Rwanda's Resiliency During the Coronavirus Disease Pandemic.

The coronavirus disease (COVID-19) pandemic has illustrated the wide range of preventative measures and responsive strategies of low- and middle-income countries (LMICs). LMICs have implemented lessons learned from previous periods of epidemics and uncertainties. Rwanda's pre-existing decentralized healthcare and mental health system which are in response to the mental health distress from the 1994 genocide, continues to be a formidable system that collaborate and combine efforts to address people's mental health needs. COVID-19 has heightened or exacerbated people's mental health within the country. Rwandans have been exposed to and endured adversities, yet their cultural forms of resilience serve as a mental health protective factor to also overcome COVID-19. Nonetheless, Rwanda has engaged in interventions targeting public safety, social and economic protection that specifically address vulnerable communitie's mental health needs. Lessons from preparedness for the Ebola virus disease (EVD) epidemic has contributed to Rwanda's organization and approach to combating COVID-19. Policies and best practices that were enacted during the EVD outbreak have guided Rwanda's response within the healthcare and mental health system. Coincidentally, this outbreak emerged during the 26th commemoration of the 1994 genocide against the Tutsi. Although for the first-time post genocide, Rwanda was not able to engage in public traditional forms of collective mourning and community healing, evidence of Rwandan's resilient spirit is demonstrated. Community resilience has been defined by Magis [401] as the "existence, development and engagement of community resources by community members to thrive in an environment characterized by change, uncertainty, unpredictability and surprise.". Referring to this definition, community resilience has been an interwoven into the cultural framework that guided Rwandans in past challenges and continues to be evident now. Rwanda's resilience throughout this pandemic remains through ongoing psychoeducation, community awareness of mental health concerns, collective messages of highlighting mental health support, and solidarity. The global community can gain knowledge from Rwanda's learned lessons of their past which has positioned itself to stand on its resilient values in times of uncertainty such as COVID-19 and endeavor to overcome through national cohesion.

A retrospective study of neonatal case management and outcomes in rural Rwanda post implementation of a national neonatal care package for sick and small infants.

BACKGROUND: Despite worldwide efforts to reduce neonatal mortality, 44% of under-five deaths occur in the first 28 days of life. The primary causes of neonatal death are preventable or treatable. This study describes the presentation, management and outcomes of hospitalized newborns admitted to the neonatal units of two rural district hospitals in Rwanda after the 2012 launch of a national neonatal protocol and standards. METHODS: We retrospectively reviewed routinely collected data for all neonates (0 to 28 days) admitted to the neonatal units at Rwinkwavu and Kirehe District Hospitals from January 1, 2013 to December 31, 2014. Data on demographic and clinical characteristics, clinical management, and outcomes were analyzed using median and interquartile ranges for continuous data and frequencies and proportions for categorical data. Clinical management and outcome variables were stratified by birth weight and differences between low birth weight (LBW) and normal birth weight (NBW) neonates were assessed using Fisher's exact or Wilcoxon rank-sum tests at the α = 0.05 significance level. RESULTS: A total of 1723 neonates were hospitalized over the two-year study period; 88.7% were admitted within the first 48 h of life, 58.4% were male, 53.8% had normal birth weight and 36.4% were born premature. Prematurity (27.8%), neonatal infection (23.6%) and asphyxia (20.2%) were the top three primary diagnoses. Per national protocol, vital signs were assessed every 3 h within the first 48 h for 82.6% of neonates (n = 965/1168) and 93.4% (n = 312/334) of neonates with infection received antibiotics. The overall mortality rate was 13.3% (n = 185/1386) and preterm/LBW infants had similar mortality rate to NBW infants (14.7 and 12.2% respectively, p = 0.131). The average length of stay in the neonatal unit was 5 days. CONCLUSIONS: Our results suggest that it is possible to provide specialized neonatal care for both LBW and NBW high-risk neonates in resource-limited settings. Despite implementation challenges, with the introduction of the neonatal care package and defined clinical standards these most vulnerable patients showed survival rates comparable to or higher than neighboring countries.

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.

Roadmap to an effective quality improvement and patient safety program implementation in a rural hospital setting.

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.