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Ofori SK, Dankwa EA, Estrada EH, Hua X, Kimani TN, Wade CG, Buckee CO, Murray MB, Hedt-Gauthier BL. COVID-19 vaccination strategies in Africa: A scoping review of the use of mathematical models to inform policy. Trop Med Int Health 2024. [PMID: 38740040 DOI: 10.1111/tmi.13994] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
OBJECTIVE Mathematical models are vital tools to understand transmission dynamics and assess the impact of interventions to mitigate COVID-19. However, historically, their use in Africa has been limited. In this scoping review, we assess how mathematical models were used to study COVID-19 vaccination to potentially inform pandemic planning and response in Africa. METHODS We searched six electronic databases: MEDLINE, Embase, Web of Science, Global Health, MathSciNet and Africa-Wide NiPAD, using keywords to identify articles focused on the use of mathematical modelling studies of COVID-19 vaccination in Africa that were published as of October 2022. We extracted the details on the country, author affiliation, characteristics of models, policy intent and heterogeneity factors. We assessed quality using 21-point scale criteria on model characteristics and content of the studies. RESULTS The literature search yielded 462 articles, of which 32 were included based on the eligibility criteria. Nineteen (59%) studies had a first author affiliated with an African country. Of the 32 included studies, 30 (94%) were compartmental models. By country, most studies were about or included South Africa (n = 12, 37%), followed by Morocco (n = 6, 19%) and Ethiopia (n = 5, 16%). Most studies (n = 19, 59%) assessed the impact of increasing vaccination coverage on COVID-19 burden. Half (n = 16, 50%) had policy intent: prioritising or selecting interventions, pandemic planning and response, vaccine distribution and optimisation strategies and understanding transmission dynamics of COVID-19. Fourteen studies (44%) were of medium quality and eight (25%) were of high quality. CONCLUSIONS While decision-makers could draw vital insights from the evidence generated from mathematical modelling to inform policy, we found that there was limited use of such models exploring vaccination impacts for COVID-19 in Africa. The disparity can be addressed by scaling up mathematical modelling training, increasing collaborative opportunities between modellers and policymakers, and increasing access to funding.
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Affiliation(s)
- Sylvia K Ofori
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Emmanuelle A Dankwa
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Eve Hiyori Estrada
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Xinyi Hua
- Department of Biostatistics, Epidemiology and Environmental Health Sciences, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
| | - Teresia N Kimani
- KAVI-Institute of Clinical Research, University of Nairobi, Nairobi, Kenya
- Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
- Paul G Allen School for Global Animal Health, Washington State University, Pullman, Washington, USA
- Department of Health Services, Kiambu County, Ministry of Health Kenya, Kiambu County, Kenya
| | - Carrie G Wade
- Countway Library, Harvard School of Medicine, Boston, Massachusetts, USA
| | - Caroline O Buckee
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Ofori SK, Dankwa EA, Ngwakongnwi E, Amberbir A, Bekele A, Murray MB, Grad YH, Buckee CO, Hedt-Gauthier BL. Evidence-based Decision Making: Infectious Disease Modeling Training for Policymakers in East Africa. Ann Glob Health 2024; 90:22. [PMID: 38523847 PMCID: PMC10959131 DOI: 10.5334/aogh.4383] [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: 12/22/2023] [Accepted: 02/17/2024] [Indexed: 03/26/2024] Open
Abstract
Background Mathematical modeling of infectious diseases is an important decision-making tool for outbreak control. However, in Africa, limited expertise reduces the use and impact of these tools on policy. Therefore, there is a need to build capacity in Africa for the use of mathematical modeling to inform policy. Here we describe our experience implementing a mathematical modeling training program for public health professionals in East Africa. Methods We used a deliverable-driven and learning-by-doing model to introduce trainees to the mathematical modeling of infectious diseases. The training comprised two two-week in-person sessions and a practicum where trainees received intensive mentorship. Trainees evaluated the content and structure of the course at the end of each week, and this feedback informed the strategy for subsequent weeks. Findings Out of 875 applications from 38 countries, we selected ten trainees from three countries - Rwanda (6), Kenya (2), and Uganda (2) - with guidance from an advisory committee. Nine trainees were based at government institutions and one at an academic organization. Participants gained skills in developing models to answer questions of interest and critically appraising modeling studies. At the end of the training, trainees prepared policy briefs summarizing their modeling study findings. These were presented at a dissemination event to policymakers, researchers, and program managers. All trainees indicated they would recommend the course to colleagues and rated the quality of the training with a median score of 9/10. Conclusions Mathematical modeling training programs for public health professionals in Africa can be an effective tool for research capacity building and policy support to mitigate infectious disease burden and forecast resources. Overall, the course was successful, owing to a combination of factors, including institutional support, trainees' commitment, intensive mentorship, a diverse trainee pool, and regular evaluations.
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Affiliation(s)
- Sylvia K. Ofori
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Emmanuelle A. Dankwa
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Emmanuel Ngwakongnwi
- Institute of Global Health Equity Research, University of Global Health Equity, Kigali, Rwanda
| | - Alemayehu Amberbir
- Institute of Global Health Equity Research, University of Global Health Equity, Kigali, Rwanda
| | - Abebe Bekele
- School of Medicine, University of Global Health Equity, Kigali, Rwanda
| | - Megan B. Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Yonatan H. Grad
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Caroline O. Buckee
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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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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Chery MJ, Dubique K, Higgins JM, Faure PA, Phillips R, Morris S, Clisbee M, Conserve DF, Ricthwood T, Lefruit RM, Hedt-Gauthier BL. COVID-19 vaccine acceptance in three rural communes in Haiti: A cross-sectional study. Hum Vaccin Immunother 2023; 19:2204048. [PMID: 37157153 PMCID: PMC10171132 DOI: 10.1080/21645515.2023.2204048] [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: 05/10/2023] Open
Abstract
Vaccines are the most effective mechanism for ending the COVID-19 pandemic. However, reluctance to accept vaccines has hindered the efforts of health authorities to combat the virus. In Haiti, as of July 2021, less than 1% of the country's population has been fully vaccinated in part due to vaccine hesitancy. Our goal was to assess Haitian attitudes toward COVID-19 vaccination and investigate the primary reasons for Moderna vaccine hesitancy. We conducted a cross-sectional survey across three rural Haitian communities, in September 2021. The research team used electronic tablets to collect quantitative data from 1,071 respondents, selected randomly across the communities. We report descriptive statistics and identify variables associated with vaccine acceptance using logistic regression built using a backward stepwise approach. Among 1,071 respondents, the overall acceptance rate was 27.0% (n = 285). The most common reason for vaccine hesitancy was "concern about side effects" (n = 484, 67.1%) followed by "concern about contracting COVID-19 from the vaccine" (n = 472, 65.4%). Three-quarters of respondents (n = 817) identified their healthcare workers as their most trustworthy source for information related to the vaccine. In the bivariate analysis, male gender (p = .06) and no history of drinking alcohol (p < .001) were significantly associated with being more likely to take the vaccine. In the final reduced model, only those with a history of drinking alcohol were significantly more likely to take the vaccine (aOR = 1.47 (1.23, 1.87) p < .001). The acceptance rate for the COVID-19 vaccine is low, and public health experts should design and strengthen vaccination campaigns to combat misinformation and public distrust.
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Affiliation(s)
- Maurice J Chery
- Research Department, Zanmi Lasante/Partners in Health Mirebalais: Hopital Universitaire de Mirebalais, Mirebalais, Haiti
| | - Kobel Dubique
- Research Department, Zanmi Lasante/Partners in Health Mirebalais: Hopital Universitaire de Mirebalais, Mirebalais, Haiti
| | - Julia M Higgins
- Strategic Information Systems, Partners in Health, Boston, MA, USA
| | - Peterson Abnis Faure
- Research Department, Zanmi Lasante/Partners in Health Mirebalais: Hopital Universitaire de Mirebalais, Mirebalais, Haiti
| | - Roslyn Phillips
- Research Department, Zanmi Lasante/Partners in Health Mirebalais: Hopital Universitaire de Mirebalais, Mirebalais, Haiti
| | - Sarah Morris
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mary Clisbee
- Research Department, Zanmi Lasante/Partners in Health Mirebalais: Hopital Universitaire de Mirebalais, Mirebalais, Haiti
| | - Donaldson F Conserve
- Department of Prevention and Community Health, George Washington University School of Public Health and Health Services: The George Washington University Milken Institute of Public Health, Washington, DC, USA
| | - Tiarney Ricthwood
- Department of Medicine & Community Health and Global Health, Duke Institute of Global Health, Durham, NC, USA
| | - Ralph M Lefruit
- Research Department, Zanmi Lasante/Partners in Health Mirebalais: Hopital Universitaire de Mirebalais, Mirebalais, Haiti
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- The Cross-Site COVID-19 Cohort Technical Working Group is Composed of the Following Members- Partners In Health/Boston: Jean Claude Mugunga, Donald Fejfar, Stefanie Joseph; Partners In Health/Haiti: Wesler Lambert, Mary Clisbee, Fernet Leandre; Partners In Health/Liberia: Prince F. Varney; Partners In Health/Lesotho: Melino Ndayizigiye, Patrick Nkundanyirazo, Afom Andom; Partners In Health/Malawi: Emilia Connolly, Chiyembekezo Kachimanga, Fabien Munyaneza; Partners In Health/Mexico: Zeus Aranda; Partners In Health/Peru: Jesus Peinado, Marco Tovar; Partners In Health/Rwanda: Vincent Cubaka, Nadine Karema; Partners In Health/Sierra Leone: Foday Boima, Gregory Jerome; Harvard Medical School: Bethany Hedt-Gauthier, Isabel Fulcher, Dale Barnhart, Megan Murray
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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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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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Baobeid A, Faghani-Hamadani T, Sauer S, Boum Y, Hedt-Gauthier BL, Neufeld N, Odhiambo J, Volmink J, Shuchman M, Di Ruggiero E, Condo JU. Gender equity in health research publishing in Africa. BMJ Glob Health 2022; 7:bmjgh-2022-008821. [PMID: 35820714 PMCID: PMC9277026 DOI: 10.1136/bmjgh-2022-008821] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/24/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Women researchers find it more difficult to publish in academic journals than men, an inequity that affects women’s careers and was exacerbated during the pandemic, particularly for women in low-income and middle-income countries. We measured publishing by sub-Saharan African (SSA) women in prestigious authorship positions (first or last author, or single author) during the time frame 2014–2016. We also examined policies and practices at journals publishing high rates of women scientists from sub-Saharan Africa, to identify potential structural enablers affecting these women in publishing. Methods The study used Namsor V.2, an application programming interface, to conduct a secondary analysis of a bibliometric database. We also analysed policies and practices of ten journals with the highest number of SSA women publishing in first authorship positions. Results Based on regional analyses, the greatest magnitude of authorship inequity is in papers from sub-Saharan Africa, where men comprised 61% of first authors, 65% of last authors and 66% of single authors. Women from South Africa and Nigeria had greater success in publishing than those from other SSA countries, though women represented at least 20% of last authors in 25 SSA countries. The journals that published the most SSA women as prominent authors are journals based in SSA. Journals with overwhelmingly male leadership are also among those publishing the highest number of SSA women. Conclusion Women scholars in SSA face substantial gender inequities in publishing in prestigious authorship positions in academic journals, though there is a cadre of women research leaders across the region. Journals in SSA are important for local women scholars and the inequities SSA women researchers face are not necessarily attributable to gender discrepancy in journals’ editorial leadership.
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Affiliation(s)
- Anwaar Baobeid
- Centre for Global Health, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Tara Faghani-Hamadani
- Centre for Global Health, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Sara Sauer
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Yap Boum
- Epicentre, Medecins Sans Frontieres, Yaoundé, Cameroon
| | | | - Nicholas Neufeld
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Jackline Odhiambo
- School of Public Health and Community Development, Maseno University, Kisumu, Kenya
| | - Jimmy Volmink
- Department of Global Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Miriam Shuchman
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Erica Di Ruggiero
- Centre for Global Health, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Jeanine U Condo
- National University of Rwanda School of Public Health, Kigali, Rwanda.,Tulane University, New Orleans, Louisiana, USA
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8
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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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9
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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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10
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Brar AS, Hedt-Gauthier BL, Hirschhorn LR. Mixed Methods Lot Quality Assurance Sampling: A novel, rapid methodology to inform equity focused maternal health programming in rural Rajasthan, India. PLoS One 2021; 16:e0250154. [PMID: 33914763 PMCID: PMC8084134 DOI: 10.1371/journal.pone.0250154] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 03/31/2021] [Indexed: 11/18/2022] Open
Abstract
India has experienced a significant increase in facility-based delivery (FBD) coverage and reduction in maternal mortality. Nevertheless, India continues to have high levels of maternal health inequity. Improving equity requires data collection methods that can produce a better contextual understanding of how vulnerable populations access and interact with the health care system at a local level. While large population-level surveys are valuable, they are resource intensive and often lack the contextual specificity and timeliness to be useful for local health programming. Qualitative methods can be resource intensive and may lack generalizability. We describe an innovative mixed-methods application of Large Country-Lot Quality Assurance Sampling (LC-LQAS) that provides local coverage data and qualitative insights for both FBD and antenatal care (ANC) in a low-cost and timely manner that is useful for health care providers working in specific contexts. LC-LQAS is a version of LQAS that combines LQAS for local level classification with multistage cluster sampling to obtain precise regional or national coverage estimates. We integrated qualitative questions to uncover mothers' experiences accessing maternal health care in the rural district of Sri Ganganagar, Rajasthan, India. We interviewed 313 recently delivered, low-income women in 18 subdistricts. All respondents participated in both qualitative and quantitative components. All subdistricts were classified as having high FBD coverage with the upper threshold set at 85%, suggesting that improved coverage has extended to vulnerable women. However, only two subdistricts were classified as high ANC coverage with the upper threshold set at 40%. Qualitative data revealed a severe lack of agency among respondents and that household norms of care seeking influenced uptake of ANC and FBD. We additionally report on implementation outcomes (acceptability, feasibility, appropriateness, effectiveness, fidelity, and cost) and how study results informed the programs of a local health non-profit.
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Affiliation(s)
- Aneel Singh Brar
- Mata Jai Kaur Maternal and Child Health Centre, Sri Ganganagar, Rajasthan, India
- School of Anthropology and Museum Ethnography, University of Oxford, Oxford, Oxfordshire, United Kingdom
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Bethany L. Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard Chan School, Boston, Massachusetts, United States of America
| | - Lisa R. Hirschhorn
- Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
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11
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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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12
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Affiliation(s)
- Grace Umutesi
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Justine Davies
- Institute for Applied Research, University of Birmingham, Birmingham, B15 2TT, UK. .,Department of Global Health, Centre for Global Surgery, Stellenbosch University, Stellenbosch, South Africa.
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
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13
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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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14
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Hedt-Gauthier BL, Jeufack HM, Neufeld NH, Alem A, Sauer S, Odhiambo J, Boum Y, Shuchman M, Volmink J. Stuck in the middle: a systematic review of authorship in collaborative health research in Africa, 2014-2016. BMJ Glob Health 2019; 4:e001853. [PMID: 31750000 PMCID: PMC6830050 DOI: 10.1136/bmjgh-2019-001853] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [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: 07/18/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 11/04/2022] Open
Abstract
Background Collaborations are often a cornerstone of global health research. Power dynamics can shape if and how local researchers are included in manuscripts. This article investigates how international collaborations affect the representation of local authors, overall and in first and last author positions, in African health research. Methods We extracted papers on 'health' in sub-Saharan Africa indexed in PubMed and published between 2014 and 2016. The author's affiliation was used to classify the individual as from the country of the paper's focus, from another African country, from Europe, from the USA/Canada or from another locale. Authors classified as from the USA/Canada were further subclassified if the author was from a top US university. In primary analyses, individuals with multiple affiliations were presumed to be from a high-income country if they contained any affiliation from a high-income country. In sensitivity analyses, these individuals were presumed to be from an African country if they contained any affiliation an African country. Differences in paper characteristics and representation of local coauthors are compared by collaborative type using χ² tests. Results Of the 7100 articles identified, 68.3% included collaborators from the USA, Canada, Europe and/or another African country. 54.0% of all 43 429 authors and 52.9% of 7100 first authors were from the country of the paper's focus. Representation dropped if any collaborators were from USA, Canada or Europe with the lowest representation for collaborators from top US universities-for these papers, 41.3% of all authors and 23.0% of first authors were from country of paper's focus. Local representation was highest with collaborators from another African country. 13.5% of all papers had no local coauthors. Discussion Individuals, institutions and funders from high-income countries should challenge persistent power differentials in global health research. South-South collaborations can help African researchers expand technical expertise while maintaining presence on the resulting research.
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Affiliation(s)
- Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Nicholas H Neufeld
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Oromia, Ethiopia
| | - Sara Sauer
- Department of Biostatistics, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Yap Boum
- Epicentre, Médecins Sans Frontières, Yaoundé, Cameroon
| | - Miriam Shuchman
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jimmy Volmink
- Department of Global Health and Dean's Office, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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15
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Odhiambo J, Ruhumuriza J, Nkurunziza T, Riviello R, Shrime M, Lin Y, Rusangwa C, Omondi JM, Toma G, Nyirimodoka A, Mpunga T, Hedt-Gauthier BL. Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing. Matern Child Health J 2019; 23:613-622. [PMID: 30600515 DOI: 10.1007/s10995-018-2674-z] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.
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Affiliation(s)
- Jackline Odhiambo
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA.
| | | | | | - Robert Riviello
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.,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
| | - Mark Shrime
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Yihan Lin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Jack M Omondi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Ministry of Health, Kigali, Rwanda
| | - Gabriel Toma
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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16
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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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17
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Odhiambo J, Amoroso CL, Barebwanuwe P, Warugaba C, Hedt-Gauthier BL. Adapting operational research training to the Rwandan context: the Intermediate Operational Research Training programme. Glob Health Action 2018; 10:1386930. [PMID: 29119872 PMCID: PMC5700541 DOI: 10.1080/16549716.2017.1386930] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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] [Indexed: 11/25/2022] Open
Abstract
Background: Promoting national health research agendas in low- and middle-income countries (LMICs) requires adequate numbers of individuals with skills to initiate and conduct research. Recently, non-governmental organizations (NGOs) have joined research capacity building efforts to increase research leadership by LMIC nationals. Partners In Health, an international NGO operating in Rwanda, implemented its first Intermediate Operational Research Training (IORT) course to cultivate Rwandan research talent and generate evidence to improve health care delivery. Objective: This paper describes the implementation of IORT to share experiences with other organizations interested in developing similar training programmes. Methods: The Intermediate Operational Research Training utilized a deliverable-driven training model, using learning-by-doing pedagogy with intensive hands-on mentorship to build research skills from protocol development to scientific publication. The course had short (two-day) but frequent training sessions (seven sessions over eight months). Trainees were clinical and programme staff working at the district level who were paired to jointly lead a research project. Results: Of 10 trainees admitted to the course from a pool of 24 applicants, nine trainees completed the course with five research projects published in peer-reviewed journals. Strengths of the course included supportive national and institutional research capacity guidelines, building from a successful training model, and trainee commitment. Challenges included delays in ethical review, high mentorship workload of up to 250 hours of practicum mentorship, lack of access to literature in subscription journals and high costs of open access publication. Conclusions: The IORT course was an effective way to support the district-based government and NGO staff in gaining research skills, as well as answering research questions relevant to health service delivery at district hospitals. Other NGOs should build on successful programmes while adapting course elements to address context-specific challenges. Mentorship for LMIC trainees is critical for effectiveness of research capacity building initiatives.
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Affiliation(s)
- Jackline Odhiambo
- a Research Department , Partners In Health/Inshuti Mu Buzima , Kigali , Rwanda
| | - Cheryl L Amoroso
- a Research Department , Partners In Health/Inshuti Mu Buzima , Kigali , Rwanda
| | - Peter Barebwanuwe
- a Research Department , Partners In Health/Inshuti Mu Buzima , Kigali , Rwanda
| | - Christine Warugaba
- a Research Department , Partners In Health/Inshuti Mu Buzima , Kigali , Rwanda
| | - Bethany L Hedt-Gauthier
- a Research Department , Partners In Health/Inshuti Mu Buzima , Kigali , Rwanda.,b Department of Global Health and Social Medicine , Harvard Medical School , Boston , MA , USA
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18
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Isanaka S, Hedt-Gauthier BL, Grais RF, Allen BGS. Estimating program coverage in the treatment of severe acute malnutrition: a comparative analysis of the validity and operational feasibility of two methods. Popul Health Metr 2018; 16:11. [PMID: 29970172 PMCID: PMC6029157 DOI: 10.1186/s12963-018-0167-3] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 06/19/2018] [Indexed: 11/18/2022] Open
Abstract
Background Many health programs can assess coverage using standardized cluster survey methods, but estimating the coverage of nutrition programs presents a special challenge due to low disease prevalence. Used since 2012, the Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) employs both qualitative and quantitative methods to identify key barriers to access and estimate coverage of therapeutic feeding programs. While the tool has been increasingly used in programs, the validity of certain methodological elements has been the subject of debate. Methods We conducted a study comparing a SQUEAC conjugate Bayesian analysis to a two-stage cluster survey estimating the coverage of a therapeutic feeding program in Niger in 2016. Results We found that the coverage estimate from the conjugate Bayesian analysis was sensitive to the prior estimation. With the exception of prior estimates produced by an external support team, all prior estimates resulted in a conflict with the likelihood result, excluding interpretation of the final coverage estimate. Allowing for increased uncertainty around the prior estimate did not materially affect conclusions. Conclusion SQUEAC is a demanding analytical method requiring both qualitative and quantitative data collection and synthesis to identify program barriers and estimate coverage. If the necessary technical capacity is not available to objectively specify an accurate prior for a conjugate Bayesian analysis, alternatives, such as a two-stage cluster survey or a larger likelihood survey, may be considered to ensure valid coverage estimation. Trial registration NCT03280082. Retrospectively registered on September 12, 2017. Electronic supplementary material The online version of this article (10.1186/s12963-018-0167-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, 8 rue Saint Sabin, 75011, Paris, France. .,Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA.
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Department of Biostatistics, Harvard School of Public Health, Boston, USA
| | - Rebecca F Grais
- Department of Research, Epicentre, 8 rue Saint Sabin, 75011, Paris, France
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19
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Rubanzana W, Hedt-Gauthier BL, Ntaganira J, Freeman MD. Exposure to Genocide as a Risk Factor for Homicide Perpetration in Rwanda: A Population-Based Case-Control Study. J Interpers Violence 2018; 33:1855-1870. [PMID: 26681788 DOI: 10.1177/0886260515619749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
A population-based case-control study was conducted to assess the relationship between genocide exposure and homicide perpetration in Rwanda. A sample of 150 homicide perpetrators who were charged with and confessed to having committed homicide between 1 May 2011 and 31 May 2013 and 450 controls were enrolled. Cases were matched to controls by neighborhood, age and sex. Socio-demographic, background and genocide-related information was collected from study subjects' next of kin. Four characteristics of genocide exposure were: genocide survivor, genocide perpetrator, having lost a first-degree relative to genocide and having a first-degree relative convicted of genocide. We assessed the impact of each genocide-exposure variable using conditional logistic regression. Of the 150 cases, 124 (82.7%) were male and 26 (17.3%) were female. The mean age of the alleged homicide perpetrators was 33 years, with a peak in the age group 20-29 years (39.3%). After adjusting for socio-demographic characteristics and past common criminal records, having a first-degree relative who had been convicted of genocide crimes was a significant predictor for homicide perpetration (odds ratio [OR] = 14.4, 95% confidence interval [CI] = 1.6-129.4). Being a genocide perpetrator, a genocide survivor and having lost a first-degree family member to genocide were not identified as risk factors for homicide perpetration. In Rwanda, young people who experienced early exposure to trauma by witnessing their first-degree relatives' active participation in the genocide, are more likely to commit homicide. Socio-economic and psychotherapeutic programs targeting this population group are needed to rehabilitate these young people for violent behavior change.
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Affiliation(s)
- Wilson Rubanzana
- 1 University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
- 2 Rwanda National Police, Forensic Medicine and Coordination Office of "Isange" One Stop Centers for Victims of Gender Based Violence and Victims of Child Abuse, Kigali, Rwanda
| | - Bethany L Hedt-Gauthier
- 1 University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
- 3 Harvard Medical School, Boston, MA, USA
| | - Joseph Ntaganira
- 1 University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Michael D Freeman
- 4 Oregon Health & Science University, Portland, OR, USA
- 5 Umeå University, Umeå, Sweden
- 6 Aarhus University, Denmark
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20
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Sonderman KA, Nkurunziza T, Kateera F, Gruendl M, Koch R, Gaju E, Habiyakare C, Matousek A, Nahimana E, Ntakiyiruta G, Riviello R, Hedt-Gauthier BL. Using mobile health technology and community health workers to identify and refer caesarean-related surgical site infections in rural Rwanda: a randomised controlled trial protocol. BMJ Open 2018; 8:e022214. [PMID: 29739786 PMCID: PMC5942430 DOI: 10.1136/bmjopen-2018-022214] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Surgical site infections (SSIs) are a significant cause of morbidity and mortality in low-income and middle-income countries, where rates of SSIs can reach 30%. Due to limited access, there is minimal follow-up postoperatively. Community health workers (CHWs) have not yet been used for surgical patients in most settings. Advancements in telecommunication create an opportunity for mobile health (mHealth) tools to support CHWs. We aim to evaluate the use of mHealth technology to aid CHWs in identification of SSIs and promote referral of patients back to healthcare facilities. METHODS AND ANALYSIS Prospective randomised controlled trial conducted at Kirehe District Hospital, Rwanda, from November 2017 to November 2018. Patients ≥18 years who undergo caesarean section are eligible. Non-residents of Kirehe District or patients who remain in hospital >10 days postoperatively will be excluded. Patients will be randomised to one of three arms. For arm 1, a CHW will visit the patient's home on postoperative day 10 (±3 days) to administer an SSI screening protocol (fever, pain or purulent drainage) using an electronic tablet. For arm 2, the CHW will administer the screening protocol over the phone. For both arms 1 and 2, the CHW will refer patients who respond 'yes' to any of the questions to a health facility. For arm 3, patients will not receive follow-up care. Our primary outcome will be the impact of the mHealth-CHW intervention on the rate of return to care for patients with an SSI. ETHICS AND DISSEMINATION The study has received ethical approval from the Rwandan National Ethics Committee and Partners Healthcare. Results will be disseminated to Kirehe District Hospital, Rwanda Ministry of Health, Rwanda Surgical Society, Partners In Health, through conferences and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03311399.
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Affiliation(s)
- Kristin A Sonderman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Magdalena Gruendl
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel Koch
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Alexi Matousek
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Partners In Health, Kigali, Rwanda
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21
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Kagabo DM, Kirk CM, Bakundukize B, Hedt-Gauthier BL, Gupta N, Hirschhorn LR, Ingabire WC, Rouleau D, Nkikabahizi F, Mugeni C, Sayinzoga F, Amoroso CL. Care-seeking patterns among families that experienced under-five child mortality in rural Rwanda. PLoS One 2018; 13:e0190739. [PMID: 29320556 PMCID: PMC5761861 DOI: 10.1371/journal.pone.0190739] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 12/11/2017] [Indexed: 02/03/2023] Open
Abstract
Background Over half of under-five deaths occur in sub-Saharan Africa and appropriate, timely, quality care is critical for saving children’s lives. This study describes the context surrounding children’s deaths from the time the illness was first noticed, through the care-seeking patterns leading up to the child’s death, and identifies factors associated with care-seeking for these children in rural Rwanda. Methods Secondary analysis of a verbal and social autopsy study of caregivers who reported the death of a child between March 2013 to February 2014 that occurred after discharge from the child’s birth facility in southern Kayonza and Kirehe districts in Rwanda. Bivariate analyses using Fisher’s exact tests were conducted to identify child, caregiver, and household factors associated with care-seeking from the formal health system (i.e., community health worker or health facility). Factors significant at α = 0.10 significance level were considered for backwards stepwise multivariate logistic regression, stopping when remaining factors were significantly associated with care-seeking at α = 0.05 significance level. Results Among the 516 eligible deaths among children under-five, 22.7% (n = 117) did not seek care from the health system. For those who did, the most common first point of contact was community health workers (45.8%). In multivariate logistic regression, higher maternal education (OR = 3.36, 95% CI: 1.89, 5.98), having diarrhea (OR = 4.21, 95%CI: 1.95, 9.07) or fever (OR = 2.03, 95%CI: 1.11, 3.72), full household insurance coverage (3.48, 95%CI: 1.79, 6.76), and longer duration of illness (OR = 22.19, 95%CI: 8.88, 55.48) were significantly associated with formal care-seeking. Conclusion Interventions such as community health workers and insurance promote access to care, however a gap remains as many children had no contact with the health system prior to death and those who sought formal care still died. Further efforts are needed to respond to urgent cases in communities and further understand remaining barriers to accessing appropriate, quality care.
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Affiliation(s)
- Daniel M. Kagabo
- Partners in Health/Inshuti Mu Buzima (PIH/IMB), Rwinkwavu, Rwanda
- * E-mail:
| | | | | | - Bethany L. Hedt-Gauthier
- Partners in Health/Inshuti Mu Buzima (PIH/IMB), Rwinkwavu, Rwanda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Neil Gupta
- Partners in Health/Inshuti Mu Buzima (PIH/IMB), Rwinkwavu, Rwanda
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Lisa R. Hirschhorn
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | | | | | | | | | - Felix Sayinzoga
- Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
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22
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Hedt-Gauthier BL, Chilengi R, Jackson E, Michel C, Napua M, Odhiambo J, Bawah A. Research capacity building integrated into PHIT projects: leveraging research and research funding to build national capacity. BMC Health Serv Res 2017; 17:825. [PMID: 29297405 PMCID: PMC5763288 DOI: 10.1186/s12913-017-2657-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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: 11/10/2022] Open
Abstract
Background Inadequate research capacity impedes the development of evidence-based health programming in sub-Saharan Africa. However, funding for research capacity building (RCB) is often insufficient and restricted, limiting institutions’ ability to address current RCB needs. The Doris Duke Charitable Foundation’s African Health Initiative (AHI) funded Population Health Implementation and Training (PHIT) partnership projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania and Zambia) to implement health systems strengthening initiatives inclusive of RCB. Methods Using Cooke’s framework for RCB, RCB activity leaders from each country reported on RCB priorities, activities, program metrics, ongoing challenges and solutions. These were synthesized by the authorship team, identifying common challenges and lessons learned. Results For most countries, each of the RCB domains from Cooke’s framework was a high priority. In about half of the countries, domain specific activities happened prior to PHIT. During PHIT, specific RCB activities varied across countries. However, all five countries used AHI funding to improve research administrative support and infrastructure, implement research trainings and support mentorship activities and research dissemination. While outcomes data were not systematically collected, countries reported holding 54 research trainings, forming 56 mentor-mentee relationships, training 201 individuals and awarding 22 PhD and Masters-level scholarships. Over the 5 years, 116 manuscripts were developed. Of the 59 manuscripts published in peer-reviewed journals, 29 had national first authors and 18 had national senior authors. Trainees participated in 99 conferences and projects held 37 forums with policy makers to facilitate research translation into policy. Conclusion All five PHIT projects strongly reported an increase in RCB activities and commended the Doris Duke Charitable Foundation for prioritizing RCB, funding RCB at adequate levels and time frames and for allowing flexibility in funding so that each project could implement activities according to their trainees’ needs. As a result, many common challenges for RCB, such as adequate resources and local and international institutional support, were not identified as major challenges for these projects. Overall recommendations are for funders to provide adequate and flexible funding for RCB activities and for institutions to offer a spectrum of RCB activities to enable continued growth, provide adequate mentorship for trainees and systematically monitor RCB activities. Electronic supplementary material The online version of this article (10.1186/s12913-017-2657-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bethany L Hedt-Gauthier
- Partners In Health, Kigali, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, 02115, USA.
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Elizabeth Jackson
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City, USA
| | - Cathy Michel
- Health Alliance International, Beira, Mozambique
| | - Manuel Napua
- Beira Operational Research Center, National Institute of Health, Beira, Mozambique
| | | | - Ayaga Bawah
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City, USA.,Regional Institute for Population Studies, University of Ghana, Accra, Ghana
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23
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Maine RG, Linden AF, Riviello R, Kamanzi E, Mody GN, Ntakiyiruta G, Kansayisa G, Ntaganda E, Niyonkuru F, Mubiligi JM, Mpunga T, Meara JG, Hedt-Gauthier BL. Prevalence of Untreated Surgical Conditions in Rural Rwanda: A Population-Based Cross-sectional Study in Burera District. JAMA Surg 2017; 152:e174013. [PMID: 29071335 DOI: 10.1001/jamasurg.2017.4013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In low- and middle-income countries, community-level surgical epidemiology is largely undefined. Accurate community-level surgical epidemiology is necessary for surgical health systems planning. Objective To determine the prevalence of surgical conditions in Burera District, Northern Province, Rwanda. Design, Setting, and Participants A cross-sectional study with a 2-stage cluster sample design (at village and household level) was carried out in Burera District in March and May 2012. A team of surgeons randomly sampled 30 villages with probability proportionate to village population size, then sampled 23 households within each village. All available household members were examined. Main Outcomes and Measures The presence of 10 index surgical conditions (injuries/wounds, hernias/hydroceles, breast masses, neck masses, obstetric fistulas, undescended testes, hypospadias, hydrocephalus, cleft lip/palate, and clubfoot) was determined by physical examination. Prevalence was estimated overall and for each condition. Multivariable logistic regression was performed to identify factors associated with surgical conditions, accounting for the complex survey design. Results Of the 2165 examined individuals, 1215 (56.2%) were female. The prevalence of any surgical condition among all examined individuals was 12% (95% CI, 9.2-14.9%). Half of conditions were hernias/hydroceles (49.6%), and 44% were injuries/wounds. In multivariable analysis, children 5 years or younger had twice the odds of having a surgical condition compared with married individuals 21 to 35 years of age (reference group) (odds ratio [OR], 2.2; 95% CI, 1.26-4.04; P = .01). The oldest group, people older than 50 years, also had twice the odds of having a surgical condition compared with the reference group (married, aged >50 years: OR, 2.3; 95% CI, 1.28-4.23; P = .01; unmarried, aged >50 years: OR, 2.38; 95% CI, 1.02-5.52; P = .06). Unmarried individuals 21 to 35 years of age and unmarried individuals aged 36 to 50 years had higher odds of a surgical condition compared with the reference group (aged 21-35 years: OR, 1.68; 95% CI, 0.74-3.82; P = .22; aged 36-50 years: OR, 3.35; 95% CI, 1.29-9.11; P = .02). There was no statistical difference in odds by sex, wealth, education, or travel time to the nearest hospital. Conclusions and Relevance The prevalence of surgically treatable conditions in northern Rwanda was considerably higher than previously estimated modeling and surveys in comparable low- and middle-income countries. This surgical backlog must be addressed in health system plans to increase surgical infrastructure and workforce in rural Africa.
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Affiliation(s)
- Rebecca G Maine
- Department of Surgery, Harborview Medical Center, Seattle, Washington.,Now with Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Allison F Linden
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts.,Section of Pediatric Surgery, General Surgery, University of Chicago Comer's Children Hospital, Chicago, Illinois
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Gita N Mody
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | | | | | - Tharcisse Mpunga
- Rwanda Ministry of Health, Butaro District Hospital, Burera, Rwanda
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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24
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Mpirimbanyi C, Nyirimodoka A, Lin Y, Hedt-Gauthier BL, Odhiambo J, Nkurunziza T, Havens JM, Omondi J, Rwamasirabo E, Ntirenganya F, Toma G, Mubiligi J, Bayitondere S, Riviello R. Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes. BMC Surg 2017; 17:121. [PMID: 29191200 PMCID: PMC5709982 DOI: 10.1186/s12893-017-0323-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 11/21/2017] [Indexed: 12/25/2022] Open
Abstract
Background Management of emergency general surgical conditions remains a challenge in rural sub-Saharan Africa due to issues such as insufficient human capacity and infrastructure. This study describes the burden of emergency general surgical conditions and the ability to provide care for these conditions at three rural district hospitals in Rwanda. Methods This retrospective cross-sectional study included all patients presenting to Butaro, Kirehe and Rwinkwavu District Hospitals between January 1st 2015 and December 31st 2015 with emergency general surgical conditions, defined as non-traumatic, non-obstetric acute care surgical conditions. We describe patient demographics, clinical characteristics, management and outcomes. Results In 2015, 356 patients presented with emergency general surgical conditions. The majority were male (57.2%) and adults aged 15–60 years (54.5%). The most common diagnostic group was soft tissue infections (71.6%), followed by acute abdominal conditions (14.3%). The median length of symptoms prior to diagnosis differed significantly by diagnosis type (p < 0.001), with the shortest being urological emergencies at 1.5 days (interquartile range (IQR):1, 6) and the longest being complicated hernia at 17.5 days (IQR: 1, 208). Of all patients, 54% were operated on at the district hospital, either by a general surgeon or general practitioner. Patients were more likely to receive surgery if they presented to a hospital with a general surgeon compared to a hospital with only general practitioners (75% vs 43%, p < 0.001). In addition, the general surgeon was more likely to treat patients with complex diagnoses such as acute abdominal conditions (33.3% vs 4.1%, p < 0.001) compared to general practitioners. For patients who received surgery, 73.3% had no postoperative complications and 3.2% died. Conclusion While acute abdominal conditions are often considered the most common emergency general surgical condition in sub-Saharan Africa, soft tissue infections were the most common in our setting. This could represent a true difference in epidemiology in rural settings compared to referral facilities in urban settings. Patients were more likely to receive an operation in a hospital with a general surgeon as opposed to a general practitioner. This provides evidence to support increasing the surgical workforce in district hospitals in order to increase surgical availability for patients.
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Affiliation(s)
- Christophe Mpirimbanyi
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda.
| | - Alexandre Nyirimodoka
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Yihan Lin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | | | - Joaquim M Havens
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | - Jack Omondi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Ministry of Health, Kigali, Rwanda
| | | | - Faustin Ntirenganya
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Gabriel Toma
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Joel Mubiligi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
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25
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Kirk CM, Uwamungu JC, Wilson K, Hedt-Gauthier BL, Tapela N, Niyigena P, Rusangwa C, Nyishime M, Nahimana E, Nkikabahizi F, Mutaganzwa C, Ngabireyimana E, Mutabazi F, Magge H. Health, nutrition, and development of children born preterm and low birth weight in rural Rwanda: a cross-sectional study. BMC Pediatr 2017; 17:191. [PMID: 29141590 PMCID: PMC5688768 DOI: 10.1186/s12887-017-0946-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 11/09/2017] [Indexed: 12/11/2022] Open
Abstract
Background As care for preterm and low birth weight (LBW) infants improves in resource-limited settings, more infants are surviving the neonatal period. Preterm and (LBW) infants are at high-risk of nutritional and medical comorbidities, yet little is known about their developmental outcomes in low-income countries. This study evaluated the health, nutritional, and developmental status of preterm/LBW children at ages 1–3 years in Rwanda. Methods Cross-sectional study of preterm/LBW infants discharged between October 2011 and October 2013 from a hospital neonatal unit in rural Rwanda. Gestational age and birth weight were gathered from hospital records to classify small for gestational age (SGA) at birth and prematurity. Children were located in the community for household assessments in November–December 2014. Caregivers reported demographics, health status, and child development using locally-adapted Ages and Stages Questionnaires (ASQ-3). Anthropometrics were measured. Bivariate associations with continuous ASQ-3 scores were conducted using Wilcoxon Rank Sum and Kruskal Wallis tests. Results Of 158 eligible preterm/LBW children discharged from the neonatal unit, 86 (54.4%) were alive and located for follow-up. Median birth weight was 1650 grams, median gestational age was 33 weeks, and 50.5% were SGA at birth. At the time of household interviews, median age was 22.5 months, 46.5% of children had feeding difficulties and 39.5% reported signs of anemia. 78.3% of children were stunted and 8.8% wasted. 67.4% had abnormal developmental screening. Feeding difficulties (p = 0.008), anemia symptoms (p = 0.040), microcephaly (p = 0.004), stunting (p = 0.034), SGA (p = 0.023), very LBW (p = 0.043), lower caregiver education (p = 0.001), and more children in the household (p = 0.016) were associated with lower ASQ-3 scores. Conclusions High levels of health, growth, and developmental abnormalities were seen in preterm/LBW children at age 1–3 years. As we achieve necessary gains in newborn survival in resource-limited settings, follow-up and early intervention services are critical for ensuring high-risk children reach their developmental potential. Electronic supplementary material The online version of this article doi: (10.1186/s12887-017-0946-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Kim Wilson
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Neo Tapela
- Partners In Health/Inshuti Mu Buzima, 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
| | | | | | | | | | | | | | | | - Francis Mutabazi
- Rwinkwavu District Hospital, Ministry of Health, Rwinkwavu, Rwanda
| | - Hema Magge
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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26
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Mukabutera A, Thomson DR, Hedt-Gauthier BL, Atwood S, Basinga P, Nyirazinyoye L, Savage KP, Habimana M, Murray M. Exogenous factors matter when interpreting the results of an impact evaluation: a case study of rainfall and child health programme intervention in Rwanda. Trop Med Int Health 2017; 22:1505-1513. [PMID: 29080285 DOI: 10.1111/tmi.12995] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Public health interventions are often implemented at large scale, and their evaluation seems to be difficult because they are usually multiple and their pathways to effect are complex and subject to modification by contextual factors. We assessed whether controlling for rainfall-related variables altered estimates of the efficacy of a health programme in rural Rwanda and have a quantifiable effect on an intervention evaluation outcomes. METHODS We conducted a retrospective quasi-experimental study using previously collected cross-sectional data from the 2005 and 2010 Rwanda Demographic and Health Surveys (DHS), 2010 DHS oversampled data, monthly rainfall data collected from meteorological stations over the same period, and modelled output of long-term rainfall averages, soil moisture, and rain water run-off. Difference-in-difference models were used. RESULTS Rainfall factors confounded the PIH intervention impact evaluation. When we adjusted our estimates of programme effect by controlling for a variety of rainfall variables, several effectiveness estimates changed by 10% or more. The analyses that did not adjust for rainfall-related variables underestimated the intervention effect on the prevalence of ARI by 14.3%, fever by 52.4% and stunting by 10.2%. Conversely, the unadjusted analysis overestimated the intervention's effect on diarrhoea by 56.5% and wasting by 80%. CONCLUSION Rainfall-related patterns have a quantifiable effect on programme evaluation results and highlighted the importance and complexity of controlling for contextual factors in quasi-experimental design evaluations.
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Affiliation(s)
- Assumpta Mukabutera
- School of Public Health, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Dana R Thomson
- School of Public Health, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Bethany L Hedt-Gauthier
- School of Public Health, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Paulin Basinga
- School of Public Health, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda.,Rwanda Biomedical Center, Kigali, Rwanda.,Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Laetitia Nyirazinyoye
- School of Public Health, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Kevin P Savage
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Megan Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
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27
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Muhirwa E, Habiyakare C, Hedt-Gauthier BL, Odhiambo J, Maine R, Gupta N, Toma G, Nkurunziza T, Mpunga T, Mukankusi J, Riviello R. Non-Obstetric Surgical Care at Three Rural District Hospitals in Rwanda: More Human Capacity and Surgical Equipment May Increase Operative Care. World J Surg 2017; 40:2109-16. [PMID: 27098541 PMCID: PMC4982876 DOI: 10.1007/s00268-016-3515-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background Most mortality attributable to surgical emergencies occurs in low- and middle-income countries. District hospitals, which serve as the first-level surgical facility in rural sub-Saharan Africa, are often challenged with limited surgical capacity. This study describes the presentation, management, and outcomes of non-obstetric surgical patients at district hospitals in Rwanda. Methods This study included patients seeking non-obstetric surgical care at three district hospitals in rural Rwanda in 2013. Demographics, surgical conditions, patient care, and outcomes are described; operative and non-operative management were stratified by hospitals and differences assessed using Fisher’s exact test. Results Of the 2660 patients who sought surgical care at the three hospitals, most were males (60.7 %). Many (42.6 %) were injured and 34.7 % of injuries were through road traffic crashes. Of presenting patients, 25.3 % had an operation, with patients presenting to Butaro District Hospital significantly more likely to receive surgery (57.0 %, p < 0.001). General practitioners performed nearly all operations at Kirehe and Rwinkwavu District Hospitals (98.0 and 100.0 %, respectively), but surgeons performed 90.6 % of the operations at Butaro District Hospital. For outcomes, 39.5 % of all patients were discharged without an operation, 21.1 % received surgery and were discharged, and 21.1 % were referred to tertiary facilities for surgical care. Conclusion Significantly more patients in Butaro, the only site with a surgeon on staff and stronger surgical infrastructure, received surgery. Availing more surgeons who can address the most common surgical needs and improving supplies and equipment may improve outcomes at other districts. Surgical task sharing is recommended as a temporary solution.
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Affiliation(s)
| | | | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Rebecca Maine
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Surgery, University of California, San Francisco, CA, USA
| | - Neil Gupta
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Gabriel Toma
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Robert Riviello
- 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.,University Teaching Hospital, Kigali, Rwanda
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Habineza H, Mutumbira C, Hedt-Gauthier BL, Borg R, Gupta N, Tapela N, Dusabeyezu S, Ngoga G, Harerimana E, Mpanumusingo E, Ngabireyimana E, Rusingiza E, Bukhman G. Treating persistent asthma in rural Rwanda: characteristics, management and 24-month outcomes. Int J Tuberc Lung Dis 2017; 21:1176-1182. [PMID: 28766486 DOI: 10.5588/ijtld.17.0039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING In 2007, the Rwandan Ministry of Health, with support from Partners In Health, introduced a district-level non-communicable disease programme that included asthma care. OBJECTIVE To describe the demographics, management and 24-month outcomes of asthma patients treated at three rural district hospitals in Rwanda. DESIGN We retrospectively reviewed electronic medical records of asthma patients enrolled from January 2007 to December 2012, and extracted information on demographics, clinical variables and 24-month outcomes. RESULTS Of the 354 patients, 66.7% were female and 41.5% were aged between 41 and 60 years. Most patients (53.1%) were enrolled with moderate persistent asthma, 40.1% had mild persistent asthma and 6.8% had severe persistent asthma. Nearly all patients (95.7%) received some type of medication, most commonly a bronchodilator. After 24 months, 272 (76.8%) patients were still alive and in care, 21.1% were lost to follow-up, 1.7% had died and 0.3% had transferred out. Of the 121 patients with an updated asthma classification at 24 months, the severity of their asthma had decreased: 17.4% had moderate and 0.8% had severe persistent asthma. CONCLUSION Our findings show improvements in asthma severity after 24 months and reasonable rates of loss to follow-up, demonstrating that asthma can be managed effectively in rural, resource-limited settings.
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Affiliation(s)
- H Habineza
- Partners In Health/Inshuti Mu Buzima, Kigali
| | | | - B L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - R Borg
- Partners In Health/Inshuti Mu Buzima, Kigali
| | - N Gupta
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - N Tapela
- Brigham and Women's Hospital, Division of Global Health Equity, Boston, Massachusetts, USA
| | | | - G Ngoga
- Partners In Health/Inshuti Mu Buzima, Kigali
| | | | | | | | - E Rusingiza
- Ministry of Health, Kigali, University of Rwanda, Kigali, Rwanda
| | - G Bukhman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, Brigham and Women's Hospital, Division of Global Health Equity, Boston, Massachusetts, USA, Partners in Health, Boston, Massachusetts, USA
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Koenig SP, Dorvil N, Dévieux JG, Hedt-Gauthier BL, Riviere C, Faustin M, Lavoile K, Perodin C, Apollon A, Duverger L, McNairy ML, Hennessey KA, Souroutzidis A, Cremieux PY, Severe P, Pape JW. Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: A randomized unblinded trial. PLoS Med 2017; 14:e1002357. [PMID: 28742880 PMCID: PMC5526526 DOI: 10.1371/journal.pmed.1002357] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is high worldwide. We assessed whether same-day HIV testing and ART initiation improves retention and virologic suppression. METHODS AND FINDINGS We conducted an unblinded, randomized trial of standard ART initiation versus same-day HIV testing and ART initiation among eligible adults ≥18 years old with World Health Organization Stage 1 or 2 disease and CD4 count ≤500 cells/mm3. The study was conducted among outpatients at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic infections (GHESKIO) Clinic in Port-au-Prince, Haiti. Participants were randomly assigned (1:1) to standard ART initiation or same-day HIV testing and ART initiation. The standard group initiated ART 3 weeks after HIV testing, and the same-day group initiated ART on the day of testing. The primary study endpoint was retention in care 12 months after HIV testing with HIV-1 RNA <50 copies/ml. We assessed the impact of treatment arm with a modified intention-to-treat analysis, using multivariable logistic regression controlling for potential confounders. Between August 2013 and October 2015, 762 participants were enrolled; 59 participants transferred to other clinics during the study period, and were excluded as per protocol, leaving 356 in the standard and 347 in the same-day ART groups. In the standard ART group, 156 (44%) participants were retained in care with 12-month HIV-1 RNA <50 copies, and 184 (52%) had <1,000 copies/ml; 20 participants (6%) died. In the same-day ART group, 184 (53%) participants were retained with HIV-1 RNA <50 copies/ml, and 212 (61%) had <1,000 copies/ml; 10 (3%) participants died. The unadjusted risk ratio (RR) of being retained at 12 months with HIV-1 RNA <50 copies/ml was 1.21 (95% CI: 1.04, 1.38; p = 0.015) for the same-day ART group compared to the standard ART group, and the unadjusted RR for being retained with HIV-1 RNA <1,000 copies was 1.18 (95% CI: 1.04, 1.31; p = 0.012). The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain. CONCLUSIONS Same-day HIV testing and ART initiation is feasible and beneficial in this setting, as it improves retention in care with virologic suppression among patients with early clinical HIV disease. TRIAL REGISTRATION This study is registered with ClinicalTrials.gov number NCT01900080.
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Affiliation(s)
- Serena P. Koenig
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- * E-mail:
| | - Nancy Dorvil
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jessy G. Dévieux
- AIDS Prevention Program, Florida International University, Miami, Florida, United States of America
| | - Bethany L. Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
| | - Cynthia Riviere
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Mikerlyne Faustin
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kerlyne Lavoile
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Christian Perodin
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Limathe Duverger
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Margaret L. McNairy
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
| | - Kelly A. Hennessey
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | | | - Patrice Severe
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean W. Pape
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
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Remera E, Boer K, Umuhoza SM, Hedt-Gauthier BL, Thomson DR, Ndimubanzi P, Kayirangwa E, Mutsinzi S, Bayingana A, Mugwaneza P, Koama JBT. Fertility and HIV following universal access to ART in Rwanda: a cross-sectional analysis of Demographic and Health Survey data. Reprod Health 2017; 14:40. [PMID: 28292306 PMCID: PMC5351174 DOI: 10.1186/s12978-017-0301-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 12/16/2015] [Accepted: 03/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV infection is linked to decreased fertility and fertility desires in sub-Saharan Africa due to biological and social factors. We investigate the relationship between HIV infection and fertility or fertility desires in the context of universal access to antiretroviral therapy introduced in 2004 in Rwanda. METHODS We used data from 3532 and 4527 women aged 20-49 from the 2005 and 2010 Rwandan Demographic and Health Surveys (RDHS), respectively. The RDHSs included blood-tests for HIV, as well as detailed interviews about fertility, demographic and behavioral outcomes. In both years, multiple logistic regression was used to assess the association between HIV and fertility outcomes within three age categories (20-29, 30-39 and 40-49 years), controlling for confounders and compensating for the complex survey design. RESULTS In 2010, we did not find a difference in the odds of pregnancy in the last 5 years between HIV-seropositive and HIV-seronegative women after controlling for potential biological and social confounders. Controlling for the same confounders, we found that HIV-seropositive women under age 40 were less likely to desire more children compared to HIV-seronegative women (20-29 years adjusted odds ratio (AOR) = 0.31, 95% CI: 0.17, 0.58; 30-39 years AOR = 0.24, 95% CI: 0.14, 0.43), but no difference was found among women aged 40 or older. No associations between HIV and fertility or fertility desire were found in 2005. CONCLUSIONS These findings suggest no difference in births or current pregnancy among HIV-seropositive and HIV-seronegative women. That in 2010 HIV-seropositive women in their earlier childbearing years desired fewer children than HIV-seronegative women could suggest more women with HIV survived; and stigma, fear of transmitting HIV, or realism about living with HIV and prematurely dying from HIV may affect their desire to have children. These findings emphasize the importance of delivering appropriate information about pregnancy and childbearing to HIV-infected women, enabling women living with HIV to make informed decisions about their reproductive life.
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Affiliation(s)
- Eric Remera
- Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda.
| | - Kimberly Boer
- Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Stella M Umuhoza
- College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Bethany L Hedt-Gauthier
- College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Inshuti Mu Buzima/Partners in Health, Rwinkwavu, Rwanda
| | - Dana R Thomson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | | | | | | | - Alice Bayingana
- Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Placidie Mugwaneza
- Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
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Guillaine N, Mwizerwa W, Odhiambo J, Hedt-Gauthier BL, Hirschhorn LR, Mugwaneza P, Umugisha JP, Cyamatare FR, Mutaganzwa C, Gupta N. A Novel Combined Mother-Infant Clinic to Optimize Post-Partum Maternal Retention, Service Utilization, and Linkage to Services in HIV Care in Rural Rwanda. Int J MCH AIDS 2017; 6:36-45. [PMID: 28798892 PMCID: PMC5547224 DOI: 10.21106/ijma.186] [Citation(s) in RCA: 9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite recent improvements in accessibility of services to prevent mother-to-child transmission of HIV, maternal retention in HIV care remains a challenge in the post-partum period. This study assessed service utilization, program retention, and linkage to routine services, as well as clinical outcomes for mothers and infants, following implementation of an integrated mother-infant clinic in rural Rwanda. METHODS We conducted a retrospective cohort study of all HIV-positive mothers and their infants enrolled in the integrated clinics in two rural districts between July 1, 2012, and June 30, 2013. At 18 months post-partum, data on mother-infant service utilization and program outcomes were reported. RESULTS Of the 185 mother-infant pairs in the clinics, 98.4% of mothers were on antiretroviral therapy (ART) and 30.3% used modern contraception at enrollment. At 18 months post-partum, 98.4% of mothers were retained and linked back to adult HIV program. All mothers were on ART and 72.0% on modern contraception. For infants, 93.0% completed follow-up. Two (1.1%) infants tested HIV positive. CONCLUSION AND GLOBAL HEALTH IMPLICATION An integrated clinic was successfully implemented in rural Rwanda with high mother retention in care and low mother to child HIV transmission rates. This model of integration of services may contribute to improved mother-infant retention in care during post-partum period and should be considered as one approach to addressing this challenge in similar settings.
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Affiliation(s)
| | | | | | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02125, USA
| | - Lisa R Hirschhorn
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02125, USA.,Partners In Health, Boston, MA 02199, USA.,Ariadne Labs, Boston, MA 02215, USA
| | | | | | | | | | - Neil Gupta
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA 02115, USA
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Mukabutera A, Thomson D, Murray M, Basinga P, Nyirazinyoye L, Atwood S, Savage KP, Ngirimana A, Hedt-Gauthier BL. Rainfall variation and child health: effect of rainfall on diarrhea among under 5 children in Rwanda, 2010. BMC Public Health 2016; 16:731. [PMID: 27495307 PMCID: PMC4975910 DOI: 10.1186/s12889-016-3435-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [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: 01/05/2016] [Accepted: 08/03/2016] [Indexed: 11/30/2022] Open
Abstract
Background Diarrhea among children under 5 years of age has long been a major public health concern. Previous studies have suggested an association between rainfall and diarrhea. Here, we examined the association between Rwandan rainfall patterns and childhood diarrhea and the impact of household sanitation variables on this relationship. Methods We derived a series of rain-related variables in Rwanda based on daily rainfall measurements and hydrological models built from daily precipitation measurements collected between 2009 and 2011. Using these data and the 2010 Rwanda Demographic and Health Survey database, we measured the association between total monthly rainfall, monthly rainfall intensity, runoff water and anomalous rainfall and the occurrence of diarrhea in children under 5 years of age. Results Among the 8601 children under 5 years of age included in the survey, 13.2 % reported having diarrhea within the 2 weeks prior to the survey. We found that higher levels of runoff were protective against diarrhea compared to low levels among children who lived in households with unimproved toilet facilities (OR = 0.54, 95 % CI: [0.34, 0.87] for moderate runoff and OR = 0.50, 95 % CI: [0.29, 0.86] for high runoff) but had no impact among children in household with improved toilets. Conclusion Our finding that children in households with unimproved toilets were less likely to report diarrhea during periods of high runoff highlights the vulnerabilities of those living without adequate sanitation to the negative health impacts of environmental events.
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Affiliation(s)
| | - Dana Thomson
- University of Rwanda School of Public Health, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Megan Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Epidemiology Departments, Harvard School of Public Health, Boston, USA
| | - Paulin Basinga
- University of Rwanda School of Public Health, Kigali, Rwanda.,Rwanda Biomedical Center (RBC), Kigali, Rwanda
| | | | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA
| | - Kevin P Savage
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | | | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Partners In Health, Kigali, Rwanda
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Mukabutera A, Thomson DR, Hedt-Gauthier BL, Basinga P, Nyirazinyoye L, Murray M. Risk factors associated with underweight status in children under five: an analysis of the 2010 Rwanda Demographic Health Survey (RDHS). BMC Nutr 2016. [DOI: 10.1186/s40795-016-0078-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Jezmir J, Cohen T, Zignol M, Nyakan E, Hedt-Gauthier BL, Gardner A, Kamle L, Injera W, Carter EJ. Use of Lot Quality Assurance Sampling to Ascertain Levels of Drug Resistant Tuberculosis in Western Kenya. PLoS One 2016; 11:e0154142. [PMID: 27167381 PMCID: PMC4864281 DOI: 10.1371/journal.pone.0154142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 04/09/2016] [Indexed: 11/13/2022] Open
Abstract
Objective To classify the prevalence of multi-drug resistant tuberculosis (MDR-TB) in two different geographic settings in western Kenya using the Lot Quality Assurance Sampling (LQAS) methodology. Design The prevalence of drug resistance was classified among treatment-naïve smear positive TB patients in two settings, one rural and one urban. These regions were classified as having high or low prevalence of MDR-TB according to a static, two-way LQAS sampling plan selected to classify high resistance regions at greater than 5% resistance and low resistance regions at less than 1% resistance. Results This study classified both the urban and rural settings as having low levels of TB drug resistance. Out of the 105 patients screened in each setting, two patients were diagnosed with MDR-TB in the urban setting and one patient was diagnosed with MDR-TB in the rural setting. An additional 27 patients were diagnosed with a variety of mono- and poly- resistant strains. Conclusion Further drug resistance surveillance using LQAS may help identify the levels and geographical distribution of drug resistance in Kenya and may have applications in other countries in the African Region facing similar resource constraints.
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Affiliation(s)
- Julia Jezmir
- Stanford Medical School, Stanford, California, United States of Amercia
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- * E-mail:
| | - Ted Cohen
- Department of Epidemiology of Microbial Disease, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Matteo Zignol
- Global TB Programme, TB Monitoring and Evaluation, World Health Organization, Geneva, Switzerland
| | - Edwin Nyakan
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Bethany L. Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Adrian Gardner
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Lydia Kamle
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Wilfred Injera
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - E. Jane Carter
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Alpert School of Medicine at Brown University, Providence, Rhode Island, United States of America
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Ndenga E, Uwizeye G, Thomson DR, Uwitonze E, Mubiligi J, Hedt-Gauthier BL, Wilkes M, Binagwaho A. Assessing the twinning model in the Rwandan Human Resources for Health Program: goal setting, satisfaction and perceived skill transfer. Global Health 2016; 12:4. [PMID: 26822614 PMCID: PMC4730618 DOI: 10.1186/s12992-016-0141-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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: 06/18/2015] [Accepted: 01/12/2016] [Indexed: 11/17/2022] Open
Abstract
Background Because of the shortage of health professionals, particularly in specialty areas, Rwanda initiated the Human Resources for Health (HRH) Program. In this program, faculty from United States teaching institutions (USF) "twin" with Rwandan Faculty (RF) to transfer skills. This paper assesses the twinning model, exploring USF and RF goal setting, satisfaction and perceptions of the effectiveness of skill transfer within the twinning model. Methods All USF and RF in the HRH Program from August 2012-May 2014 were invited to participate. An 85-item questionnaire for USF and 71-item questionnaire for RF were administered via Survey Monkey in April and May 2014. Associations among primary outcomes were assessed and factors related with outcomes were modeled using logistic regression. Results Most RF and USF reported setting goals with their twin (89 % and 71 %, respectively). Half of RF (52 %) reported effective skill transfer compared to 10 % of USF. Only 38 % of RF and 28 % of USF reported being very satisfied with the twinning model. There was significant overlap in the three operational outcomes. For RF, the following factors were associated with outcomes: for effective skill transfer, being able to communicate in a common language and working at a nursing site outside of Kigali; and for satisfaction, 7+ years of professional experience and being part of a male RF-female USF twin pair. For USF, the following factors were associated with outcomes: for setting goals, prior teaching experience; and for satisfaction, experience in low resource settings for one month or less and feeling that HRH promotes a culture of respect. Conclusions Twinning is the cornerstone of the HRH Program in Rwanda. These findings helped the HRH team identify key areas to improve the twinning experience including better recruitment and orientation of USF and RF, consideration of additional factors during the twinning process, provide language training support, facilitate joint twin activities and cross-cultural training and improve the site leadership buy-in and support of the program. These results can inform other programs using twinning to develop skills in the health workforce. Electronic supplementary material The online version of this article (doi:10.1186/s12992-016-0141-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Esperance Ndenga
- Human Resources for Health, Ministry of Health, P.O. Box 84, Kigali, Rwanda.
| | - Glorieuse Uwizeye
- Human Resources for Health, Ministry of Health, P.O. Box 84, Kigali, Rwanda.
| | - Dana R Thomson
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.
| | - Eric Uwitonze
- Human Resources for Health, Ministry of Health, P.O. Box 84, Kigali, Rwanda.
| | - Joel Mubiligi
- Human Resources for Health, Ministry of Health, P.O. Box 84, Kigali, Rwanda.
| | - Bethany L Hedt-Gauthier
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.
| | - Michael Wilkes
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.
| | - Agnes Binagwaho
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA. .,Ministry of Health, P.O. Box. 84, Kigali, Rwanda. .,Geisel School of Medicine, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
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Mpunga T, Hedt-Gauthier BL, Tapela N, Nshimiyimana I, Muvugabigwi G, Pritchett N, Greenberg L, Benewe O, Shulman DS, Pepoon JR, Shulman LN, Milner DA. Implementation and Validation of Telepathology Triage at Cancer Referral Center in Rural Rwanda. J Glob Oncol 2016; 2:76-82. [PMID: 28717686 PMCID: PMC5495446 DOI: 10.1200/jgo.2015.002162] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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] [Indexed: 11/20/2022] Open
Abstract
Purpose Connecting a cancer patient to the appropriate treatment requires the correct diagnosis provided in a timely manner. In resource-limited settings, the anatomic pathology bridge to efficient, accurate, and timely cancer care is often challenging. In this study, we present the first phase of an anatomic telepathology triage system, which was implemented and validated at the Butaro District Hospital in northern rural Rwanda. Methods Select cases over a 9-month period in three segments were evaluated by static image telepathology and were independently evaluated by standard glass slide histology. Each case via telepathology was classified as malignant, benign, infectious/inflammatory, or nondiagnostic and was given an exact histologic diagnosis. Results For cases triaged as appropriate for telepathology, correlation with classification and exact diagnosis demonstrated greater than 95% agreement over the study. Cases in which there was disagreement were analyzed for cause, and the triage process was adjusted to avoid future problems. Conclusion Challenges to obtaining a correct and complete diagnosis with telepathology alone included the need for immunohistochemistry, assessment of the quality of images, and the lack of images representing an entire sample. The next phase of the system will assess the effect of telepathology triage on turnaround time and the value of on-site immunohistochemistry in reducing that metric and the need for evaluation outside of telepathology.
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Affiliation(s)
- Tharcisse Mpunga
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Bethany L Hedt-Gauthier
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Neo Tapela
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Irenee Nshimiyimana
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Gaspard Muvugabigwi
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Natalie Pritchett
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lauren Greenberg
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Origene Benewe
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - David S Shulman
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - James R Pepoon
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Danny A Milner
- , , , Ministry of Health; , , University of Rwanda; Bethany L. Hedt-Gauthier, Neo Tapela, Natalie Pritchett, , , , Partners In Health, Kigali, Rwanda; , , , Brigham and Women's Hospital; , , Boston Children's Hospital; , Dana-Farber Cancer Institute, Boston, MA; and , Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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Linden AF, Maine RG, Hedt-Gauthier BL, Kamanzi E, Gauvey-Kern K, Mody G, Ntakiyiruta G, Kansayisa G, Ntaganda E, Niyonkuru F, Mubiligi J, Mpunga T, Meara JG, Riviello R. Validation of a community-based survey assessing nonobstetric surgical conditions in Burera District, Rwanda. Surgery 2016; 159:1217-26. [PMID: 26775073 DOI: 10.1016/j.surg.2015.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 10/02/2015] [Accepted: 10/03/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Validated, community-based surveillance methods to monitor epidemiologic progress in surgery have not yet been employed for surgical capacity building. The goal of this study was to create and assess the validity of a community-based questionnaire collecting data on untreated surgically correctable disease throughout Burera District, Rwanda, to accurately plan for surgical services at a district hospital. METHODS A structured interview to assess for 10 index surgically treatable conditions was created and underwent local focus group and pilot testing. Using a 2-stage cluster sampling design, Rwandan data collectors conducted the structured interview in 30 villages throughout the Burera District. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. RESULTS A total of 2,990 individuals were surveyed and 2,094 (70%) were available for physical examination. The calculated sensitivity and specificity of the survey tool were 44.5% (95% CI, 38.9-50.2%) and 97.7% (95% CI, 96.9-98.3%), respectively. The conditions with the highest sensitivity and specificity were hydrocephalus, clubfoot, and injuries/infections. Injuries/infections and hernias/hydroceles were the conditions most frequently found on examination that were not reported during the interview. CONCLUSION This study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity was likely related to limited access to care and poor health literacy. Accurate community-based surveys are critical to planning integrated health systems that include surgical care as a core component.
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Affiliation(s)
- Allison F Linden
- Department of Surgery, Georgetown University Hospital, Washington, DC; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA.
| | - Rebecca G Maine
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | | | - Gita Mody
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Georges Ntakiyiruta
- Department of Surgery, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | | | - Edmond Ntaganda
- Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
| | | | - Joel Mubiligi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | - John G Meara
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
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Ingabire W, Reine PM, Hedt-Gauthier BL, Hirschhorn LR, Kirk CM, Nahimana E, Nepomscene Uwiringiyemungu J, Ndayisaba A, Manzi A. Roadmap to an effective quality improvement and patient safety program implementation in a rural hospital setting. Healthc (Amst) 2015; 3:277-82. [PMID: 26699357 DOI: 10.1016/j.hjdsi.2015.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
Abstract
Implementation lessons: (1) implementation of an effective quality improvement and patient safety program in a rural hospital setting requires collaboration between hospital leadership, Ministry of Health and other stakeholders. (2) Building Quality Improvement (QI) capacity to develop engaged QI teams supported by mentoring can improve quality and patient safety.
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Affiliation(s)
| | | | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Rwanda; Department of Global Health and Social Medicine, Harvard Medical School, USA
| | - Lisa R Hirschhorn
- Department of Global Health and Social Medicine, Harvard Medical School, USA; Ariadne Labs, Boston, MA, USA
| | | | | | | | | | - Anatole Manzi
- Partners In Health/Inshuti Mu Buzima, Rwanda; Partners In Health, USA.
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Nahimana E, Ngendahayo M, Magge H, Odhiambo J, Amoroso CL, Muhirwa E, Uwilingiyemungu JN, Nkikabahizi F, Habimana R, Hedt-Gauthier BL. Bubble CPAP to support preterm infants in rural Rwanda: a retrospective cohort study. BMC Pediatr 2015; 15:135. [PMID: 26403679 PMCID: PMC4582629 DOI: 10.1186/s12887-015-0449-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 09/11/2015] [Indexed: 02/07/2023] Open
Abstract
Background Complications from premature birth contribute to 35 % of neonatal deaths globally; therefore, efforts to improve clinical outcomes of preterm (PT) infants are imperative. Bubble continuous positive airway pressure (bCPAP) is a low-cost, effective way to improve the respiratory status of preterm and very low birth weight (VLBW) infants. However, bCPAP remains largely inaccessible in resource-limited settings, and information on the scale-up of this technology in rural health facilities is limited. This paper describes health providers’ adherence to bCPAP protocols for PT/VLBW infants and clinical outcomes in rural Rwanda. Methods This retrospective chart review included all newborns admitted to neonatal units in three rural hospitals in Rwanda between February 1st and October 31st, 2013. Analysis was restricted to PT/VLBW infants. bCPAP eligibility, identification of bCPAP eligibility and complications were assessed. Final outcome was assessed overall and by bCPAP initiation status. Results There were 136 PT/VLBW infants. For the 135 whose bCPAP eligibility could be determined, 83 (61.5 %) were bCPAP-eligible. Of bCPAP-eligible infants, 49 (59.0 %) were correctly identified by health providers and 43 (51.8 %) were correctly initiated on bCPAP. For the 52 infants who were not bCPAP-eligible, 45 (86.5 %) were correctly identified as not bCPAP-eligible, and 46 (88.5 %) did not receive bCPAP. Overall, 90 (66.2 %) infants survived to discharge, 35 (25.7 %) died, 3 (2.2 %) were referred for tertiary care and 8 (5.9 %) had unknown outcomes. Among the bCPAP eligible infants, the survival rates were 41.8 % (18 of 43) for those in whom the procedure was initiated and 56.5 % (13 of 23) for those in whom it was not initiated. No complications of bCPAP were reported. Conclusion While the use of bCPAP in this rural setting appears feasible, correct identification of eligible newborns was a challenge. Mentorship and refresher trainings may improve guideline adherence, particularly given high rates of staff turnover. Future research should explore implementation challenges and assess the impact of bCPAP on long-term outcomes.
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Affiliation(s)
- Evrard Nahimana
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, 02115, Boston, MA, USA.
| | | | - Hema Magge
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. .,Division of General Pediatrics, Boston Children's Hospital, Boston, USA. .,Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA.
| | | | | | - Ernest Muhirwa
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.
| | | | | | | | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, 02115, Boston, MA, USA.
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40
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Iribagiza MK, Manikuzwe A, Aquino T, Amoroso C, Zachariah R, van Griensven J, Schneider S, Finnegan K, Cortas C, Kamanzi E, Hamon JK, Hedt-Gauthier BL. Fostering interest in research: evaluation of an introductory research seminar at hospitals in rural Rwanda. Public Health Action 2015; 4:271-5. [PMID: 26400708 DOI: 10.5588/pha.14.0093] [Citation(s) in RCA: 6] [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: 09/10/2014] [Accepted: 11/12/2014] [Indexed: 11/10/2022] Open
Abstract
SETTINGS Partners In Health Rwanda, in collaboration with the Ministry of Health, leads a multipronged approach to develop research capacity among health workers, particularly in rural areas. OBJECTIVES To describe the characteristics of participants and to assess the impact of an introductory research seminar series in three district hospitals in rural Rwanda. DESIGN This was a retrospective cohort study of seminar participants. Data were sourced from personnel records, assessment sheets and feedback forms. RESULTS A total of 126 participants, including 70 (56%) clinical and 56 (44%) non-clinical staff, attended the research seminar series; 61 (48%) received certification. Among those certified, the median assessment score on assignments was 79%. Participants read significantly more articles at 6 and 12 months (median 2 and 4 respectively, compared to 1 at baseline, P < 0.01). There was also a significant increase (P ⩽ 0.05) in self-reported involvement in research studies (28%, baseline; 59%, 12 months) and attendance at other research training (36%, baseline; 65%, 12 months). CONCLUSION The introductory research seminar series provided an important opportunity for engagement in research among clinical and non-clinical staff. Such an activity is a key component of a comprehensive research capacity building programme at rural sites, and serves as an entry point for more advanced research training.
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Affiliation(s)
- M K Iribagiza
- Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda ; International Health Science University, Kampala, Uganda
| | - A Manikuzwe
- Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda
| | - T Aquino
- Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda
| | - C Amoroso
- Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda
| | - R Zachariah
- Médecins Sans Frontières Luxembourg, Operational Center Brussels, Brussels, Belgium
| | | | - S Schneider
- Médecins Sans Frontières Luxembourg, Operational Center Brussels, Brussels, Belgium
| | - K Finnegan
- Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda ; Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - C Cortas
- Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda ; Brigham and Women's Hospital, Boston, Massachusetts, USA ; Harvard Medical School, Boston, Massachusetts, USA
| | - E Kamanzi
- Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda
| | - J K Hamon
- Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda
| | - B L Hedt-Gauthier
- Partners In Health-Inshuti Mu Buzima, Kigali, Rwanda ; Harvard Medical School, Boston, Massachusetts, USA ; National University of Rwanda School of Public Health, Kigali, Rwanda
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Rubanzana W, Ntaganira J, Freeman MD, Hedt-Gauthier BL. Risk factors for homicide victimization in post-genocide Rwanda: a population -based case- control study. BMC Public Health 2015; 15:809. [PMID: 26293322 PMCID: PMC4546077 DOI: 10.1186/s12889-015-2145-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 08/12/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Homicide is one of the leading causes of mortality in the World. Homicide risk factors vary significantly between countries and regions. In Rwanda, data on homicide victimization is unreliable because no standardized surveillance system exists. This study was undertaken to identify the risk factors for homicide victimization in Rwanda with particular attention on the latent effects of the 1994 genocide. METHODS A population-based matched case-control study was conducted, with subjects enrolled prospectively from May 2011 to May 2013. Cases of homicide victimization were identified via police reports, and crime details were provided by law enforcement agencies. Three controls were matched to each case by sex, 5-year age group and village of residence. Socioeconomic and personal background data, including genocide exposure, were provided via interview of a family member or through village administrators. Conditional logistic regression, stratified by gender status, was used to identify risk factors for homicide victimization. RESULTS During the study period, 156 homicide victims were enrolled, of which 57 % were male and 43 % were female. The most common mechanisms of death were wounds inflicted by sharp instruments (knives or machetes; 41 %) followed by blunt force injuries (36.5 %). Final models indicated that risk of homicide victimhood increased with victim alcohol drinking patterns. There was a dose response noted for alcohol use: for minimal drinking versus none, adjusted odds ratio (aOR) = 3.1, 95%CI: 1,3-7.9; for moderate drinking versus none, aOR = 10.1, 95%CI: 3.7-24.9; and for heavy drinking versus none, aOR = 11.5, 95%CI: 3.6-36.8. Additionally, having no surviving parent (aOR = 2.7, 95%CI: 1.1-6.1), previous physical and/or sexual abuse (aOR = 28.1, 95%CI: 5.1-28.3) and drinking illicit brew and/or drug use (aOR = 7.7, 95%CI: 2.4-18.6) were associated with a higher risk of being killed. The test of interaction revealed that the variables that were significantly associated with a higher risk of homicide victimhood, did not exhibit any difference according to sex of the victim. However, the effect of belonging to a religion differed between women and men, but was significantly protective for both (aOR = 0.002, 95%CI: 0.001-0.054 and aOR = 0.20, 95%CI: 0.052-0.509, respectively). CONCLUSION Homicide victims in Rwanda are relatively young and the proportion of female victims is one of the highest globally. Contrary to the initial study considerations, genocide exposure (either as a survivor or perpetrator) was not a significant predictor of homicide victimization. Rather, risk factors were similar to those described in other countries, regardless of gender status. Sensitizing communities against alcohol heavy drinking, and illicit brew drinking and/or drug abuse and physical or sexual violence could reduce the homicide rate in Rwanda.
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Affiliation(s)
- Wilson Rubanzana
- Department of Epidemiology and Biostatistics, University of Rwanda College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda.
- Rwanda National Police Directorate of Medical Service, Kigali, Rwanda.
| | - Joseph Ntaganira
- Department of Epidemiology and Biostatistics, University of Rwanda College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda.
| | - Michael D Freeman
- Oregon Health & Science University, School of Medicine, Portland, Oregon, USA.
- Umeå University, Faculty of Medicine, Section of Forensic Medicine, Umeå, Sweden.
- Department of Forensic Medicine, Aarhus University, Faculty of Health Sciences, Aarhus, Denmark.
| | - Bethany L Hedt-Gauthier
- Department of Epidemiology and Biostatistics, University of Rwanda College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda.
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.
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Mugabo L, Rouleau D, Odhiambo J, Nisingizwe MP, Amoroso C, Barebwanuwe P, Warugaba C, Habumugisha L, Hedt-Gauthier BL. Approaches and impact of non-academic research capacity strengthening training models in sub-Saharan Africa: a systematic review. Health Res Policy Syst 2015; 13:30. [PMID: 26055974 PMCID: PMC4464866 DOI: 10.1186/s12961-015-0017-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [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: 08/01/2014] [Accepted: 05/25/2015] [Indexed: 11/10/2022] Open
Abstract
Background Research is essential to identify and prioritize health needs and to develop appropriate strategies to improve health outcomes. In the last decade, non-academic research capacity strengthening trainings in sub-Saharan Africa, coupled with developing research infrastructure and the provision of individual mentorship support, has been used to build health worker skills. The objectives of this review are to describe different training approaches to research capacity strengthening in sub-Saharan Africa outside academic programs, assess methods used to evaluate research capacity strengthening activities, and learn about the challenges facing research capacity strengthening and the strategies/innovations required to overcome them. Methodology The PubMed database was searched using nine search terms and articles were included if 1) they explicitly described research capacity strengthening training activities, including information on program duration, target audience, immediate program outputs and outcomes; 2) all or part of the training program took place in sub-Saharan African countries; 3) the training activities were not a formal academic program; 4) papers were published between 2000 and 2013; and 5) both abstract and full paper were available in English. Results The search resulted in 495 articles, of which 450 were retained; 14 papers met all inclusion criteria and were included and analysed. In total, 4136 people were trained, of which 2939 were from Africa. Of the 14 included papers, six fell in the category of short-term evaluation period and eight in the long-term evaluation period. Conduct of evaluations and use of evaluation frameworks varied between short and long term models and some trainings were not evaluated. Evaluation methods included tests, surveys, interviews, and systems approach matrix. Conclusions Research capacity strengthening activities in sub-Saharan Africa outside of academic settings provide important contributions to developing in-country capacity to participate in and lead research. Institutional support, increased funds, and dedicated time for research activities are critical factors that lead to the development of successful programs. Further, knowledge sharing through scientific articles with sufficient detail is needed to enable replication of successful models in other settings.
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Affiliation(s)
- Lambert Mugabo
- Partners In Health-Inshuti Mu Buzima, P.O. Box 3432, Kigali, Rwanda. .,Global Health Corps, One Penn Plaza, Suite 6271, New York, NY, 10119, USA.
| | - Dominique Rouleau
- Partners In Health-Inshuti Mu Buzima, P.O. Box 3432, Kigali, Rwanda.
| | - Jackline Odhiambo
- Partners In Health-Inshuti Mu Buzima, P.O. Box 3432, Kigali, Rwanda.
| | | | - Cheryl Amoroso
- Partners In Health-Inshuti Mu Buzima, P.O. Box 3432, Kigali, Rwanda.
| | - Peter Barebwanuwe
- Partners In Health-Inshuti Mu Buzima, P.O. Box 3432, Kigali, Rwanda.
| | | | | | - Bethany L Hedt-Gauthier
- Partners In Health-Inshuti Mu Buzima, P.O. Box 3432, Kigali, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.
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Linden AF, Maine R, Hedt-Gauthier BL, Kamanzi E, Mody G, Ntakiyiruta G, Kansayisa G, Ntaganda E, Niyonkuru F, Mubiligi J, Mpunga T, Meara JG, Riviello R. Epidemiology of untreated non-obstetric surgical disease in Burera District, Rwanda: a cross-sectional survey. Lancet 2015; 385 Suppl 2:S9. [PMID: 26313111 DOI: 10.1016/s0140-6736(15)60804-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND In low-income and middle-income countries, surgical epidemiology is largely undefined at the population level, with operative logs and hospital records serving as a proxy. This study assesses the distribution of surgical conditions that contribute the largest burden of surgical disease in Burera District, in northern Rwanda. We hypothesise that our results would yield higher rates of surgical disease than current estimates (from 2006) for similar low-income countries, which are 295 per 100 000 people. METHODS In March and May, 2012, we performed a cross-sectional study in Burera District, randomly sampling 30 villages with probability proportionate to size and randomly sampling 23 households within the selected villages. Six Rwandan surgical postgraduates and physicians conducted physical examinations on all eligible participants in sampled households. Participants were assessed for injuries or wounds, hernias, hydroceles, breast mass, neck mass, obstetric fistula, undescended testes, hypospadias, hydrocephalus, cleft lip or palate, and club foot. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all participants. FINDINGS Of the 2165 examined individuals, the overall prevalence of any surgical condition was 12% (95% CI 9·2-14·9) or 12 009 per 100 000 people. Injuries or wounds accounted for 55% of the prevalence and hernias or hydroceles accounted for 40%, followed by neck mass (4·2%), undescended testes (1·9%), breast mass (1·2%), club foot (1%), hypospadias (0·6%), hydrocephalus (0·6%), cleft lip or palate (0%), and obstetric fistula (0%). When comparing study participant characteristics, no statistical difference in overall prevalence was noted when examining sex, wealth, education, and travel time to the nearest hospital. Total rates of surgically treatable disease yielded a statistically significant difference compared with current estimates (p<0·001). INTERPRETATION Rates of surgically treatable disease are significantly higher than previous estimates in comparable low-income countries. The prevalence of surgically treatable disease is evenly distributed across demographic parameters. From these results, we conclude that strengthening the Rwandan health system's surgical capacity, particularly in rural areas, could have meaningful affect on the entire population. Further community-based surgical epidemiological studies are needed in low-income and middle-income countries to provide the best data available for health system planning. FUNDING The Harvard Sheldon Traveling Fellowship.
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Affiliation(s)
- Allison F Linden
- Georgetown University Hospital, Department of Surgery, Washington, DC, USA; Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA.
| | - Rebecca Maine
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; University of California San Francisco Medical Center, Department of Surgery, San Francisco, CA, USA
| | - Bethany L Hedt-Gauthier
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Partners In Health, Kigali, Rwanda
| | | | - Gita Mody
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, MA, USA
| | - Georges Ntakiyiruta
- University of Rwanda College of Medicine and Health Sciences, Department of Surgery, Kigali, Rwanda
| | | | - Edmond Ntaganda
- Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
| | | | | | | | - John G Meara
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Boston Children's Hospital, Department of Plastic and Oral Surgery, Boston, MA, USA
| | - Robert Riviello
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, MA, USA
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Linden AF, Maine R, Hedt-Gauthier BL, Kamanzi E, Mody G, Ntakiyiruta G, Kansayisa G, Ntaganda E, Niyonkuru F, Mubiligi J, Mpunga T, Meara JG, Riviello R. Validation of a community-based survey assessing non-obstetric surgical conditions in Burera District, Rwanda. Lancet 2015; 385 Suppl 2:S8. [PMID: 26313110 DOI: 10.1016/s0140-6736(15)60803-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Community-based surveillance methods to monitor epidemiological progress in surgery have not yet been employed for surgical capacity building. The aim of this study was to create and assess the validity of a questionnaire that collected data for untreated surgically correctable diseases throughout Burera District, northern Rwanda, to accurately plan for surgical services. METHODS A structured interview to assess for the presence or absence of ten index surgically treatable conditions (breast mass, cleft lip/palate, club foot, hernia or hydrocele [adult and paediatric]), hydrocephalus, hypospadias, injuries or wounds, neck mass, undescended testes, and vaginal fistula) was created. The interview was built based on previously validated questionnaires, forward and back translated into the local language and underwent focus group augmentation and pilot testing. In March and May, 2012, data collectors conducted the structured interviews with a household representative in 30 villages throughout Burera District, selected using a two-stage cluster sampling design. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all households. FINDINGS 2990 individuals were surveyed, a 97% response rate. 2094 (70%) individuals were available for physical examination. The calculated overall sensitivity of the structured interview tool was 44·5% (95% CI 38·9-50·2) and the specificity was 97·7% (96·9-98·3%; appendix). The positive predictive value was 70% (95% CI 60·5-73·5), whereas the negative predictive value was 91·3% (90·0-92·5). The conditions with the highest sensitivity and specificity, respectively, were hydrocephalus (100% and 100%), clubfoot (100% and 99·8%), injuries or wounds (54·7% and 98·9%), and hypospadias (50% and 100%). Injuries or wounds and hernias or hydroceles were the conditions most frequently identified on examination that were not reported during the interview (appendix). INTERPRETATION To the best of our knowledge, this study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity limits the use of the tool, which will require further revision, and calls into question previously published unvalidated community surgical survey data. To improve validation of community-based surveys, community education efforts on common surgically treatable conditions are needed in conjunction with increased access to surgical care. Accurate community-based surveys are crucial to integrated health system planning that includes surgical care as a core component. FUNDING The Harvard Sheldon Traveling Fellowship.
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Affiliation(s)
- Allison F Linden
- Georgetown University Hospital, Department of Surgery, Washington, DC, USA; Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA.
| | - Rebecca Maine
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; University of California San Francisco Medical Center, Department of Surgery, San Francisco, CA, USA
| | - Bethany L Hedt-Gauthier
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Partners In Health, Boston, MA, USA
| | | | - Gita Mody
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, MA, USA
| | - Georges Ntakiyiruta
- University of Rwanda College of Medicine and Health Sciences, Department of Surgery, Kigali, Rwanda
| | | | - Edmond Ntaganda
- Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
| | | | | | | | - John G Meara
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Boston Children's Hospital, Department of Plastic and Oral Surgery, Boston, MA, USA
| | - Robert Riviello
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, MA, USA
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Rubanzana W, Hedt-Gauthier BL, Ntaganira J, Freeman MD. Exposure to genocide and risk of suicide in Rwanda: a population-based case-control study. J Epidemiol Community Health 2014; 69:117-22. [PMID: 25488977 PMCID: PMC4316837 DOI: 10.1136/jech-2014-204307] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [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] [Indexed: 12/22/2022]
Abstract
Background In Rwanda, an estimated one million people were killed during the 1994 genocide, leaving the country shattered and social fabric destroyed. Large-scale traumatic events such as wars and genocides have been linked to endemic post-traumatic stress disorder, depression and suicidality. The study objective was to investigate whether the 1994 genocide exposure is associated with suicide in Rwanda. Methods We conducted a population-based case–control study. Suicide victims were matched to three living controls for sex, age and residential location. Exposure was defined as being a genocide survivor, having suffered physical/sexual abuse in the genocide, losing a first-degree relative in the genocide, having been convicted for genocide crimes or having a first-degree relative convicted for genocide. From May 2011 to May 2013, 162 cases and 486 controls were enrolled countrywide. Information was collected from the police, local village administrators and family members. Results After adjusting for potential confounders, having been convicted for genocide crimes was a significant predictor for suicide (OR=17.3, 95% CI 3.4 to 88.1). Being a survivor, having been physically or sexually abused during the genocide, and having lost a first-degree family member to genocide were not significantly associated with suicide. Conclusions These findings demonstrate that individuals convicted for genocide crimes are experiencing continued psychological disturbances that affect their social reintegration into the community even 20 years after the event. Given the large number of genocide perpetrators reintegrated after criminal courts and Gacaca traditional reconciling trials, suicide could become a serious public health burden if preventive remedial action is not identified.
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Affiliation(s)
- Wilson Rubanzana
- Department of Epidemiology and Biostatistics, University of Rwanda College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda Rwanda National Police, Directorate of Medical Service, Kigali, Rwanda
| | - Bethany L Hedt-Gauthier
- Department of Epidemiology and Biostatistics, University of Rwanda College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Joseph Ntaganira
- Department of Epidemiology and Biostatistics, University of Rwanda College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda
| | - Michael D Freeman
- Oregon Health & Science University, School of Medicine, Portland, Oregon, USA Faculty of Medicine, Section of Forensic Medicine, Umeå University, Umeå, Sweden Faculty of Health Sciences, Department of Forensic Medicine, Aarhus University, Aarhus, Denmark
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Mpunga T, Tapela N, Hedt-Gauthier BL, Milner D, Nshimiyimana I, Muvugabigwi G, Moore M, Shulman DS, Pepoon JR, Shulman LN. Diagnosis of cancer in rural Rwanda: early outcomes of a phased approach to implement anatomic pathology services in resource-limited settings. Am J Clin Pathol 2014; 142:541-5. [PMID: 25239422 DOI: 10.1309/ajcpypdes6z8eley] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [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: 10/24/2022] Open
Abstract
OBJECTIVES Adequate pathology services are a prerequisite to accurate cancer diagnoses and tailoring appropriate treatment. Limitations in skilled personnel and infrastructure are among the challenges faced by developing countries. We describe a stepwise implementation of anatomic pathology laboratory services at Butaro District Hospital, designated as a Cancer Center of Excellence in rural Rwanda. METHODS The phased approach to developing pathology services up to December 2012 is described. A retrospective review of specimens submitted to Butaro District Hospital between July 1, 2012, and December 31, 2012, was conducted. Patient clinical characteristics and sociodemographics are also described. RESULTS During the study period, a total of 437 tissue specimens were submitted. Among these, 143 (32.7%) were from male patients, 244 (55.8%) were confirmed as malignant, 163 (37.3%) were benign, 28 (6.4%) were inconclusive, and two (0.5%) results were not available at the time of analysis. The median time from specimen receipt at Butaro to final reporting was 32 days (range, 7-193 days; interquartile range, 23-44 days). CONCLUSIONS Our experience demonstrates that anatomic pathology services can be established in resource-limited settings and local capacity can be built to support accurate diagnoses. Our approach included leveraging partnerships, volunteer experts, and task shifting and will be expanded to include telepathology.
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Affiliation(s)
- Tharcisse Mpunga
- Ministry of Health, Kigali, Rwanda
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Neo Tapela
- Partners In Health/Rwanda, Kigali, Rwanda
- Brigham and Women’s Hospital, Boston, MA
| | - Bethany L. Hedt-Gauthier
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
- Partners In Health/Rwanda, Kigali, Rwanda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | - Dan Milner
- Brigham and Women’s Hospital, Boston, MA
| | | | | | | | | | - James R. Pepoon
- Partners In Health/Rwanda, Kigali, Rwanda
- Brigham and Women’s Hospital, Boston, MA
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Manzi A, Munyaneza F, Mujawase F, Banamwana L, Sayinzoga F, Thomson DR, Ntaganira J, Hedt-Gauthier BL. Assessing predictors of delayed antenatal care visits in Rwanda: a secondary analysis of Rwanda demographic and health survey 2010. BMC Pregnancy Childbirth 2014; 14:290. [PMID: 25163525 PMCID: PMC4152595 DOI: 10.1186/1471-2393-14-290] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [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: 03/09/2014] [Accepted: 08/12/2014] [Indexed: 11/10/2022] Open
Abstract
Background Early initiation of antenatal care (ANC) can reduce common maternal complications and maternal and perinatal mortality. Though Rwanda demonstrated a remarkable decline in maternal mortality and 98% of Rwandan women receive antenatal care from a skilled provider, only 38% of women have an ANC visit in their first three months of pregnancy. This study assessed factors associated with delayed ANC in Rwanda. Methods This is a cross-sectional study using data collected during the 2010 Rwanda DHS from 6,325 women age 15–49 that had at least one birth in the last five years. Factors associated with delayed ANC were identified using a multivariable logistic regression model using manual backward stepwise regression. Analysis was conducted in Stata v12 applying survey commands to account for the complex sample design. Results Several factors were significantly associated with delayed ANC including having many children (4–6 children, OR = 1.42, 95% CI: 1.22, 1.65; or more than six children, OR = 1.57, 95% CI: 1.24, 1.99); feeling that distance to health facility is a problem (OR = 1.20, 95% CI: 1.04, 1.38); and unwanted pregnancy (OR = 1.41, 95% CI: 1.26, 1.58). The following were protective against delayed ANC: having an ANC at a private hospital or clinic (OR = 0.29, 95% CI: 0.15, 0.56); being married (OR = 0.85, 95% CI: 0.75, 0.96), and having public mutuelle health insurance (OR = 0.81, 95% CI: 0.71, 0.92) or another type of insurance (OR = 0.33, 95% CI: 0.23, 0.46). Conclusion This analysis revealed potential barriers to ANC service utilization. Distance to health facility remains a major constraint which suggests a great need of infrastructure and decentralization of maternal ANC to health posts and dispensaries. Interventions such as universal health insurance coverage, family planning, and community maternal health system are underway and could be part of effective strategies to address delays in ANC.
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Manzi A, Magge H, Hedt-Gauthier BL, Michaelis AP, Cyamatare FR, Nyirazinyoye L, Hirschhorn LR, Ntaganira J. Clinical mentorship to improve pediatric quality of care at the health centers in rural Rwanda: a qualitative study of perceptions and acceptability of health care workers. BMC Health Serv Res 2014; 14:275. [PMID: 24950878 PMCID: PMC4077561 DOI: 10.1186/1472-6963-14-275] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 06/17/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite evidence supporting Integrated Management of Childhood Illness (IMCI) as a strategy to improve pediatric care in countries with high child mortality, its implementation faces challenges related to lack of or poor post-didactic training supervision and gaps in necessary supporting systems. These constraints lead to health care workers' inability to consistently translate IMCI knowledge and skills into practice. A program providing mentoring and enhanced supervision at health centers (MESH), focusing on clinical and systems improvement was implemented in rural Rwanda as a strategy to address these issues, with the ultimate goal of improving the quality of pediatric care at rural health centers. We explored perceptions of MESH from the perspective of IMCI clinical mentors, mentees, and district clinical leadership. METHODS We conducted focus group discussions with 40 health care workers from 21 MESH-supported health centers. Two FGDs in each district were carried out, including one for nurses and one for director of health centers. District medical directors and clinical mentors had individual in-depth interviews. We performed a hermeneutic analysis using Atlas.ti v5.2. RESULTS Study participants highlighted program components in five key areas that contributed to acceptability and impact, including: 1) Interactive, collaborative capacity-building, 2) active listening and relationships, 3) supporting not policing, 4) systems improvement, and 5) real-time feedback. Staff turn-over, stock-outs, and other facility/systems gaps were identified as barriers to MESH and IMCI implementation. CONCLUSION Health care workers reported high acceptance and positive perceptions of the MESH model as an effective strategy to build their capacity, bridge the gap between knowledge and practice in pediatric care, and address facility and systems issues. This approach also improved relationships between the district supervisory team and health center-based care providers. Despite some challenges, many perceived a strong benefit on clinical performance and outcomes. This study can inform program implementers and policy makers of key components needed for developing similar health facility-based mentorship interventions and potential barriers and resistance which can be proactively addressed to ensure success.
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Affiliation(s)
- Anatole Manzi
- University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda.
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Harerimana JM, Nyirazinyoye L, Ahoranayezu JB, Bikorimana F, Hedt-Gauthier BL, Muldoon KA, Mills EJ, Ntaganira J. Effect of shortened Integrated Management of Childhood Illness training on classification and treatment of under-five children seeking care in Rwanda. Risk Manag Healthc Policy 2014; 7:99-104. [PMID: 24868177 PMCID: PMC4031202 DOI: 10.2147/rmhp.s56520] [Citation(s) in RCA: 7] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Integrated Management of Childhood Illness (IMCI) is an effective 11-day standard training; however, due to budgetary expenses and human resource constraints, many health professionals cannot take 11 days off work. As a result, shortened training curriculums (6-day) have been proposed. We used a cross-sectional study to evaluate the effect of this shortened training on appropriate IMCI classification and treatment of under-five childhood illness management in Rwanda. Methods A cross-sectional study was conducted in 22 health centers in Rwanda, comparing data from 121 nurses, where 55 nurses completed the 11-day and 66 nurses completed the 6-day training. Among 768 children, we evaluated clinical outcomes from May 2011 to April 2012. Descriptive statistics were used to display the sociodemographic characteristics of health providers; including level of education, sex, age, and professional experiences. Bivariable and multivariable analyses were used to test for differences between nurses in the 6-day versus 11-day training on the appropriate classification and treatment of childhood illness. Results Our findings show that at the bivariable level and after controlling for confounders in the multivariable analysis, the only significant differences detected between nurses in the long and short training was the classification of fever (adjusted odds ratio [aOR] 0.7, 95% confidence interval [CI] 0.64–0.75) and treatment of pneumonia (aOR 0.8, 95% CI 0.70–0.89). Nurses in the short training had lower odds of inappropriate misclassification and treatment for these two conditions. Conclusion There was no difference in classification and treatment of childhood illness among nurses who completed the standard and short IMCI training courses. Short-training could be a more cost-saving option for health facilities without compromising the key outcomes related to case management.
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Affiliation(s)
- Jean-Modeste Harerimana
- University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda
| | - Laetitia Nyirazinyoye
- University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda
| | | | - Ferdinand Bikorimana
- Maternal and Child Health, Child Unit, Rwandan Ministry of Health, Kigali, Rwanda
| | - Bethany L Hedt-Gauthier
- University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda ; Harvard Medical School, Boston, MA, USA
| | | | - Edward J Mills
- University of Ottawa, Ottawa, ON, Canada ; Stanford University, Stanford, CA, USA
| | - Joseph Ntaganira
- University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda
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Wroe EB, Hedt-Gauthier BL, Franke MF, Nsanzimana S, Turinimana JB, Drobac P. Depression and patterns of self-reported adherence to antiretroviral therapy in Rwanda. Int J STD AIDS 2014; 26:257-61. [PMID: 24828554 DOI: 10.1177/0956462414535206] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [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: 11/17/2022]
Abstract
We determined the prevalence of depression in HIV-infected adults on antiretroviral therapy in rural Rwanda and measured the association of depression with non-adherence. In all, 292 patients on antiretroviral therapy for ≥6 months were included. Adherence was self-reported by four-day recall, two- and seven-day treatment interruptions, and the CASE Index, which is a composite score accounting for difficulty taking medications on time, the average number of days per week a dose is missed, and the most recent missed dose. A total of 84% and 87% of participants reported good adherence by the four-day recall and CASE Index, respectively; 13% of participants reported two-day treatment interruptions; and 11% were depressed. Depression was significantly associated with two-day treatment interruptions but not with other measures of non-adherence. Self-reported adherence to antiretroviral therapy in rural Rwanda is high. Adherence assessments that do not consider treatment interruptions may miss important patterns of non-adherence, which may be especially prevalent among depressed individuals. Mental health interventions incorporated into routine HIV care may lead to improvements in mental health and adherence.
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Affiliation(s)
- Emily B Wroe
- Department of Internal Medicine, Brigham & Women's Hospital, Boston, MA, USA Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA University of Rwanda College of Medicine and Health Sciences, Butare, Rwanda
| | - Molly F Franke
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Peter Drobac
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA, USA
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