Strengthening care and research for women's cancers in Sub-Saharan Africa

Highlights • The burden of gynecologic cancers in low resource settings is overwhelming. • Areas with the highest needs have few human resources and limited infrastructure. • Cancer specialists can best help by leveraging ongoing work to assist local leaders

High rates of undiagnosed and uncontrolled hypertension upon a screening campaign in rural Rwanda:a cross-sectional study

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

High rates of undiagnosed and uncontrolled hypertension upon a screening campaign in rural Rwanda:a cross-sectional study

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

Quality of life among adult patients living with diabetes in Rwanda: a cross-sectional study in outpatient clinics

Objectives To report on the disease-related quality of life of patients living with diabetes mellitus in Rwanda and identify its predictors.Design Cross-sectional study, part of the baseline assessment of a cluster-randomised controlled trial.Setting Outpatient clinics for non-communicable diseases of nine hospitals across Rwanda.Participants Between January and August 2019, 206 patients were recruited as part of the clinical trial. Eligible participants were those aged 21–80 years and with a diagnosis of diabetes mellitus for at least 6 months. Illiterate patients, those with severe hearing or visual impairments, those with severe mental health conditions, terminally ill, and those pregnant or in the postpartum period were excludedPrimary and secondary outcome measures Disease-specific quality of life was measured with the Kinyarwanda version of the Diabetes-39 (D-39) questionnaire. A glycated haemoglobin (HbA1c) test was performed on all patients. Sociodemographic and clinical data were collected, including medical history, disease-related complications and comorbidities.Results The worst affected dimensions of the D-39 were ‘anxiety and worry’ (mean=51.63, SD=25.51), ‘sexual functioning’ (mean=44.58, SD=37.02), and ‘energy and mobility’ (mean=42.71, SD=20.69). Duration of the disease and HbA1c values were not correlated with any of the D-39 dimensions. A moderating effect was identified between use of insulin and achieving a target HbA1c of 7% in the ‘diabetes control’ scale. The most frequent comorbidity was hypertension (49.0% of participants), which had a greater negative effect on the ‘diabetes control’ and ‘social burden’ scales in women. Higher education was a predictor of less impact on the ‘social burden’ and ‘energy and mobility’ scales.Conclusions Several variables were identified as predictors for the five dimensions of quality of life that were studied, providing opportunities for tailored preventive programmes. Further prospective studies are needed to determine causal relationships.Trial registration number NCT03376607

Quality of life among adult patients living with diabetes in Rwanda: a cross-sectional study in outpatient clinics

Objectives To report on the disease-related quality of life of patients living with diabetes mellitus in Rwanda and identify its predictors. Design Cross-sectional study, part of the baseline assessment of a cluster-randomised controlled trial. Setting Outpatient clinics for non-communicable diseases of nine hospitals across Rwanda. Participants Between January and August 2019, 206 patients were recruited as part of the clinical trial. Eligible participants were those aged 21–80 years and with a diagnosis of diabetes mellitus for at least 6 months. Illiterate patients, those with severe hearing or visual impairments, those with severe mental health conditions, terminally ill, and those pregnant or in the postpartum period were excluded Primary and secondary outcome measures Disease-specific quality of life was measured with the Kinyarwanda version of the Diabetes-39 (D-39) questionnaire. A glycated haemoglobin (HbA1c) test was performed on all patients. Sociodemographic and clinical data were collected, including medical history, disease-related complications and comorbidities. Results The worst affected dimensions of the D-39 were ‘anxiety and worry’ (mean=51.63, SD=25.51), ‘sexual functioning’ (mean=44.58, SD=37.02), and ‘energy and mobility’ (mean=42.71, SD=20.69). Duration of the disease and HbA1c values were not correlated with any of the D-39 dimensions. A moderating effect was identified between use of insulin and achieving a target HbA1c of 7% in the ‘diabetes control’ scale. The most frequent comorbidity was hypertension (49.0% of participants), which had a greater negative effect on the ‘diabetes control’ and ‘social burden’ scales in women. Higher education was a predictor of less impact on the ‘social burden’ and ‘energy and mobility’ scales. Conclusions Several variables were identified as predictors for the five dimensions of quality of life that were studied, providing opportunities for tailored preventive programmes. Further prospective studies are needed to determine causal relationships

Understanding needs and solutions to promote healthy ageing and reduce multimorbidity in Rwanda:A protocol paper

Background: Ageing is often accompanied by chronic diseases, multimorbidity, and frailty, increasing the need for clinical and social care to support healthy Ageing and manage these conditions. We are currently in the UN Decade of Ageing and there is a growing focus on the need to prevent or delay some of these conditions through the “Healthy Ageing” initiative of the World Health Organization. However, there are limited data available to inform prioritisation of interventions, particularly for countries in sub-Saharan Africa.Methods: This study has five interlinked work packages (WPs), designed to understand the current needs for older people in Rwanda, health system capacity and possible solutions to unmet need. First, we will conduct a household survey in the City of Kigali (predominantly urban) and Northern Province Burera district (predominantly rural) to determine the burden of multimorbidity, frailty, access to care, and experiences and responsiveness of care in older people. This work will be supplemented by secondary analysis of data from the Rwandan STEPwise approach to non-communicable disease (NCD) risk factor surveillance (STEPs) survey of 2021. Second, we will conduct a health facility readiness assessment and healthcare provider survey to assess health system capacity and gaps to deliver effective primary care to older people in Rwanda. Third, to capture the voice of older people, we will explore the quality of healthcare as experienced by them using in-depth interviews (IDIs). In Fourth, we will synthesise data using mixed methods to understand barriers to access to quality of care in older age based on a 3-delays framework (seeking, reaching, and receiving quality health care). Finally, the project will culminate in a stakeholder workshop to ensure results are contextually appropriate and disseminated, and gaps identified are prioritized to design novel interventions to promote healthy ageing in Rwanda and the region. The study has received ethics approval from the Rwanda National Ethics Committee (RNEC), Northwestern University, USA and the University of Birmingham, UK.Discussion: This study will deliver impactful research by using multiple methodologies and working with in-country partners to develop a deep knowledge and understanding of health care systems experienced by older people in Rwanda. It will also provide a framework for sustainable healthy ageing research and policy engagement to benefit older adults living in Rwanda and inform similar work in Low- and Middle-Income countries (LMICs) during this Decade of Healthy Ageing and beyond

Understanding needs and solutions to promote healthy ageing and reduce multimorbidity in Rwanda:A protocol paper

Background: Ageing is often accompanied by chronic diseases, multimorbidity, and frailty, increasing the need for clinical and social care to support healthy Ageing and manage these conditions. We are currently in the UN Decade of Ageing and there is a growing focus on the need to prevent or delay some of these conditions through the “Healthy Ageing” initiative of the World Health Organization. However, there are limited data available to inform prioritisation of interventions, particularly for countries in sub-Saharan Africa.Methods: This study has five interlinked work packages (WPs), designed to understand the current needs for older people in Rwanda, health system capacity and possible solutions to unmet need. First, we will conduct a household survey in the City of Kigali (predominantly urban) and Northern Province Burera district (predominantly rural) to determine the burden of multimorbidity, frailty, access to care, and experiences and responsiveness of care in older people. This work will be supplemented by secondary analysis of data from the Rwandan STEPwise approach to non-communicable disease (NCD) risk factor surveillance (STEPs) survey of 2021. Second, we will conduct a health facility readiness assessment and healthcare provider survey to assess health system capacity and gaps to deliver effective primary care to older people in Rwanda. Third, to capture the voice of older people, we will explore the quality of healthcare as experienced by them using in-depth interviews (IDIs). In Fourth, we will synthesise data using mixed methods to understand barriers to access to quality of care in older age based on a 3-delays framework (seeking, reaching, and receiving quality health care). Finally, the project will culminate in a stakeholder workshop to ensure results are contextually appropriate and disseminated, and gaps identified are prioritized to design novel interventions to promote healthy ageing in Rwanda and the region. The study has received ethics approval from the Rwanda National Ethics Committee (RNEC), Northwestern University, USA and the University of Birmingham, UK.Discussion: This study will deliver impactful research by using multiple methodologies and working with in-country partners to develop a deep knowledge and understanding of health care systems experienced by older people in Rwanda. It will also provide a framework for sustainable healthy ageing research and policy engagement to benefit older adults living in Rwanda and inform similar work in Low- and Middle-Income countries (LMICs) during this Decade of Healthy Ageing and beyond

Operating Characteristics of a Tuberculosis Screening Tool for People Living with HIV in Out-Patient HIV Care and Treatment Services, Rwanda.

The World Health Organization (WHO) 2010 guidelines for intensified tuberculosis (TB) case finding (ICF) among people living with HIV (PLHIV) includes a recommendation that PLHIV receive routine TB screening. Since 2005, the Rwandan Ministry of Health has been using a five-question screening tool. Our study objective was to assess the operating characteristics of the tool designed to identify PLHIV with presumptive TB as measured against a composite reference standard, including bacteriologically confirmed TB.In a cross-sectional study, the TB screening tool was routinely administered at enrolment in outpatient HIV care and treatment services at seven public health facilities. From March to September 2011, study enrollees were examined for TB disease irrespective of TB screening outcome. The examination consisted of a chest radiograph (CXR), three sputum smears (SS), sputum culture (SC) and polymerase chain reaction line-probe assay (Hain test). PLHIV were classified as having "laboratory-confirmed TB" with positive results on SS for acid-fast bacilli, SC on Lowenstein-Jensen medium, or a Hain test.Overall, 1,767 patients were enrolled and screened of which; 1,017 (57.6%) were female, median age was 33 (IQR, 27-41), and median CD4+ cell count was 385 (IQR, 229-563) cells/mm3. Of the patients screened, 138 (7.8%) were diagnosed with TB of which; 125 (90.5%) were laboratory-confirmed pulmonary TB. Of 404 (22.9%) patients who screened positive and 1,363 (77.1%) who screened negative, 79 (19.5%) and 59 (4.3%), respectively, were diagnosed with TB. For laboratory-confirmed TB, the tool had a sensitivity of 54.4% (95% CI 45.3-63.3), specificity of 79.5% (95% CI 77.5-81.5), PPV of 16.8% and NPV of 95.8%.TB prevalence among PLHIV newly enrolling into HIV care and treatment was 65 times greater than the overall population prevalence. However, the performance of the tool was poorer than the predicted performance of the WHO recommended TB screening questions

Implementing Cancer Care in Rwanda: Capacity Building for Treatment and Scale-Up

Background: The majority of countries in sub-Saharan Africa are ill-prepared to address the rising burden of cancer. While some have been able to establish a single cancer referral center, few have been able to scale-up services nationally towards universal health coverage. The literature lacks a step-wise implementation approach for resource-limited countries to move beyond a single-facility implementation strategy and implement a national cancer strategy to expand effective coverage. Methods: We applied an implementation science framework, which describes a four-phase approach: Exploration, Preparation, Implementation, and Sustainment (EPIS). Through this framework, we describe Rwanda’s approach to establish not just a single cancer center, but a national cancer program. Results: By applying EPIS to Rwanda’s implementation approach, we analyzed and identified the implementation strategies and factors, which informed processes of each phase to establish foundational cancer delivery components, including trained staff, diagnostic technology, essential medicines, and medical informatics. These cancer delivery components allowed for the implementation of Rwanda’s first cancer center, while simultaneously serving as the nidus for capacity building of foundational components for future cancer centers. Conclusion: This “progressive scaling” approach ensured that initial investments in the country’s first cancer center was a step toward establishing future cancer centers in the country