Impact of a health system strengthening intervention on maternal and child health outputs and outcomes in rural Rwanda 2005-2010.

INTRODUCTION: Although Rwanda's health system underwent major reforms and improvements after the 1994 Genocide, the health system and population health in the southeast lagged behind other areas. In 2005, Partners In Health and the Rwandan Ministry of Health began a health system strengthening intervention in this region. We evaluate potential impacts of the intervention on maternal and child health indicators. METHODS: Combining results from the 2005 and 2010 Demographic and Health Surveys with those from a supplemental 2010 survey, we compared changes in health system output indicators and population health outcomes between 2005 and 2010 as reported by women living in the intervention area with those reported by the pooled population of women from all other rural areas of the country, controlling for potential confounding by economic and demographic variables. RESULTS: Overall health system coverage improved similarly in the comparison groups between 2005 and 2010, with an indicator of composite coverage of child health interventions increasing from 57.9% to 75.0% in the intervention area and from 58.7% to 73.8% in the other rural areas. Under-five mortality declined by an annual rate of 12.8% in the intervention area, from 229.8 to 83.2 deaths per 1000 live births, and by 8.9% in other rural areas, from 157.7 to 75.8 deaths per 1000 live births. Improvements were most marked among the poorest households. CONCLUSION: We observed dramatic improvements in population health outcomes including under-five mortality between 2005 and 2010 in rural Rwanda generally and in the intervention area specifically.

The Impact of a Community-Based Intervention Including a Monthly Food Ration on Food Insecurity Among HIV-Positive Adults During the First Year of Antiretroviral Therapy.

The objective of this study was to examine how food insecurity changed among HIV-positive adults during the first 12 months of combination antiretroviral therapy (cART) and whether any change differed according to the receipt of food support, which was provided in the context of a comprehensive community-based intervention. We conducted secondary data analyses of data from a prospective cohort study of the effectiveness of a community-based cART delivery model when added to clinic-based cART delivery in Rwanda. We included patients from four health centers that implemented a clinic-based cART delivery model alone and five health centers that additionally implemented the intervention, which included 10 months of food support. We compared food insecurity at 3, 6, and 12 months, relative to baseline, and stratified by receipt of the intervention. Relative to baseline, median food insecurity score decreased after 3, 6, and 12 months (p value <0.0001 for all) for patients receiving a food ration through the community-based model for cART delivery. Among patients receiving care under the clinic-based cART model, food insecurity scores remained unchanged at 3 and 12 months and were significantly higher after 6 months. In adjusted analyses, participants enrolled in the community-based intervention with a food ration had a lower risk of severe food insecurity and a lower risk of moderate or severe food insecurity after 12 months. A comprehensive community-based HIV program including a food ration likely contributes to an alleviation of food insecurity among adults newly initiating cART.

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.

Motivations and Constraints to Family Planning: A Qualitative Study in Rwanda's Southern Kayonza District.

BACKGROUND: While Rwanda has achieved impressive gains in contraceptive coverage, unmet need for family planning is high, and barriers to accessing quality reproductive health services remain. Few studies in Rwanda have qualitatively investigated factors that contribute to family planning use, barriers to care, and quality of services from the community perspective. METHODS: We undertook a qualitative study of community perceptions of reproductive health and family planning in Rwanda's southern Kayonza district, which has the country's highest total fertility rate. From October 2011 to December 2012, we conducted interviews with randomly selected male and female community members (n = 96), community health workers (n = 48), and health facility nurses (n = 15), representing all 8 health centers' catchment areas in the overall catchment area of the district's Rwinkwavu Hospital. We then carried out a directed content analysis to identify key themes and triangulate findings across methods and informant groups. RESULTS: Key themes emerged across interviews surrounding: (1) fertility beliefs: participants recognized the benefits of family planning but often desired larger families for cultural and historical reasons; (2) social pressures and gender roles: young and unmarried women faced significant stigma and husbands exerted decision-making power, but many husbands did not have a good understanding of family planning because they perceived it as a woman's matter; (3) barriers to accessing high-quality services: out-of-pocket costs, stock-outs, limited method choice, and long waiting times but short consultations at facilities were common complaints; (4) side effects: poor management and rumors and fears of side effects affected contraceptive use. These themes recurred throughout many participant narratives and influenced reproductive health decision making, including enrollment and retention in family planning programs. CONCLUSIONS: As Rwanda continues to refine its family planning policies and programs, it will be critical to address community perceptions around fertility and desired family size, health worker shortages, and stock-outs, as well as to engage men and boys, improve training and mentorship of health workers to provide quality services, and clarify and enforce national policies about payment for services at the local level.

Clinical outcomes of a comprehensive integrated program for HIV-exposed infants: a 3-year experience promoting HIV-free survival in rural Rwanda.

BACKGROUND: Prevention of mother-to-child transmission of HIV services are often inadequate in promoting HIV-free child survival in rural areas with limited resources. An integrated comprehensive child survival program in rural Rwanda with special emphasis on HIV-exposed infants was established in 2005 and scaled-up. The objective of this study was to report program outcomes and identify predictors of program retention. METHODS: We conducted a retrospective study of infants born to HIV-infected women enrolled in the program at or before birth from March 1, 2007, to February 28, 2010, in Eastern Rwanda. Key program elements included improved access to health care, antiretroviral prophylaxis for prevention of mother-to-child transmission of HIV, clean water sources and replacement feeding, home visits by community health workers, prevention and treatment of childhood illness, nutritional support, family planning, and socioeconomic support for the extremely vulnerable. RESULTS: Overall,1038 infants enrolled in the program in the study period during which time there was a 4-fold increase in the number of current participants. Uptake of contraception and treatment for diarrheal disease were high. The 18-month survival probability and retention probability were 0.93 (95% confidence interval: 0.91 to 0.94) and 0.88 (95% confidence interval: 0.86 to 0.90), respectively. Twenty-seven (2.6%) children tested positive for HIV, of which 1 died and none were lost-to-follow-up at 18 months. No statistically significant predictors of retention were identified. CONCLUSIONS: Our findings demonstrate that a comprehensive integrated program to promote HIV-free survival can achieve high rates of retention and survival in a highly vulnerable population, even during a period of rapid growth.

Improved retention associated with community-based accompaniment for antiretroviral therapy delivery in rural Rwanda.

BACKGROUND: Minimizing death and ensuring high retention and good adherence remain ongoing challenges for human immunodeficiency virus (HIV) treatment programs. We examined whether the addition of community-based accompaniment (characterized by daily home visits from a community health worker, directly observed treatment, nutritional support, transportation stipends, and other support as needed) to the Rwanda national model for antiretroviral therapy (ART) delivery would improve retention in care, viral load suppression, and change in CD4 count, relative to the national model alone. METHODS: We conducted a prospective observational cohort study among 610 HIV-infected adults initiating ART in 1 of 2 programs in rural Rwanda. Psychosocial and clinical characteristics were recorded at ART initiation. Death, treatment retention, and plasma viral load were assessed at 1 year. CD4 count was evaluated at 6-month intervals. Multivariable regression models were used to adjust for baseline differences between the 2 populations. RESULTS: Eighty-five percent and 79% of participants in the community-based and clinic-based programs, respectively, were retained with viral load suppression at 1 year. After adjusting for CD4 count, depression, physical health quality of life, and food insecurity, community-based accompaniment was protective against death or loss to follow-up during the first year of ART (hazard ratio, 0.17; 95% confidence interval [CI], .09-.35; P < .0001). In a second multivariable analysis, individuals receiving accompaniment were more likely to be retained with a suppressed viral load at 1 year (risk ratio: 1.15; 95% CI, 1.03-1.27; P = .01). CONCLUSIONS: These findings indicate that community-based accompaniment is effective in improving retention, when added to a clinic-based program with fewer patient support mechanisms.

Excellent clinical outcomes and high retention in care among adults in a community-based HIV treatment program in rural Rwanda.

BACKGROUND: Access to antiretroviral therapy (ART) has rapidly expanded; as of the end of 2010, an estimated 6.6 million people are receiving ART in low-income and middle-income countries. Few reports have focused on the experiences of rural health centers or the use of community health workers. We report clinical and programatic outcomes at 24 months for a cohort of patients enrolled in a community-based ART program in southeastern Rwanda under collaboration between Partners In Health and the Rwandan Ministry of Health. METHODS AND FINDINGS: A retrospective medical record review was performed for a cohort of 1041 HIV+ adult patients initiating community-based ART between June 1, 2005, and April 30, 2006. Key programatic elements included free ART with direct observation by community health worker, tuberculosis screening and treatment, nutritional support, a transportation allowance, and social support. Among 1041 patients who initiated community-based ART, 961 (92.3%) were retained in care, 52 (5%) died and 28 (2.7%) were lost to follow-up. Median CD4 T-cell count increase was 336 cells per microliter [interquartile range: (IQR): 212-493] from median 190 cells per microliter (IQR: 116-270) at initiation. CONCLUSIONS: A program of intensive community-based treatment support for ART in rural Rwanda had excellent outcomes in 24-month retention in care. Having committed to improving access to HIV treatment in sub-Saharan Africa, the international community, including country HIV programs, should set high programmatic outcome benchmarks.