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Background In Rwanda, cardiovascular diseases (CVDs) ranked second of the most common cause of death in 2016. CVD risk score tools have been recommended to identify people at high risk for management. Objective To assess the comparability of body mass index (BMI)-based and lipid-based CVD risk scores in Rwandan population. Methods Secondary analysis was conducted on 4185 study participants extracted from the dataset of Rwanda 2012-2013 non-communicable diseases risk factors survey. Individual CVD risk scores were calculated using both BMI-based and lipid-based algorithms, one at a time. Spearman rank’s coefficient and Cohen’s Kappa coefficient were used to compare the two tools. Results About 63.5% of participants were women. There was a significant positive correlation between BMI-based algorithm and lipid-based algorithm vis-à-vis a 10-year CVD risk prediction (Spearman rank correlation coefficients > 0.90, p

Objective The objective of this scoping review is to map the published literature that describes the distribution and organization of chronic care service delivery models for people living with type 1 diabetes (PLWT1D) in low- and lower-middle-income countries (LLMICs). Introduction Type 1 diabetes is an autoimmune condition commonly diagnosed in childhood and early adolescence; it cannot be prevented and is deadly without daily insulin injections. Among PLWT1D, the islet cells in the pancreas produce insufficient amounts of the glucose-regulating hormone, insulin, resulting in the need for chronic insulin replacement therapy. Epidemiological information regarding type 1 diabetes (T1D) is limited in LLMICs. Improving survival for PLWT1D in LLMICs requires early diagnosis and greater access to high quality chronic care service delivery models for T1D. The identification and reporting of service delivery model typologies for PLWT1D will allow for more specific research questions regarding individual typologies in subsequent systematic reviews. Inclusion criteria The review will consider all types of literature on the organization and distribution of chronic care services for the management of PLWT1D provided out of facilities in LLMICs, published from 2000 to the present. Methods The JBI methodology for conducting scoping reviews will be employed. The search will be implemented across PubMed, Embase, and Web of Science. Full texts of the publications selected will be reviewed and data will be extracted through a charting table. The findings will be charted to summarize the results.

BackgroundCollaborative approaches to generating knowledge between knowledge users (KUs) and researchers as a means of enhancing evidence-informed decision making have been gaining ground over the last few years. The principal study targeted rural and urban communities within the catchment areas of Cyanika health centre (Burera district, Northern Province) and Kacyiru health centre (Gasabo district, in City of Kigali), respectively to understand perceptions and preferences of communication with respect to cardiovascular disease (CVD) risk in Rwanda. This paper describes the integration of citizen science within an integrated knowledge translation (IKT) approach for this study.MethodsThe citizen science approach included deliberate, selective and targeted engagement of KUs at various steps throughout the study. It incorporated national and district levels stakeholders, primary health care stakeholders, local community leaders and influencers, and local community members (selected and trained to be termed citizen scientists) in the process of implementation. Data for this paper included minutes, reports and notes from meetings and workshops which were perused to report the immediate outcomes and challenges of citizen science within an IKT approach for a study such as described for Rwanda.ResultsAs a result of a deliberate IKT strategy, key national stakeholders attended and contributed to all phases of citizen science implementation. Project-based and relationship-based immediate outcomes were documented. In line with local community health issues reported by the citizen scientists, the local community stakeholders pledged home grown solutions. These included enhancement of compliance to implement the “kitchen garden per household” policy, teaching local residents on preparation of healthy diet from locally available food items, organizing collective physical activity, fighting against locally made substandard beverages and teaching local residents on CVD (risk factors). As an indicator of the probable uptake of research evidence, district officials appreciated citizen scientists’ work and decided to consider presented results in their next fiscal year action plan.ConclusionCitizen science proved to be an important strategy for research co-production in Rwanda. While this strategy falls within the remit of a larger IKT approach it focuses on the role and ownership of research by local community residents. This study demonstrated that to improve the relevance and impact of research in local community a deliberate IKT approach that incorporates citizen science can be invaluable.

ObjectivesTo assess the effects of integrated models of care for people with multimorbidity including at least diabetes or hypertension in low-income and middle-income countries (LMICs) on health and process outcomes.DesignSystematic review.Data sourcesWe searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Africa-Wide, CINAHL and Web of Science up to 12 December 2019.Eligibility criteriaWe included randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies and interrupted time series (ITS) studies of people with diabetes and/or hypertension plus any other disease, in LMICs; assessing the effects of integrated care.Data extraction and synthesisTwo authors independently screened retrieved records; extracted data and assessed risk of bias. We conducted meta-analysis where possible and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation.ResultsOf 7568 records, we included five studies—two ITS studies and three cluster RCTs. Studies were conducted in South Africa (n=3), Uganda/Kenya (n=1) and India (n=1). Integrated models of care compared with usual care may make little or no difference to mortality (very low certainty), the number of people achieving blood pressure (BP) or diabetes control (very low certainty) and access to care (very low certainty); may increase the number of people who achieve both HIV and BP/diabetes control (very low certainty); and may have a very small effect on achieving HIV control (very low certainty). Interventions to promote integrated delivery of care compared with usual care may make little or no difference to mortality (very low certainty), depression (very low certainty) and quality of life (very low certainty); and may have little or no effect on glycated haemoglobin (low certainty), systolic BP (low certainty) and total cholesterol levels (low certainty).ConclusionsCurrent evidence on the effects of integrated care on health outcomes is very uncertain. Programmes and policies on integrated care must consider context-specific factors related to health systems and populations.PROSPERO registration numberCRD42018099314.

Aim The primary objective of this document is to develop practice-based expert group opinion on certain important but less discussed endocrine and metabolic effects of modern sulfonylureas (SUs) and their usage in the management of diabetes mellitus (DM). Background Modern SUs may be considered a panacea in DM care with their beneficial extra-pancreatic, pleiotropic, and cardiovascular effects. Safe glycemic control with SUs could be achieved with appropriate patient selection, drug and dosage selection, and patient empowerment. Additionally, sulfonylureas also exhibit certain endocrine and metabolic effects, which could be considered beneficial in the management of DM. In this regard, a group of international clinical experts discussed the less known beneficial aspects of SUs and safe and smart prescription of modern SUs in DM care. Results The concept of glucocrinology or the relationship of glycemia with the endocrine system was emphasized during the meetings. Clinical experts arrived at a consensus for the usage of modern SUs in the presence of other endocrine dysfunction and the impact of these drugs on endocrine health. The beneficial pleiotropic and cardiovascular effects of modern SUs were also discussed. The key discussion points were considered to develop clinical expert opinions for the use of modern SUs in persons with DM. Clinical expert opinions were developed for indications, pleiotropic benefits, cardiovascular outcomes, adherence, and safe use of modern SUs. Conclusions Appropriate clinical judgement coupled with a patient-centered approach is crucial to achieve the best outcome in persons with DM. Owing to their safety, efficacy, extra-pancreatic benefits including effects on endocrine and metabolic aspects, and low cost of therapy, modern SUs could be considered as drugs/agents of choice for the treatment of diabetes. Funding Sanofi India. Electronic Supplementary Material The online version of this article (10.1007/s13300-019-0651-1) contains supplementary material, which is available to authorized users.

BackgroundIn sub-Saharan Africa (SSA), which experiences a disproportionately high cardiovascular disease (CVD) burden, population-based screening and prevention measures are hampered by low levels of knowledge about CVD and associated risk factors, and inaccurate perceptions of severity of risk.MethodsThis protocol describes the planned processes for implementing community-driven participatory research, using a citizen science method to explore CVD risk perceptions and to develop community-specific advocacy and prevention strategies in the rural and urban SSA settings. Multi-disciplinary research teams in four selected African countries will engage with and train community members living in rural and urban communities as citizen scientists to facilitate conceptualization, co-designing of research, data gathering, and co-creation of knowledge that can lead to a shared agenda to support collaborative participation in community-engaged science. The emphasis is on robust community engagement, using mobile technology to support data gathering, participatory learning, and co-creation of knowledge and disease prevention advocacy.DiscussionContextual processes applied and lessons learned in specific settings will support redefining or disassembling boundaries in participatory science to foster effective implementation of sustainable prevention intervention programmes in Low- and Middle-income countries.

Evidence to show whether lifestyle intervention programs are beneficial for patients with diabetes in resource-limited countries is lacking. The present study assessed the additional efficacy of a structured lifestyle education program, as compared to the current standard of diabetic care in Rwanda.251 consecutive adult patients attending a tertiary diabetic care practice were randomly assigned to either an intervention group (standard of care plus monthly lifestyle group education sessions of 45min duration) or to a control group. The primary outcome was between-groups difference in glycated hemoglobin (HbA1c) observed after 12-months follow up. Outcome measures in the intervention and control groups were compared using the ANCOVA test with a two-sided significance of 5%.Of the 251 subjects recruited, 223 were included in the analysis; of whom 115 were assigned to the intervention group, and 108 to the control group. After 12-months, the median HbA1c levels reduced by 1.70 (95% CI: -2.09 to -1.31; p0.001) in the intervention group; and by 0.52 (95% CI: -0.95 to -0.10; p=0.01) in the control group. The difference in HbA1c reduction between the intervention and control groups was statistically significant (p0.001) after adjustment for subjects' age, sex, education level, BMI, diabetes duration and diabetic medications.This study demonstrated that a structured lifestyle group education program for people with diabetes is an attractive option in a resource-limited setting, as it showed significant benefits in improved glycemic control over a 12-month period.ClinicalTrials.gov: NCT02032108.

Background Existing prevention and treatment strategies target the classic types of diabetes yet this approach might not always be appropriate in some settings where atypical phenotypes exist. This study aims to assess the socio-demographic and clinical characteristics of people with diabetes in rural Rwanda compared to those of urban dwellers. Methods A cross-sectional, clinic-based study was conducted in which individuals with diabetes mellitus were consecutively recruited from April 2015 to April 2016. Demographic and clinical data were collected from patient interviews, medical files and physical examinations. Chi-square tests and T-tests were used to compare proportions and means between rural and urban residents. Results A total of 472 participants were recruited (mean age 40.2 ± 19.1 years), including 295 women and 315 rural residents. Compared to urban residents, rural residents had lower levels of education, were more likely to be employed in low-income work and to have limited access to running water and electricity. Diabetes was diagnosed at a younger age in rural residents (mean ± SD 32 ± 18 vs 41 ± 17 years; p p p p Conclusions Characteristics of people with diabetes in rural Rwanda appear to differ from those of individuals with diabetes in urban settings, suggesting that sub-types of diabetes exist in Rwanda. Generic guidelines for diabetes prevention and management may not be appropriate in different populations.

Background: Atypical presentations of diabetes mellitus (DM) have been reported in non-European ethnic populations under various names. It is unclear whether those names are used for the same or different clinical phenotypes. Unclear terminology may lead to inappropriate treatment and an underestimation of the burden caused by atypical diabetes phenotypes overlapping with classic types of diabetes. This review aimed to describe the terms used for atypical forms of diabetes and to investigate whether the terms are used for similar or different phenotypes.Methods: PubMed and Scopus were searched for relevant publications in French or English available before 15 September 2015 using the terms: "Atypical diabetes", "Malnutrition Related Diabetes Mellitus (MRDM)", "Fibro-calculus pancreatic diabetes (FCPD)", Protein deficient Pancreatic Diabetes (PDPD)", "African diabetes", "Ketosis prone-type 2 diabetes", "tropical diabetes", "Flatbush diabetes", "J-type diabetes". Titles, abstracts screening and quality assessment were performed by two independent authors. Observational studies addressing atypical diabetes in humans aged 14 years and above were included. One author extracted data from selected articles.Results: 22 articles among 350 identified articles were retained for data extraction. Two atypical diabetes phenotypes were identified, each of them with a variety of names but similar definitions. One phenotype occurred in very thin people less than 30 years of age, typically from poor socio-economic backgrounds and requires insulin for life. It differs from type 1 diabetes in the tolerance of high blood glucose without ketosis in the absence of exogenous insulin. The second phenotype resembles type1 diabetes as it presents with ketosis at onset but responds well, as type2 diabetes, to oral hypoglycemic drugs after initial stabilization with insulin. It occurs in individuals who are usually over 30 years of age, with normal or overweight and absence of auto antibodies mainly found in type 1 diabetes.Conclusion: The scarce existing literature used various terms for similar diabetes phenotypes. Agreement on nomenclature for the various forms of diabetes using the above reported characteristics are needed in populations where atypical forms of diabetes exist as well as better characterization of phenotypes and genotypes to inform evidence based treatment.

BackgroundIntegrated clinical strategies to address non-communicable disease (NCDs) in sub-Saharan Africa have largely been directed to prevention and treatment of common conditions at primary health centres. This study examines the cost of organising integrated nurse-driven, physician-supervised chronic care for more severe NCDs at an outpatient specialty clinic associated with a district hospital in rural Rwanda. Conditions addressed included type 1 and type 2 diabetes, chronic respiratory disease, heart failure and rheumatic heart disease.MethodsA retrospective costing analysis was conducted from the facility perspective using data from administrative sources and the electronic medical record systems of Butaro District Hospital in rural Rwanda. We determined initial start-up and annual operating financial cost of the Butaro district advanced NCD clinic for the fiscal year 2013–2014. Per-patient annual cost by disease category was determined.ResultsA total of US$47 976 in fixed start-up costs was necessary to establish a new advanced NCD clinic serving a population of approximately 300 000 people (US$0.16 per capita). The additional annual operating cost for this clinic was US$68 975 (US$0.23 per capita) to manage a 632-patient cohort and provide training, supervision and mentorship to primary health centres. Labour comprised 54% of total cost, followed by medications at 17%. Diabetes mellitus had the highest annual cost per patient (US$151), followed by heart failure (US$104), driven primarily by medication therapy and laboratory testing.ConclusionsThis is the first study to evaluate the costs of integrated, decentralised chronic care for some severe NCDs in rural sub-Saharan Africa. The findings show that these services may be affordable to governments even in the most constrained health systems.

Background: Integrated clinical strategies to address noncommunicable disease (NCDs) in sub-Saharan Africa have largely been directed to prevention of behavioral risk factors and treatment of common conditions at primary health centers. This study examines the cost of decentralizing integrated nurse-driven, physician-supervised chronic care for more severe NCDs to outpatient specialty clinics associated with district hospitals in rural Rwanda. Conditions addressed included type 1 and type 2 diabetes, chronic respiratory disease, and heart failure. Methods: A retrospective costing analysis was conducted from the facility perspective using data from administrative sources and the electronic medical record systems of Butaro district hospital in rural Rwanda. We determined initial startup and annual operating cost of the Butaro district advanced NCD clinic for the fiscal year 2013-2014. Per-patient annual cost by disease category were determined. Findings: A total of $51,444 U.S. dollars (USD) in startup costs was necessary to establish a new advanced NCD clinic serving a population of approximately 300,000 people ($0.2 per capita). The annual operating cost for this clinic was $68,040 USD ($0.3 per capita) to manage a 632-patient cohort and provide training, supervision, and mentorship to primary health centers. Labor comprised 53% of total cost, followed by medications at 17%. Diabetes mellitus had the highest annual cost per patient ($151 USD), followed by heart failure ($104 USD), driven primarily by medication therapy and laboratory testing. Interpretation: This is the first study to evaluate the costs of integrated, decentralized chronic care for some severe NCDs in rural sub-Saharan Africa. The findings show that these services may be affordable to governments even in the most constrained health systems. Funding Statement: The authors declare: "None." Declaration of Interests: The authors declare: "None." Ethics Approval Statement: Ethical approval was obtained by the Rwanda National Ethics Committee and Institutional Review Board of Brigham and Women’s Hospital.

IntroductionMost patients diagnosed with diabetes in sub-Saharan Africa (SSA) present with poorly controlled blood glucose, which is associated with increased risks of complications and greater financial burden on both the patients and health systems. Insulin-dependent patients with diabetes in SSA lack appropriate home-based monitoring technology to inform themselves and clinicians of the daily fluctuations in blood glucose. Without sufficient home-based data, insulin adjustments are not data driven and adopting individual behavioural change for glucose control in SSA does not have a systematic path towards improvement.Methods and analysisThis study explores the feasibility and impact of implementing self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes in rural Rwandan districts. This is an open randomised controlled trial comprising of two arms: (1) Intervention group—participants will receive a glucose metre, blood test strips, logbook, waste management box and training on how to conduct SMBG in additional to usual care and (2) Control group—participants will receive usual care, comprising of clinical consultations and routine monthly follow-up. We will conduct qualitative interviews at enrolment and at the end of the study to assess knowledge of diabetes. At the end of the study period, we will interview clinicians and participants to assess the perceived usefulness, facilitators and barriers of SMBG. The primary outcomes are change in haemoglobin A1c, fidelity to SMBG protocol by patients, appropriateness and adverse effects resulting from SMBG. Secondary outcomes include reliability and acceptability of SMBG and change in the quality of life of the participants.Ethics and disseminationThis study has been approved by the Rwanda National Ethics Committee (Kigali, Rwanda No.102/RNEC/2018). We will disseminate the findings of this study through presentations within our study settings, scientific conferences and publication in a peer-reviewed journal.Trial registration numberPACTR201905538846394; pre-results.

Introduction. The prevalence of diabetes mellitus is rapidly rising in SSA. Interventions are needed to support the decentralization of services to improve and expand access to care. We describe a clinical mentorship and quality improvement program that connected nurse mentors with nurse mentees to support the decentralization of type 2 diabetes care in rural Rwanda. Methods. This is a descriptive study. Routinely collected data from patients with type 2 diabetes cared for at rural health center NCD clinics between January 1, 2013 and December 31, 2015, were extracted from EMR system. Data collected as part of the clinical mentorship program were extracted from an electronic database. Summary statistics are reported. Results. The patient population reflects the rural settings, with low rates of traditional NCD risk factors: 5.6% of patients were current smokers, 11.0% were current consumers of alcohol, and 11.9% were obese. Of 263 observed nurse mentee-patient encounters, mentor and mentee agreed on diagnosis 94.4% of the time. Similarly, agreement levels were high for medication, laboratory exam, and follow-up plans, at 86.3%, 87.1%, and 92.4%, respectively. Conclusion. Nurses that receive mentorship can adhere to a type 2 diabetes treatment protocol in rural Rwanda primary health care settings.

Background Low-income countries face a dual burden of endemic chronic non-communicable diseases (NCDs) and limited resources to implement control strategies. Access to services is even more challenging for patients in countries like Rwanda, where more than 80% of the population reside in rural areas, and there is fewer than one health care provider per 1000 people. Many studies of NCD care delivery models in low-income countries are limited to simple conditions or focus on a single disease. Since 2007, Partners in Health/Inshuti Mu Buzima (PIH/IMB) has been supporting delivery of NCD services at Ministry of Health facilities. Here we describe the model implemented and baseline characteristics of patients served. Methods Comprehensive NCD services are provided by nurses to patients with an array of complex conditions including heart failure, chronic cancer pain, hypertension, diabetes, and chronic respiratory diseases on disease-specific clinic days. Nurses receive training and longitudinal mentorship from specialist physicians and use reference-standardised diagnosis and treatment protocols. Point-of-care diagnostics are used, such as haemoglobin A1c for patients with diabetes and coagulation testing for patients on warfarin after cardiac valve surgery. Nurses are also able to perform simplified echocardiography to inform initial management of heart failure. Group education sessions and socioeconomic supports are also offered to patients. District hospital nurses serve as mentors for health centre nurses. Community health workers provide support to high-risk patients. Clinical information is documented in structured forms that are compiled in individual patient charts, and entered in an electronic medical records system. These programmes are integrated within MOH facilities and most clinicians are MOH employees. Findings At Sept 30, 2014, three district hospitals and seven health centres have implemented PIH/IMB-supported NCD programmes. 3367 patients have been enrolled, of whom 67% are female (mean age 48·1 years [SD 19·8]). Disease categories, in descending order of predominance, are: hypertension (30%), chronic respiratory disease (26%), heart failure (26%), and diabetes (16%). A small proportion (2·5%) of patients are HIV positive and 1% have more than one NCD diagnosis. More than 80% (3014) of patients live in rural districts, and of these more than 60% of those with documented occupation (683 out of total documented 1112) are subsistence farmers. Interpretation An integrated, nurse-led NCD care model has been effectively implemented in Rwanda, providing comprehensive longitudinal care embedded within the public health system in a rural resource-constrained setting. That so many patients have been treated highlights the NCD needs in rural poor populations. Positive outcomes have been described previously for heart failure, and outcomes assessments for diabetes, post-cardiac surgery, and hypertension are underway. The experience from these facilities has contributed to ongoing scale-up of district level NCD services throughout Rwanda. Funding Ministry of Health, Rwanda, Partners in Health /Inshuti Mu Buzima (PIH / IMB), Medtronic Foundation.