Background Large scale physical distancing measures and movement restrictions imposed to contain COVID-19, often referred to as ‘lockdowns’, abruptly and ubiquitously restricted access to routine healthcare services. This study describes reported barriers and coping mechanisms to accessing healthcare among chronic care patients during the nationwide COVID-19 lockdown in Rwanda. Methods This cross-sectional study was conducted among chronic care patients enrolled in pediatric development, HIV/AIDS, non-communicable diseases, mental health, and oncology programs at 3 rural Rwandan districts. Active patients with an appointment scheduled between March–June 2020 and a phone number recorded in the electronic medical record system were eligible. Data were collected by telephone interviews between 23rd April and 11th May 2020, with proxy reporting by caregivers for children and critically ill-patients. Fisher’s exact tests were used to measure associations. Logistic regression analysis was also used to assess factors associated with reporting at least one barrier to accessing healthcare during the lockdown. Results Of 220 patient respondents, 44% reported at least one barrier to accessing healthcare. Barriers included lack of access to emergency care (n = 50; 22.7%), lack of access to medication (n = 44; 20.0%) and skipping clinical appointments (n = 37; 16.8%). Experiencing barriers was associated with the clinical program (p < 0.001), with oncology patients being highly affected (64.5%), and with increasing distance from home to the health facility (p = 0.031). In the adjusted logistic regression model, reporting at least one barrier to accessing healthcare was associated with the patient's clinical program and district of residence. Forty (18.2%) patients identified positive coping mechanisms to ensure continuation of care, such as walking long distances during suspension of public transport (n = 21; 9.6%), contacting clinicians via telephone for guidance or rescheduling appointments (n = 15; 6.8%), and delegating someone else for medication pick-up (n = 6; 2.7%). Of 124 patients who reported no barriers to accessing healthcare, 9% used positive coping mechanisms. Conclusion A large proportion of chronic care patients experienced barriers to accessing healthcare during the COVID-19 lockdown. However, many patients also independently identified positive coping mechanisms to ensure continuation of care - strategies that could be formally adopted by healthcare systems in Rwanda and similar settings to mitigate effects of future lockdowns on patients.
Implementation science is both critical and feasible in evaluating, improving, and supporting effective expansion of cancer care in resource-limited settings. In ideal circumstances, it should be a prospective program, established early in the lifecycle of a new cancer treatment program and should be an integrated and continual process.
Introduction: Rwanda’s Hepatitis C elimination campaign has relied on mass screening campaigns. An alternative “micro-elimination” strategy, which focuses on specific segments of the population such as non-communicable disease (NCD) patients, could be a more efficient approach to identifying patients and linking them to care. Methods: This retrospective cross-sectional study used routine data collected during a targeted screening campaign among NCD patients in Kirehe, Kayonza, and Burera districts of Rwanda and patients receiving oncology services from the Butaro District Hospital. The campaign used rapid diagnostic tests to screen for Hepatitis B surface antigen (HBsAg) and Hepatitis C antibody (anti-HCV). We reported prevalence and 95% confidence intervals for HBsAg and anti-HCV, assessed for associations between patients’ clinical programs and hepatitis B and C, and reported outcomes along the cascade of care for the two diseases. Results: out of 7,622 were NCD patients, 3398 (45.9%) of whom self-reported a prior hepatitis screening. Prevalence of HBsAg was 2.0% (95% CI: 1.7%-2.3%) and anti-HCV was 6.7% (95% CI: 6.2%-7.3%). The prevalence of HBsAg was significantly higher among patients younger than 40 years (2.4%). Increased age was significantly associated with anti-HCV (12.0% among patients ≥70 years). Of the 148 individuals who screened positive for HbsAg, 124 had viral load results returned, 102 had detectable viral loads (median viral load: 451 UI/mL), 9 were eligible for treatment, and three were linked to care of the 507 individuals who screened positive for anti-HCV, 468 had their viral load results returned (median viral load: 1,130,000 UI/mL), 304 had detectable viral loads, and 230 were linked to care. Conclusion: Anti-HCV prevalence among Rwandan patients with NCD was high, likely due to their older age. Findings of this study indicated that HBsAg was high concentrated among NCD patients below 40 years maybe as consequence of their sexual behavior at late adolescent age. Repeated screening and elevated hepatitis risk among repeat screeners suggests suboptimal linkage to hepatitis treatment. NCD-HCV co-infected patients had high HCV viral loads and may be at risk of poor outcomes from hepatitis C. Hepatitis C micro-elimination campaigns among NCD patients are a feasible and acceptable strategy to enhance case detection in this high-prevalence population with elevated viral loads and may support linkage to care for hepatitis C among elderly populations.
IntroductionThe COVID-19 pandemic has caused disruptions in access to routine healthcare services worldwide, with a particularly high impact on chronic care patients and low and middle-income countries. In this study, we used routinely collected electronic medical records data to assess the impact of the COVID-19 pandemic on access to cancer care at the Butaro Cancer Center of Excellence (BCCOE) in rural Rwanda.MethodsWe conducted a retrospective time-series study among all Rwandan patients who received cancer care at the BCCOE between 1 January 2016 and 31 July 2021. The primary outcomes of interest included a comparison of the number of patients who were predicted based on time-series models of pre-COVID-19 trends versus the actual number of patients who presented during the COVID-19 period (between March 2020 and July 2021) across four key indicators: the number of new patients, number of scheduled appointments, number of clinical visits attended and the proportion of scheduled appointments completed on time.ResultsIn total, 8970 patients (7140 patients enrolled before COVID-19 and 1830 patients enrolled during COVID-19) were included in this study. During the COVID-19 period, enrolment of new patients dropped by 21.7% (95% prediction interval (PI): −31.3%, −11.7%) compared with the pre-COVID-19 period. Similarly, the number of clinical visits was 25.0% (95% PI: −31.1%, −19.1%) lower than expected and the proportion of scheduled visits completed on time was 27.9% (95% PI: −39.8%, −14.1%) lower than expected. However, the number of scheduled visits did not deviate significantly from expected.ConclusionAlthough scheduling procedures for visits continued as expected, our findings reveal that the COVID-19 pandemic interrupted patients’ ability to access cancer care and attend scheduled appointments at the BCCOE. This interruption in care suggests delayed diagnosis and loss to follow-up, potentially resulting in a higher rate of negative health outcomes among cancer patients in Rwanda.
Purpose: For a cancer early detection program to improve cancer outcomes, patients with abnormal initial tests must be linked to timely diagnosis and care. We describe the development and early implementation of a tablet-based electronic medical record (EMR) at rural Rwandan health care facilities to facilitate clinical documentation and tracking of patients participating in a cervical cancer screening and breast cancer early detection program. Methods: To develop the EMR tool, a multi-institutional team was established consisting of software developers and health informatics implementers from Rwanda Biomedical Centre, Partners In Health, and the Clinton Health Access Initiative. We utilized the open-source software OpenMRS linked with an android mobile app, mUzima, used on tablets offline at rural health centers. Data are synchronized to a national OpenMRS server. In four workshops, clinicians and project leaders from Rwanda's Women's Cancer Early Detection initiative identified key clinical variables and workflows to track and link patients to care. Quality assessment of data from June-November 2020 is underway to identify gaps. Results: Twenty-two informatics trainers trained 269 clinicians at 81 health facilities from June- November 2020, enabling the tablet-based tool to be routinely utilized in the cancer early detection program in 4 districts. From June-November 2020, OpenMRS data show 13,783 patients were evaluated for cervical cancer screening and 3,608 had breast evaluation. Early implementation challenges included form completion burden for clinicians and insufficient validation rules limiting data quality. Additionally, clinical reports have not been finalized, requiring manual tracking of missed visits. Informatics, programmatic, and clinical partners discussed strategies to resolve challenges at a weeklong workshop in December 2020. Conclusion: Building an informatics system to facilitate cancer early detection in rural low-resource health facilities is feasible but requires continuous adaptation, training and multidisciplinary cross-institutional collaboration. Further evaluation will investigate the tool's impact on timely patient care. Citation Format: Eric Kagabo, Todd Anderson, Nadine Karema, Jean-Marie Vianney Dusengimana, Marc Hagenimana, Francois Uwinkindi, Jean Paul Balinda, Placide Habinshuti, Joshua Byiringiro, Nang'andu Chyizuka, Lydia Pace. A Tablet-Based Electronic Medical Record System to Improve Cancer Early Detection and Linkage to Care at Health Facilities In Rwanda [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 99.
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