Clinical mentorship to improve pediatric quality of care at the health centers in rural Rwanda: a qualitative study of perceptions and acceptability of health care workers

Background: Despite evidence supporting Integrated Management of Childhood Illness (IMCI) as a strategy to improve pediatric care in countries with high child mortality, its implementation faces challenges related to lack of or poor post-didactic training supervision and gaps in necessary supporting systems. These constraints lead to health care workers’ inability to consistently translate IMCI knowledge and skills into practice. A program providing mentoring and enhanced supervision at health centers (MESH), focusing on clinical and systems improvement was implemented in rural Rwanda as a strategy to address these issues, with the ultimate goal of improving the quality of pediatric care at rural health centers. We explored perceptions of MESH from the perspective of IMCI clinical mentors, mentees, and district clinical leadership. Methods: We conducted focus group discussions with 40 health care workers from 21 MESH-supported health centers. Two FGDs in each district were carried out, including one for nurses and one for director of health centers. District medical directors and clinical mentors had individual in-depth interviews. We performed a hermeneutic analysis using Atlas.ti v5.2. Results: Study participants highlighted program components in five key areas that contributed to acceptability and impact, including: 1) Interactive, collaborative capacity-building, 2) active listening and relationships, 3) supporting not policing, 4) systems improvement, and 5) real-time feedback. Staff turn-over, stock-outs, and other facility/systems gaps were identified as barriers to MESH and IMCI implementation. Conclusion: Health care workers reported high acceptance and positive perceptions of the MESH model as an effective strategy to build their capacity, bridge the gap between knowledge and practice in pediatric care, and address facility and systems issues. This approach also improved relationships between the district supervisory team and health center-based care providers. Despite some challenges, many perceived a strong benefit on clinical performance and outcomes. This study can inform program implementers and policy makers of key components needed for developing similar health facility-based mentorship interventions and potential barriers and resistance which can be proactively addressed to ensure success

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

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

Rainfall variation and child health: effect of rainfall on diarrhea among under 5 children in Rwanda, 2010

BACKGROUND:Diarrhea among children under 5 years of age has long been a major public health concern. Previous studies have suggested an association between rainfall and diarrhea. Here, we examined the association between Rwandan rainfall patterns and childhood diarrhea and the impact of household sanitation variables on this relationship.METHODS:We derived a series of rain-related variables in Rwanda based on daily rainfall measurements and hydrological models built from daily precipitation measurements collected between 2009 and 2011. Using these data and the 2010 Rwanda Demographic and Health Survey database, we measured the association between total monthly rainfall, monthly rainfall intensity, runoff water and anomalous rainfall and the occurrence of diarrhea in children under 5 years of age.RESULTS:Among the 8601 children under 5 years of age included in the survey, 13.2 % reported having diarrhea within the 2 weeks prior to the survey. We found that higher levels of runoff were protective against diarrhea compared to low levels among children who lived in households with unimproved toilet facilities (OR?=?0.54, 95 % CI: [0.34, 0.87] for moderate runoff and OR?=?0.50, 95 % CI: [0.29, 0.86] for high runoff) but had no impact among children in household with improved toilets.CONCLUSION:Our finding that children in households with unimproved toilets were less likely to report diarrhea during periods of high runoff highlights the vulnerabilities of those living without adequate sanitation to the negative health impacts of environmental events

Sexual Violence against Children in Rwanda: Prevalence and Associated Factors

Background Information and data on the burden and factors associated with violence against children are critical in designing and implementing preventive strategies and interventions. This study aimed to examine patterns of the prevalence of sexual violence (SV) against children in Rwanda and investigate associated factors to contribute to the knowledge about violence against children in Rwanda. Methods A sample of 1,110 children aged 13-17 years from a cross-sectional national survey done in Rwanda in 2015 was analysed. Weighted descriptive statistics were applied to describe the prevalence of SV against children, and weighted logistic regression allowed us to investigate factors associated with it. Results Over eight percent (8.4%) of all children, including about three percent (2.8%) of male children and around five percent (5.6%) of female children, reported having experienced SV within the last twelve months. Being a female child, having a romantic partner, and not attending school were some factors associated with SV against children in Rwanda. Conclusion Female children reported more SV than male children. Factors associated with sexual violence pertained to the child’s characteristics, family or household background characteristics, and community relations. The study findings call for an urgent need to prevent SV against children through awareness raising about it amongst children and the general public. Rwanda J Med Health Sci 2022;5(3):302-31

Rainfall variation and child health: effect of rainfall on diarrhea among under 5 children in Rwanda, 2010

Background: Diarrhea among children under 5 years of age has long been a major public health concern. Previous studies have suggested an association between rainfall and diarrhea. Here, we examined the association between Rwandan rainfall patterns and childhood diarrhea and the impact of household sanitation variables on this relationship. Methods: We derived a series of rain-related variables in Rwanda based on daily rainfall measurements and hydrological models built from daily precipitation measurements collected between 2009 and 2011. Using these data and the 2010 Rwanda Demographic and Health Survey database, we measured the association between total monthly rainfall, monthly rainfall intensity, runoff water and anomalous rainfall and the occurrence of diarrhea in children under 5 years of age. Results: Among the 8601 children under 5 years of age included in the survey, 13.2 % reported having diarrhea within the 2 weeks prior to the survey. We found that higher levels of runoff were protective against diarrhea compared to low levels among children who lived in households with unimproved toilet facilities (OR = 0.54, 95 % CI: [0.34, 0.87] for moderate runoff and OR = 0.50, 95 % CI: [0.29, 0.86] for high runoff) but had no impact among children in household with improved toilets. Conclusion: Our finding that children in households with unimproved toilets were less likely to report diarrhea during periods of high runoff highlights the vulnerabilities of those living without adequate sanitation to the negative health impacts of environmental events

Psychosocial benefits of a mentoring program for youth-headed households in Rwanda

In Rwanda, the combined effects of the 1994 genocide and the AIDS pandemic have devastated the lives of children and families. More than 300,000 young people have been “left behind,” not only by parents and other caregivers who have died, but also by extended families and communities who stigmatize and fail to support them. The phenomenon of youth-headed households in the region is a relatively recent development. Despite the long history of fostering in sub-Saharan Africa, family and community safety nets are overstretched. Youth-headed households may be a legitimate coping strategy; however, children living in youth-headed households are less likely to attend school, have greater vulnerability to physical and mental health problems, and may demonstrate behavioral problems and hampered development. Although extended family members are a potential source of support, they are at times also the perpetrators of abuse, exploitation, and property grabbing following the parents’ death. The quasi-experimental study described in this brief tested a model of adult mentorship and support to improve psychosocial outcomes among youth-headed households. The study showed that mentoring can measurably mitigate adverse psychosocial outcomes among youth heads of households

Uptake of long acting reversible contraception following integrated couples HIV and fertility goal-based family planning counselling in Catholic and non-Catholic, urban and rural government health centers in Kigali, Rwanda.

BACKGROUND: When integrated with couples' voluntary HIV counselling and testing (CVCT), family planning including long acting reversible contraceptives (LARC) addresses prongs one and two of prevention of mother-to-child transmission (PMTCT). METHODS: In this observational study, we enrolled equal numbers of HIV concordant and discordant couples in four rural and four urban clinics, with two Catholic and two non-Catholic clinics in each area. Eligible couples were fertile, not already using a LARC method, and wished to limit or delay fertility for at least 2 years. We provided CVCT and fertility goal-based family planning counselling with the offer of LARC and conducted multivariate analysis of clinic, couple, and individual predictors of LARC uptake. RESULTS: Of 1290 couples enrolled, 960 (74%) selected LARC: Jadelle 5-year implant (37%), Implanon 3-year implant (26%), or copper intrauterine device (IUD) (11%). Uptake was higher in non-Catholic clinics (85% vs. 63% in Catholic clinics, p < 0.0001), in urban clinics (82% vs. 67% in rural clinics, p < 0.0001), and in HIV concordant couples (79% vs. 70% of discordant couples, p = .0005). Religion of the couple was unrelated to clinic religious affiliation, and uptake was highest among Catholics (80%) and lowest among Protestants (70%) who were predominantly Pentecostal. In multivariable analysis, urban location and non-Catholic clinic affiliation, Catholic religion of woman or couple, younger age of men, lower educational level of both partners, non-use of condoms or injectable contraception at enrollment, prior discussion of LARC by the couple, and women not having concerns about negative side effects of implant were associated with LARC uptake. CONCLUSIONS: Fertility goal-based LARC recommendations combined with couples' HIV counselling and testing resulted in a high uptake of LARC methods, even among discordant couples using condoms for HIV prevention, in Catholic clinics, and in rural populations. This model successfully integrates prevention of HIV and unplanned pregnancy

The impact of polio eradication on routine immunization and primary health care: a mixed-methods study.

BACKGROUND: After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC). METHODS: Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review. RESULTS: Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year. CONCLUSIONS: Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts

The Impact of Polio Eradication on Routine Immunization and Primary Health Care: A Mixed-Methods Study

BACKGROUND: After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC). METHODS: Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review. RESULTS: Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year. CONCLUSIONS: Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.This is the publisher’s final pdf. The published article is copyrighted by the author(s) and published by Oxford University Press on behalf of the Infectious Diseases Society of America. The published article can be found at: http://jid.oxfordjournals.org/.Keywords: health systems, eradication, poliomyelitis, routine immunizatio

Don't let the suffering make you fade away: An ethnographic study of resilience among survivors of genocide-rape in southern Rwanda

Rape has been used in contemporary armed conflicts to inflict physical, psychological, cultural and social damage. In endeavoring to address the psychological damage of collective violence, some researchers and global health practitioners are turning toward post-conflict mental health promotion approaches that centrally feature resilience. Though previous findings from resilience and coping research are robust, few studies have actually investigated resilience among genocide-rape survivors in cultural context in non-Western settings. This paper presents ethnographic data gathered over 14 months (September 2005 to November 2006) in southern Rwanda on resilience among genocide-rape survivors who were members of two women's genocide survivor associations. Study methods included a content analysis of a stratified purposive sample of 44 semi-structured interviews, as well as participant-, and non-participant-observation. Resilience among genocide-rape survivors in this context was found to be shaped by the cultural-linguistic specific concepts of kwihangana (withstanding), kwongera kubaho (living again), and gukomeza ubuzima (continuing life/health), and comprised of multiple sociocultural processes that enabled ongoing social connection with like others in order to make meaning, establish normalcy, and endure suffering in daily life. The results of this research show that the process of resilience among genocide-rape survivors was the same regardless of whether genocide survivor association membership was organized around the identity of genocide-rape survivorship or the identity of widowhood. However, the genocide-rape survivors' association members were more involved with directing resilience specifically toward addressing problems associated with genocide-rape compared to the members of the genocide widows' association. The findings from this research suggest that ethnographic methods can be employed to support resilience-based post-conflict mental health promotion efforts through facilitating collective sexual violence survivors to safely socially connect around their shared experiences of rape, neutralizing social threats of stigma and marginalization.Rwanda Resilience Global mental health Post-conflict Rape Women Genocide Mental health promotion