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Background: Similar to other African countries, life expectancy of people living with HIV infection has improved due to access to antiretroviral therapy (ART) in Rwanda. However, both HIV infection and use of ART are associated with cardiovascular disease (CVD) risks, due to adverse changes in some biomarkers, causing dyslipidemia and other metabolic imbalances. Biomarkers for CVD risk in HIV-infected individuals taking ART, has not been well characterized in Rwanda. We evaluated the association between the use and duration of ART and biomarkers of CVD risk among HIV infected adults in Rwanda. Methods: A total of 150 participants (18-45 years) from HIV clinics in public Health Center in Kigali included n=30 HIV-uninfected (HIV-) and n=120 HIV-infected (HIV+) adults. Among the HIV+ adults, n=40 participants were ART-naïve. Cross-sectional data were collected on healthrelated behaviors and biochemical markers of CVD risk. We compared CVD-related biomarkers between HIV-, HIV+ ART-naïve, and HIV+ on ART groups. Results: The majority of participants were women (60%) and HIV- were younger (35 ± 6 vs. 31 ± 6 years). Total cholesterol and triglycerides concentrations were associated with ART usage. Serum triglycerides concentrations were lower in HIV+ ART-naïve compared to HIV+ on ART (76.6 ± 38.9 mg/dl vs. 85.0 ± 38.3 mg/dl; p< 0.01). While total cholesterol concentrations were higher in HIV+ on ART than HIV+ ART-naïve (136.0 ± 45.1 mg/dl vs. 130.0 ± 36.5 mg/dl; p

The COVID-19 pandemic disrupted socioeconomic situation worldwide, and particularly in Rwanda which was rebuilding its economy in the aftermath of the 1994 Genocide against the Tutsi. Recent studies documented the macro-level socio-economic pandemic impact but the impact on a household’s daily life has been scarcely documented especially in low-and-middle income countries. This work reports a country-wide longitudinal community survey and describes the interplay between multiple factors to assess the socio-economic impact of COVID-19 on the Rwandan population at micro-level (household). The survey was conducted in Rwanda between December 2021 and March 2022 and data used comprised a total of 26,412 response forms received from around 4400 participants surveyed in 6 recurrent bi-weekly phases. This study revealed that the income of 57.7% of respondents has decreased and 15.5% of respondents received support to overcome the consequences. The univariate analysis results indicate that the decrease in income is more seen for females than males. The other most affected group is of daily laborer or small business (77.1%), people living in urban area (63.7%), retired people (66.4%), and people with primary school education level (62.0%). The multivariable findings highlighted that vulnerable groups: income-poor households with low socio-economic categories and females living in rural regions are among the most impacted in terms of food security, electricity, water and transport. The findings from this research will be used by policy makers to design and implement preventive and responsive measures for future pandemics that should be multifactorial and tailored to transversal parameters like gender and residence.

Most maternal and newborn deaths in low-income countries, including Rwanda, are attributable to preventable causes. Timely access to Basic Emergency Obstetric and Newborn Care (BEmONC) guidelines to support clinical decisions could lead to better obstetric care thus reduction of maternal and newborn deaths. Besides, innovative methods such as the usage and reference to healthcare guidelines using mobile devices (mhealth) may support clinical decision making. However, there is little evidence about mhealth that focuses on the clinical decision support process. This proposal aims to investigate the effect of the Safe Delivery mhealth Application(SDA) on nurses' and midwives' clinical decision making, so as to inform mhealth interventions for work in specific contexts. The study adopts a quasi-experimental design. Convergent parallel mixed - methods will be used to collect, analyze and interpret data. A pre-intervention assessment of the BEmONC outcomes: Apgar score and PPH progressions, and related knowledge, skills, and perceptions of nurses and midwives will be conducted. The intervention will take place in two district hospitals in Rwanda and entails the implementation of the SDA for six months. Six months' post-intervention, the effect of the SDA on BEmONC outcomes and the nurses' and midwives' knowledge and skills will be evaluated.

Background: Similar to other African countries, life expectancy of people living with HIV infection has improved due to access to antiretroviral therapy (ART) in Rwanda. However, both HIV infection and use of ART are associated with cardiovascular disease (CVD) risks, due to adverse changes in some biochemical markers, causing dyslipidemia and other metabolic imbalances. Biomarkers for CVD risk in HIV-infected individuals taking ART, has not been well characterized in Rwanda. We evaluated the association between the use and duration of ART and biomarkers of CVD risk among HIV infected adults in Rwanda. Methods: A total of 150 participants (18-45 years) from HIV clinics in public Health Center in Kigali included n=30 HIV-uninfected (HIV-) and n=120 HIV-infected (HIV+) adults. Among the HIV+ adults, n=40 participants were ART-naïve. Cross-sectional data were collected on health-related behaviors and biochemical markers of CVD risk. We compared CVD-related biochemical markers between HIV-, HIV+ ART-naïve and HIV+ on ART groups. Results: The majority of participants were women (60%) and HIV- were younger (35±6 vs. 31±6 years). Total cholesterol and triglycerides concentrations were associated with ART usage. Serum triglycerides concentrations were lower in HIV+ ART-naïve compared to HIV+ on ART (76.6±38.9 mg/dl vs. 85.0±38.3 mg/dl; p< 0.01). While total cholesterol concentrations was higher in HIV+ on ART than HIV+ ART-naïve (136.0±45.1 mg/dl vs. 130.0±36.5 mg/dl; pConclusion: Higher serum total cholesterol and triglycerides were associated with use of ART in young adults with HIV. Although these values were within the upper limits of normal, our findings suggest early alterations in biomarkers of cardiac risk. These findings underscore the need for early evaluation of lipid profiles as biomarkers of cardiovascular disease risk, to effectively monitor how ART may contribute to cardiovascular disease and deter treatment programs in African countries.

Background Hypertension remains the major risk factor for cardiovascular diseases (CVDs) worldwide with a prevalence and mortality in low- and middle-income countries (LMICs) among the highest. The early detection of hypertension risk factors is a crucial pillar for CVD prevention. Design and method This cross-sectional study included 4284 subjects, mean age 46 ± 16SD, 56.4% females and mean BMI 26.6 ± 3.7 SD. Data were collected through a screening campaign in rural area of Kirehe District, Eastern of Rwanda, with the objective to characterize and examine the prevalence of elevated blood pressure (BP) and other CVD risk factors. An adapted tool from the World Health Organization STEPwise Approach was used for data collection. Elevated BP was defined as ≥ 140/90 mm/Hg and elevated blood glucose as blood glucose ≥ 100 mg/dL after a 6-h fast. Results Of the sampled population, 21.2% (n = 910) had an elevated BP at screening; BP was elevated among individuals not previously known to have HTN in 18.7% (n = 752). Among individuals with a prior diagnosis of HTN, 62.2% (n = 158 of 254) BP was uncontrolled. Age, weight, smoking, alcohol history and waist circumference were associated with BP in both univariate analyses and multivariate analysis. Conclusion High rates of elevated BP identified through a health screening campaign in this Rwandan district were surprising given the rural characteristics of the district and relatively low population age. These data highlight the need to implement an adequate strategy for the prevention, diagnosis, and control of HTN that includes rural areas of Rwanda as part of a multicomponent strategy for CVD prevention.

Background Life expectancy of people living with HIV infection has improved due to access to antiretroviral therapy (ART) in Rwanda like other African countries. However, both HIV infection and use of ART are associated with cardiovascular disease (CVD) risks, due to adverse changes in some biochemical markers, causing dyslipidemia and other metabolic imbalances. The CVD risk associated with metabolic biomarkers that may affect cardiac function with use of the ART, has not been well characterized in Rwanda. We evaluated the association between the use and duration of ART and abnormal changes in biochemical markers of CVD risk among HIV infected adults in Rwanda. Methods Participants were enrolled from HIV Clinics Public Health Centers in a cross-sectional study in Kigali. A total of 150 participants between 18-45 years included 30 HIV-Uninfected (HIV-) and 120 HIV-infected (HIV+) adults. Among the HIV+ adults, 40 participants were ART-naïve. Data were collected on health-related behaviors and biochemical markers of CVD risk. We compared changes in CVD-related biochemical markers between HIV-, HIV+ ART-naïve and HIV+ on ART treatment groups. Results Majority of participants were women (60%), and HIV- were younger (35±6 vs. 31±6 years). We observed differences in levels of cholesterol and triglycerides in HIV+ ART-treated and HIV+ ART-naïve groups. Total cholesterol and triglycerides were associated with use of ART. Serum triglycerides were lower in HIV+ ART-naïve compared to HIV+ on ART treatment (61.20±18.30 mg/dl vs. 85.00±38.30 mg/dl; p< 0.01). While total cholesterol was higher in HIV+ on ART than HIV+ ART-naïve (136.00±45.00 mg/dl vs. 119.00±36.00 mg/dl; p

Background: Maternal high-risk fertility behaviors have been linked to negative maternal and child health outcomes that include anaemia, undernutrition, and child mortality. In this context, we examined the association between maternal high-risk fertility behavior and pregnancy intention among women of reproductive age in Rwanda.Methods: This cross-sectional study is based on secondary data from the 2014–15 Rwanda Demographic and Health Survey (n=5661). The outcome of interest was pregnancy intention of the last child defined as intended or unintended. Maternal high-risk fertility behaviors were measured using maternal age at delivery, birth order, and birth interval. Chi-square test and multivariable regression models were performed. Results: The prevalence of unintended pregnancy was 46.8% (n=2652). Overall, 35.8% (n=2017) of women experienced single high-risk fertility behavior, while 23.1% (n=1282) of women experienced multiple high-risk fertility behaviors. Compared to women who have not experienced high-risk fertility behavior, the multivariable odds ratio (95% CI) of unintended pregnancy among women in single-risk and multiple-risk fertility behaviors were 2.00 (1.75, 2.28; p Conclusion: Exposure to high-risk fertility behaviors is positively associated with unintended pregnancy among women in Rwanda. Therefore, reproductive and sexual health services should pay special attention to women who are 34 years old; who have more than three children already; or have children with less than 24 months’ interval between giving birth.

Background In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into the experiences of these healthcare workers in managing obstetric care emergencies are critical for improving quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. This is a qualitative part of a broader research about implementation of an mLearning and mHealth decision support tool (Safe Delivery Application), in basic emergency obstetric and newborn care services in Rwanda. Methods In this exploratory qualitative aspect of the research, the first author facilitated four focus group discussions with 26 nurses and midwives from two district hospitals in Rwanda. Each focus group discussion was made up of two parts. The first part focused on the participants’ reflections on the research results, while the second part explored their experiences of delivering obstetric care services in their respective district hospitals. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis. Results Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants’ narratives of lived experiences of providing BEmONC services are presented under two broad themes: (1) self-reflections on their current practices and (2) contextual factors influencing the delivery of BEmONC services. Conclusion The insights of nurses and midwives regarding the management of birth related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on their management of PPH and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health particularly in low and middle income countries.

Background Globally, mobile learning (mLearning) tools have attracted considerable attention as a means of continuous training for healthcare workers. Rwanda like other low-resource settings with scarce in-service training opportunities requires innovative approaches that adapt technology to context to improve healthcare workers’ knowledge and skills. One such innovation is the safe delivery application (SDA), a smartphone mLearning application for Basic Emergency Obstetric and Neonatal Care (BEmONC) content. This study assessed the effect of the SDA intervention on nurses’ and midwives’ knowledge and skills for the management of postpartum hemorrhage (PPH) and neonatal resuscitation (NR). Methods The study used a pre–post test design to compare knowledge and skills of nurses and midwives in the management of PPH and NR at two measurement points: immediately prior to SDA intervention and after 6 months of SDA intervention. The intervention took place in two district hospitals in Rwanda and included 54 participants. A paired-sample t-test was used to measure the pre–post intervention, mean knowledge and skills scores differences. Confidence intervals (CIs) and effect size were calculated. A t-test and a one-way Anova were used to test for potential confounders. Results The analysis included 54 participants. Knowledge scores and skills scores on PPH management and NR increased significantly from baseline to endline measurements. The mean difference for PPH knowledge is 17.1 out of 100; 95% CI 14.69 to 19.49 and 2.6% for PPH skills; 95% CI 1.01 to 4.25. The mean difference for NR knowledge is 19.1 out of 100; 95% CI 16.31 to 21.76 and 5.5% for NR skills; 95% CI 3.66 to 7.41. Increases were unaffected by participants’ attendance to in-service training 6 months prior and during SDA intervention and previous smartphone use. However, pre- and post-intervention skills scores were significantly different by years of experience in obstetric care. Conclusion The SDA intervention improved the knowledge and skills of nurses and midwives on the management of PPH and NR as long as 6 months after SDA introduction. The results are highly relevant in low-income countries like Rwanda, where quality of delivery care is challenged by a lack of in-service continuous training for healthcare providers.

ImportanceHypertension is the largest contributor to the Global Burden of Disease. In Rwanda, as in most low-income and middle-income countries, an increasing prevalence of hypertension and its associated morbidity and mortality is causing major healthcare and economic impact. Understanding healthcare systems context in hypertension care is necessary.ObjectiveTo study the hypertension healthcare context as perceived by healthcare providers using the Context Assessment for Community Health (COACH) tool.DesignA cross-sectional cohort responded to the COACH questionnaire and a survey about hypertension training.SettingThree tertiary care hospitals in Rwanda.ParticipantsHealthcare professionals (n=223).Primary outcome(s) and measure(s)The COACH tool consists of 49 items with eight subscales: resources, community engagement, commitment to work, informal payment, leadership, work culture, monitoring services for action (5-point Likert Scale) and sources of knowledge (on a 0–1 scale). Four questions surveyed training on hypertension.ResultsResponders (n=223, 75% women; 56% aged 20–35 years) included nurses (n=142, 64%, midwives (n=42, 19%), primary care physicians (n=28, 13%) and physician specialists (n=11, 5%)). The subscales commitment to work, leadership, work culture and informal payment scored between 4.7 and 4.1 and the community engagement, monitoring services for action and organizational resources scored between 3.1 and 3.5. Sources of knowledge had a mean score of 0.6±0.3. While 73% reported having attended a didactic hypertension seminar in the past year, only 28% had received long-term training and 51% had ConclusionsThere is a need for increased and continuous training in Rwanda. Healthcare responders stated a commitment to work and reported supportive leadership, while acknowledging limited resources and no monitoring systems. The COACH tool provides contextual guidance to develop training strategies prior to the implementation of a sustainable hypertension care programme.

Background: Globally, mobile learning (mLearning) tools have attracted considerable attention as a means of continuous training for healthcare workers. Rwanda like other low-resource settings with scarce in-service training opportunities requires innovative approaches that adapt technology to context to improve healthcare workers’ knowledge and skills. One such innovation is the safe delivery application (SDA), a smartphone mLearning application for Basic Emergency Obstetric and Neonatal Care (BEmONC) content. This study assessed the effect of the SDA intervention on nurses’ and midwives’ knowledge and skills for the management of postpartum hemorrhage (PPH) and neonatal resuscitation (NR).Methods: The study used a pre-post, quasi-experimental design to compare knowledge and skills of nurses and midwives in the management of PPH and NR at two measurement points: immediately prior SDA intervention and after 6 months SDA intervention. The intervention took place in two district hospitals in Rwanda and included 54 participants. A paired-sample t-test was used to measure the pre-post intervention, mean knowledge and skills scores differences. Confidence intervals (CIs) and effect size were calculated. A t-test and a one-way Anova was used to test for potential confounders. Results: The analysis included 54 participants. Knowledge scores and skills scores on PPH management and NR increased significantly from baseline to endline measurements. The mean difference for PPH knowledge is 17.1 out of 100; 95% CI = 14.69 to 19.49 and 2.6% for PPH skills; 95% CI = 1.01 to 4.25. The mean difference for NR knowledge is 19.1 out of 100; 95% CI = 16.31 to 21,76 and 5.5% for NR skills; 95% CI = 3.66 to 7.41. Increases were unaffected by participants’ attendance to in-service training six months prior and during SDA intervention and previous smartphone use. However, pre- and post-intervention skills scores were significantly different by years of experience in obstetric care.Conclusion: The SDA intervention improved the knowledge and skills of nurses and midwives on the management of PPH and NR as long as 6 months after SDA introduction. The results are highly relevant in low-income countries like Rwanda, where quality of delivery care is challenged by a lack of in-service continuous training for healthcare providers.

Background: Globally, mobile health (mHealth) applications are known for their potential to improve healthcare providers’ access to relevant and reliable health information. Besides, electronic decision support tools, such as the Safe Delivery mHealth Application (SDA), help to reduce clinical errors and to ensure quality care at the point of service delivery. The current study assessed the effects of the SDA on basic emergency obstetric and newborn care (BEmONC) outcomes for the most frequent complications in Rwanda; post-partum haemorrhage (PPH) and newborn asphyxia and its complications.Methods: The study adopted a quasi-experimental design. A pre-intervention record review of the BEmONC outcomes: Apgar score and PPH progressions, was conducted. The intervention took place in two district hospitals in Rwanda and entails the implementation of the SDA for six months. Six months’ post-intervention, the effect of the SDA on BEmONC outcomes was evaluated. The study included 327 participants (114 cases of PPH and 213 cases of neonatal complications). The analysis compared the outcome variables between the baseline and the endline data. Fisher’s exact test was used to compare the proportions and test between-group differences and significance level set at pResults: Unstable newborn outcome following neonatal resuscitation was recorded in 61.90% and 27.59% newborns cases at baseline and endline respectively, P-value = 0.000. Unstable maternal outcome following PPH management was recorded in 19.40 % and 6.38% maternal cases at baseline and endline respectively, P-value = 0.048. There was a significant association between the SDA intervention and newborns’ and maternal’ outcomes following neonatal resuscitation and PPH management, 6 months after baseline.Conclusion: The use of the SDA supported nurses and midwives in the management of PPH and neonatal resuscitation thus improved maternal and neonatal outcomes after 6 months of the SDA intervention.

Background: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide and in low- and middle-income countries, and hypertension (HTN) is a major risk factor for CVD. Although effective evidence-based interventions for control of HTN in high-income countries exist, implementation of these in low- and middle-income countries has been challenging due to limited capacity and infrastructure for latephase translational research. In Rwanda, the 2015 STEPS NCD (STEPwise Approach to Surveillance of Noncommunicable Diseases) risk survey reported an overall prevalence of HTN of 15% (95% confidence interval [CI]: 13.8 to 16.3) for those ages 15 to 64 years; prevalence increased with increasing age to 39% (95% CI: 35.7 to 43.1) for those ages 55 to 64 years; CVD was the third most common cause of mortality (7%). Suboptimal infrastructure and capacity in Rwanda hinders research and community knowledge for HTN control.Objectives: To address the issue of suboptimal capacity to implement evidence-based interventions in HTN, this project was designed with the following objectives: 1) to develop a regional needs assessment of infrastructure for dissemination and implementation (D & I) strategies for HTN-CVD control; 2) to develop HTNCVD research capacity through creation of countrywide resources such as core research facilities and training in the fields of HTN-CVD, D & I, and biostatistics; and 3) to engage and train multiple stakeholders in D & I and HTN-CVD evidence-based interventions.Methods: A weeklong training program in HTN-CVD, biostatistics, and D & I was conducted in Rwanda in August 2018, and pre- and post-D & I training competency questionnaires were administered.Results: Questionnaire results show a statistically significant increase in D & I knowledge and skills as a result of training (full scale pre- to post-test scores: 2.12 ± 0.78 vs. 3.94 ± 0.42; p < 0.0001).Conclusions: Using principles of community engagement and train-the-trainer methods, we will continue to adapt guidelines and treatments for HTN-CVD developed in high-income countries to the context of Rwanda with the goal of establishing a sustainable platform to address the burden of disease from HTN-CVD.HighlightsImplementation research in LMIC has been challenging due to limited capacity.A training program was developed to support implementation research strategies in Rwanda.Implementation research training resulted in significant increases in knowledge and skills.