Leveraging multisectoral approach to understand the determinants of childhood stunting in Rwanda: a systematic review and meta-analysis.

BACKGROUND: Addressing childhood stunting is a priority and an important step in the attainment of Global Nutrition Targets for 2025 and Sustainable Development Goals (SDGs). In Rwanda, the prevalence of child stunting remains high despite concerted efforts to reduce it. METHODS: Utilizing the United Nations International Children's Emergency Fund (UNICEF) framework on maternal and child nutrition, this study systematically evaluated the determinants of child stunting in Rwanda and identified available gaps. Twenty-five peer-reviewed papers and five Demographic and Health Surveys (DHS) reports were included in the final selection of our review, which allowed us to identify determinants such as governance and norms including wealth index, marital status, and maternal education, while underlying determinants were maternal health and nutrition factors, early initiation of breastfeeding, water treatment and sanitation, and immediate factors included infections. RESULTS: A total of 75% of the overall inequality in stunting was due to the difference in the social determinants of stunting between poor and nonpoor households. Maternal education (17%) and intergenerational transfer (31%) accounted for most of the inequalities in stunting, and an increase in gross domestic product per capita contributed to a reduction in its prevalence. There is a paucity of information on the impact of sociocultural norms, early life exposures, maternal health and nutrition, and Rwandan topography. CONCLUSION: The findings of this study suggest that improving women's status, particularly maternal education and health; access to improved water, sanitation, and hygiene-related factors; and the socioeconomic status of communities, especially those in rural areas, will lay a sound foundation for reducing stunting among under-5 children.

Provider perspectives on antiretroviral therapy adherence among psychiatric inpatients in Botswana.

Background: Optimal adherence to antiretroviral therapy (ART) is crucial for the effective management of HIV. Mental disorders often co-occur with HIV infection which often compromises ART adherence. Little is known about ART adherence in psychiatric settings in sub-Saharan Africa.Aims: This study aimed at exploring the health care providers' perspectives on ART adherence among psychiatric inpatients. The study further assessed the facilitators and strategies enhancing ART adherence in hospitalised psychiatric patients.Methods: In-depth interviews were conducted with 25 health care providers at the Sbrana Psychiatric Hospital in Botswana. Interviews were focused on barriers and facilitators to psychiatric inpatients' adherence to ART, and strategies and recommendations to support adherence. Data were manually analysed using a thematic analysis approach.Results: Key barriers were lack of insight, HIV-related stigma, lack of HIV-related knowledge, antiretroviral side effects and delays in re-initiating ART. Facilitators of ART adherence included motivation to be discharged from the hospital, fear of being sick, peer support, longer duration of hospitalisation, good provider-patient relationships, good diet, privacy and confidentiality and a single-tablet regimen. Health care providers described the various strategies currently used to support adherence, including directly observed therapy and family support, and recommended potential approaches to enhance psychiatric inpatient adherence to ART, including the use of injectable antiretrovirals and the introduction of halfway house centres.Conclusions: Findings from this study revealed unique insights into the numerous factors that influence ART adherence among psychiatric inpatients, and underscore the need to implement tailored strategies to support ART adherence in this population with complex health needs.

Provision of HIV services to psychiatric inpatients in Botswana: Challenges and recommendations.

Background: The high prevalence of HIV among psychiatric inpatients is well-documented, yet little is known about the provision of HIV services for these patients. Aim: This qualitative study aimed to explore and understand healthcare providers' challenges with providing HIV services to psychiatric inpatients. Setting: This study was conducted at the national psychiatric referral hospital in Botswana. Methods: The authors conducted in-depth interviews with 25 healthcare providers serving HIV-positive psychiatric inpatients. Data analysis was performed using a thematic analysis approach. Results: Healthcare providers reported challenges with transporting patients to access off-site HIV services, longer waiting periods for antiretroviral therapy (ART) initiation, patient confidentiality, fragmented services for treatment of comorbidities, and a lack of patient data integration between the national psychiatric referral hospital and other facilities such as the Infectious Diseases Care Clinic (IDCC) at the nearby district hospital. Providers' recommendations for addressing these challenges included the establishment of an IDCC at the national psychiatric referral hospital, connecting the psychiatric facility to the patient data management system to ensure integration of patient data, and provision of HIV-related in-service training to nurses. Conclusion: Psychiatric healthcare providers advocated for on-site integration of care for psychiatric illness and HIV among inpatients to address the challenges of ART provision. Contribution: The findings suggest the need to improve the provision of HIV services in the psychiatric hospitals in order to ensure better outcomes for this often-overlooked population. These findings are useful in improving clinical practice for HIV in psychiatric settings.

Understanding factors associated with rural-urban disparities of stunting among under-five children in Rwanda: A decomposition analysis approach.

Childhood stunting in its moderate and severe forms is a major global problem and an important indicator of child health. Rwanda has made progress in reducing the prevalence of stunting. However, the burden of stunting and its geographical disparities have precipitated the need to investigate its spatial clusters and attributable factors. Here, we assessed the determinants of under-5 stunting and mapped its prevalence to identify areas where interventions can be directed. Using three combined rounds of the nationally representative Rwanda Demographic and Health Surveys of 2010, 2015 and 2020, we employed the Blinder-Oaxaca decomposition analysis and the hotspot and cluster analyses to quantify the contributions of key determinants of stunting. Overall, there was a 7.9% and 10.3% points reduction in moderate stunting among urban and rural areas, respectively, and a 2.8% and 8.3% points reduction in severe stunting in urban and rural areas, respectively. Child age, wealth index, maternal education and the number of antenatal care visits were key determinants for the reduction of moderate and severe stunting. Over time, persistent statistically significant hotspots for moderate and severe stunting were observed in Northern and Western parts of the country. There is a need for an adaptive scaling approach when implementing national nutritional interventions by targeting high-burden regions. Stunting hotspots in Western and Northern provinces underscore the need for coordinated subnational initiatives and strategies such as empowering the rural poor, enhancing antenatal health care, and improving maternal health and education levels to sustain the gains made in reducing childhood stunting.

Socio-demographic and environmental determinants of under-5 stunting in Rwanda: Evidence from a multisectoral study.

Child stunting is an important household, socio-economic, environmental and nutritional stress indicator. Nationally, 33% of children under 5 in Rwanda are stunted necessitating the need to identify factors perpetuating stunting for targeted interventions. Our study assessed the individual and community-level determinants of under-5 stunting essential for designing appropriate policy and program responses for addressing stunting in Rwanda. A cross-sectional study was conducted between September 6 and October 9, 2022, in five districts of Rwanda including, Kicukiro, Ngoma, Burera, Nyabihu and Nyanza. 2788 children and their caregivers were enrolled in the study and data on the individual level (child, caregiver/household characteristics), and community-level variables were collected. A multilevel logistic regression model was used to determine the influence of individual and community-level factors on stunting. The prevalence of stunting was 31.4% (95% CI: 29.5-33.1). Of this, 12.2% were severely stunted while 19.2% were moderately stunted. In addition, male gender, age above 11 months, child disability, more than six people in the household, having two children below the age of five, a child having diarrhea 1-2 weeks before the study, eating from own plate when feeding, toilet sharing, and open defecation increased the odds of childhood stunting. The full model accounted for 20% of the total variation in the odds of stunting. Socio-demographic and environmental factors are significant determinants of childhood stunting in Rwanda. Interventions to address under-five stunting should be tailored toward addressing individual factors at household levels to improve the nutritional status and early development of children.

Distribution of antiretroviral therapy through private pharmacies and postal courier services during COVID-19 in Botswana: acceptability and reach of two out-of-facility individual differentiated service delivery models.

INTRODUCTION: The advent of COVID-19 has put pressure on health systems as they implement measures to reduce the risk of transmission to people living with HIV (PLHIV) and healthcare workers. For two out-of-facility individual differentiated service delivery (DSD) models, we assessed acceptability of antiretroviral therapy (ART) distribution through private pharmacies and reach of home delivery of ART through courier services during the COVID-19 pandemic in Botswana. METHODS: From 24 July to 24 August 2020, we conducted exit interviews with PLHIV receiving ART from 10 high-volume public facilities in Gaborone, and mapped and conducted an online survey with private pharmacies to assess willingness and capacity to dispense ART to PLHIV enrolled in the Botswana national ART program. We piloted ART home delivery from September 2020 to January 2021 in Gaborone and Kweneng East districts for PLHIV accessing ART at two Tebelopele Wellness Clinics. We used cascade analysis to measure the enrolment and eventual reach (percentage of those reached amongst those who are eligible) of ART home delivery. RESULTS: Sixty-one PLHIV and 42 private pharmacies participated. Of the PLHIV interviewed, 37 (61%) indicated willingness to access ART from private pharmacies and pay BWP50 (∼US$4) per refill for a maximum of two refills per year. All private pharmacies surveyed were willing to provide ART, and 26 (62%) would charge a dispensing fee (range = BWP50-100; ∼US$4-8) per refill. All pharmacies operated 12 h/day, 6 days/week and on public holidays. In the home delivery pilot, 650 PLHIV were due for refills, 69.5% (n = 452) of whom were eligible for home delivery. Of these, 361 were successfully offered home delivery and 303 enrolled (enrolment = 83.9%: female = 87.2%, male = 77.8%, p = 0.013). A total of 276 deliveries were made, a reach of 61%. CONCLUSIONS: Providing ART through private pharmacies and home delivery was acceptable in Botswana during COVID-19. Surveyed pharmacies were willing and able to dispense ART to PLHIV attending public sector facilities for free or for a nominal fee. Additionally, using courier services for ART home delivery is a novel and viable model in countries with a reliable courier service like Botswana and should be scaled up, particularly in urban areas.