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Tumusime R, Miller MS, Niyigena A, Dusabeyezu S, Uwitonze P, Harerimana E, Umugiraneza G, Dusingizimana W, Hatfield S, Savarimuthu S, Lawrence J, Hagenimana P, Ngenzi JMV, Murara A, Mwiseneza P, Sonenthal P, Cubaka VK, Kateera F, Kamali I. Implementation and Cost Analysis of a Novel Silicosis Case-Finding Program For Mine Workers in Rural Rwanda. Glob Health Sci Pract 2024; 12:e2300290. [PMID: 38485283 PMCID: PMC11057793 DOI: 10.9745/ghsp-d-23-00290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Abstract
Little is known about the burden of silicosis in Africa, despite extensive mining and construction operations in the region putting numerous people at risk. The implementation experience and costs of case-finding for occupational lung disease in resource-limited settings are also currently unknown. We describe the first-ever silicosis case-finding project in rural Rwanda using chest X-ray, symptom questionnaires, and spirometry. This was coupled with routine noncommunicable disease case-finding for diabetes and hypertension. We performed an ingredient-based analysis of the costs of all case-finding activities. In 2022, over 25 days, 1,032 mine workers were included in the program, of which 1,014 (98.3%) completed silicosis case-finding activities. The total cost of the program was estimated to be US$38,656, representing a cost of US$37.49 per person. We conclude that conducting large-scale occupational lung disease case-finding is clinically and economically feasible in resource-limited settings and can be effectively integrated with routine noncommunicable disease case-finding.
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Affiliation(s)
- Robert Tumusime
- Partners In Health-Rwanda/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Michael S Miller
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Anne Niyigena
- Partners In Health-Rwanda/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | | | | | | | - Wellars Dusingizimana
- Ministry of Health of Rwanda, Kigali, Rwanda
- Rwinkwavu District Hospital, Kayonza, Rwanda
| | - Samuel Hatfield
- Department of Medicine, University of California at San Francisco, San Francisco, CA, USA
| | | | - Juliana Lawrence
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | - Phoebe Mwiseneza
- Ministry of Health of Rwanda, Kigali, Rwanda
- Rwinkwavu District Hospital, Kayonza, Rwanda
| | - Paul Sonenthal
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Partners In Health, Boston, MA, USA
| | | | | | - Innocent Kamali
- Partners In Health-Rwanda/Inshuti Mu Buzima, Rwinkwavu, Rwanda
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Nuss S, Nkurunziza J, Mugabo C, Kubwimana M, Benimana F, Uwera C, Nyirasabwa T, Nyirimanzi N, Forbes C, Majyambere JP, Kateera F, Hedt-Gauthier BL, Cubaka VK. Increasing access to pediatric surgical care: Assessing district hospital readiness in rural Rwanda. World J Surg 2024; 48:290-315. [PMID: 38618642 PMCID: PMC11008909 DOI: 10.1002/wjs.12032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Introduction/Background Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda. Methods We administered the Children's Surgical Assessment Tool (CSAT), adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains. Results None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure, and information management for pediatric outpatients and referrals. In SSORT interviews (n=47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score=2.6 out of 5), psychological safety (median score=3.0 out of 5), and resistance to change (mean score=1.5 out of 5 with 5=no resistance). Conclusions This study highlights challenges in providing safe and high-quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity.
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Affiliation(s)
- Sarah Nuss
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Warren Alpert Medical School at Brown University, Providence, RI, USA
| | | | - Carol Mugabo
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | | | - Cynthia Uwera
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | | | - Callum Forbes
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- University of Global Health Equity, Butaro, Rwanda
| | | | | | - Bethany L. Hedt-Gauthier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Niyigena A, Gato S, Alayande B, Miranda E, Hedt-Gauthier B, Goodman AS, Nkurunziza T, Mazimpaka C, Hakizimana S, Ngamije P, Kateera F, Riviello R, Boatin AA. Functional recovery after cesarean delivery: a prospective cohort study in rural Rwanda. BMC Pregnancy Childbirth 2023; 23:858. [PMID: 38087238 PMCID: PMC10717631 DOI: 10.1186/s12884-023-06159-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 11/26/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Women who deliver via cesarean section (c-section) experience short- and long-term disability that may affect their physical health and their ability to function normally. While clinical complications are assessed, postpartum functional outcomes are not well understood from a patient's perspective or well-characterized by previous studies. In Rwanda, 11% of rural women deliver via c-section. This study explores the functional recovery of rural Rwandan women after c-section and assesses factors that predict poor functionality at postoperative day (POD) 30. METHODS Data were collected prospectively on POD 3, 11, and 30 from women delivering at Kirehe District Hospital between October 2019 and March 2020. Functionality was measured by self-reported overall health, energy level, mobility, self-care ability, and ability to perform usual activities; and each domain was rated on a 4-point likert scale, lower scores reflecting higher level of difficulties. Using the four functionality domains, we computed composite mean scores with a maximum score of 4.0 and we defined poor functionality as composite score of ≤ 2.0. We assessed functionality with descriptive statistics and logistic regression. RESULTS Of 617 patients, 54.0%, 25.9%, and 26.8% reported poor functional status at POD3, POD11, and POD30, respectively. At POD30, the most self-reported poor functionality dimensions were poor or very poor overall health (48.1%), and inability to perform usual activities (15.6%). In the adjusted model, women whose surgery lasted 30-45 min had higher odds of poor functionality (aOR = 1.85, p = 0.01), as did women who experienced intraoperative complications (aOR = 4.12, 95% CI (1.09, 25.57), p = 0.037). High income patients had incrementally lower significant odds of poor physical functionality (aOR = 0.62 for every US$1 increase in monthly income, 95% CI (0.40, 0.96) p = 0.04). CONCLUSION We found a high proportion of poor physical functionality 30 days post-c-section in this Rwandan cohort. Surgery lasting > 30 min and intra-operative complications were associated with poor functionality, whereas a reported higher income status was associated with lower odds of poor functionality. Functional status assessments, monitoring and support should be included in post-partum care for women who delivered via c-section. Effective risk mitigating intervention should be implemented to recover functionality after c-section, particularly among low-income women and those undergoing longer surgical procedures or those with intraoperative complications.
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Affiliation(s)
- Anne Niyigena
- Partners In Health/Inshuti Mu Buzima, KG 9 Avenue 46, PO Box 3432, Remera, Kigali, Rwanda.
| | - Saidath Gato
- Partners In Health/Inshuti Mu Buzima, KG 9 Avenue 46, PO Box 3432, Remera, Kigali, Rwanda
| | | | | | | | | | | | - Christian Mazimpaka
- Partners In Health/Inshuti Mu Buzima, KG 9 Avenue 46, PO Box 3432, Remera, Kigali, Rwanda
| | - Sadoscar Hakizimana
- Partners In Health/Inshuti Mu Buzima, KG 9 Avenue 46, PO Box 3432, Remera, Kigali, Rwanda
| | - Patient Ngamije
- Kirehe District Hospital, Ministry of Health, Kirehe, Rwanda
| | - Fredrick Kateera
- Partners In Health/Inshuti Mu Buzima, KG 9 Avenue 46, PO Box 3432, Remera, Kigali, Rwanda
| | - Robert Riviello
- Harvard Medical School, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Adeline A Boatin
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
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Mukantwari J, Gatete JDD, Niyigena A, Alayande BT, Nkurunziza T, Mazimpaka C, Boatin AA, Kateera F, Hedt-Gauthier B, Riviello R. Late and Persistent Symptoms Suggestive of Surgical Site Infections After Cesarean Section: Results from a Prospective Cohort Study in Rural Rwanda. Surg Infect (Larchmt) 2023; 24:916-923. [PMID: 38032658 PMCID: PMC10734900 DOI: 10.1089/sur.2023.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Background: Women in low-resource settings will likely develop late surgical site infections (SSIs), diagnosed after post-operative day (POD) 10. We measured SSI prevalence and predictors of late and persistent SSIs-suggestive symptoms among women who delivered via cesarean section (c-section). Patients and Methods: Women who underwent c-sections at Kirehe District Hospital (KDH) between September 2019 and February 2020 were prospectively enrolled. Data were collected on POD1, POD11, and POD30. Logistic regression identified factors associated with persistent and late SSI symptoms. Results: In total, 808 women were study enrolled. Of these, 646 women physically attended the POD11 clinic visit follow-up, while 671 received the POD30 telephone-based follow-up review. Thirty-three (5.0%) women were diagnosed with an SSI on POD11, and 39 (5.3%) had an SSI diagnosis during POD11 to POD30, giving a cumulative prevalence of 10.3% late SSI rate. Of 671, 400 (59.9%) reported at least one SSI-associated symptom between POD11 and POD30. The reported symptoms included pain (56.6%), fever (19.4%), or incision drainage (16.6%). Of these, 200 women reported still having at least one of these symptoms on POD30. Of the 400 women with late SSI symptoms, 232 (58.0%) did not seek care, and of these, 80 (48.5%), 59 (35.8%), and 15 (8.9%) could not afford transport fare, did not believe symptoms were severe for a medical visit, and were not able to travel, respectively. Lower odds of late SSI-suggestive symptoms were reported among women with health insurance (adjusted odds ratio [aOR], 0.06; p = 0.013), whereas higher late SSI-suggestive symptoms odds were among women with wealthier socioeconomic status (aOR, 2.88; p = 0.004). Conclusions: Women in rural Rwanda are at risk of late and persistent SSI-suggestive symptoms. Financial barriers and the perception that their symptoms were not serious enough for the medical visit need education on early care seeking and interventions to mitigate financial barriers for optimizing perinatal care.
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Affiliation(s)
- Joselyne Mukantwari
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University London, Ontario, Canada
| | | | - Anne Niyigena
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Barnabas Tobi Alayande
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Center for Equity in Global Surgery, University of Global Health Equity, Butaro, Rwanda
| | - Theoneste Nkurunziza
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
- Epidemiology, Department for Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | | | - Adeline A. Boatin
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Bethany Hedt-Gauthier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Center for Equity in Global Surgery, University of Global Health Equity, Butaro, Rwanda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
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Miller H, Rudolfson N, Nkurunziza T, Cherian T, Kayitesi D, Mazimpaka C, Kateera F, Riviello R, Hedt-Gauthier B. Long travel times from health center to hospital reduce caesarean section access: a study from Kirehe District, Rwanda. Pan Afr Med J 2023; 46:30. [PMID: 38107338 PMCID: PMC10724031 DOI: 10.11604/pamj.2023.46.30.25504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/01/2020] [Indexed: 12/19/2023] Open
Abstract
Introduction timely access to safe cesarean section (c-section) delivery can save the lives of mothers and neonates. This paper explores how distance affects c-section access in rural sub-Saharan Africa, where women in labor present to health centers before being referred to district hospitals for surgical care. Methods this study included all adult women delivering via c-section between April 2017 and March 2018 in Kirehe District, Rwanda. We assessed the association between travel times and village-level c-section rates. Results the estimated travel time from home-to-health center was 26 minutes (IQR: 13, 41) and from health center-to-hospital was 43 minutes (IQR: 2, 59). There was no significant association between travel time from home-to-health center and c-section rates (RR=1.01, p=0.42), but the association was significant for health center-to-hospital travel times (RR=0.96, p=0.01); for every 15-minute increase in travel time, there was a 4% decrease in c-sections for a health center catchment area. Conclusion in the context of decentralized health services, minimizing health center to hospital referral barriers is of utmost importance for improving c-section access in rural sub-Saharan Africa.
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Affiliation(s)
- Hillary Miller
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, United States of America
| | - Niclas Rudolfson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Word Health Organization Collaborating Center for Surgery and Public Health, Department of Clinical Sciences Lund University, Lund, Sweden
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
| | - Theoneste Nkurunziza
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
- Department for Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Teena Cherian
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
| | | | | | | | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
- Center for Surgery and Public Health, Brigham and Women´s Hospital, Boston, United States of America
| | - Bethany Hedt-Gauthier
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
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6
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Adler AJ, Randall T, Schwartz LN, Drown L, Matthews S, Pace LE, Mugabo C, Kateera F, Bukhman G, Baganizi E, Ng'ang'a LM. What women want: A mixed-methods study of women's health priorities, preferences, and experiences in care in three Rwandan rural districts. Int J Gynaecol Obstet 2023. [PMID: 36815725 DOI: 10.1002/ijgo.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/17/2022] [Accepted: 02/20/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To explore Rwandan women's experiences, priorities, and preferences in accessing health care for non-pregnancy-related conditions and inform development of healthcare services related to these conditions among women of reproductive age at district hospitals and health centers in Rwanda. METHODS We used a mixed-methods, exploratory sequential design. Semi-structured qualitative interviews were conducted with Rwandan women and coded thematically. A cross-sectional quantitative survey based on the qualitative data was administered to women attending health centers. RESULTS Seventeen interviews and 150 surveys were conducted. Women identified conditions including back pain, gynecologic cancers, and abnormal vaginal bleeding as concerns. They generally reported positive experiences while accessing health care and knowledge of accessing health care. Barriers to care were identified, including transportation costs and inability to miss work. Women expressed a desire for more control over their care and the importance of maintaining their dignity while accessing health care. CONCLUSION These findings provide useful insights to inform development of non-pregnancy-related healthcare services for women in Rwanda according to their priorities and preferences. The reported end-user health concerns, barriers to care, and diminished control over their care point to a need to evolve health systems around user-tailored needs and design interventions optimizing access whilst promoting dignified care.
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Affiliation(s)
- A J Adler
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - T Randall
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - L N Schwartz
- Harvard Medical School, Boston, Massachusetts, USA
| | - L Drown
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - S Matthews
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - L E Pace
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - C Mugabo
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - F Kateera
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - G Bukhman
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Partners in Health, Boston, Massachusetts, USA
| | - E Baganizi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - L M Ng'ang'a
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
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7
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Alayande BT, Prasad S, Abimpaye M, Bakorimana L, Niyigena A, Nkurunziza J, Cubaka VK, Kateera F, Fletcher R, Hedt-Gauthier B. Image-based surgical site infection algorithms to support home-based post-cesarean monitoring: Lessons from Rwanda. PLOS Glob Public Health 2023; 3:e0001584. [PMID: 36963016 PMCID: PMC10021696 DOI: 10.1371/journal.pgph.0001584] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Barnabas Tobi Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Siona Prasad
- Harvard University, Boston, Massachusetts, United States of America
| | | | - Laban Bakorimana
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Anne Niyigena
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | - Vincent K Cubaka
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Fredrick Kateera
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Richard Fletcher
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Bethany Hedt-Gauthier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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8
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Kateera F, Hedt-Gauthier B, Luo A, Niyigena A, Galvin G, Hakizimana S, Molina RL, Boatin AA, Kasonde P, Musabeyezu J, Ngonzi J, Riviello R, Semrau K, Sayinzoga F. Safe recovery after cesarean in rural Africa: Technical consensus guidelines for post-discharge care. Int J Gynaecol Obstet 2023; 160:12-21. [PMID: 35617096 PMCID: PMC10083957 DOI: 10.1002/ijgo.14284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/06/2022] [Accepted: 05/23/2022] [Indexed: 12/16/2022]
Abstract
Despite increasing cesarean rates in Africa, there remain extensive gaps in the standard provision of care after cesarean birth. We present recommendations for discharge instructions to be provided to women following cesarean delivery in Rwanda, particularly rural Rwanda, and with consideration of adaptable guidelines for sub-Saharan Africa, to support recovery during the postpartum period. These guidelines were developed by a Technical Advisory Group comprised of clinical, program, policy, and research experts with extensive knowledge of cesarean care in Africa. The final instructions delineate between normal and abnormal recovery symptoms and advise when to seek care. The instructions align with global postpartum care guidelines, with additional emphasis on care practices more common in the region and address barriers that women delivering via cesarean may encounter in Africa. The recommended timeline of postpartum visits and visit activities reflect the World Health Organization protocols and provide additional activities to support women who give birth via cesarean. These guidelines aim to standardize communication with women at the time of discharge after cesarean birth in Africa, with the goal of improved confidence and clinical outcomes among these individuals.
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Affiliation(s)
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Luo
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Grace Galvin
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Rose L Molina
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Adeline A Boatin
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katherine Semrau
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Félix Sayinzoga
- Maternal, Child and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
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9
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Habinshuti P, Nshimyiryo A, Fejfar DL, Niyigena A, Cubaka VK, Karema N, Bigirimana JB, Shyirambere C, Barnhart DA, Kateera F, Fulcher I. Impact of COVID-19 on access to cancer care in Rwanda: a retrospective time-series study using electronic medical records data. BMJ Open 2022; 12:e065398. [PMID: 36535717 PMCID: PMC9764097 DOI: 10.1136/bmjopen-2022-065398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic has caused disruptions in access to routine healthcare services worldwide, with a particularly high impact on chronic care patients and low and middle-income countries. In this study, we used routinely collected electronic medical records data to assess the impact of the COVID-19 pandemic on access to cancer care at the Butaro Cancer Center of Excellence (BCCOE) in rural Rwanda. METHODS We conducted a retrospective time-series study among all Rwandan patients who received cancer care at the BCCOE between 1 January 2016 and 31 July 2021. The primary outcomes of interest included a comparison of the number of patients who were predicted based on time-series models of pre-COVID-19 trends versus the actual number of patients who presented during the COVID-19 period (between March 2020 and July 2021) across four key indicators: the number of new patients, number of scheduled appointments, number of clinical visits attended and the proportion of scheduled appointments completed on time. RESULTS In total, 8970 patients (7140 patients enrolled before COVID-19 and 1830 patients enrolled during COVID-19) were included in this study. During the COVID-19 period, enrolment of new patients dropped by 21.7% (95% prediction interval (PI): -31.3%, -11.7%) compared with the pre-COVID-19 period. Similarly, the number of clinical visits was 25.0% (95% PI: -31.1%, -19.1%) lower than expected and the proportion of scheduled visits completed on time was 27.9% (95% PI: -39.8%, -14.1%) lower than expected. However, the number of scheduled visits did not deviate significantly from expected. CONCLUSION Although scheduling procedures for visits continued as expected, our findings reveal that the COVID-19 pandemic interrupted patients' ability to access cancer care and attend scheduled appointments at the BCCOE. This interruption in care suggests delayed diagnosis and loss to follow-up, potentially resulting in a higher rate of negative health outcomes among cancer patients in Rwanda.
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Affiliation(s)
- Placide Habinshuti
- Informatics Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Alphonse Nshimyiryo
- Research and Training Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | - Anne Niyigena
- Research and Training Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Vincent K Cubaka
- Research and Training Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Nadine Karema
- Informatics Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | | | - Dale A Barnhart
- Research and Training Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Fredrick Kateera
- Clinical Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Isabel Fulcher
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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10
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Ng'ang'a L, Ngoga G, Dusabeyezu S, Hedt-Gauthier BL, Harerimana E, Niyonsenga SP, Bavuma CM, Bukhman G, Adler AJ, Kateera F, Park PH. Feasibility and effectiveness of self-monitoring of blood glucose among insulin-dependent patients with type 2 diabetes: open randomized control trial in three rural districts in Rwanda. BMC Endocr Disord 2022; 22:244. [PMID: 36209209 PMCID: PMC9547423 DOI: 10.1186/s12902-022-01162-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prevalence of type 2 diabetes in sub Saharan Africa (SSA) has been on the rise. Effective control of blood glucose is key towards reducing the risk of diabetes complications. Findings mainly from high-income countries have demonstrated the effectiveness of self-monitoring of blood-glucose (SMBG) in controlling blood glucose levels. However, there are limited studies describing the implementation of SMBG in rural SSA. This study explores the feasibility and effectiveness of implementing SMBG among patients diagnosed with insulin-dependent type 2 diabetes in rural Rwanda. METHODS Participants were randomized into intervention (n = 42) and control (n = 38) groups. The intervention group received a glucose-meter, blood test-strips, log-book, waste management box and training on SMBG in addition to usual care. The control group continued with their usual care consisting of, routine monthly medical consultation and health education. The primary outcomes were adherence to the implementation of SMBG (testing schedule and recording data in the log-book) and change in hemoglobin A1c. Descriptive statistics and a paired t-test were used to analyze the primary outcomes. RESULTS In both the intervention and control arms, majority of the participants were female (59.5% vs 52.6%) and married (71.4% vs 73.7%). Most had at most a primary level education (83.3% vs. 89.4%) and were farmers (54.8% vs. 50.0%). Among those in the intervention group, 63.4% showed good adherence to implementing SMBG based on the number of tests recorded in the glucose meter. Only 20.3% demonstrated accurate recording of the glucose level tests in log-books. The mean difference of the HbA1C from baseline to six months post-intervention was significantly better among the intervention group -0.94% (95% CI -1.46, -0.41) compared to the control group 0.73% (95% CI -0.09, 1.54) p < 0.001. CONCLUSION Our study showed that among patients with insulin-dependent type 2 diabetes residing in rural Rwanda, SMBG was feasible and demonstrated positive outcomes in improving blood glucose control. However, there is need for strategies to enhance accuracy in recording blood glucose test results in the log-book. TRIAL REGISTRATION The trial was registered retrospectively on the Pan African Clinical Trial Registry, on 17th May 2019. The registration number is PACTR201905538846394.
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Affiliation(s)
| | - Gedeon Ngoga
- Non-Communicable Diseases Division, Rwanda Biomedical Centre, Kigali, Rwanda
- NCD Synergies, Partners In Health, Boston, MA, USA
| | | | | | | | | | - Charlotte M Bavuma
- Kigali University Teaching Hospital, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Gene Bukhman
- NCD Synergies, Partners In Health, Boston, MA, USA
- Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Alma J Adler
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Paul H Park
- NCD Synergies, Partners In Health, Boston, MA, USA
- Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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11
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Nkurunziza T, Williams W, Kateera F, Riviello R, Niyigena A, Miranda E, Bikorimana L, Nkurunziza J, Velin L, Goodman AS, Matousek A, Klug SJ, Gaju E, Hedt-Gauthier BL. mHealth-community health worker telemedicine intervention for surgical site infection diagnosis: a prospective study among women delivering via caesarean section in rural Rwanda. BMJ Glob Health 2022; 7:bmjgh-2022-009365. [PMID: 35902205 PMCID: PMC9341172 DOI: 10.1136/bmjgh-2022-009365] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Surgical site infections (SSIs) cause a significant global public health burden in low and middle-income countries. Most SSIs develop after patient discharge and may go undetected. We assessed the feasibility and diagnostic accuracy of an mHealth-community health worker (CHW) home-based telemedicine intervention to diagnose SSIs in women who delivered via caesarean section in rural Rwanda. Methods This prospective cohort study included women who underwent a caesarean section at Kirehe District Hospital between September 2019 and March 2020. At postoperative day 10 (±3 days), a trained CHW visited the woman at home, provided wound care and transmitted a photo of the wound to a remote general practitioner (GP) via WhatsApp. The GP reviewed the photo and made an SSI diagnosis. The next day, the woman returned to the hospital for physical examination by an independent GP, whose SSI diagnosis was considered the gold standard for our analysis. We describe the intervention process indicators and report the sensitivity and specificity of the telemedicine-based diagnosis. Results Of 787 women included in the study, 91.4% (n=719) were located at their home by the CHW and all of them (n=719, 100%) accepted the intervention. The full intervention was completed, including receipt of GP telemedicine diagnosis within 1 hour, for 79.0% (n=623). The GPs diagnosed 30 SSIs (4.2%) through telemedicine and 38 SSIs (5.4%) through physical examination. The telemedicine sensitivity was 36.8% and specificity was 97.6%. The negative predictive value was 96.4%. Conclusions Implementation of an mHealth-CHW home-based intervention in rural Rwanda and similar settings is feasible. Patients’ acceptance of the intervention was key to its success. The telemedicine-based SSI diagnosis had a high negative predictive value but a low sensitivity. Further studies must explore strategies to improve accuracy, such as accompanying wound images with clinical data or developing algorithms using machine learning.
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Affiliation(s)
- Theoneste Nkurunziza
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda .,Epidemiology, Department of Sport and Health Sciences, Technical University of Munich, München, Germany
| | - Wendy Williams
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Fredrick Kateera
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Robert Riviello
- Center for Surgery and Public Health, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.,Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Niyigena
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Vascular Surgery, University of Southern California, Los Angeles, California, USA
| | - Laban Bikorimana
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | - Lotta Velin
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
| | - Andrea S Goodman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Alex Matousek
- Northwest Heart and Lung Surgical Associates, Providence Sacred Heart Medical Center, Spokane, Washington, USA
| | - Stefanie J Klug
- Epidemiology, Department of Sport and Health Sciences, Technical University of Munich, München, Germany
| | - Erick Gaju
- eHealth Unit, Republic of Rwanda Ministry of Health, Kigali, Rwanda
| | - Bethany L Hedt-Gauthier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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12
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Nshimyiryo A, Barnhart DA, Kateera F, Mazimpaka C, Niyigena A, Ngoga G, Uwamahoro P, Galaris J, Gato S, Umugisha JP, Nahimana E, Cubaka VK, Umutesi G. Low COVID-19–related knowledge and access to adequate handwashing among patients with chronic diseases in rural Rwanda: a cross-sectional survey. Journal of Global Health Reports 2022. [DOI: 10.29392/001c.36464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) misinformation and inadequate access to hygiene and sanitation amenities could hamper efforts to contain COVID-19 spread in resource-limited settings. In this study, we describe knowledge of COVID-19 symptoms and preventive measures, sources of information, and access to adequate handwashing among patients with chronic diseases in three Rwandan rural districts during the onset of COVID-19 in Rwanda. Methods This was a cross-sectional survey conducted among patients who were enrolled in the HIV/AIDS, non-communicable diseases, mental health, oncology, and pediatric development programs at health facilities in Kayonza, Kirehe and Burera districts. The study sample was randomly selected and stratified by district and clinical program. Telephone-based data collection occurred between 23 April and 11 May 2020. Primary caregivers responded to the survey when the selected patient was a child under age 18 or severely ill. We defined good knowledge of COVID-19 symptoms and preventive measures as knowing that a dry cough and fever were common symptoms and social distancing or staying home and regular handwashing could prevent COVID-19 infection. Access to adequate handwashing was defined as living in a household with a handwashing station and regular access to clean water and soap. We used Fisher’s exact tests and logistic regression to measure associations between the source of information and good knowledge about COVID-19 and between socio-economic characteristics and access to adequate handwashing. Results In total, 150 patients and 70 caregivers responded to the survey. Forty-eight (22.3%) respondents had no formal education. Sources of COVID-19 information included mass media (86.8%), local government leaders (27.3%), healthcare workers (15.9%) and social media (6.8%). Twenty-seven percent (n=59) of respondents had good knowledge of COVID-19 symptoms and preventive measures. In the adjusted analysis, getting information from news media was associated with having good knowledge about COVID-19 (adjusted odds ratio, aOR: 5.46; 95% CI: 1.43-20.75]. Seventy-nine (35.9%) respondents reported access to adequate handwashing at home, with access varying significantly by the district in favour of Kayonza (61.3%). Conclusions COVID-19-related knowledge and access to adequate handwashing were low among patients with chronic diseases at the beginning of the pandemic in Rwanda. Efforts to mitigate COVID-19 spread among chronic care populations may include investment in targeted COVID-19-related education and access to adequate handwashing.
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Affiliation(s)
| | - Dale A. Barnhart
- Research and Training, Partners In Health/Inshuti Mu Buzima (PIH/IMB); Department of Global Health and Social Medicine, Harvard Medical School
| | | | | | | | | | | | | | | | | | | | | | - Grace Umutesi
- Partners In Health/Inshuti Mu Buzima (PIH/IMB); Department of Global Health, University of Washington
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13
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Kateera F, Riviello R, Goodman A, Nkurunziza T, Cherian T, Bikorimana L, Nkurunziza J, Nahimana E, Habiyakare C, Ntakiyiruta G, Matousek A, Gaju E, Gruendl M, Powell B, Sonderman K, Koch R, Hedt-Gauthier B. The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial. JMIR Mhealth Uhealth 2022; 10:e35155. [PMID: 35675108 PMCID: PMC9218905 DOI: 10.2196/35155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/30/2022] [Accepted: 05/04/2022] [Indexed: 12/02/2022] Open
Abstract
Background The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)–led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings. Objective This trial assesses whether CHW’s use of a mobile health (mHealth)–facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district. Methods A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care. Results The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively). Conclusions Home-based post–c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy. Trial Registration ClinicalTrials.gov NCT03311399; https://clinicaltrials.gov/ct2/show/NCT03311399
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Affiliation(s)
| | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States
| | - Andrea Goodman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | - Theoneste Nkurunziza
- Partners in Health, Kigali, Rwanda
- Epidemiology, Department for Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Teena Cherian
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | | | | | | | | | | | - Alexi Matousek
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States
| | - Erick Gaju
- Rwanda Ministry of Health, Kigali, Rwanda
| | - Magdalena Gruendl
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States
- Epidemiology, Department for Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Brittany Powell
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States
| | - Kristin Sonderman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States
| | - Rachel Koch
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Bethany Hedt-Gauthier
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
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14
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Kateera F, Shumbusho F, Manirambona L, Kabihizi J, Murangwa A, Serumondo J, Makuza JD, Nsanzimana S, Muvunyi CM, Kabakambira JD, Sylvain H, Camus G, Grant PM, Gupta N. Safety and efficacy of sofosbuvir-velpatasvir to treat chronic hepatitis C virus infection in treatment-naive patients in Rwanda (SHARED-3): a single-arm trial. Lancet Gastroenterol Hepatol 2022; 7:533-541. [DOI: 10.1016/s2468-1253(21)00398-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 02/07/2023]
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15
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Gupta N, Manirambona L, Shumbusho F, Kabihizi J, Murangwa A, Serumondo J, Makuza JD, Nsanzimana S, Muvunyi CM, Mukabatsinda C, Musabeyezu E, Camus G, Grant PM, Kateera F. Safety and efficacy of sofosbuvir–velpatasvir–voxilaprevir for re-treatment of chronic hepatitis C virus infection in patients with previous direct-acting antiviral treatment failure in Rwanda (SHARED-3): a single-arm trial. Lancet Gastroenterol Hepatol 2022; 7:542-551. [DOI: 10.1016/s2468-1253(21)00399-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 12/13/2022]
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16
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Koch R, Nkurunziza T, Rudolfson N, Nkurunziza J, Bakorimana L, Irasubiza H, Sonderman K, Riviello R, Hedt-Gauthier BL, Shrime M, Kateera F. Does community-based health insurance protect women from financial catastrophe after cesarean section? A prospective study from a rural hospital in Rwanda. BMC Health Serv Res 2022; 22:717. [PMID: 35642031 PMCID: PMC9153099 DOI: 10.1186/s12913-022-08101-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 05/18/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the > 79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%. However, 55.5% of the population is below the international poverty line meaning that even this copay can have a significant impact on a family's financial health. The aim of this study was to estimate the burden of OOP payments for cesarean sections in the context of CBHI and determine if having it reduces catastrophic health expenditure (CHE). METHODS This study is nested in a larger randomized controlled trial of women undergoing cesarean section at a district hospital in Rwanda. Eligible patients were surveyed at discharge to quantify household income and routine monthly expenditures and direct and indirect spending related to the hospitalization. This was used in conjunction with hospital billing records to calculate the rate of catastrophic expenditure by insurance group. RESULTS About 94% of the 340 women met the World Bank definition of extreme poverty. Of the 330 (97.1%) with any type of health insurance, the majority (n = 310, 91.2%) have CBHI. The average OOP expenditure for a cesarean section and hospitalization was $9.36. The average cost adding transportation to the hospital was $19.29. 164 (48.2%) had to borrow money and 43 (12.7%) had to sell possessions. The hospital bill alone was a CHE for 5.3% of patients. However, when including transportation costs, 15.4% incurred a CHE and including lost wages, 22.6%. CONCLUSION To ensure universal health coverage (UHC), essential surgical care must be affordable. Despite enrollment in universal health insurance, cesarean section still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although CBHI protects against CHE from the cost of healthcare, when adding in the cost of transportation, lost wages and caregivers, cesarean section is still often a catastrophic financial event. Further innovation in financial risk protection is needed to provide equitable UHC.
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Affiliation(s)
- Rachel Koch
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.
- University of Utah, Salt Lake City, USA.
| | - Theoneste Nkurunziza
- Department for Sport and Health Sciences, Epidemiology, Technical University of Munich, Munich, Germany
| | - Niclas Rudolfson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- WHO Collaborating Centre for Surgery and Public Health, Lund University, Lund, Sweden
| | | | | | | | - Kristin Sonderman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Bethany L Hedt-Gauthier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Mark Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Center for Global Surgery Evaluation, Boston, USA
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17
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Niyigena A, Alayande B, Bikorimana L, Miranda E, Rudolfson N, Ndagijimana D, Kateera F, Riviello R, Hedt-Gauthier B. The true costs of cesarean delivery for patients in rural Rwanda: Accounting for post-discharge expenses in estimated health expenditures. Int J Equity Health 2022; 21:62. [PMID: 35527274 PMCID: PMC9080175 DOI: 10.1186/s12939-022-01664-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 04/17/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda. Methods We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05. Results Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91). Conclusion Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.
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Affiliation(s)
| | - Barnabas Alayande
- University of Global Health Equity, Butaro, Rwanda.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | | | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Division of Vascular Surgery, University of Southern California, Los Angeles, CA, USA
| | - Niclas Rudolfson
- WHO Collaborating Centre for Surgery and Public Health, Lund University, Lund, Sweden
| | | | | | - Robert Riviello
- University of Global Health Equity, Butaro, Rwanda.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Bethany Hedt-Gauthier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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18
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Niyigena A, Girukubonye I, Barnhart DA, Cubaka VK, Niyigena PC, Nshunguyabahizi M, Mukamana B, Kateera F, Bitalabeho FA. Rwanda's community health workers at the front line: a mixed-method study on perceived needs and challenges for community-based healthcare delivery during COVID-19 pandemic. BMJ Open 2022; 12:e055119. [PMID: 35487742 PMCID: PMC9058292 DOI: 10.1136/bmjopen-2021-055119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE During the COVID-19 pandemic, community health workers (CHWs) served as front-line workers in the COVID-19 response while maintaining community health services. We aimed to understand challenges faced by Rwanda's CHWs during a nationwide COVID-19 lockdown that occurred between March and May 2020 by assessing the availability of trainings, supplies and supervision while exploring perceived needs and challenges. DESIGN AND SETTING This study was a mixed-method study conducted in three Rwandan districts: Burera, Kirehe and Kayonza. MAIN OUTCOME AND MEASURE Using data collected via telephone, we assessed the availability of trainings, supplies and supervision during the first national lockdown, while exploring perceived needs and challenges of CHWs who were engaged in COVID-19 response, in addition to their existing duties of delivering health services in the community. RESULTS Among the 292 quantitative survey participants, CHWs were responsible for a median of 55 households (IQR: 42-79) and visited a median of 30 households (IQR: 11-52) in the month prior to the survey (July 2020). In the previous 12 months, only 164 (56.2%) CHWs reported being trained on any health topic. Gaps in supply availability, particularly for commodities, existed at the start of the lockdown and worsened over the course of the lockdown. Supervision during the lockdown was low, with nearly 10% of CHWs never receiving supervision and only 24% receiving at least three supervision visits during the 3-month lockdown. In qualitative interviews, CHWs additionally described increases in workload, lack of personal protective equipment and COVID-specific training, fear of COVID-19, and difficult working conditions. CONCLUSION Many challenges faced by CHWs during the lockdown predated COVID-19 and persisted or were exacerbated during the pandemic. To promote the resilience of Rwanda's CHW system, we recommend increased access to PPE; investment in training, supervision and supply chain management; and financial compensation for CHWs.
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Affiliation(s)
| | | | - Dale A Barnhart
- Partners In Health, Kigali, Rwanda
- Harvard Medical School, Boston, Massachusetts, USA
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19
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Nyirahabihirwe F, Kamali I, Barnhart DA, Gakuru JDLP, Musafiri T, Rwamuhinda DD, Mutabazi P, Mukayirabuka S, Makuza JD, Kassim N, Mubiligi JM, Ndahimana JD, Kateera F. Implementation of Refugees' Inclusion in National Viral Hepatitis B and Hepatitis C Screening Campaign in Mahama Refugee Camp, Rwanda. Glob Health Sci Pract 2022; 10:GHSP-D-21-00349. [PMID: 35487545 PMCID: PMC9053140 DOI: 10.9745/ghsp-d-21-00349] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 03/15/2022] [Indexed: 12/22/2022]
Abstract
Conducting a high-quality mass screening campaign for Hepatitis B virus and Hepatitis C virus was a feasible, effective, and low-cost strategy to integrate refugees into Rwanda's national hepatitis prevention and management program. Introduction: The World Health Organization has called for the elimination of hepatitis B virus (HBV) and hepatitis C virus (HCV) as public health threats by 2030. In response to the United Nations High Commissioner for Refugees requests, Rwanda became the first country to include refugees in its national viral hepatitis prevention and management program in 2019. We used secondary data to describe the implementation of the first HBV and HCV screening program among refugees in Rwanda. Methods: Rapid diagnostic tests were used to screen for HBV surface antigen (HBsAg) and HCV antibody (anti-HCV). We used routine data collected during the HBV and HCV mass screening campaign among Burundian refugees living in Mahama camp and program records to estimate the screening coverage, the prevalence of HBV and HCV, and the cost of the campaign. Results: Over 28 days in February and March 2020, 26,498 unique individuals were screened for HBV and HCV, reflecting a screening coverage of 77.9% (95% confidence interval [CI]=76.5%, 78.4%). Coverage was greater than 90% among women aged 30–64 years, but younger age groups and men were less likely to be screened. On average, 946 clients were screened per day. The prevalence of anti-HCV was 1.1% (95% CI=1.0%, 1.3%), and the prevalence of HBsAg was 3.8% (95% CI=3.6%, 4.0%). We estimate that the total cost of the campaign was US$177,336.60, reflecting a per-person-screened cost of US$6.69. Conclusion: Conducting a mass screening was a feasible and effective strategy to achieve high screening coverage and identify refugees who were eligible for HBV and HCV treatment. This screening program in the Mahama refugee camp can serve as a reference for other refugee camps in Rwanda and elsewhere.
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Affiliation(s)
| | - Innocent Kamali
- Partners In Health- Rwanda/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Dale A Barnhart
- Partners In Health- Rwanda/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | - Jean Damascene Makuza
- Rwanda Biomedical Centre, Kigali, Rwanda.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Noor Kassim
- United Nations High Commissioner for Refugees, Kigali Rwanda
| | - Joel M Mubiligi
- Partners In Health- Rwanda/Inshuti Mu Buzima, Rwinkwavu, Rwanda
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20
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Smith SL, Nyirandagijimana B, Hakizimana J, Levy RP, Bienvenu R, Uwamwezi A, Hakizimfura O, Uwimana E, Kundu P, Mpanumusingo E, Nshimyiryo A, Rusangwa C, Kateera F, Mukasakindi H, Raviola G. Evaluating the delivery of Problem Management Plus in primary care settings in rural Rwanda: a study protocol using a pragmatic randomised hybrid type 1 effectiveness-implementation design. BMJ Open 2021; 11:e054630. [PMID: 34862298 PMCID: PMC8647529 DOI: 10.1136/bmjopen-2021-054630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Evidence-based low-intensity psychological interventions such as Problem Management Plus (PM+) have the potential to expand treatment access for depression and anxiety, yet these interventions are not yet effectively implemented in rural, public health systems in resource-limited settings. In 2017, Partners In Health adapted PM+ for delivery by primary care nurses in rural Rwanda and began integrating PM+ into health centres in collaboration with the Rwandan Ministry of Health, using established implementation strategies for mental health integration into primary care (Mentoring and Enhanced Supervision at Health Centers for Mental Health (MESH MH)). A gap in the evidence regarding whether low-intensity psychological interventions can be successfully integrated into real-world primary care settings and improve outcomes for common mental disorders remains. In this study, we will rigorously evaluate the delivery of PM+ by primary care nurses, supported by MESH MH, as it is scaled across one rural district in Rwanda. METHODS AND ANALYSIS We will conduct a hybrid type 1 effectiveness-implementation study to test the clinical outcomes of routinely delivered PM+ and to describe the implementation of PM+ at health centres. To study the clinical effectiveness of PM+, we will use a pragmatic, randomised multiple baseline design to determine whether participants experience improvement in depression symptoms (measured by the Patient Health Questionnaire-9) and functioning (measured by the WHO-Disability Assessment Scale Brief 2.0) after receiving PM+. We will employ quantitative and qualitative methods to describe and evaluate PM+ implementation outcomes using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, using routinely collected programme data and semistructured interviews. ETHICS AND DISSEMINATION This evaluation was approved by the Rwanda National Ethics Committee (Protocol #196/RNEC/2019) and deemed exempt by the Harvard University Institutional Review Board. The results from this evaluation will be useful for health systems planners and policy-makers working to translate the evidence base for low-intensity psychological interventions into practice.
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Affiliation(s)
- Stephanie L Smith
- Partners In Health, Boston, Massachusetts, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | - Roger P Levy
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | | | | | | | | | | | | | | | | | | | | | - Giuseppe Raviola
- Partners In Health, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
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21
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Rulisa A, van Kempen L, Mutesa L, Hakizimana E, Ingabire CM, Kateera F, Koenraadt CJM, van Vugt M, van den Borne B. Willingness to Contribute to Bio-Larviciding in the Fight against Malaria: A Contingent Valuation Study among Rice Farmers in Rwanda. Int J Environ Res Public Health 2021; 18:11575. [PMID: 34770086 PMCID: PMC8583195 DOI: 10.3390/ijerph182111575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 01/17/2023]
Abstract
There is broad consensus that successful and sustained larval source management (LSM) interventions, including bio-larviciding campaigns, require embeddedness in local community institutions. Ideally, these community structures should also be capable of mobilizing local resources to (co-)finance interventions. To date, farmer cooperatives, especially cooperatives of rice growers whose economic activity facilitates mosquito breeding, have remained under the radar in designing community-based bio-larviciding campaigns. This study explores the potential of rice farmer cooperatives in Bugesera district, Rwanda, to take up the aforementioned roles. To this purpose, we surveyed 320 randomly selected rice farmers who belonged to one of four rice cooperatives in the area and elicited their willingness-to-pay (WTP) for application of Bti, a popular bio-larvicide, in their rice paddies. Results from a (non-incentivized) bidding game procedure, which tested two alternative contribution schemes showed that financial contributions would be significantly different from zero and sufficient to carry a co-financing share of 15-25 per cent. A strong heterogeneity in mean WTP is revealed across cooperatives, in addition to variation among individual farmers, which needs to be anticipated when engaging farmer cooperatives in LSM.
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Affiliation(s)
- Alexis Rulisa
- Medical Research Centre Division, Rwanda Biomedical Centre, Kigali 7162, Rwanda;
- Department of Cultural Anthropology and Development Studies, Radboud University, 6525 Nijmegen, The Netherlands
| | - Luuk van Kempen
- Department of Cultural Anthropology and Development Studies, Radboud University, 6525 Nijmegen, The Netherlands
| | - Leon Mutesa
- Center for Human Genetics, College of Medicine and Health Sciences, University of Rwanda, Kigali 4285, Rwanda;
| | - Emmanuel Hakizimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali 7162, Rwanda;
| | - Chantal M. Ingabire
- Medical Research Centre Division, Rwanda Biomedical Centre, Kigali 7162, Rwanda;
| | - Fredrick Kateera
- Academic Medical Center, Department of Infectious Diseases, University of Amsterdam, 1012 Amsterdam, The Netherlands;
| | | | - Michèle van Vugt
- Center for Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam, 1012 Amsterdam, The Netherlands;
| | - Bart van den Borne
- Department of Health Education & Promotion, Maastricht University, 6211 Maastricht, The Netherlands;
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22
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Nkurunziza T, Williams WR, Kateera F, Riviello R, Miranda E, Bikorimana L, Niyigena A, Klug SJ, Hedt-Gauthier B. Feasibility and Efficacy of an Mhealth-community Health Worker Telemedicine Intervention for Surgical Site Infection Diagnosis Among Women Undergoing Cesarean Section in Rural Rwanda. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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23
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Miranda EA, Niyigena A, Bikorimana L, El-Gabri D, Riviello R, Kateera F, Hedt-Gauthier B, Cubaka V. Acceptability of Telemedicine for Early Surgical Site Infection Diagnosis after Cesarean Section. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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24
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Fletcher RR, Schneider G, Bikorimana L, Rukundo G, Niyigena A, Miranda E, Riviello R, Kateera F, Hedt-Gauthier B. The Use of Mobile Thermal Imaging and Deep Learning for Prediction of Surgical Site Infection. Annu Int Conf IEEE Eng Med Biol Soc 2021; 2021:5059-5062. [PMID: 34892344 DOI: 10.1109/embc46164.2021.9630094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The ability to detect surgical site infections (SSI) is a critical need for healthcare worldwide, but is especially important in low-income countries, where there is limited access to health facilities and trained clinical staff. In this paper, we present a new method of predicting SSI using a thermal image collected with a smart phone. Machine learning algorithms were developed using images collected as part of a clinical study that included 530 women in rural Rwanda who underwent cesarean section surgery. Thermal images were collected approximately 10 days after surgery, in conjunction with an examination by a trained doctor to determine the status of the wound (infected or not). Of the 530 women, 30 were found to have infected wounds. The data were used to develop two Convolutional Neural Net (CNN) models, with special care taken to avoid overfitting and address the problem of class imbalance in binary classification. The first model, a 6-layer naïve CNN model, demonstrated a median accuracy of AUC=0.84 with sensitivity=71% and specificity=87%. The transfer learning CNN model demonstrated a median accuracy of AUC=0.90 with sensitivity =95% and specificity=84%. To our knowledge, this is the first successful demonstration of a machine learning algorithm to predict surgical infection using thermal images alone.Clinical Relevance- This work establishes a promising new method for automated detection of surgical site infection.
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25
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Fletcher RR, Schneider G, Hedt-Gauthier B, Nkurunziza T, Alayande B, Riviello R, Kateera F. Use of Convolutional Neural Nets and Transfer Learning for Prediction of Surgical Site Infection from Color Images. Annu Int Conf IEEE Eng Med Biol Soc 2021; 2021:5047-5050. [PMID: 34892341 DOI: 10.1109/embc46164.2021.9630430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
One of the greatest concerns in post-operative care is the infection of the surgical wound. Such infections are a particular concern in global health and low-resource areas, where microbial antibiotic resistance is often common. In order to help address this problem, there is a great interest in developing simple tools for early detection of surgical wounds. Motivated by this need, we describe the development of two Convolutional Neural Net (CNN) models designed to detect an infection in a surgical wound using a color image taken from a mobile device. These models were developed using image data collected from a clinical study with 572 women in Rural Rwanda, who underwent Cesarean section surgery and had photos taken approximately 10 days after surgery. Infected wounds (N=62) were diagnosed by a trained doctor through a physical exam. In our model development, we observed a trade-off between AUC accuracy and sensitivity, and we chose to optimize for sensitivity, to match its use as a screening tool. Our naïve CNN model, with a limited number of convolutions and parameters, achieved median AUC = 0.655, true positive rate sensitivity = 0.75, specificity = 0.58, classification accuracy = 0.86. The second CNN model, developed with transfer learning using the Resnet50 architecture, produced a median AUC = 0.639 sensitivity = 0.92, specificity = 0.18, and classification accuracy 0.82. We discuss the specific training and optimization methods used to compensate for significant class imbalance and maximize sensitivity.
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26
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Niyigena A, Gato S, Miranda E, Hedt-Gauthier B, Nkurunziza T, Mazimpaka C, Hakizimana S, Riviello R, Kateera F, Boatin AA. Exploring Functional Outcomes Among Women Who Undergo C-section in a Rural District in Rwanda. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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27
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Barnhart DA, Kamali I, Nyirahabihirwe F, Mugabo C, Gakuru JDLP, Uwase M, Nizeyumuremyi E, Musafiri T, Gatete JDD, Makuza JD, Kateera F, Hedt-Gauthier B, Ndahimana JD. Knowledge among patients with Hepatitis C initiating on direct-acting antiviral treatment in rural Rwanda: A prospective cohort study. Glob Health Action 2021; 14:1953250. [PMID: 34347569 PMCID: PMC8344237 DOI: 10.1080/16549716.2021.1953250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Background Curative direct-acting antiviral treatment (DAA) has made it plausible to implement hepatitis C elimination interventions. However, poor hepatitis C knowledge among patients could impede the effectiveness of screening and treatment programs. Objective We assessed knowledge on hepatitis C among rural Rwandans initiating DAA treatment for hepatitis C in a prospective cohort. Methods We administered 15 true-false statements before treatment initiation and during one follow-up visit occurring either 1 or 2 months after treatment initiation. We assessed the average number of correct responses per patient, the proportion of correct responses to individual statements, pre-treatment predictors of knowledge, and whether post-initiation knowledge was associated with time since treatment initiation, quality of care, or adherence. Results Among 333 patients who answered knowledge questions before treatment initiation, 325 (97.6%) were re-assessed at a post-initiation visit. Pre-initiation, 72.1% knew hepatitis C was curable, 61.9% knew that hepatitis C could cause liver damage or cancer, and 42.3% knew that people with hepatitis C could look and feel fine. The average number of correct responses was 8.1 out of 15 (95% CI: 7.8–8.5), but was significantly lower among those with low educational attainment or with low literacy. Post-initiation, correct responses increased by an average of 2.0 statements (95% CI: 1.6, 2.4, p-value <0.001). Many patients still mistakenly believed that hepatitis C could be transmitted through kissing (66.5%), eating utensils (44.1%), handshakes (34.8%), and hugs (34.8%). Post-initiation knowledge is inversely associated with self-reported quality of care and unassociated with self-reported adherence. Conclusion Although knowledge improved over time, key gaps persisted among patients. Accessible public education campaigns targeted to low-literacy populations emphasizing that hepatitis C can be asymptomatic, has severe consequences, and is curable could promote participation in mass screening campaigns and linkage to care. Visual tools could facilitate clinician-provided patient education.
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Affiliation(s)
- Dale A Barnhart
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Partners In Health-Rwanda/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Innocent Kamali
- Partners In Health-Rwanda/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | - Carol Mugabo
- Partners In Health-Rwanda/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | - Mariam Uwase
- Partners In Health-Rwanda/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | | | | | - Jean Damascene Makuza
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,STIs and OBBI Division, Rwanda Biomedical Center, HIV/AIDS, Kigali, Rwanda
| | | | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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28
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Niyonsenga SP, Park PH, Ngoga G, Ntaganda E, Kateera F, Gupta N, Rwagasore E, Rwunganira S, Munyarugo A, Mutumbira C, Dusabayezu S, Eagan A, Boudreaux C, Noble C, Muhimpundu MA, Ndayisaba FG, Nsanzimana S, Bukhman G, Uwinkindi F. Implementation outcomes of national decentralization of integrated outpatient services for severe non-communicable diseases to district hospitals in Rwanda. Trop Med Int Health 2021; 26:953-961. [PMID: 33892521 PMCID: PMC8453822 DOI: 10.1111/tmi.13593] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Effective coverage of non-communicable disease (NCD) care in sub-Saharan Africa remains low, with the majority of services still largely restricted to central referral centres. Between 2015 and 2017, the Rwandan Ministry of Health implemented a strategy to decentralise outpatient care for severe chronic NCDs, including type 1 diabetes, heart failure and severe hypertension, to rural first-level hospitals. This study describes the facility-level implementation outcomes of this strategy. METHODS In 2014, the Ministry of Health trained two nurses in each of the country's 42 first-level hospitals to implement and deliver nurse-led, integrated, outpatient NCD clinics, which focused on severe NCDs. Post-intervention evaluation occurred via repeated cross-sectional surveys, informal interviews and routinely collected clinical data over two rounds of visits in 2015 and 2017. Implementation outcomes included fidelity, feasibility and penetration. RESULTS By 2017, all NCD clinics were staffed by at least one NCD-trained nurse. Among the approximately 27 000 nationally enrolled patients, hypertension was the most common diagnosis (70%), followed by type 2 diabetes (19%), chronic respiratory disease (5%), type 1 diabetes (4%) and heart failure (2%). With the exception of warfarin and beta-blockers, national essential medicines were available at more than 70% of facilities. Clinicians adhered to clinical protocols at approximately 70% agreement with evaluators. CONCLUSION The government of Rwanda was able to scale a nurse-led outpatient NCD programme to all first-level hospitals with good fidelity, feasibility and penetration as to expand access to care for severe NCDs.
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Affiliation(s)
| | - Paul H. Park
- Partners In HealthBostonMAUSA
- Division of Global Health EquityBrigham and Women’s HospitalBostonMAUSA
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
| | - Gedeon Ngoga
- Partners In HealthBostonMAUSA
- Inshuti Mu BuzimaRwinkwavuRwanda
| | | | | | - Neil Gupta
- Partners In HealthBostonMAUSA
- Division of Global Health EquityBrigham and Women’s HospitalBostonMAUSA
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
| | - Edson Rwagasore
- Rwanda Biomedical CenterRwanda Ministry of HealthKigaliRwanda
| | | | | | - Cadet Mutumbira
- Rwanda Biomedical CenterRwanda Ministry of HealthKigaliRwanda
| | | | - Arielle Eagan
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
| | - Chantelle Boudreaux
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
| | - Christopher Noble
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
| | | | | | | | - Gene Bukhman
- Partners In HealthBostonMAUSA
- Division of Global Health EquityBrigham and Women’s HospitalBostonMAUSA
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMAUSA
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29
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Powell BL, Nkurunziza T, Kateera F, Dusabe L, Kubwimana M, Koch R, Hedt-Gauthier BL, Riviello R. Synthesizing postpartum care pathways, facilitators, and barriers for women after cesarean section: a qualitative analysis from rural Rwanda. Journal of Global Health Reports 2021. [DOI: 10.29392/001c.23615] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Brittany L Powell
- Stanford University School of Medicine, Stanford, California, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Theoneste Nkurunziza
- Epidemiology, Department for Sport and Health Sciences, Technical University of Munich, Munich, Germany; Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | - Leila Dusabe
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | - Rachel Koch
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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30
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Boeke CE, Hiebert L, Waked I, Tsertsvadze T, Sharvadze L, Butsashvili M, Zakalashvili M, Naing W, Gupta N, Kateera F, McClure C, Ward JW, Ramers CB. Retreatment of Chronic Hepatitis C Infection: Real-World Regimens and Outcomes from National Treatment Programs in Three Low- and Middle-Income Countries. Clin Infect Dis 2021; 74:513-516. [PMID: 34014252 PMCID: PMC8835629 DOI: 10.1093/cid/ciab461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Indexed: 11/12/2022] Open
Abstract
Access to recommended second-line treatments is limited for patients who fail initial HCV therapy in low- and middle-income countries. Alternative regimens and associated outcomes are not well understood. Through a pooled analysis of national program data in Egypt, Georgia, and Myanmar, we observed SVR rates >90% for alternative retreatment regimens.
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Affiliation(s)
| | - Lindsey Hiebert
- Coalition for Global Hepatitis Elimination, Task Force for Global Health, Decatur, GA, United States
| | - Imam Waked
- Hepatology Department, National Liver Institute, Menoufia University, Shebeen El Kom, Egypt
| | - Tengiz Tsertsvadze
- Infectious Diseases, AIDS, and Clinical Immunology Research Center, Tbilisi, Georgia
| | | | | | | | - Win Naing
- Yangon Speciality Hospital, Liver Unit, Yangon, Myanmar
| | - Neil Gupta
- Partners in Health/ Inshuti Mu Buzima, Kigaili, Rwanda
| | | | - Craig McClure
- Clinton Health Access Initiative, Boston, MA, United States
| | - John W Ward
- Coalition for Global Hepatitis Elimination, Task Force for Global Health, Decatur, GA, United States
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31
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Umutesi G, Shyirambere C, Bigirimana JB, Urusaro S, Uwizeye FR, Nahimana E, Tuyishimire JD, Mugenzi P, Mubiligi JM, Uwinkindi F, Kateera F. Cancer care delivery innovations, experiences and challenges during the COVID-19 pandemic: The Rwanda experience. J Glob Health 2021; 11:03067. [PMID: 33884189 PMCID: PMC8053392 DOI: 10.7189/jogh.11.03067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Grace Umutesi
- Partners in Health/ Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | | | - Sandra Urusaro
- Partners in Health/ Inshuti Mu Buzima, Rwinkwavu, Rwanda
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Nshimyiryo A, Barnhart DA, Cubaka VK, Dusengimana JMV, Dusabeyezu S, Ndagijimana D, Umutesi G, Shyirambere C, Karema N, Mubiligi JM, Kateera F. Barriers and coping mechanisms to accessing healthcare during the COVID-19 lockdown: a cross-sectional survey among patients with chronic diseases in rural Rwanda. BMC Public Health 2021; 21:704. [PMID: 33838676 PMCID: PMC8035601 DOI: 10.1186/s12889-021-10783-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/06/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Large scale physical distancing measures and movement restrictions imposed to contain COVID-19, often referred to as 'lockdowns', abruptly and ubiquitously restricted access to routine healthcare services. This study describes reported barriers and coping mechanisms to accessing healthcare among chronic care patients during the nationwide COVID-19 lockdown in Rwanda. METHODS This cross-sectional study was conducted among chronic care patients enrolled in pediatric development, HIV/AIDS, non-communicable diseases, mental health, and oncology programs at 3 rural Rwandan districts. Active patients with an appointment scheduled between March-June 2020 and a phone number recorded in the electronic medical record system were eligible. Data were collected by telephone interviews between 23rd April and 11th May 2020, with proxy reporting by caregivers for children and critically ill-patients. Fisher's exact tests were used to measure associations. Logistic regression analysis was also used to assess factors associated with reporting at least one barrier to accessing healthcare during the lockdown. RESULTS Of 220 patient respondents, 44% reported at least one barrier to accessing healthcare. Barriers included lack of access to emergency care (n = 50; 22.7%), lack of access to medication (n = 44; 20.0%) and skipping clinical appointments (n = 37; 16.8%). Experiencing barriers was associated with the clinical program (p < 0.001), with oncology patients being highly affected (64.5%), and with increasing distance from home to the health facility (p = 0.031). In the adjusted logistic regression model, reporting at least one barrier to accessing healthcare was associated with the patient's clinical program and district of residence. Forty (18.2%) patients identified positive coping mechanisms to ensure continuation of care, such as walking long distances during suspension of public transport (n = 21; 9.6%), contacting clinicians via telephone for guidance or rescheduling appointments (n = 15; 6.8%), and delegating someone else for medication pick-up (n = 6; 2.7%). Of 124 patients who reported no barriers to accessing healthcare, 9% used positive coping mechanisms. CONCLUSION A large proportion of chronic care patients experienced barriers to accessing healthcare during the COVID-19 lockdown. However, many patients also independently identified positive coping mechanisms to ensure continuation of care - strategies that could be formally adopted by healthcare systems in Rwanda and similar settings to mitigate effects of future lockdowns on patients.
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Affiliation(s)
- Alphonse Nshimyiryo
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), PO BOX 3432, Kigali, Rwanda.
| | - Dale A Barnhart
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), PO BOX 3432, Kigali, Rwanda
- Harvard Medical School, Boston, USA
| | - Vincent K Cubaka
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), PO BOX 3432, Kigali, Rwanda
| | | | - Symaque Dusabeyezu
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), PO BOX 3432, Kigali, Rwanda
| | | | - Grace Umutesi
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), PO BOX 3432, Kigali, Rwanda
| | | | - Nadine Karema
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), PO BOX 3432, Kigali, Rwanda
| | - Joel M Mubiligi
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), PO BOX 3432, Kigali, Rwanda
| | - Fredrick Kateera
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), PO BOX 3432, Kigali, Rwanda
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Shumbusho F, Liu AF, Kateera F, Kabahizi J, Nsanzaimana S, Serumondo J, Damascene Makuza J, Grant PM, Musabeyezu E, Muvunyi C, Gupta N. Risk factors for difficult-to-treat hepatitis C virus genotype 4r in Rwanda and implications for elimination in sub-Saharan Africa. J Viral Hepat 2021; 28:682-686. [PMID: 33421247 DOI: 10.1111/jvh.13467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/18/2020] [Indexed: 12/20/2022]
Abstract
In sub-Saharan Africa, there exist distinct HCV genotype (GT) subtypes harbouring resistance-associated substitutions to commonly used non-structural protein 5A (NS5A) inhibitor-based direct-acting antiviral (DAA) regimens. In particular, GT4r subtype has demonstrated high rates of treatment failure. In the absence of routine viral sequencing in sub-Saharan Africa, it is important to identify sociodemographic, epidemiologic, and clinical characteristics that may be associated with GT4r infection. Methods: A secondary analysis was performed on data from 300 adults with HCV GT4 enrolled in a prospective trial assessing the safety and efficacy of sofosbuvir-ledipasvir in Rwanda in 2017. The association between characteristics at enrolment and GT subtype was assessed by chi-square analysis and logistic regression. In multivariate analysis, there were a higher proportion of participants with GT4r subtype with age <40 years (OR: 3.6, 95% CI: 1.3-10.5, p = 0.02), previous hospitalization (OR: 2.5, 95% CI: 1.3-5.0, p = 0.006), previous surgery (OR: 2.2, 95% CI: 1.1-4.2, p = 0.03), cirrhosis (OR: 3.2, 95% CI: 1.3-7.5, p = 0.008) and baseline HCV RNA >1 million IU/ml (OR: 3.4, 95% CI: 1.6-6.9, p = 0.001). Rwandan adults with GT4r are more likely to be younger, have a history of hospital admissions and surgeries and have more active or advanced liver disease compared to those with other GT4 subtypes. In the absence of advanced diagnostics to assess GT subtype, patients with these characteristics may warrant closer monitoring for treatment failure or alternative DAA regimens. More treatment experience with diverse DAA regimens is urgently needed for GT subtypes particular to this region.
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Affiliation(s)
| | - Anne F Liu
- Department of Hepatology, Gastroenterology and Endoscopy, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | | | | | | | | | - Jean Damascene Makuza
- Rwanda Biomedical Center, Kigali, Rwanda.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Philip M Grant
- Department of Infectious Diseases, Stanford University, Palo Alto, USA
| | | | - Claude Muvunyi
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Neil Gupta
- Partners In Health, Boston, USA.,Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA
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Kamali I, Barnhart DA, Nyirahabihirwe F, de la Paix Gakuru J, Uwase M, Nizeyumuremyi E, Walker S, Mazimpaka C, de Dieu Gatete J, Makuza JD, Serumondo J, Kateera F, d'Amour Ndahimana J. Initiation of hepatitis C treatment in two rural Rwandan districts: a mobile clinic approach. BMC Infect Dis 2021; 21:220. [PMID: 33632165 PMCID: PMC7908655 DOI: 10.1186/s12879-021-05920-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background To eliminate hepatitis C, Rwanda is conducting national mass screenings and providing to people with chronic hepatitis C free access to Direct Acting Antivirals (DAAs). Until 2020, prescribers trained and authorized to initiate DAA treatment were based at district hospitals, and access to DAAs remains expensive and geographically difficult for rural patients. We implemented a mobile clinic to provide DAA treatment initiation at primary-level health facilities among people with chronic hepatitis C identified through mass screening campaigns in rural Kirehe and Kayonza districts. Methods The mobile clinic team was composed of one clinician authorized to manage hepatitis, one lab technician, and one driver. Eligible patients received same-day clinical consultations, counselling, laboratory tests and DAA initiation. Using clinical databases, registers, and program records, we compared the number of patients who initiated DAA treatment before and during the mobile clinic campaign. We assessed linkage to care during the mobile clinical campaign and assessed predictors of linkage to care. We also estimated the cost per patient of providing mobile services and the reduction in out-of-pocket costs associated with accessing DAA treatment through the mobile clinic rather than the standard of care. Results Prior to the mobile clinic, only 408 patients in Kirehe and Kayonza had been initiated on DAAs over a 25-month period. Between November 2019 and January 2020, out of 661 eligible patients with hepatitis C, 429 (64.9%) were linked to care through the mobile clinic. Having a telephone number and complete address recorded at screening were strongly associated with linkage to care. The cost per patient of the mobile clinic program was 29.36 USD, excluding government-provided DAAs. Providing patients with same-day laboratory tests and clinical consultation at primary-level health facilities reduced out-of-pocket expenses by 9.88 USD. Conclusion The mobile clinic was a feasible strategy for providing rapid treatment initiation among people chronically infected by hepatitis C, identified through a mass screening campaign. Compared to the standard of care, mobile clinics reached more patients in a much shorter time. This low-cost strategy also reduced out-of-pocket expenditures among patients. However, long-term, sustainable care would require decentralization to the primary health-centre level.
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Affiliation(s)
| | - Dale A Barnhart
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | | | | | - Mariam Uwase
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | | | | | | | - Jean Damascene Makuza
- Rwanda Biomedical Centre, IHDPC, Kigali, Rwanda.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Musanabaganwa C, Cubaka V, Mpabuka E, Semakula M, Nahayo E, Hedt-Gauthier BL, Ng KCS, Murray MB, Kateera F, Mutesa L, Nsanzimana S. One hundred thirty-three observed COVID-19 deaths in 10 months: unpacking lower than predicted mortality in Rwanda. BMJ Glob Health 2021; 6:e004547. [PMID: 33627363 PMCID: PMC7907833 DOI: 10.1136/bmjgh-2020-004547] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 02/06/2023] Open
Abstract
The African region was predicted to have worse COVID-19 infection and death rates due to challenging health systems and social determinants of health. However, in the 10 months after its first case, Rwanda recorded 10316 cases and 133 COVID-19-related deaths translating to a case fatality rate (CFR) of 1.3%, which raised the question: why does Rwanda have a low COVID-19 CFR? Here we analysed COVID-19 data and explored possible explanations to better understand the disease burden in the context of Rwanda's infection control strategies.We investigated whether the age distribution plays a role in the observed low CFR in Rwanda by comparing the expected number of deaths for 10-year age bands based on the CFR reported in other countries with the observed number of deaths for each age group. We found that the age-specific CFRs in Rwanda are similar to or, in some older age groups, slightly higher than those in other countries, suggesting that the lower population level CFR reflects the younger age structure in Rwanda, rather than a lower risk of death conditional on age. We also accounted for Rwanda's comprehensive SARS-CoV-2 testing strategies and reliable documentation of COVID-19-related deaths and deduced that these measures may have allowed them to likely identify more asymptomatic or mild cases than other countries and reduced their reported CFR.Overall, the observed low COVID-19 deaths in Rwanda is likely influenced by the combination of effective infection control strategies, reliable identification of cases and reporting of deaths, and the population's young age structure.
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Affiliation(s)
| | - Vincent Cubaka
- Department of Research and Training, Partners in Health Rwanda, Kigali, Rwanda
| | - Etienne Mpabuka
- Medical Research Center, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Ernest Nahayo
- Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kamela C S Ng
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Fredrick Kateera
- Department of Research and Training, Partners in Health Rwanda, Kigali, Rwanda
| | - Leon Mutesa
- Center of Human Genetics, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Sabin Nsanzimana
- Medical Research Center, Rwanda Biomedical Center, Kigali, Rwanda
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36
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Nyirandagijimana B, Nshimyiryo A, Mukasakindi H, Odhiambo J, Uwimana E, Mukamurenzi V, Bienvenu R, Ndikubwimana JS, Uwamaliya C, Kundu P, Park PH, Mpunga T, Raviola GJ, Kateera F, Rusangwa C, Smith SL. Decentralized, primary-care delivered epilepsy services in Burera District, Rwanda: Service use, feasibility, and treatment. eNeurologicalSci 2020; 22:100296. [PMID: 33319078 PMCID: PMC7724371 DOI: 10.1016/j.ensci.2020.100296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 03/06/2020] [Accepted: 11/25/2020] [Indexed: 11/30/2022] Open
Abstract
Background Integrating epilepsy care into primary care settings could reduce the global burden of illness attributable to epilepsy. Since 2012, the Rwandan Ministry of Health and the international nonprofit Partners In Health have collaboratively used a multi-faceted implementation program- MESH MH—to integrate and scale-up care for epilepsy and mental disorders within rural primary care settings in Burera district, Rwanda. We here describe demographics, service use and treatment patterns for patients with epilepsy seeking care at MESH-MH supported primary care health centers. Methods and findings This was a retrospective cohort study using routinely collected data from fifteen health centers in Burera district, from January 2015 to December 2016. 286 patients with epilepsy completed 3307 visits at MESH-MH participating health centers over a two year period (Jan 1st 2015 to Dec 31st 2016). Men were over twice as likely to be diagnosed with epilepsy than women (OR 2.38, CI [1.77–3.19]), and children under 10 were thirteen times as likely to be diagnosed with epilepsy as those 10 and older (OR 13.27, CI [7.18–24.51]). Carbamazepine monotherapy was prescribed most frequently (34% of patients). Conclusion Task-sharing of epilepsy care to primary care via implementation programs such as MESH-MH has the potential to reduce the global burden of illness attributable to epilepsy. Primary-care delivered epilepsy services in rural Rwanda are described. High epilepsy service use, treatment uptake and follow-up was observed. Primary-care integration could increase epilepsy treatment availability globally.
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Affiliation(s)
| | | | | | - Jackline Odhiambo
- Ministry of Health, Kigali, Rwanda.,Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | | | | | - Priya Kundu
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Paul H Park
- Partners In Health, Boston, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA
| | | | - Giuseppe J Raviola
- Partners In Health, Boston, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, USA
| | | | | | - Stephanie L Smith
- Partners In Health, Boston, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, USA
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37
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Robb KA, Habiyakare C, Kateera F, Nkurunziza T, Dusabe L, Kubwimana M, Powell B, Koch R, Gruendl M, Ngamije P, Riviello R, Hedt-Gauthier B. Variability of water, sanitation, and hygiene conditions and the potential infection risk following cesarean delivery in rural Rwanda. J Water Health 2020; 18:741-752. [PMID: 33095197 DOI: 10.2166/wh.2020.220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Safe water, sanitation, and hygiene (WASH) is critical for the prevention of postpartum infections. The aim of this study was to characterize the WASH conditions women are exposed to following cesarean section in rural Rwanda. We assessed the variability of WASH conditions in the postpartum ward of a district hospital over two months, the WASH conditions at the women's homes, and the association between WASH conditions and suspected surgical site infection (SSI). Piped water flowed more consistently during the rainy month, which increased availability of water for drinking and handwashing (p < 0.05 for all). Latex gloves and hand-sanitizer were more likely to be available on weekends versus weekdays (p < 0.05 for both). Evaluation for suspected SSI after cesarean section was completed for 173 women. Women exposed to a day or more without running water in the hospital were 2.6 times more likely to develop a suspected SSI (p = 0.027). 92% of women returned home to unsafe WASH environments, with notable shortfalls in handwashing supplies and sanitation. The variability in hospital WASH conditions and the poor home WASH conditions may be contributing to SSIs after cesarean section. These relationships must be further explored to develop appropriate interventions to improve mothers' outcomes.
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Affiliation(s)
- Katharine Ann Robb
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA E-mail:
| | - Caste Habiyakare
- Kirehe District Hospital, Rwanda Ministry of Health, Kirehe, Rwanda
| | | | | | - Leila Dusabe
- Partners In Health (Inshuti Mu Buzima), Kigali, Rwanda
| | | | - Brittany Powell
- Stanford University School of Medicine, Stanford, CA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Rachel Koch
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Vanderbilt University Medical Center, Nashville, TN, USA
| | - Magdalena Gruendl
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Technical University Munich, Munich, Germany
| | - Patient Ngamije
- Kirehe District Hospital, Rwanda Ministry of Health, Kirehe, Rwanda
| | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Bethany Hedt-Gauthier
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA E-mail: ; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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38
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Van Nuil JI, Shumbusho F, Kateera F, Mukuralinda A, Kabahizi J, Muvunyi CM, Musabeyezu E, Mukabatsinda C, Mbituyumuremi A, Nsanzimana S, Mukerjee J, Gupta N. Care seeking and treatment for hepatitis C infection in Rwanda: A qualitative study of patient experiences. Glob Public Health 2020; 15:1778-1788. [PMID: 32735478 DOI: 10.1080/17441692.2020.1801787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
An estimated 71 million people live with hepatitis C virus (HCV) and without an effective vaccination, control efforts depend entirely on prevention, early diagnosis, and treatment with direct acting antiviral medication. The experiences of accessing care and treatment, as well as how HCV is locally perceived, are context specific and require an understanding of local epidemics. The objectives of this study were to explore the experiences and demand-side barriers for people with chronic HCV infection, as well as describe the social and cultural landscapes in which they experienced, managed, and perceived HCV in Rwanda. Eleven participants provided consent to participate and all completed two semi-structured interviews during treatment within a clinical trial. We identified four themes: (1) diagnosis and use of traditional medicine, (2) access and financial barriers, (3) complex social networks (4) proactivity in care-seeking. Results demonstrate the complex ways in which Rwandans understand HCV, utilise parallel health systems, activate social networks, and the importance of active agency in the opportunities and outcomes for their own health in the context of an early response to a major epidemic. Without recognising communities' understanding and expectations, it is impossible to build a sustainable and successful public health response to HCV.
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Affiliation(s)
| | | | | | | | | | | | - Emmanuel Musabeyezu
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | | | | | - Joia Mukerjee
- Partners in Health, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Neil Gupta
- Partners in Health, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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39
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Ng'ang'a L, Ngoga G, Dusabeyezu S, Hedt-Gauthier BL, Ngamije P, Habiyaremye M, Harerimana E, Ndayisaba G, Rusangwa C, Niyonsenga SP, Bavuma CM, Bukhman G, Adler AJ, Kateera F, Park PH. Implementation of blood glucose self-monitoring among insulin-dependent patients with type 2 diabetes in three rural districts in Rwanda: 6 months open randomised controlled trial. BMJ Open 2020; 10:e036202. [PMID: 32718924 PMCID: PMC7389513 DOI: 10.1136/bmjopen-2019-036202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Most patients diagnosed with diabetes in sub-Saharan Africa (SSA) present with poorly controlled blood glucose, which is associated with increased risks of complications and greater financial burden on both the patients and health systems. Insulin-dependent patients with diabetes in SSA lack appropriate home-based monitoring technology to inform themselves and clinicians of the daily fluctuations in blood glucose. Without sufficient home-based data, insulin adjustments are not data driven and adopting individual behavioural change for glucose control in SSA does not have a systematic path towards improvement. METHODS AND ANALYSIS This study explores the feasibility and impact of implementing self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes in rural Rwandan districts. This is an open randomised controlled trial comprising of two arms: (1) Intervention group-participants will receive a glucose metre, blood test strips, logbook, waste management box and training on how to conduct SMBG in additional to usual care and (2) Control group-participants will receive usual care, comprising of clinical consultations and routine monthly follow-up. We will conduct qualitative interviews at enrolment and at the end of the study to assess knowledge of diabetes. At the end of the study period, we will interview clinicians and participants to assess the perceived usefulness, facilitators and barriers of SMBG. The primary outcomes are change in haemoglobin A1c, fidelity to SMBG protocol by patients, appropriateness and adverse effects resulting from SMBG. Secondary outcomes include reliability and acceptability of SMBG and change in the quality of life of the participants. ETHICS AND DISSEMINATION This study has been approved by the Rwanda National Ethics Committee (Kigali, Rwanda No.102/RNEC/2018). We will disseminate the findings of this study through presentations within our study settings, scientific conferences and publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER PACTR201905538846394; pre-results.
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Affiliation(s)
- Loise Ng'ang'a
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | - Gedeon Ngoga
- Non-Communicable Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
- NCD Synergies, Partners in Health, Boston, Massachusetts, United States
| | - Symaque Dusabeyezu
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | | | - Patient Ngamije
- Kirehe District Hospital, Ministry of Health, Kigali, Rwanda
| | | | | | - Gilles Ndayisaba
- Non-Communicable Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Christian Rusangwa
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | | | - Charlotte M Bavuma
- Internal Medicine, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Gene Bukhman
- NCD Synergies, Partners in Health, Boston, Massachusetts, United States
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alma J Adler
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Fredrick Kateera
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | - Paul H Park
- NCD Synergies, Partners in Health, Boston, Massachusetts, United States
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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40
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Gupta N, Desalegn H, Ocama P, Lacombe K, Njouom R, Afihene M, Cunha L, Spearman CW, Sonderup MW, Kateera F. Converging pandemics: implications of COVID-19 for the viral hepatitis response in sub-Saharan Africa. Lancet Gastroenterol Hepatol 2020; 5:634-636. [PMID: 32553140 PMCID: PMC7295465 DOI: 10.1016/s2468-1253(20)30155-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Neil Gupta
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA 02115, USA; Partners In Health, Boston, MA, USA.
| | - Hailemichael Desalegn
- Medicala Department, St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Ponsiano Ocama
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Karine Lacombe
- Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, Paris, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique, INSERM, Sorbonne Université, Paris, France
| | - Richard Njouom
- Virology Department, Centre Pasteur of Cameroon, Yaounde, Cameroon
| | - Mary Afihene
- Department of Medicine, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Lina Cunha
- Hospital Privado de Maputo, Hepato-Gastroenterology Division, Department of Medicine, Maputo, Mozambique
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Faculty of Health Sciences and Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Mark W Sonderup
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Faculty of Health Sciences and Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Fredrick Kateera
- Clinical Programs Department, Partners in Health/Inshuti Mu Buzima, Kigali, Rwanda
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Cherian T, Hedt-Gauthier B, Nkurunziza T, Sonderman K, Gruendl MA, Nihiwacu E, Ramadhan B, Gaju E, Nahimana E, Habiyakare C, Ntakiyiruta G, Matousek A, Riviello R, Kateera F. Diagnosing Post-Cesarean Surgical Site Infections in Rural Rwanda: Development, Validation, and Field Testing of a Screening Algorithm for Use by Community Health Workers. Surg Infect (Larchmt) 2020; 21:613-620. [PMID: 32423365 DOI: 10.1089/sur.2020.062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: We aimed to develop and validate a screening algorithm to assist community health workers (CHWs) in identifying surgical site infections (SSIs) after cesarean section (c-section) in rural Africa. Methods: Patients were adult women who underwent c-section at a Rwandan rural district hospital between March and October 2017. A CHW administered a nine-item clinical questionnaire 10 ± 3 days post-operatively. Independently, a general practitioner (GP) administered the same questionnaire and assessed SSI presence by physical examination. The GP's SSI diagnosis was used as the gold standard. Using a simplified Classification and Regression Tree analysis, we identified a subset of screening questions with maximum sensitivity for the GP and CHW and evaluated the subset's sensitivity and specificity in a validation dataset. Then, we compared the subset's results when implemented in the community by CHWs with health center-reported SSI. Results: Of the 596 women enrolled, 525 (88.1%) completed the clinical questionnaire. The combination of questions concerning fever, pain, and discolored drainage maximized sensitivity for both the GPs (sensitivity = 96.8%; specificity = 85.6%) and CHWs (sensitivity = 87.1%; specificity = 73.8%). In the validation dataset, this subset had sensitivity of 95.2% and specificity of 83.3% for the GP-administered questions and sensitivity of 76.2% and specificity of 81.4% for the CHW-administered questions. In the community screening, the overall percent agreement between CHW and health center diagnoses was 81.1% (95% confidence interval: 77.2%-84.6%). Conclusions: We identified a subset of questions that had good predictive features for SSI, but its sensitivity was lower when administered by CHWs in a clinical setting, and it performed poorly in the community. Methods to improve diagnostic ability, including training or telemedicine, must be explored.
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Affiliation(s)
- Teena Cherian
- Department of Global Health and Social Medicine and Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine and Harvard Medical School, Boston, Massachusetts, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Kristin Sonderman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Magdalena Anna Gruendl
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Epidemiology, Technical University Munich, Munich, Germany
| | | | | | - Erick Gaju
- Rwanda Ministry of Health, Kigali, Rwanda
| | | | | | | | - Alexi Matousek
- Heart and Lung Institute, Sacred Heart Medical Center, Spokane, Washington, USA
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Fletcher RR, Olubeko O, Sonthalia H, Kateera F, Nkurunziza T, Ashby JL, Riviello R, Hedt-Gauthier B. Application of Machine Learning to Prediction of Surgical Site Infection. Annu Int Conf IEEE Eng Med Biol Soc 2020; 2019:2234-2237. [PMID: 31946345 DOI: 10.1109/embc.2019.8857942] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgical site infections are an important health concern, particularly in low-resource areas, where there is poor access to clinical facilities or trained clinical staff. As an application of machine learning, we present results from a study conducted in rural Rwanda for the purpose of predicting infection in Cesarean section wounds, which is a leading cause of maternal mortality. Questionnaire and image data were collected from 572 mothers approximately 10 days after surgery at a district hospital. Of the 572 women, 61 surgical wounds were determined to be infected as determined by a physical exam conducted by trained doctors. Machine learning models, logistic regression and Support Vector Machines (SVM), were developed independently for the questionnaire data and the image data. For the questionnaire data, the best results were achieved by the Logistic regression model, with an AUC Accuracy = 96.50% (93.0%-99.3%), Sensitivity = 0.71 (0.33 - 0.92), and Specificity = 0.99 (0.98 - 1.00). The features with the greatest predictive value were the presence of malcolored drainage from the wound and the presence of an odorous discharge from the wound. Using the image data alone, the SVM model performed best, with an AUC Accuracy = 99.5% (99.2%-100%), Sensitivity = 0.99 (0.99 - 1.00), and Specificity = 0.99 (0.99 - 1.00). Combining both questionnaire data and image data, the SVM model achieved an AUC Accuracy = 99.9% (99.7%-100%), Sensitivity = 0.99 (0.99 -1.00), and Specificity = 0.99 (0.99 - 1.00). Results from this initial study are very encouraging and demonstrate that good objective prediction of surgical infection for women in rural Rwanda is feasible using machine learning, even when using image data alone.
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Grant P, Shumbusho F, Van Nuil JI, Kateera F, Mukherjee J, Kabahizi J, Ntaganda F, Nsanzimana S, Mbituyumuremyi A, Damascene MJ, Muvunyi CM, Mukabatsinda C, Musabeyezu E, Ntirenganya C, Gupta N. Safety and Efficacy of Limited Laboratory Monitoring for Hepatitis C Treatment: A Blinded Clinical Trial in Rwanda. Hepatol Commun 2020; 4:569-576. [PMID: 32258951 PMCID: PMC7109339 DOI: 10.1002/hep4.1482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/10/2019] [Indexed: 11/29/2022] Open
Abstract
Direct-acting antivirals for hepatitis C virus (HCV) are highly effective and well-tolerated. However, only a small percentage of HCV-infected individuals globally have received therapy. Reducing the complexity of monitoring during HCV therapy, if shown to be safe, could facilitate greater access to HCV services, particularly in resource-limited settings such as sub-Saharan Africa. We enrolled a total of 300 patients who were chronically infected with genotype 4 HCV in Rwanda and treated them with fixed-dose ledispasvir/sofosbuvir for 12 weeks. For 60 consecutive participants enrolled, we blinded the study clinician to on-treatment laboratory results. We compared the efficacy, safety, and tolerability in those with blinded laboratory results to those with standard laboratory monitoring. Baseline characteristics among those with blinded laboratory values were comparable to those with standard monitoring. Among both groups, the median age was 63 years, and the median HCV viral load was 5.9 log (versus 64 years and 6.0 log, respectively). Sustained virologic response rates at 12 weeks after treatment completion were similar in those with blinded laboratories (87%) compared to those with standard laboratory monitoring (87%). There was no increase in adverse events in those with blinded laboratory results, and no participants discontinued the study medication because of an adverse event. Conclusion: On-treatment laboratory monitoring did not improve patient outcomes in those treated with ledispasvir/sofosbuvir. Eliminating this monitoring in treatment programs in resource-limited settings may facilitate and accelerate scale-up of HCV therapy.
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Affiliation(s)
- Philip Grant
- Division of Infectious DiseasesStanford UniversityPalo AltoCA
| | | | | | | | - Joia Mukherjee
- Partners In HealthRwinkwavuRwanda
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMA
| | | | | | | | | | | | | | | | | | | | - Neil Gupta
- Partners In HealthRwinkwavuRwanda
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMA
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Gupta N, Kateera F, Desalegn H, Ocama P, Njouom R, Lacombe K. Is resistance to direct-acting antivirals in sub-Saharan Africa a threat to HCV elimination? Recommendations for action. J Hepatol 2020; 72:583-584. [PMID: 31836263 DOI: 10.1016/j.jhep.2019.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/25/2019] [Indexed: 01/26/2023]
Affiliation(s)
- Neil Gupta
- Partners In Health, Boston, USA; Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA.
| | - Fredrick Kateera
- Research Department, Partners in Health/ Inshuti Mu Buzima, Kigali, Rwanda
| | - Hailemichael Desalegn
- Medical Department, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Ponsiano Ocama
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Njouom
- Virology Department, Centre Pasteur of Cameroon, Yaounde, Cameroon
| | - Karine Lacombe
- Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, Paris, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique, INSERM, Sorbonne Université, Paris, France
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Mazimpaka C, Uwitonze E, Cherian T, Hedt-Gauthier B, Kateera F, Riviello R, El-Khatib Z, Sonderman K, Gruendl M, Habiyakare C, Hakizimana S, Kayitesi D, Nkurunziza T. Perioperative Management and Outcomes After Cesarean Section-A Cross-Sectional Study From Rural Rwanda. J Surg Res 2020; 245:390-395. [PMID: 31425881 PMCID: PMC7055241 DOI: 10.1016/j.jss.2019.07.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/30/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cesarean sections (c-sections), the most common surgical procedures performed worldwide, are essential in reducing maternal and neonatal deaths. There is a paucity of research studies on c-section care and outcomes in rural African settings. The objective of this study was to describe demographic characteristics, clinical management, and maternal and neonatal outcomes among women receiving c-sections at Kirehe District Hospital (KDH) in rural Rwanda. METHODS This retrospective cohort study included all women aged ≥ 18 y residing in KDH catchment area who delivered by c-section at KDH between April 1 and September 30, 2017. Demographic and clinical characteristics of these women and their newborns were collected using patient interviews and medical chart extraction. Descriptive analyses were performed, and frequency and percentages are reported. RESULTS Of the 621 women included in the study, 45.7% (n = 284) were aged 25-34 y; 42.2% (n = 262) were married; 67.5% (n = 419) had primary education; and 75.7% (n = 470) were farmers by occupation. Burundian refugees living in the nearby Mahama Refugee Camp comprised 13.7% (n = 85) of the study population. The most common indication for c-section was having undergone a c-section previously (31.9%, n = 198), followed by acute fetal distress (30.8%, n = 191). Among those with previous c-section as the sole indication for surgery, 85.4% presented as either urgent or emergent cases. Postoperatively, 67.7% spent less than 4 d at the hospital and 96.1% had no postoperative complications before discharge. Approximately 10% (59/572) of neonates were admitted to the neonatal unit, with the most common reason being neonatal infection (59.6%, n = 31). CONCLUSIONS Our study found that previous delivery via c-section was the primary indication for c-section and that most of these cases were emergent or urgent on presentation. This study highlights the need for further research to explore the feasibility, safety, and appropriateness of vaginal birth after cesarean in rural district hospitals in sub-Saharan Africa.
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Affiliation(s)
| | - Eline Uwitonze
- Primary Health Care, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Teena Cherian
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Bethany Hedt-Gauthier
- Primary Health Care, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Fredrick Kateera
- Primary Health Care, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ziad El-Khatib
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Kristin Sonderman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Magdalena Gruendl
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Department of Epidemiology, Technical University Munich, Munich, Germany
| | | | | | - Daniella Kayitesi
- Primary Health Care, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
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May L, Nshimyiryo A, Kubwimana M, Nahimana E, Schoen N, Gadgil A, Kateera F, Feldman HA, Nyishime M, Hansen A. Performance of a Nonelectric Infant Warmer in Rwandan Health Centers. Glob Pediatr Health 2019; 6:2333794X19884820. [PMID: 31696147 PMCID: PMC6820166 DOI: 10.1177/2333794x19884820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/03/2019] [Accepted: 09/13/2019] [Indexed: 01/21/2023] Open
Abstract
Background. Neonatal hypothermia remains a challenge in resource-limited settings. Methods. We conducted a prospective mixed-methods cohort study in rural Rwandan health centers to assess the performance of an infant warmer we designed for low-resource settings. All hypothermic infants were eligible for enrollment. Outcomes. Safety: incidence of adverse reactions. Effectiveness: attainment of euthermia, rate of temperature rise. Feasibility: correct use of warmer, signs of wear. Interviews of caregivers and nurses. Findings. Of 102 encounters, there were no adverse reactions. Of 80 encounters for hypothermia when infants on warmer for ≥1 hour, 79 achieved euthermia; 73 in ≤2 hours. Of the 80 encounters, 64 had temperature rise ≥0.5°C/h. Of the 102 encounters, there were no instances of the warmer being prepared, used, or cleaned incorrectly. Five out of the 12 warmers exhibited wear. Interview participants were predominantly positive; some found time for readiness of warmer challenging. Interpretation. The warmer performed well. It is appropriate to study in larger scale.
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Affiliation(s)
- Leana May
- Boston Children's Hospital, MA, USA.,Children's Hospital of Colorado, Aurora, CO, USA
| | | | | | | | | | - Ashok Gadgil
- Lawrence Berkley National Laboratory, Berkley, CA, USA
| | | | - Henry A Feldman
- Boston Children's Hospital, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Anne Hansen
- Boston Children's Hospital, MA, USA.,Harvard Medical School, Boston, MA, USA
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47
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Nkurunziza T, Kateera F, Sonderman K, Gruendl M, Nihiwacu E, Ramadhan B, Cherian T, Nahimana E, Ntakiyiruta G, Habiyakare C, Ngamije P, Matousek A, Gaju E, Riviello R, Hedt-Gauthier B. Prevalence and predictors of surgical-site infection after caesarean section at a rural district hospital in Rwanda. Br J Surg 2019; 106:e121-e128. [PMID: 30620071 PMCID: PMC7938824 DOI: 10.1002/bjs.11060] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/30/2018] [Accepted: 10/30/2018] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | - F Kateera
- Partners In Health/Inshuti Mu Buzima, Rwanda
| | - K Sonderman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Centre for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - M Gruendl
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Public Health, Technical University Munich, Munich, Germany
| | - E Nihiwacu
- Partners In Health/Inshuti Mu Buzima, Rwanda
| | - B Ramadhan
- Partners In Health/Inshuti Mu Buzima, Rwanda
| | - T Cherian
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - E Nahimana
- Partners In Health/Inshuti Mu Buzima, Rwanda
| | | | | | | | - A Matousek
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Centre for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E Gaju
- Ministry of Health Kigali, Rwanda
| | - R Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Centre for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - B Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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48
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Nshimyiryo A, Hedt-Gauthier B, Mutaganzwa C, Kirk CM, Beck K, Ndayisaba A, Mubiligi J, Kateera F, El-Khatib Z. Risk factors for stunting among children under five years: a cross-sectional population-based study in Rwanda using the 2015 Demographic and Health Survey. BMC Public Health 2019; 19:175. [PMID: 30744614 PMCID: PMC6371425 DOI: 10.1186/s12889-019-6504-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 02/01/2019] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | - Bethany Hedt-Gauthier
- Partners In Health / Inshuti Mu Buzima, Kigali, Rwanda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, USA
| | | | | | - Kathryn Beck
- Partners In Health / Inshuti Mu Buzima, Kigali, Rwanda
| | | | - Joel Mubiligi
- Partners In Health / Inshuti Mu Buzima, Kigali, Rwanda
| | | | - Ziad El-Khatib
- Partners In Health / Inshuti Mu Buzima, Kigali, Rwanda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- World Health Programme, Université du Québec en Abitibi-Témiscamingue (UQAT), Québec, Canada
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49
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Hedt-Gauthier BL, Riviello R, Nkurunziza T, Kateera F. Growing research in global surgery with an eye towards equity. Br J Surg 2019; 106:e151-e155. [DOI: 10.1002/bjs.11066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/12/2018] [Accepted: 10/30/2018] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Global surgery research is often generated through collaborative partnerships between researchers from both low- and middle-income countries (LMICs) and high-income countries (HICs). Inequitable engagement of LMIC collaborators can limit the impact of the research.
Methods
This article describes evidence of inequities in the conduct of global surgery research and outlines reasons why the inequities in this research field may be more acute than in other global health research disciplines. The paper goes on to describe activities for building a collaborative research portfolio in rural Rwanda.
Results
Inequities in global surgery research collaborations can be attributed to: a limited number and experience of researchers working in this field; time constraints on both HIC and LMIC global surgery researchers; and surgical journal policies. Approaches to build a robust, collaborative research portfolio in Rwanda include leading research trainings focused on global surgery projects, embedding surgical fellows in Rwanda to provide bidirectional research training and outlining all research products, ensuring that all who are engaged have opportunities to grow in capacities, including leading research, and that collaborators share opportunities equitably. Of the 22 published or planned papers, half are led by Rwandan researchers, and the research now has independent research funding.
Conclusion
It is unacceptable to gather data from an LMIC without meaningful engagement in all aspects of the research and sharing opportunities with local collaborators. The strategies outlined here can help research teams build global surgery research portfolios that optimize the potential for equitable engagement.
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Affiliation(s)
- B L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Partners In Health/Rwanda, Kigali, Rwanda
| | - R Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - F Kateera
- Partners In Health/Rwanda, Kigali, Rwanda
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50
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Nahimana E, May L, Gadgil A, Rapp V, Magge H, Kubwimana M, Nshimyiryo A, Kateera F, Feldman HA, Nkikabahizi F, Sayinzoga F, Hansen A. A low cost, re-usable electricity-free infant warmer: evaluation of safety, effectiveness and feasibiliy. Public Health Action 2018; 8:211-217. [PMID: 30775282 DOI: 10.5588/pha.18.0031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 10/19/2018] [Indexed: 01/15/2023] Open
Abstract
Setting: Rural Rwandan hospitals, where thermoregulation is critical yet a challenge for pre-term, low-birth-weight (LBW) or sick newborns. Objective: To assess the safety, effectiveness, and feasibility of an inexpensive, reusable, non-electric warmer to complement kangaroo mother care (KMC). Methods: Prospective single-arm, non-randomized intervention study. Enrolled infants were hypothermic or at risk of hypothermia due to prematurity/LBW. Infants used the warmer in conjunction with KMC or as the sole source of external heat. Temperatures of the infant, warmer and air were measured for up to 6 h. Results: Overall, 33 patients used the warmer for 102 encounters: 43 hypothermic and 59 at risk of hypothermia. In 7/102 encounters (7%), the infant developed a temperature of >37.5°C (37.6°-38.2°C). For 43 hypothermic encounters and 59 at-risk encounters, hypothermia was corrected/prevented in respectively 41 (95%) and 59 (100%) instances. The warmer maintained goal temperature for the study duration in ⩾85% of uses. Two/12 warmers broke down after <10 uses. In no instances was the warmer used incorrectly. Conclusion: Our results are promising for this prototype design, and warrant testing on a wider scale.
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Affiliation(s)
- E Nahimana
- Partners In Health, Inshuti Mu Buzima, Kigali, Rwanda
| | - L May
- Boston Children's Hospital, Boston, Massachusetts, USA.,Children's Hospital of Colorado, Aurora, Colorado, USA
| | - A Gadgil
- Lawrence Berkeley National Laboratory, Berkeley, California, USA.,University of California, Berkeley, California, USA
| | - V Rapp
- Lawrence Berkeley National Laboratory, Berkeley, California, USA
| | - H Magge
- Partners In Health, Inshuti Mu Buzima, Kigali, Rwanda.,Boston Children's Hospital, Boston, Massachusetts, USA.,Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - M Kubwimana
- Partners In Health, Inshuti Mu Buzima, Kigali, Rwanda
| | - A Nshimyiryo
- Partners In Health, Inshuti Mu Buzima, Kigali, Rwanda
| | - F Kateera
- Partners In Health, Inshuti Mu Buzima, Kigali, Rwanda
| | - H A Feldman
- Boston Children's Hospital, Boston, Massachusetts, USA.,Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - F Nkikabahizi
- Rwinkwavu District Hospital, Rwanda Ministry of Health, Kayonza, Rwanda
| | | | - A Hansen
- Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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