Health Centers In Rwanda Research Articles

Acceptance of virtual patients as a continuous professional development approach among practicing nurses in primary health care settings in a low-income country: a quasi-experimental posttest setup design

BackgroundVirtual patients are an educational technological approach used in healthcare education. Its distinctive features have rendered virtual patient technology appealing for the training of medical and healthcare students, particularly in the enhancement of clinical reasoning. Virtual patients are less often applied for continuous professional development for practicing healthcare providers, and there is a scarcity of studies exploring this possibility. This study aimed to assess the acceptability of nurses for using virtual patients as a continuous professional development approach.MethodThe study used a quasi-experimental posttest setup design. The study was conducted in ten primary healthcare settings in Rwanda. Among 76 nurses who consented to participate in the study, 56 completed the intervention and responded to the study questionnaire. Following a one-week program of continuous professional development on four non-communicable diseases, the study used a self-administered questionnaire based on the Technology Acceptance Model 3 to collect data. Descriptive analysis served as the primary method for analyzing participants’ responses. The study also used a correlation test to assess the relationship of variables.ResultsAcross all items in the questionnaire, the median response tended towards either agree or strongly agree, with only a minority number of participants expressing strong disagreement, disagreement, or neutrality. The results indicated a significant positive correlation between perceived usefulness and behavior intention (p < 0.001).ConclusionThe findings indicate an acceptability and behavioral intention of adopting virtual patients as an alternative continuous professional development approach among nurses working at health centers in Rwanda or other locations with similar contexts.

Arbovirus surveillance in febrile patients attending selected health facilities in Rwanda

ABSTRACTArthropod-borne (arbo) viruses cause emerging diseases that affect the livelihoods of people around the world. They are linked to disease outbreaks resulting in high morbidity, mortality, and economic loss. In sub-Saharan Africa, numerous arbovirus outbreaks have been documented, but the circulation and magnitude of illness caused by these viruses during inter-epidemic periods remains unknown in many regions. In Rwanda, there is limited knowledge on the presence and distribution of arboviruses. This study aimed at determining the occurrence and distribution of selected arboviruses, i.e., chikungunya virus (CHIKV), o’nyong-nyong virus (ONNV), dengue virus (DENV), West Nile virus (WNV), Zika virus (ZIKV), Rift Valley fever virus (RVFV) and Crimean-Congo haemorrhagic fever virus (CCHFV), among febrile patients visiting health centres in Rwanda. A total of 2294 dry blood spots (DBS) were collected on filter papers during August 2019 – December 2020. Reverse-transcription polymerase chain reaction (RT-PCR) was performed on samples in pools of ten, using both quantitative (DENV, ZIKV, RVFV) and conventional PCR (CHIKV, ONNV, WNV, CCHFV) with virus specific primers, followed by sequencing. Demographic data and clinical manifestations of illness were analysed. ONNV infection was detected in 12 of 230 pools (5.2%) and ZIKV in three pools (1.3%). The other arboviruses were not detected. All ONNV cases were found in the Rwaniro health centre, while ZIKV infection was found among patients visiting the Kirinda and Zaza health centres. There was temporal variability in ONNV infections with most cases being recorded during the long dry season, while ZIKV infection occurred during both dry and wet seasons. Patients with ONNV were older and more were females. In conclusion, ONNV and ZIKV infection were detected in acute patients and can explain some of the feverish diseases in Rwanda.

What women want: A mixed-methods study of women's health priorities, preferences, and experiences in care in three Rwandan rural districts.

To explore Rwandan women's experiences, priorities, and preferences in accessing health care for non-pregnancy-related conditions and inform development of healthcare services related to these conditions among women of reproductive age at district hospitals and health centers in Rwanda. We used a mixed-methods, exploratory sequential design. Semi-structured qualitative interviews were conducted with Rwandan women and coded thematically. A cross-sectional quantitative survey based on the qualitative data was administered to women attending health centers. Seventeen interviews and 150 surveys were conducted. Women identified conditions including back pain, gynecologic cancers, and abnormal vaginal bleeding as concerns. They generally reported positive experiences while accessing health care and knowledge of accessing health care. Barriers to care were identified, including transportation costs and inability to miss work. Women expressed a desire for more control over their care and the importance of maintaining their dignity while accessing health care. These findings provide useful insights to inform development of non-pregnancy-related healthcare services for women in Rwanda according to their priorities and preferences. The reported end-user health concerns, barriers to care, and diminished control over their care point to a need to evolve health systems around user-tailored needs and design interventions optimizing access whilst promoting dignified care.

Effectiveness of intermittent screening and treatment of malaria in pregnancy on maternal and birth outcomes in selected districts in Rwanda: A cluster randomized controlled trial.

Malaria during pregnancy can cause serious consequences including maternal anemia and low birthweight (LBW). Routine antenatal care (ANC) in Rwanda includes malaria symptom screening at each ANC visit. This cluster randomized controlled trial investigated whether adding intermittent screening with a malaria rapid diagnostic test (RDT) at each routine ANC visit and treatment of positives during pregnancy (ISTp) is more effective than routine ANC for reducing malaria prevalence at delivery. Between September 2016- June 2018, pregnant women initiating ANC at 14 health centers in Rwanda were enrolled into ISTp or control arms. All women received an insecticide-treated bed net at enrolment. Hemoglobin concentration, placental and peripheral parasitemia, newborn outcome, birthweight, and prematurity were assessed at delivery. 975 were enrolled in ISTp and 811 in the control. Routine ANC plus ISTp did not significantly reduce PCR-confirmed placental malaria compared to control (adjusted relative risk [aRR] 0.94, 95% confidence interval [CI] 0.59-1.50, p=0.799). ISTp had no impact on anemia (aRR 1.08, 95% CI 0.57-2.04, p=0.821). The mean birthweight of singleton newborns was not significantly different between arms (3054gm vs 3096gm, p=0.395), however women in the ISTp arm had a higher proportion of LBW (aRR = 1.59, 95% CI 1.02-2.49, p=0.042). This is the only study to compare ISTp to symptomatic screening at ANC in a setting where intermittent preventive treatment is not routinely provided. ISTp did not reduce the prevalence of malaria or anemia at delivery and was associated with an increased risk of LBW. NCT03508349.

Predicting postnatal depressive symptoms in a prospective cohort study in Rwanda: the impact of poor maternal social support.

Postnatal depression is a significant public health issue that demands attention, and recent evidence indicates that rates are relatively high in low-income countries such as Rwanda. However, lack of social support is recognized as a potential risk factor for postnatal depressive symptoms. This study sought to explore the influence of poor maternal social support on postnatal depressive symptoms in a sample of women in Rwanda. A prospective cohort research design was conducted with women recruited from four different health centers in Rwanda's Southern Province. A sample of 396 pregnant women accessing antenatal care services was recruited at the baseline from their late second term or later, then followed up after giving birth. The dropout rate was 21.46%; thus, the data of 311 women were analyzed. The outcome variable was the presence of depressive symptoms (Edinburgh Postnatal Depression Scale (EPDS) (≥12 cut-off score), while predictor variables included maternal social support measured using a modified Maternal Social Support Scale (MSSS), perceived health status, socio-demographic information (marital status, wealth class, age, education, occupation), negative life events, gestational and obstetric information (parity, pregnancy intention, age at birth, children given birth, and mode of delivery). Univariate and multivariate analyses were performed. From a sample of 311 participants, over a quarter (20.9%) had elevated postnatal depressive symptoms (EPDS ≥ 12 scores). Elevated scores were predicted by poor perceived health status; respondents reporting neither poor nor good (AOR = 0.28, CI = 0.11; 0.72, p = 0.007) or good health (AOR = 0.14, CI = 0.05; 0.37, p = 0.001) were less likely to be affected. Poor maternal social support was also linked with postnatal depressive symptoms; poor partner support (AOR = 4.22; CI = 1.44; 12.34; p = 0.009) was associated with high risk, while good friend support (AOR = 0.47, CI = 0.23; 0.98, p = 0.04) was a significant protector. Additionally, violence or negative life events were also independent predictors of postnatal depressive symptoms (AOR: 2.94, CI: 1.37-6.29, p = 0.005). Postnatal depressive symptoms were found to affect one in five Rwandan women. However, good maternal social support can be a strong protector. Early interventions targeting mothers in the postnatal period and strengthened social support networks for women at risk should be developed.

Towards stronger antenatal care: Understanding predictors of late presentation to antenatal services and implications for obstetric risk management in Rwanda.

Early antenatal care (ANC) reduces maternal and neonatal morbidity and mortality through identification of pregnancy-related complications, yet 44% of Rwandan women present to ANC after 16 weeks gestational age (GA). The objective of this study was to identify factors associated with delayed initiation of ANC and describe differences in the obstetric risks identified at the first ANC visit (ANC-1) between women presenting early and late to care. This secondary data analysis included 10,231 women presenting for ANC-1 across 18 health centers in Rwanda (May 2017-December 2018). Multivariable logistic regression models were constructed using backwards elimination to identify predictors of presentation to ANC at ≥16 and ≥24 weeks GA. Logistic regression was used to examine differences in obstetric risk factors identified at ANC-1 between women presenting before and after 16- and 24-weeks GA. Sixty-one percent of women presented to ANC at ≥16 weeks and 24.7% at ≥24 weeks GA, with a mean (SD) GA at presentation of 18.9 (6.9) weeks. Younger age (16 weeks: OR = 1.36, 95% CI: 1.06, 1.75; 24 weeks: OR = 1.33, 95% CI: 0.95, 1.85), higher parity (16 weeks: 1-4 births, OR = 1.55, 95% CI: 1.39, 1.72; five or more births, OR = 2.57, 95% CI: 2.17, 3.04; 24 weeks: 1-4 births, OR = 1.93, 95% CI: 1.78, 2.09; five or more births, OR = 3.20, 95% CI: 2.66, 3.85), lower educational attainment (16 weeks: primary, OR = 0.75, 95% CI: 0.65, 0.86; secondary, OR = 0.60, 95% CI: 0.47,0.76; university, OR = 0.48, 95% CI: 0.33, 0.70; 24 weeks: primary, OR = 0.64, 95% CI: 0.53, 0.77; secondary, OR = 0.43, 95% CI: 0.29, 0.63; university, OR = 0.12, 95% CI: 0.04, 0.32) and contributing to household income (16 weeks: OR = 1.78, 95% CI: 1.40, 2.25; 24 weeks: OR = 1.91, 95% CI: 1.42, 2.55) were associated with delayed ANC-1 (≥16 and ≥24 weeks GA). History of a spontaneous abortion (16 weeks: OR = 0.74, 95% CI: 0.66, 0.84; 24 weeks: OR = 0.70, 95% CI: 0.58, 0.84), pregnancy testing (16 weeks: OR = 0.48, 95% CI: 0.33, 0.71; 24 weeks: OR = 0.41, 95% CI: 0.27, 0.61; 24 weeks) and residing in the same district (16 weeks: OR = 1.55, 95% CI: 1.08, 2.22; 24 weeks: OR = 1.73, 95% CI: 1.04, 2.87) or catchment area (16 weeks: OR = 1.53, 95% CI: 1.05, 2.23; 24 weeks: OR = 1.84, 95% CI: 1.28, 2.66; 24 weeks) as the health facility were protective against delayed ANC-1. Women with a prior preterm (OR, 0.71, 95% CI, 0.53, 0.95) or low birthweight delivery (OR, 0.72, 95% CI, 0.55, 0.95) were less likely to initiate ANC after 16 weeks. Women with no obstetric history were more likely to present after 16 weeks GA (OR, 1.18, 95% CI, 1.06, 1.32). This study identified multiple predictors of delayed ANC-1. Focusing existing Community Health Worker outreach efforts on the populations at greatest risk of delaying care and expanding access to home pregnancy testing may improve early care attendance. While women presenting late to care were less likely to present without an identified obstetric risk factor, lower than expected rates were identified in the study population overall. Health centers may benefit from provider training and standardized screening protocols to improve identification of obstetric risk factors at ANC-1.

Healthcare provider challenges to early detection of cervical cancer at primary healthcare level in Rwanda

Our objective was to assess the health facility related factors that cause delays in cervical cancer diagnosis at a primary healthcare level in Rwanda. Healthcare providers in outpatient clinics at 10 health centers in Kigali city and the Eastern province of Rwanda were surveyed. Eighty-five healthcare providers participated; 83.5% were nurses and the remainder were midwives. Only 15 (17.6%) reported prior training on visual inspection with acetic acid (VIA) cervical cancer screening, and they were distributed among 6 of the 10 health centers surveyed. However, 76.5% of respondents reported that at least one person was trained in VIA at their health center. The basic equipment necessary for cervical cancer evaluation was reported to be generally available. Overall, only 31.8% of participants had good basic knowledge level on cervical cancer screening. No association was found between respondents’ knowledge about cervical cancer screening and profession, education level, work experience or reported prior training on VIA. There is a gap in the number of primary healthcare providers with the skills to perform pelvic exam and VIA cervical cancer screening at health centers in Rwanda. As health centers are the first point of contact for patients with the healthcare system, there is a need to improve their knowledge and skills in performing cervical cancer screening and detection.

Assessment and Mapping of Intestinal Parasitic Infectionsand Associated Risk Factors from Different Northern HealthCenters in Rwanda

In this study, Rwandan health centers and hospitals from different region were targeted. For each suspected patient was given a labeled stool container to collect stool sample. The stool samples were carried to parasitological laboratory for parasitological examination. Macroscopic examination was performed, and direct smears prepared with normal saline and/ or iodine for parasites analysis under microscope (objectives 10×and 40×). Risk factors associated to intestinal parasites were assessed using structured questionnaires given to patients. Obtained cross sectional results of intestinal parasites prevalence and associated risk factors from different Rwandan Northern health centers were used, analyzed by SSPSS version 16, Microsoft Excel and Arc Map and records are incorporated into a geographical system for mapping...

Outcomes of decentralizing hypertension care from district hospitals to health centers in Rwanda, 2013-2014.

Three district hospitals (DHs) and seven health centers (HCs) in rural Rwanda. To describe follow-up and treatment outcomes in stage 1 and 2 hypertension patients receiving care at HCs closer to home in comparison to patients receiving care at DHs further from home. A retrospective descriptive cohort study using routinely collected data involving adult patients aged ⩾18 years in care at chronic non-communicable disease clinics and receiving treatment for hypertension at DH and HC between 1 January 2013 and 30 June 2014. Of 162 patients included in the analysis, 36.4% were from HCs. Patients at DHs travelled significantly further to receive care (10.4 km vs. 2.9 km for HCs, P < 0.01). Odds of being retained were significantly lower among DH patients when not adjusting for distance (OR 0.11, P = 0.01). The retention effect was consistent but no longer significant when adjusting for distance (OR 0.18, P = 0.10). For those retained, there was no significant difference in achieving blood pressure targets between the DHs and HCs. By removing the distance barrier, decentralizing hypertension management to HCs may improve long-term patient retention and could provide similar hypertension outcomes as DHs.

Nurses' and midwives' experiences of providing group antenatal and postnatal care at 18 health centers in Rwanda: A mixed methods study.

BackgroundThe East Africa Preterm Birth Initiative-Rwanda began a cluster randomized controlled trial of group antenatal care (ANC) and postnatal care (PNC) in Rwanda in 2017. That trial will report its primary outcome, gestational length at birth, after data collection concludes in 2019. This nested study includes providers of ANC and/or PNC at the 18 health centers randomized to provide the group model of ANC/PNC and the 18 health centers randomized to continue providing ANC/PNC in the traditional, individual visit model. The objective of this study is to understand the experiences of providers of group ANC/PNC and compare their job satisfaction and perceived stress with individual ANC/PNC providers.MethodsWe collected both quantitative and qualitative data from providers (nurses and midwives) who were recruited by health center directors to participate as group ANC and PNC facilitators at intervention sites and from a similar number of providers of standard ANC and PNC at control sites. Quantitative data was collected with questionnaires administered at baseline and approximately 9 months later (follow up). Qualitative data was collected in 3 focus groups of group ANC/PNC providers conducted one year after group care began.ResultsEighty-six percent of nurses and midwives surveyed who implemented group ANC and PNC reported that they prefer group care to the traditional individual model of ANC and PNC. Perceived stress levels and job satisfaction results were similar between groups. Mixed focus group discussions among both nurses and midwives experienced in group ANC and PNC suggest that the group model of care has advantages for both service beneficiaries and providers. When providers described implementation challenges, their peers in the focus groups offered them suggestions to cope and improve service delivery.DiscussionThese results are consistent with studies of providers of group ANC and PNC in other LMIC contexts with respect to the perceived benefits of group care. This study adds new insights into the ways peer providers can help one another solve implementation problems. When given the opportunity to meet as a group, these study participants offered one another peer support and shared knowledge about best practices for successful implementation of group ANC/PNC.This trial is registered at clinicaltrials.gov as NCT03154177.

Prevalence of gestational diabetes mellitus among women attending antenatal care at public health centers in Rwanda

AimThis study aimed to determine the prevalence of gestational diabetes mellitus (GDM) among women attending public health centers in Rwanda using the World Health Organization (WHO) 2013 diagnostic criteria. MethodsA cross-sectional analysis was performed on 281 pregnant women attending antenatal care at urban and rural public health centers. Diagnostic testing was performed between 24 and 32 weeks gestation using a 75 g oral glucose tolerance test. Venous plasma glucose was centrifuged within one hour and measured at one of two laboratories. Descriptive statistics were used. ResultsGDM prevalence was 3.2%, (4.28% urban and 2.13% rural). Women diagnosed with GDM were older, had higher BMI, hypertension, and glycosuria of ≥2+. None with HIV (14/281) had GDM. All women reported birth outcomes. All women with GDM (9/281) had normal glucose values postpartum and therefore it is unlikely that any women had overt diabetes. ConclusionThis study adds important information about the GDM prevalence in Rwanda, which is a resource-limited country. Although the prevalence of 3.2% was low, significant risk factors for GDM were identified. We anticipate that the risk factors for developing GDM will increase in the near future, similar to the global trend of obesity and diabetes, necessitating continued research and education in this important condition that carries a double burden of disease to both mothers and infants.

Postpartum family planning in Rwanda: a cost effectiveness analysis

Background: Globally, there is a large unmet need for family planning in the postpartum period: 90% of women in this group want family planning for birth spacing or to avoid unintended pregnancies and stop child bearing once desired family size has been reached. Women spend on average about 30 years, or three-quarters of their reproductive lives, attempting to avoid pregnancy. In total 76% of Rwandan women want family planning postpartum, yet a 26% unmet need remains. Methods: This cost effectiveness analysis compared the two most frequently-used family planning methods in Rwanda, longer-acting reversible contraception (LARC), injections and subdermal implants, and shorter-acting reversible contraceptives (non-LARC), pills and condoms. Women who do not use contraception postpartum were also represented. A time horizon of 24 months was used to reflect the World Health Organization suggested two-year spacing from birth until the next pregnancy, and the analysis was conducted from a health systems perspective. Results: For women of reproductive age (12-49 years) in Rwanda, including LARC postpartum family planning methods in the options, saves $18.73 per pregnancy averted, compared to family planning options that offer non-LARC methods exclusively. Conclusion: $2.8 million US$ per year can be saved if LARC is included as a contraceptive choice across all health centers in Rwanda; this cost savings provides the opportunity for these funds to be allocated to other high value interventions. Potential inclusion of these methods at Rwanda’s faith-based health facilities warrants further attention.

Cost-effectiveness of a mentorship and quality improvement intervention to enhance the quality of antenatal care at rural health centers in Rwanda.

To estimate cost-effectiveness of Mentorship, Enhanced Supervision for Healthcare and Quality Improvement (MESH-QI) intervention to strengthen the quality of antenatal care at rural health centers in rural Rwanda. Cost-effectiveness analysis of the MESH-QI intervention using the provider perspective. Kirehe and Rwinkwavu District Hospital catchment areas, Rwanda. MESH-QI. Incremental cost per antenatal care visit with complete danger sign and vital sign assessments. The total annual costs of standard antenatal care supervision was 10 777.21 USD at the baseline, whereas the total costs of MESH-QI intervention was 19 656.53 USD. Human resources (salary and benefits) and transport drove the majority of program expenses, (44.8% and 40%, respectively). Other costs included training of mentors (12.9%), data management (6.5%) and equipment (6.5%). The incremental cost per antenatal care visit attributable to MESH-QI with all assessment items completed was 0.70 USD for danger signs and 1.10 USD for vital signs. MESH-QI could be an affordable and effective intervention to improve the quality of antenatal care at health centers in low-resource settings. Cost savings would increase if MESH-QI mentors were integrated into the existing healthcare systems and deployed to sites with higher volume of antenatal care visits.

Intimate partner violence during pregnancy in relation to non-psychotic mental health disorders in Rwanda: a cross-sectional population-based study

ObjectivesTo investigate the prevalence of non-psychotic mental health disorders (MHDs) and the association between exposure to all forms of intimate partner violence (IPV) during pregnancy and MHDs.DesignCross-sectional population-based study conducted...

Beyond coverage: improving the quality of antenatal care delivery through integrated mentorship and quality improvement at health centers in rural Rwanda

BackgroundInadequate antenatal care (ANC) can lead to missed diagnosis of danger signs or delayed referral to emergency obstetrical care, contributing to maternal mortality. In developing countries, ANC quality is often limited by skill and knowledge gaps of the health workforce. In 2011, the Mentorship, Enhanced Supervision for Healthcare and Quality Improvement (MESH-QI) program was implemented to strengthen providers’ ANC performance at 21 rural health centers in Rwanda. We evaluated the effect of MESH-QI on the completeness of danger sign assessments.MethodsCompleteness of danger sign assessments was measured by expert nurse mentors using standardized observation checklists. Checklists completed from October 2010 to May 2011 (n = 330) were used as baseline measurement and checklists completed between February and November 2012 (12–15 months after the start of MESH-QI implementation) were used for follow-up. We used a mixed-effects linear regression model to assess the effect of the MESH-QI intervention on the danger sign assessment score, controlling for potential confounders and the clustering of effect at the health center level.ResultsComplete assessment of all danger signs improved from 2.1% at baseline to 84.2% after MESH-QI (p < 0.001). Similar improvements were found for 20 of 23 other essential ANC screening items. After controlling for potential confounders, the improvement in danger sign assessment score was significant. However, the effect of the MESH-QI was different by intervention district and type of observed ANC visit. In Southern Kayonza District, the increase in the danger sign assessment score was 6.28 (95% CI: 5.59, 6.98) for non-first ANC visits and 5.39 (95% CI: 4.62, 6.15) for first ANC visits. In Kirehe District, the increase in danger sign assessment score was 4.20 (95% CI: 3.59, 4.80) for non-first ANC visits and 3.30 (95% CI: 2.80, 3.81) for first ANC visits.ConclusionAssessment of critical danger signs improved under MESH-QI, even when controlling for nurse-mentees’ education level and previous training in focused ANC. MESH-QI offers an approach to enhance quality of care after traditional training and may be an approach to support newer providers who have not yet attended content-focused courses.

Impact of a district-wide health center strengthening intervention on healthcare utilization in rural Rwanda: Use of interrupted time series analysis

BackgroundEvaluations of health systems strengthening (HSS) interventions using observational data are rarely used for causal inference due to limited data availability. Routinely collected national data allow use of quasi-experimental designs such as interrupted time series (ITS). Rwanda has invested in a robust electronic health management information system (HMIS) that captures monthly healthcare utilization data. We used ITS to evaluate impact of an HSS intervention to improve primary health care facility readiness on health service utilization in two rural districts of Rwanda.MethodsWe used controlled ITS analysis to compare changes in healthcare utilization at health centers (HC) that received the intervention (n = 13) to propensity score matched non-intervention health centers in Rwanda (n = 86) from January 2008 to December 2012. HC support included infrastructure renovation, salary support, medical equipment, referral network strengthening, and clinical training. Baseline quarterly mean outpatient visit rates and population density were used to model propensity scores. The intervention began in May 2010 and was implemented over a twelve-month period. We used monthly healthcare utilization data from the national Rwandan HMIS to study changes in the (1) number of facility deliveries per 10,000 women, (2) number of referrals for high risk pregnancy per 100,000 women, and (3) the number of outpatient visits performed per 1,000 catchment population.ResultsPHIT HC experienced significantly higher monthly delivery rates post-HSS during the April-June season than comparison (3.19/10,000, 95% CI: [0.27, 6.10]). In 2010, this represented a 13% relative increase, and in 2011, this represented a 23% relative increase. The post-HSS change in monthly rate of high-risk pregnancies referred increased slightly in intervention compared to control HC (0.03/10,000, 95% CI: [-0.007, 0.06]). There was a small immediate post-HSS increase in outpatient visit rates in intervention compared to control HC (6.64/1,000, 95% CI: [-13.52, 26.81]).ConclusionWe failed to find strong evidence of post-HSS increases in outpatient visit rates or referral rates at health centers, which could be explained by small sample size and high baseline nation-wide health service coverage. However, our findings demonstrate that high quality routinely collected health facility data combined with ITS can be used for rigorous policy evaluation in resource-limited settings.

Does foreign aid crowd out government investments? Evidence from rural health centres in Rwanda

BackgroundRural healthcare facilities in low-income countries play a major role in providing primary care to rural populations. We examined the link of foreign aid with government investments and medical service...

False-negative malaria rapid diagnostic tests in Rwanda: impact of Plasmodium falciparum isolates lacking hrp2 and declining malaria transmission

BackgroundRapid diagnostic tests (RDTs) for histidine rich protein 2 (HRP2) are often used to determine whether persons with fever should be treated with anti-malarials. However, Plasmodium falciparum parasites with a deletion of the hrp2 gene yield false-negative RDTs and there are concerns the sensitivity of HRP2-based RDTs may fall when the intensity of transmission decreases.MethodsThis observational study enrolled 9226 patients at three health centres in Rwanda from April 2014 to April 2015. It then compared the sensitivity of RDTs based on HRP2 and the Plasmodium lactate dehydrogenase (pLDH) to microscopy (thick smears) for the diagnosis of malaria. PCR was used to determine whether deletions of the histidine-rich central repeat region of the hrp2 gene (exon 2) were associated with false-negative HRP2-based RDTs.ResultsIn comparison to microscopy, the sensitivity and specificity of HRP2- and pLDH-based RDTs were 89.5 and 86.2% and 80.2 and 94.3%, respectively. When the results for both RDTs were combined, sensitivity rose to 91.8% and specificity was 85.7%. Additionally, when smear positivity fell from 46 to 3%, the sensitivity of the HRP2-based RDT fell from 88 to 67%. Of 370 samples with false-negative HRP2 RDT results for which PCR was performed, 140 (38%) were identified as P. falciparum by PCR. Of the isolates identified as P. falciparum by PCR, 32 (23%) were negative for the hrp2 gene based on PCR. Of the 32 P. falciparum isolates negative for hrp2 by PCR, 17 (53%) were positive based on the pLDH RDT.ConclusionThis prospective study of RDT performance coincided with a decline in the intensity of malaria transmission in Kibirizi (fall in slide positivity from 46 to 3%). This decline was associated with a decrease in HRP2 RDT sensitivity (from 88 to 67%). While P. falciparum isolates without the hrp2 gene were an important cause of false-negative HRP2-based RDTs, most were identified by the pLDH-based RDT. Although WHO does not recommend the use of combined HRP2/pLDH testing in sub-Saharan Africa, these results suggest that combination HRP2/pLDH-based RDTs could reduce the impact of false-negative HRP2-based RDTs for detection of symptomatic P. falciparum malaria.

Effect of shortened Integrated Management of Childhood Illness training on classification and treatment of under-five children seeking care in Rwanda.

BackgroundIntegrated Management of Childhood Illness (IMCI) is an effective 11-day standard training; however, due to budgetary expenses and human resource constraints, many health professionals cannot take 11 days off work. As a result, shortened training curriculums (6-day) have been proposed. We used a cross-sectional study to evaluate the effect of this shortened training on appropriate IMCI classification and treatment of under-five childhood illness management in Rwanda.MethodsA cross-sectional study was conducted in 22 health centers in Rwanda, comparing data from 121 nurses, where 55 nurses completed the 11-day and 66 nurses completed the 6-day training. Among 768 children, we evaluated clinical outcomes from May 2011 to April 2012. Descriptive statistics were used to display the sociodemographic characteristics of health providers; including level of education, sex, age, and professional experiences. Bivariable and multivariable analyses were used to test for differences between nurses in the 6-day versus 11-day training on the appropriate classification and treatment of childhood illness.ResultsOur findings show that at the bivariable level and after controlling for confounders in the multivariable analysis, the only significant differences detected between nurses in the long and short training was the classification of fever (adjusted odds ratio [aOR] 0.7, 95% confidence interval [CI] 0.64–0.75) and treatment of pneumonia (aOR 0.8, 95% CI 0.70–0.89). Nurses in the short training had lower odds of inappropriate misclassification and treatment for these two conditions.ConclusionThere was no difference in classification and treatment of childhood illness among nurses who completed the standard and short IMCI training courses. Short-training could be a more cost-saving option for health facilities without compromising the key outcomes related to case management.

A seminar on gardens for the health of the skin

This is a report on a seminar held on January 12, 2013, at the Regional Dermatology Training Centre in Tanzania, sponsored by the International Society of Dermatology as part of its Taskforce Program for Skin Care for All: Community Dermatology. There were four themes: (i) Gardens attached to health centers increase their attractiveness and result in increased attendance and, thus, increase the utilization of effective skin care interventions. Literature on the positive effect of greenery surrounding health centers on health and the environment is reviewed. (ii) Adding an expert on agriculture to the staff of health centers in Rwanda has provided nutrition and safe medicines. (iii) In southern India, these interventions are channeled through the empowerment of tribal women in an area noted for anxiety due to unemployment in the tea and forestry industry. The gardens are used for teaching about nutrition and herbal medicines, and the women are further attracted by childcare facilities. (iv) Measuring barrier function defects gives early warning of malnutrition of the skin after damage by trauma or by ultraviolet radiation. Higher cost research techniques may help to provide the science required to produce its evidence base. In conclusion, Gardens for health should be adopted as policy by skin care providers.