Validating the Global Surgery Geographical Accessibility Indicator : Differences in Modeled Versus Patient-Reported Travel Times

Background: Since long travel times to reach health facilities are associated with worse outcomes, geographic accessibility is one of the six core global surgery indicators; this corresponds to the second of the “Three Delays Framework,” namely “delay in reaching a health facility.” Most attempts to estimate this indicator have been based on geographical information systems (GIS) algorithms. The aim of our study was to compare GIS derived estimates to self-reported travel times for patients traveling to a district hospital in rural Rwanda for emergency obstetric care. Methods: Our study includes 664 women who traveled to undergo a Cesarean delivery in Kirehe, Rwanda. We compared self-reported travel time from home to the hospital (excluding waiting time) with GIS estimated travel times, which were computed using the World Health Organization tool AccessMod, using linear regression. Results: The majority of patients used multiple modes of transportation (walking = 48.5%, public transport = 74.2%, private transport = 2.9%, and ambulance 70.6%). Self-reported times were longer than GIS estimates by a factor of 1.49 (95% CI 1.40–1.57). Concordance was higher when the GIS model took into account that all patients in Rwanda are referred via their health center (β = 1.12; 95% CI 1.05–1.18). Conclusions: To our knowledge, in this largest to date GIS validation study for geographical access to healthcare in low- and middle-income countries, a standard GIS model was found to significantly underestimate real travel time, which likely is in part because it does not model the actual route patients are travelling. Therefore, previous studies of 2-h access to surgery will need to be interpreted with caution, and future studies should take local travelling conditions into account

Improved quality of life following direct‐acting antiviral treatment for chronic hepatitis C infection in Rwanda: Results from a clinical trial in sub‐Saharan Africa (the SHARED study)

Around 71 million people are living with chronic hepatitis C virus (HCV) infection, with approximately 14% residing in Sub‐Saharan Africa. Direct acting anti‐viral (DAA) therapies offer clear benefits for liver‐related morbidity and mortality, and data from high‐income settings suggest that DAA treatments also provide significant benefits in terms of health‐related quality of life (HRQL). In this study, we assessed the effect of DAA treatment on HRQL for individuals treated for HCV in a clinical trial in Rwanda. We assessed the HRQL of participants using an 83‐question composite survey at Day 0 (‘baseline’) and Week 24 (‘endpoint’). Data were analyzed in R. 296 participants were included in this analysis. Their ages ranged from 19‐90 and 184 (62.2%) were female. There were significant improvements from baseline to endpoint median scores for all physical and mental quality of life sub‐scales. Additionally, a reduction – before and after treatment ‐ in the proportion of those classified as depressed and needing social support was statistically significant (both p<0.001). Economic productivity increased after treatment (p<0.001) and households classified as food secure increased from baseline to endpoint (p<0.001). These results demonstrate that Rwandans with chronic HCV infection experience both clinical and HRQL benefits, including household level benefits like substantial gains in workforce stability, economic productivity, and poverty alleviation, from DAA treatment. A stronger demonstration of accurate and broader household level benefits achieved through treatment of HCV with DAAs will help financing and investment for HCV in resource‐constrained settings become an urgent priority