Food insecurity and level of depression among patients with chronic diseases, and associated factors during the COVID-19 lockdown: a cross-sectional study in rural Rwanda.

OBJECTIVES: We aimed to describe access to food and symptoms of depression among patients with chronic diseases or their caregivers, and assess associated factors during the COVID-19 lockdown in rural Rwanda. DESIGN: A cross-sectional study. SETTING AND PARTICIPANTS: A stratified random sampling technique was used to recruit 220 patients enrolled in the HIV, non-communicable diseases, mental health, paediatric development clinic and oncology programmes in three rural districts of Rwanda. OUTCOME MEASURES: Telephone-based interviews were conducted to collect data on the number of daily meals before and during the COVID-19, and depression was assessed using the Patient Health Questionnaire-9. We used logistic regression analysis to investigate factors associated with households reporting a reduction in daily meals and with the survey respondent reporting symptoms of depression. RESULTS: Of the participants, 19.1% reported a reduction in daily number of meals for either adults or children in their households during lockdown and 24.6% had depression. Reporting a reduction in daily meals was associated with the district of residence and estimated household's monthly income. Self-reported depression was significantly associated with negative experiences during lockdown, including reporting feeling depressed or fear (AOR 4.82; 95% CI 2.08 to 11.21), loneliness (AOR 4.33; 95% CI 1.32 to 14.13), reduction in daily meals (AOR 4.15; 95% CI 1.56 to 11.00) and lack of access to healthcare (OR 3.29; 95% CI 1.32 to 8.23). CONCLUSIONS: Our findings suggest that significant reduction in access to food affected rural Rwandans with chronic diseases during COVID-19 lockdown, and the lockdown effect varied by household's pre-pandemic level of vulnerability to food insecurity. Reduction in household meals, as well as other self-reported effects of the lockdown, were associated with worse psychological status of survey respondents. Economic and food support should be considered by governments and non-governmental organisations to protect those most vulnerable including patients with chronic diseases against the effects of pandemics and their associated containment measures.

The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial.

BACKGROUND: The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)-led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings. OBJECTIVE: This trial assesses whether CHW's use of a mobile health (mHealth)-facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district. METHODS: A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care. RESULTS: The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively). CONCLUSIONS: Home-based post-c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy. TRIAL REGISTRATION: ClinicalTrials.gov NCT03311399; https://clinicaltrials.gov/ct2/show/NCT03311399.

Sustainability Assessment of a District-Wide Quality Improvement on Newborn Care Program in Rural Rwanda: A Mixed-Method Study.

Background: Neonatal mortality continues to be a global challenge, particularly in low- and middle-income countries. There is growing work to reduce mortality through improving quality of systems and care, but less is known about sustainability of improvements in the setting post initial implementation. We conducted a 12-month sustainability assessment of All Babies Count (ABC), a district-wide quality improvement project including mentoring and improvement collaborative designed to improve quality and reduce neonatal mortality in two districts in rural Rwanda. Methods: We measured changes in key neonatal process, coverage, and outcome indicators between the completion of ABC implementation and 12 months after the completion. In addition, we conducted 4 focus group discussions and 15 individual in-depth interviews with health providers and facility and district leaders to understand factors that influenced sustainability of improvements. We used an inductive, content analytic approach to derive six themes related to the ABC sustainability to explain quantitative results. Findings: Twelve months after the completion of ABC implementation, we found continued improvements in core quality, coverage, and neonatal outcomes. During ABC, the percentage of women with 4 antenatal visits increased from 12% to 30% and remained stable 12 months post-ABC (30%, p = 0.7) with an increase in facility-based delivery from 92.6% at the end of ABC to 95.8% (p = 0.01) at 12-month post-ABC. During ABC intervention, the 2 districts decreased neonatal mortality from 30.1 to 19.4 deaths per 1,000 live births with maintenance of the lower mortality 12 months post-ABC (19.4 deaths per 1,000 live births, p = 0.7). Leadership buy-in and development of self-reliance encouraging internally generated solutions emerged as key factors to sustain improvements while staff turnover, famine, influx of refugees, and unintended consequences of new national newborn care policies threatened sustainability. Interpretation: Despite discontinuity of key ABC support, health facilities kept the momentum of good practices and were able to maintain or increase the level of prenatal, neonatal quality of care and outcomes over a period of 12 months following the end of initial ABC implementation. Additional studies are needed to determine the longer-term sustainability beyond one year.

Safety and effectiveness of a non-electric infant warmer for hypothermia in Rwanda: A cluster-randomized stepped-wedge trial.

BACKGROUND: Neonatal hypothermia is a common source of morbidity and mortality in low resource settings. We developed the Dream Warmer, a low cost, re-usable non-electric infant warmer to prevent and treat hypothermia. METHODS: We conducted a cluster-randomized stepped-wedge trial. The primary aim was to assess the effect on overall euthermia rates of introducing the warmer compared to standard of care in rural Rwandan hospitals. The secondary aims were to assess effects of warmer introduction on mortality, as well as the safety and feasibility of the warmer. Ten district hospitals participated in the study from November 19th 2019 to July 15th 2020. Patients were eligible to use the warmer if they were 1) hypothermic (temp < 36·5 °C) or 2) or at risk of hypothermia (weight < 2·5 kg or estimated post menstrual age < 35 weeks) when Kangaroo Mother Care was not available. An encounter was defined as the data from an individual infant on a single day. Trial of a Non Electric Infant Warmer for Prevention and Treatment of Hypothermia in Rwanda [NCT03890211]. FINDINGS: Over the study period, 3179 patients were enrolled across the ten neonatal wards, yielding 12,748 encounters; 464 unique infants used the warmer 892 times, 79% eligible due to hypothermia. Because of limited study nurse resources, the warmer was used in only 18% of eligible encounters. Despite this low rate of warmer use, the rate of euthermia rose from 51% (95% CI 50-52%) of encounters pre-intervention to 67% (66-68%) post-intervention; p < 0·0001. Among the encounters in which the warmer was used, only 11% (9-13%) remained hypothermic. While mortality rates pre- and post-intervention did not change, mortality rate among those who used the warmer was significantly lower than among those who did not (0·9% vs 2·8%, p = 0·01). Use of the warmer did not affect hyperthermia rates. There were no safety concerns or instances of incorrect warmer use. INTERPRETATION: Introduction of the warmer increased rates of euthermia with no associated safety concerns.

The All Babies Count Initiative: Impact of a Health System Improvement Approach on Neonatal Care and Outcomes in Rwanda.

INTRODUCTION: Poor-quality care contributes to a significant portion of neonatal deaths globally. The All Babies Count (ABC) initiative was an 18-month district-wide approach designed to improve clinical and system performance across 2 rural Rwandan districts. METHODS: This pre-post intervention study measured change in maternal and newborn health (MNH) quality of care and neonatal mortality. Data from the facility and community health management information system and newly introduced indicators were extracted from facility registers. Medians and interquartile ranges were calculated for the health facility to assess changes over time, and a mixed-effects logistic regression model was created for neonatal mortality. A difference-in-differences analysis was conducted to compare the change in district neonatal mortality with the rest of rural Rwanda. RESULTS: Improvements were seen in multiple measures of facility readiness and MNH quality of care, including antenatal care coverage, preterm labor management, and postnatal care quality. District hospital case fatality decreased, with a statistically significant reduction in district neonatal mortality (odds ratio [OR]=0.54; 95% confidence interval [CI]=0.36, 0.83) and among preterm/low birth weight neonates (OR=0.47; 95% CI=0.25, 0.90). Neonatal mortality was reduced from 30.1 to 19.6 deaths/1,000 live births in the intervention districts and remained relatively stable in the rest of rural Rwanda (difference in differences -12.9). CONCLUSION: The ABC initiative contributed to improved MNH quality of care and outcomes in rural Rwanda. A combined clinical and health system improvement approach could be an effective strategy to improve quality and reduce neonatal mortality.

Diagnosing Post-Cesarean Surgical Site Infections in Rural Rwanda: Development, Validation, and Field Testing of a Screening Algorithm for Use by Community Health Workers.

Background: We aimed to develop and validate a screening algorithm to assist community health workers (CHWs) in identifying surgical site infections (SSIs) after cesarean section (c-section) in rural Africa. Methods: Patients were adult women who underwent c-section at a Rwandan rural district hospital between March and October 2017. A CHW administered a nine-item clinical questionnaire 10 ± 3 days post-operatively. Independently, a general practitioner (GP) administered the same questionnaire and assessed SSI presence by physical examination. The GP's SSI diagnosis was used as the gold standard. Using a simplified Classification and Regression Tree analysis, we identified a subset of screening questions with maximum sensitivity for the GP and CHW and evaluated the subset's sensitivity and specificity in a validation dataset. Then, we compared the subset's results when implemented in the community by CHWs with health center-reported SSI. Results: Of the 596 women enrolled, 525 (88.1%) completed the clinical questionnaire. The combination of questions concerning fever, pain, and discolored drainage maximized sensitivity for both the GPs (sensitivity = 96.8%; specificity = 85.6%) and CHWs (sensitivity = 87.1%; specificity = 73.8%). In the validation dataset, this subset had sensitivity of 95.2% and specificity of 83.3% for the GP-administered questions and sensitivity of 76.2% and specificity of 81.4% for the CHW-administered questions. In the community screening, the overall percent agreement between CHW and health center diagnoses was 81.1% (95% confidence interval: 77.2%-84.6%). Conclusions: We identified a subset of questions that had good predictive features for SSI, but its sensitivity was lower when administered by CHWs in a clinical setting, and it performed poorly in the community. Methods to improve diagnostic ability, including training or telemedicine, must be explored.

Performance of a Nonelectric Infant Warmer in Rwandan Health Centers.

Background. Neonatal hypothermia remains a challenge in resource-limited settings. Methods. We conducted a prospective mixed-methods cohort study in rural Rwandan health centers to assess the performance of an infant warmer we designed for low-resource settings. All hypothermic infants were eligible for enrollment. Outcomes. Safety: incidence of adverse reactions. Effectiveness: attainment of euthermia, rate of temperature rise. Feasibility: correct use of warmer, signs of wear. Interviews of caregivers and nurses. Findings. Of 102 encounters, there were no adverse reactions. Of 80 encounters for hypothermia when infants on warmer for ≥1 hour, 79 achieved euthermia; 73 in ≤2 hours. Of the 80 encounters, 64 had temperature rise ≥0.5°C/h. Of the 102 encounters, there were no instances of the warmer being prepared, used, or cleaned incorrectly. Five out of the 12 warmers exhibited wear. Interview participants were predominantly positive; some found time for readiness of warmer challenging. Interpretation. The warmer performed well. It is appropriate to study in larger scale.

Four delays of child mortality in Rwanda: a mixed methods analysis of verbal social autopsies.

OBJECTIVES: We sought to understand healthcare-seeking patterns and delays in obtaining effective treatment for rural Rwandan children aged 1-5 years by analysing verbal and social autopsies (VSA). Factors in the home, related to transport and to quality of care in the formal health sector (FHS) were thought to contribute to delays. DESIGN: We collected quantitative and qualitative cross-sectional data using the validated 2012 WHO VSA tool. Descriptive statistics were performed. We inductively and deductively coded narratives using the three delays model, conducted thematic content analysis and used convergent mixed methods to synthesise findings. SETTING: The study took place in the catchment areas of two rural district hospitals in Rwanda-Kirehe and Southern Kayonza. Participants were caregivers of children aged 1-5 years who died in our study area between March 2013 and February 2014. RESULTS: We analysed 77 VSAs. Although 74% of children (n=57) had contact with the FHS before dying, most (59%, n=45) died at home. Many caregivers (44%, n=34) considered using traditional medicine and 23 (33%) actually did. Qualitative themes reflected difficulty recognising the need for care, the importance of traditional medicine, especially for 'poisoning' and poor perceived quality of care. We identified an additional delay-phase IV-which occurred after leaving formal healthcare facilities. These delays were associated with caregiver dissatisfaction or inability to adhere to care plans. CONCLUSION: Delays in deciding to seek care (phase I) and receiving quality care in FHS (phase III) dominated these narratives; delays in reaching a facility (phase II) were rarely discussed. An unwillingness or inability toadhere to treatment plans after leaving facilities (phase IV) were an important additional delay. Improving quality of care, especially provider capacity to communicate danger signs/treatment plans and promote adherence in the presence of alternative explanatory models informed by traditional medicine, could help prevent childhood deaths.

Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy.

BACKGROUND: Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood. METHODS: We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death. RESULTS: We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4-2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3-3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5-15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6-1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1-2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2-1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7-4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2-2.3), household size (aOR: 1.2; 95% CI: 1.0-1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2-3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4-1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0-1.8). CONCLUSION: In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.

Successful implementation of a combined learning collaborative and mentoring intervention to improve neonatal quality of care in rural Rwanda.

BACKGROUND: Globally, neonatal mortality remains high despite interventions known to reduce neonatal deaths. The All Babies Count (ABC) initiative was a comprehensive health systems strengthening intervention designed by Partners In Health in collaboration with the Rwanda Ministry of Health to improve neonatal care in rural public facilities. ABC included provision of training, essential equipment, and a quality improvement (QI) initiative which combined clinical and QI mentorship within a learning collaborative. We describe ABC implementation outcomes, including development of a QI change package. METHODS: ABC was implemented over 18 months from 2013 to 2015 in two Rwandan districts of Kirehe and Southern Kayonza, serving approximately 500,000 people with 24 nurse-led health centers and 2 district hospitals. A process evaluation of ABC implementation and its impact on healthcare worker (HCW) attitudes and QI practice was done using program documents, standardized surveys and focus groups with facility QI team members attending ABC Learning Sessions. The Change Package was developed using mixed methods to identify projects with significant change according to quantitative indicators and qualitative feedback obtained during focus group discussions. Outcome measures included ABC implementation process measures, HCW-reported impact on attitudes and practice of QI, and resulting change package developed for antenatal care, delivery management and postnatal care. RESULTS: ABC was implemented across all 26 facilities with an average of 0.76 mentorship visits/facility/month and 118 tested QI change ideas. HCWs reported a reduction in barriers to quality care delivery related to training (p = 0.018); increased QI capacity (knowledge 37 to 89%, p <  0.001); confidence (47 to 89%, p <  0.001), QI leadership (59 to 91%, p <  0.001); and peer-to-peer learning (37 to 66%, p = 0.024). The final change package included 46 change ideas. Themes associated with higher impact changes included provision of mentorship and facility readiness support through equipment provision. CONCLUSIONS: ABC provides a feasible model of an integrated approach to QI in rural Rwanda. This model resulted in increases in HCW and facility capacity to design and implement effective QI projects and facilitated peer-to-peer learning. ABC and the change package are being scaled to accelerate improvement in neonatal outcomes.

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.

Advancing the health of women and newborns: predictors of patient satisfaction among women attending antenatal and maternity care in rural Rwanda.

OBJECTIVE: Identify predictors of patient satisfaction with antenatal care (ANC) and maternity services in rural Rwanda. DESIGN: Cross-sectional. SETTING: Twenty-six health facilities in Southern Kayonza (SK) and Kirehe districts. PARTICIPANTS: Sample of women ≥ 16 years old receiving antenatal and delivery care between November and December 2013. INTERVENTION: Survey of patient satisfaction with antenatal and delivery care to inform quality improvement (QI) initiatives aimed at reducing neonatal mortality. MAIN OUTCOME MEASURE: Overall satisfaction with antenatal and delivery care (reported as excellent or very good). RESULTS: In multivariate logistic regression analysis, high perceived quality [odds ratio (OR) = 3.03, 95% confidence intervals (CI): 1.565.88], respect [OR = 4.13, 95% CI: 2.16-7.89], and confidentiality [SK: OR = 7.50, 95% CI: 2.16-26.01], [Kirehe: OR = 1.54, 95% CI: 0.60-3.94] were associated with higher overall satisfaction with ANC, while having ≥1 child compared to none [OR = 0.46, 95% CI: 0.25-0.84] was associated with lower satisfaction. For maternity services, <5 years of school versus ≥5 years [OR = 0.13, 95% CI: 0.026-0.69] and higher cleanliness [OR = 19.23, 95% CI: 2.22-166.83], self-reported quality [OR = 10.52, 95% CI: 1.81-61.22], communication [OR = 8.78, 95%CI: 1.95-39.59], and confidentiality [OR = 8.66, 95% CI: 1.20-62.64] were all positively associated with high satisfaction. Higher comfort [OR: 0.050, 95% CI: 0.0034-0.71] and Kirehe vs. SK district [OR: 0.21, 95% CI: 0.042-1.01] were associated with lower satisfaction. CONCLUSIONS: Patient-centeredness (including interpersonal relationships), organizational factors, and location are important individual determinants of satisfaction for women seeking maternal care at study facilities. Understanding variation in these factors should inform QI efforts in maternal and newborn health programs.

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.

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.

Health, nutrition, and development of children born preterm and low birth weight in rural Rwanda: a cross-sectional study.

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.

Health worker attrition at a rural district hospital in Rwanda: a need for improved placement and retention strategies.

INTRODUCTION: The shortage and maldistribution of health care workers in sub-Saharan Africa is a major concern for rural health facilities. Rural areas have 63% of sub-Saharan Africa population but only 37% of its doctors. Although attrition of health care workers is implicated in the human resources for health crisis in the rural settings, few studies report attrition rates and risk factors for attrition in rural district hospitals in sub-Saharan Africa. METHODS: We assessed attrition of health care workers at a Kirehe District Hospital in rural Rwanda. We included all hospital staff employed as of January 1, 2013 in this retrospective cohort study. We report the proportion of staff that left employment during 2013, and used a logistic regression to assess individual characteristics associated with attrition. RESULTS: Of the 142 staff employed at Kirehe District Hospital at the start of 2013, 31.7% (n=45) of all staff and 81.8% (n=9) of doctors left employment in 2013. Being a doctor (OR=10.0, 95% CI: 1.9-52.1, p=0.006) and having up to two years of experience at the hospital (OR=5.3, 95% CI: 1.3-21.7, p=0.022) were associated with attrition. CONCLUSION: Kirehe District Hospital experienced high attrition rates in 2013, particularly among doctors. Opportunities for further training through Rwanda's Human Resources for Health program in 2013 and a two-year compulsory service program for doctors that is not linked to interventions for rural retention may have driven these patterns. Efforts to link these programs with rural placement and retention strategies are recommended.

Race to the Top: evaluation of a novel performance-based financing initiative to promote healthcare delivery in rural Rwanda.

BACKGROUND: Performance-based financing (PBF) has demonstrated a range of successes and failures in improving health outcomes across low- and middle-income countries. Evidence indicates that the success of PBF depends, in large part, on the model selected, in relation to a variety of contextual factors. OBJECTIVE: Partners In Health∣Inshuti Mu Buzima aimed to evaluate health outcomes associated with a novel capacity-building model of PBF at health centers throughout Kirehe district, Rwanda. DESIGN: Thirteen health centers in Kirehe district, which provide healthcare to a population of over 300,000 people, agreed to participate in a PBF initiative scheme that integrated data feedback, quality improvement coaching, peer-to-peer learning, and district-level priority setting. Health centers' progress toward collectively agreed upon site-specific health targets was assessed every 6 months for 18 months. Incentives were awarded only when health centers met goals on all three priorities health centers had collectively agreed upon: 90% coverage of community-based health insurance, 70% contraceptive prevalence rate, and zero acute severe malnutrition cases. Improvement across all four time points and facilities was measured using mixed-effects linear regression. FINDINGS: At 6-month follow-up, 4 of 13 health centers had met 1 target. At 12-month follow-up, 7 centers had met 1 target, and by 18-month follow-up, 6 centers had met 2 targets and 2 centers had met all 3. Average health center performance had improved significantly across the district for all three targets: mean insurance coverage increased from 68% at baseline to 93% (p<0.001); mean number of acute malnutrition cases in the previous 6 months declined from 24 to 5 per facility (p<0.001); and contraceptive prevalence increased from 42 to 59% (p<0.001). A number of innovative improvement initiatives were identified. CONCLUSION: The combining of PBF, district engagement/support, and peer-to-peer learning resulted in significant improvements despite resource constraints and is now being considered as a model for scale-up in other districts of Rwanda.

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.

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.