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Objective: Public health interventions are often implemented at large scale, and their evaluation seems to be difficult because they are usually multiple and their pathways to effect are complex and subject to modification by contextual factors. We assessed whether controlling for rainfall-related variables altered estimates of the efficacy of a health programme in rural Rwanda and have a quantifiable effect on an intervention evaluation outcomes.Methods: We conducted a retrospective quasi-experimental study using previously collected cross-sectional data from the 2005 and 2010 Rwanda Demographic and Health Surveys (DHS), 2010 DHS oversampled data, monthly rainfall data collected from meteorological stations over the same period, and modelled output of long-term rainfall averages, soil moisture, and rain water run-off. Difference-in-difference models were used.Results: Rainfall factors confounded the PIH intervention impact evaluation. When we adjusted our estimates of programme effect by controlling for a variety of rainfall variables, several effectiveness estimates changed by 10% or more. The analyses that did not adjust for rainfall-related variables underestimated the intervention effect on the prevalence of ARI by 14.3%, fever by 52.4% and stunting by 10.2%. Conversely, the unadjusted analysis overestimated the intervention's effect on diarrhoea by 56.5% and wasting by 80%.Conclusion: Rainfall-related patterns have a quantifiable effect on programme evaluation results and highlighted the importance and complexity of controlling for contextual factors in quasi-experimental design evaluations. [ABSTRACT FROM AUTHOR]

Background: HIV infection is linked to decreased fertility and fertility desires in sub-Saharan Africa due to biological and social factors. We investigate the relationship between HIV infection and fertility or fertility desires in the context of universal access to antiretroviral therapy introduced in 2004 in Rwanda. Methods: We used data from 3532 and 4527 women aged 20-49 from the 2005 and 2010 Rwandan Demographic and Health Surveys (RDHS), respectively. The RDHSs included blood-tests for HIV, as well as detailed interviews about fertility, demographic and behavioral outcomes. In both years, multiple logistic regression was used to assess the association between HIV and fertility outcomes within three age categories (20-29, 30-39 and 40-49 years), controlling for confounders and compensating for the complex survey design. Results: In 2010, we did not find a difference in the odds of pregnancy in the last 5 years between HIV-seropositive and HIV-seronegative women after controlling for potential biological and social confounders. Controlling for the same confounders, we found that HIV-seropositive women under age 40 were less likely to desire more children compared to HIV-seronegative women (20-29 years adjusted odds ratio (AOR) = 0.31, 95% CI: 0.17, 0.58; 30-39 years AOR = 0.24, 95% CI: 0.14, 0.43), but no difference was found among women aged 40 or older. No associations between HIV and fertility or fertility desire were found in 2005. Conclusions: These findings suggest no difference in births or current pregnancy among HIV-seropositive and HIV-seronegative women. That in 2010 HIV-seropositive women in their earlier childbearing years desired fewer children than HIV-seronegative women could suggest more women with HIV survived; and stigma, fear of transmitting HIV, or realism about living with HIV and prematurely dying from HIV may affect their desire to have children. These findings emphasize the importance of delivering appropriate information about pregnancy and childbearing to HIV-infected women, enabling women living with HIV to make informed decisions about their reproductive life. [ABSTRACT FROM AUTHOR]

Background: Postnatal care (PNC) in the first seven days is important for preventing morbidity and mortality in mothers and new-borns. Sub-Saharan African countries, which account for 62 % of maternal deaths globally, have made major efforts to increase PNC utilisation, but utilisation rates remains low even in countries like Rwanda where PNC services are universally available for free. This study identifies key socio-economic and demographic factors associated with PNC utilisation in Rwanda to inform improved PNC policies and programs.Methods: This is a secondary analysis of the 2010 Demographic and Health Survey, a national multi-stage, cross-sectional survey. In bivariate analysis, we used chi-square tests to identify demographic and socio-economic factors associated with PNC utilisation at α = 0.1. Pearson's R statistic (r > 0.5) was used to identify collinear covariates, and to choose which covariate was more strongly associated with PNC utilisation. Manual backward stepwise logistic regression was performed on the remaining covariates to identify key factors associated with PNC utilisation at α = 0.05. All analyses were performed in Stata 13 adjusting for sampling weights, clustering, and stratification.Results: Of the 2,748 women with a live birth in the last two years who answered question about PNC utilisation, 353 (12.8 %) returned for PNC services within seven days after birth. Three factors were positively associated with PNC use: delivering at a health facility (OR: 2.97; 95 % CI: 2.28-3.87), being married but not involved with one's own health care decision-making (OR: 1.69; 95 % CI: 1.17, 2.44) compared to being married and involved; and being in the second (OR: 1.46; 95 % CI: 1.01-2.09) or richest wealth quintile (OR: 2.04; 95 % CI: 1.27-3.29) compared to the poorest. Mother's older age at delivery was negatively associated with PNC use (20-29 - OR: 0.51, 95 % CI: 0.29-0.87; 30-39 - OR: 0.47, 95 % CI: 0.27-0.83; 40-49 - OR: 0.32, 95 % CI: 0.16-0.64).Conclusions: Low PNC utilisation in Rwanda appears to be a universal problem though older age and poverty are further barriers to PNC utilisation. A recent change in the provision of BCG vaccination to new-borns might promote widespread PNC utilisation. We further recommend targeted campaigns to older mothers and poorest mothers, focusing on perceptions of health system quality, cultural beliefs, and pregnancy risks. [ABSTRACT FROM AUTHOR]

Background: Disability affects approximately 15% of the world’s population, and has adverse socio-economic effects, especially for the poor. In Rwanda, there are a number of government compensation programs that support the poor, but not specifically persons with disability (PWDs). This study investigates the relationship between poverty and government compensation on disability among working-age adults in Rwanda. Methods: This was a secondary analysis of 35,114 adults aged 16 to 65 interviewed in the 2010/2011 Rwanda Household Wealth and Living Conditions survey, a national cross-sectional two-stage cluster survey, stratified by district. This study estimated self-reported major disability, and used chi-square tests to estimate associations (p<0.1) with income, government compensation, occupation type, participation in public works programs, and household poverty status. Non-collinear economic variables were included in a multivariate logistic regression, along with socio-demographic confounders that modified the relationship between any economic predictor and the outcome by 10% or more. All analyses adjusted for sampling weights, stratification, and clustering of households. Results: Over 4% of working-age adults reported having a major disability and the most prevalent types of disability in order were physical, mental, and then sensory disability. In bivariate analysis, annual income, occupation type, and poverty status were associated with major disability (p<0.001 for all). Occupation type was dropped because it was collinear with income. Age, education, and urban/rural residence were confounders. In the multivariate analysis, adults in all income groups had about half the odds of disability compared to adults with no income (Rwf1-120,000 OR = 0.57; Rwf120,000–250,000 OR = 0.61; Rwf250,000–1,000,000 OR = 0.59; Rwf1,000,000+ OR = 0.66; p<0.05 for all), and non-poor adults had 0.77 the odds of disability compared to poor adults (p = 0.001). Conclusion: Given that personal income rather than government programming is associated with disability in Rwanda, we recommend deliberately targeted services to those with disability via cash transfers, placements in disability-appropriate employment, and micro-savings programs. [ABSTRACT FROM AUTHOR]

Background: Because of the shortage of health professionals, particularly in specialty areas, Rwanda initiated the Human Resources for Health (HRH) Program. In this program, faculty from United States teaching institutions (USF) "twin" with Rwandan Faculty (RF) to transfer skills. This paper assesses the twinning model, exploring USF and RF goal setting, satisfaction and perceptions of the effectiveness of skill transfer within the twinning model.Methods: All USF and RF in the HRH Program from August 2012-May 2014 were invited to participate. An 85-item questionnaire for USF and 71-item questionnaire for RF were administered via Survey Monkey in April and May 2014. Associations among primary outcomes were assessed and factors related with outcomes were modeled using logistic regression.Results: Most RF and USF reported setting goals with their twin (89% and 71%, respectively). Half of RF (52%) reported effective skill transfer compared to 10% of USF. Only 38% of RF and 28% of USF reported being very satisfied with the twinning model. There was significant overlap in the three operational outcomes. For RF, the following factors were associated with outcomes: for effective skill transfer, being able to communicate in a common language and working at a nursing site outside of Kigali; and for satisfaction, 7+ years of professional experience and being part of a male RF-female USF twin pair. For USF, the following factors were associated with outcomes: for setting goals, prior teaching experience; and for satisfaction, experience in low resource settings for one month or less and feeling that HRH promotes a culture of respect.Conclusions: Twinning is the cornerstone of the HRH Program in Rwanda. These findings helped the HRH team identify key areas to improve the twinning experience including better recruitment and orientation of USF and RF, consideration of additional factors during the twinning process, provide language training support, facilitate joint twin activities and cross-cultural training and improve the site leadership buy-in and support of the program. These results can inform other programs using twinning to develop skills in the health workforce. [ABSTRACT FROM AUTHOR]

Background: In Rwanda, women who self-reported in household surveys ever experiencing intimate partner violence (IPV) increased from 34 % in 2005 to 56 % in 2010. This coincided with a new constitution and majority-female elected parliament in 2003, and 2008 legislation protecting against gender-based violence. The increase in self-reported IPV may reflect improved social power for women, and/or disruptions to traditional gender roles that increased actual IPV.Methods: This is a cross-sectional study of IPV in 4338 couples interviewed in the 2005 and 2010 Rwanda Demographic and Health Surveys (RDHSs). Factors associated with physical or sexual IPV in the last 12 months were modeled using manual backward stepwise logistic regression. Analyses were conducted in Stata v13 adjusting for complex survey design.Results: Risk factors for IPV in 2005 (p < 0.05) were: experiencing emotional IPV (OR = 18.1), beating husband/partner unprovoked (OR = 12.3), witnessing IPV against mother (OR = 1.82), husband/partner consumes alcohol often (OR = 3.13), and polygynous marriage (OR = 1.51), whereas having a husband/partner with secondary education (OR = 0.43) was protective. Factors associated with increased IPV in 2010 (p < 0.05) were husband/partner (OR = 1.30) or woman (OR = 1.36) believes IPV is justified, husband/partner has sex with non-marital partners (OR = 2.52), bottom wealth quintile (OR = 1.25), polygynous marriage (OR = 2.29), having a son (OR = 2.05) or only daughters (OR = 2.58) versus no children, and having a husband/partner employed with in-kind versus cash compensation (OR = 1.58). In 2010, woman being involved with her own health (OR = 0.79) or earnings (OR = 0.57) decision-making was protective against IPV. Several variables were not available in the 2010 RDHS.Conclusions: Our results may provide evidence of both increased self-reporting of IPV and social power disruption. Rwanda's Isange One Stop Center project, with medical, legal, and psychosocial services for domestic violence victims, is currently scaling to all 44 district hospitals, and police station gender desks reduce barriers to legal reporting of IPV. Additional support to Abunzi mediators to hear IPV cases in communities, and involvement of men in grassroots efforts to redefine masculinity in Rwanda are suggested. Additional research is needed to understand why self-reported IPV has increased in Rwanda, and to evaluate effectiveness of IPV interventions. [ABSTRACT FROM AUTHOR]

Background: PrePex Male Circumcision (MC) has been demonstrated as an effective and scalable strategy to prevent HIV infection in low- and middle-income countries. This study describes the follow-up and outcomes of clients who underwent PrePex MC between January 2011 and December 2012 with weekly follow-up at the Rwanda Military Hospital, the first national hospital in Rwanda to adopt PrePex. Methods: Data on570 clients age 21 to 54 were extracted from patient records. We compared socio-demographic and clinical characteristics, the operator's qualification, HIV status, pain before and after device removal, urological status, device size and follow-up time between clients who were formally discharged and those who defaulted. We reported bivariate associations between each covariate and discharge status, number of people with adverse events by discharge status, and time to formal discharge or defaulting using life table methods. Data were entered into Epidata and analyzed with Stata v13. Results: Among study participants, 96.5% were circumcised by non-physician operators, 85.4%were under 30years, 98.9% were HIV-negative and 97.9% were without any urological problems that could delay the healing time. Most (70.7%) defaulted before formal discharge. Pain before (p<0.001) and after PrePex device removal (p = 0.001) were associated with discharge status, although very few cases were reported, and pain was more commonly missing among defaulters. Twenty-seven adverse events were reported (7 formally discharged, 20 defaulters). Median follow-up time was seven weeks among formally discharged and six weeks among defaulters (p<0.001). Conclusion: Given that all socio-demographic and most clinical characteristics were not associated with defaulting, we hypothesize that clients stopped returning once they determined they were healed. We recommend less frequent follow-up protocols to encourage clinical visits until formal discharge. Based on these results and recommendations, we believe PrePex MC is a practical circumcision strategy in Rwanda and in sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Background: Major improvements to Rwanda's health system, infrastructure, and social programs over the last decade have led to a rapid fertility transition unique from other African countries. The total fertility rate fell from 6.1 in 2005 to 4.6 in 2010, with a 3-fold increase in contraceptive usage. Despite this rapid national decline, many women still have large numbers of children. This study investigates predictors of fertility during this fertility transition to inform policies that improve individuals' reproductive health and guide national development. Methods: We used Poisson regression to separately model number of children born to ever married/cohabitated women (n = 8,309) and never married women (n = 1,220) age 15 to 49 based on 2010 Rwanda Demographic and Health Survey data. We used backward stepwise regression with a time offset to identify individual and household factors associated with woman's fertility level, accounting for sampling weights, clustering, and stratification. Results: In ever married/cohabitating women, high fertility was significantly associated (p < 0.05) with the following variables: unmet need for contraception (IRR = 1.07), women's desire for children (5+ versus 0-2 children: IRR = 1.22), woman's number of siblings (8-20 versus 0-4: IRR = 1.03), and couples who desired different numbers of children (husband wants more: IRR = 1.04; husband wants fewer: IRR = 1.04). Low fertility in ever married/cohabitating women was associated with women's education (higher versus no education: IRR = 0.66), household wealth (highest versus lowest quintile: IRR = 0.93), and delayed sexual debut (25+ versus 8-18 years: IRR = 0.49). In never married women, low fertility was associated with education (higher versus no education: IRR = 0.22), household wealth (highest versus lowest quintile: IRR = 0.58), delayed sexual debut (25-49 versus 8-18 years: IRR = 0.43), and having an unmet need for contraception (IRR = 0.69). Conclusions: Although the study design does not allow causal conclusions, these results suggest several strategies to further reduce Rwanda's national fertility rate and support families to achieve their desired fertility. Strategies include policies and programs that promote delayed sexual debut via educational and economic opportunities for women, improved access to reproductive health information and services at schools and via health campaigns, and involvement of men in family planning decision making. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Early initiation of antenatal care (ANC) can reduce common maternal complications and maternal and perinatal mortality. Though Rwanda demonstrated a remarkable decline in maternal mortality and 98% of Rwandan women receive antenatal care from a skilled provider, only 38% of women have an ANC visit in their first three months of pregnancy. This study assessed factors associated with delayed ANC in Rwanda., Methods: This is a cross-sectional study using data collected during the 2010 Rwanda DHS from 6,325 women age 15-49 that had at least one birth in the last five years. Factors associated with delayed ANC were identified using a multivariable logistic regression model using manual backward stepwise regression. Analysis was conducted in Stata v12 applying survey commands to account for the complex sample design., Results: Several factors were significantly associated with delayed ANC including having many children (4-6 children, OR = 1.42, 95% CI: 1.22, 1.65; or more than six children, OR = 1.57, 95% CI: 1.24, 1.99); feeling that distance to health facility is a problem (OR = 1.20, 95% CI: 1.04, 1.38); and unwanted pregnancy (OR = 1.41, 95% CI: 1.26, 1.58). The following were protective against delayed ANC: having an ANC at a private hospital or clinic (OR = 0.29, 95% CI: 0.15, 0.56); being married (OR = 0.85, 95% CI: 0.75, 0.96), and having public mutuelle health insurance (OR = 0.81, 95% CI: 0.71, 0.92) or another type of insurance (OR = 0.33, 95% CI: 0.23, 0.46)., Conclusion: This analysis revealed potential barriers to ANC service utilization. Distance to health facility remains a major constraint which suggests a great need of infrastructure and decentralization of maternal ANC to health posts and dispensaries. Interventions such as universal health insurance coverage, family planning, and community maternal health system are underway and could be part of effective strategies to address delays in ANC.

We examined whether the addition of community-based accompaniment to Rwanda's national model for antiretroviral treatment (ART) was associated with greater improvements in patients' psychosocial health outcomes during the first year of therapy. We enrolled 610 HIV-infected adults with CD4 cell counts under 350 cells/μL initiating ART in one of two programs. Both programs provided ART and required patients to identify a treatment buddy per national protocols. Patients in one program additionally received nutritional and socioeconomic supplements, and daily home-visits by a community health worker ("accompagnateur") who provided social support and directly-observed ingestion of medication. The addition of community-based accompaniment was associated with an additional 44.3 % reduction in prevalence of depression, more than twice the gains in perceived physical and mental health quality of life, and increased perceived social support in the first year of treatment. Community-based accompaniment may represent an important intervention in HIV-infected populations with prevalent mental health morbidity.