Dr. Alemayehu Amberbir

Background: Non-communicable diseases (NCDs) such as diabetes and hypertension have become a prominent public health concern in Malawi, where health care services for NCDs are generally restricted to urban centres and district hospitals, while the vast majority of Malawians live in rural settings. Whether similar quality of diabetes care can be delivered at health centres compared to hospitals is not known. Methods: We implemented a pilot project of decentralized diabetes care at eight health centres in four districts in Malawi. We described differences between district hospitals and rural health centres in terms of patient characteristics, diabetes complications, cardiovascular risk factors, and aspects of the quality of care and used multivariate logistic regression to explore factors associated with adequate diabetes and blood pressure control. Results: By March 2019, 1339 patients with diabetes were registered of whom 286 (21%) received care at peripheral health centres. The median duration of care of patients in the diabetes clinics during the study period was 8.8 months. Overall, HIV testing coverage was 93.6%, blood pressure was recorded in 92.4%; 68.5% underwent foot examination of whom 35.0% had diabetic complications; 30.1% underwent fundoscopy of whom 15.6% had signs of diabetic retinopathy. No significant differences in coverage of testing for diabetes complications were observed between health facility types. Neither did we find significant differences in retention in care (72.1 vs. 77.6%; p=0.06), adequate diabetes control (35.0% vs. 37.8%; p=0.41) and adequate blood pressure control (51.3% vs. 49.8%; p=0.66) between hospitals and health centres. In multivariate analysis, male sex was associated with adequate diabetes control, while lower age and normal body mass index were associated with adequate blood pressure control; health facility type was not associated with either. Conclusion: Quality of care did not appear to differ between hospitals and health centres, but was insufficient at both levels.

Background While cross-ancestral differences in glucose and lipid metabolism are widely reported in adults, there is a paucity of data on pregnant women during various stages of pregnancy. There is no consensus on what defines normal lipid ranges during pregnancy. Establishing reference ranges is crucial to reduce the risk of missing associated maternal and fetal health issues. Therefore, we aimed to investigate the metabolic profiles of healthy pregnant women and to establish national Rwandan reference ranges for these metabolites. Methods We derived the data from two ongoing longitudinal cohort studies conducted in predominantly rural Rwanda and urban Germany (Leipzig), providing repeat data from the second and third trimesters of pregnancy. We measured concentrations of glucose, total cholesterol (TC), high-density lipoprotein cholesterol (HDL), and triglycerides (TG), and estimated their associations with trimesters and cohorts using multivariable linear regression. We estimated the reference ranges using the 5th and 95th percentiles for each metabolic marker. Results For Rwanda and Leipzig, lipids and lipoproteins increased across trimesters, except for HDL, which remained equally low for Rwanda and significantly decreased for Leipzig. Concentrations of TC, low-density lipoprotein, and non-HDL were significantly higher in Leipzig compared to Rwanda for both trimesters, while HDL was significantly lower in Rwanda. Rwanda exhibited significantly higher TG levels in the second trimester than Leipzig, although this difference did not persist into the third trimester. Glucose concentrations were significantly higher in Rwanda than in Leipzig for both trimesters. Conclusions This is the first representative study investigating lipid and lipoprotein concentrations in pregnant women from Rwanda and comparing them to a European sample. This study shows that lipid, lipoprotein, and glucose concentrations differ by ancestry and stage of pregnancy. The higher TG and glucose concentrations in Rwanda may indicate an emerging burden of metabolic disorders in Africa.

INTRODUCTION: This protocol outlines the establishment and implementation of a Human Development and Demographic Surveillance System (HD2SS) in Butaro, Rwanda. The HD2SS will facilitate prospective, continuous monitoring of the population, tracking vital statistics, social events, and key health and demographic indicators in a defined population. The system will enable accurate and validated assessment of the impact of health and related population-level interventions, supporting evidence-based decision-making and data-driven improvements in healthcare and socioeconomic outcomes at a population level. METHODS: The HD2SS will be implemented in the Butaro sector, home to 38,013 individuals across 68 villages. The Butaro sector was purposively selected due to the existence of the University of Global Health Equity and Partners In Health-supported Butaro healthcare delivery. Data, including location, demographic, socioeconomic, and health-related variables, will be collected using the annual household census and stored using the Survey Solutions system for real-time electronic data capture, ensuring data quality, security, and confidentiality. Data analysis will enable the identification of emerging trends, the development of interventions, and the evaluation of related policies and programs. CONCLUSION: The HD2SS will provide currently limited but much-needed data to inform improvements in public health programming and socioeconomic development and strengthen local health research capacity. Regular dissemination of findings will ensure stakeholders, including local health authorities and development partners, are informed and able to use the results to improve health and social development outcomes in Rwanda.

The coronavirus disease 2019 (COVID-19) pandemic led to disruptions of health service delivery in many countries; some were more resilient in either limiting or rapidly responding to the disruption than others. We used mixed methods implementation research to understand factors and strategies associated with resiliency in Rwanda and Bangladesh, focussing on how evidence-based interventions targeting amenable under-five mortality that had been used during the Millennium Development Goal (MDG) period (2000-15) were maintained during the early period of COVID-19.

Background Respectful maternity care (RMC) is an essential strategy to scale up mothers' positive experiences during childbirth. However, few studies have been conducted to quantify the practice in Rwanda. The main objective of this study was to determine the proportion of the RMC approach in health facilities and associated factors in Musanze District in Rwanda. Methods This is a health facility-based cross-sectional study conducted among 335 women who delivered at eight healthcare facilities including hospital and health centers in Musanze District between March to May 2024. We used simple random sampling to select health centers and included all participants who satisfied the inclusion criteria until the predetermined sample size was reached. The proportion of RMC as an outcome variable was calculated from the 30-item PCMC Scale, and RMC was considered to have been received if a woman responded “2 = yes, most of the time” and “3 = yes, all the time” to all the 30 items. We used multivariate logistic regression to identify factors associated with the provision of RMC such as employment status, parity, and place of delivery. The results were reported using odds ratios with the 95% CI. Variables were proved statistically significant based on p < 0.05. Results 335 participants were enrolled in this study. The majority of respondents were between 25–34 years (54.0%) and married (74.3%). The proportion of respectful maternity care was 65.1% (95% CI: 59.7–70.2). Being employed was associated with receiving RMC [AOR = 17.75, 95%CI:8.06–39.06, p < 0.001]. Primiparous women compared to multiparous had higher odds of receiving RMC [AOR = 5.15, 95%CI:2.07–12.79, p < 0.001]. Cesarean deliveries were associated with a greater likelihood of RMC compared to those who delivered vaginally [AOR = 6.00, 95%CI:2.40–15.03, p-value = 0.003]. Women who delivered at health centers were more likely to receive RMC than those who delivered in hospitals [AOR = 3.72, 95% CI: 1.41–9.83, p = 0.008]. Daytime deliveries were more likely to receive RMC than nighttime deliveries (AOR = 3.11, 95% CI: 1.52–6.37, p = 0.002). Additionally, women with insurance other than Rwanda’s Community Based Health Insurance had higher odds of receiving RMC (AOR = 4.46, 95% CI: 1.88–10.61, p < 0.001). Conclusion The level of respectful maternity care in Musanze District was found to be 65.1%. Interventions to improve respectful maternity care should focus on training healthcare providers about its components, including dignity and respect, autonomy and communication, and social support, in addition to educating the community to request quality care. These findings call upon policy makers to involve different stakeholders to come up with interventions to improve quality of care during childbirth.

The growing burden of asthma in low- and middle-income countries has been linked to urbanisation and lifestyle changes. However, this burden has not been well characterised in adults. Therefore, we investigated the prevalence of self-reported diagnosed asthma and associated factors in urban and rural adults in Malawi, Southern Africa. Within a cross-sectional population-based survey to determine the burden and risk factors for non-communicable diseases (NCDs) in the city of Lilongwe and rural Karonga district, we collected information on self-reported previously diagnosed asthma and asthma-related symptoms using an interviewer-led questionnaire. Other data collected included: demographic characteristics, socioeconomic status indicators, NCD comorbidities, environmental exposures, and anthropometric measurements. We used multivariable logistic regression models to explore factors associated with self-reported asthma adjusting for variables associated with the outcome in univariable analysis. Findings were corrected for multiple comparisons using the Bonferroni method. We analysed data from 30,483 adult participants (54.6% urban,45.4% rural and 61.9% female). A prior asthma diagnosis was reported in 5.1% of urban and 4.5% of rural participants. In urban females, being obese (>30 kg/m2) compared to normal weight (18.5–24.9 kg/m2) was associated with greater odds of asthma (OR = 1.59, 95% CI [1.26–2.01], p<0.001), after adjusting for confounders. We observed associations between previously diagnosed heart disease and asthma in female participants which remained significant in rural females after Bonferroni correction (OR = 2.30,95%CI [1.32–4.02], p = 0.003). Among rural males, current smokers had reduced odds of diagnosed asthma (OR = 0.46,95%CI [0.27–0.79], p = 0.004) compared to those who had never smoked. In Malawi the prevalence of self-reported diagnosed asthma was greatest in females and urban dwellers. Notably, our findings indicate relationships between excess body weight as well as comorbidities and diagnosed asthma in females. Future investigations using longitudinally collected data and clinical measurements of asthma are needed to better understand these associations.

Objective As populations age, multimorbidity and frailty have emerged as major health challenges. While their associations with disability and mortality are well documented, their impact on quality of life (QoL) in sub-Saharan Africa remains underexplored. We examined the associations between frailty, multimorbidity and QoL among older adults in Rwanda. Design A cross-sectional population-based study. Multimorbidity was defined as having two or more chronic conditions, including hypertension, diabetes, heart disease and mental health conditions. Frailty scores were derived using the Fried phenotype, and QoL was measured using the European Health Instrument Survey-Quality of Life index (scaled 0%–100%). Sequential linear regression models were used to examine independent associations. Setting Rural and urban settings of Rwanda. Participant We analysed data from 4369 adults (≥40 years). Results The mean QoL score was 48.2% (±15.6). Frailty and multimorbidity prevalence were 14.5% (95% CI 13.5 to 15.6) and 55.2% (95% CI 53.7 to 56.6), respectively, while 55.0% (95% CI 53.3 to 56.3) were classified as prefrail. Frailty and multimorbidity are independently associated with poorer QoL. Compared with robust individuals, prefrail and frail individuals experienced a 3.66 (95% CI −4.63 to –2.70) and 7.30 (95% CI −8.76 to –5.83) percentage point reduction in QoL, respectively. Multimorbidity was associated with a 4.66% (95% CI −5.54 to –3.79) point decrease in QoL. Impairments in activities of daily living partly mediated these associations. Conclusions Frailty and multimorbidity showed a strong negative association with QoL, with frailty having a stronger effect. These findings underscore the need for age-responsive healthcare strategies, including frailty screening and integrated chronic care, to enhance QoL among older adults in Rwanda.

Objective: To determine how often men in Malawi attend health facilities and if testing for human immunodeficiency virus (HIV) is offered during facility visits. Methods: We conducted a cross-sectional, community-representative survey of men (15-64 years) from 36 villages in Malawi. We excluded men who ever tested HIV-positive. Primary outcomes were: health facility visits in the past 12 months (for their own health (client visit) or to support the health services of others (guardian visit)); being offered HIV testing during facility visits; and being tested that same day. We disaggregated all results by HIV testing history: tested ≤ 12 months ago, or in need of testing (never tested or tested > 12 months before). Findings: We included 1116 men in the analysis. Mean age was 34 years (standard deviation: 13.2) and 55% (617/1116) of men needed HIV testing. Regarding facility visits, 82% (920/1116) of all men and 70% (429/617) of men in need of testing made at least one facility visit in the past 12 months. Men made a total of 1973 visits (mean two visits): 39% (765/1973) were as guardians and 84% (1657/1973) were to outpatient departments. Among men needing HIV testing, only 7% (30/429) were offered testing during any visit. The most common reason for not testing was not being offered services (37%; 179/487). Conclusion: Men in Malawi attend health facilities regularly, but few of those in need of HIV testing are offered testing services. Health screening services should capitalize on men's routine visits to outpatient departments as clients and guardians.

Background: People living with HIV are at an increased risk of diabetes mellitus due to HIV infection and exposure to antiretroviral therapy (ART). Despite this, integrated diabetes screening has not been implemented commonly in African HIV clinics. Our objective was to explore the feasibility of integrating diabetes screening into existing routine HIV viral load (VL) monitoring and to determine a group of HIV patients that benefit from a targeted screening for diabetes. Methods: A mixed methods study was conducted from January to July 2018 among patients on ART aged ≥18 y and healthcare workers at an urban HIV clinic in Zomba Central Hospital, Malawi. Patients who were due for routine VL monitoring underwent a finger-prick for simultaneous point-of-care glucose measurement and dried blood spot sampling for a VL test. Diabetes was diagnosed according to WHO criteria. We collected demographic and medical history information using an interviewer-administered questionnaire and electronic medical records. We conducted focus group discussions among healthcare workers about their experience and perceptions regarding the integrated diabetes screening program. Results: Of patients undergoing routine VL monitoring, 1316 of 1385 (95%) had simultaneous screening for diabetes during the study period. The median age was 44 y (IQR: 38–53); 61% were female; 28% overweight or obese; and median ART duration was 83 mo (IQR: 48–115). At baseline, median CD4 count was 199 cells/mm3 (IQR: 102–277) and 50% were in WHO clinical stages I or II; 45% were previously exposed to stavudine and 88% were virologically suppressed (<1000 copies/mL). Diabetes prevalence was 31/1316 (2.4%). Diabetes diagnosis was associated with age ≥40 y (adjusted OR [aOR] 7.44; 95% CI: 1.74 to 31.80), being overweight and/or obese (aOR 2.46; 95% CI: 1.13 to 5.38) and being on a protease inhibitor-based ART regimen (aOR 5.78; 95% CI: 2.30 to 14.50). Healthcare workers appreciated integrated diabetes screening but also reported challenges including increased waiting time, additional workload and inadequate communication of results to patients. Conclusions: Integrating diabetes screening with routine VL monitoring (every 2 y) seems feasible and was valued by healthcare workers. The additional cost of adding diabetes screening into VL clinics requires further study and could benefit from a targeted approach prioritizing patients aged ≥40 y, being overweight/obese and on protease inhibitor-based regimens.

Background: The COVID-19 pandemic resulted in drops in access to and availability of a number of evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M) across a wide range of countries, including Rwanda. We aimed to understand the strategies and contextual factors associated with preventing or mitigating drops nationally and subnationally, and the extent to which previous efforts to reduce U5M supported the maintenance of healthcare delivery. Methods: We used a convergent mixed methods implementation science approach, guided by hybrid implementation research and resiliency frameworks. We triangulated data from three sources: desk review of available documents, existing routine data from the health management information system, and key informant interviews (KIIs). We analyzed quantitative data through scatter plots using interrupted time series analysis to describe changes in EBI access, uptake, and delivery. We used a Poisson regression model to estimate the impact of COVID-19 on health management information system indicators, adjusting for seasonality. We used thematic analysis of coded interviews to identify emerging patterns and themes. Results: We found moderate 4% (IRR = 0.96; 95%CI: 0.93, 1.00) and 5% (IRR = 0.95; 95%CI: 0.92, 0.99) drops in pentavalent and rotavirus 2 doses vaccines administered, respectively. Nationally, there was a 5% drop in facility-based delivery (IRR = 0.95; 95%CI: 0.92, 0.99). Lockdown and movement restrictions and community and health-worker fear of COVID-19 were barriers to service delivery early in the pandemic. Key implementation strategies to prevent or respond to EBI drops included leveraging community-based healthcare delivery, data use for decision-making, mentorship and supervision, and use of digital platform. Conclusions: While Rwanda had drops in some EBIs early in the pandemic, especially during the initial lockdown, this was rapidly identified, and response implemented. The resiliency of the health system was associated with the Rwandan health system’s ability to learn and adapt, encouraging a flexible response to fit the situation.

Objectives The study aimed to evaluate the cumulative incidence of gestational diabetes (GD) among pregnant women receiving antenatal care at the King Faisal Hospital (KFH) in Kigali, Rwanda, using the criteria established by the International Association of Diabetes and Pregnancy Study Groups and endorsed by the WHO in 2013. Design Prospective cohort study. Setting KFH-Kigali, Rwanda. Participants A total of 284 pregnant women were enrolled between May 2023 and April 2024. Results The cumulative incidence rate of GD was 19.5% (95% CI 15% to 24.6%). Most participants (78%) were from Kigali City. Most participants belong to high-income households (96.5%) and were employed (85%). Risk factors associated with the development of GD included increased body mass index (adjusted relative risk (aRR) 3.2; 95% CI 2.02 to 5.3), a history of macrosomia (aRR 4.9; 95% CI 1.6 to 12) and family history of type 2 diabetes (aRR 4.6; 95% CI 1.3 to 14). Women diagnosed with GD had a significantly higher risk of adverse outcomes, including pre-eclampsia and gestational hypertension (aRR 6.7; 95% CI 1.7 to 26) polyhydramnios (aRR 6.4; 95% CI 1.94 to 8.9), postpartum haemorrhage (aRR 3; 95% CI 2.7 to 3.9) and caesarean delivery (aRR 4.9; 95% CI 1.6 to 9.1). Neonatal complications were also common in infants born to mothers with GD, including neonatal hypoglycaemia (aRR 2.2; 95% CI 1.2 to 4.5), neonatal intensive care unit admission (aRR 1.7; 95% CI 1 to 4.6) and macrosomia (aRR 2.3; 95% CI 1.01 to 3.5). Conclusions This study provides important data on the cumulative incidence of GD at the KFH in Rwanda and highlights the key maternal and neonatal factors and adverse outcomes associated with the condition. Given the growing global burden of obesity and diabetes, further research and public health education are essential for mitigating the double burden of GD on maternal and neonatal health.

The COVID-19 pandemic posed unprecedented challenges and threats to health systems, particularly affecting delivery of evidence-based interventions (EBIs) to reduce under-5 mortality (U5M) in resource-limited settings such as Bangladesh. We explored the level of disruption of these EBIs, strategies and contextual factors associated with preventing or mitigating service disruptions, and how previous efforts supported the work to maintain EBIs during the pandemic. We utilized a mixed methods implementation science approach, with data from: 1) desk review of available literature; 2) existing District Health Information System 2 (DHIS2) in Bangladesh; and 3) key informant interviews (KIIs), exploring evidence on changes in coverage, implementation strategies, and contextual factors influencing primary healthcare EBI coverage during March–December 2020. We used interrupted time series analysis (timeframe January 2019 to December 2020) using a Poisson regression model to estimate the impact of COVID-19 on DHIS2 indicators. We audio recorded, transcribed, and translated the qualitative data from KIIs. We used thematic analysis of coded interviews to identify emerging patterns and themes using the implementation research framework. Bangladesh had an initial drop in U5M-oriented EBIs during the early phase of the pandemic, which began recovering in June 2020. Barriers such as lockdown and movement restrictions, difficulties accessing medical care, and redirection of the health system’s focus to the COVID-19 pandemic, resulted in reduced health-seeking behavior and service utilization. Strategies to prevent and respond to disruptions included data use for decision-making, use of digital platforms, and leveraging community-based healthcare delivery. Transferable lessons included collaboration and coordination of activities and community and civil society engagement, and investing in health system quality. Countries working to increase EBI implementation can learn from the barriers, strategies, and transferable lessons identified in this work in an effort to reduce and respond to health system disruptions in anticipation of future health system shocks.

Abstract Background The prevalence of Human Immunodeficiency Virus (HIV) among prisoners remains high in many countries, especially in Africa, despite a global decrease in HIV incidence. Programs to reach incarcerated populations with HIV services have been implemented in Malawi, but the success of these initiatives is uncertain. We explored which challenges prisoners face in receiving essential HIV services and whether HIV risk behavior is prevalent in prisons. Methods We conducted a mixed-methods (qualitative and quantitative), cross-sectional study in 2018 in six prisons in Southern Malawi, two large central prisons with on-site, non-governmental organization (NGO) supported clinics and 4 smaller rural prisons. Four hundred twelve prisoners were randomly selected and completed a structured questionnaire. We conducted in-depth interviews with 39 prisoners living with HIV, which we recorded, transcribed and translated. We used descriptive statistics and logistic regression to analyze quantitative data and content analysis for qualitative data. Results The majority of prisoners (93.2%) were male, 61.4% were married and 63.1% were incarcerated for 1–5 years. Comprehensive services were reported to be available in the two large, urban prisons. Female prisoners reported having less access to general medical services than males. HIV risk behavior was reported infrequently and was associated with incarceration in urban prisons (adjusted odds ratio [aOR] 18.43; 95% confidence interval [95%-CI] 7.59–44.74; p = < 0.001) and not being married (aOR 17.71; 95%-CI 6.95–45.13; p = < 0.001). In-depth interviews revealed that prisoners living with HIV experienced delays in referrals for more severe illnesses. Prisoners emphasized the detrimental impact of poor living conditions on their personal health and their ability to adhere to antiretroviral therapy (ART). Conclusions Malawian prisoners reported adequate knowledge about HIV services albeit with gaps in specific areas. Prisoners from smaller, rural prisons had suboptimal access to comprehensive HIV services and female prisoners reported having less access to health care than males. Prisoners have great concern about their poor living conditions affecting general health and adherence to ART. These findings provide guidance for improvement of HIV services and general health care in Malawian institutionalized populations such as prisoners.

Background The Ethiopian government implemented a national community health program, the Health Extension Program (HEP), to provide community-based health services to address persisting access-related barriers to care using health extension workers (HEWs). We used implementation research to understand how Ethiopia leveraged the HEP to widely implement evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M) and address health inequities. Methods This study was part of a six-country case study series using implementation research to understand how countries implemented EBIs between 2000–2015. Our mixed-methods research was informed by a hybrid implementation science framework using desk review of published and gray literature, analysis of existing data sources, and 11 key informant interviews. We used implementation of pneumococcal conjugate vaccine (PCV-10) and integrated community case management (iCCM) to illustrate Ethiopia’s ability to rapidly integrate interventions into existing systems at a national level through leveraging the HEP and other implementation strategies and contextual factors which influenced implementation outcomes. Results Ethiopia implemented numerous EBIs known to address leading causes of U5M, leveraging the HEP as a platform for delivery to successfully introduce and scale new EBIs nationally. By 2014/15, estimated coverage of three doses of PCV-10 was at 76%, with high acceptability (nearly 100%) of vaccines in the community. Between 2000 and 2015, we found evidence of improved care-seeking; coverage of oral rehydration solution for treatment of diarrhea, a service included in iCCM, doubled over this period. HEWs made health services more accessible to rural and pastoralist communities, which account for over 80% of the population, with previously low access, a contextual factor that had been a barrier to high coverage of interventions. Conclusions Leveraging the HEP as a platform for service delivery allowed Ethiopia to successfully introduce and scale existing and new EBIs nationally, improving feasibility and reach of introduction and scale-up of interventions. Additional efforts are required to reduce the equity gap in coverage of EBIs including PCV-10 and iCCM among pastoralist and rural communities. As other countries continue to work towards reducing U5M, Ethiopia’s experience provides important lessons in effectively delivering key EBIs in the presence of challenging contextual factors.

Background: Depression is a leading cause of death and disability worldwide, including in low- and middle-income countries (LMICs). Depression often coexists with chronic medical conditions and is associated with worse clinical outcomes. This confluence has led to calls to integrate mental health treatment with chronic disease care systems in LMICs. This article describes the rationale and protocol for a trial comparing the clinical effectiveness and cost-effectiveness of two different intervention packages to implement evidence-based antidepressant management and psychotherapy into chronic noncommunicable disease (NCD) clinics in Malawi. Methods: Using constrained randomization, the Sub-Saharan Africa Regional Partnership (SHARP) for mental health capacity building will assign five Malawian NCD clinics to a basic implementation strategy via an internal coordinator, a provider within the chronic care clinic who champions depression services by providing training, supervision, operations, and reporting. Another five clinics will be assigned to depression services implementation via an internal coordinator along with an external quality assurance committee, which will provide a quarterly audit of intervention component delivery with feedback to providers and the health management team. Results: The authors will compare key implementation outcomes (fidelity to intervention), clinical effectiveness outcomes (patient health), and cost-effectiveness and will assess characteristics of clinics that may influence uptake and fidelity. Next steps: This trial will provide key information to guide the Malawi Ministry of Health in scaling up depression management in existing NCD settings. The SHARP trial is anticipated to substantially contribute to enhancing both mental health treatment and implementation science research capacity in Malawi and the wider region.

Childhood stunting in its moderate and severe forms is a major global problem and an important indicator of child health. Rwanda has made progress in reducing the prevalence of stunting. However, the burden of stunting and its geographical disparities have precipitated the need to investigate its spatial clusters and attributable factors. Here, we assessed the determinants of under‐5 stunting and mapped its prevalence to identify areas where interventions can be directed. Using three combined rounds of the nationally representative Rwanda Demographic and Health Surveys of 2010, 2015 and 2020, we employed the Blinder‐Oaxaca decomposition analysis and the hotspot and cluster analyses to quantify the contributions of key determinants of stunting. Overall, there was a 7.9% and 10.3% points reduction in moderate stunting among urban and rural areas, respectively, and a 2.8% and 8.3% points reduction in severe stunting in urban and rural areas, respectively. Child age, wealth index, maternal education and the number of antenatal care visits were key determinants for the reduction of moderate and severe stunting. Over time, persistent statistically significant hotspots for moderate and severe stunting were observed in Northern and Western parts of the country. There is a need for an adaptive scaling approach when implementing national nutritional interventions by targeting high‐burden regions. Stunting hotspots in Western and Northern provinces underscore the need for coordinated subnational initiatives and strategies such as empowering the rural poor, enhancing antenatal health care, and improving maternal health and education levels to sustain the gains made in reducing childhood stunting.

Introduction Ageing is often accompanied by chronic diseases, multimorbidity and frailty, increasing the need for clinical and social care to support healthy ageing and manage these conditions. We are currently in the UN Decade of Ageing, and there is a growing focus on the need to prevent or delay some of these conditions through the ‘Healthy Ageing’ initiative of the WHO. However, there are limited data available to inform prioritisation of interventions, particularly for countries in sub-Saharan Africa. Methods and analysis This study will use a mixedmethods, stepwise approach to identify the current needs for older people in Rwanda, health system capacity and possible solutions to unmet need. First, we will conduct a household survey in the City of Kigali (predominantly urban) and Northern Province Burera district (predominantly rural) to determine the burden of multimorbidity, frailty, access to care, and experiences and responsiveness of care in older people. This work will be supplemented by secondary analysis of data from the Rwandan STEPwise approach to non-communicable disease risk factor surveillance (STEPs) survey of 2021. Second, we will conduct a health facility readiness assessment and healthcare provider survey to assess health system capacity and gaps to deliver effective primary care to older people in Rwanda. Third, to capture the voices of older people, we will explore the quality of healthcare as experienced by them using in-depth interviews. Fourth, we will synthesise data using mixed methods to understand barriers to access to quality of care among people of older ages based on a Three Delays framework (seeking, reaching and receiving quality healthcare). Finally, the project will culminate in a stakeholder workshop to ensure results are contextually appropriate and disseminated, and gaps identified are prioritised to design novel interventions to promote healthy ageing in Rwanda and the region. Ethics and dissemination The study has received ethics approval from the Rwanda National Ethics Committee, Northwestern University, USA, and the University of Birmingham, UK. This study will deliver impactful research by using multiple methodologies and working with in-country partners to develop a deep knowledge and understanding of healthcare systems experienced by older people in Rwanda. It will also provide a framework for sustainable healthy ageing research and policy engagement to benefit older adults living in Rwanda and inform similar work in low- and middle-income countries during this Decade of Healthy Ageing and beyond.