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During the COVID-19 pandemic, a group of health program implementors and research analysts across seven low- and middle-income countries (LMICs) alongside Boston-based collaborators convened to implement data-driven approaches for public health response. An intensive statistics and data science training short course was developed to ensure that in-country researchers could implement the necessary statistical methods for COVID-19 surveillance. The main goal of the course was to enable interpretation of findings from time series analyses and flag potential data issues. This manuscript summarizes our experience teaching this course, including a detailed course overview, participant feedback, and thoughts on how targeted, online courses can be used to support statistical capacity building in LMICs.

Background/Aims Paediatric surgical care is a critical component of child health and basic universal health coverage and therefore should be included in comprehensive evaluations of surgical capacity. This study adapted and validated the Children’s Surgical Assessment Tool (CSAT), a tool developed for district and tertiary hospitals in Nigeria to evaluate hospital infrastructure, workforce, service delivery, financing, and training capacity for paediatric surgery, for use in district hospitals in Rwanda. Methods We used a three-round modified Delphi process to adapt the CSAT to the Rwandan context. An expert panel of surgeons, anaesthesiologists, paediatricians, and health systems strengthening experts were invited to participate based on their experience with paediatric surgical or anaesthetic care at district hospitals or with health systems strengthening in the Rwandan context. We used the Content Validity Index to validate the final tool. Results The adapted tool had a final score of 0.84 on the Content Validity Index, indicating a high level of agreement among the expert panel. The final tool comprised 171 items across five domains: facility characteristics, service delivery, workforce, financing, and training/research. Conclusion The adapted CSAT is appropriate for use in district hospitals in Rwanda to evaluate the capacity for paediatric surgery. This study provides a framework for adapting and validating a comprehensive paediatric surgical assessment tool to local contexts in LMICs and used in similar settings in sub-Saharan Africa.

Abstract During pregnancy, multiple immune regulatory mechanisms establish an immune-tolerant environment for the allogeneic fetus, including cellular signals called cytokines that modify immune responses. However, the impact of maternal HIV infection on these responses is incompletely characterized. We analyzed paired maternal and umbilical cord plasma collected during labor from 147 people with HIV taking antiretroviral therapy and 142 HIV-uninfected comparators. Though cytokine concentrations were overall similar between groups, using Partial Least Squares Discriminant Analysis we identified distinct cytokine profiles in each group, driven by higher IL-5 and lower IL-8 and MIP-1α levels in pregnant people with HIV and higher RANTES and E-selectin in HIV-unexposed umbilical cord plasma (P-value

Abstract Background Although community health worker (CHW) programs focus on improving access to healthcare, some individuals may not receive the intended quality or quantity of an intervention. The objective of this research was to examine if certain populations of pregnant women differentially experience the implementation of a community health worker-led maternal health intervention in Zanzibar. Methods We included pregnant women enrolled in the Safer Deliveries (Uzazi Salama) program, which operated in 10 of 11 districts in Zanzibar, Tanzania between January 1, 2017, and June 19, 2019 (N = 33,914). The outcomes of interest were receipt of the entire postpartum intervention (three CHW visits) and time to first postpartum CHW visit (days). Visits by CHWs were done at the women’s home, however, a telehealth option existed for women who were unable to be reached in-person. We conducted statistical tests to investigate the bivariate associations between our outcomes and each demographic and health characteristic. We used multivariate logistic regression to estimate the relationships between covariates and the outcomes and multivariate linear regression to estimate the association between covariates and the average time until first postpartum visit. Results Higher parity (OR = 0.85; P = 0.014; 95%CI: 0.75–0.97), unknown or unreported HIV status (OR = 0.64; p

Article processing charges (APCs) for open access (OA) journals perpetuate inequities in scientific knowledge. High APCs systematically restrict low- and middle-income country (LMIC) researchers from contributing to research knowledge, preventing the dissemination of high-value, high-quality, and sustainable LMIC-driven solutions. Otolaryngology journals are no exception. The authors propose solutions to rectify the inequities in academic publishing because of APCs, including innovative solutions adopted by several major journals. Addressing these inequities requires medical society and journal editorial board leadership to ensure equitable APC policies.

Abstract Introduction Women who deliver via cesarean section (c-section) experience short- and long-term disability that may affect their physical health and their ability to function normally. While clinical complications are assessed, postpartum functional outcomes are not well understood from a patient’s perspective or well-characterized by previous studies. In Rwanda, 11% of rural women deliver via c-section. This study explores the functional recovery of rural Rwandan women after c-section and assesses factors that predict poor functionality at postoperative day (POD) 30. Methods Data were collected prospectively on POD 3, 11, and 30 from women delivering at Kirehe District Hospital between October 2019 and March 2020. Functionality was measured by self-reported overall health, energy level, mobility, self-care ability, and ability to perform usual activities; and each domain was rated on a 4-point likert scale, lower scores reflecting higher level of difficulties. Using the four functionality domains, we computed composite mean scores with a maximum score of 4.0 and we defined poor functionality as composite score of ≤ 2.0. We assessed functionality with descriptive statistics and logistic regression. Results Of 617 patients, 54.0%, 25.9%, and 26.8% reported poor functional status at POD3, POD11, and POD30, respectively. At POD30, the most self-reported poor functionality dimensions were poor or very poor overall health (48.1%), and inability to perform usual activities (15.6%). In the adjusted model, women whose surgery lasted 30–45 min had higher odds of poor functionality (aOR = 1.85, p = 0.01), as did women who experienced intraoperative complications (aOR = 4.12, 95% CI (1.09, 25.57), p = 0.037). High income patients had incrementally lower significant odds of poor physical functionality (aOR = 0.62 for every US$1 increase in monthly income, 95% CI (0.40, 0.96) p = 0.04). Conclusion We found a high proportion of poor physical functionality 30 days post-c-section in this Rwandan cohort. Surgery lasting > 30 min and intra-operative complications were associated with poor functionality, whereas a reported higher income status was associated with lower odds of poor functionality. Functional status assessments, monitoring and support should be included in post-partum care for women who delivered via c-section. Effective risk mitigating intervention should be implemented to recover functionality after c-section, particularly among low-income women and those undergoing longer surgical procedures or those with intraoperative complications.

Background The COVID-19 pandemic has disrupted health services worldwide, which may have led to increased mortality and secondary disease outbreaks. Disruptions vary by patient population, geographic area, and service. While many reasons have been put forward to explain disruptions, few studies have empirically investigated their causes. Objective We quantify disruptions to outpatient services, facility-based deliveries, and family planning in seven low- and middle-income countries during the COVID-19 pandemic and quantify relationships between disruptions and the intensity of national pandemic responses. Methods We leveraged routine data from 104 Partners In Health-supported facilities from January 2016 to December 2021. We first quantified COVID-19-related disruptions in each country by month using negative binomial time series models. We then modelled the relationship between disruptions and the intensity of national pandemic responses, as measured by the stringency index from the Oxford COVID-19 Government Response Tracker. Results For all the studied countries, we observed at least one month with a significant decline in outpatient visits during the COVID-19 pandemic. We also observed significant cumulative drops in outpatient visits across all months in Lesotho, Liberia, Malawi, Rwanda, and Sierra Leone. A significant cumulative decrease in facility-based deliveries was observed in Haiti, Lesotho, Mexico, and Sierra Leone. No country had significant cumulative drops in family planning visits. For a 10-unit increase in the average monthly stringency index, the proportion deviation in monthly facility outpatient visits compared to expected fell by 3.9% (95% CI: −5.1%, −1.6%). No relationship between stringency of pandemic responses and utilisation was observed for facility-based deliveries or family planning. Conclusions Context-specific strategies show the ability of health systems to sustain essential health services during the pandemic. The link between pandemic responses and healthcare utilisation can inform purposeful strategies to ensure communities have access to care and provide lessons for promoting the utilisation of health services elsewhere.

Abstract Background Lot Quality Assurance Sampling (LQAS), a tool used for monitoring health indicators in low resource settings resulting in “high” or “low” classifications, assumes that determination of the trait of interest is perfect. This is often not true for diagnostic tests, with imperfect sensitivity and specificity. Here, we develop Lot Quality Assurance Sampling for Imperfect Tests (LQAS-IMP) to address this issue and apply it to a COVID-19 serosurveillance study design in Haiti. Methods We first derive a modified procedure, LQAS-IMP, that accounts for the sensitivity and specificity of a diagnostic test to yield correct classification errors. We then apply the novel LQAS-IMP to design an LQAS system to classify prevalence of SARS-CoV-2 antibodies among healthcare workers at eleven Zanmia Lasante health facilities in Haiti. Finally, we show the performance of the LQAS-IMP procedure in a simulation study. Results We found that when an imperfect diagnostic test is used, the classification errors in the standard LQAS procedure are larger than specified. In the modified LQAS-IMP procedure, classification errors are consistent with the specified maximum classification error. We then utilized the LQAS-IMP procedure to define valid systems for sampling at eleven hospitals in Haiti. Conclusion The LQAS-IMP procedure accounts for imperfect sensitivity and specificity in system design; if the accuracy of a test is known, the use of LQAS-IMP extends LQAS to applications for indicators that are based on laboratory tests, such as SARS-CoV-2 antibodies.

Background: Community health worker (CHW)-led maternal health programs have contributed to increased facility-based deliveries and decreased maternal mortality in sub-Saharan Africa. The recent adoption of mobile devices in these programs provides an opportunity for real-time implementation of machine learning predictive models to identify women most at risk for home-based delivery. However, it is possible that falsified data could be entered into the model to get a specific prediction result – known as an “adversarial attack”. The goal of this paper is to evaluate the algorithm's vulnerability to adversarial attacks. Methods: The dataset used in this research is from the Uzazi Salama (“Safer Deliveries”) program, which operated between 2016 and 2019 in Zanzibar. We used LASSO regularized logistic regression to develop the prediction model. We used “One-At-a-Time (OAT)” adversarial attacks across four different types of input variables: binary – access to electricity at home, categorical – previous delivery location, ordinal – educational level, and continuous – gestational age. We evaluated the percent of predicted classifications that change due to these adversarial attacks. Results: Manipulating input variables affected prediction results. The variable with the greatest vulnerability was previous delivery location, with 55.65% of predicted classifications changing when applying adversarial attacks from previously delivered at a facility to previously delivered at home, and 37.63% of predicted classifications changing when applying adversarial attacks from previously delivered at home to previously delivered at a facility. Conclusion: This paper investigates the vulnerability of an algorithm to predict facility-based delivery when facing adversarial attacks. By understanding the effect of adversarial attacks, programs can implement data monitoring strategies to assess for and deter these manipulations. Ensuring fidelity in algorithm deployment secures that CHWs target those women who are actually at high risk of delivering at home.

Abstract Background Caesarean sections account for roughly one third of all surgical procedures performed in low-income countries. Due to lack of standardised post-discharge follow-up protocols and practices, most of available data are extracted from clinical charts during hospitalization and are thus sub-optimal for answering post-discharge outcomes questions. This study aims to determine enablers and barriers to returning to the hospital after discharge among women who have undergone a c-section at a rural district hospital in Rwanda. Methods Women aged ≥ 18 years who underwent c-section at Kirehe District Hospital in rural Rwanda in the period March to October 2017 were prospectively followed. A structured questionnaire was administered to participants and clinical data were extracted from medical files between March and October 2017. At discharge, consenting women were given an appointment to return for follow-up on postoperative day 10 (POD 10) (± 3 days) and provided a voucher to cover transport and compensation for participation to be redeemed on their return. Study participants received a reminder call on the eve of their scheduled appointment. We used a backward stepwise logistic regression, at an α = 0.05 significance level, to identify enablers and barriers associated with post-discharge follow-up return. Results Of 586 study participants, the majority (62.6%) were between 21–30 years old and 86.4% had a phone contact number. Of those eligible, 90.4% returned for follow-up. The predictors of return were counselling by a female data collector (OR = 9.85, 95%CI:1.43–37.59) and receiving a reminder call (OR = 16.47, 95%CI:7.07–38.38). Having no insurance reduced the odds of returning to follow-up (OR = 0.03, 95%CI:0.03–0.23), and those who spent more than 10.6 Euro for transport to and from the hospital were less likely to return to follow-up (OR = 0.14, 95%CI:0.04- 0.50). Conclusion mHealh interventions using calls or notifications can increase the post-discharge follow-up uptake. The reminder calls to patients and discharge counselling by a gender-matching provider had a positive effect on return to care. Further interventions are needed targeting the uninsured and patients facing transportation hardship. Additionally, association between counselling of women patients by a female data collector and greater return to follow-up needs further exploration to optimize counselling procedures.

Abstract Introduction While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda. Methods We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05. Results Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91). Conclusion Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Abstract Background Many children in low- and middle-income countries fail to reach their cognitive potential, with experiences before age 3 critical in shaping long-term development. Zanzibar’s Jamii ni Afya program is the first national, digitally enabled community health volunteer (CHV) program promoting early childhood development (ECD) following the Nurturing Care Framework within an integrated maternal and child healthcare package. Using program baseline data, we explored home environment, caregivers’ parenting, health and nutrition knowledge and practices, and ECD outcomes in Zanzibar. Methods We conducted a national household survey among 499 children aged 18-29 months using two-stage cluster sampling in February 2019. The primary outcome was child development score measured using the Caregiver Reported Early Developmental Index (CREDI), with higher scores representing higher levels of child development. We analyzed CREDI scores, along with MICS questions on parenting knowledge, practices, and characteristics of the home environment. We developed multivariate regression models to assess associations between caregiver-child interactions, knowledge of dietary diversity, and ECD. Results Ten percent of children had overall CREDI z-scores 2 standard deviations [SD] or more below the global reference population mean, with 28% of children at risk of developmental delay with z-scores 1 SD or more below the mean. Cognitive and language domains were of highest concern (10.2 and 12.7% with z-score

Knowing the target oxygen saturation (SpO2) range that results in the best outcomes for acutely hypoxemic adults is important for clinical care, training, and research in low-income and lower-middle income countries (collectively LMICs). The evidence we have for SpO2 targets emanates from high-income countries (HICs), and therefore may miss important contextual factors for LMIC settings. Furthermore, the evidence from HICs is mixed, amplifying the importance of specific circumstances. For this literature review and analysis, we considered SpO2 targets used in previous trials, international and national society guidelines, and direct trial evidence comparing outcomes using different SpO2 ranges (all from HICs). We also considered contextual factors, including emerging data on pulse oximetry performance in different skin pigmentation ranges, the risk of depleting oxygen resources in LMIC settings, the lack of access to arterial blood gases that necessitates consideration of the subpopulation of hypoxemic patients who are also hypercapnic, and the impact of altitude on median SpO2 values. This process of integrating prior study protocols, society guidelines, available evidence, and contextual factors is potentially useful for the development of other clinical guidelines for LMIC settings. We suggest that a goal SpO2 range of 90-94% is reasonable, using high-performing pulse oximeters. Answering context-specific research questions, such as an optimal SpO2 target range in LMIC contexts, is critical for advancing equity in clinical outcomes globally.

Introduction The COVID-19 pandemic has caused disruptions in access to routine healthcare services worldwide, with a particularly high impact on chronic care patients and low and middle-income countries. In this study, we used routinely collected electronic medical records data to assess the impact of the COVID-19 pandemic on access to cancer care at the Butaro Cancer Center of Excellence (BCCOE) in rural Rwanda.Methods We conducted a retrospective time-series study among all Rwandan patients who received cancer care at the BCCOE between 1 January 2016 and 31 July 2021. The primary outcomes of interest included a comparison of the number of patients who were predicted based on time-series models of pre-COVID-19 trends versus the actual number of patients who presented during the COVID-19 period (between March 2020 and July 2021) across four key indicators: the number of new patients, number of scheduled appointments, number of clinical visits attended and the proportion of scheduled appointments completed on time.Results In total, 8970 patients (7140 patients enrolled before COVID-19 and 1830 patients enrolled during COVID-19) were included in this study. During the COVID-19 period, enrolment of new patients dropped by 21.7% (95% prediction interval (PI): −31.3%, −11.7%) compared with the pre-COVID-19 period. Similarly, the number of clinical visits was 25.0% (95% PI: −31.1%, −19.1%) lower than expected and the proportion of scheduled visits completed on time was 27.9% (95% PI: −39.8%, −14.1%) lower than expected. However, the number of scheduled visits did not deviate significantly from expected.Conclusion Although scheduling procedures for visits continued as expected, our findings reveal that the COVID-19 pandemic interrupted patients’ ability to access cancer care and attend scheduled appointments at the BCCOE. This interruption in care suggests delayed diagnosis and loss to follow-up, potentially resulting in a higher rate of negative health outcomes among cancer patients in Rwanda.

IntroductionIn sub-Saharan Africa, youth living with HIV, especially those who have lost one or both parents, face economic, socially and psychological challenges that hinder adherence to ART, ultimately leading to poor health outcomes. Partners In Health/Inshuti Mu Buzima implemented an Adolescent Support Group (ASG) to support HIV-positive youth aged 15–25 years. During the evaluation of the ASG program, we sought to better understand youths' lived experiences to improve our delivery of HIV care.MethodsWe conducted qualitative in-depth, semi-structured individual interviews with youth enrolled in the ASG program. All interviews were conducted in-person or by telephone. Thematic analysis applying the framework approach with parallel inductive coding in Kinyarwanda and English was used.ResultsWe interviewed 35 youth who ranged in age from 16 to 29 years. The main themes related to the lived experiences of youth were (a) Experiences living with HIV, including disclosure, stigma, interactions with the health care system, and medication adherence; (b) external challenges, defined as challenges that were not related to the implementation of the ASG program; and (c) personal vision. Almost all youth reported acquiring HIV from their mothers and disclosure of HIV status occurred around the age of 10. Disclosure was often unintentional and followed by internalized and enacted stigma. Many reported poor past medication adherence which improved following enhanced counselling. External challenges were overwhelmingly economic in nature, and orphanhood was a root cause of other challenges such as difficulty accessing education, lack of transport to health facility, and lack of insurance fees. Despite these challenges, youth have an optimistic view of the future with dreams of health, economic attainment, marriage, and children.ConclusionHealthcare providers should empower caregivers to support HIV disclosure. Supporting youth as they face many economic challenges could help address socio-economic barriers to good health and promote holistic well-being.

BackgroundMaternal and neonatal health outcomes in low- and middle-income countries (LMICs) have improved over the last two decades. However, many pregnant women still deliver at home, which increases the health risks for both the mother and the child. Community health worker programs have been broadly employed in LMICs to connect women to antenatal care and delivery locations. More recently, employment of digital tools in maternal health programs have resulted in better care delivery and served as a routine mode of data collection. Despite the availability of rich, patient-level data within these digital tools, there has been limited utilization of this type of data to inform program delivery in LMICs.MethodsWe use program data from 38,787 women enrolled in Safer Deliveries, a community health worker program in Zanzibar, to build a generalizable prediction model that accurately predicts whether a newly enrolled pregnant woman will deliver in a health facility. We use information collected during the enrollment visit, including demographic data, health characteristics and current pregnancy information. We apply four machine learning methods: logistic regression, LASSO regularized logistic regression, random forest and an artificial neural network; and three sampling techniques to address the imbalanced data: undersampling of facility deliveries, oversampling of home deliveries and addition of synthetic home deliveries using SMOTE.ResultsOur models correctly predicted the delivery location for 68%–77% of the women in the test set, with slightly higher accuracy when predicting facility delivery versus home delivery. A random forest model with a balanced training set created using undersampling of existing facility deliveries accurately identified 74.4% of women delivering at home.ConclusionsThis model can provide a “real-time” prediction of the delivery location for new maternal health program enrollees and may enable early provision of extra support for individuals at risk of not delivering in a health facility, which has potential to improve health outcomes for both mothers and their newborns. The framework presented here is applicable in other contexts and the selection of input features can easily be adapted to match data availability and other outcomes, both within and beyond maternal health.

Abstract Background Understanding the burden of common mental health disorders, such as depressive disorder, is the first step in strengthening prevention and treatment in humanitarian emergencies. However, simple random sampling methods may lead to a high risk of coercion in settings characterized by a lack of distinction between researchers and aid organizations, mistrust, privacy concerns, and the overarching power differential between researchers and populations affected by crises. This case analysis describes a sampling approach developed for a survey study of depressive disorder in a Syrian refugee camp in Greece (n = 135). Discussion Syrian refugees face an extraordinarily high burden of depressive disorder during the asylum process (43%), necessitating population screening, prevention, and treatment. In order to preserve the informed consent process in this refugee camp setting, the research team developed a two-phase sampling strategy using a map depicting the geographical layout of the housing units within the camp. In the first phase, camp management announced a research study was being undertaken and individuals were invited to volunteer to participate. The participants’ container (housing) numbers were recorded on the map, but were not linked to the survey data. Then, in the second phase, the camp map was used for complementary sampling to reach a sample sufficient for statistical analysis. As a result of the two phases of the sampling exercise, all eligible adults from half the containers in each block were recruited, producing a systematic, age- and sex-representative sample. Conclusions Combining sampling procedures in humanitarian emergencies can reduce the risk of coerced consent and bias by allowing participants to approach researchers in the first phase, with a second phase of sampling conducted to recruit a systematic sample. This case analysis illuminates the feasibility of a two-phase sampling approach for drawing a quasi-random, representative sample in a refugee camp setting.

BackgroundThe 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. ObjectiveThis 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. MethodsA 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. ResultsThe 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). ConclusionsHome-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 RegistrationClinicalTrials.gov NCT03311399; https://clinicaltrials.gov/ct2/show/NCT03311399

Abstract Background Despite the need for mental health surveillance in humanitarian emergencies, there is a lack of validated instruments. This study evaluated a sequential screening process for major depressive disorder (MDD) using the two- and eight-item Patient Health Questionnaires (PHQ-2 and PHQ-8, respectively). Methods This study analyzed data collected during a cross-sectional survey in a Syrian refugee camp in Greece (n = 135). The response rate for each instrument was assessed, and response burden was calculated as the number of items completed. The sequential screening process was simulated to replicate the MDD classifications captured if the PHQ-2 was used to narrow the population receiving the full PHQ-8 assessment. All respondents were screened using the PHQ-2. Only respondents scoring ≥ 2 are considered at risk for symptoms of MDD and complete the remaining six items. The positive and negative percent agreement of this sequential screening process were evaluated. Results The PHQ-2, PHQ-2/8 sequential screening process, and PHQ-8 were completed by 91%, 87%, and 84% of respondents, respectively. The sequential screening process had a positive percent agreement of 89% and a negative percent agreement of 100%, and eliminated the need to complete the full PHQ-8 scale for 34 (25%) respondents. Conclusions The benefits of the sequential screening approach for the classification of MDD presented here are twofold: preserving classification accuracy relative to the PHQ-2 alone while reducing the response burden of the PHQ-8. This sequential screening approach is a pragmatic strategy for streamlining MDD surveillance in humanitarian emergencies.

Access to hepatitis C (HCV) testing and treatment is still limited globally. To address this, the Government of Rwanda launched a voluntary mass screening and treatment campaign in 2017. We studied the progression of patients through the cascade of HCV care during this campaign. We conducted a retrospective cohort study and included all patients screened at 46 hospitals between April 2017 and October 2019. We used hierarchical logistic regression to assess factors associated with HCV positivity, gaps in care, and treatment failure. A total of 860,801 people attended the mass screening during the study period. Some 5.7% tested positive for anti-HCV, and 2.9% were confirmed positive. Of those who were confirmed positive, 52% initiated treatment, and 72% of those initiated treatment, completed treatment and returned for assessment 12 weeks afterward. The cure rate was 88%. HCV positivity was associated with age, socio-economic status, sex, marital status, and HIV coinfection. Treatment failure was associated with cirrhosis, baseline viral load, and a family history of HCV. Our results suggest that future HCV screening and testing interventions in Rwanda and other similar settings should target high-risk groups. High dropout rates suggest that more effort should be put into patient follow-up to increase adherence to care.

The global movement to use routine information for managing health systems to achieve the Sustainable Development Goals, relies on administrative data which have inherent biases when used to estimate coverage with health services. Health policies and interventions planned with incorrect information can have detrimental impacts on communities. Statistical inferences using administrative data can be improved when they are combined with random probability survey data. Sometimes, survey data are only available for some districts. We present new methods for extending combined estimation techniques to all districts by combining additional data sources. Our study uses data from a probability survey (n = 1786) conducted during 2015 in 19 of Benin's 77 communes and administrative count data from all of them for a national immunization day (n = 2,792,803). Communes are equivalent to districts. We extend combined-data estimation from 19 to 77 communes by estimating denominators using the survey data and then building a statistical model using population estimates from different sources to estimate denominators in adjacent districts. By dividing administrative numerators by the model-estimated denominators we obtain extrapolated hybrid prevalence estimates. Framing the problem in the Bayesian paradigm guarantees estimated prevalence rates fall within the appropriate ranges and conveniently incorporates a sensitivity analysis. Our new methodology, estimated Benin's polio vaccination rates for 77 communes. We leveraged probability survey data from 19 communes to formulate estimates for the 58 communes with administrative data alone; polio vaccination coverage estimates in the 58 communes decreased to ranges consistent with those from the probability surveys (87%, standard deviation = 0.09) and more credible than the administrative estimates. Combining probability survey and administrative data can be extended beyond the districts in which both are collected to estimate coverage in an entire catchment area. These more accurate results will better inform health policy-making and intervention planning to reduce waste and improve health in communities.

ObjectiveA scoping review of discharge instructions for women undergoing cesarean section (c-section) in sub-Saharan Africa (SSA).MethodStudies were identified from PubMed, Globus Index Medicus, NiPAD, EMBASE, and EBSCO databases. Eligible papers included research based in a SSA country, published in English or French, and containing information on discharge instructions addressing general postnatal care, wound care, planning of future births, or postpartum depression targeted for women delivering by c-section. For analysis, we used the PRISMA guidelines for scoping reviews followed by a narrative synthesis. We assessed quality of evidence using the GRADE system.ResultsWe identified 78 eligible studies; 5 papers directly studied discharge protocols and 73 included information on discharge instructions in the context of a different study objective. 37 studies addressed wound care, with recommendations to return to a health facility for dressing changes and wound checks between 3 days to 6 weeks. 16 studies recommended antibiotic use at discharge, with 5 specifying a particular antibiotic. 19 studies provided recommendations around contraception and family planning, with 6 highlighting intrauterine device placement immediately after birth or 6-weeks postpartum and 6 studies discussing the importance of counselling services. Only 5 studies provided recommendations for the evaluation and management of postpartum depression in c-section patients; these studies screened for depression at 4-8 weeks postpartum and highlighted connections between c-section delivery and the loss of self-esteem as well as connections between emergency c-section delivery and psychiatric morbidity.ConclusionFew studies in SSA directly examine discharge protocols and instructions for women following c-section. Those available demonstrate wide variation in recommendations. Research is needed to develop structured evidence-based instructions with clear timelines for women. These instructions should account for financial burden, access to resources, and education of patients and communities.

Objective A scoping review of discharge instructions for women undergoing cesarean section (c-section) in sub-Saharan Africa (SSA). Method Studies were identified from PubMed, Globus Index Medicus, NiPAD, EMBASE, and EBSCO databases. Eligible papers included research based in a SSA country, published in English or French, and containing information on discharge instructions addressing general postnatal care, wound care, planning of future births, or postpartum depression targeted for women delivering by c-section. For analysis, we used the PRISMA guidelines for scoping reviews followed by a narrative synthesis. We assessed quality of evidence using the GRADE system. Results We identified 78 eligible studies; 5 papers directly studied discharge protocols and 73 included information on discharge instructions in the context of a different study objective. 37 studies addressed wound care, with recommendations to return to a health facility for dressing changes and wound checks between 3 days to 6 weeks. 16 studies recommended antibiotic use at discharge, with 5 specifying a particular antibiotic. 19 studies provided recommendations around contraception and family planning, with 6 highlighting intrauterine device placement immediately after birth or 6-weeks postpartum and 6 studies discussing the importance of counselling services. Only 5 studies provided recommendations for the evaluation and management of postpartum depression in c-section patients; these studies screened for depression at 4–8 weeks postpartum and highlighted connections between c-section delivery and the loss of self-esteem as well as connections between emergency c-section delivery and psychiatric morbidity. Conclusion Few studies in SSA directly examine discharge protocols and instructions for women following c-section. Those available demonstrate wide variation in recommendations. Research is needed to develop structured evidence-based instructions with clear timelines for women. These instructions should account for financial burden, access to resources, and education of patients and communities.

The global movement to use routine information for managing health systems to achieve the Sustainable Development Goals, relies on administrative data which have inherent biases when used to estimate coverage with health services. Health policies and interventions planned with incorrect information can have detrimental impacts on communities. Statistical inferences using administrative data can be improved when they are combined with random probability survey data. Sometimes, survey data are only available for some districts. We present new methods for extending combined estimation techniques to all districts by combining additional data sources. Our study uses data from a probability survey (n = 1786) conducted during 2015 in 19 of Benin’s 77 communes and administrative count data from all of them for a national immunization day (n = 2,792,803). Communes are equivalent to districts. We extend combined-data estimation from 19 to 77 communes by estimating denominators using the survey data and then building a statistical model using population estimates from different sources to estimate denominators in adjacent districts. By dividing administrative numerators by the model-estimated denominators we obtain extrapolated hybrid prevalence estimates. Framing the problem in the Bayesian paradigm guarantees estimated prevalence rates fall within the appropriate ranges and conveniently incorporates a sensitivity analysis. Our new methodology, estimated Benin’s polio vaccination rates for 77 communes. We leveraged probability survey data from 19 communes to formulate estimates for the 58 communes with administrative data alone; polio vaccination coverage estimates in the 58 communes decreased to ranges consistent with those from the probability surveys (87%, standard deviation = 0.09) and more credible than the administrative estimates. Combining probability survey and administrative data can be extended beyond the districts in which both are collected to estimate coverage in an entire catchment area. These more accurate results will better inform health policy-making and intervention planning to reduce waste and improve health in communities.

IntroductionTo combat poor clinical outcomes among HIV-positive youth, Partners In Health/Inshuti Mu Buzima (PIH/IMB) implemented Adolescent Support Groups (ASGs), which combined peer support and group-based economic incentives to promote treatment adherence, economic empowerment, and viral suppression. This study assesses the association between ASG membership and clinical outcomes among HIV-positive youth living in rural Rwanda.MethodsWe constructed a retrospective cohort using PIH/IMB's electronic medical record (EMR) system. ASG members were matched to control youth within strata defined by health facility, year of birth, and whether the patient had enrolled in HIV services as a pediatric patient, as a PMTCT mother, or through another route. Our 12-month outcomes of interest were a) death-free retention in care, b) death-free retention with active follow-up, c) ≥80% adherence to appointment keeping, and d) viral load suppression (ResultsTwo-hundred sixty ASG members were identified in the EMR and matched to 209 control youth for analysis. After 12 months of follow-up, ASG members had similar outcomes to the control youth in terms of death-free retention (93% vs. 94%), death-free retention with active follow-up (79% vs. 78%), ≥80% adherence to appointment keeping (42% vs. 43%), and viral suppression (48% vs. 51%). We did not observe any significant associations between ASG participation and clinical outcomes in crude or adjusted models, nor did ASG members experience greater improvements than control youth in our difference-in-difference analysis.ConclusionsThe ASG program did not improve retention, appointment adherence, or viral suppression among HIV positive youth in rural Rwanda. Challenges implementing the intervention as designed underscore the importance of incorporating implementation strategies and youth perspectives in program design. This population remains vulnerable to poor clinical outcomes, and additional research is needed to better serve youth living with HIV.

Introduction To combat poor clinical outcomes among HIV-positive youth, Partners In Health/Inshuti Mu Buzima (PIH/IMB) implemented Adolescent Support Groups (ASGs), which combined peer support and group-based economic incentives to promote treatment adherence, economic empowerment, and viral suppression. This study assesses the association between ASG membership and clinical outcomes among HIV-positive youth living in rural Rwanda. Methods We constructed a retrospective cohort using PIH/IMB’s electronic medical record (EMR) system. ASG members were matched to control youth within strata defined by health facility, year of birth, and whether the patient had enrolled in HIV services as a pediatric patient, as a PMTCT mother, or through another route. Our 12-month outcomes of interest were a) death-free retention in care, b) death-free retention with active follow-up, c) ≥80% adherence to appointment keeping, and d) viral load suppression (Results Two-hundred sixty ASG members were identified in the EMR and matched to 209 control youth for analysis. After 12 months of follow-up, ASG members had similar outcomes to the control youth in terms of death-free retention (93% vs. 94%), death-free retention with active follow-up (79% vs. 78%), ≥80% adherence to appointment keeping (42% vs. 43%), and viral suppression (48% vs. 51%). We did not observe any significant associations between ASG participation and clinical outcomes in crude or adjusted models, nor did ASG members experience greater improvements than control youth in our difference-in-difference analysis. Conclusions The ASG program did not improve retention, appointment adherence, or viral suppression among HIV positive youth in rural Rwanda. Challenges implementing the intervention as designed underscore the importance of incorporating implementation strategies and youth perspectives in program design. This population remains vulnerable to poor clinical outcomes, and additional research is needed to better serve youth living with HIV.

Introduction: Antimicrobial resistance (AMR) is a global public health threat. Worse still, there is a paucity of data from low- and middle-income countries to inform rational antibiotic use. Objective: Assess the feasibility of setting up microbiology capacity for AMR testing and estimate the cost of setting up microbiology testing capacity at rural district hospitals in Rwanda. Methods: Laboratory needs assessments were conducted, and based on identified equipment gaps, appropriate requisitions were processed. Laboratory technicians were trained on microbiology testing processes and open wound samples were collected and cultured at the district hospital (DH) laboratories before being transported to the National Reference Laboratory (NRL) for bacterial identification and antibiotic susceptibility testing. Quality control (QC) assessments were performed at the DHs and NRL. We then estimated the cost of three scenarios for implementing a decentralized microbiology diagnostic testing system. Results: There was an eight-month delay from the completion of the laboratory needs assessments to the initiation of sample collection due to the regional unavailability of appropriate supplies and equipment. When comparing study samples processed by study laboratory technicians and QC samples processed by other laboratory staff, there was 85.0% test result concordance for samples testing at the DHs and 90.0% concordance at the NRL. The cost for essential equipment and supplies for the three DHs was $245,871. The estimated costs for processing 600 samples ranged from $29,500 to $92,590. Conclusion: There are major gaps in equipment and supply availability needed to conduct basic microbiology assays at rural DHs. Despite these challenges, we demonstrated that it is feasible to establish microbiological testing capacity in Rwandan DHs. Building microbiological testing capacity is essential for improving clinical care, informing rational antibiotics use, and ultimately, contributing to the establishment of robust national antimicrobial stewardship programs in rural Rwanda and comparable settings.

Abstract Background Most maternal health programs in low- and middle- income countries estimate gestational age to provide appropriate antenatal care at the correct times throughout the pregnancy. Although various gestational dating methods have been validated in research studies, the performance of these methods has not been evaluated on a larger scale, such as within health systems. The objective of this research was to investigate the magnitude and impact of errors in estimated delivery dates on health facility delivery among women enrolled in a maternal health program in Zanzibar. Methods This study included 4225 women who were enrolled in the Safer Deliveries program and delivered before May 31, 2017. The exposure of interest was error in estimated delivery date categorized as: severe overestimate, when estimated delivery date (EDD) was 36 days or more after the actual delivery date (ADD); moderate overestimate, when EDD was 15 to 35 days after ADD; accurate, when EDD was 6 days before to 14 days after ADD; and underestimate, when EDD was 7 days or more before ADD. We used Chi-squared tests to identify factors associated with errors in estimated delivery dates. We performed logistic regression to assess the impact of errors in estimated delivery dates on health facility delivery adjusting for age, district of residence, HIV status, and occurrence of past home delivery. Results In our data, 28% of the estimated delivery dates were a severe overestimate, 23% moderate overestimate, 41% accurate, and 8% underestimate. Compared to women with an accurate delivery date, women with a moderate or severe overestimate were significantly less likely to deliver in a health facility (OR = 0.71, 95% CI: [0.59, 0.86]; OR = 0.74, 95% CI: [0.61, 0.91]). When adjusting for multiple confounders, women with moderate overestimates were significantly less likely to deliver in a health facility (AOR = 0.76, 95% CI: [0.61, 0.93]); the result moved slightly towards null for women with severe overestimates (AOR = 0.84, 95% CI: [0.69, 1.03]). Conclusions The overestimation of women’s EDDs reduces the likelihood of health facility delivery. To address this, maternal health programs should improve estimation of EDD or attempt to curb the effect of these errors within their programs.

Abstract Background Child growth stunting remains a challenge in sub-Saharan Africa, where 34% of children under 5 years are stunted, and causing detrimental impact at individual and societal levels. Identifying risk factors to stunting is key to developing proper interventions. This study aimed at identifying risk factors of stunting in Rwanda. Methods We used data from the Rwanda Demographic and Health Survey (DHS) 2014–2015. Association between children’s characteristics and stunting was assessed using logistic regression analysis. Results A total of 3594 under 5 years were included; where 51% of them were boys. The prevalence of stunting was 38% (95% CI: 35.92–39.52) for all children. In adjusted analysis, the following factors were significant: boys (OR 1.51; 95% CI 1.25–1.82), children ages 6–23 months (OR 4.91; 95% CI 3.16–7.62) and children ages 24–59 months (OR 6.34; 95% CI 4.07–9.89) compared to ages 0–6 months, low birth weight (OR 2.12; 95% CI 1.39–3.23), low maternal height (OR 3.27; 95% CI 1.89–5.64), primary education for mothers (OR 1.71; 95% CI 1.25–2.34), illiterate mothers (OR 2.00; 95% CI 1.37–2.92), history of not taking deworming medicine during pregnancy (OR 1.29; 95%CI 1.09–1.53), poorest households (OR 1.45; 95% CI 1.12–1.86; and OR 1.82; 95%CI 1.45–2.29 respectively). Conclusion Family-level factors are major drivers of children’s growth stunting in Rwanda. Interventions to improve the nutrition of pregnant and lactating women so as to prevent low birth weight babies, reduce poverty, promote girls’ education and intervene early in cases of malnutrition are needed.

Background Curative direct-acting antiviral treatment (DAA) has made it plausible to implement hepatitis C elimination interventions. However, poor hepatitis C knowledge among patients could impede the effectiveness of screening and treatment programs. Objective We assessed knowledge on hepatitis C among rural Rwandans initiating DAA treatment for hepatitis C in a prospective cohort. Methods We administered 15 true-false statements before treatment initiation and during one follow-up visit occurring either 1 or 2 months after treatment initiation. We assessed the average number of correct responses per patient, the proportion of correct responses to individual statements, pre-treatment predictors of knowledge, and whether post-initiation knowledge was associated with time since treatment initiation, quality of care, or adherence. Results Among 333 patients who answered knowledge questions before treatment initiation, 325 (97.6%) were re-assessed at a post-initiation visit. Pre-initiation, 72.1% knew hepatitis C was curable, 61.9% knew that hepatitis C could cause liver damage or cancer, and 42.3% knew that people with hepatitis C could look and feel fine. The average number of correct responses was 8.1 out of 15 (95% CI: 7.8–8.5), but was significantly lower among those with low educational attainment or with low literacy. Post-initiation, correct responses increased by an average of 2.0 statements (95% CI: 1.6, 2.4, p-value

Introduction The identification of spatial–temporal clusters of forced migrant mortality is urgently needed to inform preventative policies and humanitarian response. As a first step towards understanding the geography of forced migrant mortality, this study investigates spatial–temporal patterns in death at a global scale.Methods We used information on the location and dates of forced migrant deaths reported in the International Organization for Migration’s Missing Migrant Project from 2014 to 2018. Kulldorff’s spatial–temporal and seasonal scans were used to detect spatial–temporal and temporal heterogeneity in mortality.Results A total of 16 314 deaths were reported during the study period. A preponderance of deaths occurred at sea each year (range 26%–54% across 5 years). Twelve spatial–temporal clusters of forced migrant mortality were detected by maximum likelihood testing. Annually, the period of August–October was associated with a 40-percentage-point increase in the risk of mortality, relative to other time periods.Conclusions Death during forced migration occurs close to national borders and during periods of intense conflict. This evidence may inform the design of policies and targeting of interventions to prevent forced migration-related deaths.

Background: In many developing countries, rheumatic heart disease (RHD) is diagnosed at an advanced stage and requires surgery for patient survival. However, access to cardiac surgery in this context is limited and often provided through partnerships, requiring centralized patient data systems for monitoring and follow-up. Objectives: This study used data from a national postoperative RHD registry to analyze clinical outcomes of Rwandan patients who received surgery between 2006 and 2017. Methods: The RHD registry was created in 2017 using data compiled from Rwanda Ministry of Health and RHD surgery partners. We extracted pre- and post-operative data on patients who were alive and in care. We excluded patients who died or were lost to follow-up, as their data was not collected in the registry. We evaluated the association between demographic, surgical, and follow-up characteristics and most recent patient symptoms, categorized by New York Heart Association (NYHA) class. Findings: Among the 191 patients eligible for inclusion in this study, 107(56.0%) were female, 110(57.6%) were adults at the time of surgery (>15 years), and 128(67.4%) had surgery in Rwanda. Most patients (n = 166, 86.9%) were on penicillin prophylaxis. Of the patients with mechanical valves, 47(29.9%) had therapeutic International Normalized Ratio values. 90% of patients were asymptomatic (NYHA I) at the time of most recent visit. NYHA class was not significantly associated with any of the considered variables. The median length of follow-up for patients was four years (IQR: 2, 5 years). Conclusion: This study shows both the feasibility and challenges of creating a RHD registry 11 years after the national initiation of RHD surgeries. Most patients captured in the registry are asymptomatic; however, collecting details on patients who had died or were lost to follow-up has proven difficult. Implementing strategies to maintain a complete and up-to-date registry will facilitate follow-up for pre- and postoperative patients.

Background: To reduce the non-communicable diseases (NCDs) burden, the World Health Organization has set a target to reach 80% availability of the affordable essential medicines required to treat NCDs by 2025. Objectives: This study described the availability, costs, and stock-outs of essential NCD drugs in three rural Rwandan districts. Methods: We retrospectively assessed 54 NCD drugs listed for district hospitals or health centers in the Rwanda national essential medicines list. Data were collected from three district hospitals and 17 health centers that host NCD clinics. We extracted data on drug availability, quantity dispensed, costs, stock-outs, and the replenishing supplier for these drugs between January 1 and December 31, 2017. Results: Overall, 71% of essential medicines for health centers and 78% of essential medicines for district hospitals were available at facilities. Only 15% of health centers experienced a stock-out of beclomethasone, while 77% experienced at least one stock-out of amlodipine and metformin. The median length of stock-out ranged from nine to 72 days, and 78% of the stock-outs across all health centers were replenished by a Non-Governmental Organization (NGO) partner. Except for enoxaparin and metformin, all district hospitals experienced at least one stock-out of each drug. The median length of stock-out ranged from 3.5 to 228 days, and 82% of the stock-outs across all district hospitals were replenished by the Rwandan Ministry of Health (RMOH). The least expensive drug was digoxin ($0.02, Interquartile range (IQR): 0.01, 0.10), while the most expensive was beclomethasone ($9.35, IQR: 3.00, 13.20). Conclusions: This study shows the viability of drug-supported NCD care in rural settings of sub-Saharan Africa. Stock-outs are a challenge; our study emphasizes the importance of the MOH/NGO partnerships in this context. Medicine costs are also challenging, though, in these districts, drugs are more affordable through community-based health insurance, government, and NGO partner subsidies.

Abstract 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.

Background The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. Methods The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. Results In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. Conclusion The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

Abstract Background Over one million Syrian asylum seekers have travelled to Greece with the ultimate aim of reaching other countries in western Europe. Depression prevalence and associated sociodemographic and displacement characteristics have been reported for resettled migrants. However, the prevalence of major depressive disorder (MDD) and its risk factors have not been described among migrants engaged in the asylum process ensuing from the Syrian crisis. This study provides new data about the mental health status of migrants in transition in the context of protracted asylum procedures. Methods We conducted a cross-sectional survey in a Syrian refugee camp in the Attica region of Greece from January 16–31, 2017. Individuals ≥18 years of age with verbal Arabic or English language skills were eligible to participate. The Patient Health Questionnaire-8 (PHQ-8), an eight-item validated diagnostic and severity measure, was used to screen for MDD. We analysed the relationships between MDD and sociodemographic and displacement characteristics using multivariable logistic regression. Results A total of 135 surveys were completed, representing 40% of the adult population in the refugee camp. The mean age of the participants was 30 years (18–61 years); women comprised 41% of the sample; 74% of the participants had ever married; 67% had children; and 33% of participants had not attended secondary school, including 11% who had never attended school. Median time since departing the country of origin was 12 months (

Abstract Background Breast cancer is the most common malignancy encountered during pregnancy. However, the burden of pregnancy-associated breast cancer (PABC) and subsequent care is understudied in sub-Saharan Africa (SSA). Here, we describe the characteristics, diagnostic delays and treatment of women with PABC seeking care at a rural cancer referral facility in Rwanda. Methods Data from female patients aged 18–50 years with pathologically confirmed breast cancer who presented for treatment between July 1, 2012 and February 28, 2014 were retrospectively reviewed. PABC was defined as breast cancer diagnosed in a woman who was pregnant or breastfeeding. Numbers and frequencies are reported for demographic and diagnostic delay variables and Wilcoxon rank sum and Fisher’s exact tests are used to compare characteristics of women with PABC to women with non-PABC at the alpha = 0.05 significance level. Treatment and outcomes are described for women with PABC only. Results Of the 117 women with breast cancer, 12 (10.3%) had PABC based on medical record review. The only significant demographic differences were that women with PABC were younger (p = 0.006) and more likely to be married (p = 0.035) compared to women with non-PABC. There were no significant differences in diagnostic delays or stage at diagnosis between women with PABC and women with non-PABC women. Eleven of the women with PABC received treatment, three had documented treatment delays or modifications due to their pregnancy or breastfeeding, and four stopped breastfeeding to initiate treatment. At the end of the study period, six patients were alive, three were deceased and three patients were lost to follow-up. Conclusions PABC was relatively common in our cohort but may have been underreported. Although patients with PABC did not experience greater diagnostic delays, most had treatment modifications, emphasizing the potential value of PABC-specific treatment protocols in SSA. Larger prospective studies of PABC are needed to better understand particular challenges faced by these patients and inform policies and practices to optimize care for women with PABC in Rwanda and similar settings.

Abstract Background Inadequate 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. Methods Completeness 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. Results Complete assessment of all danger signs improved from 2.1% at baseline to 84.2% after MESH-QI (p

Abstract Background In low-resource settings, access to emergency cesarean section is associated with various delays leading to poor neonatal outcomes. In this study, we described the delays a mother faces when needing emergency cesarean delivery and assessed the effect of these delays on neonatal outcomes in Rwanda. Methods This retrospective study included 441 neonates and their mothers who underwent emergency cesarean section in 2015 at three district hospitals in Rwanda. Four delays were measured: duration of labor prior to hospital admission, travel time from health center to district hospital, time from admission to surgical incision, and time from decision for emergency cesarean section to surgical incision. Neonatal outcomes were categorized as unfavorable (APGAR

Abstract Background In sub-Saharan Africa, neonatal mortality post-cesarean delivery is higher than the global average. In this region, most emergency cesarean sections are performed at district hospitals. This study assesses maternal predictors for poor neonatal outcomes post-emergency cesarean delivery in three rural district hospitals in Rwanda. Methods This retrospective study includes a random sample of 441 neonates from Butaro, Kirehe and Rwinkwavu District Hospitals, born between 01 January and 31 December 2015. We described the demographic and clinical characteristics of the mothers of these neonates using frequencies and proportions. We assessed the association between maternal characteristics with poor neonatal outcomes, defined as death within 24 h or APGAR

IntroductionReliable Health Management and Information System (HMIS) data can be used with minimal cost to identify areas for improvement and to measure impact of healthcare delivery. However, variable HMIS data quality in low- and middle-income countries limits its value in monitoring, evaluation and research. We aimed to review the quality of Rwandan HMIS data for maternal and newborn health (MNH) based on consistency of HMIS reports with facility source documents.MethodsWe conducted a cross-sectional study in 76 health facilities (HFs) in four Rwandan districts. For 14 MNH data elements, we compared HMIS data to facility register data recounted by study staff for a three-month period in 2017. A HF was excluded from a specific comparison if the service was not offered, source documents were unavailable or at least one HMIS report was missing for the study period. World Health Organization guidelines on HMIS data verification were used: a verification factor (VF) was defined as the ratio of register over HMIS data. A VF1.10 indicated over- and under-reporting in HMIS, respectively.ResultsHigh proportions of HFs achieved acceptable VFs for data on the number of deliveries (98.7%;75/76), antenatal care (ANC1) new registrants (95.7%;66/69), live births (94.7%;72/76), and newborns who received first postnatal care within 24 hours (81.5%;53/65). This was slightly lower for the number of women who received iron/folic acid (78.3%;47/60) and tested for syphilis in ANC1 (67.6%;45/68) and was the lowest for the number of women with ANC1 standard visit (25.0%;17/68) and fourth standard visit (ANC4) (17.4%;12/69). The majority of HFs over-reported on ANC4 (76.8%;53/69) and ANC1 (64.7%;44/68) standard visits.ConclusionThere was variable HMIS data quality by data element, with some indicators with high quality and also consistency in reporting trends across districts. Over-reporting was observed for ANC-related data requiring more complex calculations, i.e., knowledge of gestational age, scheduling to determine ANC standard visits, as well as quality indicators in ANC. Ongoing data quality assessments and training to address gaps could help improve HMIS data quality.

Background: Despite the urgency of mental health surveillance and treatment in humanitarian emergencies, there has been little evaluation of instruments that keep response burden to a minimum. We aimed to evaluate a sequential screening process for the detection of major depressive disorder that improves the efficiency of screening-confirmation procedures using the two-item and eight-item Patient Health Questionnaires (PHQ-2 and PHQ-8, respectively) in a refugee population. Methods: We analysed data from a cross-sectional survey completed by Syrian refugees in a camp in Greece between January and February, 2017. All survey items were translated to and back-translated from Arabic. Face-to-face interviews took place in an area with audio privacy. We used logistic regression to measure the correlation between the PHQ-2 classification and the summed score of the remaining six items of the PHQ-8, and used empirical data to simulate the sequential screening process for major depressive disorder. The sequential process replicates the diagnoses captured if the PHQ-2 were used to narrow the population who would complete the full PHQ-8 assessment. First, respondents complete the PHQ-2; next, only respondents who score above a threshold are considered at risk for depression and complete the remaining six items. We compared the positive and negative percent agreement of the PHQ-2 and sequential screening process. Response burden was assessed through item and instrument completion. Findings: We included data from 135 respondents, representing 40% of the adult population in the refugee camp at the time of the survey. Mean age was 30 years (range 18–61 years); 41% of respondents were women. The PHQ-2 and PHQ-8 instruments were completed by 123 (91%) and 113 (84%) respondents, respectively (p=0·014). The scores of the PHQ-2 and remaining six items of the PHQ-8 were significantly correlated (p

Background: Since the start of the Syrian war in 2011, 250 000 Syrians have sought asylum in Greece, and more than 1 million people have attempted to reach other countries in the European Union by travel through Greece. Migrants face a myriad of poor mental health outcomes, including major depression requiring treatment. However, the prevalence of major depression among Syrians undergoing the asylum process—a potential window for intervention—has not been reported. This study quantified the prevalence of major depression among Syrian migrants in a refugee camp setting. Methods: We did a cross-sectional survey via face-to-face interviews in a Syrian refugee camp in Greece from January 16–31, 2017. Individuals aged 18 years or older, residing in the refugee camp, and with verbal Arabic or English language skills were eligible to participate. The Patient Health Questionnaire-8 (PHQ-8) was used to evaluate depression. Sociodemographic and displacement data were collected using a standardised instrument. The study was approved by the Harvard T H Chan School of Public Health (Protocol IRB16-2015) and all participants provided oral informed consent. Findings: 135 surveys were completed, with a response rate of 97%, representing 38% of the adult population in the refugee camp. The mean age of participants was 31·4 years (range 18–61 years); 40·7% of the sample was female; 74·4% of the participants had ever married; and 67·2% had children. 33·4% of participants had not attended secondary school, including 11·4% who had never attended school. The median time spent in the asylum process in Greece was 10 months (

Background: Health data can be useful for effective service delivery, decision making, and evaluating existing programs in order to maintain high quality of healthcare. Studies have shown variability in data quality from national health management information systems (HMISs) in sub-Saharan Africa which threatens utility of these data as a tool to improve health systems. The purpose of this study is to assess the quality of Rwanda's HMIS data over a 5-year period. Methods: The World Health Organization (WHO) data quality report card framework was used to assess the quality of HMIS data captured from 2008 to 2012 and is a census of all 495 publicly funded health facilities in Rwanda. Factors assessed included completeness and internal consistency of 10 indicators selected based on WHO recommendations and priority areas for the Rwanda national health sector. Completeness was measured as percentage of non-missing reports. Consistency was measured as the absence of extreme outliers, internal consistency between related indicators, and consistency of indicators over time. These assessments were done at the district and national level. Results: Nationally, the average monthly district reporting completeness rate was 98% across 10 key indicators from 2008 to 2012. Completeness of indicator data increased over time: 2008, 88%; 2009, 91%; 2010, 89%; 2011, 90%; and 2012, 95% (p

PrePex Male Circumcision (MC) has been demonstrated as an effective and scalable strategy to prevent HIV infection in low- and middle-income countries. This study describes the follow-up and outcomes of clients who underwent PrePex MC between January 2011 and December 2012 with weekly follow-up at the Rwanda Military Hospital, the first national hospital in Rwanda to adopt PrePex.Data on 570 clients age 21 to 54 were extracted from patient records. We compared socio-demographic and clinical characteristics, the operator's qualification, HIV status, pain before and after device removal, urological status, device size and follow-up time between clients who were formally discharged and those who defaulted. We reported bivariate associations between each covariate and discharge status, number of people with adverse events by discharge status, and time to formal discharge or defaulting using life table methods. Data were entered into Epidata and analyzed with Stata v 13.Among study participants, 96.5% were circumcised by non-physician operators, 85.4%were under 30 years, 98.9% were HIV-negative and 97.9% were without any urological problems that could delay the healing time. Most (70.7%) defaulted before formal discharge. Pain before (p

BackgroundAlthough the importance of concurrent treatment for multidrug-resistant tuberculosis (MDR-TB) and HIV co-infection has been increasingly recognized, there have been few studies reporting outcomes of MDR-TB and HIV co-treatment. We report final outcomes of comprehensive, integrated MDR-TB and HIV treatment in Lesotho and examine factors associated with death or treatment failure.MethodsWe reviewed clinical charts of all adult patients who initiated MDR-TB treatment in Lesotho between January 2008 and September 2009. We calculated hazard ratios (HR) and used multivariable Cox proportional hazards regression to identify predictors of poor outcomes.ResultsOf 134 confirmed MDR-TB patients, 83 (62%) were cured or completed treatment, 46 (34%) died, 3 (2%) transferred, 1 (1%) defaulted, and 1 (1%) failed treatment. Treatment outcomes did not differ significantly by HIV status. Among the 94 (70%) patients with HIV co-infection, 53% were already on antiretroviral therapy (ART) before MDR-TB treatment initiation, and 43% started ART a median of 16 days after the start of the MDR-TB regimen. Among HIV co-infected patients who died, those who had not started ART before MDR-TB treatment had a shorter median time to death (80 days vs. 138 days, p=0.065). In multivariable analysis, predictors of increased hazard of failure or death were low and severely low body mass index (HR 2.75, 95% confidence interval [CI] 1.27-5.93; HR 5.50, 95% CI 2.38-12.69), and a history of working in South Africa (HR 2.37, 95% CI 1.24-4.52).ConclusionsFavorable outcomes can be achieved in co-infected patients using a community-based treatment model when both MDR-TB and HIV disease are treated concurrently and treatment is initiated promptly.