Bubble CPAP to support preterm infants in rural Rwanda: a retrospective cohort study

Background: Complications from premature birth contribute to 35 % of neonatal deaths globally; therefore, efforts to improve clinical outcomes of preterm (PT) infants are imperative. Bubble continuous positive airway pressure (bCPAP) is a low-cost, effective way to improve the respiratory status of preterm and very low birth weight (VLBW) infants. However, bCPAP remains largely inaccessible in resource-limited settings, and information on the scale-up of this technology in rural health facilities is limited. This paper describes health providers’ adherence to bCPAP protocols for PT/VLBW infants and clinical outcomes in rural Rwanda. Methods: This retrospective chart review included all newborns admitted to neonatal units in three rural hospitals in Rwanda between February 1st and October 31st, 2013. Analysis was restricted to PT/VLBW infants. bCPAP eligibility, identification of bCPAP eligibility and complications were assessed. Final outcome was assessed overall and by bCPAP initiation status. Results: There were 136 PT/VLBW infants. For the 135 whose bCPAP eligibility could be determined, 83 (61.5 %) were bCPAP-eligible. Of bCPAP-eligible infants, 49 (59.0 %) were correctly identified by health providers and 43 (51.8 %) were correctly initiated on bCPAP. For the 52 infants who were not bCPAP-eligible, 45 (86.5 %) were correctly identified as not bCPAP-eligible, and 46 (88.5 %) did not receive bCPAP. Overall, 90 (66.2 %) infants survived to discharge, 35 (25.7 %) died, 3 (2.2 %) were referred for tertiary care and 8 (5.9 %) had unknown outcomes. Among the bCPAP eligible infants, the survival rates were 41.8 % (18 of 43) for those in whom the procedure was initiated and 56.5 % (13 of 23) for those in whom it was not initiated. No complications of bCPAP were reported. Conclusion: While the use of bCPAP in this rural setting appears feasible, correct identification of eligible newborns was a challenge. Mentorship and refresher trainings may improve guideline adherence, particularly given high rates of staff turnover. Future research should explore implementation challenges and assess the impact of bCPAP on long-term outcomes

Quality of life of Australian chronically-ill adults: patient and practice characteristics matter

BackgroundTo study health-related quality of life (HRQOL) in a large sample of Australian chronically-ill patients and investigate the impact of characteristics of patients and their general practices on their HRQOL and to assess the construct validity of SF-12 in Australia.MethodsCross sectional study with 96 general practices and 7606 chronically-ill patients aged 18 years or more using standard SF-12 version 2. Factor analysis was used to confirm the hypothesized component structure of the SF-12 items. SF-12 physical component score (PCS-12) and mental component score (MCS-12) were derived using the standard US algorithm. Multilevel regression analysis (patients at level 1 and practices at level 2) was applied to relate PCS-12 and MCS-12 to patient and practice characteristics.ResultsThere were significant associations between lower PCS-12 or MCS-12 score and poorer general health (10.8 (regression coefficient) lower for PCS-12 and 7.3 lower for MCS-12), low socio-economic status (5.1 lower PCS-12 and 2.9 lower MCS-12 for unemployed, 0.8 lower PCS-12 and 1.7 lower MCS-12 for non-owner-occupiers, 1.0 lower PCS-12 for less well-educated) and having two or more chronic conditions (up to 2.7 lower PCS-12 and up to 1.5 lower MCS-12 than those having a single disease). Younger age was associated with lower MCS-12 (2.2 and 6.0 lower than middle age and older age respectively) but higher PCS-12 (4.7 and 7.6 higher than middle age and older age respectively). Satisfaction with quality of care (regression coefficient = 1.2) and patients who were married or cohabiting (regression coefficient = 0.6) was positively associated with MCS-12. Patients born in non-English-speaking countries were more likely to have a lower MCS-12 (1.5 lower) than those born in Australia. Employment had a stronger association with the quality of life of males than that of females. Those attending smaller practices had lower PCS-12 (1.0 lower) and MCS-12 (0.6 lower) than those attending larger practices. At the patient level (level 1) 42% and 21% of the variance respectively for PCS-12 and MCS-12 were explained by the patients and practice characteristics. At the practice level (level 2), 73% and 49% of the variance respectively for PCS-12 and MCS-12 were explained by patients and practice characteristics.ConclusionThe strong association between patient characteristics such as socio-economic status, age, and ethnicity and SF-12 physical and mental component summary scores underlines the importance of considering these factors in the management of chronically-ill patients in general practice. The SF-12 appears to be a valid measure for assessing HRQOL of Australian chronically-ill patients.Upali W. Jayasinghe, Judith Proudfoot, Christopher A. Barton, Cheryl Amoroso, Chris Holton, Gawaine Powell Davies, Justin Beilby and Mark F. Harri

Adapting operational research training to the Rwandan context: the Intermediate Operational Research Training programme

ABSTRACT Background:: Promoting national health research agendas in low- and middle-income countries (LMICs) requires adequate numbers of individuals with skills to initiate and conduct research. Recently, non-governmental organizations (NGOs) have joined research capacity building efforts to increase research leadership by LMIC nationals. Partners In Health, an international NGO operating in Rwanda, implemented its first Intermediate Operational Research Training (IORT) course to cultivate Rwandan research talent and generate evidence to improve health care delivery. Objective:: This paper describes the implementation of IORT to share experiences with other organizations interested in developing similar training programmes. Methods:: The Intermediate Operational Research Training utilized a deliverable-driven training model, using learning-by-doing pedagogy with intensive hands-on mentorship to build research skills from protocol development to scientific publication. The course had short (two-day) but frequent training sessions (seven sessions over eight months). Trainees were clinical and programme staff working at the district level who were paired to jointly lead a research project. Results:: Of 10 trainees admitted to the course from a pool of 24 applicants, nine trainees completed the course with five research projects published in peer-reviewed journals. Strengths of the course included supportive national and institutional research capacity guidelines, building from a successful training model, and trainee commitment. Challenges included delays in ethical review, high mentorship workload of up to 250 hours of practicum mentorship, lack of access to literature in subscription journals and high costs of open access publication. Conclusions:: The IORT course was an effective way to support the district-based government and NGO staff in gaining research skills, as well as answering research questions relevant to health service delivery at district hospitals. Other NGOs should build on successful programmes while adapting course elements to address context-specific challenges. Mentorship for LMIC trainees is critical for effectiveness of research capacity building initiatives

Adapting operational research training to the Rwandan context: the Intermediate Operational Research Training programme

ABSTRACT Background:: Promoting national health research agendas in low- and middle-income countries (LMICs) requires adequate numbers of individuals with skills to initiate and conduct research. Recently, non-governmental organizations (NGOs) have joined research capacity building efforts to increase research leadership by LMIC nationals. Partners In Health, an international NGO operating in Rwanda, implemented its first Intermediate Operational Research Training (IORT) course to cultivate Rwandan research talent and generate evidence to improve health care delivery. Objective:: This paper describes the implementation of IORT to share experiences with other organizations interested in developing similar training programmes. Methods:: The Intermediate Operational Research Training utilized a deliverable-driven training model, using learning-by-doing pedagogy with intensive hands-on mentorship to build research skills from protocol development to scientific publication. The course had short (two-day) but frequent training sessions (seven sessions over eight months). Trainees were clinical and programme staff working at the district level who were paired to jointly lead a research project. Results:: Of 10 trainees admitted to the course from a pool of 24 applicants, nine trainees completed the course with five research projects published in peer-reviewed journals. Strengths of the course included supportive national and institutional research capacity guidelines, building from a successful training model, and trainee commitment. Challenges included delays in ethical review, high mentorship workload of up to 250 hours of practicum mentorship, lack of access to literature in subscription journals and high costs of open access publication. Conclusions:: The IORT course was an effective way to support the district-based government and NGO staff in gaining research skills, as well as answering research questions relevant to health service delivery at district hospitals. Other NGOs should build on successful programmes while adapting course elements to address context-specific challenges. Mentorship for LMIC trainees is critical for effectiveness of research capacity building initiatives

Experience with a Massive Open Online Course in Rural Rwanda

The growing utilization of massive open online courses (MOOCs) is opening opportunities for students worldwide, but the completion rate for MOOCs is low (Liyanagunawardena, Adams, & Williams, 2013). Partners In Health (PIH) implemented a “flipped” MOOC in Rwanda that incorporated in-class sessions to facilitate participant completion. In October 2013, PIH invited its employees, as well as those at the Ministry of Health, to participate in an online MOOC. Each site had at least one volunteer facilitator who accompanied participants throughout the course by providing course materials and facilitating the understanding of the online material during the weekly class sessions. Following the conclusion of the course, all participants were asked to complete an online survey. A total of 38 out of 62 registered participants completed the survey and of these 38 participants, 20 (52.6%) successfully finished the course. The number of in-person sessions attended was significantly associated with course completion (p < 0.05), and 85% who successfully completed the course attended at least three of seven sessions. Sixteen (80%) participants believed that the completion of this course would help them with career advancement. Half of the participants (19 of 38, 50%) were employed with a position related to research. Other job titles included the following: nurses (4 of 38, 10.5%), a pharmacist (1 of 38, 2.6%), a clinical psychologist (1 of 38, 2.6%), a dentist (1 of 38, 2.6%), and others (10 of 38, 26.3%). The job title was not significantly related to course completion. Our experience, with a completion rate of over 50%, yields several lessons for incorporating MOOCs into capacity-building programs to leverage the potential of online learning in resource-limited areas

Next wave of interventions to reduce under-five mortality in Rwanda: a cross-sectional analysis of demographic and health survey data

Background: Sustained investments in Rwanda’s health system have led to historic reductions in under five (U5) mortality. Although Rwanda achieved an estimated 68% decrease in the national under U5 mortality rate between 2002 and 2012, according to the national census, 5.8% of children still do not reach their fifth birthday, requiring the next wave of child mortality prevention strategies. Methods: This is a cross-sectional study of 9002 births to 6328 women age 15–49 in the 2010 Rwanda Demographic and Health Survey. We tested bivariate associations between 29 covariates and U5 mortality, retaining covariates with an odds ratio p < 0.1 for model building. We used manual backward stepwise logistic regression to identify correlates of U5 mortality in all children U5, 0–11 months, and 12–59 months. Analyses were performed in Stata v12, adjusting for complex sample design. Results: Of 14 covariates associated with U5 mortality in bivariate analysis, the following remained associated with U5 mortality in multivariate analysis: household being among the poorest of the poor (OR = 1.98), child being a twin (OR = 2.40), mother having 3–4 births in the past 5 years (OR = 3.97) compared to 1–2 births, mother being HIV positive (OR = 2.27), and mother not using contraceptives (OR = 1.37) compared to using a modern method (p < 0.05 for all). Mother experiencing physical or sexual violence in the last 12 months was associated with U5 mortality in children ages 1–4 years (OR = 1.48, p < 0.05). U5 survival was associated with a preceding birth interval 25–50 months (OR = 0.67) compared to 9–24 months, and having a mosquito net (OR = 0.46) (p < 0.05 for both). Conclusions: In the past decade, Rwanda rolled out integrated management of childhood illness, near universal coverage of childhood vaccinations, a national community health worker program, and a universal health insurance scheme. Identifying factors that continue to be associated with childhood mortality supports determination of which interventions to strengthen to reduce it further. This study suggests that Rwanda’s next wave of U5 mortality reduction should target programs in improving neonatal outcomes, poverty reduction, family planning, HIV services, malaria prevention, and prevention of intimate partner violence

Approaches and impact of non-academic research capacity strengthening training models in sub-Saharan Africa: a systematic review

Background: Research is essential to identify and prioritize health needs and to develop appropriate strategies to improve health outcomes. In the last decade, non-academic research capacity strengthening trainings in sub-Saharan Africa, coupled with developing research infrastructure and the provision of individual mentorship support, has been used to build health worker skills. The objectives of this review are to describe different training approaches to research capacity strengthening in sub-Saharan Africa outside academic programs, assess methods used to evaluate research capacity strengthening activities, and learn about the challenges facing research capacity strengthening and the strategies/innovations required to overcome them. Methodology The PubMed database was searched using nine search terms and articles were included if 1) they explicitly described research capacity strengthening training activities, including information on program duration, target audience, immediate program outputs and outcomes; 2) all or part of the training program took place in sub-Saharan African countries; 3) the training activities were not a formal academic program; 4) papers were published between 2000 and 2013; and 5) both abstract and full paper were available in English. Results: The search resulted in 495 articles, of which 450 were retained; 14 papers met all inclusion criteria and were included and analysed. In total, 4136 people were trained, of which 2939 were from Africa. Of the 14 included papers, six fell in the category of short-term evaluation period and eight in the long-term evaluation period. Conduct of evaluations and use of evaluation frameworks varied between short and long term models and some trainings were not evaluated. Evaluation methods included tests, surveys, interviews, and systems approach matrix. Conclusions: Research capacity strengthening activities in sub-Saharan Africa outside of academic settings provide important contributions to developing in-country capacity to participate in and lead research. Institutional support, increased funds, and dedicated time for research activities are critical factors that lead to the development of successful programs. Further, knowledge sharing through scientific articles with sufficient detail is needed to enable replication of successful models in other settings