Evaluating the delivery of Problem Management Plus in primary care settings in rural Rwanda: a study protocol using a pragmatic randomised hybrid type 1 effectiveness-implementation design

IntroductionEvidence-based low-intensity psychological interventions such as Problem Management Plus (PM+) have the potential to expand treatment access for depression and anxiety, yet these interventions are not yet effectively implemented in rural, public health systems in resource-limited settings. In 2017, Partners In Health adapted PM+ for delivery by primary care nurses in rural Rwanda and began integrating PM+ into health centres in collaboration with the Rwandan Ministry of Health, using established implementation strategies for mental health integration into primary care (Mentoring and Enhanced Supervision at Health Centers for Mental Health (MESH MH)). A gap in the evidence regarding whether low-intensity psychological interventions can be successfully integrated into real-world primary care settings and improve outcomes for common mental disorders remains. In this study, we will rigorously evaluate the delivery of PM+ by primary care nurses, supported by MESH MH, as it is scaled across one rural district in Rwanda.Methods and analysisWe will conduct a hybrid type 1 effectiveness-implementation study to test the clinical outcomes of routinely delivered PM+ and to describe the implementation of PM+ at health centres. To study the clinical effectiveness of PM+, we will use a pragmatic, randomised multiple baseline design to determine whether participants experience improvement in depression symptoms (measured by the Patient Health Questionnaire-9) and functioning (measured by the WHO-Disability Assessment Scale Brief 2.0) after receiving PM+. We will employ quantitative and qualitative methods to describe and evaluate PM+ implementation outcomes using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, using routinely collected programme data and semistructured interviews.Ethics and disseminationThis evaluation was approved by the Rwanda National Ethics Committee (Protocol #196/RNEC/2019) and deemed exempt by the Harvard University Institutional Review Board. The results from this evaluation will be useful for health systems planners and policy-makers working to translate the evidence base for low-intensity psychological interventions into practice.</jats:sec

Characteristics and early outcomes of cervical cancer patients at Butaro District Hospital, Rwanda: a retrospective review

Background: Cancer treatment facilities are scarce in rural areas of low-income and middle-income countries, where the highest burden of cervical cancer exists. The Butaro Cancer Center of Excellence (BCCOE), in rural Rwanda, is a Rwandan Ministry of Health facility supported by Partners In Health and Dana-Farber/Brigham and Women's Cancer Center. The cervical cancer programme includes diagnosis, staging, and treatment. However, because of resource limitations, only 15 patients per month could be referred for radiotherapy to the Uganda Cancer Institute. In this study, we describe cervical cancer treatment at BCCOE and early patient outcomes. Methods: In July, 2016, we retrospectively reviewed records for patients with cervical cancer enrolled between July 1, 2012, and June 30, 2015, at BCCOE. We extracted data on patients' characteristics, disease stage, treatment, and outcomes. Findings: We included 438 patients: median age was 52 years (IQR 42–60 years), 35 patients (8%) had laboratory-confirmed HIV, 142 (36%) smoked tobacco, median number of pregnancies was 7 (IQR 5–9), and 41 (10%) had had a hysterectomy before enrolment. 258 patients (60%) had a diagnosis confirmed by pathology, and 391 patients (91%) had a documented disease stage. Of these, 13 (3%) were Stage I, 183 (47%) were Stage II, 154 (39%) were Stage-III, and 41 (11%) were Stage IV. There was a curative, instead of palliative or undecided, intent for 85% of Stage I patients, 91% of Stage II, and, 12% of Stage III. 165 women (38%) were referred for concurrent radiation therapy, chemotherapy, and brachytherapy in Uganda, and 19 (4%) were referred for radical hysterectomy. At their last recorded visit, 77 patients (18%) had no evidence of recurrence, including: 6 (46%) Stage I patients, 66 (37%) Stage II, 5 (3%) Stage III, but no Stage IV patients (p =<0·0001). Overall, 114 patients (27%) were lost to follow-up during or after treatment. Interpretation: Our experience shows that a cervical cancer treatment programme is viable in a low-resource, rural setting. However, many challenges exist, especially the severity of disease at intake (about half of patients presented with Stage III or IV disease) and that there are no radiation facilities in Rwanda. Further, a quarter of patients were eventually lost to follow-up during the study. Future implementation interventions will focus on strategies to overcome these challenges. Funding: Partners in Health, Dana-Farber Cancer Institute, Rwandan Ministry of Health

International radiotherapy referrals from rural Rwanda: Implementation processes and early clinical outcomes

Purpose Low-and middle-income countries disproportionately comprise 65% of cancer deaths. Cancer care delivery in resource-limited settings, especially low-income countries in sub-Saharan Africa, is exceedingly complex, requiring multiple modalities of diagnosis and treatment. Given the vast human, technical, and financial resources required, access to radiotherapy remains limited in sub-Saharan Africa. Through 2017, Rwanda has not had in-country radiotherapy services. The aim of this study was to describe the implementation and early outcomes of the radiotherapy referral program at the Butaro Cancer Centre of Excellence and to identify both successful pathways and barriers to care. Methods Butaro District Hospital is located in a rural area of the Northern Province and is home to the Butaro Cancer Centre of Excellence. We performed a retrospective study from routinely collected data of all patients with a diagnosis of cervical, head and neck, or rectal cancer between July 2012 and June 2015. Results Between 2012 and 2015, 580 patients were identified with these diagnoses and were potential candidates for radiation. Two hundred eight (36%) were referred for radiotherapy treatment in Uganda. Of those referred, 160 (77%) had cervical cancer, 31 (15%) had head and neck cancer, and 17 (8%) had rectal cancer. At the time of data collection, 101 radiotherapy patients (49%) were alive and had completed treatment with no evidence of recurrence, 11 (5%) were alive and continuing treatment, and 12 (6%) were alive and had completed treatment with evidence of recurrence. Conclusion This study demonstrates the feasibility of a rural cancer facility to successfully conduct out-of-country radiotherapy referrals with promising early outcomes. The results of this study also highlight the many challenges and lessons learned in providing comprehensive cancer care in resource-limited settings.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Pursuing equity in cancer care: implementation, challenges and preliminary findings of a public cancer referral center in rural Rwanda

Background: Cancer services are inaccessible in many low-income countries, and few published examples describe oncology programs within the public sector. In 2011, the Rwanda Ministry of Health (RMOH) established Butaro Cancer Center of Excellence (BCCOE) to expand cancer services nationally. In hopes of informing cancer care delivery in similar settings, we describe program-level experience implementing BCCOE, patient characteristics, and challenges encountered. Methods: Butaro Cancer Center of Excellence was founded on diverse partnerships that emphasize capacity building. Services available include pathology-based diagnosis, basic imaging, chemotherapy, surgery, referral for radiotherapy, palliative care and socioeconomic access supports. Retrospective review of electronic medical records (EMR) of patients enrolled between July 1, 2012 and June 30, 2014 was conducted, supplemented by manual review of paper charts and programmatic records. Results: In the program’s first 2 years, 2326 patients presented for cancer-related care. Of these, 70.5 % were female, 4.3 % children, and 74.3 % on public health insurance. In the first year, 66.3 % (n = 1144) were diagnosed with cancer. Leading adult diagnoses were breast, cervical, and skin cancer. Among children, nephroblastoma, acute lymphoblastic leukemia, and Hodgkin lymphoma were predominant. As of June 30, 2013, 95 cancer patients had died. Challenges encountered include documentation gaps and staff shortages. Conclusion: Butaro Cancer Center of Excellence demonstrates that complex cancer care can be delivered in the most resource-constrained settings, accessible to vulnerable patients. Key attributes that have made BCCOE possible are: meaningful North–south partnerships, innovative task- and infrastructure-shifting, RMOH leadership, and an equity-driven agenda. Going forward, we will apply our experiences and lessons learned to further strengthen BCCOE, and employ the developed EMR system as a valuable platform to assess long-term clinical outcomes and improve care

Palliative Care and Pain Control

Palliative care has been shown to provide significant and diverse benefits for patients with serious, complex, or life-limiting health problems. Such benefits include the following: Reduced physical, psychological, and spiritual suffering (Abernethy and others 2003; Gwyther and Krakauer 2011; Higginson and others 2014; Krakauer 2008; Singer and others 2016; Temel and others 2010; WHO 2008; Zimmerman and others 2014) Improved quality of life (Singer and others 2016; Zimmerman and others 2014) Prolonged survival in some situations (Connor and others 2007; Temel and others 2010). Palliative care also can lower costs to health care systems (Chalkidou and others 2014; DesRosiers and others 2014; Gomez-Batiste and others 2012; Jamison and others 2013; Knaul and others 2017; Summers 2016). For these reasons, it is recognized globally as an ethical responsibility of all health care systems and a necessary component of universal health coverage (World Health Assembly 2014). Yet palliative care is rarely accessible in low- and middle-income countries (LMICs). This chapter describes an essential package (EP) of palliative care services and treatments that could and should be accessible to everyone everywhere, as well as the sites or platforms where those services and treatments could be offered. Thus, it was necessary to make a preliminary estimate of the burden of health-related suffering requiring palliative care.To roughly estimate the need for palliative care, we identified the serious, complex, or life-limiting conditions listed in the International Classification of Diseases (ICD)-10 that most commonly result in physical, psychological, social, or spiritual suffering (WHO 2015a). We then estimated the types, prevalence, and duration of suffering resulting from each condition. On the basis of this characterization of the burden of suffering, we propose an EP of palliative care and pain control designed to do the following: Prevent or relieve the most common and severe suffering related to illness or injury. Be affordable, even in LMICs. Provide financial risk protection for patients and families by providing a realistic alternative to expensive, low-value treatment. We costed the EP in one low-income country (Rwanda), one lower-middle-income country (Vietnam), and one upper-middle-income country (Mexico) and projected these costs for LMICs in general (Knaul and others 2017). At the conclusion of this chapter, we provide guidance on how to integrate the EP into health systems as an essential element of universal health coverage (UHC) in LMICs. We also discuss how to augment the EP as soon as is feasible to further prevent and relieve suffering.This chapter draws directly on the work of the Lancet Commission on Global Access to Palliative Care and Pain Control (the Lancet Commission) (Knaul and others 2017)