Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: A randomized unblinded trial

BACKGROUND

Attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is high worldwide. We assessed whether same-day HIV testing and ART initiation improves retention and virologic suppression.

METHODS AND FINDINGS

We conducted an unblinded, randomized trial of standard ART initiation versus same-day HIV testing and ART initiation among eligible adults ≥18 years old with World Health Organization Stage 1 or 2 disease and CD4 count ≤500 cells/mm3. The study was conducted among outpatients at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic infections (GHESKIO) Clinic in Port-au-Prince, Haiti. Participants were randomly assigned (1:1) to standard ART initiation or same-day HIV testing and ART initiation. The standard group initiated ART 3 weeks after HIV testing, and the same-day group initiated ART on the day of testing. The primary study endpoint was retention in care 12 months after HIV testing with HIV-1 RNA <50 copies/ml. We assessed the impact of treatment arm with a modified intention-to-treat analysis, using multivariable logistic regression controlling for potential confounders. Between August 2013 and October 2015, 762 participants were enrolled; 59 participants transferred to other clinics during the study period, and were excluded as per protocol, leaving 356 in the standard and 347 in the same-day ART groups. In the standard ART group, 156 (44%) participants were retained in care with 12-month HIV-1 RNA <50 copies, and 184 (52%) had <1,000 copies/ml; 20 participants (6%) died. In the same-day ART group, 184 (53%) participants were retained with HIV-1 RNA <50 copies/ml, and 212 (61%) had <1,000 copies/ml; 10 (3%) participants died. The unadjusted risk ratio (RR) of being retained at 12 months with HIV-1 RNA <50 copies/ml was 1.21 (95% CI: 1.04, 1.38; p = 0.015) for the same-day ART group compared to the standard ART group, and the unadjusted RR for being retained with HIV-1 RNA <1,000 copies was 1.18 (95% CI: 1.04, 1.31; p = 0.012). The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain.

CONCLUSIONS

Same-day HIV testing and ART initiation is feasible and beneficial in this setting, as it improves retention in care with virologic suppression among patients with early clinical HIV disease.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov number NCT01900080.

Stuck in the middle: a systematic review of authorship in collaborative health research in Africa, 2014-2016

Background

Collaborations are often a cornerstone of global health research. Power dynamics can shape if and how local researchers are included in manuscripts. This article investigates how international collaborations affect the representation of local authors, overall and in first and last author positions, in African health research.

Methods

We extracted papers on 'health' in sub-Saharan Africa indexed in PubMed and published between 2014 and 2016. The author's affiliation was used to classify the individual as from the country of the paper's focus, from another African country, from Europe, from the USA/Canada or from another locale. Authors classified as from the USA/Canada were further subclassified if the author was from a top US university. In primary analyses, individuals with multiple affiliations were presumed to be from a high-income country if they contained any affiliation from a high-income country. In sensitivity analyses, these individuals were presumed to be from an African country if they contained any affiliation an African country. Differences in paper characteristics and representation of local coauthors are compared by collaborative type using χ² tests.

Results

Of the 7100 articles identified, 68.3% included collaborators from the USA, Canada, Europe and/or another African country. 54.0% of all 43 429 authors and 52.9% of 7100 first authors were from the country of the paper's focus. Representation dropped if any collaborators were from USA, Canada or Europe with the lowest representation for collaborators from top US universities-for these papers, 41.3% of all authors and 23.0% of first authors were from country of paper's focus. Local representation was highest with collaborators from another African country. 13.5% of all papers had no local coauthors.

Discussion

Individuals, institutions and funders from high-income countries should challenge persistent power differentials in global health research. South-South collaborations can help African researchers expand technical expertise while maintaining presence on the resulting research.

Disruptions in maternal health service use during the COVID-19 pandemic in 2020: experiences from 37 health facilities in low-income and middle-income countries

The COVID-19 pandemic has heterogeneously affected use of basic health services worldwide, with disruptions in some countries beginning in the early stages of the emergency in March 2020. These disruptions have occurred on both the supply and demand sides of healthcare, and have often been related to resource shortages to provide care and lower patient turnout associated with mobility restrictions and fear of contracting COVID-19 at facilities. In this paper, we assess the impact of the COVID-19 pandemic on the use of maternal health services using a time series modelling approach developed to monitor health service use during the pandemic using routinely collected health information systems data. We focus on data from 37 non-governmental organisation-supported health facilities in Haiti, Lesotho, Liberia, Malawi, Mexico and Sierra Leone. Overall, our analyses indicate significant declines in first antenatal care visits in Haiti (18% drop) and Sierra Leone (32% drop) and facility-based deliveries in all countries except Malawi from March to December 2020. Different strategies were adopted to maintain continuity of maternal health services, including communication campaigns, continuity of community health worker services, human resource capacity building to ensure compliance with international and national guidelines for front-line health workers, adapting spaces for safe distancing and ensuring the availability of personal protective equipment. We employ a local lens, providing prepandemic context and reporting results and strategies by country, to highlight the importance of developing context-specific interventions to design effective mitigation strategies.

Risk factors for stunting among children under five years: a cross-sectional population-based study in Rwanda using the 2015 Demographic and Health Survey

BACKGROUND

Child growth stunting remains a challenge in sub-Saharan Africa, where 34% of children under 5 years are stunted, and causing detrimental impact at individual and societal levels. Identifying risk factors to stunting is key to developing proper interventions. This study aimed at identifying risk factors of stunting in Rwanda.

METHODS

We used data from the Rwanda Demographic and Health Survey (DHS) 2014-2015. Association between children's characteristics and stunting was assessed using logistic regression analysis.

RESULTS

A total of 3594 under 5 years were included; where 51% of them were boys. The prevalence of stunting was 38% (95% CI: 35.92-39.52) for all children. In adjusted analysis, the following factors were significant: boys (OR 1.51; 95% CI 1.25-1.82), children ages 6-23 months (OR 4.91; 95% CI 3.16-7.62) and children ages 24-59 months (OR 6.34; 95% CI 4.07-9.89) compared to ages 0-6 months, low birth weight (OR 2.12; 95% CI 1.39-3.23), low maternal height (OR 3.27; 95% CI 1.89-5.64), primary education for mothers (OR 1.71; 95% CI 1.25-2.34), illiterate mothers (OR 2.00; 95% CI 1.37-2.92), history of not taking deworming medicine during pregnancy (OR 1.29; 95%CI 1.09-1.53), poorest households (OR 1.45; 95% CI 1.12-1.86; and OR 1.82; 95%CI 1.45-2.29 respectively).

CONCLUSION

Family-level factors are major drivers of children's growth stunting in Rwanda. Interventions to improve the nutrition of pregnant and lactating women so as to prevent low birth weight babies, reduce poverty, promote girls' education and intervene early in cases of malnutrition are needed.

Assessing predictors of delayed antenatal care visits in Rwanda: a secondary analysis of Rwanda demographic and health survey 2010

Background

Early initiation of antenatal care (ANC) can reduce common maternal complications and maternal and perinatal mortality. Though Rwanda demonstrated a remarkable decline in maternal mortality and 98% of Rwandan women receive antenatal care from a skilled provider, only 38% of women have an ANC visit in their first three months of pregnancy. This study assessed factors associated with delayed ANC in Rwanda.

Methods

This is a cross-sectional study using data collected during the 2010 Rwanda DHS from 6,325 women age 15–49 that had at least one birth in the last five years. Factors associated with delayed ANC were identified using a multivariable logistic regression model using manual backward stepwise regression. Analysis was conducted in Stata v12 applying survey commands to account for the complex sample design.

Results

Several factors were significantly associated with delayed ANC including having many children (4–6 children, OR = 1.42, 95% CI: 1.22, 1.65; or more than six children, OR = 1.57, 95% CI: 1.24, 1.99); feeling that distance to health facility is a problem (OR = 1.20, 95% CI: 1.04, 1.38); and unwanted pregnancy (OR = 1.41, 95% CI: 1.26, 1.58). The following were protective against delayed ANC: having an ANC at a private hospital or clinic (OR = 0.29, 95% CI: 0.15, 0.56); being married (OR = 0.85, 95% CI: 0.75, 0.96), and having public mutuelle health insurance (OR = 0.81, 95% CI: 0.71, 0.92) or another type of insurance (OR = 0.33, 95% CI: 0.23, 0.46).

Conclusion

This analysis revealed potential barriers to ANC service utilization. Distance to health facility remains a major constraint which suggests a great need of infrastructure and decentralization of maternal ANC to health posts and dispensaries. Interventions such as universal health insurance coverage, family planning, and community maternal health system are underway and could be part of effective strategies to address delays in ANC.

Using electronic technology to improve clinical care - results from a before-after cluster trial to evaluate assessment and classification of sick children according to Integrated Management of Childhood Illness (IMCI) protocol in Tanzania

Background

Poor adherence to the Integrated Management of Childhood Illness (IMCI) protocol reduces the potential impact on under-five morbidity and mortality. Electronic technology could improve adherence; however there are few studies demonstrating the benefits of such technology in a resource-poor settings. This study estimates the impact of electronic technology on adherence to the IMCI protocols as compared to the current paper-based protocols in Tanzania.

Methods

In four districts in Tanzania, 18 clinics were randomly selected for inclusion. At each site, observers documented critical parts of the clinical assessment of children aged 2 months to 5 years. The first set of observations occurred during examination of children using paper-based IMCI (pIMCI) and the next set of observations occurred during examination using the electronic IMCI (eIMCI). Children were re-examined by an IMCI expert and the diagnoses were compared. A total of 1221 children (671 paper, 550 electronic) were observed.

Results

For all ten critical IMCI items included in both systems, adherence to the protocol was greater for eIMCI than for pIMCI. The proportion assessed under pIMCI ranged from 61% to 98% compared to 92% to 100% under eIMCI (p < 0.05 for each of the ten assessment items).

Conclusions

Use of electronic systems improved the completeness of assessment of children with acute illness in Tanzania. With the before-after nature of the design, potential for temporal confounding is the primary limitation. However, the data collection for both phases occurred over a short period (one month) and so temporal confounding was expected to be minimal. The results suggest that the use of electronic IMCI protocols can improve the completeness and consistency of clinical assessments and future studies will examine the long-term health and health systems impact of eIMCI.

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda

BACKGROUND

The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda.

METHODS

The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors.

RESULTS

In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions.

CONCLUSION

The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

Clinical mentorship to improve pediatric quality of care at the health centers in rural Rwanda: a qualitative study of perceptions and acceptability of health care workers

BACKGROUND

Despite evidence supporting Integrated Management of Childhood Illness (IMCI) as a strategy to improve pediatric care in countries with high child mortality, its implementation faces challenges related to lack of or poor post-didactic training supervision and gaps in necessary supporting systems. These constraints lead to health care workers' inability to consistently translate IMCI knowledge and skills into practice. A program providing mentoring and enhanced supervision at health centers (MESH), focusing on clinical and systems improvement was implemented in rural Rwanda as a strategy to address these issues, with the ultimate goal of improving the quality of pediatric care at rural health centers. We explored perceptions of MESH from the perspective of IMCI clinical mentors, mentees, and district clinical leadership.

METHODS

We conducted focus group discussions with 40 health care workers from 21 MESH-supported health centers. Two FGDs in each district were carried out, including one for nurses and one for director of health centers. District medical directors and clinical mentors had individual in-depth interviews. We performed a hermeneutic analysis using Atlas.ti v5.2.

RESULTS

Study participants highlighted program components in five key areas that contributed to acceptability and impact, including: 1) Interactive, collaborative capacity-building, 2) active listening and relationships, 3) supporting not policing, 4) systems improvement, and 5) real-time feedback. Staff turn-over, stock-outs, and other facility/systems gaps were identified as barriers to MESH and IMCI implementation.

CONCLUSION

Health care workers reported high acceptance and positive perceptions of the MESH model as an effective strategy to build their capacity, bridge the gap between knowledge and practice in pediatric care, and address facility and systems issues. This approach also improved relationships between the district supervisory team and health center-based care providers. Despite some challenges, many perceived a strong benefit on clinical performance and outcomes. This study can inform program implementers and policy makers of key components needed for developing similar health facility-based mentorship interventions and potential barriers and resistance which can be proactively addressed to ensure success.

Major depressive disorder prevalence and risk factors among Syrian asylum seekers in Greece

Background

Over one million Syrian asylum seekers have travelled to Greece with the ultimate aim of reaching other countries in western Europe. Depression prevalence and associated sociodemographic and displacement characteristics have been reported for resettled migrants. However, the prevalence of major depressive disorder (MDD) and its risk factors have not been described among migrants engaged in the asylum process ensuing from the Syrian crisis. This study provides new data about the mental health status of migrants in transition in the context of protracted asylum procedures.

Methods

We conducted a cross-sectional survey in a Syrian refugee camp in the Attica region of Greece from January 16–31, 2017. Individuals ≥18 years of age with verbal Arabic or English language skills were eligible to participate. The Patient Health Questionnaire-8 (PHQ-8), an eight-item validated diagnostic and severity measure, was used to screen for MDD. We analysed the relationships between MDD and sociodemographic and displacement characteristics using multivariable logistic regression.

Results

A total of 135 surveys were completed, representing 40% of the adult population in the refugee camp. The mean age of the participants was 30 years (18–61 years); women comprised 41% of the sample; 74% of the participants had ever married; 67% had children; and 33% of participants had not attended secondary school, including 11% who had never attended school. Median time since departing the country of origin was 12 months (< 1–74 months). Median time spent in the asylum process in Greece was 10 months (< 1–49 months). MDD was detected in 44% (95% CI: 37–50) of participants. Being a woman (Adjusted Odds Ratio [AOR]: 3.23, p = 0.019), each additional child (AOR: 1.61, p = 0.006), and increased time in the asylum process in Greece (AOR: 1.15, p = 0.043) were significant risk factors for MDD. Ever being married was associated with reduced odds of MDD (AOR: 0.23, p = 0.042).

Conclusions

Syrian migrants face an extraordinarily high burden of MDD as they seek asylum. Incorporation of screening and treatment into service provision within refugee camps is urgently needed, particularly as migrants spend extended periods of time in transition due to protracted asylum procedures.

Pursuing equity in cancer care: implementation, challenges and preliminary findings of a public cancer referral center in rural Rwanda

Background

Cancer services are inaccessible in many low-income countries, and few published examples describe oncology programs within the public sector. In 2011, the Rwanda Ministry of Health (RMOH) established Butaro Cancer Center of Excellence (BCCOE) to expand cancer services nationally. In hopes of informing cancer care delivery in similar settings, we describe program-level experience implementing BCCOE, patient characteristics, and challenges encountered.

Methods

Butaro Cancer Center of Excellence was founded on diverse partnerships that emphasize capacity building. Services available include pathology-based diagnosis, basic imaging, chemotherapy, surgery, referral for radiotherapy, palliative care and socioeconomic access supports. Retrospective review of electronic medical records (EMR) of patients enrolled between July 1, 2012 and June 30, 2014 was conducted, supplemented by manual review of paper charts and programmatic records.

Results

In the program’s first 2 years, 2326 patients presented for cancer-related care. Of these, 70.5 % were female, 4.3 % children, and 74.3 % on public health insurance. In the first year, 66.3 % (n = 1144) were diagnosed with cancer. Leading adult diagnoses were breast, cervical, and skin cancer. Among children, nephroblastoma, acute lymphoblastic leukemia, and Hodgkin lymphoma were predominant. As of June 30, 2013, 95 cancer patients had died. Challenges encountered include documentation gaps and staff shortages.

Conclusion

Butaro Cancer Center of Excellence demonstrates that complex cancer care can be delivered in the most resource-constrained settings, accessible to vulnerable patients. Key attributes that have made BCCOE possible are: meaningful North–south partnerships, innovative task- and infrastructure-shifting, RMOH leadership, and an equity-driven agenda. Going forward, we will apply our experiences and lessons learned to further strengthen BCCOE, and employ the developed EMR system as a valuable platform to assess long-term clinical outcomes and improve care.

Toward utilization of data for program management and evaluation: quality assessment of five years of health management information system data in Rwanda

BACKGROUND

Health data can be useful for effective service delivery, decision making, and evaluating existing programs in order to maintain high quality of healthcare. Studies have shown variability in data quality from national health management information systems (HMISs) in sub-Saharan Africa which threatens utility of these data as a tool to improve health systems. The purpose of this study is to assess the quality of Rwanda's HMIS data over a 5-year period.

METHODS

The World Health Organization (WHO) data quality report card framework was used to assess the quality of HMIS data captured from 2008 to 2012 and is a census of all 495 publicly funded health facilities in Rwanda. Factors assessed included completeness and internal consistency of 10 indicators selected based on WHO recommendations and priority areas for the Rwanda national health sector. Completeness was measured as percentage of non-missing reports. Consistency was measured as the absence of extreme outliers, internal consistency between related indicators, and consistency of indicators over time. These assessments were done at the district and national level.

RESULTS

Nationally, the average monthly district reporting completeness rate was 98% across 10 key indicators from 2008 to 2012. Completeness of indicator data increased over time: 2008, 88%; 2009, 91%; 2010, 89%; 2011, 90%; and 2012, 95% (p<0.0001). Comparing 2011 and 2012 health events to the mean of the three preceding years, service output increased from 3% (2011) to 9% (2012). Eighty-three percent of districts reported ratios between related indicators (ANC/DTP1, DTP1/DTP3) consistent with HMIS national ratios. Conclusion and policy implications: Our findings suggest that HMIS data quality in Rwanda has been improving over time. We recommend maintaining these assessments to identify remaining gaps in data quality and that results are shared publicly to support increased use of HMIS data.

Perceived improvement in integrated management of childhood illness implementation through use of mobile technology: qualitative evidence from a pilot study in Tanzania

This study examined health care provider and caretaker perceptions of electronic Integrated Management of Childhood Illness (eIMCI) in diagnosing and treating childhood illnesses. The authors conducted semi-structured interviews among caretakers (n = 20) and health care providers (n = 11) in the Pwani region of Tanzania. This qualitative study was nested within a larger quantitative study measuring impact of eIMCI on provider adherence to IMCI protocols. Caretakers and health care workers involved in the larger study provided their perceptions of eIMCI in comparison with the conventional paper forms. One health care provider from each participating health center participated in qualitative interviews; 20 caretakers were selected from 1 health center involved in the quantitative study. Interviews were conducted in Swahili and lasted 5-10 min each. Providers expressed positive opinions of eIMCI, noting that the personal digital assistants were faster and easier to use than were the paper forms and encouraged adherence to IMCI procedures. Caretakers also held a positive view of eIMCI, noting improved service from providers, more thorough examination of their child, and a perception that providers who used the personal digital assistants were more knowledgeable. Research indicates widespread nonadherence to IMCI guidelines, suggesting improved methods for implementing IMCI are necessary. The authors conclude that eIMCI represents a promising method for improving health care delivery because it improves health care provider and caretaker perception of the clinical encounter. Further investigation into this technology is warranted.

Baseline assessment of adult and adolescent primary care delivery in Rwanda: an opportunity for quality improvement

BACKGROUND

As resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda.

METHODS

Patients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard.

RESULTS

Four hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (p = 0.03 and p = 0.04, respectively).

CONCLUSION

Fundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.

Diagnosis of cancer in rural Rwanda: early outcomes of a phased approach to implement anatomic pathology services in resource-limited settings

OBJECTIVES

Adequate pathology services are a prerequisite to accurate cancer diagnoses and tailoring appropriate treatment. Limitations in skilled personnel and infrastructure are among the challenges faced by developing countries. We describe a stepwise implementation of anatomic pathology laboratory services at Butaro District Hospital, designated as a Cancer Center of Excellence in rural Rwanda.

METHODS

The phased approach to developing pathology services up to December 2012 is described. A retrospective review of specimens submitted to Butaro District Hospital between July 1, 2012, and December 31, 2012, was conducted. Patient clinical characteristics and sociodemographics are also described.

RESULTS

During the study period, a total of 437 tissue specimens were submitted. Among these, 143 (32.7%) were from male patients, 244 (55.8%) were confirmed as malignant, 163 (37.3%) were benign, 28 (6.4%) were inconclusive, and two (0.5%) results were not available at the time of analysis. The median time from specimen receipt at Butaro to final reporting was 32 days (range, 7-193 days; interquartile range, 23-44 days).

CONCLUSIONS

Our experience demonstrates that anatomic pathology services can be established in resource-limited settings and local capacity can be built to support accurate diagnoses. Our approach included leveraging partnerships, volunteer experts, and task shifting and will be expanded to include telepathology.

Longer travel time to district hospital worsens neonatal outcomes: a retrospective cross-sectional study of the effect of delays in receiving emergency cesarean section in Rwanda

Background

In low-resource settings, access to emergency cesarean section is associated with various delays leading to poor neonatal outcomes. In this study, we described the delays a mother faces when needing emergency cesarean delivery and assessed the effect of these delays on neonatal outcomes in Rwanda.

Methods

This retrospective study included 441 neonates and their mothers who underwent emergency cesarean section in 2015 at three district hospitals in Rwanda. Four delays were measured: duration of labor prior to hospital admission, travel time from health center to district hospital, time from admission to surgical incision, and time from decision for emergency cesarean section to surgical incision. Neonatal outcomes were categorized as unfavorable (APGAR <7 at 5 min or death) and favorable (alive and APGAR ≥7 at 5 min). We assessed the relationship between each type of delay and neonatal outcomes using multivariate logistic regression.

Results

In our study, 9.1% (40 out of 401) of neonates had an unfavorable outcome, 38.7% (108 out of 279) of neonates’ mothers labored for 12–24 h before hospital admission, and 44.7% (159 of 356) of mothers were transferred from health centers that required 30–60 min of travel time to reach the district hospital. Furthermore, 48.1% (178 of 370) of cesarean sections started within 5 h after hospital admission and 85.2% (288 of 338) started more than 30 min after the decision for cesarean section was made. Neonatal outcomes were significantly worse among mothers with more than 90 min of travel time from the health center to the district hospital compared to mothers referred from health centers located on the same compound as the hospital (aOR = 5.12, p = 0.02). Neonates with cesarean deliveries starting more than 30 min after decision for cesarean section had better outcomes than those starting immediately (aOR = 0.32, p = 0.04).

Conclusions

Longer travel time between health center and district hospital was associated with poor neonatal outcomes, highlighting a need to decrease barriers to accessing emergency maternal services. However, longer decision to incision interval posed less risk for adverse neonatal outcome. While this could indicate thorough pre-operative interventions including triage and resuscitation, this relationship should be studied prospectively in the future.

Beyond coverage: improving the quality of antenatal care delivery through integrated mentorship and quality improvement at health centers in rural Rwanda

BACKGROUND

Inadequate antenatal care (ANC) can lead to missed diagnosis of danger signs or delayed referral to emergency obstetrical care, contributing to maternal mortality. In developing countries, ANC quality is often limited by skill and knowledge gaps of the health workforce. In 2011, the Mentorship, Enhanced Supervision for Healthcare and Quality Improvement (MESH-QI) program was implemented to strengthen providers' ANC performance at 21 rural health centers in Rwanda. We evaluated the effect of MESH-QI on the completeness of danger sign assessments.

METHODS

Completeness of danger sign assessments was measured by expert nurse mentors using standardized observation checklists. Checklists completed from October 2010 to May 2011 (n = 330) were used as baseline measurement and checklists completed between February and November 2012 (12-15 months after the start of MESH-QI implementation) were used for follow-up. We used a mixed-effects linear regression model to assess the effect of the MESH-QI intervention on the danger sign assessment score, controlling for potential confounders and the clustering of effect at the health center level.

RESULTS

Complete assessment of all danger signs improved from 2.1% at baseline to 84.2% after MESH-QI (p <  0.001). Similar improvements were found for 20 of 23 other essential ANC screening items. After controlling for potential confounders, the improvement in danger sign assessment score was significant. However, the effect of the MESH-QI was different by intervention district and type of observed ANC visit. In Southern Kayonza District, the increase in the danger sign assessment score was 6.28 (95% CI: 5.59, 6.98) for non-first ANC visits and 5.39 (95% CI: 4.62, 6.15) for first ANC visits. In Kirehe District, the increase in danger sign assessment score was 4.20 (95% CI: 3.59, 4.80) for non-first ANC visits and 3.30 (95% CI: 2.80, 3.81) for first ANC visits.

CONCLUSION

Assessment of critical danger signs improved under MESH-QI, even when controlling for nurse-mentees' education level and previous training in focused ANC. MESH-QI offers an approach to enhance quality of care after traditional training and may be an approach to support newer providers who have not yet attended content-focused courses.

Prevalence and predictors of surgical-site infection after caesarean section at a rural district hospital in Rwanda

Background

There are few prospective studies of outcomes following surgery in rural district hospitals in sub-Saharan Africa. This study aimed to estimate the prevalence and predictors of surgical-site infection (SSI) following caesarean section at Kirehe District Hospital in rural Rwanda.

Methods

Adult women who underwent caesarean section between March and October 2017 were given a voucher to return to the hospital on postoperative day (POD) 10 (±3 days). At the visit, a physician evaluated the patient for an SSI. A multivariable logistic regression model was used to identify risk factors for SSI, built using backward stepwise selection.

Results

Of 729 women who had a caesarean section, 620 were eligible for follow-up, of whom 550 (88·7 per cent) returned for assessment. The prevalence of SSI on POD 10 was 10·9 per cent (60 women). In the multivariable analysis, the following factors were significantly associated with SSI: bodyweight more than 75 kg (odds ratio (OR) 5·98, 1·56 to 22·96; P = 0·009); spending more than €1·1 on travel to the health centre (OR 2·42, 1·31 to 4·49; P = 0·005); being a housewife compared with a farmer (OR 2·93, 1·08 to 7·97; P = 0·035); and skin preparation with a single antiseptic compared with a combination of two antiseptics (OR 4·42, 1·05 to 18·57; P = 0·043). Receiving either preoperative or postoperative antibiotics was not associated with SSI.

Conclusion

The prevalence of SSI after caesarean section is consistent with rates reported at tertiary facilities in sub-Saharan Africa. Combining antiseptic solutions for skin preparation could reduce the risk of SSI.

Approaches and impact of non-academic research capacity strengthening training models in sub-Saharan Africa: a systematic review

Background

Research is essential to identify and prioritize health needs and to develop appropriate strategies to improve health outcomes. In the last decade, non-academic research capacity strengthening trainings in sub-Saharan Africa, coupled with developing research infrastructure and the provision of individual mentorship support, has been used to build health worker skills. The objectives of this review are to describe different training approaches to research capacity strengthening in sub-Saharan Africa outside academic programs, assess methods used to evaluate research capacity strengthening activities, and learn about the challenges facing research capacity strengthening and the strategies/innovations required to overcome them.

Methodology

The PubMed database was searched using nine search terms and articles were included if 1) they explicitly described research capacity strengthening training activities, including information on program duration, target audience, immediate program outputs and outcomes; 2) all or part of the training program took place in sub-Saharan African countries; 3) the training activities were not a formal academic program; 4) papers were published between 2000 and 2013; and 5) both abstract and full paper were available in English.

Results

The search resulted in 495 articles, of which 450 were retained; 14 papers met all inclusion criteria and were included and analysed. In total, 4136 people were trained, of which 2939 were from Africa. Of the 14 included papers, six fell in the category of short-term evaluation period and eight in the long-term evaluation period. Conduct of evaluations and use of evaluation frameworks varied between short and long term models and some trainings were not evaluated. Evaluation methods included tests, surveys, interviews, and systems approach matrix.

Conclusions

Research capacity strengthening activities in sub-Saharan Africa outside of academic settings provide important contributions to developing in-country capacity to participate in and lead research. Institutional support, increased funds, and dedicated time for research activities are critical factors that lead to the development of successful programs. Further, knowledge sharing through scientific articles with sufficient detail is needed to enable replication of successful models in other settings.

Outcomes for patients with rheumatic heart disease after cardiac surgery followed at rural district hospitals in Rwanda

BACKGROUND

In sub-Saharan Africa, continued clinical follow-up, after cardiac surgery, is only available at urban referral centres. We implemented a decentralised, integrated care model to provide longitudinal care for patients with advanced rheumatic heart disease (RHD) at district hospitals in rural Rwanda before and after heart surgery.

METHODS

We collected data from charts at non-communicable disease (NCD) clinics at three rural district hospitals in Rwanda to describe the outcomes of 54 patients with RHD who received cardiac valve surgery during 2007-2015.

RESULTS

The majority of patients were adults (46/54; 85%), and 74% were females. The median age at the time of surgery was 22 years in adults and 11 years in children. Advanced symptoms-New York Heart Association class III or IV-were present in 83% before surgery and only 4% afterwards. The mitral valve was the most common valve requiring surgery. Valvular surgery consisted mostly of a single valve (56%) and double valve (41%). Patients were followed for a median of 3 years (range 0.2-7.9) during which 7.4% of them died; all deaths were patients who had undergone bioprosthetic valve replacement. For patients with mechanical valves, anticoagulation was checked at 96% of visits. There were no known bleeding or thrombotic events requiring hospitalisation.

CONCLUSION

Outcomes of postoperative patients with RHD tracked in rural Rwanda health facilities were generally good. With appropriate training and supervision, it is feasible to safely decentralise follow-up of patients with RHD to nurse-led specialised NCD clinics after cardiac surgery.

Depression and patterns of self-reported adherence to antiretroviral therapy in Rwanda

We determined the prevalence of depression in HIV-infected adults on antiretroviral therapy in rural Rwanda and measured the association of depression with non-adherence. In all, 292 patients on antiretroviral therapy for ≥6 months were included. Adherence was self-reported by four-day recall, two- and seven-day treatment interruptions, and the CASE Index, which is a composite score accounting for difficulty taking medications on time, the average number of days per week a dose is missed, and the most recent missed dose. A total of 84% and 87% of participants reported good adherence by the four-day recall and CASE Index, respectively; 13% of participants reported two-day treatment interruptions; and 11% were depressed. Depression was significantly associated with two-day treatment interruptions but not with other measures of non-adherence. Self-reported adherence to antiretroviral therapy in rural Rwanda is high. Adherence assessments that do not consider treatment interruptions may miss important patterns of non-adherence, which may be especially prevalent among depressed individuals. Mental health interventions incorporated into routine HIV care may lead to improvements in mental health and adherence.

Research capacity building integrated into PHIT projects: leveraging research and research funding to build national capacity

Background

Inadequate research capacity impedes the development of evidence-based health programming in sub-Saharan Africa. However, funding for research capacity building (RCB) is often insufficient and restricted, limiting institutions’ ability to address current RCB needs. The Doris Duke Charitable Foundation’s African Health Initiative (AHI) funded Population Health Implementation and Training (PHIT) partnership projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania and Zambia) to implement health systems strengthening initiatives inclusive of RCB.

Methods

Using Cooke’s framework for RCB, RCB activity leaders from each country reported on RCB priorities, activities, program metrics, ongoing challenges and solutions. These were synthesized by the authorship team, identifying common challenges and lessons learned.

Results

For most countries, each of the RCB domains from Cooke’s framework was a high priority. In about half of the countries, domain specific activities happened prior to PHIT. During PHIT, specific RCB activities varied across countries. However, all five countries used AHI funding to improve research administrative support and infrastructure, implement research trainings and support mentorship activities and research dissemination. While outcomes data were not systematically collected, countries reported holding 54 research trainings, forming 56 mentor-mentee relationships, training 201 individuals and awarding 22 PhD and Masters-level scholarships. Over the 5 years, 116 manuscripts were developed. Of the 59 manuscripts published in peer-reviewed journals, 29 had national first authors and 18 had national senior authors. Trainees participated in 99 conferences and projects held 37 forums with policy makers to facilitate research translation into policy.

Conclusion

All five PHIT projects strongly reported an increase in RCB activities and commended the Doris Duke Charitable Foundation for prioritizing RCB, funding RCB at adequate levels and time frames and for allowing flexibility in funding so that each project could implement activities according to their trainees’ needs. As a result, many common challenges for RCB, such as adequate resources and local and international institutional support, were not identified as major challenges for these projects. Overall recommendations are for funders to provide adequate and flexible funding for RCB activities and for institutions to offer a spectrum of RCB activities to enable continued growth, provide adequate mentorship for trainees and systematically monitor RCB activities.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2657-6) contains supplementary material, which is available to authorized users.

Validating the Global Surgery Geographical Accessibility Indicator: Differences in Modeled Versus Patient-Reported Travel Times

Background

Since long travel times to reach health facilities are associated with worse outcomes, geographic accessibility is one of the six core global surgery indicators; this corresponds to the second of the “Three Delays Framework,” namely “delay in reaching a health facility.” Most attempts to estimate this indicator have been based on geographical information systems (GIS) algorithms. The aim of our study was to compare GIS derived estimates to self-reported travel times for patients traveling to a district hospital in rural Rwanda for emergency obstetric care.

Methods

Our study includes 664 women who traveled to undergo a Cesarean delivery in Kirehe, Rwanda. We compared self-reported travel time from home to the hospital (excluding waiting time) with GIS estimated travel times, which were computed using the World Health Organization tool AccessMod, using linear regression.

Results

The majority of patients used multiple modes of transportation (walking = 48.5%, public transport = 74.2%, private transport = 2.9%, and ambulance 70.6%). Self-reported times were longer than GIS estimates by a factor of 1.49 (95% CI 1.40–1.57). Concordance was higher when the GIS model took into account that all patients in Rwanda are referred via their health center (β = 1.12; 95% CI 1.05–1.18).

Conclusions

To our knowledge, in this largest to date GIS validation study for geographical access to healthcare in low- and middle-income countries, a standard GIS model was found to significantly underestimate real travel time, which likely is in part because it does not model the actual route patients are travelling. Therefore, previous studies of 2-h access to surgery will need to be interpreted with caution, and future studies should take local travelling conditions into account.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05480-8) contains supplementary material, which is available to authorized users.

Rainfall variation and child health: effect of rainfall on diarrhea among under 5 children in Rwanda, 2010

Background

Diarrhea among children under 5 years of age has long been a major public health concern. Previous studies have suggested an association between rainfall and diarrhea. Here, we examined the association between Rwandan rainfall patterns and childhood diarrhea and the impact of household sanitation variables on this relationship.

Methods

We derived a series of rain-related variables in Rwanda based on daily rainfall measurements and hydrological models built from daily precipitation measurements collected between 2009 and 2011. Using these data and the 2010 Rwanda Demographic and Health Survey database, we measured the association between total monthly rainfall, monthly rainfall intensity, runoff water and anomalous rainfall and the occurrence of diarrhea in children under 5 years of age.

Results

Among the 8601 children under 5 years of age included in the survey, 13.2 % reported having diarrhea within the 2 weeks prior to the survey. We found that higher levels of runoff were protective against diarrhea compared to low levels among children who lived in households with unimproved toilet facilities (OR = 0.54, 95 % CI: [0.34, 0.87] for moderate runoff and OR = 0.50, 95 % CI: [0.29, 0.86] for high runoff) but had no impact among children in household with improved toilets.

Conclusion

Our finding that children in households with unimproved toilets were less likely to report diarrhea during periods of high runoff highlights the vulnerabilities of those living without adequate sanitation to the negative health impacts of environmental events.