Exploring contextual factors influencing the implementation of evidence-based care for hypertension in Rwanda: a cross-sectional study using the COACH questionnaire.

IMPORTANCE: Hypertension is the largest contributor to the Global Burden of Disease. In Rwanda, as in most low-income and middle-income countries, an increasing prevalence of hypertension and its associated morbidity and mortality is causing major healthcare and economic impact. Understanding healthcare systems context in hypertension care is necessary. OBJECTIVE: To study the hypertension healthcare context as perceived by healthcare providers using the Context Assessment for Community Health (COACH) tool. DESIGN: A cross-sectional cohort responded to the COACH questionnaire and a survey about hypertension training. SETTING: Three tertiary care hospitals in Rwanda. PARTICIPANTS: Healthcare professionals (n=223). PRIMARY OUTCOMES AND MEASURES: The COACH tool consists of 49 items with eight subscales: resources, community engagement, commitment to work, informal payment, leadership, work culture, monitoring services for action (5-point Likert Scale) and sources of knowledge (on a 0-1 scale). Four questions surveyed training on hypertension. RESULTS: Responders (n=223, 75% women; 56% aged 20-35 years) included nurses (n=142, 64%, midwives (n=42, 19%), primary care physicians (n=28, 13%) and physician specialists (n=11, 5%)). The subscales commitment to work, leadership, work culture and informal payment scored between 4.7 and 4.1 and the community engagement, monitoring services for action and organizational resources scored between 3.1 and 3.5. Sources of knowledge had a mean score of 0.6±0.3. While 73% reported having attended a didactic hypertension seminar in the past year, only 28% had received long-term training and 51% had <3-year experience working with hypertension care delivery. The majority (99%) indicated a need for additional training in hypertension care. CONCLUSIONS: There is a need for increased and continuous training in Rwanda. Healthcare responders stated a commitment to work and reported supportive leadership, while acknowledging limited resources and no monitoring systems. The COACH tool provides contextual guidance to develop training strategies prior to the implementation of a sustainable hypertension care programme.

Dissemination and Implementation Program in Hypertension in Rwanda: Report on Initial Training and Evaluation.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide and in low- and middle-income countries, and hypertension (HTN) is a major risk factor for CVD. Although effective evidence-based interventions for control of HTN in high-income countries exist, implementation of these in low- and middle-income countries has been challenging due to limited capacity and infrastructure for late-phase translational research. In Rwanda, the 2015 STEPS NCD (STEPwise Approach to Surveillance of Noncommunicable Diseases) risk survey reported an overall prevalence of HTN of 15% (95% confidence interval [CI]: 13.8 to 16.3) for those ages 15 to 64 years; prevalence increased with increasing age to 39% (95% CI: 35.7 to 43.1) for those ages 55 to 64 years; CVD was the third most common cause of mortality (7%). Suboptimal infrastructure and capacity in Rwanda hinders research and community knowledge for HTN control. OBJECTIVES: To address the issue of suboptimal capacity to implement evidence-based interventions in HTN, this project was designed with the following objectives: 1) to develop a regional needs assessment of infrastructure for dissemination and implementation (D & I) strategies for HTN-CVD control; 2) to develop HTN-CVD research capacity through creation of countrywide resources such as core research facilities and training in the fields of HTN-CVD, D & I, and biostatistics; and 3) to engage and train multiple stakeholders in D & I and HTN-CVD evidence-based interventions. METHODS: A weeklong training program in HTN-CVD, biostatistics, and D & I was conducted in Rwanda in August 2018, and pre- and post-D & I training competency questionnaires were administered. RESULTS: Questionnaire results show a statistically significant increase in D & I knowledge and skills as a result of training (full scale pre- to post-test scores: 2.12 ± 0.78 vs. 3.94 ± 0.42; p < 0.0001). CONCLUSIONS: Using principles of community engagement and train-the-trainer methods, we will continue to adapt guidelines and treatments for HTN-CVD developed in high-income countries to the context of Rwanda with the goal of establishing a sustainable platform to address the burden of disease from HTN-CVD.

Human Papillomavirus Genotype-Specific Persistence and Potential Risk Factors among Korean Women: Results from a 2-Year Follow-up Study.

PURPOSE: High-risk human papillomavirus (HPV) infection progression should be considered a critical factor for preventing cervical cancer, although most infections are transient and rarely persist. This study aimed to examine the specific types of HPV infections, their change patterns, and the potential risk factors among Korean women. MATERIALS AND METHODS: We included 4,588 women who visited hospitals in Busan and Suwon for cervical cancer screening, and 1,224 of thesewomen attended a 2-yearfollow-up. Infection statuswas evaluated using HPV DNA testing (Hybrid Capture 2) and genotyping testing (Linear Array). Data regarding the potential risk factors for HPV infection were collected by trained nurses using structured questionnaires. RESULTS: Among the 1,224 women (mean age, 47 years), 105 women (8.6%) were HPV-positive at baseline. HPV infections had been cleared among 92 women (87.6%) within 2 years. Only 13 infections (12.4%) were remained, and the 10 cases of them are high-risk HPV types including genotype 33, 45, 16, 35, and 52. Among women who were negative at baseline, the HPV incidence was 4.8%. The HPV incidence was marginally associated with having multiple sexual partners (odds ratio, 2.0; 95% confidence interval, 1.0 to 3.9), although it was not significantly associated with HPV persistence. CONCLUSION: Most HPV infections (88%) among Korean women were cleared within 2 years, with only a small number of persistent infections. The persistent HPV genotypes were different in our study, compared to those from previous studies. Having multiple sexual partners was associated with acquiring a HPV infection, but not with persistence.

Nationwide statistical analysis of myeloid malignancies in Korea: incidence and survival rate from 1999 to 2012.

BACKGROUND: Large-scale epidemiologic analysis for hematologic malignancies will be helpful to understand the trends in incidence and survival. METHODS: The Korea Central Cancer Registry (KCCR) updated the nationwide analysis on the incidence and survival of myeloid malignancies, from the Korean National Cancer Incidence Database between 1999 and 2012. Myeloid malignancies were classified based on the International Classification of Diseases for Oncology 3(rd) edition (ICD-O-3). RESULTS: Overall 3,771 cases of myeloid diseases, which was 1.7% of all cancers, were identified in 2012. The highest incidence of myeloid malignancies was observed in age 70s and male predominance was noted (1.3:1). Acute myeloid leukemia (AML) was the most frequent subtype, followed by myeloproliferative neoplasms (MPN), myelodysplastic syndrome (MDS) and MDS/MPN: age-standardized incidence rates (ASR) in 2012 for each disease were 2.02, 1.95, 1.13, and 0.12 per 100,000 persons, respectively. The ASR for all myeloid malignancies was increased from 3.31 in 1999 to 5.70 in 2012 with the annual percentage change (APC) of 5.4 %. Five-year relative survival rate (RS) for myeloid malignancies has gradually improved for decades. RS changed from 26.3% to 34.8% in AML, specifically from 51.6% to 69.6% in acute promyelocytic leukemia (APL) and from 23.8% to 29.9% in non-APL AML, between 1996-2000 and 2008-2012. RS also increased from 81.8% to 87.1% in MPN, with a significant improvement in CML (from 74.5% to 85.5%), and from 27.3% to 31.7% in MDS/MPN between 2001-2005 and 2008-2012. However, there was no survival improvement in MDS during the study period (45.6% in 2001-2005 to 44.4% in 2008-2012). CONCLUSION: This report updated the nationwide statistical analysis on myeloid malignancies since 2008, showing increasing incidence and improving trends in survival.