Next wave of interventions to reduce under-five mortality in Rwanda: a cross-sectional analysis of demographic and health survey data.

BACKGROUND: Sustained investments in Rwanda's health system have led to historic reductions in under five (U5) mortality. Although Rwanda achieved an estimated 68% decrease in the national under U5 mortality rate between 2002 and 2012, according to the national census, 5.8% of children still do not reach their fifth birthday, requiring the next wave of child mortality prevention strategies. METHODS: This is a cross-sectional study of 9002 births to 6328 women age 15-49 in the 2010 Rwanda Demographic and Health Survey. We tested bivariate associations between 29 covariates and U5 mortality, retaining covariates with an odds ratio p < 0.1 for model building. We used manual backward stepwise logistic regression to identify correlates of U5 mortality in all children U5, 0-11 months, and 12-59 months. Analyses were performed in Stata v12, adjusting for complex sample design. RESULTS: Of 14 covariates associated with U5 mortality in bivariate analysis, the following remained associated with U5 mortality in multivariate analysis: household being among the poorest of the poor (OR = 1.98), child being a twin (OR = 2.40), mother having 3-4 births in the past 5 years (OR = 3.97) compared to 1-2 births, mother being HIV positive (OR = 2.27), and mother not using contraceptives (OR = 1.37) compared to using a modern method (p < 0.05 for all). Mother experiencing physical or sexual violence in the last 12 months was associated with U5 mortality in children ages 1-4 years (OR = 1.48, p < 0.05). U5 survival was associated with a preceding birth interval 25-50 months (OR = 0.67) compared to 9-24 months, and having a mosquito net (OR = 0.46) (p < 0.05 for both). CONCLUSIONS: In the past decade, Rwanda rolled out integrated management of childhood illness, near universal coverage of childhood vaccinations, a national community health worker program, and a universal health insurance scheme. Identifying factors that continue to be associated with childhood mortality supports determination of which interventions to strengthen to reduce it further. This study suggests that Rwanda's next wave of U5 mortality reduction should target programs in improving neonatal outcomes, poverty reduction, family planning, HIV services, malaria prevention, and prevention of intimate partner violence.

Care-seeking patterns among families that experienced under-five child mortality in rural Rwanda.

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.

Community-Based Accompaniment and the Impact of Distance for HIV Patients Newly Initiated on Antiretroviral Therapy: Early Outcomes and Clinic Visit Adherence in Rural Rwanda.

Community-based accompaniment (CBA) has been associated with improved antiretroviral therapy (ART) patient outcomes in Rwanda. In contrast, distance has generally been associated with poor outcomes. However, impact of distance on outcomes under the CBA model is unknown. This retrospective cohort study included 537 adults initiated on ART in 2012 in two rural districts in Rwanda. The primary outcomes at 6 months after ART initiation included overall program status, missed a visit and missed three consecutive visits. The associations between cost surface distance (straight-line distance adjusted for surface features) and outcomes were assessed using logistic regression, controlling for potential confounders. Died/lost-to-follow-up and missed three consecutive visits were not associated with distance. Patients within 0-1 km cost surface distance were significantly more likely to miss a visit, potentially due to stigma of attending clinic within one's community. These results suggest that CBA may mediate the impact of long distances on outcomes.

Adapting operational research training to the Rwandan context: the Intermediate Operational Research Training programme.

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.

Five-year Outcomes Among Children Receiving Antiretroviral Therapy in a Community-based Accompaniment Program in Rural Rwanda.

Of 277 HIV-infected children in rural Rwanda enrolled in a community-based accompaniment program, 95.0% were retained in care 5 years after treatment initiation, with only 9 (3.3%) deaths and 3 (1.1%) defaults. Of 235 (84.8%) children with a documented viral load result, 201 (85.5%) demonstrated viral load suppression (<1000 copies/mL).

Bubble CPAP to support preterm infants in rural Rwanda: a retrospective cohort study.

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.

Leveraging community health worker system to map a mountainous rural district in low resource setting: a low-cost approach to expand use of geographic information systems for public health.

BACKGROUND: Geographic Information Systems (GIS) have become an important tool in monitoring and improving health services, particularly at local levels. However, GIS data are often unavailable in rural settings and village-level mapping is resource-intensive. This study describes the use of community health workers' (CHW) supervisors to map villages in a mountainous rural district of Northern Rwanda and subsequent use of these data to map village-level variability in safe water availability. METHODS: We developed a low literacy and skills-focused training in the local language (Kinyarwanda) to train 86 CHW Supervisors and 25 nurses in charge of community health at the health center (HC) and health post (HP) levels to collect the geographic coordinates of the villages using Global Positioning Systems (GPS). Data were validated through meetings with key stakeholders at the sub-district and district levels and joined using ArcMap 10 Geo-processing tools. Costs were calculated using program budgets and activities' records, and compared with the estimated costs of mapping using a separate, trained GIS team. To demonstrate the usefulness of this work, we mapped drinking water sources (DWS) from data collected by CHW supervisors from the chief of the village. DWSs were categorized as safe versus unsafe using World Health Organization definitions. RESULT: Following training, each CHW Supervisor spent five days collecting data on the villages in their coverage area. Over 12 months, the CHW supervisors mapped the district's 573 villages using 12 shared GPS devices. Sector maps were produced and distributed to local officials. The cost of mapping using CHW supervisors was $29,692, about two times less than the estimated cost of mapping using a trained and dedicated GIS team ($60,112). The availability of local mapping was able to rapidly identify village-level disparities in DWS, with lower access in populations living near to lakes and wetlands (p < .001). CONCLUSION: Existing national CHW system can be leveraged to inexpensively and rapidly map villages even in mountainous rural areas. These data are important to provide managers and decision makers with local-level GIS data to rapidly identify variability in health and other related services to better target and evaluate interventions.

Using electronic medical records for HIV care in rural Rwanda.

Partners In Health (PIH) implemented an electronic medical record (EMR) system in Rwanda in 2005 to support and improve HIV and TB patient care. The system holds detailed patient records, accessible to clinicians through printed reports or directly via a computer in the consultation rooms. Ongoing assessment of data quality and clinical data use has led multiple interventions to be put in place. One such evaluation cycle led to the implementation of a system which identified 15 previously undiagnosed pediatric patients with HIV. Another cycle led to an EMR intervention which helped to decrease the proportion of completed critical CD4 lab results that did not reach clinicians by 34.2% (p=.002). Additionally an automated data quality improvement system reduced known errors by 92% by providing local data officers a tool and training to allow them to easily access and correct data errors. Electronic systems can be used to support care in rural resource-poor settings, and frequent assessment of data quality and clinical use of data can be used to support that goal.

"Should I and can I?" A mixed methods study of clinician beliefs and attitudes in the management of lifestyle risk factors in primary health care.

BACKGROUND: Primary health care (PHC) clinicians have an important role to play in addressing lifestyle risk factors for chronic diseases. However they intervene only rarely, despite the opportunities that arise within their routine clinical practice. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about this for PHC clinicians working outside general practice. The aim of this study was to explore the beliefs and attitudes of PHC clinicians about incorporating lifestyle risk factor management into their routine care and to examine whether these varied according to their self reported level of risk factor management. METHODS: A cross sectional survey was undertaken with PHC clinicians (n = 59) in three community health teams. Clinicians' beliefs and attitudes were also explored through qualitative interviews with a purposeful sample of 22 clinicians from the teams. Mixed methods analysis was used to compare beliefs and attitudes for those with high and low levels of self reported risk factor management. RESULTS: Role congruence, perceived client acceptability, beliefs about capabilities, perceived effectiveness and clinicians' own lifestyle were key themes related to risk factor management practices. Those reporting high levels of risk factor screening and intervention had different beliefs and attitudes to those PHC clinicians who reported lower levels. CONCLUSION: PHC clinicians' level of involvement in risk factor management reflects their beliefs and attitudes about it. This provides insights into ways of intervening to improve the integration of behavioural risk factor management into routine practice.

Job satisfaction of staff and the team environment in Australian general practice.

OBJECTIVE: To study the work satisfaction of general practice staff, the differences between types of staff, and the individual and organisational factors associated with work satisfaction. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional multipractice study based on a self-completed job satisfaction survey of 626 practice staff in 96 general practices in Australia between 16 December 2003 and 8 October 2004. MAIN OUTCOME MEASURES: Job satisfaction scores for all staff and for general practitioners alone; relationship between job satisfaction and the team climate, practice size, particular jobs within practices, demographic characteristics of participants, and geographical location of practices. RESULTS: The response rate was 65%. Job satisfaction was high, with a mean score of 5.66 (95% CI, 5.60-5.72). Multilevel analysis showed that all general practice staff were highly satisfied if they worked in a practice with a good team climate. Practice managers reported the highest satisfaction with their work. Practice size and individual characteristics such as the sex of the participant were unrelated to job satisfaction. GPs tended to have lower satisfaction than other staff in relation to income, recognition for good work and hours of work. Rural GPs were more satisfied. CONCLUSIONS: Most general practice staff are satisfied with their work. Facilitating teamwork may be a key strategy for both recruitment and retention of the general practice workforce, especially staff who are not GPs.