neurosurgeons (2 studies) [Table 1].
Table 1: Summary of findings from non-randomized qualitative research in low- and middle-income countries. (Based on the Consolidated criteria for reporting qualitative studies - COREQ)[3]

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Attitude toward neurosurgical diseases

Disparities in epilepsy care in Sub-Saharan Africa were attributed to sociocultural differences between Africans. Africans attributed metaphysical characteristics to epilepsy, and this, in turn, led to the stigmatization of people with epilepsy. As a result, patients who believe in the supernatural provenance of epilepsy were more likely to resort to alternative and traditional medical practices. Also, patients would disclose their epileptic status to a limited entourage.[7] To do this successfully, people with epilepsy would move to places where few people knew them. Similarly, one-quarter of Ethiopian patients concealed their neurosurgical disease from their family.[8]

In the Nigerian study, patients with limb paralysis and neuro-oncologic diseases understood their conditions (81.7%) and accepted the prognosis (92.6%). Few patients (7.4%) were unaware of the implications of their disease and needed clarification. Surprisingly, 22.0% of Nigerian patients felt that the life-altering diagnosis was an opportunity to start afresh. Some patients (5.5%) would have preferred not to know about their disease, and 2.8% did not want the bad news to be broken to both them and their families. After learning about their disease, 88.0% of patients turned to religion for comfort, whereas 98.0% felt their government would not assist them.[9]

Few East African patients got information about their neurosurgical condition from non-hospital sources (internet, television, radio, and books). They trusted their neurosurgeons and felt the information given to them was enough.

Attitude toward neurosurgical procedures

Ethiopian patients admitted their religion played a critical role in their attitude toward neurosurgical procedures. Few patients felt anxiety pre- or postoperatively, but they viewed surgical treatment as a last resort.[8]

Awake craniotomy was considered an enjoyable experience by all the Brazilian patients. Most patients (94.1%) understood how and why awake craniotomy was performed. They attributed this to the preoperative counseling. As a result, they were calm and felt the operation lasted only a few minutes (76.5%). Patients who had previously undergone surgery (29.4%), preferred awake craniotomy.[10]

Sunil Pandya, an Indian neurosurgeon, reported on his operative experience following spine surgery. He expressed concerns following his operation. Pandya recognized getting an above-average postoperative experience due to his status as a neurosurgeon but noted that the average patient would have had an unpleasant experience. He noted that most neurosurgical patients did not voice their discontent despite the availability of channels for this purpose.[11]

Attitude toward neurosurgical providers

South Korean interviewees preferred their neurosurgeons to have their name tags on (76.0%). The participants did not have a preference for facial hair, wearing accessories, hair length, and hair dyeing. They felt the ideal age for a chief neurosurgeon was 50–59 years, and they expected neurosurgery professors to be tidy and formally dressed.[12] In India, Pandya urged neurosurgeons to take postoperative complaints seriously and to communicate better the side and adverse effects of medications with patients.[11] Moreover, Ethiopian patients preferred a paternalistic doctor-patient relationship.[8]


The risk of bias was low across all six studies. Two of the studies, Adeleye & Fatiregun[7] and Mun et al.[12] had medium risks of bias because they failed to precise their recruitment strategy and the relationship between researchers and participants. The study with the lowest risk of bias was the one by Bramall et al.[8] [Table 2].
Table 2: Rigor evaluation of the studies included in the review. Evaluation from the Critical appraisal skills programme's qualitative research checklist[4]

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 » Discussion and Conclusions Top

Neurosurgical procedures and the doctor-patient relationship

Interventions aimed at increasing access to neurosurgical care ought to benefit the most vulnerable. Socioeconomic and cultural factors influence patient attitudes toward health, thereby limiting access to neurosurgical care and leading to health outcome inequities.[13],[14]Also, the community a patient belongs to determines the health risks they are exposed to.[15]Patients from high-income countries, for example, tend to have higher literacy rates, lower utilization of alternative medicine, better social protection, and access to advanced neurosurgical care.[16],[17],[18]While LMIC patients have higher prevalence rates, present more severe lesions, and have a worse prognosis than patients from high-income countries.[19],[20],[21] This disparity translates into better health outcomes and lower risks than LMIC patients.

The perceptions of LMIC patients toward neurosurgery are strongly influenced by their socioeconomic status, culture, and religion.[7],[8],[9],[10],[11],[12] By studying the health attitudes of patients, neurosurgeons will better understand and mitigate the burden of diseases amenable to neurosurgery.[22] The socioeconomic determinants of health are amenable to targeted individual and communal interventions.[15] At the individual level, expectations and experiences influence patient satisfaction and outcomes. This statement is especially true with elective and non-traumatic neurosurgical procedures that have a large proportion of patient-reported outcomes.[23],[24] As the access to neurosurgical care increases in LMICs, there will be a concordant rise in the number of elective and complex neurosurgical procedures. Patient exposure to new procedures accompanied by an efficient patient- and caregiver-centered education can reduce apprehensions.[25],[26] We can learn from the Brazilian experience that context-appropriate communication in tandem with the implementation of new surgical modalities increases patient acceptance and satisfaction.

LMIC patients appreciate timely and efficient communication.[8],[9],[10],[11] The perioperative period is a good moment for patients, caregivers, and the neurosurgery team to address all concerns and misconceptions.[27] If neurosurgeons learn to identify and manage patient beliefs, they can participate meaningfully in this process.[8],[9],[10] Meaningful participation is only possible if the neurosurgeons establish a relationship of trust with their patients. In Ethiopia, Brammall et al. reported that the preferred doctor-patient relationship was the paternalistic model.[8] Ethiopian patients expected guidance from and ceded some decision making to their neurosurgeons. This attitude is logical, given the hierarchical nature of the Ethiopian society. This finding is transferable to other cultures in LMICs.

Patients in high-income countries are more likely to trust their neurosurgeons if they receive strong recommendations from other doctors, if the neurosurgeon has multiple degrees, and if the neurosurgeon is affiliated with an academic center.[28] Hence, neurosurgeons begin building this relationship of trust from the moment they decide to become neurosurgeons. Every career decision, relationship, and achievement they make strengthens the trust between them and their future patients. LMIC patients hold their neurosurgeons in high regard.[8],[9],[10],[11],[12] By paying extra attention to their appearance and demeanour, LMIC neurosurgeons effectively solidify the trust their patients place in them. Patients expect neurosurgeons to dress formally, vehiculate a sense of experience and provide their patients with almost all the disease- and procedure-related information.[8],[12]

Risk of bias

The six studies were rigorous scientifically. The risk of bias was low in four studies and medium in two, resulting in an overall low risk of bias. The most important concern was the unclear definition of the researcher-participant relationship. The definition of this relationship gives the reader an idea of the potential biases due to the researchers' experiences, beliefs, and membership to the group studied.


The authors' access limited the systematic search to databases. Studies that were not available online or in a paywalled database were not included in this review.

 » Conclusion Top

There are few studies from LMICs on the attitudes of patients toward neurosurgery. We believe this might be due to low research activity among LMIC neurosurgeons. The citations on this subject are from Latin America, Africa, and Asia. Moreover, there is variability in the qualitative methodology and rigor across existing publications. Future studies should focus on the gaps identified in this review. Initiatives aimed at increasing the quantity and quality of research from LMICs should be encouraged.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

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Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349-57.  Back to cited text no. 3
Critical Appraisal Skills Programme. Qualitative Checklist [Internet]. CASP Checkl2015 [cited 2020 Apr 17]. Available from:  Back to cited text no. 4
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  [Table 1], [Table 2]


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