MGHD 2018

Background: Post cesarean section infections (PCSIs) remain a burden in Low and Middle Income Countries (LMICs) with an important need to be closely monitored and addressed. Although, many hospitals have established PCSIs surveillance systems, these haven’t been able to capture most of infections occurring after a patient has been discharged, leading to inaccurately reports in PCSI rates. Primary objective: To identify the accurate rate of post cesarean section infection in Kacyiru hospital by April 2018. Secondary Objective: To assess the potential risk factors associated with post cesarean section infections in Kacyiru by April 2018. Methodology: A new PCSI surveillance system was implemented in parallel with the existing hospital system, from November 2017 to February 2018, targeting all women who had cesarean section (CS) delivery. The new system observed and monitored a patient while at the hospital (during hospitalization and readmissions) and telephone calls follow-up were made with the patient on the 10th and 30th post-operation days after discharge. Results: 540 women have had a CS delivery at Kacyiru hospital during the study period and 340 (63%) completed the new surveillance. The new system identified a PCSIs rate of 11.2% while the hospital system reported 3.1%. During hospitalization and readmissions, the two systems collected similar information, but the new system was able to identify many PCSIs after discharge. Women who have had a prolonged labor – longer than 12 hours - (odds ratio=5.9, p=0.003) and those who have had rupture of membrane before CS procedure (odds ratio=2.1, p=0.024) were found to be at high risk of PCSIs. Conclusions: PCSIs surveillance using telephone call during post discharge period is feasible and require relatively low cost. This method allowed identifying a disparity in the rate of reported cases by the hospital. The new surveillance method should be implemented by the hospital on periodic basis. An emphasis on early management of labor and close monitoring of women with premature rupture of membranes is required. Keywords: Post cesarean section infections, surveillance, risk factors, cesarean section.

Introduction: One of the major consequences of irrational dispensation of antimalarial and antibiotic drugs is the development of drug resistance. Antimalarial and oral antibiotics in Rwanda are prescription only medicines; therefore they should be exclusively dispensed under medical prescription. Factors underlying dispensation of antimalarial and antibiotics without medical prescription in Rubavu retail pharmacies were unknown. Objective: The aim of this study was to determine the factors underlying dispensation of antimalarial and antibiotics without a prescription in Rubavu retail pharmacy by February 2018. Methods: This was a descriptive cross-sectional study, conducted in the 15 retail pharmacies within Rubavu district from December 2017 to February 2018. Data was collected in two phases. The first phase was direct participant observation in order to measure the percentage of antimalarial and antibiotics that were requested without medical prescription by pharmacy clients. The second phase was a self-administered questionnaire in order to understand the dispensing practices and reasons for dispensing of antimalarial and antibiotics without a prescription. Results: The study showed that the 66% of antimalarial and 76% of antibiotics requested were without medical prescription. 77.5% and 90.0% of pharmacy healthcare providers reported to recommend respectively antimalarial and antibiotics. With regards to dispensing incomplete doses of antimalarial and antibiotics, findings from this study showed that 42.5% and 57.5% of respondents reported to dispense less than full course of therapy of antimalarial and antibiotics, respectively. With regards to barriers to good dispensing practice, 52.5% of participants reported that pharmacy management encourages pharmacy health workers to dispense regardless of the prescription, whereas 87.5% reported that there is a culture of self-medication and self-diagnosis in the region. In addition to that half of participants reported that dispensers are influenced by patients’ requests. Conclusion: The study highlighted a high percentage of both antimalarial and antibiotic drugs requested without medical prescriptions. Education about good pharmacy practices, enforcement of regulation concerning retail pharmacy ownership and availability of regular inspection are required to improve retail pharmacy dispensing practice.

Background: Rwanda faces a high burden of mental health (MH) problems as consequence of the 1994 genocide against the Tutsi. In order to scale up access to mental health care, efforts have been made to decentralize mental health into primary health care. However, little is known about the capacity of primary healthcare nurses to identify, manage and prevent common MH problems. Objective: To assess mental health literacy (MHL) and factors that may be associated among health center nurses in Rubavu district by April 2018. Methods: A total of 74 nurses (28 males; 46 females) were recruited from all Rubavu health centers to participate in this cross-sectional study. Participants completed a paper-and-pencil questionnaire on their socio-demographic characteristics and MHL (recognition of mental health problems, knowledge about risk factors and existing treatments for common mental health problems, and knowledge about mental health promotion activities). Frequency analyses were used to determine the level of mental MHL and chi-Square test was applied to assess associations between variables. Analyses were conducted with SPSS, 24. Results: Substance Use Disorder was the most widely recognized disorder (with 72% of participants identifying it correctly), followed by PTSD (63%) and Depression (61%). Half of the participants were able to correctly identify Schizophrenia and Somatic Symptom Disorder (51%), whereas only 26% recognized Generalized Anxiety Disorder. Although the large majority of participants were able to identify risk factors for common MH problems (eg. financial problems: 73%), they also endorsed false cultural beliefs about the etiology of MH problems (eg. possession by evil spirits: 72%). In addition to that, 58% to 71% of participants indicated that counselors/psychologists as the most helpful professionals for all the assessed MH problems.Participants’ education level, length of professional experience and previous trainings about mental health were not significantly associated with the level of mental health literacy (all P > .05). Conclusion: Overall, the level of mental health literacy among Rubavu health center nurses is limited, with differing levels in various aspects of mental health literacy. Recommendations are made to improve the academic training of nurses on mental health and to provide in-service training on mental health. This may improve the quality of mental health services.

Introduction: Chronic Kidney Disease is a condition that affects individuals worldwide and Rwanda is no exception. Malnutrition is a significant issue among dialysis patients and dramatically increases risk of morbidity and mortality. Dialysis patients also often have abnormal potassium, phosphorus, calcium and albumin laboratory values. The problem is that the overall nutritional status of stage 5 chronic kidney disease patients on dialysis in Rwanda is unknown and the objective of this study was to determine the nutrition status of a cohort of patients on dialysis with Stage 5 CKD at select facilities in Kigali and Gisenyi. Methods: In this cross-sectional study, adults who had been on hemodialysis for more than 30 days were recruited from dialysis centers in Kigali and Gisenyi. Nutrition status was measured by performing a physical exam and interview known as the Subjective Global Assessment (SGA), calculating body mass index (BMI), and collecting laboratory values for potassium, phosphorus, calcium and albumin. SGA scores categorized participants into A (nourished), B (moderately malnourished) or C (severely malnourished). BMI was categorized as underweight (<22 kg/m2), normal/overweight (22-29.9 kg/m2), and obese (>30. kg/m2). Laboratory values were categorized as high, normal or low. Results: 34 patients were assessed 19 (59.4%) of whom were males and 13 (40.6%) were females. Mean age for all was 52.4 years. 28% of participants were classified as moderately malnourished (SGA B) and 62.4% of participants were underweight (BMI <22 kg/m2). There was a correlation (p =0.0117) between moderate malnutrition and underweight. 69% of participants presented with high potassium (> 5.10meq/l, mean value 5.49 mEq/L), while the majority of participants were normal for phosphorus, calcium and albumin. There was no association between low albumin and moderate malnutrition (p=0.0687) and low albumin and underweight (p=0.6834). Conclusion: Malnutrition is prevalent among hemodialysis patients in Rwanda and there may be an increased risk of morbidity and mortality among patients due to low BMI scores. When creating nutrition recommendations for hemodialysis patients, potassium restriction should be emphasized. Additional research could help to draw further conclusions around malnutrition, laboratory values and dialysis in the region.

Rwanda Biomedical Centre/Medical Procurement and Production Division (RBC/MPPD) has the mission to avail to all Rwandan people the right medicines, in the right quantity, at the right place, at the right moment, in the right condition and at the right cost. To fulfill this mission, RBC/MPPD executes the active distribution to District Pharmacies who are the main customers serving all the public Health Facilities. The lead time (the time between when new stock of essential medicines is ordered and when it is received and available for use) is among the main factors to consider in this active distribution. The literature states that the lead time has a major effect on quantities required for stock levels and when lead times are underestimated, the likely results are shortages, expensive emergency purchases and poor customer satisfaction. This project assessed the distribution lead time of essential medicines at RBC/MPPD, and found that the average lead time is 20 days. Our goal was to find the root causes of the significant length and implement an intervention in order to shorten it from 20 days to 14 days in order to make the essential medicines regularly available to the population through improved work. We employed a mixed method explanatory sequential design composed of quantitative and qualitative data. For the quantitative part, we sampled 120 orders of active distribution, for the period December 2016-November 2017, and we measured the central tendency and the spread of each step of the process using the file audit. The following four steps were found as too long:  Time in days between when order is received by Order Processing (OP) staff and when order is processed by RBC/MPPD, taking 5 days  Time from starting picking products, checking and production of delivery note invoice, taking 5 days,  Time in days between picking creation, transmission and starting picking the products by RBC/MPPD, taking 4 days,  Time in days between Order submission by DP and order transmission to Order Processing staff by Customer care staff, taking 3 days. Thus, the delay is likely to be imputed only to RBC/MPPD side and not on customers’ side regardless the order submission step by DP. The qualitative study used a semi structured interview process with 11 RBC/MPPD participants. The thematic analysis results suggested that the main causes of the long lead time were related to the RBC/MPPD human resources, RBC/MPPD workload, RBC/MPPD stock level, RBC/MPPD warehouse facilities, active distribution calendar observance, RBC/MPPD distribution design and RBC/MPPD system. Those causes have been found interconnected, one impacting on another and their coincidence worsens the delay and this is the origin of the long maximum times observed in our results. We found the root causes of the long distribution lead time at RBC/MPPD and these findings should guide in future to disseminate the results and to implement the intervention in order to execute the recommendations delivered. This will contribute to the regular availability of essential medicines and to the customer satisfaction through an improved distribution system.

Background: VTE is among the major causes of maternal mortality worldwide. Increasing knowledge among pregnant women as well as promoting adherence to medications for pregnant women diagnosed with VTE can reduce risks for getting this condition. There was no data or research on the level of knowledge about VTE among pregnant women in Rwanda. Methods: A cross-sectional study on pregnant women who attended antenatal care services at three referral hospitals in Kigali city using a questionnaire. Demographic data and VTE knowledge levels were collected. Results: The knowledge level about VTE among the pregnant women who participated in this study is 9.33%. 76.33% have knowledge on the severity of VTE whereas 15.67% have good knowledge of the availability of treatment of VTE. Participants at CHUK whose occupation was in healthcare field and those who had more than 5 children had a significantly higher level of VTE knowledge. Conclusion: This study shows that knowledge of VTE among pregnant women attending antenatal care in the three-referral hospitals in Kigali is low. More attention must be paid to education and awareness to ensure safe and high-quality antenatal care and thus maternal mortality reduction.

Background: Breast cancer is a principal cause of cancer related deaths in women worldwide including Rwanda. Excellent knowledge, attitude and practices of breast cancer will help to reduce the number of women who present at late stages of the disease when little or no benefit can be obtained from any form of treatment. This study assessed the knowledge, attitudes, and practices about breast cancer among nurses and midwives within the Kibogora hospital and its health centers. Methods and Subjects: This cross-sectional study was conducted from January 2017 to May 2018 among a random sample of 114 nurses and midwives at Kibogora Hospital and its Health Centers in Rural Rwanda. A structured and pretested questionnaire, which was self - administered, was used for data collection. 114 participants completed and returned questionnaires. Results: Study results have shown that there were more respondents in the 31-40 years (53; 46%). The mean age was 37.3 (SD=8.1, range: 23-57) years. Eighty-three (73%) were females while 31 (27%) were males. 73 (64%) worked at hospital while 39 (34%) worked at health center. 88 (77.7%) were married, 22 (19%) were single, 2 (2%) were divorced, 1 (1%) was widowed. Ninety-four (82%) of respondents had high education (University); 18 (16%) had secondary education level and 2(2%) were missing. There were more respondents in the 0-10 years (56; 49%) age ranges of working experience. The overall percentage of breast cancer knowledge was 65.57%. The knowledge of breast cancer signs/symptoms, risk factors and general knowledge were 77.28%, 49.92% and 77.33 %respectively. 43.78% were considered having good attitude. 23.14% were considered having satisfactory attitude. 12.57%) were considered having low attitude. Formal education (60; 41%) was the first source of information followed by Healthcare providers (43; 29%), Majority of participants responded that BSE had to be started at 15 years old (57; 50%). Fifty-six (56; 49.1%) responded that BSE has to be done daily. Seventy participants (70; 61%) did BSE, while forty-four (44; 39%) did not. The study revealed satisfactory knowledge of breast cancer symptoms but poor knowledge of risk factors and low levels of breast cancer screening practices among nurses and midwives who participated. More than half had good and satisfactory attitude. Nurses and midwives at Kibogora Hospital and its health centers in this study were not well informed about breast cancer despite their important role in breast cancer awareness for their clients. Researcher recommended a greater focus on breast cancer education program to improve the knowledge about breast cancer, change misconceptions about risk factors and improve the attitude towards breast cancer.

Background: Compliance to stroke treatment guidelines is crucial in the care and outcome of stroke patients. This study aimed at establishing the current compliance rate to the guidelines and identifying the possible barriers to their use at Oshen-King Faisal Hospital in an effort to increase the compliance rate to their use. Literature has shown that stroke has high prevalence both in developed and developing countries including in Rwanda. It has been found that following evidence-based guidelines improves the outcome of stroke patients. Studies have identified barriers to use of stroke treatment guidelines and possible measures to overcome them. Methodology: The study was conducted at Oshen-King Faisal Hospital (KFH). Medical files of stroke patients admitted to the hospital between January and December 2017 were audited against the stroke treatment guidelines to establish the current compliance rate. Self-administered questionnaires were distributed to all clinicians who handle stroke cases to identify the possible barriers to use of the stroke treatment guidelines. Results: Fifty stroke files were audited and it was found that the current compliance rate to stroke treatment guidelines is 76%, which is below the hospital target of 90%. Fifty-five clinicians completed the questionnaire and the main barriers to use of stroke treatment guidelines identified were the guidelines being time consuming and not user-friendly, a lack of training on the guidelines, low familiarity with and unknown location of the guidelines. Discussion: This study found that the compliance rate to stroke treatment guidelines is lower than the hospital target and the main barriers to its use were mainly related to the guidelines themselves. Therefore KFH management should put in place measures that remove the identified barriers and facilitate compliance to the stroke treatment guidelines. Conclusion: Compliance to stroke treatment guidelines at KFH is low but can be improved if the identified barriers are addressed and put in place by hospital management

Background: Appropriate Infant and Young Child Feeding (ICYF) practices among children aged 6 to 23 month contribute to preventing not only malnutrition but also to reducing mortality and morbidity rate in under five children due to infectious diseases as consequence of poor nutrition. Minimum Meal frequency is one of the key indicators of IYCF. Uptake of Minimum Meal Frequency is low in the Western Province of Rwanda and the factors associated are not known. Objective: The main purpose of this thesis project was to assess the factors associated with Minimum Meal Frequency in Western Province and propose recommendation(s) to inform decision and policy makers on policy reformulation aimed at improving appropriate MMF among children aged 6 to 23 month in Western Province. Methods: The study was a secondary data analysis of data from Demographic Health Survey (DHS) 2014-2015. The outcome variable was Minimum Meal Frequency (MMF). A total of 606 children of age between 6 to 23 month were included in the analysis. Bivariate and multivariate analyses were used to assess the factors associated with MMF. Result: Appropriate Minimum Meal frequency among children between the ages of 6 and 23 months was found to be low (37.6%) among children between ages of 6 to 23 month in Western Province in Rwanda. Children from richest families were more like to receive the appropriate MMF (OR: 2.47, 95% CI, 1.19-5.80), children whose mother’s educated were more likely to receive the appropriate MMF, (OR: 4.07, 95%CI, 0.83-19.9), Children whose fathers were educated were more likely to receive the appropriate MMF, (OR: 6.6,95% CI, 0.50-9.68), children who were currently breastfed were more likely to receive appropriate MMF (3.29, 95% CI, 1.11-9.72) and child who mother attended the ANC visits were more likely to receive appropriate MMF (9.29 95% CI, 1.04-82.75) were associated with appropriate Minimum meal Frequency in Western Province. Conclusion: Interventions targeting the poor families for improving their economic status, promoting the education for both men and women, strengthening the interventions to increase ANC visits may help to improve the uptake of appropriate MMF in Western Province. Key words: Minimum Meal frequency, Malnutrition, Infant and Young Child Feeding.

Background: Since the introduction of the Treat-All Policy, treatment is given to every HIV positive person in Rwanda regardless any other eligibility criteria. Studies done in Rwanda demonstrated that adolescents present treatment failure compared to adult; level of adherence to treatment has been proven to be a predictor of patient outcome. This study aimed at exploring factors that are associated with poor adherence among adolescents enrolled on HIV treatment in two district hospitals in rural Rwanda. Method: A mixed methods approach was used to determine the levels of adherence and explore its risk factors. Participants were identified from electronic medical record, and self-report data were collected using a pre-designed questionnaire. In-depth interviews were conducted to explore the factors associated with poor outcomes. Adherence level was measured at two levels: Appointment keeping and treatment adherence. Results: A total of 139 adolescents were identified from EMR. 58% of all registered adolescent had good appointment keeping. Of the registered ones 72 voluntarily responded to the self-report questionnaire. Of the 72 who voluntarily responded to the self report questions, 87% reported adhering to treatment at the level of 95% and above; 13% had poor adherence over 30 days prior to the reporting day. 53% of the respondents had good adherence of having taken drugs at 95% level and 47% presented with poor adherence within 3 days prior to the reporting day. Poverty, stigma, and Orphanage was the leading causes of poor adherence. Conclusion: The level of adherence to HIV treatment is low among adolescents and youth in rural Rwanda; collaboration between health care providers, local government and the community is needed to design a community-based approach to respond to the poor adherence among adolescents in rural Rwanda.

Studies have shown that there are a substantial number of insulin syringes and needles used at homes by the patients living with diabetes. The number of these sharp materials increases over time as the population living with diabetes enrolled on insulin is growing. This has become a public issue and the current research indicates the growing need to address this problem by the stakeholders involved in diabetes care. In similar settings, like Ethiopia and Pakistan, studies have shown that the majority of diabetics on insulin disposed the used sharp materials in traditional toilets, streets, household garbage or backwoods. In Rwanda, no similar study has been done and the legislation is not clear about how and where the used sharp materials have to be handled. This study aims at quantifying the magnitude of this problem in Rwanda, identifying the root causes and propose a solution. We used a cross-sectional study design with an open-ended questionnaire for the participants recruited from Rwanda Diabetes Association (RDA) and Ruhengeri hospital. The sample was conveniently selected. For a period of two months, the first one at RDA and the second at Ruhengeri Hospital, a nurse administered the questionnaire to the patients who walked in the clinic and who regularly used insulin syringes and needles. The information from the questionnaire was recorded in excel and analyzed later using SPSS with P-value set at 0.05 The findings of this study presented in the fourth chapter have been deduced from 201 study participants; 163 were from RDA and 38 from Ruhengeri hospital. 132 (65.7) improperly disposed of needles and syringes. This is slightly lower than other low and middle-income countries where this kind of study was conducted, the number of diabetics on insulin who Page 6 of 61 disposed the used sharp materials in traditional toilettes and normal garbage were 96 (47.76%) and 27 (13.43%) respectively. The data analysis found an association of proper disposal practice of used sharp disposal with the participants’ point of care, patients’ education by a nurse or doctors, as well as the challenges faced in disposing the syringes and needles used at homes of the study participants. In addition, these study results also helped to understand one of the root causes of improper disposal practices of the patients on insulin in Rwanda. These are mainly the lack of education about the proper syringe and needle disposal and lack of the appropriate container.

Background: Depression among Cancer patients can be as high as 58%. In general, it affects approximately 18% of people in developed countries and 9% in developing countries. Without proper screening and diagnosis, the necessary care and follow-up would not be possible for these patients. Few studies have been conducted in East African countries to assess the prevalence of depression in cancer patients. In order to improve service delivery and patient care in oncology, the mental health and oncology departments at the Butaro Cancer Center of Excellence in Butaro Hospital collaboratively implemented an initiative in December 2017 to screen depression among oncology patients using the Patient Health Questionnaire-9 item scale (PHQ-9). Objective: By April 2018, this study aimed to identify the prevalence of depression using the PHQ-9 and to describe the demographics of the adult patients receiving oncology care at the BCCE from the period of December 4th to the 20th, 2017. The results of this study will benefit the population suffering from cancer by enabling them to be referred and to receive appropriate care for depression, thus improving their quality of life (QOL). Method: A cross-sectional study was applied to audit the prevalence of depression among patients attending the Butaro Ambulatory Cancer Center (BACC) between December 4th to the 20th, 2017. Results The results of this study revealed a prevalence of depression of nearly 36%. Two variables were significantly associated with depression: Type of cancer (p=0.001) and socio-economic status (p=0.041). Conclusion: As the screening program is still at its early stages, additional studies are required to understand the association between the variables and depression, as well as to differentiate between depression triggered by cancer and pre-existing depression. The screening provided by the BACC also aims to improve the service delivery, improving the quality of life of patients with depression and cancer by having supporting evidence for policy making in Rwanda in regards of the screening for depression in people suffering from cancer.

Background: Outcomes in acute lymphoblastic leukaemia (ALL) in low income countries are poor, with only 20-50% of patients successfully treated. Many of the failures are due to relapsed disease but mortality from complications of therapy is also increased. Hunger et al. have proposed regimens of graduated intensity for ALL in resource-limited centres so that capacity for managing toxicity, particularly neutropenic fever can be built over time without excessive treatment-related deaths (Hunger, Sung, & Howard, 2009). The Butaro Cancer Center of Excellence (BCCOE) is located in a Rwandan district hospital with limited antibiotics, no microbiology and no intensive care. The centre began treating ALL in 2012 with the Hunger 1 regimen; few deaths from toxicity were experienced but the cure rate was unacceptably low (Rubagumya, Xu, et al., 2017). In October 2016 the centre transitioned to using the Hunger 2 regimen, which is more intense and incorporates a delayed intensification phase. Objective: The objective was to assess the toxicity and interim outcomes at 24 weeks of the first 25 patients treated with the Hunger 2 regimen for ALL at BCCOE in Rwanda starting from October 2016. Methods: The sample included all patients, both adult and paediatric, with a pathology-confirmed diagnosis of ALL, from October 2016 to September 2017, who were treated with the Hunger 2 regimen. Patients who received previous treatment with chemotherapy were excluded. A retrospective cohort study design was used, with patient status at week 24 as the key outcome variable, as well as survival of episodes of neutropenic fever. Routine data was collected by manual chart review. Results: Twenty-four patients had a bone marrow diagnosis of ALL during the study period, but only 17 of those survived to start treatment with the Hunger 2 regimen. The cohort included a high Page 7 of 41 proportion of patients with high-risk features such as older age, T-cell subtype and white blood count (WBC) greater than 50,000 at presentation. Most treatment delays were caused by neutropenia and thrombocytopenia, with negligible delays due to medication stockouts or social factors. There was a high use of red blood cell and platelet transfusions during the induction phase. Patients had a median of one episode of neutropenic fever. Median time to antibiotics was 10.5 hours. Identified infections included malaria, pyoderma, pneumonia and enterocolitis.. The most common antibiotics used were ceftriaxone and ceftazidime. All episodes resolved with no patient deaths. The majority of patients (63%) who commenced treatment achieved remission and were still alive and in treatment at week 24. Two patients failed induction, one patient died during induction, another patient abandoned treatment and another transferred out. Conclusion: This study suggests that neutropenic fever may be less of a limiting factor in ALL treatment in resource-poor settings than has been supposed, as all patients survived this complication despite limited resources. The high number of deaths prior to treatment was surprising; this may be due to delayed presentation but deserves further study. The ability to report on ultimate outcomes of the treatment and associations with risk factors was limited by the short duration of follow-up and small cohort size.

Background: Dairy farmers in Rwanda face numerous challenges in their production levels related to low Artificial Insemination success rate. Due to poor knowledge on heat period detection. It is apparent that those beneficiaries do not have the ability to track the estrous period of their cows to maximize their cows’ potential. Their ability to detect exactly when their cows are on heat can help increase success of artificial insemination. If they miss out this period, they lose out on income from milk and the nearest family also miss out the calf. This study aimed to increase the artificial insemination success rate among Girinka beneficiaries in Huye district from 40% to 60% by April 2018. Method: A training was provided to 74 GIRNKA cattle farmers in in Huye district. The two-day training focused on heat period detection, estrus cycle and manifestation of cows in heat period. Results: The overall average knowledge on cattle estrus cycle significantly increased from 37.16% pre-intervention to 92.34% post-intervention (P= 0.008 and CI= 0.50, 0.61). All six questions about the knowledge of participants showed significant increase statistically, with the knowledge of estrus cycle having the biggest increase in knowledge score from 31% preintervention to 95.9% post intervention, 65% improvement (P<0.001, CI= 0.53, 0.77). The smallest increase in knowledge score was related to knowledge on heat period of cows, increased from 55.4% pre-intervention to 98.65% post-intervention, 43% improvement (P <0.001 and CI= 0.31, 0.55). The AI success rate significantly increased from 44% preintervention to 58.7% post-intervention (P<0.001, CI = 12.20%, 16.77%). Conclusion: Training farmers on heat period detection, estrus cycle and manifestation of cows in heat period can increase the success rate of AI and is recommended to provide the same training to other GIRNKA beneficiaries. Keywords: Artificial insemination (AI), estrus, cattle, heat detection.

Background: The high academic and professional expectations from university programs often put students under pressure and may lead to psychological distress. This project aims to measure the level of psychological distress among college students at Kepler University program, Kigali, in order to provide the administration with recommendations for effective interventions to improve students’ psychological health. Methods: A cross-sectional study design used the General Health Questionnaire GHQ-12 to measure the level of psychological distress among college students at Kepler. The ethical approval was obtained from the Institutional Review Board IRB of the School. Descriptive statistics were calculated using Excel and associations between variables were analyzed in Stata 13. Results: Out of 125 students to whom questionnaires were administered, 108 responded and returned the questionnaire, giving a response rate of 85%. The overall percentage of students with psychological distress was 42% (n=44), while 58% (n=62) of respondents had no psychological distress. The proportion of students at risk of developing psychological distress is high. Enjoying dayto- day activities, feeling under stress, and feeling unhappy and feeling depressed were the three most problematic symptoms reported. Unemployed students had a higher risk of developing psychological distress than their employed peers. Conclusion: The school management and counselor in collaboration with the careers department should establish a structured career advisory program to support students have a smooth transition from academic to professional placement and reduce the psychological distress.

4 ACKNOWLEDGEMENT I am grateful to Dr. Akiiki Bitalabeho and Ms. Jenae Logan, my supervisors who have guided me through this process. I’m also so much grateful to Dr. Rex Wong who set the direction for this study, and was of great help at every stage of executing this practicum project. His advice made this practicum easier and every piece of it was of great value. My classmates of the MGHD class of 2018 at the University of Global Health Equity (UGHE) have been awesome; it was an honor to attend class with you. 5 ABSTRACT Young adults are at great risk of sexual and reproductive health problems such as negative peer influence, substance abuse, lack of enough sexual and reproductive knowledge, lack of access to enough sexual and reproductive services including contraceptives like condoms, and a lack of an environment that enables free expression on sexuality. Understanding the level of sexual and reproductive health knowledge among young people contributes to the control and prevention of negative sexual and reproductive health outcomes including the contraction of STIs/HIV/AIDS, unwanted pregnancies, and unsafe abortion. It also reduces stigma around the utilization of reproductive health services by young adults, and hence encourages open and free access to contraceptive methods. This study utilized a pre- and post- intervention design to assess the impact of sexual and reproductive health education on the level of knowledge of safe sex practice among young adult freshmen students of the academic year 2017/2018 of IPRC-South, Huye district, Rwanda. A structured questionnaire with closed-ended questions was used to assess the knowledge level of the participants both for the pre- and post intervention tests. Education on sexual and reproductive health, but especially safe sex practice was offered to the participants as the intervention for two weeks. Each class of study participants was taught for two hours on the three topics of the questionnaire: HIV/STIs, Family planning and contraception and sex practices. A hand out containing the correct answers to the questionnaire and other educational materials used during the intervention were provided to the study participants. Pre- and post- test scores were calculated, and descriptive statistics were used to present the student demographic data using frequencies and percentages. Associations between respondents’ 6 gender, department, sexual activity and religion to the knowledge scores were assessed. All statistical tests were conducted using Microsoft word Excel. The study found the respondents’ overall average pre-intervention knowledge score of 65.4%, which was low. However, the overall average knowledge increased to 83.8%, after the intervention. It was observed that the study participants had high levels of sexual and reproductive health knowledge on the sections of STIs/HIV/AIDS and Family planning & contraception, but had poor knowledge on sex practices; which may be attributable to the lack of consistent sexual and reproductive education programs for the young adults. The study recommends consistent investment in sexual and reproductive education as it increases sexual and reproductive knowledge, which in turn reduces negative sexual and reproductive health outcomes such as unsafe abortion, unwanted pregnancies, contraction of STIs/HIV/AIDS and others. It is important for the administration of IPRC-South to not only invest in consistent education programs on sexual and reproductive health but also to consider investment in students’ sexual and reproductive health in order to increase access to services, including access to contraceptives like condoms, and free counseling and testing.

Introduction: Malnutrition globally remains a public health concern affecting 206 million under-nutrition children that is complex and needs special attention. In Rwanda, stunting continues to be a threat to the development in various ways, including weakening the intellectual capacity of children. Moderate acute malnutrition (MAM) is higher among under-five children than severe acute malnutrition (SAM) and easy to manage through outpatient malnutrition programs, but still receives less attention. Poor recovery of MAM is a leading factor in stunting, however, the factors affecting the delayed recovery of MAM children remains unknown. Objective: To identify the factors affecting poor growth among MAM children enrolled in the supplemental feeding program (SFP) in the rural health center of Rwanda, and provides proper recommendations. Methods: Mixed method study, with 24 participants, both caregivers and healthcare workers working in the SFP in December 2017. The sample of eligible caregivers were obtained from the nutrition register book available at the Health Center among those whose children were enrolled in SFP from April to June 2017. A survey and semi-structured interview guide were used. The quantitative data summarized using descriptive statistics, and the qualitative data using content and thematic analysis and presented as topics supported by quotes. Results: Six factors affecting the delayed recovery of MAM children enrolled in the SFP were identified, enrolled children do not consume the provided support due to sharing/ selling, limited family planning, insufficient food and poverty, inadequate child care, poor service, and low attendance at the community-based nutrition program (CBNP). Furthermore, increasing the support or the length of SFP, the involvement of local leaders, establishing early childhood development centers, improving health service including communication and home visit, and accountability of caregivers, were proposed as ways forward. The major benefit of the SFP was the knowledge of nutrition practices. Conclusion: Gaps in households and health facilities continue to affect MAM Children enrolled in the SFP. Interventions based on the identified contributing factors and suggestions obtained may improve the SFP and nutrition status of underfive children in Rwanda. Keywords: Malnutrition, Moderate acute malnutrition, Supplementary food program, delay recovery, Rwanda

Background: Low back pain (LBP) is common among computer users and poses a huge financial burden to patients, their families and society. Proper ergonomics can help to reduce the incidence of LBP, yet little is known on the magnitude of this problem or ergonomic compliance at KFH, Kigali. Objectives: The study aimed to investigate the prevalence of LBP among computer users at KFH workstation, ergonomics compliance, and the associated risk factors by February 2018. Methods: A quantitative cross- sectional study design was done on 36 computer users at KFH. A self reported questionnaire with 27 questions was used to determine the prevalence of LBP and identify associated risk factors. An ergonomic observation checklist with 10 criteria was used to assess the workstation ergonomics compliance rate. Results: A total of 36 computer users responded to questionnaires and consented to be observed. The LBP prevalence among computer users was 80.6%. The mean ergonomics knowledge score was 51.39%, and the mean ergonomic compliance rate was 18.8%. There were no statistically significant associations detected between the presence of LBP and gender, age, computer ergonomics knowledge level, or ergonomic compliance level. Conclusion: The results of this study inform the decision makers at KFH that the prevalence of LBP among computer users at KFH was high yet their ergonomic knowledge and compliance were very low. It is recommended that KFH strive to protect and improve their employees’ health by providing extra keyboards and mouses to those who use laptops as well as simple wood boards to raise the laptops, and by providing cushion rolls for lumbar support and foot steps/stools to those whose feet do not step flat on the floor to their computer using staff. These small investments will be more cost effective, efficient and practical than buying new adjustable orthopedic chairs and desks. It is also recommended that the hospital provide guidelines and staff trainings on proper computer ergonomics annually, to raise staff awareness on this issue. These practical measures may ultimately reduce the high prevalence of LBP at KFH.

Background: Laboratory test Turn Around Time (TAT) is the time from ordering to time results are available. This is very important to improve patient care processes by quick diagnosis and early treatment. In King Faisal Hospital, Kigali, (KFH) the standard of Lab TAT is 3 hours. However, in 2014, lab TAT was 7 hours in accident and emergency department. Objective: To reduce the median turn-around time for full blood count lab test from 06:16 hours to 3 hours by May 2018. Method: Using a cross-sectional study method, we investigated the TAT of FBC tests for all nonemergency full blood count samples from patients during the day shift who were admitted in internal medicine, surgical and pediatric wards in the period of 4 months, using time study and observations Results: The overall median TAT from ordering to time results were available was 06 hours 16 minutes. Out of the 186 samples, only 26 (14%) met the KFH target TAT of 3 hours. The longest delay was due to the gap between the time order was written and the sample was taken followed by time from when lab signed for reception of samples to time results were available. Recommendation: we recommend a new lab ordering system in the wards to shorten the time between ordering and taking the sample by putting a container at the nursing station, all lab request forms will be deposited into the container by doctors as a visual cue for the nurses to process the order. The associated policy should be developed. Furthermore, the recruitment of 1 nurse per unit and two additional lab technicians to reduce staff workload is needed. Finally, a study with longer time period with larger sample size is recommended.

Background: Type 1 Diabetes Mellitus (T1DM) is an emerging epidemic in sub-Saharan Africa. The Rwandan Diabetic Association (RDA) is a non-governmental organization helping pediatric and young adult T1DM patients, through the support in public district hospitals in rural Rwanda. TIDM patients are required to come back every quarter for their clinic follow-up, insulin refill and plasma glucose concentration monitoring (HbA1C). They are reminded about their clinic visits through radio communication. However, adherence to the quarterly visits was low. We explore the impact of a mobile health (mHealth) intervention on adherence to clinic visits and HbA1C check-up through a pilot study, in three rural sites in Rwanda. Objectives: To determine the effectiveness of phone calls and SMS reminders in improving attendance to follow-up visit. Methods: Multicenter non-randomized three-arms pilot study: i) using SMS and radio communication as a reminder; ii) using phone calls by clinic staff, in addition to radio communication, to remind patients of their visit and iii) relying exclusively on the radio announcements RDA makes prior to every visit (control group). The data, pre and postintervention, was analyzed using Excel to describe patients’ demographics and clinical status using percentages, frequencies, and medians with their interquartile ranges. Fisher’s Exact Test was conducted to assess the difference in outcomes between the three groups. The primary measure is the attendance to clinic visits and change in HbA1C level among the intervention study arms. A cost assessment of the budget needed to conduct the outreach visits was also performed, adding the cost of the interventions. A multilevel logistic analysis was also performed to compare the odds of attending in the different groups. Results: A total of 49 patients were enrolled in the study. Attendance rates of control, SMS messaging and phone calls groups were 71.4%, 91.6% and 100%, respectively. The attendance rates of the interventions groups were not statistically significant (0.11 for the phone calls group and 0.17 for the SMS group). There was an increase in HbA1c between baseline and follow-up visits (9.5% versus 10.3%). The cost of SMS messaging was lower compared to phone calls reminders (US$ 0.06 per text versus US$ 0.35 per phone call). Conclusions: Associating phone calls reminders and SMS reminders to the usual RDA’s procedure of radio announcements is more effective than radio announcements only in increasing attendance to follow-up visits. SMS reminders involve lower costs. Limitations to this study included duration of the study, sample size and funding. Keywords: Type 1 Diabetes Mellitus, sub-Saharan Africa, follow-up, mHealth.