Patient‐Reported Perceptions and Barriers in Accessing Surgical Care in a Tertiary Healthcare Setting: A Cross‐Sectional Study From Pakistan

ABSTRACT

Background and Aims

Surgery plays a vital role in reducing morbidity and mortality, yet many patients in low‐ and middle‐income countries face barriers to accessing surgical care; context‐specific evidence from urban tertiary centers in Pakistan remains scarce, limiting the ability to design locally targeted interventions. Understanding patient perceptions and identifying these barriers is essential to inform targeted interventions, improve hospital environments, and enhance equitable surgical service utilization. This study aimed to evaluate patient perceptions and identify these barriers at a tertiary hospital in Lahore, Pakistan.

Methodology

A cross‐sectional study was conducted from January to June 2025, enrolling 607 surgical patients aged ≥ 18 years via convenience sampling. Data were collected through a validated, interview‐administered questionnaire. Analyses were performed using descriptive statistics, Chi‐square tests, and binary logistic regression in SPSS v27.

Results

Among participants (61.8% male, 63.9% aged 18–30), perceptions were mixed: 38.7% agreed that surgery improves health, 41.5% preferred non‐surgical alternatives, and 36.1% reported that cultural beliefs influenced their decisions. A majority (58.3%) reported experiencing significant barriers. Multivariate analysis identified key predictors: males (AOR: 2.015, p = 0.002) and those with a past family history of surgery (AOR: 3.79, p = 0.001) were more likely to report barriers. Conversely, graduates (AOR: 0.205, p = 0.007) and employed participants (AOR: 0.147, p = 0.007) were less likely to report barriers. Marital status was a strong predictor, with single participants facing significantly higher barriers than married ones (AOR: 3.417, p < 0.001).

Conclusion

Patient willingness to undergo surgery is shaped by complex socio‐cultural and economic factors. The paradox of individuals with easier access reporting more barriers suggests that proximity alone is insufficient without trust, quality, and positive prior experiences. Targeted interventions should focus on patient education, improving hospital environments, and providing culturally sensitive counseling to enhance surgical uptake and equity.

1. Introduction

Surgery serves as a vital pillar of modern medicine, providing life‐saving interventions for a broad range of conditions, from traumatic injuries and obstetric complications to cancer and congenital defects [1]. The global surgical need is immense; the Lancet Commission on Global Surgery estimated that nearly five billion people lack access to safe, affordable surgical and anaesthesia care when required, with the highest burden concentrated in low‐ and middle‐income countries (LMICs) [2]. This gap is not merely an inconvenience but a major driver of preventable morbidity and mortality, contributing to an estimated 17 million deaths each year, surpassing the combined toll of HIV/AIDS, tuberculosis, and malaria [3, 4]. For this reason, strengthening surgical systems has increasingly been recognised as a core component of universal health coverage and a prerequisite for achieving sustainable development goals [3]. In LMICs, the challenge of providing surgical care is both systemic and structural [5]. Despite surgical conditions contributing substantially to the global burden of disease, access to essential surgical care remains inequitable. An estimated 5 billion people lack access to safe, timely, and affordable surgical services globally, with nearly 90% of people in LMICs unable to obtain basic surgical care compared to a much smaller gap in high‐income countries [6]. While global targets recommend at least 5000 surgeries per 100,000 population annually, most LMICs perform only ~877 procedures per 100,000, indicating unmet surgical needs. In Pakistan, accessible care for key surgical procedures is estimated at ~74.8%, and high out‐of‐pocket costs lead to catastrophic and impoverishing health expenditure for a significant proportion of patients [6]. Recent evidence shows persistent structural and financial barriers to surgical care in LMICs, limiting data collection and outcomes research and sustaining inequities in surgical access [7]. Health systems in these settings are chronically underfunded, leading to a shortage of infrastructure, essential equipment, reliable supply chains, and, most critically, a trained surgical and anaesthesia workforce [8, 9]. Such deficits limit operating theatre capacity, create delays in access to essential drugs, and foster over‐reliance on out‐of‐pocket expenditure, which often drives households into catastrophic health costs [9]. Moreover, the perceptions of patients about surgery, such as fear of surgery, fear of anaesthesia, lack of confidence in anaesthesia, fear of complications, fear of high costs of surgery, and fear of poor quality of care, all contribute significantly to their choice of treatment and are often the reason they are not willing or ready to undergo a surgical procedure, and it delays timely surgical care [10]. Patients' perceptions about surgery are closely linked to their recovery experiences, as poor recovery can be both distressing and dissatisfying. Many variables, including economic concerns, regional systems, and accessibility, can impact healthcare decisions [11]. Clinical factors such as a physician's reputation, professional experience, technical expertise, and even social media presence tend to carry more weight than non‐clinical factors like insurance coverage or geographical location [12]. Patients' choices may also be influenced by factors such as the type of surgery required, recommendations from family and friends, word‐of‐mouth, and physician referrals when selecting a surgeon [13]. The problem of surgeries is both systemic and personal. The barriers on the patient end include a lack of awareness, poverty, cultural beliefs, and living in remote areas, as well as a preference for traditional medicine [14]. Lack of access to surgical care worldwide is hampered by familiar obstacles: limited infrastructure, resource constraints, and a severe shortage of trained healthcare providers. The existence of these barriers usually leaves patients without assistance [15]. These barriers indicate deeper social and structural challenges that extend far beyond the hospital environment [16]. In LMICs, workforce shortages are projected to increase over the next several years, placing additional pressure on the existing health system and potentially influencing patient outcomes [17]. Tertiary hospitals are increasingly overburdened because patients are not treated through the primary care system, as they either fail to access basic surgical facilities or simply do not trust local health facilities [18]. It results in overcrowding of surgical wards, increased waiting times, and a worse overall experience for patients [19]. Within this context, understanding the specific perceptions and barriers from the patient's perspective is a practical necessity for designing effective interventions. While previous research has outlined broad challenges, there is a pressing need for context‐specific evidence from key urban centres, such as Lahore, to inform localized policy and clinical practice. Therefore, this study aimed to explore the perceptions and identify the barriers to accessing surgical care among patients at a tertiary care hospital in Lahore, Pakistan.

2. Materials and Methods

2.1. Study Design and Setting

A hospital‐based cross‐sectional study was conducted at a large public‐sector tertiary care facility. The hospital serves as a major referral center for Punjab province, offering comprehensive surgical services including general, orthopedic, neurosurgery, cardiothoracic, and plastic surgery. With over 1200 beds, it caters to a diverse urban and rural population, making it a representative site for studying surgical care access in Pakistan [20].

2.2. Study Population and Sample Size

The sample size was calculated using the Daniel formula [21].

$$n=\frac{z^{2}p(1-P)}{d^2},$$

$$n=\frac{{1.96}^2\text{.}0.5\times 0.5}{{0.05}^2},$$

$$n=384.16.$$

The calculated sample size was 384 participants, using Daniel's formula with a 95% confidence interval (CI), an expected prevalence of 50%, and a 5% margin of error. A total of 607 patients provided informed consent and fully completed the interview‐administered questionnaire, forming the final study sample. Non‐probability, convenience sampling technique was selected to collect data from patients. They were approached in the surgical outpatient and inpatient departments of the tertiary care hospital. Data were collected over a 6‐month period, from January to June 2025, during which all eligible patients admitted to the surgical wards or visiting the surgical outpatient department (OPD) for elective procedures were systematically approached for participation. The recruitment process was conducted daily, and within the convenience sampling framework, all eligible patients present each day were systematically invited to participate in order to maximize recruitment and enhance representativeness. Trained research staff explained the study purpose, ensured understanding, and obtained written informed consent from each willing participant. During the 6‐month study period, patients were approached from both outpatient and inpatient settings. A total of 300 patients were included from the OPD, and 307 from the inpatient wards. Overall, 607 patients were successfully recruited and included in the study.

2.3. Inclusion and Exclusion Criteria

The study included adult patients aged 18 years and above who had undergone clinically recommended elective surgical procedures at the tertiary care hospital and were in the post‐operative recovery phase at the time of data collection. Participants were recruited from both the surgical OPD (post‐operative review visits) and inpatient wards, provided they were mentally alert, able to communicate in Urdu or Punjabi, and willing to provide written informed consent. Only post‐operative patients (i.e., those who had already undergone surgery) were included in this study to ensure a uniform assessment of perceptions and barriers related to surgical care. This approach minimized variability arising from differences between pre‐operative and post‐operative experiences. Patients were excluded if they were undergoing emergency surgical interventions, admitted to intensive care units, or had cognitive impairments or severe physical conditions that limited their ability to comprehend or respond to the questionnaire. Additionally, individuals with significant communication barriers (e.g., hearing or speech impairments) and those who declined to participate were excluded from the study.

2.4. Data Collection

The data were collected through a face‐to‐face, interview‐administered questionnaire conducted by four trained researchers. Each interview lasted approximately 15–30 min. Written informed consent was obtained from all participants prior to enrollment. Participation was voluntary, and respondents were informed of their right to withdraw at any time. Confidentiality was ensured by assigning unique identification codes; personal identifiers were stored separately from research data and kept under lock and key.

2.5. Questionnaire Development

A structured questionnaire was developed to assess patient perceptions and barriers related to surgical care, based on a comprehensive review of relevant literature [16, 22, 23, 24, 25]. The instrument consisted of three sections, totaling 28 items. The first section captured demographic and socioeconomic information, including age, gender, education, employment status, marital status, family history of surgery, perceived access to healthcare, and type of health facility used. The second section (10 items) evaluated patients' perceptions toward surgical treatment using statements rated on a 5‐point Likert scale ranging from “strongly disagree” to “strongly agree”, assessing domains such as trust in surgical outcomes, fear of complications or anaesthesia, perceived benefits of surgery, and influence of cultural or religious beliefs. The third section (10 items) explored barriers to accessing surgical care, covering financial, logistical, systemic, and sociocultural factors, and was also measured on a 5‐point Likert scale. To ensure content validity, the questionnaire was reviewed by a panel of 10 consultant surgeons who assessed the relevance and clarity of each item; the calculated content validity index (CVI) was 0.906, indicating strong validity. A pilot study was conducted with 30 patients prior to the main data collection to assess feasibility, clarity, and reliability, during which minor linguistic and structural refinements were made. The Cronbach's alpha coefficient was 0.701, indicating acceptable internal consistency and reliability of the instrument [26]. The final version was administered through face‐to‐face interviews by trained personnel to ensure accurate understanding and response, particularly among participants with limited literacy.

2.6. Statistical Analysis

Data were entered and analyzed using IBM SPSS Statistics, Version 27.0. The analysis was conducted in three stages: descriptive, bivariate, and multivariate. Descriptive statistics were computed for all variables, with categorical socio‐demographic variables summarized as frequencies and percentages. The primary outcome variable, barriers to surgical care, was operationalized as a binary variable. Responses to the 10‐item barriers scale were dichotomized, where Strongly Agree and Agree were scored as 1, and Neutral, Disagree, and Strongly Disagree were scored as 0. A summative score was calculated for each participant, and in line with methods used in similar studies [27], participants with scores greater than 5 (> 50%) were categorized as “facing more barriers” while those scoring 5 or less were categorized as facing fewer barriers [28]. Bivariate analyses were performed to assess associations, with Fisher's exact test (used for variables with small or zero cell counts) and Chi‐square tests used to evaluate relationships between socio‐demographic characteristics, individual perception items, and the binary barriers outcome. To identify independent predictors of the primary outcome and adjust for potential confounders, binary logistic regression was performed. Results were reported as unadjusted (OR) and adjusted odds ratios (AOR) with 95% CI. All statistical tests were two‐sided, and a p‐value < 0.05 was considered statistically significant. Additionally, forest plots were used to visualize the interaction effects, providing a clearer insight into the impact of confounding variables on the relationships between variables. All analyses (including subgroup analyses) were prespecified in the study protocol, and none were exploratory.

2.7. Ethical Approval

The study received ethical approval from the Institutional Research and Ethics Committee (IREC) of The University of Lahore. The research was conducted in accordance with the ethical principles of the Declaration of Helsinki (2013), including voluntary participation, informed consent, confidentiality, and participant autonomy.

3. Results

3.1. Demographic Characteristics

Out of the 607 participants included in the study, the majority were male (61.8%, n = 375) and aged between 18 and 30 years (63.9%, n = 388). Over two‐thirds of the participants were single (57.7%, n = 350), and more than half reported having completed graduation (45.6%, n = 277), followed by post‐graduation (21.9%, n = 133). In terms of employment, 42.3% (n = 257) were unemployed, while 39.2% (n = 238) were employed and 18.5% (n = 112) ran their own business. A significant proportion of patients (64.3%, n = 390) reported a past family history of surgery, indicating prior exposure to surgical care within their households. In this study, access to healthcare was defined as: available (services and resources are present), acceptable (services are culturally and socially suitable for patients), and affordable (services can be obtained without causing financial hardship) [29]. For analysis, self‐reported responses were grouped as: Easy Access (all three criteria met), Limited Access (one or two criteria met), No Access (none of the criteria met). Regarding healthcare access, nearly 60% (59.6%, n = 362) reported easy access to healthcare services, while 22.9% (n = 139) faced limited access and 17.5% (n = 106) reported no access. Most participants (73.6%, n = 447) utilized both government and private health facilities for their medical needs, compared to 17.1% (n = 104) who used only private facilities and 9.2% (n = 56) who relied solely on government hospitals (Table 1).

Table 1.

Demographic characteristics of patients.

Demographic characteristics	Variable	Frequency (n = 607)	Percentage (%)
Gender	Male	375	61.8
	Female	232	38.2
Age	18–30 Years	388	63.9
	30–50 Years	124	20.4
	> 50 Years	95	15.7
Education	No education	3	0.5
	Secondary education	141	23.2
	Higher secondary education	53	8.7
	Graduation	277	45.6
	Post‐graduation	133	21.9
Employment status	Employed	238	39.2
	Un‐employed	257	42.3
	Own business	112	18.5
Marital status	Single	350	57.7
	Married	257	42.3
Past family surgical history	Yes	390	64.3
	No	186	30.6
	Not sure	31	5.1
Access to healthcare	Easy access	362	59.6
	Limited access	139	22.9
	No access	106	17.5
Type of health facility used	Government hospital	56	9.2
	Private hospital	104	17.1
	Both	447	73.6

3.2. Perceptions of Patients Regarding Surgical Treatment

Gender‐stratified analysis was performed to explore differences in access and barriers between males and females, as previous literature suggests that gender can significantly influence healthcare access and utilization [30]. The majority of participants (38.7%) agreed that surgery has a positive impact on overall health outcomes. Most respondents (57.7%) agreed that healthcare professionals play an important role in reducing the need for surgery. When asked whether their perception is influenced by factors such as success rate, risk, recovery time, and cost, the highest response was disagreement at 35.3%. Confidence in recovery after surgery was most commonly expressed through agreement, at 37.6%. About 30.3% agreed they had been adequately informed about the benefits and risks of surgical procedures. A total of 41.5% of participants reported a preference for alternative, non‐surgical treatments. Over one‐third (36.1%) of participants agreed that culture or society influences surgical decisions. Trust in the healthcare system was most strongly expressed through strong agreement (31.1%). 50.2% of participants agreed that the hospital environment, including cleanliness, staff behaviour, and facilities, influenced their decision to undergo surgery. Lastly, 44.5% agreed that the opinions of family and friends also affect their decision. Comparison by gender showed statistically significant differences in all perception responses (p < 0.001) (Table 2).

Table 2.

Perceptions of patients regarding surgical treatment.

Perceptions	Variables	Total N (%)	Male n (%)	Female n (%)	p value
I believe that surgery has a positive impact on overall health outcomes.	Strongly Agree	55 (9.1)	18 (3.0)	37 (6.1)	< 0.001*
	Agree	235 (38.7)	100 (16.5)	135 (22.2)
	Neutral	28 (4.6)	7 (1.2)	21 (3.5)
	Disagree	98 (16.1)	91 (15)	7 (1.2)
	Strongly Disagree	191 (31.5)	159 (26.2)	32 (5.3)
Healthcare professionals play an important role in minimizing the need for surgical intervention.	Strongly Agree	30 (4.9)	14 (2.3)	16 (2.6)	< 0.001
	Agree	350 (57.7)	184 (30.3)	166 (27.3)
	Neutral	145 (23.9)	106 (17.5)	39 (6.4)
	Disagree	41 (6.8)	31 (5.1)	10 (1.6)
	Strongly Disagree	41 (6.8)	40 (6.6)	1 (0.2)
My perception of surgery is influenced by its success rate, potential risks, recovery time, and cost.	Strongly Agree	58 (9.6)	14 (2.3)	44 (7.2)	< 0.001
	Agree	147 (24.2)	92 (15.2)	55 (9.1)
	Neutral	157 (25.9)	147 (24.2)	10 (1.6)
	Disagree	214 (35.3)	122 (20.1)	92 (15.2)
	Strongly Disagree	31 (5.1)	0	31 (5.1)
I feel confident about my ability to recover successfully after undergoing surgery.	Strongly Agree	113 (18.6)	41 (6.8)	72 (11.9)	< 0.001
	Agree	228 (37.6)	177 (29.2)	51 (8.4)
	Neutral	187 (30.8)	112 (18.5)	75 (12.4)
	Disagree	75 (12.4)	42 (6.9)	33 (5.4)
	Strongly Disagree	4 (0.7)	3 (0.5)	1 (0.2)
I have been adequately informed abut the potential benefits and risks associated with surgical procedures.	Strongly Agree	26 (4.3)	10 (1.6)	16 (2.6)	< 0.001
	Agree	184 (30.3)	118 (19.4)	66 (10.9)
	Neutral	117 (19.3)	47 (7.7)	70 (11.5)
	Disagree	114 (18.8)	99 (16.3)	15 (2.5)
	Strongly Disagree	166 (27.3)	101 (16.6)	65 (10.7)
If available, I would prefer alternative (non‐surgical) treatment options over surgery.	Strongly Agree	42 (6.9)	17 (2.8)	25 (4.1)	< 0.001
	Agree	252 (41.5)	175 (28.8)	77 (12.7)
	Neutral	146 (24.1)	110 (18.1)	36 (5.9)
	Disagree	126 (20.8)	32 (5.3)	94 (15.5)
	Strongly Disagree	41 (6.8)	41 (6.8)	0
Cultural or societal beliefs influence my decision to undergo surgery.	Strongly Agree	109 (18.0)	38 (6.3)	71 (11.7)	< 0.001
	Agree	219 (36.1)	154 (25.4)	65 (10.7)
	Neutral	185 (30.5)	113 (18.6)	72 (11.9)
	Disagree	28 (4.6)	6 (1.0)	22 (3.6)
	Strongly Disagree	66 (10.9)	64 (10.5)	2 (0.3)
I trust the healthcare system to provide safe and effective surgical care.	Strongly Agree	189 (31.1)	80 (13.2)	109 (18)	< 0.001
	Agree	0	0	0
	Neutral	162 (26.7)	121 (19.9)	41 (6.8)
	Disagree	185 (30.5)	133 (21.9)	52 (8.6)
	Strongly Disagree	71 (11.7)	41 (6.8)	30 (4.9)
The hospital environment (cleanliness, facilities, staff behavior) affects my willingness to proceed with surgery.	Strongly Agree	66 (10.9)	15 (2.5)	51 (8.4)	< 0.001
	Agree	305 (50.2)	170 (28)	135 (22.2)
	Neutral	123 (20.3)	112 (18.5)	11 (1.8)
	Disagree	110 (18.1)	77 (12.7)	33 (5.4)
	Strongly Disagree	3 (0.5)	1 (0.2)	2 (0.3)
The opinions of my family and friends influence my decision regarding surgery.	Strongly Agree	56 (9.2)	43 (7.1)	13 (2.1)	< 0.001
	Agree	270 (44.5)	157 (25.9)	113 (18.6)
	Neutral	120 (19.8)	110 (18.1)	10 (1.6)
	Disagree	100 (16.5)	5 (0.8)	95 (15.7)
	Strongly Disagree	61 (10)	60 (9.9)	1 (0.2)

Note: N = total number of participants; n = total number of participants available with data. Bold values indicate statistical significance. Fisher's exact test was used for variables with small or zero cell counts. *Chi‐square test was applied.

3.3. Patients' Perceptions of Surgical Outcomes and Influencing Factors

The graphs (Figure 1) present age‐wise variations in (a) confidence in recovery after surgery and (b) the impact of cultural and societal norms on surgical decision‐making. In Figure 1a, the majority of participants across all age groups reported agreement regarding confidence in recovery after surgery, with 22.24% in the 18–30 years group, 9.06% in the 30–50 years group, followed by those aged > 50 years (4.77%). The association between age and confidence in recovery was statistically significant (p = 0.012). In Figure 1b, agreement that cultural and societal norms influence surgical decisions was most prominent among participants aged 18–30 years (22.24%), followed by those aged 30–50 years (9.06%). In contrast, the highest response among participants aged > 50 years was neutrality (5.7%), indicating uncertainty. This association was also statistically significant (p = 0.028).

Figure 1.

Perception of confidence in recovery after surgery and the influence of cultural and societal norms on surgical decision‐making by age.

The graphs (Figure 2) illustrate participants' perceptions regarding (a) the positive impact of surgery on overall health outcomes and (b) the influence of success rate, risks, recovery time, and cost, stratified by past family surgical history and type of healthcare facility used. In Figure 2a[i], the majority of participants with a past family surgical history reported agreement that surgery has a positive impact on overall health outcomes (25.7%), whereas those without such a history showed higher disagreement (16.4%). In Figure 2a[ii], agreement was highest among participants utilizing both government and private healthcare facilities (26%), compared to those using only government hospitals (1.6%) or private hospitals (11%). The association between patients' perceptions of the positive impact of surgery on overall health outcomes and past family surgical history and type of health facility was statistically significant (p < 0.001). In Figure 2b[i], the highest proportion of participants with a past family surgical history reported disagreement (29.4%) that their perception is influenced by success rate, risks, recovery time, and cost, followed by neutral responses among those without such a history. In Figure 2b[ii], disagreement was most prominent among participants using both types of healthcare facilities (25%), while agreement was comparatively lower across all facility types. The association of factors influencing surgical decision‐making (success rate, risks, recovery time, and cost) with past family surgical history and type of health facility was also statistically significant (p < 0.001).

Figure 2.

Perceptions of surgical outcomes and influencing factors by family history and healthcare facility type.

3.4. Barriers Faced by Patients

The majority of patients (58.3%) faced barriers to surgical treatment. Although gender differences were not statistically significant (p = 0.334), a slightly higher percentage of males (35.1%) reported more barriers than females. Education showed a strong relationship (p < 0.001), with 33.6% of those holding a graduation degree experiencing more barriers. Among employment groups, 30.5% of unemployed participants reported facing more barriers (p < 0.001). A total of 44.5% of patients with a family history of surgery reported more barriers (p < 0.001). Regarding access to healthcare, 48.4% of participants with easy access reported more barriers (p < 0.001), suggesting higher expectations or greater awareness. Additionally, 44.3% of patients utilizing both government and private hospitals faced more barriers compared to others (p < 0.001) (Table 3).

Table 3.

Barriers faced by patients towards surgical treatment.

Demographic characteristics	Variable	More barriers faced	Fewer barriers faced	χ 2	p value
Gender	Male	213 (35.1%)	162 (26.7%)	0.932	0.334
	Female	141 (23.2%)	91 (15%)
Age	18–30 Years	160 (26.4%)	228 (37.6%)	2.270	0.321
	30–50 Years	58 (9.6%)	66 (10.9%)
	> 50 Years	35 (5.8%)	60 (9.9%)
Education	No education	2 (0.3%)	1 (0.2%)	247.908	< 0.001*
	Secondary education	2 (0.3%)	139 (22.9%)
	Higher secondary education	46 (7.6%)	7 (1.2%)
	Graduation	204 (33.6%)	73 (12%)
	Post‐graduation	100 (16.5%)	33 (5.4%)
Employment status	Employed	101 (16.6%)	137 (22.6%)	44.705	< 0.001
	Un‐employed	185 (30.5%)	72 (11.9%)
	Own business	68 (11.2%)	44 (7.2%)
Marital status	Single	199 (32.8%)	151 (24.9%)	0.727	0.394
	Married	155 (25.5%)	102 (16.8%)
Past family surgical history	Yes	270 (44.5%)	120 (19.8%)	61.017	< 0.001
	No	65 (10.7%)	121 (19.9%)
	Not sure	19 (3.1%)	12 (2.0%)
Access to healthcare	Easy access	294 (48.4%)	68 (11.2%)	223.469	< 0.001
	Limited access	55 (9.1%)	84 (13.8%)
	No access	5 (0.8%)	101 (16.6%)
Type of health facility used	Government hospital	18 (3.0%)	38 (6.3%)	18.016	< 0.001
	Private hospital	67 (11.0%)	37 (6.1%)
	Both	269 (44.3%)	178 (29.3%)

Note: Chi‐square test was applied. p < 0.05 was considered statistically significant. Bold values indicate statistical significance. *Fisher's exact test was used for variables with small or zero cell counts.

3.5. Regression Analysis of Barriers Faced by Patients

In the univariate analysis, several factors were significantly associated with barriers. Participants with secondary education were less likely to face barriers (OR: 0.462, p = 0.001). Employed participants were less likely to report barriers (OR: 0.477, p = 0.002), while unemployed participants were more likely to face barriers (OR: 1.663, p = 0.033). Participants with no past family history of surgery were less likely to face barriers (OR: 0.339, p = 0.007). Those reporting easy access to healthcare were more likely to report barriers (OR: 4.335, p < 0.001), as were those with limited access (OR: 2.226, p < 0.001). Use of government hospitals was associated with a lower likelihood of barriers (OR: 0.313, p < 0.001). Other variables, including gender, age groups, no education, higher secondary education, graduation, marital status, and private hospital use, were not significant in univariate analysis.

In the multivariate analysis, the significant predictors remained consistent. Males had greater odds of facing barriers than females (AOR: 2.015, p = 0.002). Graduation‐level education was associated with a lower likelihood of barriers than postgraduate education (AOR: 0.205, p = 0.007). Employed participants had lower odds than unemployed participants (AOR: 0.147, p = 0.007). Single participants continued to have higher odds of reporting barriers than married ones (AOR: 3.417, p < 0.001). A past family history of surgery was associated with increased odds of barriers (AOR: 3.79, p = 0.001). Patients relying on government hospitals were less likely to face barriers than those using both private and public services (AOR: 0.312, p = 0.024). All other variables were not statistically significant in the multivariate model (Table 4).

Table 4.

Regression analysis of barriers faced by patients.

Demographic characteristics	Variable	OR	95% CI		p value	AOR	95% CI		p value
			LCI	UCI			LCI	UCI
Gender	Male	0.849	0.608	1.184	0.334	2.015	1.649	4.775	0.002**
	Female	Reference
Age	18–30 Years	0.831	0.523	1.321	0.434	0.719	0.325	1.589	0.415
	30–50 Years	0.664	0.384	1.146	0.141	0.492	0.199	1.216	0.125
	> 50 Years	Reference
Education	No education	0.660	0.058	7.516	0.738	0.432	0.045	1.015	0.051
	Secondary education	0.462	0.231	1.234	0.001***	0.562	0.098	1.123	0.001***
	Higher secondary education	2.169	0.893	5.266	0.087	0.587	0.116	2.972	0.520
	Graduation	0.922	0.573	1.484	0.739	0.205	0.064	0.653	0.007**
	Post‐graduation	Reference
Employment status	Employed	0.477	0.302	0.754	0.002**	0.147	0.036	0.596	0.007**
	Un‐employed	1.663	1.042	2.652	0.033*	0.255	0.053	1.240	0.090
	Own business	Reference
Marital status	Single	0.867	0.625	1.203	0.394	3.417	1.857	4.797	0.001***
	Married	Reference
Past family surgical history	Yes	1.421	0.669	3.020	0.361	3.79	1.979	4.944	0.001***
	No	0.339	0.155	0.742	0.007**	2.454	0.845	7.129	0.099
	Not sure	Reference
Access to healthcare	Easy access	4.335	2.256	5.659	0.001***	2.209	0.349	4.996	0.400
	Limited access	2.226	1.063	3.548	0.001***	0.654	0.098	4.372	0.661
	No access	Reference
Type of health facility used	Government hospital	0.313	0.173	0.567	0.001***	0.312	0.114	0.855	0.024*
	Private hospital	1.198	0.769	1.868	0.425	0.569	0.254	1.275	0.171
	Both	Reference

Note: Bold values indicate statistical significance. Statistical significance at *p < 0.05, **p < 0.01, ***p < 0.001.

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; LCI, lower confidence interval; OR, odds ratio; UCI, upper confidence interval.

Forest plot displaying AOR with 95% CI from the binary logistic regression analysis of factors associated with barriers faced by patients toward surgical treatment (n = 607). The X‐axis is on a logarithmic scale, with AOR; 1 (marked by a vertical line) represents no effect. Values to the left indicate a lower likelihood, while those to the right indicate a higher likelihood (Figure 3).

Figure 3.

Forest plot of adjusted odds ratio.

4. Discussion

Surgical diseases are major public health problems worldwide. Pakistan is an LMIC, and the existing surgical systems cannot keep up with the increasing needs of surgical care [31]. It is estimated that another 10 million surgeries must be performed annually to address this unmet need [31]. In the current study regarding perceptions, 38.7% of participants agreed that surgery has a positive impact on overall health outcomes, while a considerable proportion (31.5%) strongly disagreed. In contrast, a recent study by Okoye et al. [32] found that 98% of participants perceived surgery as having an impact on health. This difference may be explained by variations in sociodemographic characteristics, cultural beliefs, prior healthcare experiences, and economic constraints, which can strongly influence patients' perceptions about surgery. The current study showed that 44.5% of participants agreed that family and friends, while 36.1%, cultural and social beliefs influenced their decision to undergo surgery. Additionally, 30.3% believed that the potential benefits and risks, and 35.5% reported that the surgery was influenced by its success rate, potential risks, recovery time, and cost. In contrast, a recent study by Vipin Raj et al. [33] reported that family expectations and obligations (17%), health beliefs and traditional practices (28%), and religious practices (6%) influenced patients' decisions; interestingly, 2 out of every 10 patients chose to undergo surgery even though they felt it did not reduce overall risk [33]. Similarly, another study found that 49% of participants agreed to enhanced recovery after surgery, reflecting a moderate level of acceptance, likely influenced by awareness, perceived benefits, and institutional practices [33, 34, 35]. These findings highlight the need to enhance the surgical benefits education of patients and their families, cultural and religious belief‐related misconceptions, and accessibility constraints to promptly accept surgical treatment.

Notably, in the current study, individuals with higher education, employment, and no family history of surgery reported fewer barriers, whereas single participants, those having easy access to healthcare, and those with prior family surgical experience were more likely to encounter barriers. Among the reported factors, cleanliness, facility availability, and staff behaviour significantly influenced patients' willingness to undergo surgery (48.4%, p < 0.001). This finding highlights the importance of the healthcare environment and service quality in surgical decision‐making. In LMICs, the majority of surgical and anaesthetic services are delivered by general practitioners (27.1%) and paramedical staff, such as clinical technicians and nurses (26.76%). In contrast, specialist surgeons are typically concentrated in well‐resourced facilities, including private hospitals, NGOs, and mission hospitals (27.92%). Smaller facilities, such as health centres and community hospitals, remain underserved, with only 18.2%–19.96% of surgical services being provided in these settings [36]. These results suggest that overcoming paradoxical access challenges may be achieved by increasing the equitable distribution of surgical specialities and improving care delivery in low‐level facilities. In the current study, over half of the participants (58.3%) complained about experiencing barriers on the way to surgical treatment, which highlights the substantial difficulty of receiving surgical care. In our analysis, the probability of experiencing barriers was higher among males (35.1%) than among females (23.2%). On the contrary, a recent report by Reid et al. [30] demonstrated a higher likelihood of women experiencing barriers to surgical treatment (29.1% of men and 43.6% of women; p = 0.000). This difference suggests that while women may face barriers linked to family expectations, cultural norms, and financial dependency, men are more likely to encounter problems arising from delayed health‐seeking behaviour, work‐related demands, and reluctance to prioritize their own health. In the current study, education was strongly associated with barriers to surgical treatment, with university graduates having the lowest likelihood of experiencing barriers (p = 0.007). Employment status was also an important factor, as unemployed respondents were more likely to face barriers (p = 0.007), while employed individuals reported fewer barriers. Similarly, a recent study by Vipin Raj et al. [33] indicated that 22% of barriers to medical practices were related to education, and financial constraints accounted for only 3% of barriers. The results indicated that poor education or low awareness of medical procedures is a significant factor in creating barriers to accessing surgery, whereas financial stability and workplace encouragement are protective factors that tend to minimize disincentive barriers to accessing surgical care. In the current study, the regression analysis showed that singles were more likely to encounter the barriers than married individuals (ORa = 3.417, p < 0.001). On the contrary, the recent study by Neuman et al. [37] reported a lower risk among spouses (ORa = 1). The result showed that marriage provides additional support, as married individuals have fewer barriers to surgical care than singles. In addition, 44.5% of patients with a family history of surgery indicated a significant association with barriers (p < 0.001). In comparison, another study reported that family history was documented in 76% of individuals who underwent screening, while another study reported a higher rate of 87% [38]. This finding indicates that fear or negative past surgical history or even financial constraints in the family unit may entail reluctance to undergo surgical care in the future. In combination, these findings indicate that barriers to surgical treatment are multifactorial. These findings support the need to implement targeted measures, such as financial support schemes, patient education, and trust in public hospitals, to minimize disparities and improve surgical care. These findings underscore the need for patient education, culturally sensitive counseling, and improved communication about the benefits and risks of surgery. Strengthening trust in the healthcare system, optimizing hospital environments, and addressing socio‐economic disparities could enhance patient acceptance of surgical interventions.

4.1. Limitations

This study was limited by its single‐centre design and convenience sampling, which may limit the generalizability of its findings to other settings in Pakistan. Self‐reported responses may also be subject to recall and social desirability biases. Additionally, the cross‐sectional nature of the study hinders causal inference regarding the relationship between perceptions and identified barriers. Furthermore, the predominance of younger participants (aged 18–30 years, 63.9%) may reflect differential willingness to participate in the post‐operative setting, as older patients were more likely to decline due to fatigue or discomfort; this age skew may limit the representativeness of findings across all age groups.

4.2. Future Implication

Future research should employ multicenter or community‐based designs with larger, more diverse samples to validate and expand upon these findings. Qualitative studies exploring cultural and psychological dimensions of surgical hesitancy could offer deeper insights. Policymakers and healthcare providers should integrate patient‐centred education, trust‐building strategies, and context‐specific interventions to improve the accessibility and acceptance of surgical care across socioeconomic groups.

5. Conclusion

This study highlighted that a substantial proportion of patients in a tertiary healthcare setting in Pakistan perceive surgery as having a positive impact on overall health outcomes, and significant barriers influence their willingness to undergo surgical treatment. Perceptions toward surgery were influenced by cultural beliefs, trust in the healthcare system, hospital environment, and the opinions of family and friends. Educational level, employment status, marital status, past family surgical history, and type of healthcare facility used were found to be key determinants of perceived barriers. Policymakers and healthcare providers should consider these factors when designing interventions to improve surgical care and reduce inequities in access.

Author Contributions

Muhammad Aamir: conceptualization, methodology, supervision, investigation, project administration. Adeel Aslam: conceptualization, investigation, methodology, supervision, project administration. Nimra Muhammad Boota: methodology, software, data curation, conceptualization, writing – original draft, writing – review and editing. Amin Elahi and Mateen Elahi: conceptualization, methodology, software, data curation. Asma Ghulam Mustafa: conceptualization, methodology, software, data curation, writing – original draft, writing – review and editing. Sumera Saeed Akhtar: conceptualization, project administration, supervision. All authors have read and approved the final version of the manuscript. Dr. Sumera Saeed Akhtar had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author, Muhammad Aamir, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. The data underlying this article will be shared upon reasonable request by the corresponding author.