Factors associated with recovery from stunting at 24 months of age among infants and young children enrolled in the Pediatric Development Clinic (PDC): A retrospective cohort study in rural Rwanda.

INTRODUCTION: Stunting (low height/length-for-age) in early life is associated with poor long-term health and developmental outcomes. Nutrition interventions provided during the first 1,000 days of life can result in improved catch-up growth and development outcomes. We assessed factors associated with stunting recovery at 24 months of age among infants and young Children enrolled in Pediatric Development Clinics (PDC) who were stunted at 11 months of age. METHODS: This retrospective cohort study included infants and young children who enrolled in PDCs in two rural districts in Rwanda between April 2014 and December 2018. Children were included in the study if their PDC enrollment happened within 2 months after birth, were stunted at 11 months of age (considered as baseline) and had a stunting status measured and analyzed at 24 months of age. We defined moderate stunting as length-for-age z-score (LAZ) < -2 and ≥-3 and severe stunting as LAZ <-3 based on the 2006 WHO child growth standards. Stunting recovery at 24 months of age was defined as the child's LAZ changing from <-2 to > -2. We used logistic regression analysis to investigate factors associated with stunting recovery. The factors analyzed included child and mother's socio-demographic and clinical characteristics. RESULTS: Of the 179 children who were eligible for this study, 100 (55.9%) were severely stunted at age 11 months. At 24 months of age, 37 (20.7%) children recovered from stunting, while 21 (21.0%) severely stunted children improved to moderate stunting and 20 (25.3%) moderately-stunted children worsened to severe stunting. Early stunting at 6 months of age was associated with lower odds of stunting recovery, with the odds of stunting recovery being reduced by 80% (aOR: 0.2; 95%CI: 0.07-0.81) for severely stunted children and by 60% (aOR: 0.4; 95% CI: 0.16-0.97) for moderately stunted children (p = 0.035). Lower odds of stunting recovery were also observed among children who were severely stunted at 11 months of age (aOR: 0.3; 95% CI: 0.1-0.6, p = 0.004). No other maternal or child factors were statistically significantly associated with recovery from stunting at 24 months in our final adjusted model. CONCLUSION: A substantial proportion of children who were enrolled in PDC within 2 months after birth and were stunted at 11 months of age recovered from stunting at 24 months of age. Children who were severely stunted at 11 months of age (baseline) and those who were stunted at 6 months of age were less likely to recover from stunting at 24 months of age compared to those with moderate stunting at 11 months and no stunting at 6 months of age, respectively. More focus on prevention and early identification of stunting during pregnancy and early life is important to the healthy growth of a child.

Impact of COVID-19 on access to cancer care in Rwanda: a retrospective time-series study using electronic medical records data.

INTRODUCTION: The COVID-19 pandemic has caused disruptions in access to routine healthcare services worldwide, with a particularly high impact on chronic care patients and low and middle-income countries. In this study, we used routinely collected electronic medical records data to assess the impact of the COVID-19 pandemic on access to cancer care at the Butaro Cancer Center of Excellence (BCCOE) in rural Rwanda. METHODS: We conducted a retrospective time-series study among all Rwandan patients who received cancer care at the BCCOE between 1 January 2016 and 31 July 2021. The primary outcomes of interest included a comparison of the number of patients who were predicted based on time-series models of pre-COVID-19 trends versus the actual number of patients who presented during the COVID-19 period (between March 2020 and July 2021) across four key indicators: the number of new patients, number of scheduled appointments, number of clinical visits attended and the proportion of scheduled appointments completed on time. RESULTS: In total, 8970 patients (7140 patients enrolled before COVID-19 and 1830 patients enrolled during COVID-19) were included in this study. During the COVID-19 period, enrolment of new patients dropped by 21.7% (95% prediction interval (PI): -31.3%, -11.7%) compared with the pre-COVID-19 period. Similarly, the number of clinical visits was 25.0% (95% PI: -31.1%, -19.1%) lower than expected and the proportion of scheduled visits completed on time was 27.9% (95% PI: -39.8%, -14.1%) lower than expected. However, the number of scheduled visits did not deviate significantly from expected. CONCLUSION: Although scheduling procedures for visits continued as expected, our findings reveal that the COVID-19 pandemic interrupted patients' ability to access cancer care and attend scheduled appointments at the BCCOE. This interruption in care suggests delayed diagnosis and loss to follow-up, potentially resulting in a higher rate of negative health outcomes among cancer patients in Rwanda.

Food insecurity and level of depression among patients with chronic diseases, and associated factors during the COVID-19 lockdown: a cross-sectional study in rural Rwanda.

OBJECTIVES: We aimed to describe access to food and symptoms of depression among patients with chronic diseases or their caregivers, and assess associated factors during the COVID-19 lockdown in rural Rwanda. DESIGN: A cross-sectional study. SETTING AND PARTICIPANTS: A stratified random sampling technique was used to recruit 220 patients enrolled in the HIV, non-communicable diseases, mental health, paediatric development clinic and oncology programmes in three rural districts of Rwanda. OUTCOME MEASURES: Telephone-based interviews were conducted to collect data on the number of daily meals before and during the COVID-19, and depression was assessed using the Patient Health Questionnaire-9. We used logistic regression analysis to investigate factors associated with households reporting a reduction in daily meals and with the survey respondent reporting symptoms of depression. RESULTS: Of the participants, 19.1% reported a reduction in daily number of meals for either adults or children in their households during lockdown and 24.6% had depression. Reporting a reduction in daily meals was associated with the district of residence and estimated household's monthly income. Self-reported depression was significantly associated with negative experiences during lockdown, including reporting feeling depressed or fear (AOR 4.82; 95% CI 2.08 to 11.21), loneliness (AOR 4.33; 95% CI 1.32 to 14.13), reduction in daily meals (AOR 4.15; 95% CI 1.56 to 11.00) and lack of access to healthcare (OR 3.29; 95% CI 1.32 to 8.23). CONCLUSIONS: Our findings suggest that significant reduction in access to food affected rural Rwandans with chronic diseases during COVID-19 lockdown, and the lockdown effect varied by household's pre-pandemic level of vulnerability to food insecurity. Reduction in household meals, as well as other self-reported effects of the lockdown, were associated with worse psychological status of survey respondents. Economic and food support should be considered by governments and non-governmental organisations to protect those most vulnerable including patients with chronic diseases against the effects of pandemics and their associated containment measures.

Promotion of early and exclusive breastfeeding in neonatal care units in rural Rwanda: a pre- and post-intervention study.

BACKGROUND: Early initiation of breastfeeding after birth and exclusive breastfeeding for the first six months improves child survival, nutrition and health outcomes. However, only 42% of newborns worldwide are breastfed within the first hour of life. Small and sick newborns are at greater risk of not receiving breastmilk and often require additional support for feeding. This study compares breastfeeding practices in Rwandan neonatal care units (NCUs) before and after the implementation of a package of interventions aimed to improve breastfeeding. METHODS: This pre-post intervention study was conducted at two district hospital NCUs in rural Rwanda from October-December 2017 (pre-intervention) and September 2018-March 2019 (post-intervention). Only newborns admitted before their second day of life (DOL) were included. Data were extracted from patient charts for clinical and demographic characteristics, feeding, and patient outcomes. Exclusive breastfeeding at discharge was based on last recorded infant feeding on the day of discharge. Logistic regression analysis was used to evaluate factors associated with exclusive breastfeeding at discharge. RESULTS: Pre-intervention, 255 newborns were admitted in the NCUs and 793 were admitted in post-intervention. Exclusive breastfeeding on the day of birth (DOL0) increased from 5.4% (12/255) to 35.9% (249/793). At discharge, exclusive breastfeeding increased from 69.6% (149/214) to 87.0% (618/710). The mortality rate decreased from 16.1% (41/255) to 10.5% (83/793). Factors associated with greater odds of exclusive breastfeeding at discharge included admission during the post-intervention period (aOR 4.91; 95% CI 1.99, 12.11), and admission for infection (aOR 2.99; 95% CI 1.13, 7.93). Home deliveries (aOR 0.15; 95% CI 0.05, 0.47), preterm delivery (aOR 0.36; 95% CI 0.15, 0.87) and delayed first breastmilk feed (aOR 0.04 for DOL3 vs. DOL0; 95% CI 0.01, 0.35) reduced odds of exclusive breastfeeding at discharge. CONCLUSIONS: Expansion and adoption of evidenced-based guidelines, using innovative approaches, aimed at the unique needs of small and sick newborns may help to improve earlier initiation of breastfeeding, decrease mortality, and improve exclusive breastfeeding on discharge from hospital among small and sick newborns. These interventions should be replicated in similar settings to determine their effectiveness.

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.

INTRODUCTION: Evidence-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 ANALYSIS: We 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 DISSEMINATION: This 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.

Evaluation of an mHealth tool to improve nutritional assessment among infants under 6 months in paediatric development clinics in rural Rwanda: Quasi-experimental study.

Infants born preterm, low birthweight or with other perinatal complications require frequent and accurate growth monitoring for optimal nutrition and growth. We implemented an mHealth tool to improve growth monitoring and nutritional status assessment of high risk infants. We conducted a pre-post quasi-experimental study with a concurrent control group among infants enrolled in paediatric development clinics in two rural Rwandan districts. During the pre-intervention period (August 2017-January 2018), all clinics used standard paper-based World Health Organization (WHO) growth charts. During the intervention period (August 2018-January 2019), Kirehe district adopted an mHealth tool for child growth monitoring and nutritional status assessment. Data on length/height; weight; length/height-for-age (L/HFA), weight-for-length/height (WFL/H) and weight-for-age (WFA) z-scores; and interval growth were tracked at each visit. We conducted a 'difference-in-difference' analysis to assess whether the mHealth tool was associated with greater improvements in completion and accuracy of nutritional assessments and nutritional status at 2 and 6 months of age. We observed 3529 visits. mHealth intervention clinics showed significantly greater improvements on completeness for corrected age (endline: 65% vs. 55%; p = 0.036), L/HFA (endline: 82% vs. 57%; p ≤ 0.001), WFA (endline: 93% vs. 67%; p ≤ 0.001) and WFL/H (endline: 90% vs. 59%; p ≤ 0.001) z-scores compared with control sites. Accuracy of growth monitoring did not improve. Prevalence of stunting, underweight and inadequate interval growth at 6-months corrected age decreased significantly more in the intervention clinics than in control clinics. Results suggest that integrating mHealth nutrition interventions is feasible and can improve child nutrition outcomes. Improved tool design may better promote accuracy.

Safety and effectiveness of a non-electric infant warmer for hypothermia in Rwanda: A cluster-randomized stepped-wedge trial.

BACKGROUND: Neonatal hypothermia is a common source of morbidity and mortality in low resource settings. We developed the Dream Warmer, a low cost, re-usable non-electric infant warmer to prevent and treat hypothermia. METHODS: We conducted a cluster-randomized stepped-wedge trial. The primary aim was to assess the effect on overall euthermia rates of introducing the warmer compared to standard of care in rural Rwandan hospitals. The secondary aims were to assess effects of warmer introduction on mortality, as well as the safety and feasibility of the warmer. Ten district hospitals participated in the study from November 19th 2019 to July 15th 2020. Patients were eligible to use the warmer if they were 1) hypothermic (temp < 36·5 °C) or 2) or at risk of hypothermia (weight < 2·5 kg or estimated post menstrual age < 35 weeks) when Kangaroo Mother Care was not available. An encounter was defined as the data from an individual infant on a single day. Trial of a Non Electric Infant Warmer for Prevention and Treatment of Hypothermia in Rwanda [NCT03890211]. FINDINGS: Over the study period, 3179 patients were enrolled across the ten neonatal wards, yielding 12,748 encounters; 464 unique infants used the warmer 892 times, 79% eligible due to hypothermia. Because of limited study nurse resources, the warmer was used in only 18% of eligible encounters. Despite this low rate of warmer use, the rate of euthermia rose from 51% (95% CI 50-52%) of encounters pre-intervention to 67% (66-68%) post-intervention; p < 0·0001. Among the encounters in which the warmer was used, only 11% (9-13%) remained hypothermic. While mortality rates pre- and post-intervention did not change, mortality rate among those who used the warmer was significantly lower than among those who did not (0·9% vs 2·8%, p = 0·01). Use of the warmer did not affect hyperthermia rates. There were no safety concerns or instances of incorrect warmer use. INTERPRETATION: Introduction of the warmer increased rates of euthermia with no associated safety concerns.

Barriers and coping mechanisms to accessing healthcare during the COVID-19 lockdown: a cross-sectional survey among patients with chronic diseases in rural Rwanda.

BACKGROUND: Large scale physical distancing measures and movement restrictions imposed to contain COVID-19, often referred to as 'lockdowns', abruptly and ubiquitously restricted access to routine healthcare services. This study describes reported barriers and coping mechanisms to accessing healthcare among chronic care patients during the nationwide COVID-19 lockdown in Rwanda. METHODS: This cross-sectional study was conducted among chronic care patients enrolled in pediatric development, HIV/AIDS, non-communicable diseases, mental health, and oncology programs at 3 rural Rwandan districts. Active patients with an appointment scheduled between March-June 2020 and a phone number recorded in the electronic medical record system were eligible. Data were collected by telephone interviews between 23rd April and 11th May 2020, with proxy reporting by caregivers for children and critically ill-patients. Fisher's exact tests were used to measure associations. Logistic regression analysis was also used to assess factors associated with reporting at least one barrier to accessing healthcare during the lockdown. RESULTS: Of 220 patient respondents, 44% reported at least one barrier to accessing healthcare. Barriers included lack of access to emergency care (n = 50; 22.7%), lack of access to medication (n = 44; 20.0%) and skipping clinical appointments (n = 37; 16.8%). Experiencing barriers was associated with the clinical program (p < 0.001), with oncology patients being highly affected (64.5%), and with increasing distance from home to the health facility (p = 0.031). In the adjusted logistic regression model, reporting at least one barrier to accessing healthcare was associated with the patient's clinical program and district of residence. Forty (18.2%) patients identified positive coping mechanisms to ensure continuation of care, such as walking long distances during suspension of public transport (n = 21; 9.6%), contacting clinicians via telephone for guidance or rescheduling appointments (n = 15; 6.8%), and delegating someone else for medication pick-up (n = 6; 2.7%). Of 124 patients who reported no barriers to accessing healthcare, 9% used positive coping mechanisms. CONCLUSION: A large proportion of chronic care patients experienced barriers to accessing healthcare during the COVID-19 lockdown. However, many patients also independently identified positive coping mechanisms to ensure continuation of care - strategies that could be formally adopted by healthcare systems in Rwanda and similar settings to mitigate effects of future lockdowns on patients.

Quality improvement strategies to improve inpatient management of small and sick newborns across All Babies Count supported hospitals in rural Rwanda.

BACKGROUND: Neonatal mortality contributes to nearly half of child deaths globally and the majority of these deaths are preventable. Poor quality of care is a major driver of neonatal mortality in low- and middle-income countries. The All Babies Count (ABC) intervention was designed to reduce neonatal mortality through provision of equipment and supplies, training, mentorship, and data-driven quality improvement (QI) with peer-to-peer learning through learning collaborative sessions (LCS). We aim to describe the ABC scale-up in seven rural district hospitals from 2017 to 2019 focusing on the QI strategies implemented in hospital neonatal care units (NCUs) and the resultant neonatal care outcomes. METHODS: A pre-post quasi experimental study was conducted in 7 rural hospitals in Rwanda in two phases. The baseline periods were April-June 2017 for Phase I and July-September 2017 for Phase II; with end-line data collected during the same periods in 2019. Data included facility audits of supplies and staffing, LCS surveys of QI skills, and reports of implemented QI change ideas. Data on NCU admissions and deaths were extracted from Health Management Information System (HMIS). Facility-reported change ideas were coded into common themes. Changes in post-post neonatal mortality were measured using Chi-squared tests. RESULTS: NCUs were run by a median of 1 nurse [interquartile range (IQR):1-2] at baseline and endline. Median NCU admissions increased from 121 [IQR: 77-155] to 137 [IQR: 79-184]. Availability of advanced equipment improved (syringe pumps: 57-100 %, vital sign monitors: 51-100 % and CPAP machine: 14-100 %). There were significant improvements in QI skills among NCU staff. All 7 NCUs (100 %) addressed non-adherence to protocol as a priority gap, 5 NCUs (86 %) also improved communication with families. NCU case fatality rate declined from 12.4 to 7.8 % (p = 0.001). CONCLUSIONS: The ABC package of interventions combining the provision of essential equipment to NCU, clinical training and strong mentorship, QI coaching, and the LCS approach for peer-to-peer learning was associated with significant neonatal mortality reduction and services utilization in the intervention hospitals.

Father involvement in the care of children born small and sick in Rwanda: Association with children's nutrition and development.

BACKGROUND: Little is known about father's involvement in the care of children born with perinatal risk factors. This study aimed to understand father's involvement in the care of children born preterm, low birth weight (LBW) and/or with hypoxic ischemic encephalopathy (HIE) in rural Rwanda and assess child and home environment factors associated with father involvement. METHODS: A cross-sectional study of children born preterm, LBW or with HIE who were discharged from Kirehe District Hospital neonatal unit from May 2015 to April 2016 and those enrolled in a neonatal unit follow-up programme from May 2016 to November 2017. Interviews were conducted when the children were ages 24-47 months in the child's home. Primary caregivers reported on father involvement in parenting, home environment, child disability, and child development outcomes. Children's nutritional status were directly measured. Only children whose fathers were living in the home were included in the sample. Bivariate analyses were conducted using Fisher's exact test and Wilcoxon Rank Sum test. RESULTS: A total of 236 children aged 24-47 months were included in this study, 66.4% were born preterm or LBW with a mean age of 33.3 months. 73.5% of children were at risk of disability and 77.7% had potential delay in overall child development. 15.5% of fathers reported engaging in four or more activities with their child in the last 3 days. Factors associated with father involvement included smaller household size (p = 0.004), mother engaged in decision-making (p = 0.027), being on-track in developmental milestones for problem solving (p = 0.042) and mother's involvement in learning activities (p = 0.043); the number of activities a father engaged in was significantly associated with the child's overall development (p = 0.032). CONCLUSION: We found that father involvement in activities to support learning was low amongst children born preterm/LBW and/or with HIE. Programme interventions should encourage fathers to engage with their children given the benefits for children's development.

Decentralized, primary-care delivered epilepsy services in Burera District, Rwanda: Service use, feasibility, and treatment.

BACKGROUND: Integrating epilepsy care into primary care settings could reduce the global burden of illness attributable to epilepsy. Since 2012, the Rwandan Ministry of Health and the international nonprofit Partners In Health have collaboratively used a multi-faceted implementation program- MESH MH-to integrate and scale-up care for epilepsy and mental disorders within rural primary care settings in Burera district, Rwanda. We here describe demographics, service use and treatment patterns for patients with epilepsy seeking care at MESH-MH supported primary care health centers. METHODS AND FINDINGS: This was a retrospective cohort study using routinely collected data from fifteen health centers in Burera district, from January 2015 to December 2016. 286 patients with epilepsy completed 3307 visits at MESH-MH participating health centers over a two year period (Jan 1st 2015 to Dec 31st 2016). Men were over twice as likely to be diagnosed with epilepsy than women (OR 2.38, CI [1.77-3.19]), and children under 10 were thirteen times as likely to be diagnosed with epilepsy as those 10 and older (OR 13.27, CI [7.18-24.51]). Carbamazepine monotherapy was prescribed most frequently (34% of patients). CONCLUSION: Task-sharing of epilepsy care to primary care via implementation programs such as MESH-MH has the potential to reduce the global burden of illness attributable to epilepsy.

Assessing factors associated with poor maternal mental health among mothers of children born small and sick at 24-47 months in rural Rwanda.

BACKGROUND: Global investments in neonatal survival have resulted in a growing number of children with morbidities surviving and requiring ongoing care. Little is known about the caregivers of these children in low- and middle-income countries, including maternal mental health which can further negatively impact child health and development outcomes. We aimed to assess the prevalence and factors associated with poor maternal mental health in mothers of children born preterm, low birthweight (LBW), and with hypoxic ischemic encephalopathy (HIE) at 24-47 months of age in rural Rwanda. METHODS: Cross-sectional study of children 24-47 months born preterm, LBW, or with HIE, and their mothers discharged from the Neonatal Care Unit (NCU) at Kirehe Hospital between May 2015-April 2016 or discharged and enrolled in a NCU follow-up program from May 2016-November 2017. Households were interviewed between October 2018 and June 2019. Mothers reported on their mental health and their child's development; children's anthropometrics were measured directly. Backwards stepwise procedures were used to assess factors associated with poor maternal mental health using logistic regression. RESULTS: Of 287 total children, 189 (65.9%) were born preterm/LBW and 34.1% had HIE and 213 (74.2%) screened positive for potential caregiver-reported disability. Half (n = 148, 51.6%) of mothers reported poor mental health. In the final model, poor maternal mental health was significantly associated with use of violent discipline (Odds Ratio [OR] 2.29, 95% Confidence Interval [CI] 1.17,4.45) and having a child with caregiver-reported disability (OR 2.96, 95% CI 1.55, 5.67). Greater household food security (OR 0.80, 95% CI 0.70-0.92) and being married (OR = 0.12, 95% CI 0.04-0.36) or living together as if married (OR = 0.13, 95% CI 0.05, 0.37) reduced the odds of poor mental health. CONCLUSIONS: Half of mothers of children born preterm, LBW and with HIE had poor mental health indicating a need for interventions to identify and address maternal mental health in this population. Mother's poor mental health was also associated with negative parenting practices. Specific interventions targeting mothers of children with disabilities, single mothers, and food insecure households could be additionally beneficial given their strong association with poor maternal mental health.

High Burden of Undernutrition among At-Risk Children in Neonatal Follow-Up Clinic in Rwanda.

Background: Sufficient knowledge of the disproportionate burden of undernutrition among vulnerable children is required for accelerating undernutrition reduction in low-income countries. Objectives: We aimed to assess the prevalence of stunting, underweight and wasting and associated factors among high-risk children born preterm, with low birth weight or other birth and neurodevelopmental injuries, who received nutritional support and clinical care follow-up in a Pediatric Development Clinic (PDC) in rural Rwanda. Methods: This cross-sectional study included all children from rural areas enrolled in PDC between April 2014-September 2017 aged 6-59 months at their last visit during this period. Anthropometric measurements, socioeconomic and clinical characteristics were extracted from an electronic medical records system. We used the World Health Organization child growth standards to classify stunting, underweight and wasting. Factors associated with undernutrition were identified using logistic regression analysis. Results: Of 641 children, 58.8% were stunted, 47.5% were underweight and 25.8% were wasted. Small for gestational age was associated with increased odds of stunting [OR 2.63; 95% CI 1.58-4.36] and underweight (OR 2.33; 95% CI 1.46-3.71), while history of feeding difficulties was significantly associated with wasting (OR: 3.36; 95% CI: 2.20-5.13) and underweight (OR: 2.68; 95% CI: 1.78-4.04). Later age at PDC enrollment was associated with increased odds of stunting (OR: 1.06; 95% CI: 1.01-1.11), underweight (OR: 1.09; 95% CI: 1.05-1.14) and wasting (OR: 1.07; 95% CI: 1.04-1.10). Conclusions: The prevalence of stunting, underweight and wasting are high in this at-risk population, highlighting the need for specific interventions to address undernutrition among children with similar characteristics. Early PDC enrollment of high-risk infants may reduce undernutrition risk.

Health management information system (HMIS) data verification: A case study in four districts in Rwanda.

INTRODUCTION: Reliable Health Management and Information System (HMIS) data can be used with minimal cost to identify areas for improvement and to measure impact of healthcare delivery. However, variable HMIS data quality in low- and middle-income countries limits its value in monitoring, evaluation and research. We aimed to review the quality of Rwandan HMIS data for maternal and newborn health (MNH) based on consistency of HMIS reports with facility source documents. METHODS: We conducted a cross-sectional study in 76 health facilities (HFs) in four Rwandan districts. For 14 MNH data elements, we compared HMIS data to facility register data recounted by study staff for a three-month period in 2017. A HF was excluded from a specific comparison if the service was not offered, source documents were unavailable or at least one HMIS report was missing for the study period. World Health Organization guidelines on HMIS data verification were used: a verification factor (VF) was defined as the ratio of register over HMIS data. A VF<0.90 or VF>1.10 indicated over- and under-reporting in HMIS, respectively. RESULTS: High proportions of HFs achieved acceptable VFs for data on the number of deliveries (98.7%;75/76), antenatal care (ANC1) new registrants (95.7%;66/69), live births (94.7%;72/76), and newborns who received first postnatal care within 24 hours (81.5%;53/65). This was slightly lower for the number of women who received iron/folic acid (78.3%;47/60) and tested for syphilis in ANC1 (67.6%;45/68) and was the lowest for the number of women with ANC1 standard visit (25.0%;17/68) and fourth standard visit (ANC4) (17.4%;12/69). The majority of HFs over-reported on ANC4 (76.8%;53/69) and ANC1 (64.7%;44/68) standard visits. CONCLUSION: There was variable HMIS data quality by data element, with some indicators with high quality and also consistency in reporting trends across districts. Over-reporting was observed for ANC-related data requiring more complex calculations, i.e., knowledge of gestational age, scheduling to determine ANC standard visits, as well as quality indicators in ANC. Ongoing data quality assessments and training to address gaps could help improve HMIS data quality.

Nutritional evaluation and growth of infants in a Rwandan neonatal follow-up clinic.

Children born preterm, low birth weight (LBW) or with other perinatal risk factors are at high-risk of malnutrition. Regular growth monitoring and early intervention are essential to promote optimal feeding and growth; however, monitoring growth in preterm infants can be complex. This study evaluated growth monitoring of infants under 6 months enrolled in Paediatric Development Clinics (PDCs) in rural Rwanda. We reviewed electronic medical records (EMR) of infants enrolled in PDCs before age 2 months with their first visit between January 2015 and December 2016 and followed them until age 6 months. Nurse classification of anthropometric measures and nutritional status were extracted from the EMR. Interval growth and length-for-age, weight-for-length, and weight-for-age z-scores were calculated using World Health Organization anthropometry software as a 'gold standard' comparison to nurse classifications. Two hundred and ninety-four patients enrolled and had 2,033 visits during the study period. Referral reasons included prematurity/LBW (73.8%) and hypoxic ischemic encephalopathy (28.2%). Nurses assessed interval growth at 58.7% of visits, length-for-age at 66.4%, weight-for-length at 65.6% and weight-for-age at 66.4%. Nurses and gold standard assessment agreed on interval growth at 53.3% of visits and length-for-age at 63.7%, weight-for-length at 78.2% and weight-for-age at 66.3%. At 6 months, 46.5% were stunted, 19.9% were wasted and 44.2% were underweight. There were significant challenges to optimizing growth and growth monitoring among high-risk infants served by PDCs, including incomplete and inaccurate assessments. Developing tools for clinician decision support in assessing growth and providing specialized nutritional counselling are essential to supporting optimal outcomes in this population.

Performance of a Nonelectric Infant Warmer in Rwandan Health Centers.

Background. Neonatal hypothermia remains a challenge in resource-limited settings. Methods. We conducted a prospective mixed-methods cohort study in rural Rwandan health centers to assess the performance of an infant warmer we designed for low-resource settings. All hypothermic infants were eligible for enrollment. Outcomes. Safety: incidence of adverse reactions. Effectiveness: attainment of euthermia, rate of temperature rise. Feasibility: correct use of warmer, signs of wear. Interviews of caregivers and nurses. Findings. Of 102 encounters, there were no adverse reactions. Of 80 encounters for hypothermia when infants on warmer for ≥1 hour, 79 achieved euthermia; 73 in ≤2 hours. Of the 80 encounters, 64 had temperature rise ≥0.5°C/h. Of the 102 encounters, there were no instances of the warmer being prepared, used, or cleaned incorrectly. Five out of the 12 warmers exhibited wear. Interview participants were predominantly positive; some found time for readiness of warmer challenging. Interpretation. The warmer performed well. It is appropriate to study in larger scale.

Risk factors for stunting among children under five years: a cross-sectional population-based study in Rwanda using the 2015 Demographic and Health Survey.

BACKGROUND: Child growth stunting remains a challenge in sub-Saharan Africa, where 34% of children under 5 years are stunted, and causing detrimental impact at individual and societal levels. Identifying risk factors to stunting is key to developing proper interventions. This study aimed at identifying risk factors of stunting in Rwanda. METHODS: We used data from the Rwanda Demographic and Health Survey (DHS) 2014-2015. Association between children's characteristics and stunting was assessed using logistic regression analysis. RESULTS: A total of 3594 under 5 years were included; where 51% of them were boys. The prevalence of stunting was 38% (95% CI: 35.92-39.52) for all children. In adjusted analysis, the following factors were significant: boys (OR 1.51; 95% CI 1.25-1.82), children ages 6-23 months (OR 4.91; 95% CI 3.16-7.62) and children ages 24-59 months (OR 6.34; 95% CI 4.07-9.89) compared to ages 0-6 months, low birth weight (OR 2.12; 95% CI 1.39-3.23), low maternal height (OR 3.27; 95% CI 1.89-5.64), primary education for mothers (OR 1.71; 95% CI 1.25-2.34), illiterate mothers (OR 2.00; 95% CI 1.37-2.92), history of not taking deworming medicine during pregnancy (OR 1.29; 95%CI 1.09-1.53), poorest households (OR 1.45; 95% CI 1.12-1.86; and OR 1.82; 95%CI 1.45-2.29 respectively). CONCLUSION: Family-level factors are major drivers of children's growth stunting in Rwanda. Interventions to improve the nutrition of pregnant and lactating women so as to prevent low birth weight babies, reduce poverty, promote girls' education and intervene early in cases of malnutrition are needed.

Using Electronic Medical Record Data to Improve HIV Patient Monitoring, Clinical Decision-Making, and Quality Improvement: Lessons from Rwanda.

In developing countries, clinical guidelines and patient follow-up are primarily paper-based. We describe the use of Electronic Medical Record data for evidence-based clinical decisions and improved HIV patients monitoring in rural Rwanda.